Professional Documents
Culture Documents
ACS Surgery Principles and Practice 2006
ACS Surgery Principles and Practice 2006
PROFESSIONALISM IN SURGERY
Wiley W. Souba, M.D., Sc.D., F.A.C.S., Penn State College of Medicine
OUTPATIENT SURGERY
Richard B. Reiling, M.D., F.A.C.S., Wright State University School of Medicine, and Daniel
P. McKellar, M.D., F.A.C.S., Wright State University School of Medicine
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POSTOPERATIVE PAIN
Henrik Kehlet, M.D., Ph.D., F.A.C.S.(Hon.), University of Copenhagen School of Medicine
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NECK MASS
Barry J. Roseman, M.D., Roseman and Budayr, M.D., P.C., Maryville, Tennessee, and Orlo
H. Clark, M.D., F.A.C.S., University of California, San Francisco, School of Medicine
PAROTIDECTOMY
Leonard R. Henry, M.D., Uniformed Services University of the Health Sciences, and John A.
Ridge, M.D., Ph.D., F.A.C.S., , Fox Chase Cancer Center
NECK DISSECTION
Miriam N. Lango, M.D., Fox Chase Cancer Center, Bert W. O'Malley, Jr., M.D., F.A.C.S.,
University of Pennsylvania School of Medicine, and Ara A. Chalian, M.D., F.A.C.S.,
University of Pennsylvania School of Medicine
PAROTID MASS
Ashok R. Shaha, M.D., F.A.C.S., Joan and Sanford I. Weill Medical College of Cornell
University
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3. BREAST, SKIN, AND SOFT TISSUE
BREAST COMPLAINTS
D. Scott Lind, M.D., F.A.C.S., University of Florida College of Medicine, Barbara L. Smith,
M.D., Ph.D., F.A.C.S., Harvard Medical School, and Wiley W. Souba, M.D., Sc.D., F.A.C.S.,
Penn State College of Medicine
SKIN LESIONS
Alan E. Seyfer, M.D., F.A.C.S., Uniformed Services University of the Health Sciences
BREAST PROCEDURES
D. Scott Lind, M.D., F.A.C.S., University of Florida College of Medicine, Barbara L. Smith,
M.D., Ph.D., F.A.C.S., Harvard Medical School, and Wiley W. Souba, M.D., Sc.D., F.A.C.S.,
Penn State College of Medicine
4. THORAX
DYSPHAGIA
Ahmad S. Ashrafi, M.D., F.R.C.S.C., University of Pittsburgh Medical Center, and R. Sudhir
Sundaresan, M.D., F.A.C.S., F.R.C.S.C., University of Ottawa Faculty of Medicine
PARALYZED DIAPHRAGM
Bryan F. Meyers, M.D., F.A.C.S., Washington University School of Medicine in St. Louis,
and Benjamin D. Kozower, M.D., Washington University School of Medicine in St. Louis
PLEURAL EFFUSION
Rafael S. Andrade, M.D., University of Minnesota Medical School, and Michael Maddaus,
M.D., F.A.C.S., University of Minnesota Medical School
PERICARDIAL PROCEDURES
Shari L. Meyerson, M.D., Duke University Medical Center, and Thomas A. D’Amico, M.D.,
F.A.C.S., Duke University School of Medicine
PULMONARY RESECTION
Ara A. Vaporciyan, M.D., B.S., F.A.C.S., University of Texas Medical School at Houston
DIAPHRAGMATIC PROCEDURES
Ayesha S. Bryant, M.D., M.S.P.H., University of Alabama at Birmingham School of
Medicine, and Robert James Cerfolio, M.D., F.A.C.S., F.C.C.P., University of Alabama at
Birmingham School of Medicine
MEDIASTINAL PROCEDURES
Joseph B. Shrager, M.D., F.A.C.S., University of Pennsylvania School of Medicine, and
Vivek Patel, M.B.B.S., University of Pennsylvania Medical Center
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ABDOMINAL MASS
Romano Delcore, M.D., F.A.C.S., University of Kansas School of Medicine, and Laurence Y.
Cheung, M.D., F.A.C.S., University of Kansas School of Medicine
JAUNDICE
Jeffrey S. Barkun, M.D., F.A.C.S., McGill University Faculty of Medicine, and Alan N.
Barkun, M.D., McGill University Faculty of Medicine
INTESTINAL OBSTRUCTION
W. Scott Helton, M.D., F.A.C.S., University of Illinois at Chicago College of Medicine, and
Piero M. Fisichella, University of Illinois at Chicago College of Medicine
MORBID OBESITY
Harvey J. Sugerman, M.D., F.A.C.S., Virginia Commonwealth University Medical College of
Virginia
CROHN DISEASE
Susan Galandiuk, M.D., F.A.C.S., F.A.S.C.R.S., University of Louisville School of Medicine
DIVERTICULITIS
John P. Welch, M.D., F.A.C.S., University of Connecticut School of Medicine, and Jeffrey L.
Cohen, M.D., F.A.C.S., F.A.S.C.R.S., University of Connecticut School of Medicine
MOTILITY DISORDERS
Nancy N. Baxter, M.D., Ph.D., F.R.C.S.C., F.A.S.C.R.S., University of Minnesota Medical
School, and Robert D. Madoff, M.D., F.A.C.S., F.A.S.C.R.S., University of Minnesota
Medical School
GASTROINTESTINAL ENDOSCOPY
Alicia Fanning, M.D., Cleveland Clinic, and Jeffrey L. Ponsky, M.D., F.A.C.S., Cleveland
Clinic Health Sciences Center of the Ohio State University
BARIATRIC PROCEDURES
Eric J. DeMaria, M.D., F.A.C.S., Duke University School of Medicine
GASTRODUODENAL PROCEDURES
E. Ramsay Camp, M.D., University of Florida College of Medicine, and Steven N. Hochwald,
M.D., F.A.C.S., University of Florida College of Medicine
HEPATIC RESECTION
Yunan Fong, M.D., F.A.C.S., Memorial Sloan-Kettering Cancer Center, and Leslie H.
Blumgart, M.D., F.A.C.S., F.R.C.S., Memorial Sloan-Kettering Cancer Center
PANCREATIC PROCEDURES
Keith D. Lillemoe, M.D., F.A.C.S., Indiana University School of Medicine, and John L.
Cameron, M.D., F.A.C.S., Johns Hopkins University School of Medicine
SPLENECTOMY
Eric C. Poulin, M.D., M.Sc., F.A.C.S., F.R.C.S.C., University of Ottawa Faculty of Medicine,
Christopher M. Schlachta, M.D., F.A.C.S., University of Toronto Faculty of Medicine, and
Joseph Mamazza, M.D., F.A.C.S., F.R.C.S.C., University of Toronto Faculty of Medicine
ADRENALECTOMY
Abdelrahman A. Nimeri, M.D.,University of California, San Francisco, School of Medicine
and L. Michael Brunt, M.D., F.A.C.S.,Washington University School of Medicine, St. Louis
INTESTINAL ANASTOMOSIS
Julian Britton, M.S., F.R.C.S., University of Oxford
INTESTINAL STOMAS
J. Graham Williams, M.Ch., F.R.C.S., Royal Wolverhampton Hospitals NHS Trust,
Wolverhampton, UK
APPENDECTOMY
Hung S. Ho, M.D., F.A.C.S., University of California, Davis, School of Medicine
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6. VASCULAR SYSTEM
STROKE AND TRANSIENT ISCHEMIC ATTACK
Thomas S. Maldonado, M.D., New York University School of Medicine, and Thomas S.
Riles, M.D., F.A.C.S., New York University School of Medicine
VENOUS THROMBOEMBOLISM
John T. Owings, M.D., F.A.C.S., University of California, Davis, School of Medicine
DIABETIC FOOT
Cameron M. Akbari, M.D., F.A.C.S., Georgetown University School of Medicine, and Frank
W. LoGerfo, M.D., F.A.C.S., Harvard Medical School
AORTOILIAC RECONSTRUCTION
Mark K. Eskandari, M.D., F.A.C.S., Northwestern University Feinberg School of Medicine
SURGICAL TREATMENT OF THE INFECTED AORTIC GRAFT
Victor J. D'Addio, M.D., F.A.C.S., Mary Washington Hospital, Fredericksburg, Virginia, and
G. Patrick Clagett, M.D., F.A.C.S., University of Texas Southwestern Medical Center at
Dallas
RAYNAUD PHENOMENON
Tina R. Desai, M.D., F.A.C.S., University of Chicago Pritzker School of Medicine, and Ryan
Headley, M.D., University of Chicago Pritzker School of Medicine
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8. CRITICAL CARE
CARDIAC RESUSCITATION
Terry J. Mengert, M.D., University of Washington School of Medicine
PULMONARY INSUFFICIENCY
Robert H. Bartlett, M.D., F.A.C.S., University of Michigan Medical School, and Preston B.
Rich, M.D, F.A.C.S., University of North Carolina at Chapel Hill School of Medicine
MECHANICAL VENTILATION
Matthew J. Sena, M.D., University of California, Davis, School of Medicine, and Avery B.
Nathens, M.D., Ph.D., M.P.H., F.A.C.S., University of Washington School of Medicine
ACID-BASE DISORDERS
John A. Kellum, M.D., University of Pittsburgh School of Medicine, and Juan Carlos Puyana,
M.D., F.A.C.S., Javeriana University School of Medicine, Bogotá, Columbia
HEPATIC FAILURE
Walid S. Arnaout, M.D., F.A.C.S., Cedars-Sinai Medical Center, Los Angeles, and Achilles
A. Demetriou, M.D., Ph.D., F.A.C.S., Cedars-Sinai Medical Center, Los Angeles
ENDOCRINE PROBLEMS
Robert H. Bartlett, M.D., F.A.C.S., University of Michigan Medical School, and Preston B.
Rich, M.D, F.A.C.S., University of North Carolina School of Medicine
ANTIBIOTICS
Nicolas V. Christou, M.D., Ph.D., F.A.C.S., McGill University Faculty of Medicine
NOSOCOMIAL INFECTION
E. Patchen Dellinger, M.D., F.A.C.S., University of Washington School of Medicine
INTRA-ABDOMINAL INFECTION
Robert G. Sawyer, M.D., F.A.C.S., University of Virginia School of Medicine, Jeffrey S.
Barkun, M.D., F.A.C.S., McGill University Faculty of Medicine, Robert L. Smith, M.D.,
University of Virginia School of Medicine, Tae Chong, M.D., University of Virginia School
of Medicine, and George Tzimas, M.D., Kypselis General Hospital, Athens, Greece
FUNGAL INFECTION
Elias J. Anaissie, M.D., University of Arkansas College of Medicine, Albair B. Bishara,
M.D., University of Arkansas College of Medicine, and Joseph S. Solomkin, M.D., F.A.C.S.,
University of Cincinnati College of Medicine
VIRAL INFECTION
Jennifer W. Janelle, M.D., University of Florida College of Medicine, and Richard J. Howard,
M.D., Ph.D., F.A.C.S., University of Florida College of Medicine
NUTRITIONAL SUPPORT
Rolando H. Rolandelli, M.D., F.A.C.S., Temple University Hospital, Dipin Gupta, M.D.,
F.A.C.S., Temple University School of Medicine, and Douglas W. Wilmore, M.D., F.A.C.S.,
Harvard Medical School
CARDIOPULMONARY MONITORING
James W. Holcroft, M.D., F.A.C.S., University of California, Davis, School of Medicine, and
John T. Anderson, M.D., F.A.C.S., University of California, Davis, School of Medicine
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ORGAN PROCUREMENT
Sander S. Florman, M.D., Ph.D., F.A.C.S., Tulane University School of Medicine, Thomas E.
Starzl, M.D., F.A.C.S., University of Pittsburgh School of Medicine, and Charles M. Miller,
M.D., F.A.C.S., Mount Sinai School of Medicine
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© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 1 Professionalism in Surgery — 1
1 PROFESSIONALISM IN SURGERY
Wiley W. Souba, M.D., SC.D., F.A.C.S.
Over the past decade, the American health care system has had to of technical and specialized knowledge that it both teaches and
cope with and manage an unprecedented amount of change. As a advances; it sets and enforces its own standards; and it has a ser-
consequence, the medical profession has been challenged along vice orientation, rather than a profit orientation, enshrined in a
the entire range of its cultural values and its traditional roles and code of ethics.3-5 To put it more succinctly, a profession has cogni-
responsibilities. It would be difficult, if not impossible, to find tive, collegial, and moral attributes. These qualities are well
another social issue directly affecting all Americans that has under- expressed in the familiar sentence from the Hippocratic oath: “I
gone as rapid and remarkable a transformation—and oddly, a will practice my art with purity and holiness and for the benefit of
transformation in which the most important protagonists (i.e., the the sick.”
patients and the doctors) remain dissatisfied.1 The escalating commercialization and secularization of medicine
Nowhere is this metamorphosis more evident than in the field have evoked in many physicians a passionate desire to reconnect
of surgery. Marked reductions in reimbursement, explosions in with the core values, practices, and behaviors that they see as exem-
surgical device biotechnology, a national medical malpractice cri- plifying the very best of what medicine is about. This tension
sis, and the disturbing emphasis on commercialized medicine have between commercialism on the one hand and humanism and
forever changed the surgical landscape, or so it seems. The very altruism on the other is a central part of the professionalism chal-
foundation of patient care—the doctor-patient relationship—is in lenge we face today.6 As the journalist Loretta McLaughlin once
jeopardy. Surgeons find it increasingly difficult to meet their wrote, “The rush to transform patients into units on an assembly
responsibilities to patients and to society as a whole. In these cir- line demeans medicine as a caring as well as curative field, demeans
cumstances, it is critical for us to reaffirm our commitment to the the respect due every patient and ultimately demeans illness itself
fundamental and universal principles and values of medical as a significant human condition.”7
professionalism. Historically, the legitimacy of medical authority is based on
The concept of medicine as a profession grounded in com- three distinct claims2,8: first, that the knowledge and competence
passion and sympathy for the sick has come under serious chal- of the professional have been validated by a community of peers;
lenge.2 One eroding force has been the growth and sovereignty second, that this knowledge has a scientific basis; and third, that
of biomedical research. Given the high position of science and the professional’s judgment and advice are oriented toward a set
technology in our societal hierarchy, we may be headed for a of values. These aspects of legitimacy correspond to the collegial,
form of medicine that includes little caring but becomes exclu- cognitive, and moral attributes that define a profession.
sively focused on the mechanics of treatment, so that we deal Competence and expertise are certainly the basis of patient
with sick patients much as we would a flat tire or a leaky faucet. care, but other characteristics of a profession are equally important
In such a form of medicine, healing becomes little more than a [see Table 1]. Being a professional implies a commitment to excel-
technical exercise, and any talk of morality that is unsubstantiat- lence and integrity in all undertakings. It places the responsibility
ed by hard facts is considered mere opinion and therefore car- to serve (care for) others above self-interest and reward. Accord-
ries little weight. ingly, we, as practicing medical professionals, must act as role
The rise of entrepreneurialism and the growing corporatization models by exemplifying this commitment and responsibility, so
of medicine also challenge the traditions of virtue-based medical that medical students and residents are exposed to and learn the
care. When these processes are allowed to dominate medicine, kinds of behaviors that constitute professionalism [see Sidebar
health care becomes a commodity. As Pellegrino and Thomasma Elizabeth Blackwell: A Model of Professionalism].
remark, “When economics and entrepreneurism drive the profes- The medical profession is not infrequently referred to as a voca-
sions, they admit only self-interest and the working of the market- tion. For most people, this word merely refers to what one does for
place as the motives for professional activity. In a free-market a living; indeed, its common definition implies income-generating
economy, effacement of self-interest, or any conduct shaped pri- activity. Literally, however, the word vocation means “calling,” and
marily by the idea of altruism or virtue, is simply inconsistent with the application of this definition to the medical profession yields a
survival.”2
These changes have caused a great deal of anxiety and fear
among both patients and surgeons nationwide. The risk to the
profession is that it will lose its sovereignty, becoming a passive Table 1—Elements of a Profession
rather than an active participant in shaping and formulating health
policy in the future. The risks to the public are that issues of cost A profession
will take precedence over issues of quality and access to care and • Is a learned discipline with high standards of knowledge and
performance
that health care will be treated as a commodity—that is, as a priv-
• Regulates itself via a social contract with society
ilege rather than a right. • Places responsibility for serving others above self-interest and reward
• Is characterized by a commitment to excellence in all undertakings
• Is practiced with unwavering personal integrity and compassion
The Meaning of Professionalism
• Requires role-modeling of right behavior
A profession is a collegial discipline that regulates itself by • Is more than a job—it is a calling and a privilege
means of mandatory, systematic training. It has a base in a body
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 1 Professionalism in Surgery — 2
4. Professional organizations are responsible for fostering profes- employees destroyed reports revealing that University doctors sub-
sionalism in their membership. mitted inflated billings to Medicare and Medicaid.The department
chair lost his job, was barred from participation in Medicare, and,
If professionalism is indeed embodied in the principles dis-
as part of his plea bargain, had to pay a $500,000 fine, perform
cussed [see Table 1], the next question that arises is, how do we
1,000 hours of community service, and write an article in a med-
translate theory into practice? That is, what do these principles look
ical journal about billing errors. The University spent many mil-
like in action? To begin with, a competent surgeon must possess
lions in legal fees and eventually settled the billing issues with the
the medical knowledge, judgment, technical ability, professional-
ism, clinical excellence, and communication skills required for pro- Federal government for one of the highest Physicians at Teaching
vision of high-quality patient-centered care. Furthermore, this Hospitals (PATH) settlements ever.
expertise must be demonstrated to the satisfaction of the profes- Fortunately, such extreme cases of unprofessionalism are quite
sion as a whole. The Accreditation Council on Graduate Medical uncommon. Nevertheless, it remains our responsibility as profes-
Education (ACGME) has identified six competencies that must be sionals to prevent such behaviors from developing and from being
demonstrated by the surgeon: (1) patient care, (2) medical knowl- reinforced. To this end, we must lead by example. A study pub-
edge, (3) practice-based learning and improvement, (4) interper- lished in 2004 demonstrated an association between displays of
sonal and communication skills, (5) professionalism, and (6) sys- unprofessional behavior in medical school and subsequent discipli-
tems-based practice. These competencies are now being integrat- nary action by a state medical board.14 The authors concluded that
ed into the training programs of all accredited surgical residencies. professionalism is an essential competency that students must
A surgical professional must also be willing and able to take demonstrate to graduate from medical school.Who could disagree?
responsibility. Such responsibility includes, but is not necessarily
limited to, the following three areas: (1) provision of the highest- The Future of Surgical Professionalism
quality care, (2) maintenance of the dignity of patients and co-
workers, and (3) open, honest communication. Assumption of It is often subtly implied—or even candidly stated—that no
responsibility as a professional involves leading by example, placing matter how well we adjust to the changing health care environ-
the delivery of quality care above the patient’s ability to pay, and ment, the practice of surgery will never again be quite as reward-
displaying compassion. Cassell reminds us that a sick person is not ing as it once was. This need not be the case. The ongoing
just “a well person with a knapsack of illness strapped to his back”12 advances in surgical technology, the increasing opportunities for
and that whereas “it is possible to know the suffering of others, to community-based surgeons to enroll their patients into clinical tri-
help them, and to relieve their distress, [it is not possible] to als, and the growing emphasis on lifelong learning as part of main-
become one with them in their torment.”13 Illness and suffering are tenance of certification are factors that not only help satisfy social
not just biologic problems to be solved by biomedical research and and organizational demands for quality care but also are in the
technology: they are also enigmas that can serve to point out the best interest of our patients.
limitations, vulnerabilities, and frailties that we want so much to In the near future, maintenance of certification for surgeons will
deny, as well as to reaffirm our links with one another. involve much more than taking an examination every decade.The
Most important, professionalism demands unwavering person- ACS is taking the lead in helping to develop new measures of com-
al integrity. Regrettably, examples of unprofessional behavior exist. petence.Whatever specific form such measures may take, display-
An excerpt from a note from a third-year medical student to the ing professionalism and living up to a set of uncompromisable
core clerkship director reads as follows: “I have seen attendings core values15 will always be central indicators of the performance
make sexist, racist jokes or remarks during surgery. I have met res- of the individual surgeon and the integrity of the discipline of
idents who joke about deaf patients and female patients with facial surgery as a whole.
hair. [I have encountered] teams joking and counting down the Although surgeons vary enormously with respect to personali-
days until patients die.” This kind of exposure to unprofessional ty, practice preferences, areas of specialization, and style of relating
conduct and language can influence young people negatively, and to others, they all have one role in common: that of healer. Indeed,
it must change. it is the highest of privileges to be able to care for the sick. As the
It is encouraging to note that many instances of unprofessional playwright Howard Sackler once wrote, “To intervene, even
conduct that once were routinely overlooked—such as mistreating briefly, between our fellow creatures and their suffering or death,
medical students, speaking disrespectfully to coworkers, and fraud- is our most authentic answer to the question of our humanity.”
ulent behavior—now are being dealt with. Still, from time to time Inseparable from this privilege is a set of responsibilities that are
an incident is made public that makes us all feel shame. In March not to be taken lightly: a pledge to offer our patients the best care
2003, the Seattle Times carried a story about the chief of neuro- possible and a commitment to teach and advance the science and
surgery at the University of Washington, who pleaded guilty to a practice of medicine. Commitment to the practice of patient-cen-
felony charge of obstructing the government’s investigation and tered, high-quality, cost-effective care is what gives our work
admitted that he asked others to lie for him and created an atmos- meaning and provides us with a sense of purpose.16 We as surgeons
phere of fear in the neurosurgery department. According to the must participate actively in the current evolution of integrated
United States Attorney in Seattle, University of Washington health care; by doing so, we help build our own future.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 1 Professionalism in Surgery — 4
References
1. Fein R:The HMO revolution. Dissent, spring 1998, April 24, 1995 13. Cassell EJ: Recognizing suffering. Hastings Center
p 29 8. Starr PD: The social transformation of American Report 21:24, 1991
2. Pellegrino ED, Thomasma DC: Helping and Heal- medicine. Basic Books, New York, 1982 14. Papadakis M, Hodgson C, Teherani A, et al: Un-
ing. Georgetown University Press,Washington, DC, 9. Webster’s Third New International Dictionary of professional behavior in medical school is associat-
1997 the English Language, Unabridged. Gove PB, Ed. ed with subsequent disciplinary action by a state
3. Brandeis LD: Familiar medical quotations. Merriam-Webster Inc, Springfield, Massachusetts, medical board. Acad Med 79:244, 2004
Business—A Profession. Maurice Strauss, Ed. Little 1986, p 1811 15. Souba W: Academic medicine’s core values: what
Brown & Co, Boston, 1986 do they mean? J Surg Res 115:171, 2003
10. Osler’s “Way of Life” and Other Addresses, with
4. Cogan ML: Toward a definition of profession. Commentary and Annotations. Hinohara S, Niki 16. Souba W: Academic medicine and our search for
Harvard Educational Reviews 23:33, 1953 H, Eds. Duke University Press, Durham, North meaning and purpose. Acad Med 77:139, 2002
5. Greenwood E: Attributes of a profession. Social Carolina, 2001
17. Speigel R: Elizabeth Blackwell: the first woman
Work 22:44, 1957 11. Gruen RI, Arya J, Cosgrove EM, et al: Profession- doctor. Snapshots In Science and Medicine,
6. Souba W, Day D: Leadership values in academic alism in surgery. J Am Coll Surg 197:605, 2003 http://science-education.nih.gov/snapshots.
medicine. Acad Med (in press) 12. Cassell EJ: The function of medicine. Hastings nsf/story?openform&pds~Elizabeth_Blackwell_
7. McLaughlin L:The surgical express. Boston Globe, Center Report 7:16, 1977 Doctor
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 1 Professionalism in Surgery — 5
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 2 PERFORMANCE MEASURES IN SURGICAL PRACTICE — 1
2 PERFORMANCE MEASURES IN
SURGICAL PRACTICE
John D. Birkmeyer, M.D., F.A.C.S.
With the growing recognition that the quality of surgical care tations, and offering recommendations for selecting the optimal
varies widely, there is a rising demand for good measures of surgi- quality measure.
cal performance. Patients and their families need to be able to
make better-informed decisions about where to get their surgical
care—and from whom.1 Employers and payers need data on Overview of Current Performance Measures
which to base their contracting decisions and pay-for-performance The number of performance measures that have been devel-
initiatives.2 Finally, clinical leaders need tools that can help them oped for the assessment of surgical quality is already large and
identify “best practices” and guide their quality-improvement efforts. continues to grow. For present purposes, it should be sufficient to
To meet these different needs, an ever-broadening array of perfor- consider a representative list of commonly used quality indicators
mance measures is being developed. that have been endorsed by leading quality-measurement organi-
The consensus about the general desirability of surgical perfor- zations or have already been applied in hospital accreditation, pay-
mance measurement notwithstanding, there remains considerable for-performance, or public reporting efforts [see Table 2]. A more
uncertainty about which specific measures are most effective in exhaustive list of performance measures is available on the
measuring surgical quality. The measures currently in use are National Quality Measures Clearinghouse (NQMC) Web site,
remarkably heterogeneous, encompassing a range of different ele- sponsored by the Agency for Healthcare Research and Quality
ments. In broad terms, they can be grouped into three main cate- (AHRQ) (http://www.qualitymeasures.ahrq.gov).
gories: measures of health care structure, process-of-care measures, To date, the National Quality Forum (NQF), the Joint Com-
and measures reflecting patient outcomes. Although each of these mission on Accreditation of Healthcare Organizations (JCAHO),
three types of performance measure has its unique strengths, each and the Center for Medicare and Medicaid Services (CMS) have
is also associated with conceptual, methodological, or practical focused primarily on preventive care and hospital-based medical
problems [see Table 1]. Obviously, the baseline risk and frequency care, with an emphasis on process-of-care variables. In surgery,
of the procedure are important considerations in weighing the these groups have all endorsed one process measure—appropriate
strengths and weaknesses of different measures.3 So too is the un- and timely use of prophylactic antibiotics [see Table 2]—in partner-
derlying purpose of performance measurement; for example, mea- ship with the Centers for Disease Control and Prevention (CDC).
sures that work well when the primary intent is to steer patients to In 2006, CMS, as part of its Surgical Care Improvement Program
the best hospitals or surgeons (selective referral) may not be opti- (SCIP), is also endorsing process measures related to prevention of
mal for quality-improvement purposes. postoperative cardiac events, venous thromboembolism, and res-
Several reviews of performance measurement have been pub- piratory complications.
lished in the past few years.3-5 In what follows, I expand on these The AHRQ has focused primarily on quality measures that take
reviews, providing an overview of the measures commonly used to advantage of readily available administrative data. Because little
assess surgical quality, considering their main strengths and limi- information on process of care is available in these datasets, these
Table 1 Primary Strengths and Limitations of Structural, Process, and Outcome Measures
Type of
Examples Strengths Limitations
Measure
measures are mainly structural (e.g., hospital procedure volume) Table 2 Performance Measures Currently
or outcome-based (e.g., risk-adjusted mortality).
Used in Surgical Practice
The Leapfrog Group (http://www.leapfroggroup.org), a coali-
tion of large employers and purchasers, developed perhaps the
most visible set of surgical quality indicators for its value-based Performance Measure
Diagnosis or Procedure
Developer/Endorser
purchasing initiative.The organization’s original (2000) standards
focused exclusively on procedure volume, but these were expand- Critical illness Staffing with board-certified intensivists (LF)
ed in 2003 to include selected process variables (e.g., the use of
Appropriate antibiotic prophylaxis (correct
beta blockers in patients undergoing abdominal aortic aneurysm Any surgical procedure approach: give 1 hr preoperatively, discon-
repair) and outcome measures. tinue within 24 hr) (NQF, JCAHO, CMS)
Another strength is that process measures are generally less con- ity indicators, including complications, hospital readmission, and
strained by sample-size problems than outcome measures are. various patient-centered measures of satisfaction or health status.
Important outcome measures (e.g., perioperative death) are rela- Several large-scale initiatives involving direct outcome assess-
tively rare, but most targeted process measures are relevant to a ment in surgery are currently under way. For example, proprietary
much larger proportion of patients. Moreover, because process health care rating firms (e.g., Healthgrades) and state agencies are
measures generally target aspects of general perioperative care, assessing risk-adjusted mortalities by using Medicare or state-level
they can often be applied to patients who are undergoing numer- administrative datasets. Most of the current outcome-measure-
ous different procedures, thereby increasing sample sizes and, ulti- ment initiatives, however, involve the use of large clinical registries,
mately, improving the precision of the measurements. of which the cardiac surgery registries in New York, Pennsylvania,
and a growing number of other states are perhaps the most visible
LIMITATIONS
examples. At the national level, the Society for Thoracic Surgeons
At present, a major limitation of process measures is the lack of a and the American College of Cardiology have implemented sys-
reliable data infrastructure. Administrative datasets do not have the tems for tracking the morbidity and mortality associated with car-
clinical detail and specificity required for close evaluation of process- diac surgery and percutaneous coronary interventions, respective-
es of care. Measurement systems based on clinical data, including ly. Although the majority of the outcome-measurement efforts to
that of the National Surgical Quality Improvement Program date have been procedure-specific (and largely limited to cardiac
(NSQIP) of the Department of Veterans Affairs (VA),15 focus on procedures), NSQIP has assessed hospital-specific morbidities
patient characteristics and outcomes and do not collect information and mortalities aggregated across surgical specialties and proce-
on processes of care. Currently, most pay-for-performance programs dures. Efforts to apply the same measurement approach outside
rely on self-reported information from hospitals, but the reliability of the VA are now being implemented.16
such data is uncertain (particularly when reimbursement is at stake).
STRENGTHS
A second limitation is that at present, targeted process measures
in surgery pertain primarily to general perioperative care and often Direct outcome measures have at least two major strengths.
relate to secondary rather than primary outcomes. Although the First, they have obvious face validity and thus are likely to garner a
value of antibiotic prophylaxis in reducing the risk of superficial high degree of support from hospitals and surgeons. Second, out-
surgical site infection (SSI) should not be underestimated, super- come measurement, in and of itself, may improve performance—
ficial SSI is not among the most important adverse events of major the so-called Hawthorne effect. For example, surgical morbidity
surgery (including death). Thus, improvements in the use of pro- and mortality in VA hospitals have fallen dramatically since the
phylactic antibiotics will not address the fundamental problem of implementation of NSQIP in 1991.15 Undoubtedly, many surgical
variation in the rates of important outcomes from one hospital to leaders at individual hospitals made specific organizational or
another and from one surgeon to another. Except, possibly, in the process improvements after they began receiving feedback on their
case of coronary artery bypass grafting (CABG), the processes hospitals’ performance. However, it is very unlikely that even a full
that determine the success of individual procedures have yet to be inventory of these specific changes would explain such broad-
identified. based and substantial improvements in morbidity and mortality.
LIMITATIONS
Outcome Measures One limitation of hospital- or surgeon-specific outcome mea-
Direct outcome measures reflect the end result of care, either sures is that they are severely constrained by small sample sizes.
from a clinical perspective or from the patient’s viewpoint. Mor- For the large majority of surgical procedures, very few hospitals
tality is by far the most commonly used surgical outcome mea- (or surgeons) have sufficient adverse events (numerators) and
sure, but there are other outcomes that could also be used as qual- cases (denominators) to be able to generate meaningful, proce-
a b
20.0 20.0
16.0 16.0
Mortality (%), 1998–99
12.0 12.0
8.0 8.0
4.0 4.0
0 0
Highest Lowest Lowest Highest Highest Lowest Lowest Highest
Unadjusted Mortality for Hospital Volume, Unadjusted Mortality for Hospital Volume,
Resection of Esophageal 1994–1997 Resection of Pancreatic 1994–1997
Cancer, 1994–1997 Cancer, 1994–1997
Figure 1 Illustrated is the relative ability of historical (1994–1997) measures of hospital volume and risk-
adjusted mortality to predict subsequent (1998–1999) risk-adjusted mortality in Medicare patients undergoing
(a) esophageal or (b) pancreatic resection for cancer.8
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 2 PERFORMANCE MEASURES IN SURGICAL PRACTICE — 4
(or away from worse ones). For example, a measure based on pre- ble of distinguishing levels of performance on an individual basis.
vious performance should reliably identify providers who are likely From the perspective of providers in particular, a measure cannot
to have superior performance now and in the future. At the same be considered fair unless it reliably reflects the performance of in-
time, a good performance measure should not provide incentives dividual hospitals or physicians. Unfortunately, as noted (see above),
for perverse behaviors (e.g., carrying out unnecessary procedures to small caseloads (and, sometimes, variations in the case mix) make
meet a specific volume standard) or negatively affect other domains this degree of discrimination difficult or impossible to achieve with
of quality (e.g., patient autonomy, access, and satisfaction). most procedures. Even so, information that at least improves the
Measures that work well for quality improvement may not be chances of a good outcome on average is still of real value to patients.
particularly useful for selective referral; the converse is also true. Many performance measures can achieve this less demanding ob-
For example, appropriate use of perioperative antibiotics in surgi- jective even if they do not reliably reflect individual performance.
cal patients is a good quality-improvement measure: it is clinical- For example, a 2002 study used clinical data from the Cooper-
ly meaningful, linked to lower SSI rates, and directly actionable. ative Cardiovascular Project to assess the usefulness of the Health-
This process of care would not, however, be particularly useful for grades hospital ratings for acute myocardial infarction (based pri-
selective referral purposes. In the first place, patients are unlikely marily on risk-adjusted mortality from Medicare data).24 Compared
to base their decision about where to undergo surgery on patterns with the one-star (worst) hospitals, the five-star (best) hospitals had
of perioperative antibiotic use. Moreover, surgeons with high rates a significantly lower mortality (16% versus 22%) after risk adjust-
of appropriate antibiotic use do not necessarily do better with ment with clinical data; they also discharged significantly more
respect to more important outcomes (e.g., mortality). A physi- patients on appropriate aspirin, beta-blocker, and angiotensin-
cian’s performance on one quality indicator often correlates poor- converting enzyme inhibitor regimens. However, the Healthgrades
ly with his or her performance on other indicators for the same or ratings proved not to be useful for discriminating between any two
other clinical conditions.23 individual hospitals. In only 3% of the head-to-head comparisons
As a counterexample, the two main performance measures for did five-star hospitals have a statistically lower mortality than one-
pancreatic cancer surgery—hospital volume and operative mor- star hospitals.
tality—are very informative in the context of selective referral: Thus, some performances measures that clearly identify groups
patients can markedly improve their chances of surviving surgery of hospitals or providers that exhibit superior performance may be
by selecting hospitals highly ranked on either measure [see Figure 1]. limited in their ability to differentiate individual hospitals from
Neither of these measures, however, is particularly useful for qual- one another. There may be no simple way of resolving the basic
ity-improvement purposes. Volume is not readily actionable, and tension implied by performance measures that are unfair to
mortality is too unstable at the level of individual hospitals (again, providers yet informative for patients.This tension does, however,
because of the small sample sizes) to serve as a means of identify- underscore the importance of being clear about (1) what the pri-
ing top performers, determining best practices, or evaluating the mary purpose of performance measurement is (quality improve-
effects of improvement activities. ment or selective referral) and (2) whose interests are receiving top
Many believe that a good performance measure must be capa- priority (the provider or the patient).
References
1. Lee TH, Meyer GS, Brennan TA: A middle tion for lung cancer. N Engl J Med 345:181, 236:344, 2002
ground on public accountability. N Engl J Med 2001 17. Dimick JB, Welch HG, Birkmeyer JD: Surgical
350:2409, 2004 10. Begg CB, Reidel ER, Bach PB, et al: Variations mortality as an indicator of hospital quality: the
2. Galvin R, Milstein A: Large employers’ new stra- in morbidity after radical prostatectomy. N Engl problem with small sample size. JAMA 292:847,
tegies in health care. N Engl J Med 347:939, J Med 346:1138, 2002 2004
2002 18. Finlayson EV, Birkmeyer JD, Stukel TA, et al:
11. Finlayson EVA, Birkmeyer JD: Effects of hospi-
3. Birkmeyer JD, Birkmeyer NJ, Dimick JB: Mea- tal volume on life expectancy after selected can- Adjusting surgical mortality rates for patient co-
suring the quality of surgical care: structure, pro- cer operations in older adults: a decision analy- morbidities: more harm than good? Surg
cess, or outcomes? J Am Coll Surg 198:626, 2004 sis. J Am Coll Surg 196:410, 2002 132:787, 2002
4. Landon BE, Normand SL, Blumenthal D, et al: 12. Pronovost PJ, Angus DC, Dorman T, et al: 19. Fisher ES, Whaley FS, Krushat WM, et al: The
Physician clinical performance assessment: pros- Physician staffing patterns and clinical outcomes accuracy of Medicare’s hospital claims data: prog-
pects and barriers. JAMA 290:1183, 2003 in critically ill patients: a systematic review. JAMA ress, but problems remain. Am J Public Health
5. Bird SM, Cox D, Farewell VT, et al: Perform- 288:2151, 2002 82:243, 1992
ance indicators: good, bad, and ugly. J R Statist 13. Pronovost PJ, Needham DM, Waters H, et al: 20. Iezzoni LI, Foley SM, Daley J, et al: Com-
Soc 168:1, 2005 Intensive care unit physician staffing: financial orbidities, complications, and coding bias. Does
6. Halm EA, Lee C, Chassin MR: Is volume relat- modeling of the Leapfrog standard. Crit Care the number of diagnosis codes matter in pre-
ed to outcome in health care? A systematic re- Med 32:1247, 2004 dicting in-hospital mortality? JAMA 267:2197,
view and methodologic critique of the literature. 1992
14. Shahian DM, Normand SL: The volume-out-
Ann Intern Med 137:511, 2002 come relationship: from Luft to Leapfrog. Ann 21. Iezzoni LI: The risks of risk adjustment. JAMA
7. Dudley RA, Johansen KL, Brand R, et al: Se- Thorac Surg 75:1048, 2003 278:1600, 1997
lective referral to high volume hospitals: estimat- 15. Khuri SF, Daley J, Henderson WG: The com- 22. Birkmeyer J: Unpublished data, 2005
ing potentially avoidable deaths. JAMA 283:1159, parative assessment and improvement of quality 23. Palmer RH, Wright EA, Orav EJ, et al: Con-
2000 of surgical care in the Department of Veterans sistency in performance among primary care
8. Birkmeyer JD, Dimick JB, Staiger DO: Hospital Affairs. Arch Surg 137:20, 2002 practitioners. Med Care 34(9 suppl):SS52, 1996
volume and operative mortality as predictors of 16. Fink A, Campbell DJ, Mentzer RJ, et al: The 24. Krumholz HM, Rathore SS, Chen J, et al: Eval-
subsequent performance. Ann Surg (in press) National Surgical Quality Improvement Pro- uation of a consumer-oriented internet health
9. Bach PB, Cramer LD, Schrag D, et al:The influ- gram in non–Veterans Administration hospitals: care report card: the risk of quality ratings based
ence of hospital volume on survival after resec- initial demonstration of feasibility. Ann Surg on mortality data. JAMA 287:1277, 2002
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
Elements of Contemporary Practice 3 Patient Safety in Surgical Care: A Systems Approach — 1
In high-profile events such as the explosion at Chernobyl, the where a systems approach might contribute to improving surgical
near meltdown at Three Mile Island, the explosion of the chemi- care. In addition, I consider current obstacles to quality improve-
cal plant in Bhopal, the collision of a U.S. submarine with a ment and discuss how surgeons can take the lead in overcoming
Japanese fishing boat, and the explosion of the space shuttle these obstacles. Finally, I consider patient safety in the broader
Challenger, the casualties are notable for their number and their context: the lessons learned from exploring patient safety issues
celebrity. The differences between these events notwithstanding, are likely to be equally applicable to wider quality of care issues.
each one arose in large part from faults in a complex system.
Human error played a role as well, but it was generally under-
stood to be only a relatively small part of a larger systemic failure. The Magnitude of the Problem
In contrast, medical injuries affect one patient at a time and, The two most widely cited estimates of adverse medical events
until recently, rarely received much publicity. Nevertheless, there are the Harvard Medical Practice Study (HMPS)10 and the study
is now considerable public concern about patient safety and the of adverse surgical events in Colorado and Utah.11 The HMPS,
overall quality of patient care.1-3 It is estimated that there may be a population-based study of hospitalized patients in New York
nearly 100,000 error-related deaths each year in the United State during 1984, found that nearly 4% of patients experienced
States.4 This estimate far exceeds the casualties from more pub- an adverse event (i.e., an unintended injury caused by treatment
licized nonmedical disasters and, if anywhere near correct, makes that resulted in a prolonged hospital stay or a measurable dis-
medically related injuries one of the leading causes of death, ability at discharge) and that about half of such events occurred
according to the Centers for Disease Control and Prevention in surgical patients. The Colorado/Utah study, using a random
(CDC) (http://www.cdc.gov/scientific.htm). Perhaps surprising- sample of 15,000 nonpsychiatric discharges during 1992, found
ly, however, both patients and physicians still appear to place that the annual incidence of adverse surgical events was 3.0%
much less emphasis on system flaws as a cause of medical injury and that 54% of these events were preventable. Nearly half of all
than on individual human error.2 One reason for this may be that adverse surgical events were accounted for by technique-related
“error in medicine is almost always seen as a special case of med- complications, wound infections, and postoperative bleeding.
icine rather than as a special case of error.… The unfortunate Eleven common operations were associated with a significantly
result has been the isolation of medical errors from much of the higher risk of an adverse event [see Table 1], and eight were asso-
body of theory, analysis, and application that has developed to
deal with error in fields such as aviation and nuclear power.”5 In
Table 1 Procedures Associated with a Significantly
addition, within the field of medicine, it is accepted that compli-
cations or bad outcomes can occur even in the best circum- Higher Incidence of Adverse Surgical Events11
stances. When a system is not expected to work perfectly at all
times, it is difficult to distinguish problems related to individual Incidence of Adverse Confidence
Procedure
error from those related to flaws in the system. Events (%) Interval (%)
Various organizations—including the National Patient Safety AAA repair 18.9 8.3–37.5
Foundation (http://www.npsf.org), the National Quality Forum
(NQF) (http://www.qualityforum.org), and the Institute of Lower extremity arterial bypass 14.1 6.0–29.7
Medicine (IOM) (http://www.iom.edu)—are responding to the CABG/valve replacement 12.3 7.9–18.7
concerns about patient safety and the quality of medical care.6-8
In addition to the basic professional obligation to provide high- Colon resection 6.8 2.9–14.8
quality care, there is evidence that such care is less expensive and Cholecystectomy 5.9 3.7–9.3
is therefore crucial for cost control. Moreover, the growing con-
Prostatectomy 5.9 2.3–14.3
cern about patient safety has begun to change the way patients
select providers. For example, one survey found that between TURP/TURBT 5.5 2.7–10.7
1996 and 2000, the percentage of patients who would choose a
Knee/hip replacements 4.9 2.9–8.4
highly rated surgeon whom they had not seen before in prefer-
ence to a less highly rated one whom they had seen before Spinal surgery 4.5 2.8–7.3
increased substantially.9 Thus, improving patient safety is also an
Hysterectomy 4.4 2.9–6.8
issue of provider self-interest.
In what follows, I attempt to evaluate current information on Appendectomy 3.0 1.4–6.6
patient safety and the quality of surgical care in the context of sys- AAA—abdominal aortic aneurysm CABG—coronary artery bypass grafting
tem failure, with a particular emphasis on indicating how and TURP—transurethral prostatectomy TURBT—transurethral resection of bladder tumor
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
CP Elements of Contemporary Practice 3 Patient Safety in Surgical Care: A Systems Approach — 2
Table 2 Procedures Associated with a Significantly characterizing adverse events as either preventable or unpre-
Higher Incidence of Preventable Adverse ventable given the prevailing state of knowledge. Preventable
Surgical Events11 errors were further subclassified as diagnostic errors or treatment
errors; treatment errors included preventive errors such as failure
of prophylaxis and failure to monitor and follow up treat-
Incidence of Confidence ment.10,30 The HMPS found preventability to vary according to
Procedure Preventable Adverse Interval (%)
Events (%)
the type of event: 74% of early surgical adverse events were
judged preventable, compared with 65% of nonsurgical adverse
AAA repair 8.1 2.2–25.5 events; and more than 90% of late surgical failures, diagnostic
mishaps, and nonprocedural therapeutic mishaps were judged
Lower extremity arterial bypass 11.0 4.2–26.1
preventable.
CABG/valve replacement 4.7 2.3–9.7 In an attempt to make study data more directly comparable,
Federal agencies developed standard definitions of the applicable
Colon resection 5.9 2.4–13.8
terms [see Sidebar Definitions of Terms Related to Patient
Cholecystectomy 3.0 1.6–5.8 Safety].31 Even when terms are agreed on, however, differences in
TURP/TURBT 3.9 1.7–8.7
end points may render studies noncomparable or lead to differ-
ing conclusions. For instance, a study of Veterans Affairs (VA)
Hysterectomy 2.8 1.6–4.7 hospitals reported much lower estimates of preventable deaths
Appendectomy 1.5 0.5–4.5 than those cited by the HMPS.32 The study authors noted that
many of the patients who died “preventable” deaths would have
died of natural causes anyway within a few months even if they
ciated with a significantly higher risk of a preventable event [see had received optimal care. However, to argue that a patient would
Table 2]. Other noteworthy studies have reported comparable or have died soon regardless of care does not mean that flaws do not
higher estimates.12-18 exist in the care system.
A well-publicized 2003 report estimated that retention of Judgments of causality are affected by hindsight bias, as illus-
sponges or surgical instruments occurred in between 1/8,801 trated by a study of anesthetic care in which outcome differences
and 1/18,760 inpatient operations at nonspecialty acute care significantly influenced the perception of negligence, even when
hospitals.19 This figure is probably an underestimate. the care provided was equivalent in all other respects.33
Wrong-site surgery, brought to public attention by a wrong- Accordingly, there is often a tendency to focus too narrowly on
sided amputation in Florida, has proved to be more than an iso- adverse outcomes while paying insufficient attention to the
lated event. The Florida Board of Medicine tabulated 44 wrong- processes that give rise to these outcomes.
site operations in 1999–2000,20 and a database begun in 1998 by The situation is further complicated by underreporting of
the Joint Commission for Accreditation of Healthcare Organi- error. Underreporting is more likely if side effects are delayed or
zations (JCAHO) contained 150 cases of wrong-site, wrong-per- unpredictable, if there is a longer survival or latent interval, or if
son, or wrong-procedure surgery as of December 2001.21 The in- a patient has been transferred from one facility to another.
creased frequency of reports of wrong-site surgery since the initial Inadequate doses of antibiotics or anesthetics may not be report-
headlines probably reflects earlier underreporting.22 ed if they cause no immediately evident injury.The lack of detail
Medication errors (e.g., wrong drug, wrong dose, wrong in many medical records may contribute to underreporting as
patient, wrong time, or wrong route of administration) are alarm- well. A major cause of underreporting is the use of a punitive
ingly frequent.23-27 A study of radiopharmaceutical misadminis-
trations showed that 68.9% of such errors involved the wrong iso-
tope, 24% the wrong patient, 6.5% the wrong dose, and 0.6% the
wrong route.28 Blood transfusions continue to be plagued by
Definitions of Terms Related to Patient Safety31
patient misidentification as well. Device-related deaths and seri-
ous injuries also occur at an alarming rate, even after premarket • An adverse event is an injury that was caused by medical man-
agement and that results in measurable disability.
safety testing.29 In 2002, the Food and Drug Administration
• An error is the failure of a planned action to be completed as
(FDA) received more than 2,500 such reports from clinical intended or the use of a wrong plan to achieve an aim. Errors can
facilities and more than 3,500 from health professionals and include problems in practice, products, procedures, and systems.
consumers. • A preventable adverse event is an adverse event that is attrib-
There remain significant differences of opinion regarding sur- utable to error.
gically related adverse events, with some disputing the published • An unpreventable adverse event is an adverse event resulting
estimates and others arguing about the extent to which such from a complication that cannot be prevented given the current
state of knowledge.
events are preventable. Furthermore, not everyone agrees with
• A near miss is an event or situation that could have resulted in
the HMPS definition of medical error. Some argue that iatro- accident, injury, or illness but did not, either by chance or
genic illnesses caused by conceptual error (e.g., a contraindicat- through timely intervention.
ed, unsound, or inappropriate medical approach) should be dis- • A medical error is an adverse event or near miss that is pre-
tinguished from the side effects of an intended action that was ventable with the current state of medical knowledge.
correct in the circumstances (e.g., an indicated diagnostic or • A system is a regularly interacting or interdependent group of
therapeutic procedure).29 Others would distinguish accidents items forming a unified whole.
(i.e., unplanned, unexpected, and undesired events) from true • A systems error is an error that is not the result of an individual’s
side effects (which result from correct management and which actions but the predictable outcome of a series of actions and
factors that make up a diagnostic or treatment process.
are often accepted as reasonable therapeutic tradeoffs).
The HMPS attempted to address some of these issues by
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
CP Elements of Contemporary Practice 3 Patient Safety in Surgical Care: A Systems Approach — 3
reporting system. In such systems, caregivers are often reluctant as other undesired consequences.53 For instance, physicians who
to discuss error out of concern that the error reports might be relinquish privileges on their own initiative may be more lenient-
used against them.34 If protected from disciplinary actions, how- ly treated than those against whom action was initiated by a peer
ever, they seem more willing to report problems.35,36 It is essen- review committee. The data reviewed by such committees often
tial to recognize that when the introduction of an anonymous, are legally discoverable, and the lack of anonymity and confiden-
nonpunitive reporting system leads to an increased number of tiality of the data deters voluntary participation. Even when peer
error reports, this is more likely to be a reflection of previous review does identify problems, it may be unable to implement
underreporting than of deteriorating safety or quality.37 solutions.
Because of all these factors, it remains difficult to estimate the The shortcomings of hospital incident reports are similar to
number of error-related medical injuries with precision.To some, those of peer review. Incident reports also place limited emphasis
that the rate of adverse events was lower in the Colorado/Utah on close calls and tend to lack systematic follow-up. Frequently,
study than in the HMPS suggests that safety is improving. This reporters are reluctant to file their reports out of fear that their
is encouraging if true, but there is still a great deal of room for employment might be jeopardized or that the reported party
further improvement.38 Even if one accepts the more conserva- might seek retribution.
tive estimates of error frequency, the aggregate number of fatal The present professional liability system is particularly contro-
medical errors far exceeds that of more publicized nonmedical versial. Two of its most notable shortcomings are (1) that only a
disasters. These lower estimates would not be tolerated in non- small percentage of cases of true medical injury ever become the
medical settings and should not be tolerated in patient care. basis of legal action and (2) that many of the claims that are
brought have no merit.54 In addition, the liability system com-
pensates fewer than one in eight patients who are harmed;
Shortcomings of Existing Quality-Improvement Methods awards such compensation only after years of litigation; is based
Clearly, there is no lack of efforts aimed at quality improve- on determination of fault where experts cannot agree (often as a
ment. Unfortunately, many such efforts have notable shortcom- result of hindsight bias); and causes devastating emotional dam-
ings that prevent them from addressing current concerns about age to physicians (and their families),12,55,56 which may adversely
safety and quality in an optimal fashion. affect their problem-solving abilities. To the extent that experi-
Morbidity and mortality (M & M) conferences are perhaps the ence with or fear of a malpractice action deters efforts at quality
most traditional venue for discussion of adverse events. They do improvement, it is counterproductive. Yet another shortcoming
not consider all complications, however, nor are they consistent- of the liability system is that insurance premiums often are deter-
ly well attended.39-41 Furthermore, M & M conferences tend to mined by economic factors outside the field of medicine and are
be intradepartmental, which means that there is often little not adjusted for claims experience. State legislative policy, osten-
opportunity to discuss system problems that may involve other sibly aimed at moderating liability crises, may have counterintu-
departments. In addition, M & M conferences typically do not itive effects on median awards: whereas limits on awards for pain
consider “near misses” (i.e., close calls), even though close calls and suffering reduce total awards, limits on lawyers’ fees actual-
are important in identifying both actual and potential system ly increase them.57
defects. Finally, M & M conferences have a tradition of blaming The National Practitioner Data Bank (NPDB) has many of
individuals rather than focusing on the circumstances within the limitations of the liability system. It also contains information
which the individuals acted. This tradition serves to perpetuate a on settlements in which the merits of the case may not have been
defensive attitude among trainees that is counterproductive. fully considered; to the extent that settlements may reflect mon-
Continuing Medical Education (CME) focuses on the link etary convenience or legal philosophy more than practitioner
between knowledge and quality of patient care. Although there is performance, this information may be misleading. The NPDB
a clear relationship between CME and performance on board may also contain other inaccurate, incomplete, or inappropriate
recertification examinations,42 the actual relationship between information.
CME and better patient care is far more complex. There is evi-
dence suggesting that performance on cognitive examinations is
related to performance in practice43,44 and that board certification Patient Care as a System
is linked with improved outcomes,45 but the data are not conclu- The magnitude of the medical quality problem and the short-
sive. Systematic reviews of differences in the impact of various comings of current efforts to address this problem indicate that a
CME strategies on actual practice change have raised serious con- change of approach is needed. Given the impressive success of
cerns about the value of some current CME.46 The most effective systems approaches to safety and quality improvement in non-
change strategies (e.g., reminders, patient-mediated interventions, medical settings, it is worthwhile to consider taking a similar
outreach visits, input from opinion leaders, and multifaceted activ- approach to patient care.
ities) appear to be those that place substantial emphasis on per- A system may be broadly defined as a regularly interacting or
formance change rather than just on learning.47,48 interdependent group of items that form a unified whole; in the
Clinical pathways and guidelines, by standardizing medical context of patient safety, the term system refers to the individual
processes, may help improve safety and quality, especially in components of care. A simple system may involve a specific task;
high-risk procedures.49 Some critics argue, however, that guide- a complex system may involve smaller, simpler subsystems. The
lines often do not apply to particular patients and can be difficult complexity of a system derives both from the number of compo-
to use in patients with other, more urgent medical problems. nent subsystems and the interactions among them.
Others suggest that guidelines are mostly beneficial in treatment Systems become flawed when a problem in one or more steps
and prevention and contribute little to diagnosis.50,51 Finally, or subsystems can lead to an undesired outcome. Overt problems
guidelines may become outdated quickly.52 are relatively easy to identify and correct; latent errors are more
Peer review, originally intended as a mechanism for profes- insidious. Latent errors are often introduced by people who work
sional self-evaluation, is subject to anticompetitive abuse as well at the “blunt end” of the system (e.g., management or house-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
CP Elements of Contemporary Practice 3 Patient Safety in Surgical Care: A Systems Approach — 4
keeping) but are not active participants. Such errors can then trap to be a tradeoff between problems related to fatigue and those
“sharp end” participants (e.g., anesthesiologists, nurses, or sur- related to handoffs: reducing the former increases the latter, and
geons) into overt errors. A typical accident pathway is one in vice versa.
which organizational processes give rise to latent errors, latent The similarities between medical and nonmedical systems
errors produce system defects that may interact with external notwithstanding, it must be recognized that medical systems are
events in generating unsafe acts, and unsafe acts precipitate an distinctive with respect to complexity of content and organiza-
active failure that then penetrates a safety barrier.58 Indeed, in a tional structure. Whereas nonmedical systems are typically man-
complex system, the greatest risk of an adverse event may come aged vertically through hierarchical control, patient care systems
not from a major subsystem breakdown or isolated operator errors tend to comprise numerous diverse components that are only
but from the unrecognized accumulation of latent errors.59-61 loosely aggregated.71 Within the patient care system, subsystems
Such was the case with the explosion of the Challenger.62 (including quality improvement components) tend to function in
The probability that a system flaw will result in an adverse isolation, and intrasystem changes tend to be managed laterally
outcome reflects the probability of error within each step or across individual subsystems. The result, all too often, is ineffi-
component of the larger system, the total number of steps or cient or even contradictory policies, which increase the chances
components, and the degree of coupling among the steps or of error.
components. Errors in tightly coupled systems are more likely to
propagate than those in loosely coupled systems. For example,
the probability of a successful outcome in a tightly coupled, lin- Basic Principles of Human Performance and Human
ear 20-step process with a 1% error rate per step is 0.99 factored Error
20 times, or 0.818. In loosely coupled systems, a successful out- Systemic factors are not the sole cause of system failure:
come is less dependent on satisfactory completion of each step. human factors play a role as well. A great deal of work has been
The usual trade-off for this additional safety is greater system done on analyzing human error and its relationship to perfor-
complexity, which can itself introduce errors. It also must be kept mance.72 The overall implication of this work is that to achieve
in mind that the presence of latent errors can make systems meaningful improvements in safety and quality, it is necessary to
appear to be more loosely coupled than they actually are. shift the focus from fallible individuals to the situational and
Consideration of these general characteristics of systems organizational latent failures that these individuals inherit.58
reveals many areas where they are applicable to medicine—in Human performance may be classified as skill-based, rule-
particular, to surgery and anesthesiology. Moreover, in a number based, or knowledge-based behavior, as follows73:
of respects, the habitats of surgeons (e.g., the OR, the ICU, and
1. Skill-based performance is governed by stored patterns of pre-
the ED) resemble those seen in various high-tech, high-risk non-
programmed instructions, and it occurs without conscious
medical industries, and strong parallels have been noted between
control. Such performance makes use of long-term memory.
behavioral issues on the flight deck and observed behavior in the
2. Rule-based performance involves solving problems through
OR.63,64 It is more than coincidence that the ICU, with its
stored rules of the if-then variety. Like skill-based perfor-
emphasis on technology, is a common site of adverse events.65,66
mance, it uses long-term memory; however, unlike skill-based
The usefulness of considering patient care as a system may be
performance, it is associated with a consciousness that a prob-
seen by examining some of the issues surrounding technology.To
lem exists.59 The rules are usually based on experience from
understand the role of technology in a system, it is necessary to
previous similar situations and are structured hierarchically,
understand not only the devices and techniques involved but also
with the main rules on top; their strength is an apparent func-
the people using the technology and the means by which they
tion of how recently and how frequently they are used.72 Rule-
interact with the system. Each change in technology initiates a
based performance varies according to expertise: novices tend
new learning cycle, and the resulting environment is one that is
to rely on a few main rules, whereas experts have many side
especially conducive to error.67 It is relatively unusual, however,
rules and exceptions.
for an isolated error to lead to a system failure; instead, such fail-
3. Knowledge-based performance involves conscious analytic
ures typically involve multiple malfunctions, either occurring
processes and stored knowledge. It relies on working memo-
within a single element of the system or spread out across more
ry, which is comparatively slow and of relatively limited capac-
than one element.
ity. Typically, people resort to knowledge-based performance
The potential value of a systems approach to patient care is
when their skills are inapplicable or their repertoire of rules
further suggested by data associating improved outcomes associ-
has been exhausted.
ated with higher hospital or surgeon volume.68,69 Whether “prac-
tice makes perfect” or “perfect makes practice” remains unre- Successful problem solving has three main phases: planning,
solved, but in either case, it seems likely that the improved out- storage, and execution. The errors resulting from failures in per-
comes are a reflection of better care systems. That some high- formance may be classified as slips, lapses, or mistakes,60 depend-
volume hospitals and surgeons have below-average outcomes ing on which phase of the problem-solving sequence is involved.
and many low-volume hospitals and surgeons have excellent ones Slips are failures of the execution phase or storage phase, or both,
is consistent with this view.70 and may occur regardless of whether the plan from which they
Additional supportive evidence comes from critical incident arose was adequate; lapses are storage failures. Generally, slips are
analyses of adverse surgical events,41 which reveal that the same overt, whereas lapses are covert. Mistakes are failures of planning,
types of factors that contribute to nonmedical system failures reflecting basic deficiencies or failures in selecting an objective or
also contribute to adverse surgical events. Of these factors, the specifying the means to achieve it, regardless of how well the plan
three most common are inexperience (on the part of both resi- was executed.
dents and attending surgeons), breakdowns in communication Specific types of errors tend to be associated with specific
(e.g., handoffs and personnel conflicts), and fatigue or excessive modes of failure [see Table 3].60 Slips and lapses are failures of
workload. Often, these factors interact. For example, there seems skill-based performance and generally precede recognition of a
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
CP Elements of Contemporary Practice 3 Patient Safety in Surgical Care: A Systems Approach — 5
Table 3 Common Modes of Failure Associated The above classifications explain basic behavioral mechanisms
with Specific Types of Performance60 but may be modified to meet specific needs.34 Some authorities
classify error according to whether it can be addressed by engi-
neering, design, societal, or procedural changes; others empha-
Failures of Skill-Based Performance
size psychological intervention and modification; and still others
Inattention Overattention classify errors by their mode of appearance. As an example, clas-
sification by mode of appearance might include errors of omis-
Double-capture slips Omissions sion, errors of insertion, errors of repetition, and errors of substi-
Omissions following interruptions Repetitions
tution (e.g., misadministration of lidocaine, heparin, or potassi-
Reduced intentionality Reversals
Perceptual confusions
um chloride as a result of poor package labeling).
Interference errors
experience failures of observation that lead to adverse events. In is delivered. In addition, nonphysicans will have important roles
watching for rare occurrences, it is difficult to remain alert for to play, as illustrated by studies relating nurse staffing levels to
longer than 10 to 20 minutes; thus, knowing when and how to quality of care.86,87
verify data is an important metacognitive skill.
Psychological framing effects also play a role in error.
Examples of such effects are the irrational preference for estab- Examples of Systems Approaches to Improving Quality
lished treatments when outcomes are framed in terms of gain Given the complexity of health care, embarking on a systems
(e.g., survival) and the similarly irrational preference for risky approach to safety improvement may seem a daunting prospect.
treatments when outcomes are framed in terms of loss (e.g., mor- Accordingly, it is worthwhile to look at examples of successful
tality). The impetus to “do the right thing” can facilitate error.62 quality improvement systems that have already been implemented.
Patient care often involves team behavior, and such behavior Anesthesiologists were among the first physicians to take such
can affect individual performance.5,74 Lack of cohesion and an approach to safety, and the success of their efforts is irrefutable:
mutual support among team members can compromise perfor- anesthesia-related mortality has fallen from approximately
mance. Too informal a team structure may undermine patterns 2/10,000 to the current 1/200,000 to 1/300,00088-90—a degree of
of authority and responsibility and hinder effective decision-mak- safety approaching that advocated for nonmedical industries (i.e.,
ing. Conversely, too strong a hierarchy may make it excessively < 3.4 defects or errors/106 products or events).91 This improve-
difficult for juniors to question decisions made by those at high- ment is primarily the result of a broad effort involving teamwork,
er levels of authority. Rigid behavior may impair the ability to practice guidelines, automation, procedure simplification, and
cope with unforeseen events and discourage initiative. standardization of many functions. Previously, for instance, there
For good teamwork, it is essential that team members share a was no standard design for anesthesia machines, and it was not
clear understanding of what is happening and what should hap- unusual for more than one type to be in use in the same hospital.
pen. This understanding is referred to as situational awareness.74 This is no longer the case. It is clear that considerable benefit can
Unfortunately, there is a common tendency to believe that the be derived from a better appreciation of the human-technology
prevailing level of situational awareness is higher than it is. For interface and the ergonomics of equipment design.92
example, the aviation industry improved its safety record when it Successful surgical examples exist as well, such as the Northern
identified and removed barriers impeding junior officers from New England Cardiovascular Disease Study Group,93 Inter-
communicating with the captain, and these improvements mountain Health Systems in Utah, and the Maine Medical
occurred after good communication was already thought to Assessment Foundation.94 These examples share four important
exist.82 characteristics: (1) providers responded to practice variations by
In the OR, teams consist of crews from nursing, surgery, and participating in outcomes research; (2) voluntary, physician-initi-
anesthesia. As an example of suboptimal situational awareness, ated interventions were as effective as, if not more effective than,
the various crews often have fundamentally different perceptions external regulatory mechanisms in reducing morbidity and mor-
of their respective roles. Anesthesiologists and nurse anesthetists tality; (3) a systems approach to quality improvement produced
are much more likely to feel that a preoperative briefing is impor- better results than a bad-apple approach; and (4) quality-
tant for team effectiveness than surgeons and surgical nurses are, improvement programs successfully included groups that other-
whereas surgeons and surgical nurses are more likely to feel that wise might have been competitors. None of these efforts increased
junior team members should not question the decisions of senior liability exposure; often, they reduced it. Because the practice pro-
staff members.83 Such varying perceptions not only can compro- files were physician-initiated, there was little risk that the findings
mise patient safety but also represent lost opportunities for teach- would be used to make decisions about credentialing, reimburse-
ing or learning. Unfortunately, there is often little consensus on ment, or contracting.94 In addition, the funding parties (including
how optimal team coordination should be achieved. insurers) usually agreed to confidentiality in return for the bene-
The importance of teamwork issues in the OR is illustrated by fit associated with voluntary physician involvement.
a study that analyzed time needed to learn minimally invasive Trauma care has also benefited from a systems approach. A
cardiac surgery.84 On the fast-learning teams, the members had study of 22,000 patients from a regional trauma system conclud-
worked well together in the past, they went through the early ed that the most common single error across all phases of care
learning phase together before adding new members, they sched- was failure to evaluate the abdomen appropriately.95 Errors in the
uled several of the new procedures close together, they discussed resuscitative and operative phases were more common, but
each case in detail beforehand and afterward, and they carefully errors in critical care had the greatest impact on preventable
tracked results. Of particular interest was that surgeons on the mortality. The perception of preventability increased in parallel
fast-learning teams were less experienced than those on the slow- with appreciation of the importance of the system.
learning teams but more willing to accept input from the rest of Another example is the Veterans Affairs National Surgical
the team. Quality Improvement Project (NSQIP),96 which consists of com-
Communication and teamwork are also important in the emer- parative, site-specific, and outcomes-based annual reports; peri-
gency department. One study reported an average of 8.8 team- odic assessment of performance; self-assessment tools; struc-
work failures per malpractice incident, with more than half of the tured site visits; and dissemination of best practices. After the
deaths and permanent disabilities judged to be avoidable.85 inception of data collection, 30-day mortality after major proce-
The key message is that errors frequently are a product of the dures decreased by 27% and 30-day morbidity by 45%. The
context in which they occur. It is tempting to assume that a few NSQIP also identified risk factors for prolonged length of stay
“bad apples” are responsible for most safety and quality prob- after major elective surgery; the most important of these were
lems. In reality, however, bad apples are relatively few, and they intraoperative processes of care and postoperative adverse
account for only a small percentage of medical errors.To achieve events.97 Other notable findings of the project were (1) that for a
significant overall improvements in quality, all physicians will number of common procedures, there were no statistically sig-
have to make efforts to improve the context in which patient care nificant associations between procedure or specialty volume and
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
CP Elements of Contemporary Practice 3 Patient Safety in Surgical Care: A Systems Approach — 7
30-day mortality and (2) that savings from improved surgical emphasis on evidence-based data might lead to skewed prioriti-
care far exceeded investment in the project.98 The NSQIP is now zation of safety measures and thus might prevent relatively few
expanding into academic medical centers with the aim of achiev- adverse events.105
ing comparable results there. Finally, one might focus on an area where there is unexplained
The conspicuous success of these large-scale examples should variation in a relevant outcome measure. Such variation might
not obscure the fact that most successful efforts have been on a exist in reference to either an internal or an external benchmark
smaller scale in single institutions.77,99 Thus, individual efforts at (the latter being preferable).49
quality improvement are not incidental but essential. An area for evaluation having been identified, the second step
is to identify the relevant subsystems and all of their components.
This can be challenging, particularly with complex systems. It is
Identifying Systems and System Failures advisable to start by assembling a team whose members repre-
The intensive systematic investigation of quality problems is sent all the possible components. Being inclusive rather than
known as root cause analysis (RCA).The first step in such analy- exclusive minimizes the chances of missing latent errors; it also,
sis is to identify the specific area to be studied. One approach is at least potentially, maximizes the number of possible solutions.
to focus on an area of recurring concern (e.g., habitual misuse of The next step is to determine the appropriate data source.
medical devices) or on the result of a particular critical incident Medical-record audits yield far greater detail than claims data do,
that should never have happened or must never happen again. but such audits are expensive, labor-intensive, and time-consum-
Both the JCAHO and the NQF have identified some of these ing. Moreover, the information the records contain on environ-
“never” events and suggested methods for avoiding them; the ment or behavior may be irrelevant or even contradictory.
NQF has also drafted additional proposals suitable for evidence- Screening criteria can help identify and reduce some of these
based practices. Another approach is to monitor an area where problems.106 Use of administrative data can help avoid many of
there is no immediate concern but where a recent change in pol- the shortcomings of medical-record review, but such data often
icy or equipment might introduce unanticipated problems. A use- lack the requisite accuracy. In either type of analysis, it is impor-
ful source for specific topics is the online journal created by the tant to remember that the process is evolutionary: it is rare that
Agency for Healthcare Research and Quality, AHRQ WebM&M one starts with a perfect set of measures.
(www.webmm.ahrq.gov).This free site includes expert analysis of It may be difficult to generate interest in analyses of a critical
medical errors in five specialty areas (including surgery), as well incident whose causes are so unusual that they are unlikely ever
as interactive learning modules on patient safety. to combine in the same way again in a given institution. Although
In the absence of a specific safety or quality concern, it may be the findings from such an analysis might seem to be of little use,
worthwhile to focus on an area where quality-improvement the incident might occur frequently enough at a regional or
efforts are likely to be fruitful—for instance, patient notification national level to make the analysis worthwhile. Thus, it is impor-
systems,77 patient safety systems,100 analyses of system failures in tant to tabulate such seemingly rare incidents (including near
laparoscopic surgery,101 or analyses of medical microsystems.102 misses) even if there is little direct or immediate institutional ben-
Critical analyses of evidence-based practices identified 11 surgi- efit. Besides their potential value in larger contexts, such data
cally relevant quality-improvement practices for which the data might help the institution predict, and thereby avoid, other forms
are strong enough to support more widespread implementation of errors (especially latent ones) and system failures. The strate-
[see Table 4].103,104 It has been argued, however, that exclusive gy of making potential adverse consequences of latent errors vis-
ible to those who manage and operate similar systems is the basis
of the highly successful Aviation Safety Reporting System.58
Some industries have modified RCA to meet particular needs,
Table 4 Surgically Relevant Quality- including health care.67,73 A manual for RCA use in patient care
Improvement Practices Appropriate is available through the JCAHO, and various centers and hospi-
for Widespread Implementation103 tals have reported on RCA use.107,108 RCA can be automated,109
but the potential advantages of automation may be offset by
Appropriate use of prophylaxis to prevent venous thromboembolism in dependence on the developer’s interpretation of the risk reduc-
patients at risk tion process or by the factors identified as the principal event.
Use of perioperative beta blockers in appropriate patients to prevent
perioperative morbidity and mortality
Use of maximum sterile barriers while placing central venous catheters General Techniques for Safety Improvement
to prevent infection
Appropriate use of antibiotic prophylaxis to prevent postoperative infec- Many safety-improvement techniques derived from nonmed-
tions ical systems have been successfully applied to medical systems
Requesting that patients recall and state what they have been told dur- [see Table 5].110,111 Other successful strategies include prioritiza-
ing the informed consent process
Continuous aspiration of subglottic secretions to prevent ventilator-
tion of tasks, distribution of the work load over time or resources,
associated pneumonia changing the nature of the task, monitoring and checking all
Use of pressure-relieving bedding materials to prevent pressure ulcers available data, effective leadership, open communication, mobi-
Use of real-time ultrasound guidance during central line placement to lization and use of all available resources, and team building.5
prevent complications The general idea is to redesign the problem space to reduce the
Patient self-management for warfarin to achieve appropriate outpatient cognitive work load.73,112
anticoagulation and prevent complications
Appropriate provision of nutrition, with particular emphasis on early
A key step in improving patient safety is the establishment of a
enteral nutrition in critically ill and surgical patients safety culture throughout the workplace. An appropriate culture
Use of antibiotic-impregnated central venous catheters to prevent views errors as they are viewed in control theory—namely, as sig-
catheter-related infections nals for needed changes. The focus should be on learning rather
than on accountability. If the team or organization is designed to
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
CP Elements of Contemporary Practice 3 Patient Safety in Surgical Care: A Systems Approach — 8
The current system of professional liability is frequently cited it is by no means evident that improving quality would cost more.
as an obstacle to quality improvement. Unfortunately, there is lit- Correcting underuse might increase costs, but such increases
tle incentive for change among many of the vested interests might well be outweighed by savings from correcting overuse and
involved. The many millions of dollars spent on public advertis- misuse. Given that current market approaches to health care
ing and political lobbying are likely to produce little change and have yet to contain costs, it would seem appropriate to at least
could be better spent in direct efforts to improve safety. No-fault attempt quality improvement before resorting to rationing.
compensation, no-fault reporting systems, and a program of Other economic considerations also factor into the lack of a
research have been proposed as alternatives,123,124 but all of these coherent business case for quality improvement. For instance,
proposals appear to have shortcomings.125 Moreover, patients’ sophisticated medical information systems are a necessity today;
loss of trust in many health care providers has allowed lawyers to however, such systems often remain in a relatively primitive state
gain leverage with the argument that they act on behalf of the “lit- because the fear of technical obsolescence makes buyers reluc-
tle guy.” tant to capitalize new systems.Thus, while potentially usable data
Many physicians believe that for significant improvements in accumulate, the ability to extract meaningful information may
quality to be achieved, a major reform of the professional liabili- deteriorate, making it more difficult and costly to define and
ty system is essential. Certainly, tort reform is necessary, but the implement evidence-based practice.
real prerequisite for better identification and management of sys-
tem failures is increased protection for privileged discussion of
such failures.122 Indeed, the Quality Interagency Coordination Future Implementation of Quality-Improvement Efforts
Task Force argues that RCAs undertaken to determine the inter- Given that quality improvement is both necessary and possi-
nal shortcomings of hospital care systems should not be subject ble, the question then becomes, who should spearhead this
to discovery in litigation and that appropriate legislation should process? Although consumers, purchasers, government, insurers,
be enacted in conjunction with or before the implementation of academic medicine, organized medicine, and health care
any reporting systems.31 The IOM supports a larger federal role providers all hold stakes in the process, it is physicians, with their
in these efforts. history of patient advocacy and scientific innovation, who are
The importance of liability reform notwithstanding, the issues best situated to provide the needed leadership.121,128 Such advo-
involved in enhancing safety and quality are more involved than cacy and innovation are a primary basis of the trust placed in the
can be addressed solely by changes in the liability system. For medical profession; to decline the challenge to improve health
instance, safety and quality problems are known to exist in care quality may seriously undermine this trust. When trust is
nations where professional liability is not an issue. In addition, it forfeited, the consequences can be dire, as the recent history of
is clear that physicians still tend to act defensively even in a no- the accounting industry illustrates.
fault liability system. Minimizing such defensiveness requires Excellent examples of physician-led efforts at quality improve-
that greater emphasis be placed on measurement for improve- ment exist, but they remain relatively isolated. Unless physicians
ment than on measurement for judgment.126,127 act to expand such efforts significantly, groups outside the pro-
Fortunately, there appears to be a growing sense that open dis- fession are likely to fill the void and possibly close the window of
cussion of medical errors is appropriate.60 Moreover, it seems opportunity for physician leadership. For instance, the Leapfrog
that such open communication may both reduce the probability Group (http://www.leapfroggroup.org), which represents more
of legal action and enhance public confidence in providers. than 26 million Americans, has already conducted hospital sur-
Nevertheless, some hospitals continue to separate risk manage- veys regarding computerized drug orders, ICU physician
ment from quality-assurance issues, to the detriment of both.128 staffing, coronary artery bypass surgery, coronary angioplasty,
Building a strong business case for quality improvement is abdominal aortic aneurysm repair, carotid endarterectomy,
complicated because even when there is good evidence that esophageal cancer surgery, high-risk obstetrics, and neonatal crit-
improving quality is cost-effective, the parties involved may dis- ical care, with a particular eye to identifying preventable adverse
agree on who should be rewarded and what the reward should events and evaluating the relation between volume and outcome.
be.119,120,129 Thus, if physician-related quality improvements One potential policy implication of these findings is that health
financially benefit a managed care company rather than a physi- care purchasers might adopt policies that transfer patients need-
cian, physicians might have little incentive to implement them— ing a particular procedure to high-volume providers with demon-
or even some incentive not to. Accordingly, it would seem sensi- strated good outcomes.132 Such policies might affect the overall
ble to focus initial quality-improvement efforts on areas where distribution of health care services and unfairly penalize low-vol-
the various interests are aligned.130 Even then, however, caution ume, high-quality providers, while teaching us little or nothing
is needed. For example, one study found that 24% of physicians about precisely which system components are relevant to
faced incentives derived from patient-satisfaction surveys, 19% improved outcome. The data on volume-outcome relations are
faced incentives derived from quality-of-care measures, and 14% intriguing, but many of the studies done to date have major
faced incentives derived from profiling based on use of medical methodological problems.68-70,102 Moreover, the majority of
resources.131 Patient satisfaction is important from the perspec- patients and physicians are not convinced that such regionaliza-
tive of continuity of care, but it is not clear how improved patient tion would be effective.2 For now, at least, it seems premature to
satisfaction alone might address problems of overuse and misuse. adopt such a policy.
Some have suggested that aggressive quality-improvement For any successful improvement in patient safety, an effective
efforts might make health care costs more difficult to control. It reporting system is vital. It is generally agreed that such systems
must be acknowledged, however, that to date, neither voluntary should be being nonpunitive and strictly confidential (if not
action by the health care industry, managed care, nor market anonymous).133 There is some debate, however, as to whether
competition appears to have achieved such control. For the most they should be voluntary or mandatory. On one hand, voluntary
part, the emphasis has been on managing cost rather than reduc- reporting has a high inaccuracy rate even when mandated by
ing waste.Yet waste is essentially a synonym for poor quality, and state or federal regulations. On the other hand, many surgeons
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
CP Elements of Contemporary Practice 3 Patient Safety in Surgical Care: A Systems Approach — 10
believe that mandatory reporting may increase the pressure to tendencies in the presence of uncertainty, residents (like pilots)
conceal errors rather than analyze them; that it is unworkable in may develop better responses to underspecified situations.
the current legal system; and that it may result not in construc- Residents should also be monitored to ensure that they learn to
tive error-reducing solutions but merely in more punishment or assess and address knowledge deficits as well as learn healthy
censure.134 habits in responding to errors. In this way, the learning curve can
There is also some debate as to whether patient-safety efforts be made less painful for all concerned.140
should (at least initially) focus on medical injuries or on medical
errors.135,136 An approach focusing on injuries recognizes the dif-
ficulty of identifying medical errors and is based on a public Conclusion
health improvement model that has proved useful in addressing Error in medicine is a dauntingly complex topic, and the
other types of injuries; it also recognizes that most medical injuries progress made in reducing such errors has, in many cases, been
are not caused by negligence. Such an approach seems more com- disappointingly slow. Unfortunately, changing the traditional par-
patible with the current liability system and may help restore adigm is a far more complex task than the simplistic solutions
physicians’ stature as patient advocates. An approach focusing on often made by the popular media would suggest. A call for sur-
errors suggests that focusing on injuries diverts attention from geons to report results, issued roughly 100 years ago, was largely
cases where there is an underlying system flaw, with the result that ignored.141 At that time, however, the basic principles of human
the flaw is not corrected. Although this is probably true, the first performance and error were not as well understood as they now
approach is likely to achieve greater initial buy-in on the part of are, and the tools necessary for systems analysis did not exist.
physicians and thus may be a more pragmatic first step. It is crucial for all parties involved in health care to acknowledge
Successful change requires not only agreement that a change is that most medical errors are attributable to system flaws rather
necessary and desirable but also agreement on what the change than to incompetence or neglect. Moreover, it is important for
should be. In that regard, the aviation industry is frequently pro- physicians to lead the changes needed to make systems-based
posed as a model for health care. However, aviation safety is practice the norm. Support for such initiatives, if needed, will
enhanced by the availability of various monitors (e.g., flight data come from multiple sources, including patients, public and private
recorders) that supply information on aircraft position and flight sector purchasers, and specialty boards and societies.142 Making
conditions. A model applying these techniques to surgery has efforts to improve surgeon performance, patient safety, and the
been described,101 but independent confirmation of relevant fac- overall quality of surgical care not only is the right thing to do but
tors still seems impractical in most clinical surgical situations. also is in surgeons’ own best interests.9 There is little doubt that
Actually, surgery may be more akin to the maritime industry, in performance assessment will increase; surgeons who do not assess
which the ship captain makes judgments about circumstances their performance will be at a disadvantage to those who do.
that are difficult to verify, than it is to the aviation industry. If so, Part of what is at stake is physicians’ authority, in more than
it is probably relevant that the maritime industry has been less one sense of the word. Physicians do continue to enjoy unchal-
successful at safety improvement than the aviation industry has. lenged authority, in the sense of being conceded to possess spe-
In any case, there are many underutilized opportunities for qual- cialized knowledge. However, in the sense of being able to con-
ity improvement in health care, and the training lessons of avia- trol one’s destiny, physicians’ authority often seems to be slip-
tion, whereby pilots are forced to deal with unusual situations ping away into the hands of outside agencies. Much of the
that help reveal gaps or errors in their understanding, are one decline in the latter type of authority is a reflection of a decline
such opportunity. Even if the aviation model does not fully apply, in the public’s overall trust in the profession. If physicians turn
its level of success should remain a goal. down the opportunity to lead the necessary efforts to improve
Particular attention should be paid to incorporating current patient safety and quality of care, they may anticipate further
concepts of performance and error into surgical education.137 An erosion of public trust and further loss of their remaining auton-
optimal structure for such education might be an objective-based omy. The growing demand for accountability seems unstop-
curriculum that provides residents with defined skills, rules, and pable. If surgeons provide the requisite leadership now, their
knowledge.138,139 The blame-and-shame approach must be elimi- ability to control their destiny is likely to be enhanced rather than
nated from the learning atmosphere. Once made aware of their further diminished.
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and the safety of patients. N Engl J Med 347:1249, costs and lengths of stay and improving efficiency 119. Coye MJ: No Toyotas in health care: why medical
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© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 4 RISK STRATIFICATION — 1
4 RISK STRATIFICATION,
PREOPERATIVE TESTING, AND
OPERATIVE PLANNING
Cyrus J. Parsa, M.D., Andrew E. Luckey, M.D., Nicolas V. Christou, M.D., F.A.C.S., and Alden H. Harken, M.D., F.A.C.S.
Class I Normal, healthy patient An inguinal hernia in a fit patient or a fibroid uterus in a healthy woman
Morbid obesity, severely limiting heart disease, angina pectoris, healed myocardial
Patient with severe systemic disease that limits activity
Class III infarction, insulin-dependent diabetes, moderate to severe pulmonary
but is not incapacitating
insufficiency
Moribund patient not expected to survive 24 hr without Ruptured aortic aneurysm with profound shock, massive pulmonary embolus,
Class V
an operation major cerebral trauma with increasing intracranial pressure
surgical site infection. Numerous mechanisms contribute to the such tests are ordered, there is a 50% probability of an abnormal
deleterious effects of smoking: smoking inhibits clearance of pul- test result.15 When an SMA-20 is ordered, the probability of an
monary secretions, adversely affects the immune system and col- abnormal test result is quite high. Moreover, although these
lagen production, and contributes to wound hypoxia (thereby abnormalities are reported, they rarely alter the physician’s behav-
increasing susceptibility to infection).11 Some studies have sug- ior or result in cancellation or postponement of the operation [see
gested that even passive smoking can reduce blood flow velocity Table 3].15 Accordingly, current practice is to a take a much more
in the coronary arteries of healthy young adults.12 selective approach to preoperative laboratory evaluation.
A 2002 trial demonstrated that preoperative smoking cessation
FACTORS AFFECTING CARDIAC RISK
reduced the incidence of postoperative complications from 52%
to 18%.10 A 2003 study reported similar results: patients who
stopped smoking 4 weeks before operation had significantly lower Previous and Current Cardiovascular Disease
postoperative wound infection rates than patients who continued In the United States, approximately 30% of the 27 million
to smoke up to the time of operation.11 Ideally, cessation of smok- patients scheduled to undergo anesthesia for surgical procedures
ing at least 4 to 6 weeks before operation is recommended. yearly are known to have risk factors for coronary artery disease
(CAD).8 Given that cardiovascular disease is the leading cause of
Alcohol Abuse death in the United States,9 it is not altogether surprising that
The effects of chronic alcohol abuse on perioperative risk are cardiovascular factors account for the greatest proportion of
not as well studied as those of smoking. Alcohol abuse has been operative risk. Significant cardiovascular risk factors include
defined as the consumption of at least five drinks (containing angina pectoris, dyspnea and evidence of right-side or left-side
more than 60 g of ethanol) daily for several months or years.13 heart failure, any cardiac rhythm other than sinus rhythm, more
(These numbers are probably appropriate for 70 kg men but may than five ectopic ventricular beats per minute, aortic stenosis
be modified in other populations.) The pathogenic mechanism is with left ventricular hypertrophy, mitral regurgitation, and previ-
certainly multifactorial but is postulated to involve ethanol-medi- ous MI. An estimated 1 million patients scheduled to undergo
ated suppression of the immune system; this immune suppression elective noncardiac surgical procedures experience a periopera-
is reversible, at least during abstinence in nonsurgical patients. tive complication each year in the United States, and another
Other deleterious effects of chronic alcohol ingestion include
alcoholic cardiomyopathy, decreased platelet count and function,
reduced fibrinogen level, and compromised wound healing. Table 2 Minimal Preoperative Test Requirements*
Various alcohol abstinence periods, ranging from 1 week to 3
months, have been reported to decrease these adverse effects.14
at the Mayo Clinic7
Long-term abuse of alcohol is often associated with central
nervous system impairment and hepatic dysfunction, as well as Age (yr) Tests Required
malnutrition. Alcohol abusers, even those who exhibit no overt < 40 None
alcohol-related organ dysfunction, experience greater morbidity
than nonabusers and exhibit longer recovery times.14 40–59 Electrocardiography, measurement of creatinine and
glucose
PREOPERATIVE TESTING
≥ 60 Complete blood cell count, electrocardiography,
It was once generally agreed that surgical patients should chest roentgenography, measurement of creati-
nine and glucose
undergo a series of routine screening tests before operation. This
approach has proved not only unhelpful but also confusing and *In addition, the following guidelines apply. (1) A complete blood cell count is indicated in
all patients who undergo blood typing and who are crossmatched. (2) Measurement of
expensive. Perhaps predictably, it has been observed that the potassium is indicated in patients taking diuretics or undergoing bowel preparation.
more tests are ordered, the more abnormal values are obtained. (3) Chest roentgenography is indicated in patients with a history of cardiac or pulmonary
disease or with recent respiratory symptoms. (4) A history of cigarette smoking in patients
On the reasonable assumption that a test performed in a healthy older than 40 years who are scheduled for an upper abdominal or thoracic surgical proce-
person will yield an abnormal result 5% of the time, when 10 dure is an indication for spirometry (forced vital capacity).
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 4 RISK STRATIFICATION — 3
Table 3 Effect of Abnormal Screening Test Results patients older than 50 years, but it is 3.1% in comparable vascu-
on Physician Behavior15 lar surgery patients, in whom the prevalence of asymptomatic
CAD is predictably high.17
Abnormal Test Resulting Management
Screening Test Results (%) Change (%) Functional Capacity
Hemoglobin level 5 (for < 10 g/dl; Abnormal result rarely led to Patients who are able to exercise on a regular basis without lim-
< 9 g/dl was rare) change itations generally have sufficient cardiovascular reserve to allow
Abnormal result rarely led to them to withstand stressful operations. Those with limited exer-
Total leukocyte count <1
change cise capacity often have poor cardiovascular reserve, which may
Bleeding time 3.8
become manifest after noncardiac surgery. Poor functional status
(and exercise capacity) is associated with worse short- and long-
Coagulation time 4.8 Abnormal result rarely led to
change term outcomes in patients undergoing noncardiac operations, as
Partial thromboplastin 15.6 well as with shorter nonoperative lifespans.18
time
Functional capacity is readily expressed in terms of metabolic
Chest x-ray 2.5–3.7 2.1 equivalents (METs). One MET is equivalent to the energy
ECG 4.6–31.7 0–2.2
expended (or the oxygen used) in sitting and reading (3.5 ml
O2/kg/min). For a 70 kg person, one MET amounts to 245 ml
1.4 O2/min. Multiples of the baseline MET value can then be used to
Sodium, potassium Abnormal result rarely led to quantify the aerobic demands posed by specific activities, as in
2.5
change
5.2 the Duke Activity Status Index [see Table 4].19
Energy expenditures for activities such as eating, dressing, walk-
Urinalysis 1–34.1 0.1–2.8 ing around the house, and dishwashing range from 1 to 4 METs.
Climbing a flight of stairs, walking on level ground at 6.4 km/hr,
running a short distance, scrubbing floors, and playing golf repre-
50,000 have a perioperative MI. The risk of intraoperative or sent expenditures of 4 to 10 METs. Strenuous sports (e.g., swim-
postoperative MI is much higher in patients who have suffered ming, singles tennis, and football) often demand expenditures
heart muscle damage within the preceding 6 months. In large ret- exceeding 10 METs. It has been established that perioperative
rospective reviews, 37% of patients experienced reinfarction cardiac and long-term risks are increased in patients unable to
when they underwent operation within 3 months of an infarction; meet the 4-MET demand associated with most normal daily
however, the incidence of reinfarction decreased to 16% when activities. Thus, the surgeon’s assessment of the patient’s exercise
the operation was performed between 3 and 6 months after the capacity is a practical, inexpensive, and gratifyingly accurate pre-
first infarction and to 4.5% when the operation was performed dictor of that patient’s ability to tolerate a surgical stress.
more than 6 months afterward.16 The estimated economic impact
of these complications is $20 billion annually.8 Type of Surgical Procedure
There is currently a trend toward more aggressive surgery in The procedure-specific cardiac risk associated with a noncar-
sicker patients, among whom the prevalence of ischemic heart diac operation is related almost exclusively to the duration and
disease is increasing. As a result, there is a growing need for expert intensity of the myocardial stressors involved. Procedure-specific
guidance in the preoperative evaluation of patients who are risk for noncardiac surgery can be classified as high, intermediate,
known to have or to be at risk for CAD. Although the literature is or low [see Table 5].20 High-risk procedures include major emer-
replete with suggested management algorithms, no firm consen- gency surgery, particularly in the elderly; aortic and other major
sus has been reached. Much of the continuing controversy is vascular operations; peripheral vascular surgery; and any opera-
related to the obvious difficulties of conducting large randomized, tion that is expected to be prolonged and to be associated with
controlled clinical trials on this topic, as well as to the relatively large fluid shifts or substantial blood loss. Intermediate-risk pro-
low incidence of perioperative cardiac events (< 10%). The inci- cedures include intraperitoneal and intrathoracic operations,
dence of postoperative MI is 0.7% in male general surgery carotid endarterectomy, head and neck procedures, orthopedic
surgery, and prostate operations. Low-risk procedures include
Table 4 MET Scores for Selected Activities endoscopic and superficial procedures, cataract operations, and
(Duke Activity Status Index) breast surgery.
Despite the prevalence of cardiovascular disease, many patients
presenting for noncardiac surgery have never received a meticu-
MET Score Activity
lous (or even a superficial) cardiovascular evaluation. Further-
Light activities of daily home life (e.g., eating, getting more, the proposed operations themselves may create sustained
1–4 dressed, using the toilet, cooking, washing dishes) cardiovascular stresses that are quite beyond what patients may
Walking 1–2 blocks on level ground at 2–3 mph
have experienced in daily life. It is therefore crucial for the car-
Climbing one flight of stairs diovascular consultant to identify underlying conditions and to
Walking up a hill evaluate and treat them using cost-effective and evidence-based
Walking on level ground at rate > 4 mph
5–9 Running a short distance guidelines, thereby benefiting patients both in the short term and
More strenuous household chores (e.g., scrubbing floors, in the long term.The goal of the consultation is to determine the
moving furniture) most appropriate testing and treatment strategies for optimizing
Moderate recreational activities (e.g., hiking, dancing, golf)
patient care while avoiding unnecessary testing.
Strenuous athletic activities (e.g., tennis, running, basketball,
> 10 swimming) Specialized Testing
Heavy professional work
Recognition of the limitations of routine testing [see Preopera-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 4 RISK STRATIFICATION — 4
at high ischemic risk for whom consideration of coronary angiog- ed only when invasive delineation of CAD would be indicated in
raphy and possible revascularization was appropriate.34 Patients the absence of the noncardiac surgical problem.
at moderate ischemic risk (fewer than four segments) were able
to proceed with surgery under beta-blockade therapy. In a study ACC/AHA Guidelines
of 136 patients undergoing vascular surgery, all 15 postoperative Comprehensive identification of patients who are at substantial
complications occurred in the 35 patients who had a positive risk for perioperative cardiac morbidity remains a difficult task.
response to dobutamine stress echocardiography.35 Other investi- As noted [see Preoperative Testing, above], routine preoperative
gators subsequently confirmed that stress echocardiography testing has significant inherent limitations. An evaluation strategy
using either dobutamine or dipyridamole offered useful prognos- that avoids these limitations has been proposed by combined task
tic information that facilitated the development of treatment forces from the American College of Cardiology and the AHA.39
algorithms.8 This strategy bases diagnostic and therapeutic approaches on
clinical screening for disease state and functional capacity. It
Thallium scintigraphy Radionuclide scanning with thalli- employs specialized testing conservatively—that is, only when the
um-201 after exercise or pharmacologically induced stress is a additional information provided by the proposed test is likely to
useful method of identifying zones of potential ischemia; provoca- have an impact on outcome. The ACC/AHA strategy has proved
tive coronary perfusion imaging studies provide a great deal of efficient and cost-effective in vascular surgery patients.
valuable data. The highest-risk patients undergoing noncardiac The ACC/AHA guidelines take the form of an eight-step algo-
surgery, however, are those with exercise limitations, who typical- rithm for patient risk stratification and subsequent determination
ly have peripheral vascular, orthopedic, or neurologic disease. As of appropriate cardiac evaluation; this algorithm is available on
a result, various pharmacologic methods of modeling the effects the ACC’s web site (www.acc.org/clinical/guidelines/perio/update/
of exercise have been developed, including those that induce fig1.htm). Steps 1 through 3 of the algorithm are concerned with
coronary vasodilation (using dipyridamole or adenosine) or assessing the urgency of the operation and determining whether
increase heart work (using dobutamine or arbutamine).The most a cardiac evaluation or intervention has recently been performed.
extensively investigated of these methods is dipyridamole thalli- If there has been no recent cardiac evaluation or intervention and
um scintigraphy.36 the operation is elective, steps 4 through 7 are activated. These
In the mid-1980s, the usefulness of scintigraphy was assessed steps are concerned with identifying clinical predictors of cardiac
in vascular surgical patients. It was found that nearly all periop- risk, assessing functional status, and estimating the risk of the
erative adverse events occurred in patients with redistribution proposed operation. Specifically, the surgeon must determine
defects; few, if any, occurred in patients without preoperative whether the patient has a major clinical predictor of cardiac risk.
redistribution abnormalities. These findings led to widespread As defined by the ACC/AHA task force,39 major clinical predic-
use of dipyridamole thallium, generating more than $500 million tors include unstable coronary syndrome, decompensated CHF,
in national health care costs annually.8 In the early 1990s, inves- significant arrhythmias, and severe valvular disease. Intermediate
tigators challenged previous findings in a prospective, triple- clinical predictors include mild angina pectoris, diabetes mellitus,
blinded study that assessed both adverse outcome and perioper- chronic renal failure with serum creatinine levels higher than 2
ative MI (by means of continuous ECG and transesophageal mg/dl, and a history of MI or CHF. Poor functional status is
echocardiography).37 In contrast to previous reports, no associa- defined as inability to perform activities involving energy expen-
tion between redistribution defects and perioperative ischemia or ditures greater than 4 METs. Step 8 of the algorithm—noninva-
adverse events was noted, and the majority of episodes occurred sive cardiac testing for further determination of cardiac risk—is
in patients without redistribution defects. These findings pro- employed in accordance with the information gained from steps
voked a more extensive study involving 457 consecutive unselect- 1 through 7 [see Table 6].39 The purpose is to identify patients who
ed patients undergoing abdominal aortic surgery.29 The investiga- need further cardiac evaluation and aggressive cardiac stabiliza-
tors found that thallium redistribution was not significantly tion in the perioperative period.
associated with perioperative MI, prolonged ischemia, or other
FACTORS AFFECTING NONCARDIAC RISK
adverse events. The current consensus is that routine thallium
scintigraphy has no real screening value when applied to a large
unselected vascular or nonvascular population or to patients Respiratory Status
already classified clinically as low- or high-risk candidates for Testing of pulmonary function may be indicated on the basis
noncardiac surgery. of physical findings (e.g. cough, wheezing, dyspnea on exertion,
rales or rhonchi) or a history of cigarette smoking. Limited pul-
Coronary angiography Coronary angiography is an inva- monary reserve may be revealed by observing the patient for dys-
sive procedure that even today is associated with a mortality of pnea while he or she is climbing one or two flights of stairs.
0.01% to 0.05% and a morbidity rate of 0.03% to 0.25%.38 It is Forced expiratory volume can be directly measured with a hand-
indicated only for patients who have unstable coronary syn- held spirometer whenever there is a question of possible pul-
dromes, those who are undergoing intermediate- or high-risk monary compromise.40 Once identified, patients with pulmonary
noncardiac procedures after equivocal noninvasive test results, insufficiency [see 8:4 Pulmonary Insufficiency] may benefit from a
and those who may have an indication for elective coronary revas- preoperative program that includes smoking cessation,9 use of
cularization.23 Although antecedent myocardial revascularization bronchodilators, physiotherapy, and specific antibiotics.
appears to reduce the risk associated with subsequent noncardiac
surgery,8 the efficacy of elective preoperative revascularization Nutritional Status
remains controversial.This latter measure probably is not benefi- In 1936, Studley demonstrated that weight loss was a robust
cial; in fact, the incidence of complications during or after revas- predictor of operative risk.41 Loss of more that 15% of body
cularization is often comparable to that during or after the non- weight during the previous 6 months is associated with an
cardiac surgical procedure itself. Routine angiography is indicat- increased incidence of postoperative complications, including
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 4 RISK STRATIFICATION — 6
Table 6 Predictors of Cardiac Risk for Noncardiac ade, or by administration of stress-dose steroids [see 8:10 Endo-
Surgical Procedures39 crine Problems].
Uncontrolled hypertension
Diabetes mellitus As of 2003, 10.9 million persons were
Family history of CAD known to have diabetes mellitus in the United States, and anoth-
Hypercholesterolemia er 5.7 million were estimated to be harboring the disease without
Smoking history being aware of it.9 In diabetic patients, the risk of CAD is two to
Minor risk factors ECG abnormalities (dysrhythmia, bundle branch
(probable CAD) block, LVH)
four times higher than it is in the general population.47 Diabetic
Peripheral vascular disease autonomic neuropathy is associated with an impaired vasodilator
MI > 3 mo previously, asymptomatic without treatment response of coronary resistance vessels to increased sympathetic
CABG or PTCA > 3 mo but < 6 yr previously, without stimulation.48 Moreover, diabetes is frequently associated with
anginal symptoms or anginal medications
silent ischemia; if detected by Holter monitoring, it has a positive
Angina class I or II predictive value of 35% for perioperative cardiac events.49 The
Compensated or previous heart failure, ejection frac- incidence of ischemic events in asymptomatic diabetic patients is
tion < 0.35
Physiologic age > 70 yr
similar to that in patients with stable CAD.50 Accordingly, clini-
Intermediate risk fac- Diabetes mellitus cians should lower their threshold for cardiac testing when man-
tors (stable CAD) Ventricular arrhythmia aging diabetic patients.
History of perioperative ischemia Asymptomatic diabetic patients with two or more cardiac risk
Absence of symptoms after infarction with maximal
therapy
factors should be evaluated by means of stress testing if their
CABG or PTCA > 6 wk but < 3 mo previously, or functional capacity is low or if they are to undergo a vascular pro-
> 6 yr previously, or with antianginal therapy cedure or any major operation. Only those diabetics who have
MI > 6 wk but < 3 mo previously good functional capacity and are undergoing minor or interme-
Clinical ischemia plus malignant arrhythmia diate-risk procedures should proceed directly to operation.This is
Clinical ischemia plus congestive heart failure a more aggressive interventional approach than is followed for the
Major risk factors Residual ischemia after MI general population. It should be kept in mind that, common
(unstable CAD) Angina class III or IV
assumptions notwithstanding, perioperative beta blockade is not
CABG or PTCA within past 6 wk
MI within past 6 wk precluded in diabetic patients and can offer substantial protection
against ischemia. A 2003 study reported a 50% reduction in car-
CABG—coronary artery bypass grafting CAD—coronary artery disease LVH—left
ventricular hypertrophy MI—myocardial infarction PTCA—percutaneous transluminal diovascular and microvascular complications in diabetic patients
coronary angioplasty who underwent intensive glucose control, exercise therapy, and
preventive medical management.51
lastogram is an effective screening tool in patients with suspected experience. Classic studies have shown that well-informed
abnormalities. Prothrombin time, partial thromboplastin time, and patients require less analgesia in the postoperative period and
platelet count constitute sufficient preoperative testing in a patient experience significantly less pain than less well informed
with a suspected bleeding problem. Antithrombin, protein C, pro- patients.59 Subsequent investigations have supported these con-
tein S, and factor V Leiden levels constitute sufficient preoperative clusions. Perioperative information facilitates coping, reduces pre-
screening in a patient with suspected hypercoagulable disease. operative anxiety, and may enhance postoperative recovery.60
Such information can be provided orally or in the form of book-
lets or videotapes.
Assessment of Physical and Mental Happiness
Calculation of the risks and benefits of surgical (or, indeed,
any) therapy has become a much more complex process than it Reduction of Perioperative Cardiac Risk
once was. Simple assessment of survival or basic quality of life is A number of trials have indicated that perioperative beta block-
no longer sufficient: more sophisticated measures are required. ade can reduce the risk of perioperative cardiac complications in
Generic instruments now exist that are aimed at evaluating a patients with known or suspected CAD who are undergoing major
patient’s level of productive assimilation into his or her environ- noncardiac procedures.61-63 One prospective study randomly
ment. The Short Form–36 (SF-36) is designed to assess physical assigned 200 noncardiac surgical patients to receive either atenolol
and mental happiness in eight domains of health: (1) physical or placebo.64 Atenolol was administered intravenously before and
function (10 items); (2) physical role limitations (4 items); (3) after surgery, then continued orally until hospital discharge. Of the
bodily pain (2 items); (4) vitality (4 items); (5) general health per- original 200 patients, 194 survived hospitalization, and 192 were
ceptions (5 items); (6) emotional role limitations (3 items); (7) followed for 2 years. Mortality, even after hospital discharge and
social function (2 items); and (8) mental health (5 items). The discontinuance of beta blockade, was significantly lower in
underlying assumption is that mental and physical functions are atenolol-treated patients than in control subjects both at 6 months
readily separable aspects of health, but of course, this is not real- and at 2 years. These findings, though somewhat puzzling, have
ly the case.52,53 Predictably, patients’ responses on the SF-36 tend sparked considerable enthusiasm for perioperative beta blockade.
to be strongly influenced by the type of operation they had. For Some clinicians, however, have expressed reservations.63
example, a patient who has undergone total hip arthroplasty will In 1999, a Dutch echocardiographic cardiac risk evaluation
feel better immediately; one who has undergone lung resection for study group published a prospective, randomized, multicenter
cancer may not feel particularly well immediately afterward but, study of perioperative beta blockade in extremely high risk vascu-
ideally, will be relieved of a cancer scare; and one who has under- lar surgical patients.61 Of the 1,351 patients screened, 846 exhib-
gone abdominal aneurysm repair will feel worse immediately, ited cardiac risk factors that would have made them moderate- or
though conscious of an improved life expectancy. Less pre- high-risk patients according to either Goldman’s or Lee’s classifi-
dictably, however, patients’ perceptions of their own surgical out- cation system. Of these 846 patients, 173 had positive results on
comes are equally strongly influenced by when in the postopera- dobutamine stress echocardiography, and 112 of the 173 agreed
tive period the questions are asked.54 The answers obtained 6 to undergo randomization. Of these 112 patients, 59 were ran-
months after operation will differ from those obtained at 1 month domly assigned to perioperative beta blockade with bisoprolol,
or 12 months. If the questions are asked several times, the answers and 53 served as control subjects. Of the patients undergoing beta
change; indeed, the mere asking of the question may change the blockade, 3.4% died of cardiac causes or experienced a nonfatal
answer.55 For an outcome measure to be effective by current stan- MI, compared with 34% of the control subjects. Admittedly, this
dards, it must be not only feasible, valid, and reliable but also sen- is a study of very high risk patients; nonetheless, the conclusions
sitive to change.56,57 are striking, and it is tempting to extrapolate them to lower-risk
An outcome tool that has been further refined to focus specifi- noncardiac surgical patients. In the human heart, alpha1-, beta1-,
cally on cardiovascular capacity and disease is the Specific Activ- and beta2-adrenergic receptors promote inotropy, chronotropy,
ity Scale (SAS). Unfortunately for assessment purposes, attempts myocyte apoptosis, and direct myocyte toxicity.63 Expanded use of
to use the SAS and the SF-36 simultaneously have yielded signif- beta-adrenergic receptor inhibition in the perioperative period has
icantly divergent results. Such results underscore the complexities been supported by several groups of investigators.65-68
of standardizing tests of ability, intelligence, and happiness.58 Prophylactic use of other agents (e.g., aspirin, alpha2-adrener-
Quality is subjective. Some patients are happy when they seem- gic agents, nitroglycerin, and calcium channel blockers) has been
ingly have every reason to be unhappy; others are unhappy when studied, but at present, the data are insufficient to support routine
they seemingly have every reason to be happy. Scientific tools for use of any of these.69,70 Risk reduction should focus on strategies
collectively examining psychosocial productivity in groups of for which there is good evidence (e.g., maintenance of normo-
patients may still be largely lacking, but this does not mean that thermia, avoidance of extreme anemia, control of postoperative
surgeons have no methods of evaluating and enhancing a given pain, and perioperative beta blockade). A stepwise approach to
patient’s prospects for comfort. Indeed, any surgeon whose con- preoperative assessment allows judicious use of both noninvasive
tribution to patient management stops with superb operative and invasive procedures while preserving a low rate of cardiac
technique, or even with exemplary perioperative care added to complications [see Figure 1].23
technique, is not making optimal use of his or her privileged posi-
tion. By incorporating a patient’s values into the anticipated out-
come, surgeons are uniquely positioned to achieve the best possi- Epidemiology of Surgical Risk
ble outcome-to-value ratios. In a 1999 prospective study, a team of VA investigators exam-
ined the outcomes of surgical procedures in an effort to identify
PATIENT EDUCATION
variables related to poor surgical results. Initial results were
Education of the patient about the postoperative care plan plays reported from 23,919 patients who underwent one of 11 noncar-
a major role in modifying his or her response to the operative diac operations performed by surgeons from five specialties (gen-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 4 RISK STRATIFICATION — 8
eral surgery, urology, orthopedic surgery, vascular surgery, and gies in terms of cost in relation to each QALY saved.73 Although
neurosurgery).71 The authors concluded that prolonged hospital the question this study was designed to answer was slightly differ-
stay could be related to advanced age, diminished functional sta- ent from what surgeons typically address before noncardiac
tus, and higher ASA class. Other preoperative patient characteris- surgery, several instructive findings emerged:
tics were associated with increased morbidity and mortality [see
1. For a 55-year-old man with typical chest pain, the incremental
Table 7].72
cost-effectiveness ratio for routine coronary angiography versus
exercise echocardiography was $36,400/QALY saved.
Changing Paradigms of Cost-effectiveness 2. For a 55-year-old man with atypical chest pain, the incremen-
tal cost-effectiveness ratio for exercise electrocardiography ver-
It is now clear that postoperative survival, by itself, is no longer
sus no testing was $57,700/QALY saved.
an adequate assay of surgical success. Risk must be stratified
3. The incremental cost-effectiveness ratio for exercise echocardio-
before operation, and the degree of risk must be evaluated in the
graphy versus stress electrocardiography was $41,900/QALY
light of both the quantity and the quality of life to be expected
saved.
after operation. Cost must then be appropriately factored in: a
modern health care system will want to know the cost of a risk- The literature makes it very clear, however, that none of the
stratified, quality-adjusted postoperative year of life. A 1999 study available diagnostic strategies are more cost-effective than com-
assessed the cost-effectiveness of various cardiac diagnostic strate- munication with the patient.
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© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 5 OUTPATIENT SURGERY — 1
5 OUTPATIENT SURGERY
Richard B. Reiling, M.D., F.A.C.S., and Daniel P. McKellar, M.D., F.A.C.S.
A safe and cost-effective approach to elective surgery begins with setting was accompanied by a transfer of all the measures
a careful history, a thorough physical examination, well-chosen designed to ensure patient safety, including peer review. However,
laboratory tests, and consultation as appropriate and proceeds to this same transfer has not occurred in the office-based setting,
selection of the optimal procedure, assessment of patient suit- where at least 15% of outpatient surgical procedures are current-
ability, and choice of the most appropriate site in which to per- ly being performed.5 There is a growing concern that better reg-
form the procedure. In what follows, we address these issues ulation is needed for office-based surgical units. Surgery con-
specifically as they pertain to outpatient surgery: from selection of ducted in office settings has been found to pose about a 10-fold
suitable patients and procedures to determination of appropriate higher risk of adverse incidents and death than surgery conduct-
outpatient settings in which to perform the procedures, to peri- ed in ambulatory centers.6
operative management (e.g., premedication, anesthesia, monitor- Certain relative contraindications to outpatient surgical proce-
ing, and immediate postoperative care), to discharge and postop- dures have been identified, but these vary depending on the
erative pain control. patient, the physician, and the setting [see Table 1].The surgeon is
Accumulating evidence indicates that outpatient surgery can responsible for detecting undiagnosed and unsuspected acute
offer significant advantages over inpatient surgery. For example, and chronic conditions before operation. The anesthesiologist
patients who undergo breast surgery with same-day dismissal are shares the responsibility for uncovering potential preoperative
not at a disadvantage; on the contrary, they report faster recovery problems if the patient will require complex anesthesia that must
and better psychological adjustment.1 Moreover, the pronounced be given by an anesthesiologist; otherwise, the surgeon is also
shift toward outpatient surgery has been accompanied by an responsible for this aspect of care. In addition, the surgical unit
equally impressive technological revolution, which has led to the plays a role in determining which types of patients can be treat-
development of operative approaches that require less postopera- ed. Likewise, these determinations should be made in the office-
tive care. based practice before undertaking any surgical intervention.This
is best accomplished in a well-thought-out governance plan.
Hospital-affiliated units or units in immediate proximity to a full-
Selection of Patients for Inpatient and Outpatient service hospital that have an agreement for rapid transfer are bet-
Procedures ter able to accept patients with more serious concomitant illness-
Just as inpatient and outpatient procedures must be carefully es than facilities physically separated from the acute care hospital.
selected with an eye to difficulty and severity of illness, so too Surgeons also tend to select certain apparently higher-risk
should patients be carefully selected. The following six questions patients for treatment in hospital outpatient or ambulatory surgi-
should be asked: cal units rather than in freestanding day surgical units, as reflect-
ed in the higher rate of admission for hospital-based units [see
1. Is the facility adequately equipped and appropriate for the
Tables 2 through 4].7
intended procedure, and are quality standards maintained?
Some reimbursement plans, including the Center for Medicare
2. Can the procedure routinely be performed safely without
and Medicaid Services (CMS), possess a curious feature by
hospital admission?
which patients are considered outpatients if they are discharged
3. Is the patient at risk for major complications if the opera-
from the facility within 24 hours. Obviously, an outpatient who
tion is performed in the facility?
4. Do concomitant or comorbid conditions present unaccept-
able risks in the intended setting?
5. Will the patient require any special instructions or psycho- Table 1—Relative Contraindications to
logical counseling before the operation?
6. Do the patient and the family understand their own obli- Outpatient Surgery
gations regarding postoperative care in an outpatient setting?
Procedures with an anticipated significant blood loss
Surgeons and anesthesiologists have gained an immense Procedures associated with significant postoperative pain
amount of experience in outpatient management of many diffi- Procedures necessitating extended postoperative I.V. therapy
cult procedures that were once considered to be best suited for ASA class IV (or III if the systemic disease is not under control, as with
more controlled inpatient environments. Procedures that were unstable angina, asthma, diabetes mellitus, and morbid obesity)
regarded as unsafe in an outpatient setting as late as the mid- Known coagulation problems, including the use of anticoagulants
1990s are now being performed in ambulatory centers, and there
Inadequate abillity or understanding on the part of caretakers with
is evidence that this shift has not increased patient risk.2-4 respect to requirements for postoperative care
Ambulatory centers are integrated with or based in hospitals, and
the transfer of surgical care from the inpatient to the ambulatory
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 5 OUTPATIENT SURGERY — 2
stays overnight is effectively an inpatient, even if the length of stay units according to level of service, in the same way as the
is less than 24 hours. Outpatient facilities exist that are physical- American College of Surgeons (ACS) has classified units accord-
ly separated from an inpatient hospital but that also can accept ing to type of surgery performed and level of anesthesia available,
patients for this 24-hour arrangement. Such freestanding facili- is a sensible one that is likely to be more fully developed and
ties must clearly ensure safety and quality in the unit to the same more widely applied in the coming years.
extent as facilities approved by the Joint Commission on Patient acceptance is critical in outpatient surgery for reasons
Accreditation of Healthcare Organizations (JCAHO). of safety and liability. If the patient or any responsible relative of
In addition, the concept of recovery care has been introduced the patient does not accept or is extremely critical of nonadmis-
for facilities that provide postoperative care. In this concept, facil- sion surgical care and cannot be easily assured of its advantages
ities are classified according to the defined length of stay (e.g., and safety, inpatient treatment is indicated, regardless of the pol-
extended recovery and 23-hour care).8 The idea of classifying icy of the third-party payor or other regulatory bodies. Certain
Class I Normal, healthy patient An inguinal hernia in a fit patient or a fibroid uterus in a healthy woman
Morbid obesity, severely limiting heart disease, angina pectoris, healed myocardial
Patient with severe systemic disease that limits activity
Class III infarction, insulin-dependent diabetes, moderate to severe pulmonary
but is not incapacitating
insufficiency
Moribund patient not expected to survive 24 hr without Ruptured aortic aneurysm with profound shock, massive pulmonary embolus,
Class V
an operation major cerebral trauma with increasing intracranial pressure
Emergency surgery—the suffix “E” is added to denote the poorer status of any patient in one of these five categories who is operated on in
Emergency (E)
an emergency
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 5 OUTPATIENT SURGERY — 3
Surgical Category
ASA
Class
1 2 3 4
complicating factors, such as substantial distance from the facili- sions are for problems related to the patient’s preoperative car-
ty, the lack of sufficient support at home, and the presence of sig- diovascular and respiratory status, but the major reason for
nificant comorbid illnesses, also call for inpatient treatment admission is still uncontrollable nausea and vomiting.4 Moreover,
regardless of the payor’s policy. It then becomes the responsibili- most complications are related to factors other than the setting of
ty of the surgeon to notify the third-party payor of these contin- the surgical procedure (outpatient or inpatient). Admission to the
gencies in a simple and nonconfrontational manner, as well as to hospital after ambulatory surgery because of urinary retention,
explain to the patient and family why it is necessary to deviate for example, is related to the use of general anesthesia, the age of
from the more usual outpatient approach for which the payor the patient, and the administration of more than 1,200 ml of I.V.
would more readily provide reimbursement. Efforts to coerce the fluids before, during, and after the operation.9
patient or the family to accept outpatient surgery not only engen- Patients in American Society of Anesthesiologists (ASA) class
der bad will between physician and patient but also tend to give III (or even class IV) [see Table 3] are appropriate candidates for
rise to more postoperative problems (either real or factitious). ambulatory surgery if their systemic diseases are medically stable
Third-party payors, for their part, must understand and accept and the intended procedure will be relatively short. A report on
that some patients, for whatever reason, will refuse nonadmission patient morbidity and mortality within 1 month after ambulatory
surgery. It is the responsibility of third-party payors and their cus- surgery showed only eight morbid events in over 10,500 ASA III
tomers (i.e., corporations or employers) to provide adequate patients and two deaths, both occurring in ASA II patients.2
information to those covered (i.e., employees and families) about
the advantages and safety of outpatient surgery. Such education Age
should be provided well before surgical intervention is sought or Extremes of age by themselves automatically increase the ASA
needed. Too often, the patient and the family are unaware of the classification from I to II. Even though age is not correlated with
payor’s guidelines. Finally, patients and their families must also hospital admission after ambulatory surgery, elderly patients often
realize the need for cost-effective care and be willing to play their have concomitant conditions that may have gone unrecognized but
part in achieving it. It is reassuring that patients and families are should have been brought to light before the operation.This is the
increasingly accepting the concept of same-day discharge, which obvious justification for the higher ASA classification—that is, to
is becoming more widely prevalent. make the surgical team aware of the potential increased risk. In ad-
dition, the family or social support networks available to elderly pa-
SPECIFIC PATIENT RISK FACTORS
tients are often of questionable value and may even pose their own
Careful monitoring and improvement of the patient’s physical risks after the operation. Most studies have failed to show age-relat-
status before operation reduce mortality and morbidity. ed increases in complications or recovery. Fine motor skills and cog-
Therefore, one should accept a patient with a poor preoperative nitive function diminish with age, however, so elderly patients re-
physical status for outpatient treatment only when it is clear that quire closer surveillance in the postanesthesia period.
concomitant disease is well controlled and that the patient will Young children, especially neonates, present separate problems
have adequate postoperative monitoring and treatment at home. that must be independently evaluated by the surgeon and the
In evaluating the risk factors for any surgical intervention, the fol- anesthesiologist.
lowing variables should be considered: (1) the patient’s age, (2) the
proposed anesthetic approach (type and duration), (3) the extent of Drug Therapy for Preexisting Disease
the surgical procedure (including the surgical site), (4) the patient’s Two questions must be answered about a patient taking med-
overall physiologic status, (5) the presence or absence of concomi- ication for preexisting disease. First, should the drug or drugs be
tant diseases, (6) baseline medications, and (7) the patient’s general discontinued or the dosage altered before operation [see Table 5]?
mental status. The aim is to return the patient to the preoperative Second, do the medications necessitate special laboratory evalua-
functional level with respect to respiration, cardiovascular stability, tions before operation (e.g., a prothrombin time and internation-
and mental status; no deviations should be acceptable. al normalized ratio [INR] for patients taking anticoagulants)?
Several studies aimed at determining reasons for admission Whereas dosages of some medications, such as adrenocorti-
after ambulatory surgical procedures indicate that many admis- costeroids, may have to be temporarily increased, certain oral
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 5 OUTPATIENT SURGERY — 4
does not certify outpatient surgery facilities.The goal of the ACS Table 7 Premedications
initiative is simply to present readily acceptable guidelines that
meet a minimum standard for surgical care without the necessity Recommended Dose
of a costly and time-consuming accreditation process.The guide- Drug (Trade Onset
Class and Route of
Name) (min)
lines are “intended to ensure and maintain superior quality of Administration
care for the surgical patient who undergoes an outpatient proce-
Midazolam* (Versed) Titrate in 0.5–1.0 mg aliquots I.V. 1–5
dure in an office-based or ambulatory surgical facility.”13 (total, ~ 2–3 mg)
The concept of governance in an ASC is key to quality. In 7.5–15 mg p.o. 15–30
Anxiolytics
effect, governance comprises the rules and regulations that deter- Diazepam (Valium) 4–10 mg (0.05–0.15 µg/kg) I.V. 1–5
mine how the facility does business. The ultimate authority and 5–10 mg p.o. 15–40
responsibility reside with the governing body. The processes out-
lined in the governance manual should include the following13: Fentanyl (Sublimaze) 0.5–1.0 µg/kg I.V. or I.M.
Narcotics† —
Sufentanil (Sufenta) 0.1–0.25 µg/kg
1. Specifying mission and goals, including the types of ser-
*Drug of choice. Oral administration allows children to be separated from parents as early
vices provided. as 15 min after ingestion, with no prolongation of recovery.
†Long-acting narcotics such as meperidine and morphine are usually not recommended for
2. Defining organizational structure. use in outpatient surgery.
3. Adopting policies and procedures for the orderly conduct
of the ASC.
4. Adopting a quality-assurance (QA) program. in physicians’ offices.14 The data were obtained from the 1989
5. Reviewing and taking appropriate action on all legal affairs Part B Medicare Annual Data and thus are somewhat dated;
of the unit and its staff. however, it is likely that the situation has not changed greatly over
6. Ensuring financial management and accountability. the succeeding years.The 1993 report contained disturbing find-
7. Establishing a policy on patients’ rights. ings: in 20% of the medical records, reasonable quality of care
8. Approving all arrangements for ancillary medical care was not documented; in 13%, an indication for surgery was not
delivered in the ASC, including laboratory, radiologic, documented; for a small number of operations, the physician’s
pathologic, and anesthesia services. office was not an appropriate setting; and in 16% of sample cases,
9. Conducting the operation of the unit without discrimina- procedure codes did not match the operations performed.
tion on any basis (including the presence of disabilities). Physicians performing surgery in the office-based setting need to
pay careful attention to compliance with documentation require-
Other regulatory agencies must also be taken into account in ments concerning safety. The headline in a surgical newspaper
the management of an ASC, especially if laboratory, x-ray, and article about the OIG report described office-based surgery as
pharmacy services are being offered. Examples include the “the Wild West of surgery”15—not the image that the surgical pro-
Clinical Laboratory Improvement Amendments (CLIA) of 1988 fession would like to project!
and the Occupational Safety and Health Administration (OSHA)
standards on hazard communication (29CFR1910.1200) and
blood-borne pathogens (29CFR1910.1030). In addition, compli- Performance of the Operation
ance with local and state fire and safety regulations and state
nuclear regulatory agencies is essential. PREOPERATIVE PATIENT EDUCATION
An important aspect of the ACS guidelines is that they take Time spent in preoperative preparation of the patient—
into account the differing capabilities of individual facilities. The whether by the surgeon, anesthesiologist, nurse, or other person-
ACS classifies ambulatory surgical facilities into three cate- nel—is time well spent. Surgical patients are especially suscepti-
gories—classes A, B, and C—on the basis of the level of anesthe- ble to preoperative anxiety and stress during the week before the
sia provided, the types of procedures performed, and the degree intended surgical procedure.This increased stress level continues
of sedation employed.13 The suggested guidelines for each class of into the postoperative period, until the patient is assured of an
unit differ; for example, less resuscitation equipment would be uneventful recovery.16 Well-informed patients have been demon-
required in a class A facility than in a class C facility. This differ- strated to have less stress perioperatively.17
entiation makes it easier for a small OSF to demonstrate compli- Preoperative education needs to cover topics of particular con-
ance with reasonable guidelines, in that the relevant requirements cern for patients, which include intraoperative awareness, awak-
are not as extensive as they would be for a more comprehensive ening after sedation, postoperative pain and nausea, and socio-
center.13 economic aspects such as return to work and loss of income.
Hospital-based ambulatory care units that are extensions of Education needs to take place sufficiently far in advance; rarely
inpatient facilities obviously have many advantages for the sur-
geon and the patient, but they are often less efficient and conve-
nient than other ambulatory facilities. On the other hand, it is eas- Table 8 Premedication and Recovery Time 19
ier to assess the safety and quality of hospital-based units, in that
the QA functions of the hospital must extend to such units. Type Number of Patients Recovery Time* (min)
JCAHO is now well established in the voluntary accreditation
process for ambulatory health care facilities, as well as for inpa- No premedication 1,015 179 ± 113
tient facilities. Even though accreditation is still voluntary, it is Diazepam 98 168 ± 104
clear that a mandate already exists for some sort of QA for ambu- Pentobarbital 25 231 ± 88
latory facilities. Narcotics (meperidine,
388 208 ± 101
morphine)
In 1993, the Office of the Inspector General (OIG) reported
Hydroxyzine 92 192 ± 120
on the appropriateness of the surgical setting, the medical neces-
sity of the surgical procedure, and the quality of care performed *Values are ± SD.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 5 OUTPATIENT SURGERY — 7
does discussion immediately before the procedure, such as in the pronounced. Newer short-acting narcotics are now available, but
preoperative area, lessen stress levels. they have side effects of their own.
Preoperative teaching for children is a special case. Such teach-
ing must be age appropriate, and it should address sources of par- Anxiolytics
ticular distress in children, especially separation from caregivers Most barbiturates are long-acting agents and thus are not indi-
and changes in dietary habits. cated for outpatient procedures. Very short acting barbiturates,
such as thiopental, are occasionally used during anesthesia.
ORAL-INTAKE GUIDELINES
Nonbarbiturate tranquilizers, such as midazolam or diazepam,
Prolonged fasting does not guarantee an empty stomach. In are being used more often, primarily because they do not cause
contrast, liquids pass through the stomach quite quickly; the half- much sleepiness and because they may reduce the amount of
time of clear liquids is 10 to 20 minutes. There is less content in anesthetic required. Midazolam has become the medication of
the stomach of patients 2 hours after consuming small amounts choice because of its ease of administration (it is nonirritating as
of clear liquids than in the fasting patient.18 The risk of dangerous a parenteral injection), rapid onset, and flexibility (an oral for-
hypoglycemia should be more of a concern than stomach volume. mulation is now available, and is especially useful for children). In
For that reason, patients should be permitted small quantities of addition, these benzodiazepines are useful in stopping convulsions.
clear liquids up to 2 hours before the procedure, and the old
standard of “NPO past midnight” should be abandoned. These Antinauseants
recommendations are especially applicable to infants and chil- Administration of antinauseants is often begun in the preoper-
dren, but they also apply to elderly patients and debilitated ative setting.21 Given that PONV is a common cause of prolonged
patients with diabetes or other metabolic diseases. recovery and of subsequent hospital admission, preventive mea-
sures aimed at high-risk patients are preferable to treatment.
PREMEDICATION
Premedication is an important adjunct to local and regional Antacids and Histamine Antagonists
general anesthesia [see Table 7].19 It can facilitate performance of Antacids and histamine antagonists are sometimes used in an ef-
the procedure by alleviating fear and anxiety, supplementing anal- fort to diminish the risk of gastric aspiration and the consequent
gesia, reducing gastric acidity and volume, reducing oral and air- deleterious effects of acidic gastric contents on the respiratory tract,
way secretions, decreasing histaminic effects in patients with mul- but they have not been proved to be beneficial in this respect. It is
tiple allergies, limiting postoperative nausea and vomiting important to remember that most of the commonly used antacid
(PONV), and controlling infection. preparations are composed of particulate matter, so aspiration of
On the other hand, premedication, especially with narcotics, the antacid can itself be a serious problem. Patients who are as-
can also delay recovery; in fact, patients may actually take longer sumed to be at high risk for aspiration (e.g., diabetic, obese, or preg-
to recover from premedication and local anesthesia than from nant patients or patients with gastroesophageal reflux disease
general anesthesia. Still, no patient should be denied premedica- [GERD], stroke, or swallowing difficulties) should be premedicated
tion out of fear that it might delay discharge. Some studies have with an H2 receptor antagonist on the evening before and the
shown that premedication with agents other than long-acting nar- morning of the operation. Alternatively, these high-risk patients may
cotics does not prolong recovery time [see Table 8].20 Narcotic pre- be premedicated with a nonparticulate (i.e., clear) antacid, such as
medications are the usual cause of PONV and one of the major sodium citrate; a 50 ml dose of sodium citrate 1 hour before the op-
reasons for admission of outpatients to the hospital. eration raises the pH to a safe level, albeit at the expense of a slight-
The five major categories of agents used for premedication are ly increased gastric residual volume.22 Rapid infusions of H2 in-
(1) anticholinergic drugs, (2) narcotics, (3) anxiolytics, (4) antinau- hibitors at the time of surgery are discouraged because of the
seants and antiemetics, and (5) antacids and histamine antagonists. possibility that bradycardia will result.
Anticholinergic Drugs ANESTHESIA
Atropine and scopolamine are not routinely indicated for out- It is beyond the scope of this chapter to address general anes-
patient premedication, because newer anesthetics are less irritat- thesia in depth. We merely note that one should be prepared to
ing than older ones and because use of anticholinergic agents may meet all of the contingencies that can accompany general anes-
increase the incidence of cardiac irregularities. If an anticholiner- thesia, especially when anesthesia is delivered by someone other
gic is needed, glycopyrrolate, 0.2 to 0.3 mg I.M. or I.V., is a bet- than an anesthesiologist and is not immediately supervised by an
ter alternative in that it does not cross the blood-brain barrier and anesthesiologist. The patient’s cardiac activity, blood pressure,
causes less tachycardia than atropine does. temperature, respiration, and neuromuscular activity should be
properly monitored. The incidence of postoperative complica-
Narcotics tions is related to the anesthetic technique23: one of 268 patients
The primary effect of narcotics is the relief of pain; however, who receive local anesthesia experience postoperative complica-
they also have significant side effects that limit their usefulness for tions, compared with one of 106 patients who undergo sedation.
outpatient procedures. Fentanyl is appropriate for outpatient Obviously, the anesthetic technique used reflects the invasiveness
surgery because of its short duration of action and its limited side of the surgical procedure.
effects; it should be given within 30 minutes of the actual induc-
tion of anesthesia. Long-acting narcotics, especially meperidine Local Anesthetics for Local and Regional Anesthesia
and morphine, are usually not indicated in the outpatient setting. As outpatient surgery has become more popular, so too has the
As outpatient surgical procedures become more lengthy and use of local anesthetics for local and regional control of pain [see
complex, larger doses of short-acting narcotics such as fentanyl 1:5 Postoperative Pain]. Local anesthetics are usually administered
are being used. As the doses are increased, however, the advan- by the surgeon. It is crucial that the patient accept this type of
tages of short-acting drugs over long-acting drugs become less anesthesia and be psychologically suited for it; obviously, local or
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 5 OUTPATIENT SURGERY — 8
Epinephrine-Containing
Plain Solutions Solutions
Drug
Maximum Adult Duration Maximum Adult Duration
Dose (mg) (min) Dose (mg) (min)
regional anesthesia can be very disturbing and disruptive when (e.g., the fingers, the toes, the nose, and the external ears). In
administered inadequately or when given to an emotionally unsta- addition, adrenergic agents should not be used in unstable cardiac
ble patient. During the preoperative conference or the patient patients unless absolutely necessary.
education session, the surgeon, the anesthesiologist, or both Administration of long-acting local anesthetics (e.g., 0.25%
should make a point of describing how the anesthetic will be bupivacaine, injected in the skin edges at the end of the proce-
administered and what sensations will ensue. dure) seems to limit postoperative pain and thus to encourage
Local anesthetics can be classified into three groups according early activity and ambulation. Often, this technique not only post-
to their potency and duration of action: (1) low potency and short pones pain but reduces it as well. Bupivacaine is not, however, rec-
duration (e.g., procaine and chloroprocaine), (2) moderate ommended for patients younger than 12 years.
potency and intermediate duration (e.g., lidocaine, mepivacaine,
and prilocaine), and (3) high potency and long duration (e.g., Adjunctive Use of Local Anesthetics to Prolong Anesthetic Effect
tetracaine, bupivacaine, and etidocaine) [see Table 9]. It is clear that even when regional anesthetics, general anes-
Most local anesthetics are administered by infiltration into the thetics, or both are employed, adjunctive use of local anesthetics
extravascular space. In some areas, especially the hands, intravas- at the end of the procedure prolongs the anesthetic effect. In addi-
cular (I.V. regional) infiltration has been used with considerable tion, once the patient realizes that ambulation is possible without
success; however, inadvertent intravascular administration of discomfort, he or she is more likely to leave the hospital sooner
epidural doses of the high-potency agents can lead to life-threat- and is less likely to need additional postoperative analgesia.
ening complications [see Toxicity and Allergy, below]. Although Several centers are currently experimenting with administering
such complications have not been reported in association with local anesthetics before operation; the hypothesis, which is still
inadvertent intravascular administration during infiltration for unproven, is that preoperative administration may result in less
local anesthesia, it is advisable to check carefully to be sure that use of postoperative analgesics and a longer anesthetic effect than
the injecting needle is not located in an intravascular site. administration at the end of the procedure.
Intravascular injection can usually be prevented by constantly Injection of joint capsules with long-acting anesthetics and nar-
aspirating during infiltration and by infiltrating only while with- cotics (e.g., morphine sulfate) relieves a great deal of postopera-
drawing the needle. tive pain. Bathing of wounds with bupivacaine is a safe and effec-
Mixing local anesthetics is an effective means of obtaining the ad- tive method of decreasing postoperative pain.26 The addition of
vantages of more than one drug at once. At the Lichtenstein Hernia epinephrine can extend the prolongation of analgesia to 12 hours
Institute, in Los Angeles,24 patients undergoing repair of inguinal after operation.
hernias receive a 50-50 mixture of 1% lidocaine and 0.5% bupiva-
caine.The maximum therapeutic dose of lidocaine is 300 mg alone Nonsteroidal Anti-inflammatory Drugs
and 500 mg with epinephrine; the maximum therapeutic dose of Some centers use nonsteroidal anti-inflammatory drugs
bupivacaine is 175 mg alone and 225 mg with epinephrine.The ad- (NSAIDs) to reduce inflammation and thus pain [see 1:5
dition of 1 mEq/10 ml of sodium bicarbonate to the solution short- Postoperative Pain]. In addition, it has been shown that NSAIDs sig-
ens the onset time25 and reduces discomfort by raising the pH.This nificantly reduce the need for opioid analgesics after abdominal
combination of drugs has several advantages: (1) lidocaine has a procedures. Administration of ketorolac over a short period (i.e., 5
rapid onset, whereas bupivacaine prolongs the duration of the effect; days or less), first at the time of operation (60 mg I.M. in the OR;
(2) the negative chronotropic and inotropic action of lidocaine may lower doses for patients weighing less than 50 kg, those older than
well counteract the cardiac excitability of bupivacaine; and (3) use of 65 years, and those with impaired renal function) and then every 6
multiple drugs makes it less likely that the maximum therapeutic hours thereafter (10 to 15 mg p.o.), has improved recovery after
dose of any single agent will be exceeded. many operations, especially perianal and inguinal procedures.
Regional anesthesia, usually in the form of a regional nerve (Ketorolac is, however, contraindicated as a preoperative prophy-
block, is generally administered by an anesthesiologist but can be lactic analgesic.) Other NSAIDs can be given in transdermal
adequately administered by a knowledgeable surgeon. patches (which are not recommended for children) or transnasally.
The use of epinephrine with local anesthetics prolongs the
duration of the anesthetic effect without delaying its onset; how- Toxicity and Allergy
ever, epinephrine should not be used with anesthetics at sites Whenever local anesthetics are used, especially when they are
where the vascular supply distal to the site of infusion is marginal administered regionally for major nerve blockade, the possibility
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 5 OUTPATIENT SURGERY — 9
of systemic toxicity should be considered. Such toxicity often anesthetic of unrelated structure. An intradermal skin test, in
results from inadvertent intravascular injection of these agents, which 0.1 ml of the anesthetic drug is injected intradermally into
leading to a sudden increase in systemic concentration.20 The the volar aspect of the forearm, may be tried. A negative reaction
rate of injection is inversely related to the patient’s tolerance of indicates that the drug probably can be used safely; nevertheless,
the drug: the higher the injection rate, the lower the tolerance. In resources for handling major cardiopulmonary irregularities
general, arterial infusion is less likely to cause a toxic reaction should be available when anesthetics are used in previously sen-
than venous infusion because of the delay in circulation through sitized patients.30
the distal capillary network. Other factors that can lead to toxic
reactions are a diminished drug detoxification rate, systemic aci- Control of Nausea and Vomiting
dosis, and individual sensitivities, which are highly variable. Many predisposing factors play a role in causing PONV. Not
In the CNS, toxic reactions range from drowsiness to frank all of these factors can be managed. Nevertheless, it behooves the
convulsions. One study found that the incidence of mild toxic surgeon and the anesthesiologist to identify patients at risk so as
reactions to local and regional anesthetics was 0.38% and the to minimize the incidence of this debilitating syndrome, which is
incidence of convulsions was 0.12%.27 In the cardiovascular sys- responsible for a large number of hospital admissions after out-
tem, toxicity is initially manifested by elevated blood pressure; patient surgical procedures.
eventually, depression of systemic resistance and myocardial con- Some of the more common causes of nausea are often over-
tractility leads to cardiovascular collapse.The myocardial depres- looked. Pain is in itself capable of causing nausea and vomiting.
sion associated with intravascular injection of 0.75% bupivacaine Accordingly, adequate control of pain is essential, and the patient
for epidural anesthesia has been reported to be strongly resistant must not be deprived of analgesics under the false assumption
to treatment in pregnant women.28 Systemic toxicity is also man- that the medications are the only cause of the nausea. Changes in
ifested by alterations in the metabolic system, such as derange- body activity, especially assumption of the upright position by a
ment of acid-base balance. (Respiratory or metabolic acidosis patient with hypotension, can also cause nausea, as is experi-
leads to an increased sensitivity to local anesthetics.) All such enced before a vasovagal attack. In some patients who are prone
reactions are best managed by prevention. Constant vigilance is to motion sickness, the sensation of motion is aggravated by the
necessary to ensure that inadvertent intravascular injection does surgical procedure, the anesthetics, and pain. A preoperative his-
not occur at the time of infiltration. Any serious reactions (e.g., tory of frequent attacks of motion sickness is often a signal that
convulsions and cardiovascular collapse) that arise despite pre- the patient is prone to nausea and vomiting.
cautions are treated with standard measures. The use of narcotics in premedication, as well as in induction
Many patients claim to be allergic to anesthetics (which they and maintenance of anesthesia, is definitely a cause of increased
often refer to generically as Novocain), but true allergic reactions postoperative nausea and vomiting; however, some of the newer
are rare.29 A careful history of allergic drug reactions should be opioid analgesics (e.g., fentanyl, sufentanil, and alfentanil), when
taken, including reactions to concomitant medications such as given judiciously as premedications [see Table 7], appear to reduce
epinephrine. It is important to explain to a patient the nature of anxiety, decrease anesthetic requirements, and relieve pain in the
any reaction that occurs so that if the reaction is not in fact an early postoperative period.31 One should have a thorough under-
allergic one, he or she will not give a history of allergy to anes- standing of the proper use of these medications before employing
thetics in the future. them in the ambulatory setting.
Allergic reactions are mediated by the release of histamine. Benzquinamide, trimethobenzamide, promethazine, and
Previous exposure to the offending local anesthetic can lead to prochlorperazine have all been used in an effort to control PONV
the production of IgE antibodies, which initiate anaphylaxis on but with only limited success.32 Droperidol had been popular for
subsequent exposure; however, anesthetics can also initiate com- this purpose, but in December 2001, the Food and Drug
plement-mediated release of histamine without previous expo- Administration added a so-called black-box warning to the drug’s
sure. Histamine release leads to characteristic symptoms: skin labeling because of the potential for fatal cardiac arrhythmias;
erythema, followed by erythema in various regions of the body consequently, droperidol is now rarely used.33 Metoclopramide
and edema of the upper airway. Abdominal cramps and cardiac acts specifically on the upper GI tract and is a useful premedica-
instability may also be present. tion because it also encourages gastric emptying and prevents
If an allergic reaction occurs, administration of the drug aspiration; however, it is a short-acting agent and thus may have
should be stopped immediately. Epinephrine, 0.3 to 0.5 ml of a to be given again after a long procedure.The usual dose of meto-
1:1,000 dilution, should immediately be given either locally (I.M. clopramide for the average adult patient is 10 to 20 mg.34,35
or subcutaneously) or, if the reaction is severe, systemically.30 Given that a history of motion sickness is a good predictor of
Diphenhydramine, 0.5 to 1.0 mg/kg, should also be given sys- increased risk for nausea and vomiting, it is not surprising that
temically. If bronchospasm occurs, aminophylline, 3 to 5 mg/kg
I.V., should be administered. Corticosteroids have been used in
this setting, but there is little evidence that such therapy is help- Table 10 Treatment of Allergic
ful [see Table 10].
Reactions to Local Anesthetics
One common cause of allergic reactions is sensitivity to
paraben derivatives, which are preservatives used in local anes-
thetics. Paraben preservatives resemble para-aminobenzoic acid Agent Route of Administration Recommended Dose
(PABA), a metabolic-breakdown product of ester-type anesthet- Epinephrine I.M. or subcutaneously 0.3–0.5 ml of
ics (e.g., procaine, benzocaine, and tetracaine). PABA is a mem- 1:1,000 dilution
ber of a class of compounds that are highly allergenic. Patients Diphenhydramine Systemically 0.5–1.0 mg/kg
sensitive to sunscreens containing PABA often show cross-sensi- Aminophylline I.V. 3–5 mg/kg
tivity to ester-type local anesthetics. Patients who are allergic to a Corticosteroids I.V. 1g
local anesthetic usually can be safely given a preservative-free
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 5 OUTPATIENT SURGERY — 10
dimenhydrinate is effective in many cases. Indeed, in some cases, Table 11 Modified Aldrete Phase I Postanesthetic
it is significantly more effective than droperidol.36 Recovery Score42,43
Phase I, or early recovery, includes the patient’s return to con- SpO2 > 92% on room air 2
sciousness and recovery of vital reflexes. Generally, phase I takes Oxygen saturation
Requires supplemental O2 to maintain 1
place in the postanesthesia care unit (PACU). Currently, howev- SpO2 > 90%
er, as a result of increasing use of short-acting anesthetics39 and SpO2 < 90% even with O2 supplement 0
conscious sedation, this phase sometimes occurs in the OR, thus *Either spontaneously or on command.
eliminating the need for recovery in the PACU. This fast-track SpO2—pulse oximetry
for ambulatory surgery and the importance of optimizing treat- from an ambulatory surgical facility had a higher incidence of
ment of any preexisting medical conditions. PONV.68 A similar study of adult patients, however, did not docu-
Social factors account for as many as 41% of delays in dis- ment increased risk of PONV in patients required to drink fluids
charge from the ASC.The most common social reason for delayed before discharge, nor did it document decreased risk in patients
discharge is the lack of an adult escort to accompany the patient who were not so required.69 Given these findings, we believe that
home.58,59 To prevent this occurrence, patients should be coun- patients should be allowed to choose whether they want to drink
seled preoperatively in the office on the need for someone to ac- fluids before discharge; oral fluid intake should not be a mandatory
company them home from the ASC, and the availability of the discharge criterion.
escort should be verified when the patient presents to the ASC Several categories of antiemetic agents are available for preven-
before the scheduled procedure. tion and treatment of PONV, the most common of which are the
antihistamines, the antidopaminergics, and the antiserotoninergics.60
System-related factors Many system-related factors may The antihistamines have long been used to treat motion sick-
delay discharge or increase the postoperative admission rate from ness and other disturbances of the vestibular pathway. They may
the ASC. These include patient prescriptions that are not ready, be more effective than other antiemetics after middle-ear proce-
nurses who are too busy to instruct and discharge patients, dures. Common side effects include dry mouth and sedation.
uncompleted paperwork, or physicians who have not discharged One of the most commonly used antidopaminergic antiemetics is
the patient.59 Because the PACU may close before the patient is promethazine. This agent possesses both antihistaminic and anti-
fully recovered, some patients need to remain in the ASC until cholinergic properties and is therefore useful for treating motion
their recovery is complete.53 For an ASC to be efficient and prof- sickness.60 Droperidol has also been widely used for prevention of
itable, as well as to promote patient satisfaction, these types of PONV. However, because of its association with fatal cardiac ar-
unnecessary delays should be anticipated and avoided. rhythmias, which prompted the December 2001 black-box warning
from the FDA—the most serious warning an FDA-approved drug
Nausea and Vomiting can carry—and because of studies documenting slower recovery
PONV is distressing to patients and is a common source of from anesthesia with droperidol than with other agents, the current
patient dissatisfaction with ambulatory surgery and anesthesia.60-64 consensus is that the use of droperidol should be limited.70 Side ef-
In addition, PONV often causes delayed discharge from the fects of antidopaminergic agents include anxiety, dizziness, drowsi-
ASC or unplanned hospital admission, thereby inconveniencing ness, extrapyramidal effects, and hypotension.These effects are dose
patients and increasing the cost to the ASC.37,57 Patients who related and may continue after discharge.60,70
experience PONV report more difficulty in resuming normal The selective serotonin receptor antagonist ondansetron is very
activities and may require a longer recovery period.65 PONV may effective in preventing and treating PONV.71 The optimal prophy-
also lead to a variety of postoperative problems, including aspira- lactic dose for adults is 4 mg.72 The side effects commonly seen with
tion pneumonitis, dehydration, esophageal rupture, and wound antihistamines (e.g., blurred vision, dry mouth, and diplopia) are
dehiscence.66 rare with ondansetron.70,72
The etiology of PONV is complex and includes factors related Metoclopramide reduces PONV by increasing lower esoph-
to the procedure, the anesthetic, and the patient. Certain opera- ageal sphincter pressure and increasing gastric emptying. This
tions, including ophthalmic procedures, orchiectomy, and middle- agent may be useful in counteracting the effects of narcotics on
ear procedures, are associated with a high incidence of PONV. gastric motility. Because it does not affect the vestibular system,
Certain anesthetics (e.g., narcotics, etomidate, and ketamine) have metoclopramide is usually employed as an adjunct to other
been shown to carry a greater risk of PONV than other agents do.60 agents in the treatment of PONV. However, its use is somewhat
Use of propofol as an induction agent has been shown to decrease controversial.60,66
the incidence of PONV.67 Other anesthetic-related causes include The synthetic glucocorticoid dexamethasone is also a safe and
gastric distention during mask ventilation, hypotension related to effective agent in preventing PONV.73,74 The delayed onset of
regional anesthesia, and vagal stimulation. Of the patient-related action and prolonged effectiveness of dexamethasone make it
causes, younger age, anxiety, pain, underlying medical conditions ideal for use in conjunction with other agents in patients who are
such as gastroparesis, and a previous history of PONV are also at particularly high risk for PONV.73 Dexamethasone has few side
known to be associated with a higher incidence of PONV. effects and is more cost-effective than other agents.75
Prevention of PONV depends on a clear understanding of the In summary, the management of PONV requires a systematic
etiology and on an accurate assessment of the patient’s level of approach. Identifying patients who are at high risk and providing
risk for this complication. Given the cost and side effects of the multimodal treatment can often prevent PONV.76
medications required, prophylaxis for all patients undergoing
ambulatory surgery is not advisable60; however, prophylaxis for Pain
patients known to be at high risk for PONV may result in Effective pain management after ambulatory surgery depends
decreased cost to the patient and facility, greater patient satisfac- on a clear understanding of the mechanisms of pain, a careful
tion, and fewer associated complications. assessment of the type and degree of pain, and appropriate selec-
PONV prophylaxis should include both pharmacologic and non- tion of pain-control methods so as to optimize patient comfort
pharmacologic interventions. Preoperative sedation to alleviate anx- while minimizing side effects. Incomplete pain control is associ-
iety may facilitate control of PONV, as may adequate management ated with several significant complications, such as PONV,
of postoperative pain [see Pain, below]. Judicious selection of anes- reduced mobility, and inability to cough and breathe deeply. In
thetic agents also helps reduce the incidence of PONV. Limiting pa- addition, pain is associated with delayed discharge from phase II
tient motion after certain operations (e.g., ophthalmic procedures) of recovery, more frequent return visits by the patient to a health
may be beneficial. A more flexible approach to postoperative fluid care facility, and higher rates of unplanned hospital admis-
intake may be helpful as well. One pediatric study found that pa- sion.77,78 Postoperative pain also can be physiologically harmful,
tients who were required to drink liquids before being discharged causing increased release of catecholamines with resultant eleva-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 5 OUTPATIENT SURGERY — 13
tion of blood pressure and pulse rate. Inadequate postoperative Overall, opioids are the most commonly used pain medica-
pain control is a significant source of patient dissatisfaction with tions after ambulatory surgery. They can be delivered via many
ambulatory surgery.55 By limiting mobility, postoperative pain different routes, including oral, I.V., I.M., transcutaneous,
may hamper patient recovery. Moreover, inability to manage pain intranasal, oral transmucosal, and subcutaneous. The main con-
adequately after certain procedures makes it difficult (or even cerns with respect to opioid use are the side effects and the
impossible) for surgeons to perform these procedures in an potential for abuse. Common side effects include respiratory
ambulatory setting.79 depression, sedation, reduction of rapid-eye-movement sleep,
Assessment of postoperative pain requires good communication impaired GI motility, urinary retention, PONV, and allergic reac-
between the surgeon and the patient. Patients have varying sensi- tions. PONV is a particular problem; however, if other agents
tivity to pain and respond differently to pain medication. Use of a (e.g., NSAIDs and adjuvants) are being used as well, the opioid
measurement tool such as the verbal analogue scale can facilitate dosage can be reduced and the incidence of PONV thereby low-
assessment of postoperative pain. A 1998 study found that 40% of ered.83 Because of the many side effects of opioid analgesics, the
patients reported moderate to severe pain in the first 24 hours after preoperative teaching should include instructions to patients
ambulatory surgery and that the best predictor of severe pain at regarding the management of these side effects. The patient
home was inadequate pain control during the first few hours after should also be instructed on avoiding driving and use of heavy
the operation.79 It is therefore crucial to assess patients’ pain and machinery while taking these medications.
treat it aggressively before discharging them from the ASC. Adjuvant methods of controlling pain include infiltration of local
A key component of pain control after ambulatory surgery is anesthetics (e.g., bupivacaine) into the surgical site, continuous or
education of patients regarding the degree of postoperative pain patient-controlled regional anesthesia (PCRA) systems, local nerve
they may experience. It is not uncommon for patients to com- blocks, and transcutaneous electrical nerve stimulation (TENS).
plain that they were given no information about how much pain Often, these measures add substantially to control of pain after am-
to expect and how to manage it. During the preoperative visit, bulatory surgery. In particular, PCRA is very effective in certain
patients should be informed about various nonpharmacologic procedures.83 In this approach, a catheter is placed in the surgical
methods of alleviating pain. Depending on the procedure to be site or near local peripheral nerves and attached to an elastometric
performed, appropriate methods may include application of ice, (balloon) pump containing bupivacaine; the patient can then con-
elevation of an affected extremity, wearing of loose-fitting cloth- trol administration of the local anesthetic.
ing, sitz baths, or modified sleeping positions.80 During the same
visit, patients should also be informed about the medications Infection
they will be given for pain control—specifically, names, dosages, The incidence of postoperative infection in ambulatory
potential side effects, drug interactions, and precautions. Finally, surgery patients varies, depending on the procedure performed
patients should be told how to notify their physician if they con- and the risk factors for infection present. Overall, however, infec-
tinue to experience excessive pain. tion rates after ambulatory surgery tend to be substantially lower
The best pharmacologic strategy for controlling postoperative than those after inpatient surgery.84,85 Actual infection rates can
pain is to employ regimens comprising multiple analgesics that be difficult to quantify in ambulatory surgery patients but should
work synergistically.78 So-called balanced analgesia involves giv- nonetheless be measured both as an indicator of quality and as
ing medications from three different analgesic groups: nonopi- an aid to reducing the incidence of infection.86
oids, opioids, and adjuvants.81 Patients should be given a list of potential signs of infection
The nonopioid agents most commonly used after outpatient sur- (i.e., redness, drainage, excessive pain around the incision, and
gery are the NSAIDs and acetaminophen. NSAIDs act peripherally fever) and instructed to call the physician if these appear. The
and have anti-inflammatory, analgesic, and antipyretic effects.They presence of any of these signs is an indication for examination by
are very effective against mild to moderate pain. Side effects include a physician. Most of the postoperative surgical site infections that
gastric mucosal irritation and inhibition of platelet aggregation; occur in ambulatory surgery patients can be treated in the office
however, newer NSAIDs that selectively inhibit the cyclooxyge- with local wound care.
nase-2 (COX-2) enzyme exhibit these effects to a much lesser de- Many other types of infection may occur in ambulatory surgery
gree.82 One of the most commonly used NSAIDs in ambulatory patients, of which pneumonia, urinary tract infections, and pros-
surgery patients is ketorolac, which may be administered either I.V. thetic-device infections are the most common. Generally, these in-
or I.M. Its onset of action occurs approximately 30 minutes after fections develop several days after the procedure; thus, it is impor-
administration, with peak effect coming at about 75 minutes.81 This tant to schedule a postoperative visit around this time.
agent causes reversible inhibition of platelet aggregation, which re-
solves 24 to 48 hours after the drug is stopped; it also has an ad- Urinary Retention
verse affect on renal function. Accordingly, ketorolac should be Postoperative urinary retention occurs in 0.5% to 5% of
used with caution in elderly patients and in patients with altered re- ambulatory surgery patients.87,88 Patients at high risk for this
nal function.83 complication are those who have previously experienced urinary
Acetaminophen acts to alleviate pain by a central mechanism. retention and those who are undergoing particular types of pro-
It lacks the antiplatelet effects of NSAIDs and has few side cedures (e.g., herniorrhaphy and anal procedures). Other predis-
effects. Acetaminophen should not be given to patients with liver posing factors are advanced age,88 spinal anesthesia,87 use of anti-
disease or chronic alcoholism.The maximum daily dose of aceta- cholinergics, bladder overdistention, use of analgesics, unrelieved
minophen in adults is 4,000 mg; thus, as noted [see Discharge pain, preoperative use of beta blockers,89 and a history of preop-
Instructions, above], patients must be cautioned not to take any erative catheterization.
other acetaminophen-containing medications.This is a matter of Surgeons often require ambulatory surgery patients to void
particular concern because many of the commonly used oral nar- before discharge; however, this practice unnecessarily delays dis-
cotic pain preparations already include a significant amount of charge of low-risk ambulatory surgery patients. A 1999 study
acetaminophen, which patients may not realize.81 showed that low-risk patients could be safely discharged without
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 5 OUTPATIENT SURGERY — 14
voiding and did not benefit from being required to void sponta- Table 14 Predisposing Factors to Complications
neously before discharge.87 The incidence of postoperative urinary during and after Outpatient Anesthesia23
retention in these patients was 0%. In low-risk patients who were
discharged without voiding, the mean time to voiding after dis- Predisposing Factor Incidence of Complications
charge was 75 minutes, indicating that discharge had been expe-
dited by at least that length of time. In high-risk patients, howev- Preexisting disease
er, catheterization before discharge should be considered if they None (ASA I) 1/156
are unable to void. In addition, once discharged, high-risk patients Diabetes mellitus 1/149
should have ready access to a medical facility and should be Asthma 1/139
instructed to return if they are still unable to void 8 to 12 hours Chronic pulmonary disease 1/112
Hypertension (diuretic therapy) 1/87 (1/64)*
after discharge.
Heart disease 1/74*
The presence or absence of symptoms is not a reliable indica-
Type of anesthesia
tor of urinary retention: many patients are asymptomatic even
Local only 1/268
with bladder volumes greater than 600 ml.87,90 Alternative meth- Regional only 1/277
ods of diagnosing urinary retention, such as ultrasonography or Local/regional with sedation 1/106*
catheterization of patients known to be at high risk for urinary General (combination of techniques) 1/120*
retention and unable to void before discharge, are more reliable. Duration of anesthesia
Bladder overdistention is a significant cause of postoperative < 1 hr 1/155
urinary retention.9,87 Judicious use of fluids helps minimize post- 1–2 hr 1/84
operative urinary retention in patients at high risk.Those who are 2–3 hr 1/54*
at high risk for retention and are receiving substantial amounts of > 3 hr 1/35*
I.V. fluids should be considered for early catheterization to help Significantly different from initial value for the group; P < 0.05.
prevent excessive distention of the bladder with resultant reten-
tion and bladder atony.
Patients who require catheterization more than once postoper- disturbances, and PONV may be noted as well. How PDPH is
atively may be safely discharged home after placement of an treated depends on the severity of the symptoms. For mild symp-
indwelling catheter. The catheter should be left in place for 24 to toms, the patient should be instructed to take appropriate amounts
72 hours, after which time it can be removed in the physician’s of fluids, remain recumbent, decrease environmental stimuli (e.g.,
office. In the absence of any complicating circumstances, there is lights and noise), and take analgesics; caffeine may be a helpful ad-
generally no need to admit patients to a hospital simply because juvant.37 For severe, persistent symptoms, the patient may have to
of urinary retention. undergo a blood-patch procedure, in which a small amount of his
or her blood is injected epidurally to patch the dural leak.93
Other Postoperative Problems A small amount of incisional bleeding after ambulatory surgery
Other common postoperative problems that may develop in is common. Patients must be carefully taught how to monitor for
ambulatory surgery patients are headache, insomnia, constipa- excessive bleeding and how to perform initial management of inci-
tion, bleeding, and pharyngitis. Many of these problems can be sional bleeding with direct pressure and dressing changes. They
handled by providing reassurance and carrying out simple inter- must also be instructed to call the physician if bleeding persists.
ventions; however, some problems (e.g., headache and bleeding)
DOCUMENTATION OF OUTCOMES
may necessitate direct physician intervention to ensure that they
do not worsen. Evidence-based medicine is becoming the basis for accredita-
Headache occurs in 10% to 38% of patients in the first 24 hours tion, reimbursement, and public acceptance of the care-delivery
after the operation.37 It may be related to caffeine withdrawal, in system. Outpatient surgery is no exception to this trend.Therefore,
which case it is easily treated with caffeine-containing beverages, of- clear documentation and follow-up are important.The Federated
ten before discharge. Spinal headache, or postdural puncture head- Ambulatory Surgery Association (FASA) has published a list of
ache (PDPH), however, may be much more difficult to treat.This predisposing factors for complications during and after surgery
condition results from leakage of CSF from a tear in the dura dur- [see Table 14].23 It is imperative that the staff of any surgical unit
ing spinal anesthesia; thanks to advances in spinal-needle design, it be just as diligent in documenting outcomes as it is in docu-
is now less common than it once was.91,92 PDPH is most common- menting other parameters in preparation for surgery. National
ly a frontal or occipital headache that worsens with sitting or stand- benchmarks, such as those developed by the FASA, should be
ing and lessens with recumbency. Photophobia, diplopia, auditory used as guidelines for measuring the safety of any unit.
Discussion
Growth of Outpatient Surgery
delivery of surgical health care. Just a few years ago, it was esti-
The recent evolution of health care in response primarily to mated that more than 40% of all operative procedures would be
socioeconomic factors has been spectacular, and the process is by performed in the outpatient setting. By 2000, however, 70% of
no means complete.The most striking result to date is the emer- operative procedures were already being performed on an outpa-
gence of ambulatory surgery as the predominant mode for the tient basis. In 1996, an estimated 31.5 million procedures were
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 5 OUTPATIENT SURGERY — 15
performed during 20.8 million ambulatory surgical visits.94 The Economic benefits aside, the major issue in the movement of
majority (84%) of these visits still took place in hospitals, howev- surgical activities out of the hospital and into a more convenient
er, with the remainder in freestanding units.94 Although proce- and economical environment is how best to ensure that patients
dures such as endoscopies and lens extraction and insertion were continue to receive safe, high-quality care. This consideration
predominant at this time, there were also many breast biopsies, must in all circumstances be the primary issue underlying the
herniorrhaphies, and orthopedic procedures. planning of elective surgery. More and more, third-party payors
The explosive growth of ambulatory surgery was initiated by expect surgical care to be provided to their clients (patients, to us)
economic factors, but it has had some positive effects on patient in a cost-effective environment. On the whole, this is not a bad
care, for the following reasons: thing. If, however, they also expect that surgical care can be pro-
vided just as cost-effectively to diabetic patients, morbidly obese
1. Development of new technology. Newer techniques, such as
patients, and patients with serious cardiac or respiratory disease,
laparoscopic surgery, minimize the need for hospitalization
there is a real danger that patients’ welfare could be compro-
and decrease the pain and suffering that patients must endure.
mised. Accordingly, it is crucial that all third parties who are not
It is not yet clear, however, whether such developments will
inevitably lead to a reduction in total health care costs. One directly involved in the care of the patient permit the surgeon and
study reported that the cholecystectomy rate increased from the anesthesiologist to exercise sound medical judgment in regard
1.35 per 1,000 enrollees in an HMO in 1988 to 2.15 per 1,000 to what type of care is needed and where such care can best be
in 1990 and that the total cost for cholecystectomies rose by delivered. Surgeons must not delegate their responsibility for
11.4% despite a unit cost savings of 25.1%.95 The authors sug- safeguarding their patients’ well-being.
gested that these results might be attributable to changing The ACS has issued several statements on ambulatory
indications for gallbladder operations; however, it is much surgery.96 In their 1983 statement, the ACS approved “the con-
more likely that a significant number of patients suffering from cept that certain procedures may be performed in an ambulatory
gallbladder dysfunction who were reluctant to undergo an surgical facility” but emphasized that “a prime concern about
open procedure are now willing to accept the lesser discomfort ambulatory surgery is assurance of quality” and that “a discussion
and inconvenience characteristic of a laparoscopic procedure. between patient and surgeon about performance of the procedure
What the appropriate cholecystectomy rate may be is a ques- on an ambulatory basis should result in a mutually agreeable
tion for the future to answer; in the meantime, many patients decision.”96 More than two decades later, this is still the position
are living more comfortably, having had the dysfunctional of the ACS. The College is continually evaluating evolving med-
organ removed. The situation is similar in the treatment of ical technology, both inpatient and outpatient.
GERD. Repairs to the esophagogastric junction can now be Outpatient surgery would seem to have an obvious advantage
done without a long and difficult postoperative course. In over inpatient surgery with respect to cost savings, especially if the
addition, there have been major advances in anesthetic tech- main focus of the comparison is the high charges for 1 or more
niques and postoperative management of pain and PONV. days of inpatient care. Such a comparison may be misleading
2. Cost savings achieved by Medicare and other payors. In insofar as it suggests that the entire cost of inpatient care can be
1987, Medicare approved over 200 procedures as suitable for saved when the procedure is done on an outpatient basis. The
ASCs. Currently, more than 1,200 procedures are so desig- hospital inpatient charge reflects the costs of a number of func-
nated, with more procedures being approved every year. The tions associated with early convalescence in the hospital, includ-
endorsement of cost-efficient delivery systems by employers ing nursing, diet, and housekeeping; some of these costs are also
and the reduction of employee benefits by insurers are associated with immediate postoperative care in the outpatient
encouraging employees (as both consumers and patients) to recovery area and consequently will be reflected in the outpatient
be more cost-conscious. When patients are involved in the facility’s bill as well.The comparison may also be misleading inso-
actual cost of medical care, they tend to accept more efficient far as it ignores the inherent costs of outpatient surgery. In some
modes of delivery.This is even more likely to be the case when cases, medical personnel perform functions that do not appear on
they are at risk for the cost of care. the bill, such as follow-up care, care by phone, and home visits to
3. Physician concern.The emergence of the concept of managed evaluate recovery, as well as dressing changes and other services
care has exerted a strong influence on physician involvement similar to those provided by family members or friends.The costs
in ambulatory surgery. Concerns over the safety of major sur- associated with buying or renting durable medical equipment
gical procedures being performed in the outpatient setting (e.g., beds and commodes), preparing meals, and various other
have largely been removed, and surgeons are becoming more activities must also be taken into account. Clearly, there are
aggressive. Clearly, surgeons have benefited from the ease and avenues for development in the postoperative setting that might
convenience of outpatient surgery, especially with respect to raise expenses for outpatient surgery, but certainly not to the level
scheduling and protection from cancellations due to emer- of an inpatient stay.
gencies. Equally clearly, however, they will now have to be It is to be hoped that new Medicare and state regulations man-
more vigilant, given that outpatient surgical facilities tend to dating evaluation of quality of care in outpatient surgical facilities
be less well monitored and supervised. will provide definitive statistics for determining actual cost sav-
4. Patient awareness of quality assurance. Today’s patients (or ings. Cost data must be analyzed thoroughly if we are to assess
consumers) are more medically knowledgeable than ever the true contribution of outpatient surgery to cost containment.
before and more concerned with actively seeking out institu- As medicine advances into the 21st century, the changes in
tions that deliver high-quality and cost-efficient care. patient care have been and will continue to be nothing but spec-
Consumers are highly sensitive to the issue of quality, but their tacular, and one can only speculate what is to come. If this cen-
definitions of this attribute are not always based on the same tury brings about the same level of innovation that was experi-
criteria that surgeons use.To patients, quality is a combination enced in the 20th century, the future for surgery and the surgical
of effectiveness, safety, cost, convenience, and comfort. patient is bright, exciting, and to be greatly anticipated.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 5 OUTPATIENT SURGERY — 16
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Lectures 154:1, 1997 sia. Anesth Analg 62:341, 1983 admission of scheduled ambulatory surgery
6. Vila H Jr, Soto R, Cantor AB, et al: Comparative 30. Aldrete JA, Johnson DA: Evaluation of intracuta- patients. J Clin Anesth 9:446, 1997
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physician offices and ambulatory surgery centers. anesthetic agents. Anesth Analg 49:173, 1970 Inpatient hospital admission and death after out-
Arch Surg 138:991, 2003 31. Parnass SM: Controlling postoperative nausea patient surgery in elderly patients: importance of
7. Maini BS: Personal communication (1999) and vomiting. Ambulatory Surgery 1:61, 1993 patient and system characteristics and location of
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8. Recovery Care. Federated Ambulatory Surgery 32. Cohen SE,Woods WA,Wyner J: Antiemetic effica-
Association, September 2001 cy of droperidol and metoclopramide. Anesthesio- 55. Coley KC, Williams BA, DaPos SV, et al:
http://www.fasa.org/recoverycare.html logy 60:67, 1984 Retrospective evaluation of unanticipated admis-
sions and readmissions after same day surgery
9. Petros JG, Rimm EB, Robillard RJ, et al: Factors 33. Important drug warning (letter). Akorn Pharma-
and associated costs. J Clin Anesth 14:349, 2002
influencing postoperative urinary retention in ceuticals, December 4, 2001
patients undergoing elective inguinal herniorrha- www.fda.gov/medwatch/SAFETY/2001/inap- 56. Chung F, Mezei G, Tong D: Preexisting medical
phy. Am J Surg 161:431, 1991 sine.htm conditions as predictors of adverse events in day-
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therapy. Surg Clin North Am 65:1049, 1983 of postoperative nausea and vomiting: comparison 57. Chung F, Mezei G: Factors contributing to a pro-
of propofol, droperidol and metoclopramide. Can longed stay after ambulatory surgery. Anesth
11. Natof HE: Ambulatory surgery: preexisting med- J Anaesth 43:115, 1996 Analg 89:1352, 1999
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35. Steinbrook RA, Freiberger D, Gosnell JL, et al: 58. Pavlin DJ, Rapp SE, Polissar NL: Factors affect-
12. Patient Safety Principles for Office-Based Pro- Prophylactic antiemetics for laparoscopic chole- ing discharge time in adult outpatients. Anesth
cedures. American College of Surgeons, May 15, cystectomy: ondansetron versus droperidol plus Analg 87:816, 1998
2003 metoclopramide. Anesth Analg 83:1081, 1996
http://www.facs.org/dept/hpa/views/patsafety2.html 59. Chung F: Recovery pattern and home readiness
36. Bidwai AV, Meuleman T, Thatte WB: Prevention after ambulatory surgery. Anesth Analg 80:896,
13. Guidelines for Optimal Ambulatory Surgical Care of postoperative nausea with dimenhydrinate 1995
and Office-based Surgery, 3rd ed. American Col- (Dramamine) and droperidol (Inapsine) (abstract).
lege of Surgeons, Chicago, 2000 60. Marley RA: Postoperative nausea and vomiting:
Anesth Analg 68:S25, 1989 the outpatient enigma. J Perianesth Nurs 11:147,
14. Physician Office Surgery (abstr). Project No. 37. Marley RA, Swanson J: Patient care after dis- 1996
5079. Office of Evaluation and Inspection, charge from the ambulatory surgical center. J
Washington, DC, 1993 61. Tong D, Chung F, Wong D: Predictive factors in
Perianesth Nurs 16:399, 2001 global and anesthesia satisfaction in ambulatory
15. Wild D: Will the office setting remain the Wild 38. Marshall SI, Chung F: Discharge criteria and surgical patients. Anesthesiology 87:856, 1997
West of surgery? General Surgery News 31:1, 2004 complications after ambulatory surgery. Anesth
62. Macario A, Weinger M, Carney S, et al: Which
16. Johnston M: Anxiety in surgical patients. Psychol Analg 88:508, 1999
clinical anesthesia outcomes are important to
Med 10:145, 1980 39. Apfelbaum JL, Walawander CA, Grasela TH, et avoid? The perspective of patients. Anesth Analg
17. Wallace LM: Psychological preparation as a al: Eliminating intensive postoperative care in 89:652, 1999
method of reducing the stress of surgery. J Hum same-day surgery patients using short-acting
63. Lee PJ, Pandit SK, Green CR, et al: Postanes-
Stress 10:62, 1984 anesthetics. Anesthesiology 97:66, 2002
thetic side effects in the outpatient: which are the
18. Schreiner MS, Nicolson SC: Pediatric ambulato- 40. Watkins AC, White PF: Fast-tracking after ambu- most important? Anesth Analg 80:S271, 1995
ry anesthesia: NPO—Before or after surgery? J latory surgery. J Perianesth Nurs 16:399, 2001
64. Orkin FK:What do patients want? Preferences for
Clin Anesth 7:589, 1995 41. McGrath B, Chung F: Postoperative recovery and immediate postoperative recovery. Anesth Analg
19. Philip BK, Covino BG: Local and regional anes- discharge. Anesthesiol Clin North America 74:S225, 1992
thesia. Anesthesia for Ambulatory Surgery, 2nd 21:367, 2003
65. Carroll NV, Miederhoff P, Cox FM, et al:
ed. Wetchler BV, Ed. JB Lippincott Co, 42. Aldrete JA, Kroulik D: A postanesthetic recovery Postoperative nausea and vomiting after discharge
Philadelphia, 1991, p 318 score. Anesth Analg 49:924, 1970 from outpatient surgery centers. Anesth Analg
20. Meridy HW: Criteria for selection of ambulatory 43. Aldrete JA: The post anesthesia recovery score 80:903, 1995
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management: a retrospective study of 1,553 cases. aging PONV 2004. General Surgery News,
44. Theodorou-Michaloliakou C, Chung FF, Chua
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JG: Does a modified postanaesthetic discharge
21. Abramowitz MD, Oh TH, Epstein BS, et al: The scoring system determine home-readiness sooner? 67. Jobalia N, Mathieu A: A meta-analysis of pub-
antiemetic effect of droperidol following outpa- Can J Anaesth 40:A32, 1993 lished studies confirms decreased postoperative
tient strabismus surgery in children. nausea/vomiting with propofol. Anesthesiology
45. Dunn D: Preoperative assessment criteria and
Anesthesiology 59:279, 1983 81:A133, 1994
patient teaching for ambulatory surgery patients. J
22. Schmidt JF, Schierup L, Banning AM: The effect Perianesth Nurs 13:274, 1998 68. Schreiner MS, Nicholson SC, Martin T, et al:
of sodium citrate on the pH and the amount of Should children drink before discharge from day
46. Cheng CJ, Smith I, Watson BJ: A multi centre
gastric contents before general anaesthesia. Acta telephone survey of compliance with postopera- surgery? Anesthesiology 76:528, 1992
Anaesthesiol Scand 28:263, 1984 tive instructions. Anaesthesia 57:805, 2002 69. Jin F, Norris A, Chung F, et al: Should adult
23. FASA Special Study 1. Federated Ambulatory 47. Correa R, Menezes RB, Wong J, et al: Compliance patients drink fluids before discharge from ambu-
Surgery Association, Alexandria, Virginia, 1986 with postoperative instructions: a telephone survey of latory surgery? Anesth Analg 87:306, 1998
24. Amid PK, Shulman AG, Lichtenstein IL: Local 750 day surgery patients. Anaesthesia 56:447, 2001 70. Grond S, Lynch J, Diefenbach C, et al: Com-
anesthesia for inguinal hernia repair—step-by- 48. Wilson FL: Measuring patient’s ability to read parison of ondansetron and droperidol in the pre-
step procedure. Ann Surg 220:735, 1994 and comprehend: a first step in patient education. vention of nausea and vomiting after inpatient
25. Arthur GR, Covino BG:What’s new in local anes- Nursingconnections 8:17, 1995 gynecologic surgery. Anesth Analg 81:603, 1995
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71. Russel D, Kenny GN: 5-HT3 antagonists in 80. Doyle CE: Preoperative strategies for managing Urinary retention following routine neurosurgi-
postoperative nausea and vomiting. Br J Anaesth postoperative pain at home after day surgery. J cal spine procedures. Surg Neurol 55:23, 2001
69:63S, 1992 Perianesth Nurs 14:373, 1999 90. Stallard S, Prescott S: Postoperative urinary
72. Khalil SN, Kataria B, Pearson K, et al: 81. Moline BM: Pain management in the ambulato- retention in general surgical patients. Br J Surg
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79:845, 1994 82. Reuben SS, Connelly NR: Postoperative anal- Quincke and Whitacre 27-gauge needles in
73. Henzi I, Walder B, Tramer MR: Dexamethasone gesic effects of celecoxib or rofecoxib after spinal orthopedic patients: incidence of failed spinal
for the prevention of postoperative nausea and fusion surgery. Anesth Analg 91:1221, 2000 anesthesia and postdural puncture headache.
vomiting: a quantitative systematic review. Anesth Analg 79:124, 1994
83. Rawal N: Postoperative pain management in day
Anesth Analg 90:186, 2000 surgery. Anaesthesia 53:50, 1998 92. Jost U, Hirschauer M, Weinig E, et al: Experience
74. Fujii Y, Uemura A: Dexamethasone for the pre- with G27 Whitacre needle in in-patient and out-
84. Manian FA, Meyer L: Comprehensive surveil- patient settings—incidence of post dural puncture
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and curettage: a randomized controlled trial. and inpatient surgery. Infect Control Hosp Intensivmed Notfallmed Schmerzther 35:381,
Obstet Gynecol 99:58, 2002 Epidemiol 11:515, 1990 2000
75. Subramaniam B, Madan R, Sadhasivam S, et al: 85. Zoutman D, Pearce P, McKenzie M, et al: 93. Duffy PJ, Crosby ET: The epidural blood patch:
Dexamethasone is a cost-effective alternative to Surgical wound infections occurring in day resolving the controversies. Can J Anaesth 46:78,
ondansetron in preventing PONV after paedi- surgery patients. Am J Infect Control 18:277, 1999
atric strabismus repair. Br J Anaesth 86:84, 2001 1990
94. Advance Data Number 300. Centers for Disease
76. Gan TJ: Postoperative nausea and vomiting: can 86. Vilar-Compte D, Roldan R, Sandoval S, et al: Control and Prevention/National Center for
it be eliminated? JAMA 287:1233, 2002 Surgical site infections in ambulatory surgery: a Health Sciences, 1998
77. Redmond M, Florence B, Glass PS: Effective 5-year experience. Am J Infect Control 29:99,
95. Legorreta AP, Silber JA, Costantino GN, et al:
analgesic modalities for ambulatory patients. 2001
Increased cholecystectomy rate after the intro-
Anesthesiol Clin North America 21:329, 2003 87. Pavlin DJ, Pavlin EG, Fitzgibbon DR, et al: duction of laparoscopic cholecystectomy. JAMA
78. Tong D, Chung F: Postoperative pain control in Management of bladder function after outpa- 270:1429, 1993
ambulatory surgery. Surg Clin North Am tient surgery. Anesthesiology 91:42, 1999
96. Ambulatory surgery. ACS Reports. American
79:401, 1999 88. Tammela T: Postoperative urinary retention— College of Surgeons, Chicago, 1983
79. Beauregard L, Pomp A, Choiniere M: Severity why the patient cannot void. Scand J Urol 97. Green CR, Pandit SK: Preoperative preparation.
and impact of pain after day-surgery. Can J Nephrol 175:75, 1995 The Ambulatory Anesthesia Handbook. Twersky
Anaesth 45:304, 1998 89. Boulis NM, Mian FS, Rodriguez D, et al: RS, Ed. CV Mosby, St Louis, 1995, p 180
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 6 Fast Track Surgery — 1
Over the past several decades, surgery has undergone revolution- surgery must be based on a process of multidisciplinary collabo-
ary changes that are leading to improved treatments (involving ration that embraces not only the surgeon, the anesthesiologist,
lower risk and better outcome) for an increasing number of dis- the physiotherapist, and the surgical nurse but also the patient.
eases. These salutary developments are the result of more ad- More specifically, fast track surgery depends on the inclusion and
vanced anesthetic techniques, new methods of reducing the peri- integration of a number of key constituent elements (see below).
operative stress response, wider application of minimally invasive
techniques, improved understanding of perioperative pathophysi-
ology, and more sophisticated approaches to the prevention of Constituent Elements
postoperative organ dysfunction. Currently, many operations that
EDUCATION OF THE PATIENT
once necessitated hospitalization can readily be performed in the
outpatient setting; in addition, many major procedures are now To obtain the full advantages of a fast track surgical program,
associated with a significantly reduced duration of hospitalization it is essential to provide patients with information about their peri-
and a shorter convalescence. operative care in advance of the procedure. Such educational
Although these anesthetic and surgical developments are the efforts often serve to reduce patients’ level of anxiety and need for
result of basic scientific and clinical research, they have also been pain relief, thereby providing a rational basis for collaboration
influenced by governmental and managed care policies aimed at with health care personnel, a process that is crucial for enhancing
encouraging more cost-effective treatments. Such extraclinical postoperative rehabilitation.1-3 Patients can supplement the infor-
influences, coupled with new clinical developments, have resulted mation they receive directly from health care providers by access-
in novel approaches designed to enhance the cost-effectiveness of ing reference sources such as www.facs.org/public_info/operation/
health care, such as so-called fast track surgery, critical pathways, aboutbroch.html, a collection of electronic brochures on specific
and various types of clinical guidelines. To understand the true clinical procedures that is provided by the American College of
potential value of such approaches, it is essential to recognize that Surgeons.
their aim is not merely to ensure that fewer health care dollars are
OPTIMIZATION OF ANESTHESIA
spent but, more important, to ensure that better and more effi-
cient health care is delivered. Although these novel approaches The introduction of rapid-onset, short-acting volatile anesthet-
may reduce cost, their primary purpose is to improve surgical ics (e.g., desflurane and sevoflurane), opioids (e.g., remifentanil),
management by reducing complications and providing better out- and muscle relaxants has enabled earlier recovery from anesthesia
comes. In what follows, we outline the basic concept, primary and thereby facilitated ambulatory and fast track surgery.4 Al-
components, and current results of fast track surgery, which is a though use of these newer general anesthetic agents has resulted
comprehensive approach to the elective surgical patient that is in quicker recovery of vital organ function after minor surgical
designed to accelerate recovery, reduce morbidity, and shorten procedures, it has not been shown to decrease stress responses or
convalescence. mitigate organ dysfunction after major procedures.
Regional anesthetic techniques (e.g., peripheral nerve blocks
and spinal or epidural analgesia), on the other hand, have several
Basic Concept advantages in addition to providing anesthesia. Such advantages
Fast track surgery involves a coordinated effort to combine (1) include improved pulmonary function, decreased cardiovascular
preoperative patient education; (2) newer anesthetic, analgesic, demands, reduced ileus, and more effective pain relief. Neural
and surgical techniques whose aim is to reduce surgical stress blockade is the most effective technique for providing postopera-
responses, pain, and discomfort; and (3) aggressive postoperative tive pain relief, and it has been shown to reduce endocrine and
rehabilitation, including early enteral nutrition and ambulation. It metabolic responses to surgery [see 1:5 Postoperative Pain]. For a
also includes an up-to-date approach to general principles of pronounced reduction in perioperative stress after a major opera-
postoperative care (e.g., use of tubes, drains, and catheters; mon- tion, continuous epidural analgesia for 24 to 72 hours is neces-
itoring; and general rehabilitation) that takes into account the sary.5,6 A meta-analysis of randomized trials evaluating regional
revisions to traditional practice mandated by current scientific anesthesia (primarily involving patients undergoing operations on
findings. It is believed that by these means, fast track surgery can the lower body) found that morbidity was 30% lower with region-
shorten the time required for full recovery, reduce the need for al anesthesia than with general anesthesia.7 However, the effect of
hospitalization and convalescence, and lower the incidence of continuous epidural analgesia on outcome after major abdominal
generalized morbidity related to pulmonary, cardiac, thromboem- or thoracic procedures has been questioned in the past several
bolic, and infectious complications.1-3 years. In three large randomized trials,8-10 no beneficial effect on
For an accelerated recovery program of this type to succeed, overall morbidity could be demonstrated, except for a slight
proper organization is essential. In general terms, fast track improvement in pulmonary outcome, and the duration of hospi-
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 6 Fast Track Surgery — 2
talization was not reduced. It should be remembered, however, tions for hip fracture received either low-dose GH (20 mg/kg/day)
that in these studies, either an epidural opioid regimen or a pre- or placebo.28 Overall, those in the GH group were able to return
dominantly epidural opioid regimen was employed and that the to their prefracture living situation earlier than those in the place-
perioperative care regimens either were not described or were not bo group. A 1999 study reported increased mortality when GH
revised according to current scientific data regarding the use of was administered to ICU patients,29 but a 2001 meta-analysis
nasogastric tubes, early oral feeding, mobilization, and other care failed to confirm this observation.30 More work is necessary
parameters.3 We believe, therefore, that for further assessment of before definitive conclusions can be formed in this regard.
the role of continuous epidural local analgesic regimens that Postoperative insulin resistance is an important metabolic fac-
include local anesthetics in improving outcome, an integrated tor for catabolism. There is evidence to suggest that preoperative
approach within the context of fast track surgery is required.6 oral or intravenous carbohydrate feeding may reduce postopera-
Perioperative measures should also be taken to preserve intra- tive insulin resistance.31 Whether this approach yields clinical
operative normothermia. Hypothermia may lead to an augment- benefits in terms of improved recovery remains to be deter-
ed stress response during rewarming, impaired coagulation and mined,31,32 but its simplicity, its clear pathophysiologic rationale,
leukocyte function, and increased cardiovascular demands. and its low cost make it a potentially attractive option.
Preservation of intraoperative and early postoperative normother-
CONTROL OF NAUSEA, VOMITING, AND ILEUS
mia has been shown to decrease surgical site infection, intraoper-
ative blood loss, postoperative cardiac morbidity, and overall The ability to resume a normal diet after a surgical procedure
catabolism.11 (whether minor or major) is essential to the success of fast track
surgery. To this end, postoperative nausea, vomiting, and ileus
REDUCTION OF SURGICAL STRESS
must be controlled. Principles for rational prophylaxis of nausea
The neuroendocrine and inflammatory stress responses to and vomiting have been developed on the basis of systematic
surgery increase demands on various organs, and this increased reviews33: for example, 5-HT3 receptor antagonists, droperidol,
demand is thought to contribute to the development of postop- and dexamethasone have been shown to be effective in this
erative organ system complications. At present, the most impor- regard, whereas metoclopramide is ineffective.There is some rea-
tant of the techniques used to reduce the surgical stress response son to think that multimodal antiemetic combinations may be
are regional anesthesia, minimally invasive surgery, and pharma- superior to single antiemetic agents; unfortunately, the data cur-
cologic intervention (e.g., with steroids, beta blockers, or anabol- rently available on combination regimens are relatively sparse. In
ic agents).12 addition, analgesic regimens in which opioids are cut back or
Neural blockade with local anesthetics reduces endocrine and eliminated have been shown to decrease postoperative nausea
metabolic (specifically, catabolic) activation and sympathetic stim- and vomiting.
ulation, thereby decreasing the demands placed on organs and Paralytic ileus remains a significant cause of delayed recovery
reducing loss of muscle tissue; however, regional anesthetic tech- from surgery and contributes substantially to postoperative dis-
niques have no relevant effect on inflammatory responses.5,6 comfort and pain. Of the various techniques available for manag-
Minimally invasive surgical techniques clearly decrease pain ing ileus,34,35 continuous epidural analgesia with local anesthetics
and lessen inflammatory responses,13-15 but they appear to have is the most effective, besides providing excellent pain relief. Now
relatively little, if any, effect on endocrine and metabolic responses. that cisapride has been taken off the market, no effective anti-
Pharmacologic intervention with a single dose of a glucocorti- ileus drugs are available. In a 2001 study, however, a peripheral-
coid (usually dexamethasone, 8 mg) given before a minor proce- ly acting mu opioid receptor antagonist significantly reduced
dure has led to reduced nausea, vomiting, and pain, as well as to nausea, vomiting, and ileus after abdominal procedures, without
decreased inflammatory responses (interleukin-6), with no ob- reducing analgesia.36 If further studies confirm these findings, use
served side effects.16,17 This intervention may facilitate recovery of peripherally acting opioid antagonists may become a popular
from minor (i.e., ambulatory) procedures18; however, the data and effective way of improving postoperative recovery; this treat-
from major procedures are inconclusive.The use of perioperative ment is simple and apparently has no major side effects.
beta blockade to reduce sympathetic stimulation and thereby
ADEQUATE TREATMENT OF POSTOPERATIVE PAIN
attenuate cardiovascular demands has been shown to reduce car-
diac morbidity,19 as well as to reduce catabolism in burn patients Despite ongoing development and documentation of effective
[see Elements of Contemporary Practice:2 Risk Stratification, Pre- postoperative analgesic regimens—such as continuous epidural
operative Testing, and Operative Planning].20,21 Perioperative beta analgesia in major operations, patient-controlled analgesia
blockade may therefore become an important component of efforts (PCA), and multimodal (balanced) analgesia that includes non-
to facilitate recovery in fast track surgical programs. steroidal anti-inflammatory drugs as well as stronger agents37-39
For patients whose nutritional status is normal, oral feeding ad [see 1:5 Postoperative Pain]—postoperative pain still is too often
libitum is appropriate in the postoperative period. For patients inadequately treated. Improved pain relief, facilitated by an acute
who are elderly or nutritionally depleted, nutritional supplementa- pain service,40 is a central component of any fast track surgery
tion, administration of an anabolic agent (e.g., oxandrolone or an- program and is a prerequisite for optimal mobilization and oral
other anabolic steroid,22-24 insulin,25 or growth hormone [GH]26,27) nutrition, as well as a valuable aid in reducing surgical stress
to enhance deposition of lean tissue, or both may be beneficial. responses.37
Most of the studies addressing the use of anabolic agents have
APPROPRIATE USE OF TUBES, DRAINS, AND CATHETERS
focused on critically ill catabolic patients, in whom both indirect
effects (e.g., improved nitrogen balance26) and direct effects (e.g., There is substantial support in the literature for the idea that
improved wound healing and decreased length of stay with GH in nasogastric tubes should not be used routinely in patients undergo-
burned children27 and decreased mortality with insulin in critical- ing elective abdominal surgery.1,2 Randomized trials indicated that
ly ill patients25) on outcome have been demonstrated. In a study drains offered little benefit after cholecystectomy, joint replace-
published in 2000, a group of elderly patients undergoing opera- ments, colon resection, thyroidectomy, radical hysterectomy, or
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 6 Fast Track Surgery — 3
pancreatic resection1,3,41 but that they might limit seroma forma- or a slightly modified fast track care program. On the whole, the
tion after mastectomy.1,3 Such postmastectomy drainage does not preliminary results from these studies are very positive: fast track
necessarily impede hospital discharge, and the patient generally surgery is associated with shorter hospital stays, reduced or at
may be treated on an outpatient basis. Urinary catheterization has least comparable morbidities, and low readmission rates, with no
been routinely performed after many operations, but scientific doc- apparent decrease in safety.
umentation of the requirement for this measure is often lacking. In Studies of fast track surgery in which organ function was
general, catheterization beyond 24 hours is not recommended with assessed postoperatively and compared with organ function after
colorectal procedures, except with the lowest rectal procedures, for traditional care found fast track surgery to be associated with ear-
which 3 to 4 days of catheterization may be indicated.3 lier ambulation,43,44 superior postoperative muscle function,44
Although tubes, drains, and catheters may lead to morbidity improved oral nutritional intake,45 better preservation of lean body
only when used for extended periods, they do tend to hinder mass,43,45 reduced postoperative impairment of pulmonary func-
mobilization, and they can raise a psychological barrier to the pa- tion,43 earlier recovery of GI motility,46 and mitigation of the de-
tient’s active participation in postoperative rehabilitation. There- crease in exercise capacity and impairment of cardiovascular
fore, such devices should be used not routinely but selectively, in response to exercise that are usually expected after an operation.43
accordance with the available scientific documentation. The few randomized trials performed to date (mostly involving
patients undergoing cholecystectomy, colonic resection, or mastec-
NURSING CARE, NUTRITION, AND MOBILIZATION
tomy) reported that fast track programs increased or at least main-
Postoperative nursing care should include psychological sup- tained patient satisfaction while achieving major cost reductions.
port for early rehabilitation, with a particular focus on encourag-
ing the patient to resume a normal diet and become ambulatory
as soon as possible. Early resumption of an oral diet is essential for Future Developments
self-care; furthermore, according to a 2001 meta-analysis of con- The initial promising results from the fast track surgical pro-
trolled trials, it may reduce infectious complications and shorten grams studied suggest that such programs can achieve major care
hospital stay after abdominal procedures, without increasing the improvements in terms of reducing postoperative stay. At present,
risk of anastomotic dehiscence.42 In addition, early resumption of however, sufficient scientific documentation is lacking for many
enteral feeding may reduce catabolism and may be facilitated by commonly performed major operations. Thus, there is a need for
the methods used to reduce postoperative nausea, vomiting, and additional data—in particular, data on the potential positive
ileus (see above). effects of fast track surgery on postoperative morbidity. The nec-
Postoperative bed rest is undesirable because it increases mus- essary data would probably be best obtained through multicenter
cle loss, decreases strength, impairs pulmonary function and tis- trials using identical protocols. Randomized trials within the same
sue oxygenation, and predisposes to venous stasis and throm- unit that allocate some patients to suboptimal care recommenda-
boembolism.3 Accordingly, every effort should be made to enforce tions for pain relief, mobilization, and nutrition would be difficult
postoperative mobilization; adequate pain relief is a key adjuvant to perform, if not unethical, though a few such reports have been
measure in this regard. published on colon surgery patients.44,47
Organization is essential for good postoperative nursing care: a As yet, it has not been conclusively demonstrated that reducing
prescheduled care map should be drawn up, with goals for reha- the duration of hospitalization necessarily reduces morbidity,48
bilitation listed for each day. though data from studies addressing colonic and vascular proce-
dures suggest that nonsurgical (i.e., cardiopulmonary and throm-
DISCHARGE PLANNING
boembolic) morbidity may be reduced and overall postoperative
Given that a primary result of fast track surgery is reduced recovery (assessed in terms of exercise performance and muscle
length of hospitalization, discharge planning must be a major con- power) enhanced. More study is required in this area. Future tri-
sideration in the preoperative patient information program, as als should also focus on identifying any factors that might be lim-
well as during hospitalization. Careful, detailed discharge plan- iting even more aggressive early recovery efforts, so that more
ning is essential for reducing readmissions and increasing patient effective fast track programs can be designed. Finally, studies are
safety and satisfaction. The discharge plan should include (1) needed to identify potential high-risk patient groups for whom fast
detailed information on the expected time course of recovery, (2) track surgery may not be appropriate or who may need to be hos-
recommendations for convalescence, and (3) encouragement of pitalized for slightly longer periods to optimize organ function.47
enteral intake and mobilization. For patients with a significant There has been considerable interest in whether the use of crit-
degree of postoperative disability, various acute care facilities are ical pathways improves postoperative care. Preliminary studies
available after hospital discharge. It should be kept in mind, how- involving coronary artery bypass grafting, total knee replacement,
ever, that the integrated care approach fundamental to fast track colectomy, thoracic procedures, and hysterectomy suggested that
surgery is specifically intended as a way of limiting or preventing critical pathways may reduce length of hospital stay, but the
such disability, thereby reducing patients’ need for and depen- reduction is no greater than can be observed in neighboring hos-
dence on postdischarge care facilities. pitals that do not use critical pathways.49 Thus, the initial enthusi-
asm for critical pathways notwithstanding, conclusive evidence
that they have a beneficial effect on postoperative care is still lack-
Reported Results ing.The continuously decreasing length of stay noted in hospitals
Ongoing efforts to formulate multimodal strategies aimed at without fast track programs may be partly attributable to the
improving postoperative outcome have led to the development of intense competition within the health care system, which can lead
a variety of fast track surgical programs [see Table 1]. Most of the to changes in care principles even without the formal adoption of
studies published to date have been descriptive ones reporting critical pathways or similar systems.49
consecutive patient series from single centers, the findings from All of the studies on the economic implications of fast track sur-
which have often been confirmed by other groups using the same gical programs and critical pathways have documented substantial
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 6 Fast Track Surgery — 4
Abdominal procedures
Inguinal hernia repair59-61 1.5–6 hr Large consecutive series using local infiltration anesthesia in > 95%, with one
series59 using unmonitored anesthesia; documented low morbidity, with no urinary
retention; patient satisfaction ~90%, cost reduction > $250 with local anesthesia
Cholecystectomy (laparoscopic,62-67 > 80% discharge on same day Large consecutive series, with documented safety and patient satisfaction > 80%;
mini-incision68) cost reduction of $750/patient in randomized study64; recovery of organ functions
within 2–3 days, with <1 wk convalescence67; similar results with mini-incision in
consecutive series68
Fundoplication69,70 > 90% < 23 hr Large consecutive series with documented safety70
Open43,44,46,47,56,71-76 and laparo- 2–4 days Consecutive series including high-risk patients; reduced cardiopulmonary morbidity,
scopic72,77-79 colorectal procedures readmission rates 0%–15%; no documented advantages of laparoscopy-assisted
colonic resection, though costs may be reduced72; ileus reduced to < 48 hr in
> 90% of patients,46,56 with improved muscle and pulmonary function in fast track
patients and better preservation of postoperative body composition43; one random-
ized study showed similar morbidity, readmissions, and satisfaction with fast track
versus traditional care47
Complex pelvic-colorectal 3–6 days Short stay80 (~4–6 days) even with additional stoma; low readmission rate (7%)
procedures80,81
Rectal prolapse82 80% < 24 hr Consecutive series (N = 63) with Altemeier repair; 5% readmission rate (nonserious
indications)
Pancreaticoduodenectomy,83,84 — Hospital stay decreased by implementation of clinical pathway
complex biliary tract procedures85
Mastectomy86-90 90% < 1 day Large cumulative series; documented safety and major cost reduction with high
patient satisfaction; no increased morbidity with fast track, but less wound pain and
improved arm movement and no increase in risk of psychosocial complications
Vascular procedures
Carotid endarterectomy91-94 90% < 1 day Surgery done with local anesthesia; specialized nurses and wards
Lower-extremity arterial bypass95 2–3 days Large series (N = 130); documented safety
Abdominal aortic aneurysmectomy96,97 ~3 days Preliminary studies (N = 5096 and N = 7797); documented early recovery and safety;
one study with epidural analgesia,97 one without96
Urologic procedures
Radical prostatectomy98 ~75% 1 day Large consecutive series (N = 252); documented safety and patient satisfaction
Laparoscopic adrenalectomy99-101 < 1 day Small series; safety and low morbidity suggested
Cystectomy102,103 7 days Improved mobilization, bowel function, and sleep recovery with fast track surgery102;
low mortality; ileus a problem102,103
Laparoscopic donor nephrectomy104 < 1 day Preliminary study (N = 41); low readmission rate (2%)
Pulmonary procedures106-110 ~1 day in some series,106,107 Shortest stay with fast track protocol including revision of drainage principles106,107;
~4–5 days in others safety with very early discharge suggested
Other procedures
Craniotomy111 ~40% < 24 hr Large consecutive series (N = 241) including tumor surgery; local anesthesia used;
low readmission rate; safety suggested
Parathyroid procedures112 ~90% ambulatory Selected consecutive series (N = 100); regional anesthesia and intraoperative
adenoma localization employed; documented safety
Vaginal procedures113 ~1 day Consecutive series (N = 108); surgery done with local anesthesia
cost savings. It should, however, be borne in mind that the last thereby achieving additional cost savings. As noted, the large-scale
portion of a hospital stay is much less expensive than the initial data with detailed patient description and stratification that are
portion; thus, the cost savings in this area may turn out to be needed to clarify the improvements achieved by fast track surgery
smaller than they would at first appear.50-52 This cavil should not are, unfortunately, lacking at present, but so far, all indications are
hinder further development and documentation of fast track that postoperative morbidity is comparable or reduced.
surgery, because inherent in the concept is the idea that revision A commonly expressed concern is that fast track surgery might
and optimization of perioperative care may also reduce morbidity, increase the burden on general practitioners and other parts of the
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 6 Fast Track Surgery — 5
nonhospital care system. The evidence currently available clearly addressed patient functional status after fast track colonic surgery
indicates that increased use of ambulatory surgery is safe and is suggested that muscle function, exercise capacity, and body compo-
associated with a very low readmission rate.53,54 After major proce- sition are better preserved with this approach than with traditional
dures such as colorectal surgery, however, readmissions are often care, in which surgical stress, insufficient nutrition, and prolonged
unpredictable, and the readmission rate is not significantly reduced immobilization typically lead to significant deterioration of organ
by keeping patients in the hospital for an additional 2 to 3 days.55,56 function. Accordingly, an optimal fast track surgery regimen should
Moreover, in some studies of patients who have undergone coro- aim at early recovery of organ function, not just early discharge.
nary bypass57 and hip replacement,58 earlier discharge and hospital In summary, the basic concept of fast track surgery, which
cost savings have been offset by increased use of postacute rehabil- could be expressed as multimodal control of perioperative patho-
itation services. Thus, any assessment of the costs associated with physiology, seems to be a highly promising approach to improving
fast track surgery should include the total period during which care surgical outcome. We believe that the principles and techniques
(including both hospital care and rehabilitation care) is delivered. embodied in this approach will eventually be integrated into the
Again, however, it should be emphasized that the basic concept care of all surgical patients. To this end, resources should be allo-
of fast track surgery implies control of perioperative pathophysiolo- cated for evaluation and documentation of the effects of fast track
gy with the aim of enhancing recovery and thereby reducing the surgery and related systems on cost, postoperative morbidity, safe-
need for postdischarge care.The relatively few published studies that ty, and overall patient well-being.
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© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 7 INFECTION CONTROL IN SURGICAL PRACTICE — 1
7 INFECTION CONTROL IN
SURGICAL PRACTICE
Vivian G. Loo, M.D., M.Sc., and A. Peter McLean, M.D., F.A.C.S.
Surgical procedures, by their very nature, interfere with the nor- example, the emergence of drug-resistant microorganisms, such as
mal protective skin barrier and expose the patient to microorgan- methicillin-resistant Staphylococcus aureus (MRSA), glycopeptide-
isms from both endogenous and exogenous sources. Infections intermediate S. aureus (GISA), multidrug-resistant Mycobacterium
resulting from this exposure may not be limited to the surgical site tuberculosis, and multidrug-resistant Enterococcus strains.13-16 Such
but may produce widespread systemic effects. Prevention of surgi- complications reemphasize the need to focus on infection control
cal site infections (SSIs) is therefore of primary concern to sur- as an essential component of preventive medicine.
geons and must be addressed in the planning of any operation. Besides the impact of morbidity and mortality on patients, there
Standards of control have been developed for every step of a sur- is the cost of treating nosocomial infections, which is a matter of
gical procedure to help reduce the impact of exposure to microor- concern for surgeons, hospital administrators, insurance compa-
ganisms.1-3 Traditional control measures include sterilization of nies, and government planners alike. Efforts to reduce the occur-
surgical equipment, disinfection of the skin, use of prophylactic rence of nosocomial infections are now a part of hospital cost-con-
antibiotics, and expeditious operation. trol management programs.17,18 The challenge to clinicians is how
The Study on the Efficacy of Nosocomial Infection Control to reduce cost while maintaining control over, and preventing
(SENIC), conducted in United States hospitals between 1976 and spread of, infection.
1986, showed that surgical patients were at increased risk for all
types of infection.The nosocomial, or hospital-acquired, infection
rate at that time was estimated to be 5.7 cases out of every 100 The Surgical Wound and Infection Control
hospital admissions.4 These infections included SSIs as well as Nosocomial infections are defined as infections acquired in the
bloodstream, urinary, and respiratory infections. Today, the hospital.There must be no evidence that the infection was present
increased use of minimally invasive surgical procedures and early or incubating at the time of hospital admission. Usually, an infec-
discharge from the hospital necessitates postdischarge surveil- tion that manifests 48 to 72 hours after admission is considered to
lance5 in addition to in-hospital surveillance for the tracking of be nosocomially acquired. An infection that is apparent on the day
nosocomial infections. With the reorganization of health care of admission is usually considered to be community acquired,
delivery programs, nosocomial infections will appear more fre- unless it is epidemiologically linked to a previous admission or to
quently in the community and should therefore be considered a an operative procedure at the time of admission.
part of any patient care assessment plan.
IDENTIFICATION OF RISK FACTORS
Care assessment programs designed to help minimize the risk
of nosocomial infections were first introduced in 1951 by the Joint The risk of development of an SSI depends on host factors,
Commission on Accreditation of Healthcare Organizations perioperative wound hygiene, and the duration of the surgical pro-
(JCAHO). Since then, as medical technology has changed, cedure. The risk of development of other nosocomial infections
JCAHO has redesigned the survey process. In its plan for infection depends on these and other factors, including length of the hospi-
control programs, JCAHO strongly recommends that the survey, tal stay and appropriate management of the hospital environment
documentation, and reporting of infections be made mandatory [see Activities of an Infection Control Program, below]. Identifi-
for the purpose of hospital accreditation.6 cation of host and operative risk factors can help determine the
Effective infection control and prevention requires an orga- potential for infection and point toward measures that might be
nized, hospital-wide program aimed at achieving specific objec- necessary for prevention and control.
tives. The program’s purpose should be to obtain relevant infor-
mation on the occurrence of nosocomial infections both in Host Risk Factors
patients and in employees. The data should be documented, ana- Host susceptibility to infection can be estimated according to the
lyzed, and communicated with a plan for corrective measures. following variables: older age, severity of disease, physical-status
Such surveillance activities, combined with education, form the classification (see below), prolonged preoperative hospitalization,
basis of an infection control program. morbid obesity, malnutrition, immunosuppressive therapy, smok-
Data relating to host factors are an integral part of infection ing, preoperative colonization with S. aureus, and coexistent infec-
data analysis. Documentation of host factors has made for a bet- tion at a remote body site.19
ter appreciation of the associated risks and has allowed compara- A scale dividing patients into five classes according to their
tive evaluation of infection rates. Development of new surgical physical status was introduced by the American Society of
equipment and technological advances have influenced the impact Anesthesiologists (ASA) in 1974 and tested for precision in
of certain risk factors, such as lengthy operation and prolonged 1978.20 The test results showed that the ASA scale is a workable
hospital stay. Clinical investigations have helped improve the system, although it lacks scientific definition [see Table 1].
understanding of host factors and have influenced other aspects of Significant differences in infection rates have been shown in
surgical practice.7-12 Excessive use of and reliance on antibiotics patients with different illnesses. In one prospective study, the
have led to problems not previously encountered in practice—for severity of underlying disease (rated as fatal, ultimately fatal, or
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 7 INFECTION CONTROL IN SURGICAL PRACTICE — 2
Table 1 American Society of Anesthesiologists and an operation lasting over T hours (where T represents the
Physical-Status Scale 75th percentile of distribution of the duration of the operative
procedure being performed, rounded to the nearest whole num-
Class 1 A normally healthy individual ber of hours).
Class 2 A patient with mild systemic disease
Class 3 A patient with severe systemic disease that is not Modified NNIS basic risk index for procedures using
incapacitating laparoscopes For cholecystectomy and colon surgery proce-
Class 4 A patient with incapacitating systemic disease that is a dures, the use of a laparoscope lowered the risk of SSI within each
constant threat to life
NNIS risk index category.27 Hence, for these procedures, when
Class 5 A moribund patient who is not expected to survive 24 hr
with or without operation the procedure is performed laparoscopically, the risk index should
be modified by subtracting 1 from the basic NNIS risk index
E Added for emergency procedures score. With this modification, the risk index has values of M (or
–1), 0, 1, 2, or 3. For appendectomy and gastric surgery, use of a
laparoscope affected SSI rates only when the NNIS basic risk
nonfatal) was shown to have predictive value for endemic noso- index was 0, thereby yielding five risk categories: 0–Yes, 0–No, 1,
comial infections: the nosocomial infection rate in patients with 2, and 3, whereYes or No refers to whether the procedure was per-
fatal diseases was 23.6%, compared with 2.1% in patients with formed with a laparoscope.27
nonfatal diseases.21
Operation-specific risk factors It is likely that operation-
Operative Risk Factors specific logistic regression models will increasingly be used to cal-
Several factors related to the operative procedure may be asso- culate risk. For example, in spinal fusion surgery, Richards and
ciated with the risk of development of an SSI [see 1:2 Prevention of colleagues identified diabetes mellitus, ASA score greater than 3,
Postoperative Infection].These include method of hair removal (and operation duration longer than 4 hours, and posterior surgical
likelihood of consequent skin injury), inappropriate use of antimi- approach as significant independent predictors of SSI.28 Other
crobial prophylaxis, duration of the operation, and wound classi- logistic regression models have been developed for craniotomy
fication. The influence of hair removal methods on SSI has been and cesarean section.29,30 These models should permit more pre-
examined by many investigators. Lower infection rates were cise risk adjustment.
reported with the use of depilatory agents and electric clippers
PREVENTIVE MEASURES
than with razors.7,8 Antimicrobial prophylaxis is used for all oper-
ations that involve entry into a hollow viscus. Antimicrobial pro- In any surgical practice, policies and procedures should be in
phylaxis is also indicated for clean operations in which an intra- place pertaining to the making of a surgical incision and the pre-
articular or intravascular prosthetic device will be inserted and for vention of infection.These policies and procedures should govern
any operation in which an SSI would have a high morbidity.19 A the following: (1) skin disinfection and hand-washing practices of
comprehensive study determined that there is considerable varia- the operating team, (2) preoperative preparation of the patient’s
tion in the timing of administration of prophylactic antibiotics, but skin (e.g., hair removal and use of antiseptics), (3) the use of pro-
that the administration within 2 hours before surgery reduces the phylactic antibiotics, (4) techniques for preparation of the opera-
risk of SSI.9 tive site, (5) management of the postoperative site if drains, dress-
Operative wounds are susceptible to varying levels of bacterial ings, or both are in place, (6) standards of behavior and practice
contamination, by which they are classified as clean, clean-contami- for the operating team (e.g., the use of gown, mask, and gloves),
nated, contaminated, or dirty.22 In most institutions, the responsibil- (7) special training of the operating team, and (8) sterilization and
ity for classifying the incision site is assigned to the operating room disinfection of instruments.
circulating nurse; one assessment suggests that the accuracy of deci-
sions made by this group is as high as 88%.23 Hand Hygiene
Although hand washing is considered the single most important
Composite Risk Indices measure for preventing nosocomial infections, poor compliance is
The Centers for Disease Control and Prevention (CDC) estab- frequent.31 Role modeling is important in positively influencing this
lished the National Nosocomial Infections Surveillance (NNIS) behavior. One study showed that a hand-washing educational pro-
system in 1970 to create a national database of nosocomial infec- gram contributed to a reduction in the rate of nosocomial infec-
tions.24 The NNIS system has been used to develop indices for tions.32 Good hand-washing habits can be encouraged by making
predicting the risk of nosocomial infection in a given patient. facilities (with sink, soap, and towel) visible and easily accessible in
patient care areas [see 1:2 Prevention of Postoperative Infection].
NNIS basic risk index NNIS developed a composite risk Cleansers used for hand hygiene include plain nonantimicro-
index composed of the following criteria: ASA score, wound class, bial soap, antimicrobial soaps, and waterless alcohol-based hand
and duration of surgery. Reporting on data collected from 44 antiseptics. Plain soaps have very little antimicrobial activity; they
United States hospitals between 1987 and 1990, NNIS demon- mainly remove dirt and transient flora.33 Compared with plain
strated that this risk index is a significantly better predictor for soaps, antimicrobial soaps achieve a greater log reduction in elim-
development of SSI than the traditional wound classification sys- inating transient flora and have the additional advantage of sus-
tem alone.25,26 The NNIS risk index is a useful method of risk tained activity against resident hand flora.33 Alcohol-based hand
adjustment for a wide variety of procedures. antiseptics have an excellent spectrum of antimicrobial activity
The NNIS risk index is scored as 0, 1, 2, or 3. A patient’s and rapid onset of action, dry rapidly, and do not require the use
score is determined by counting the number of risk factors pres- of water or towels.34 Therefore, they are recommended for routine
ent from among the following: an ASA score of 3, 4, or 5; a sur- decontamination of hands during patient care except when hands
gical wound that is classified as contaminated or dirty/infected; are visibly soiled. Emollients are often added to alcohol-based
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 7 INFECTION CONTROL IN SURGICAL PRACTICE — 3
Hepatitis C virus The average incidence of seroconversion (www.cdc.gov/mmwr/pdf/rr/rr4313.pdf). The following measures
after percutaneous exposure from an HCV-positive source is 1.8% should be considered:
(range, 0% to 7%).55-57 Mucous membrane exposure to blood
1. The use of risk assessments and development of a written
rarely results in transmission, and no transmission has been docu-
tuberculosis control protocol.
mented from exposure of intact or nonintact skin to blood.50,58
There is no recommended postexposure prophylaxis regimen for 2. Early identification and treatment of persons who have
HCV. The use of immunoglobulin has not been demonstrated to tuberculosis.
be protective.50 There are no antiviral medications recommended 3. Tuberculosis screening programs for health care workers.
for postexposure prophylaxis.50 4. Training and education.
5. Evaluation of tuberculosis infection control programs.61
Human immunodeficiency virus Exposure to blood and
body substances of patients who have AIDS or who are seroposi- Activities of an Infection Control Program
tive for HIV constitutes a health hazard to hospital employees.The
magnitude of the risk depends on the degree and method of expo- SURVEILLANCE
sure [see 8:21 Acquired Immunodeficiency Syndrome].
The presence of HIV infection in a patient is not always known. The cornerstone of an infection control program is surveillance.
Because the prevalence of HIV in the North American patient pop- This process depends on the verification, classification, analysis,
ulation is less than 1% (range, 0.09% to 0.89%), and because a care- reporting, and investigation of infection occurrences, with the
giver’s risk of seroconversion after needlestick injury is likewise less intent of generating or correcting policies and procedures. Five
than 1%, the CDC recommends taking standard precautions [see surveillance methods can be applied62,63:
8:20 Viral Infection] and following in all patients the same guidelines 1. Total, or hospital-wide, surveillance-collection of compre-
for invasive procedures that one would use in cases of known HBV- hensive data on all infections in the facility, with the aim of
infected patients [see Table 2].48 Infection control personnel have in- correcting problems as they arise. This is labor intensive.
troduced realistic control measures and educational programs to 2. Surveillance by objective, or targeted surveillance, in which
help alleviate fears that health care workers might have about com- a specific goal is set for reducing certain types of infection.
ing in contact with patients infected with HIV. This concept is priority-directed and can be further subdi-
Exposure to Tuberculosis vided into two distinct activities:
a. The setting of outcome objectives, in which the objectives
In studies of health care workers, positive results on tuberculin for the month or year are established and all efforts
skin testing have ranged from 0.11% to 10%.59,60 Health care applied to achieve a desired rate of infection. As with the
workers who are immunocompromised are at high risk for devel- hospital-wide approach, a short-term plan would be made
opment of disease postexposure.59 to monitor, record, and measure results and provide feed-
The CDC recommendation for tuberculosis prevention places back on the data.
emphasis on a hierarchy of control measures, including adminis- b. The setting of process objectives, which incorporates the
trative engineering controls and personal respiratory protection patient care practices of doctors and nurses as they relate to
outcome (e.g., wound infections and their control).
3. Periodic surveillance—intensive surveillance of infections
Table 3 ACS Recommendations for and patient-care practices by unit or by service at different
times of the year.
Preventing Transmission of Hepatitis54 4. Prevalence survey—the counting and analysis of all active
Surgeons should continue to utilize the highest standards of infec- infections during a specified time period.This permits iden-
tion control, involving the most effective known sterile barriers, uni- tification of nosocomial infection trends and problem areas.
versal precautions, and scientifically accepted measures to pre-
vent blood exposure during every operation. This practice should 5. Outbreak surveillance—the identification and control of out-
extend to all sites where surgical care is rendered and should breaks of infection. Identification can be made on the basis
include safe handling practices for needles and sharp instru- of outbreak thresholds if baseline bacterial isolate rates are
ments.
available and outbreak thresholds can be developed. Prob-
Surgeons have the same ethical obligations to render care to
patients with hepatitis as they have to render care to other lems are evaluated only when the number of isolates of a par-
patients. ticular bacterial species exceeds outbreak thresholds.
Surgeons with natural or acquired antibodies to HBV are protected
from acquiring HBV from patients and cannot transmit the disease Surveillance techniques include the practice of direct patient
to patients. All surgeons and other members of the health care observation7 and indirect observation by review of microbiology
team should know their HBV immune status and become immu-
nized as early as possible in their medical career. reports, nursing Kardex, or the medical record to obtain data on
Surgeons without evidence of immunity to HBV who perform proce- nosocomial infections. The sensitivity of case finding by microbi-
dures should know their HBsAg status and, if this is positive, ology reports was found to be 33% to 65%; by Kardex, 85%; and
should also know their HBeAg status. In both instances, expert
medical advice should be obtained and all appropriate measures
by total chart review, 90%.62 These methods may be used either
taken to prevent disease transmission to patients. Medical advice separately or in combination to obtain data on clinical outcomes.
should be rendered by an expert panel composed and convened One use of surveillance data is to generate information for indi-
to fully protect practitioner confidentiality. The HBeAg-positive sur-
geon and the panel should discuss and agree on a strategy for vidual surgeons, service chiefs, and nursing personnel as a
protecting patients at risk for disease transmission. reminder of their progress in keeping infections and diseases
On the basis of current information, surgeons infected with HCV under control.This technique was used by Cruse in 1980 to show
have no reason to alter their practice but should seek expert
medical advice and appropriate treatment to prevent chronic liver
a progressive decrease in infection rates of clean surgical wounds
disease. to less than 1% over 10 years.8 In other settings, endemic rates of
bloodstream, respiratory, and urinary tract infections were cor-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 7 INFECTION CONTROL IN SURGICAL PRACTICE — 6
tion, the epidemic curve helps to determine the probable incu- acquisition include length of hospital stay, liver transplantation,
bation period and how the disease is being transmitted (i.e., a presence of feeding tubes, dialysis, and exposure to cephalo-
common source versus person to person). sporins.78 Contact precautions are indicated for patients infected
4. Review the charts of case patients to determine demographics or colonized with VRE.79
and exposures to staff, medications, therapeutic modalities, Strategies to prevent and control the emergence and spread of
and other variables of importance. antimicrobial-resistant microorganisms have been developed.
5. Perform a line listing of case patients to determine whether These include optimal use of antimicrobial prophylaxis for surgi-
there is any common exposure. cal procedures; optimizing choice and duration of empirical ther-
6. Calculate the infection rate. The numerator is the number of apy; improving antimicrobial prescribing patterns by physicians;
infected patients and the denominator is the number of pa- monitoring and providing feedback regarding antibiotic resis-
tients at risk. tance; formulating and using practice guidelines for antibiotic
7. Formulate a tentative hypothesis to explain the reservoir and usage; developing a system to detect and report trends in antimi-
the mode of transmission. A review of the literature on similar crobial resistance; ensuring that caregivers respond rapidly to the
outbreaks may be necessary. detection of antimicrobial resistance in individual patients; incor-
8. Test the hypothesis, using a case-control study, cohort study, porating the importance of controlling antimicrobial resistance
prospective intervention study, or microbiologic study. A case- into the institutional mission and climate; increasing compliance
control study is usually used, because it is less labor intensive. with basic infection control policies and procedures; and develop-
For a case-control study, control subjects should be selected ing a plan for identifying, transferring, discharging, and readmit-
from an uninfected surgical population of patients who were ting patients colonized or infected with specific antimicrobial-
hospitalized at the same time as those identified during the epi- resistant microorganisms.80
demic period and matched for age, gender, service operation,
operation date, and health status (ASA score). Two or three Severe Acute Respiratory Syndrome
control patients are usually selected for every case patient.The The severe acute respiratory syndrome (SARS) first emerged in
cases and controls are then compared with respect to possible Guangdong Province, China, in November 2002. SARS is caused
exposures that may increase the risk of disease. Patient, per- by a novel coronavirus (SARS-CoV) that may have originated from
sonnel, and environmental microbiologic isolates (if any) an animal reservoir.81 It is characterized by fever, chills, cough, dys-
should be kept for fingerprinting (e.g., pulsed-field gel electro- pnea, and diarrhea and radiologic findings suggestive of atypical
pheresis, random amplified polymorphic DNA polymerase pneumonia.82 As of August 7, 2003, a total of 8,422 probable cases,
chain reaction). with 916 deaths (11%), had been reported from 29 countries.83
9. Institute infection control measures. This may be done at any The incubation period is estimated to be 10 days, and patients
time during the investigation.The control measures should be appear to be most infectious during the second week of illness.83
reviewed after institution to determine their efficacy and the Available evidence suggests that SARS-CoV is spread through con-
possible need for changing them. tact, in droplets, and possibly by airborne transmission.83 Accord-
10. Report the incident to the infection control committee and, at ingly, health care workers must adhere to contact, droplet, and air-
the completion of the investigation, submit a report. The borne precautions when caring for SARS patients. Included in such
administrators, physicians, and nurses involved should be precautions are the use of gloves, gowns, eye protection, and the
informed and updated as events change.68 N95 respirator.83 A comprehensive review of SARS is available at
the WHO web site (www.who.int/csr/sars/en/WHOconsensus.pdf).
ANTIMICROBIAL-RESISTANT MICROORGANISMS
ENVIRONMENTAL CONTROL
Hospitals and communities worldwide are facing the challenge
posed by the spread of antimicrobial-resistant microorganisms. Strains Control of the microbial reservoir of the patient’s immediate
of MRSA are increasing in hospitals and are an important cause of environment in the hospital is the goal of an infection control pro-
nosocomial infections; in the United States in the year 2002, the pro- gram. Environmental control begins with design of the hospital’s
portion of S.aureus isolates resistant to methicillin or oxacillin was more physical plant.The design must meet the functional standards for
than 55%.69 MRSA strains do not merely replace methicillin-sus- patient care and must be integrated into the architecture to pro-
ceptible strains as a cause of hospital-acquired infections but actually vide traffic accessibility and control. Since the 1960s, the practice
increase the burden of nosocomial infections.70 Moreover, there are of centralizing seriously ill patients in intensive care, dialysis, and
reports that MRSA may be becoming a community-acquired transplant units has accentuated the need for more careful analy-
pathogen.71,72 A proactive approach for controlling MRSA at all lev- sis and planning of space.The primary standards for these special
els of health care can result in decreased MRSA infection rates.73,74 care units and ORs require planning of floor space, physical sur-
Strains of GISA, an emerging pathogen, exhibit reduced sus- faces, lighting, ventilation, water, and sanitation to accommodate
ceptibility to vancomycin and teicoplanin. The first GISA strain easy cleaning and disinfecting of surfaces, sterilization of instru-
was isolated in 1996 in Japan.75 DNA fingerprinting suggests that ments, proper food handling, and garbage disposal. These activi-
these GISA strains evolved from preexisting MRSA strains that ties should then be governed by workable policies that are under-
infected patients in the months before the GISA infection. standable to the staff. Preventive maintenance should be a basic
Contact precautions are indicated for patients infected or colo- and integral activity of the physical plant department.
nized with GISA; infection control guidelines to prevent the Surveillance of the environment by routine culturing of operat-
spread of GISA are available.76 ing room floors and walls was discontinued in the late 1970s.
VRE accounts for 31% of all enterococci in the NNIS system.70 Autoclaves and sterilization systems should, however, be continu-
Transmission usually occurs through contact with the contami- ously monitored with routine testing for efficiency and perfor-
nated hands of a health care worker.The environment is an impor- mance.The results should be documented and records maintained.
tant reservoir for VRE, but it is not clear whether the environment Investigations of the physical plant should be reserved for spe-
plays a significant role in transmission.77 Risk factors for VRE cific outbreaks, depending on the organism and its potential for
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 7 INFECTION CONTROL IN SURGICAL PRACTICE — 8
causing infection.This was demonstrated by the incident of a clus- Benefits of an Infection Control Program
ter outbreak of sternal wound Legionella infections in post–cardio- The establishment of an infection control program can greatly
vascular surgery patients after they were exposed to tap water dur- benefit a hospital. An infection control program supports patient
ing bathing.84 Because outbreaks of nosocomial respiratory infec- care activities and is a means for continuous quality improvement
tions caused by L. pneumophila continue to be a problem,85 the in the care that is given, in addition to being an accreditation
CDC includes precautionary measures for this disease in its pneu- requirement. In Canada and the United States, the need for infec-
monia prevention guidelines.86 In addition, several water-treat- tion control programs is supported by all governing agents, includ-
ment measures are available to help eradicate or clear the water of ing the Canadian Council on Hospital Accreditation, JCAHO, the
these bacteria.87 American Hospital Association (AHA), the Canadian Hospital
Hospital-acquired aspergillosis is caused by another ubiquitous
Association, the Association for Practitioners in Infection Control
type of microorganism that is often a contaminant of ambient air
(APIC), the Society of Hospital Epidemiologists of America (SHEA)
during construction.The patients most at risk are usually immuno-
Joint Commission Task Force, and the Community and Hospital
suppressed (i.e., neutropenic). It is recommended that preventive
Infection Control Association–Canada (CHICA-Canada).
measures be organized for these patients when construction is
An infection control program requires a multidisciplinary com-
being planned.88 The provision of clean (i.e., HEPA-filtered) air in
mittee that includes an infection control practitioner, who may be
positive pressure-ventilated rooms, with up to 12 air exchanges an
a nurse or a technician. In the original concept, Infection Control
hour, is the basic requirement for these patients.42
Officer was the title given to the person in charge of the program.
A comprehensive review of environmental infection control in
As the practice has expanded into research and more sophisticat-
health care facilities is available at the CDC Web site (www.cdc.gov/
ed data analysis, physicians and nurses have had to update their
mmwr/pdf/rr/rr5210.pdf).This review contains recommendations
epidemiologic skills, and some hospitals have acquired the services
for preventing nosocomial infections associated with construction,
of an epidemiologist.The historical development of infection con-
demolition, and renovation.
trol programs in hospitals dates to the late 1970s.The SENIC pro-
EDUCATION ject endorsed the use of nurses89 because of their patient care
A strategy for routine training of the health care team is neces- expertise; the literature contains many examples of collaboration
sary at every professional level. The process may vary from insti- between infection control officers and nurse practitioners.
tution to institution, but some form of communication should be Controlling and preventing the spread of infections in health
established for the transmittal of information about the following: care facilities has taken many forms:
work with the infection control service to make decisions in the fol- grams are available to assist with professional and organizational de-
lowing areas: (1) assessing the effectiveness and pertinence of infec- velopment (see below), and the APIC certification program supports
tion control policies and protocols in their areas and (2) raising infec- continuous professional improvement. A viable and useful program
tion control–related concerns. for surveillance and collection of data requires a computer database
program networked to microbiology, the OR, and nursing units.
INFECTION CONTROL SERVICE
Methods for collecting, editing, storing, and sharing data should be
Collecting surveillance data on nosocomial infections and taking based on the CDC’s NNIS system,26 which promotes the use of
actions to decrease nosocomial infections are the benchmarks of the high-quality indicators for future monitoring and comparison
infection control service. In the traditional sense, the service provides among health care institutions.
information on all types of endemic infections (e.g., wound, urinary Training programs for infection control practitioners are avail-
tract, and bloodstream) to the benefit of the health care system.The able through the following organizations:
cost-effectiveness of data collection was demonstrated by the SENIC
study.90 Since then, other studies have shown that there are benefits Society of Hospital Epidemiologists of America (SHEA)
in reducing nosocomial infection.17,18,50 Cruse and Foord presented 19 Mantua Road, Mt. Royal, NJ 08061
data to show that clean-wound infection rates could be brought be- Telephone: 856-423-7222; Fax: 856-423-3420
low 0.8%.8 Such reductions bring multiple benefits because nosoco- E-mail: sheamtg@talley.com
mial infections have a substantial impact on morbidity, mortality, Web site: www.shea-online.org
length of stay, and cost90; for example, the extra costs of treating Association for Professionals in Infection Control (APIC)
bloodstream infections in an intensive care setting were recently esti- 1275 K Street NW, Suite 1000
mated to be $40,000 per survivor.91 Washington, DC 20005-4006
INFECTION CONTROL PRACTITIONERS Telephone: 202-789-1890; Fax: 202-789-1899
E-mail: APICinfo@apic.org
The reshaping of hospitals because of cost constraints will have an Web site: www.apic.org
effect on the work of infection control practitioners. Already, some
institutions have regrouped responsibilities and changed the role of Community and Hospital Infection Control Association–Canada
these professionals. Given the accreditation mandate, the need to (CHICA-Canada)
continue an active program may be reviewed. Many training pro- Web site: www.chica.org
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at the 4th Decennial International Conference
sponse Personnel. Sept 27–28, 1994, Ottawa methicillin-resistant Staphylococcus aureus on the
on Nosocomial and Healthcare-Associated Infec-
tions; March 5-9, 2000, Atlanta, Georgia, p 151 50. Updated U.S. Public Health Service Guidelines incidence of nosocomial staphylococcal infec-
for the management of occupational exposures tions. J Infect Dis 148:763, 1983
31. Pittet D, Mourouga P, Perneger TV: Compliance
to HBV, HCV, and HIV and recommendations 71. Herold BC, Immergluck LC, Maranan MC, et
with handwashing in a teaching hospital. Ann
for postexposure prophylaxis. MMWR Morb Mor- al: Community-acquired methicillin-resistant
Intern Med 130:126, 1999
tal Wkly Rep 50(RR-11):1, 2001 Staphylococcus aureus in children with no identi-
32. Pittet D, Hugonnet S, Harbath S, et al: Effec-
51. White MC, Lynch P: Blood contact and expo- fied predisposing risk. JAMA 279:593, 1998
tiveness of a hospital-wide programme to improve
sure among operating room personnel: a multi- 72. Shopsin B, Mathema B, Martinez J, et al: Prev-
compliance with hand hygiene. Lancet 356:1307,
center study. Am J Infect Control 21:243, 1993 alence of methicillin-resistant and methicillin-
2000
52. Chen CC,Willeke K: Aerosol penetration through susceptible Staphylococcus aureus in the commu-
33. Larson EL: APIC guideline for handwashing
surgical masks. Am J Infect Control 20:177, nity. J Infect Dis 182:359, 2000
and hand antisepsis in health care settings. Am J
1992 73. Jans B, Suetens C, Struelens M: Decreasing
Infect Control 23:251, 1995
53. Rich P, Belozer ML, Norris P, et al: Allergic con- MRSA rates in Belgian hospitals: results from
34. Rotter ML: Hand washing and hand disinfec-
tact dermatitis to two antioxidants in latex the national surveillance network after introduc-
tion. Hospital Epdemiology and Infection Con-
gloves: 4,4´-thiobis(6-tert-butyl-meta-cresol) tion of national guidelines. Infect Control Hosp
trol, 2nd ed. Mayhall CG, Ed. Lippincott
(Lowinox 44S36) and butylhydroxyanisole. J Am Epidemiol 21:419, 2000
Williams & Wilkins, Philadelphia, 1999, p 1339
Acad Dermatol 24:37, 1991 74. Verhoef J, Beaujean D, Blok H, et al: A Dutch
35. Spaulding EH: Chemical disinfection and anti-
54. Statement on the surgeon and hepatitis. Bull Am approach to methicillin-resistant Staphylococcus
sepsis in the hospital. J Hosp Res 9:5, 1972
Coll Surg 84(4):21, 1999 aureus. Eur J Clin Microbiol Infect Dis 18:461,
36. Association for the Advancement of Medical 1999
55. Lanphear BP, Linnemann CC Jr, Cannon CG,
Instrumentation Flash sterilization: steam steril-
et al: Hepatitis C virus infection in healthcare 75. Hiramatsu K, Hanaki H, Ino T, et al:
ization of patient care items for immediate use
workers: risk of exposure and infection. Infect Methicillin-resistant clinical strain with reduced
(ANSI/AAMI ST37-1996). Association for the
Control Hosp Epidemiol 15:745, 1994 vancomycin susceptibility. J Antimicrob
Advancement of Medical Instrumentation,
56. Risk of hepatitis C seroconversion after occupa- Chemother 40:135, 1997
Arlington, Virginia, 1996
tional exposure in health care workers. Italian 76. Interim guidelines for prevention and control of
37. Dean AG: Transmission of Salmonella typhi by
Study Group on Occupational Risk of HIV and staphylococcal infection associated with reduced
fiberoptic endoscopy. Lancet 2:134, 1977
Other Bloodborne Infections. Am J Infect Con- susceptibility to vancomycin. MMWR Morb Mor-
38. Langenberg W, Rauws EAJ, Oudbier JH, et al: trol 23:273, 1995 tal Wkly Rep 46:626, 1997
Patient-to-patient transmission of Campylobacter
57. Mitsui T, Iwano K, Masuko K, et al: Hepatitis C 77. Notskin GA, Stosor V, Cooper I, et al: Recovery
pylori infection by fiberoptic gastroduoden-
virus infection in medical personnel after needle- of vancomycin-resistant enterococci on finger-
oscopy and biopsy. J Infect Dis 161:507, 1990
stick accident. Hepatology 16:1109, 1994 tips and environmental surfaces. Infect Control
39. Rutala WA: APIC guideline for selection and use Hosp Epidemiol 16:577, 1995
58. Sartori M, La Terra G, Aglietta M, et al:
of disinfectants. Am J Infect Control 24:313,
Transmission of hepatitis C via blood splash into 78. Boyce JM: Vancomycin-resistant enterococcus:
1996
conjunctiva (letter). Scand J Infect Dis 25:270, detection, epidemiology, and control measures.
40. Rutala WA, Weber DJ: Disinfection of endo- 1993 Infect Dis Clin North Am 11:367, 1997
scopes: review of new chemical sterilants used
59. McKenna MT, Hutton MD, Cauthen G, et al: 79. Recommendations for preventing the spread of
for high-level disinfection. Infect Control Hosp
The association between occupation and tuber- vancomycin resistance: recommendations of the
Epidemiol 20:69, 1999
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41. Enforcement priorities for single-use devices Crit Care Med 154:587, 1996 Committee (HICPAC). MMWR Morb Mortal
reprocessed by third parties and hospitals. Wkly Rep 44(RR-12):1, 1995
United States Department of Health and Human 60. Menzies D, Fanning A, Yuan L, et al: Tubercu-
Services, August 2000 losis among health care workers. N Engl J Med 80. Goldmann DA, Weinstein RA, Wenzel RP, et al:
332:92, 1995 Strategies to prevent and control the emergence
42. The American Institute of Architects and the and spread of antimicrobial-resistant microor-
Facilities Guidelines Institute: Guidelines for 61. Guidelines for preventing the transmission of
Mycobacterium tuberculosis in health-care facilities ganisms in hospitals. JAMA 275:234, 1996
Design and Construction of Hospital and Health
Care Facilities, 2001. American Institute of MMWR Morb Mortal Wkly Rep 43(RR-13):1, 81. Guan Y, Zheng BJ, He YQ, et al: Isolation and
Architects Press, Washington, DC, 2001 1994 characterization of viruses related to the SARS
62. Pottinger JM, Herwaldt LA, Perl TM: Basics of coronavirus from animals in southern China.
43. Sheretz RJ, Reagan DR, Hampton KD, et al: A Science 302: 276, 2003
cloud adult: the Staphylococcus aureus–virus surveillance-an overview. Infect Control Hosp
interaction revisited. Ann Intern Med 124:539, Epidemiol 18:513, 1997 82. Lee N, Hui D, Wu A, et al: A major outbreak of
1996 63. Haley RW: Surveillance by objective: a new pri- severe acute respiratory syndrome in Hong
ority-directed approach to the control of nosoco- Kong. N Engl J Med 348: 1986, 2003
44. Immunization of health-care workers: recom-
mendations of the Advisory Committee on mial infections. Am J Infect Control 13:78, 1985 83. WHO: Consensus document. Global Meeting
Immunization Practices (ACIP) and the Hospi- 64. Taylor S, McKenzie M, Taylor G, et al: Wound on the Epidemiology of SARS, Geneva, May
tal Infection Control Practices Advisory Com- infection in total joint arthroplasty: effect of 16–17, 2003.
mittee (HICPAC). MMWR Morb Mortal Wkly extended wound surveillance on infection rates. http://www.who.int/csr/sars/en/WHOconsensus.pdf
Rep 46(RR-18):1, 1997 Can J Surg 37:217, 1994 84. Lowry PW, Blankenship RJ, Gridley W, et al: A
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cluster of Legionella sternal-wound infections 87. Muraca PW, Yu VL, Goetz A: Disinfection of grams in preventing nosocomial infections in US
due to postoperative topical exposure to contam- water distribution systems for Legionella: a hospitals. Am J Epidemiol 121:182, 1985
inated tap water. N Engl J Med 324:109, 1991 review of application procedures and method-
ologies. Infect Control Hosp Epidemiol 11:79, 90. Jarvis WR: Selected aspects of the socioeconom-
85. Arnow PM, Chou T, Weil D, et al: Nosocomial 1990 ic impact of nosocomial infections: morbidity,
Legionnaires’ disease caused by aerosolized tap mortality, cost and prevention. Infect Control
88. Walsh TJ, Dixon DM: Nosocomial aspergillosis:
water from respiratory devices. J Infect Dis 146: Hosp Epidemiol 17:552, 1996
environmental microbiology, hospital epidemiol-
460, 1982 ogy, diagnosis, and treatment. Eur J Epidemiol 91. Pittet D, Tarara D, Wenzel RP: Nosocomial
86. Guidelines for prevention of nosocomial pneu- 5:131, 1989 bloodstream infection in critically ill patients:
monia. MMWR Morb Mortal Wkly Rep 46(RR- 89. Haley RW, Culver DH, White JW, et al: The effi- excess length of stay, extra costs and attributable
1):1, 1997 cacy of infection surveillance and control pro- mortality. JAMA 271:1598, 1994
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 8 MINIMIZING THE RISK OF MALPRACTICE CLAIMS — 1
Of all the challenges that surgeons face, perhaps none can be so when they are accompanied with a claim for punitive damages.
threatening and draining—on an emotional, personal, and pro- Such claims, announced in the formal complaint, are then typi-
fessional level—as being a defendant in a medical malpractice cally followed promptly with a grim letter to the defendant physi-
claim. This is especially true when the individual initiating the cian from the insurers involved, reminding the physician that
claim is the very patient the defendant physician was earnestly there is no coverage for punitive damages awarded. The allega-
trying to help.The purpose of this chapter is to provide the prac- tions in the plaintiff’s complaint necessary to support a claim for
ticing surgeon with practical information about the genesis and punitive damages are hurtful and sometimes outrageous; the
mechanics of malpractice suits. Application of this knowledge physician is accused of willful, reckless, and wanton behavior bor-
may decrease the likelihood of being named in a malpractice suit dering on intent to injure the plaintiff.The awards sought in such
or having to endure the ordeal of a jury trial. cases reach far beyond fair compensation for the injured plaintiff.
Rather, punitive damages are calculated to punish the defendant
physician—the perceived wrongdoer—and to serve as public
The Malpractice Climate sanctions. The physician against whom punitive damages are
Record verdicts are now commonplace. Our state, Pennsylva- sought then undergoes pretrial discovery, sometimes shortly after
nia, has contributed its share: the year 2001 saw a $100 million suit is filed. This process involves requests (interrogatories) for
malpractice award in Philadelphia—the third highest ever in the detailed accounting of personal assets that might be available to
United States. Just 1 month before that award came two others: be attached in the event of a judgment in the plaintiff’s favor.
one for $55 million and another for $49.6 million. In 1998, Phil- Whether or not punitive damages are sought, it is difficult for
adelphia paid out more malpractice case settlement awards and most physicians to regard being harpooned by a medical mal-
jury verdicts than the entire state of California. In 1999, there were practice claim as merely a cost of doing business, and for many,
33 medical malpractice verdicts in Philadelphia that exceeded $1 the arduous and seemingly never-ending nature of the claim is
million, compared with 19 the previous year. Statewide, by the end distracting and potentially debilitating.
of 2001, settlements in Pennsylvania had risen 15% to 20%.
The adverse malpractice environment has taken its toll on
insurers, and a number of them have gone into bankruptcy.1 St. Who Brings Medical Malpractice Claims?
Paul Companies, for years a mainstay for physicians’ profession- Despite the self-aggrandizing proclamations of trial lawyer
al liability coverage, has announced its intention to drop its med- associations, professional negligence has little to do with whether
ical malpractice business nationwide. Despite some effort at tort claims are brought for patient injuries. Nor has any research
reform on the state level, physicians are leaving Pennsylvania and established that a higher incidence of medical malpractice litiga-
other states because the practice of medicine has found itself tion has brought about a better quality of medical care delivery.
embroiled in a war with patients, the court system, and political Brennan and colleagues have shown that there is no relationship
lobby interests influenced by trial lawyers who have built power- between the occurrence of adverse events and the assertion of
ful law firms by profiting from the system. claims, nor is there any association between adverse events and
negligent or substandard care.2 These authors did, however, find
a relationship between the degree of disability and the payment of
Personal Issues for the Defendant Physician claims.
How physicians cope personally with being a defendant in a Only a small fraction of patients who are injured through sub-
medical malpractice suit varies, but a number of factors come to standard care or treatment actually bring claims or suits.3 Localio
bear on the amount of stress that litigation inflicts. These factors and colleagues concluded that although 1% of hospitalized
include the physician’s previous exposure to litigation claims, patients suffer a significant injury as a result of negligence, fewer
degree of familiarity with the legal system and the litigation than 2% of these patients initiate a malpractice claim.4 Other
process, and previous experience testifying in the courtroom or in authors have found that only 2% to 4% of patients injured
depositions; the size of the claim as measured by the seriousness through negligence file claims, yet five to six times as many
of the alleged injury; and the presence or absence of a claim for patients who suffered injuries that are not legally compensable
punitive damages—which, of course, are not insured by profes- also file malpractice claims.5
sional liability policies. Some physicians experience a sense of
profound isolation when they are first named in a suit, particu-
larly when service of suit papers is accompanied by the standard Who Are the Defendants in Medical Malpractice Cases?
instruction from their risk management office or legal counsel not The experience one of us (G.H.F.) has acquired in defending
to discuss the case with anyone. malpractice claims for over 25 years at the same teaching hospi-
Allegations of negligence or substandard care, in and of them- tal vouches for the contention that those targeted in medical mal-
selves, are bitter pills to swallow, but they are all the more painful practice suits are not the incompetent, the unskilled, or the care-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 8 MINIMIZING THE RISK OF MALPRACTICE CLAIMS — 2
less. Entman and colleagues studied the quality of care rendered rather than the adverse outcome, determined the decision to
to 446 obstetric patients and performed a blinded comparison of bring the claim.They found that 71% of the depositions revealed
adverse outcomes, with physicians grouped according to fre- problems with physician-patient communication in four major
quency of medical malpractice claims against them.6 The authors categories: (1) perceived unavailability (“you never knew where
found no relationship between the number of adverse outcomes the doctor was,” “you asked for a doctor and no one came,” “no
and the frequency of claims experienced. In addition, other one returned our calls”); (2) devaluing of the patient’s or the
research has shown that no relationship exists between the pres- family’s views (e.g., perceived insensitivity to cultural or socio-
ence or absence of claims history and traditional indicators of economic differences); (3) poor delivery of medical information
physician ability, such as board certification, status, prestige of (e.g., lack of informed consent, failure to keep patients informed
medical school attended, country of medical school, medical during care, or failure to explain why a complication occurred);
school ranking, or solo practice.7,8 An examination of the files of and (4) failure to understand the patient’s perspective.
the National Practitioners Data Base, which lists those on whose Levinson and colleagues studied specific communication
behalf either jury awards or monetary settlements were paid, behaviors associated with malpractice history.10 Although they
would reveal the names of some of the most highly regarded did not discover a relationship between those two factors in the
physicians in the United States. surgeons they studied, they found that primary care physicians
who had no claims filed against them used more statements of
orientation (i.e., they educated patients about what to expect),
Reducing Malpractice Claims used humor more with their patients, and employed communi-
Clearly, some suits cannot be prevented. When catastrophic cation techniques designed to solicit their patients’ level of under-
injuries follow surgery or treatment, the emotional impact of the standing and opinions (i.e., they encouraged patients to provide
tragedy, coupled with overwhelming economic pressures, can verbal feedback).
create an environment in which a claim is assured. On the other Hickson and colleagues studied specific factors that led
hand, not all adverse outcomes from treatment result in claims. patients to file malpractice claims after perinatal injuries by sur-
Why is it that some patients and families sue for adverse out- veying patients whose claims had been closed after litigation.11
comes and some do not? Why do some patients sue for adverse Dissatisfaction with physician-patient communication was a sig-
outcomes that are expected and that occur in the context of high- nificant factor: 13% of the sample believed that their physicians
quality care? The answers to those questions typically have to do would not listen, 32% felt that their physicians did not talk open-
with physician-patient relationships rather than with professional ly, 48% believed that their physicians had deliberately misled
skill. them, and 70% indicated that their physicians had not warned
It has become increasingly clear that surgeons can reduce the them about long-term developmental problems.
likelihood of litigation by adopting a few key habits and practices In our own experience with defending malpractice suits, we
with their patients and their patients’ families. These include have seen instances in which attending physicians who had devel-
building trust through open communication, making effective oped a positive rapport with their patients were not named in a
use of informed consent, keeping accurate and complete medical suit, whereas other physicians involved in the patient’s care were
records, and educating office staff. named. In suits that progressed through pretrial discovery, we
have observed instances in which patients were willing to drop
COMMUNICATION AND INTERPERSONAL SKILLS IN THE
from the suit physicians with whom they had a good rapport,
PHYSICIAN-PATIENT RELATIONSHIP
leaving in the suit others with whom they had a less positive rela-
Although advancing medical technology has elevated patients’ tionship—or with whom they had had no communication.
level of expectation regarding treatment outcome, easy public Patients apparently made these decisions without regard to the
access to medical information on the Internet has encouraged extent of each defendant’s factual involvement in the case.
patients to become partners with their physicians in their own A component of the motivation to sue may be simply an unsat-
care. Experience with juries over the past few decades continues isfactory or incomplete explanation of how and why an adverse
to support the belief that in general, laypersons have a high outcome occurred. Patients who remain uninformed often
regard for physicians and a deep respect for their superior level of assume the worst—that their physician is uncomfortable talking
knowledge and training. At the same time, patients expect and about the complication because he or she made a mistake, was
deserve to receive intelligible and thorough explanations from careless, or is hiding something. In our experience, malpractice
their physicians regarding their diagnosis, their treatment plan, plaintiffs have sometimes claimed that when they sat through the
and the risks and benefits of their treatment. Even when the dis- process of jury education during the trial, it was the first time
ease process is beyond the physician’s control, the physician can they received any explanation of the complication for which they
still create an environment for effective communication with the had brought suit.
patient. Years of listening to patients and their family members When children suffer injuries, parents often seek desperately to
tell about their experiences at depositions and trials has con- avoid blaming themselves and so may attempt to transfer the
firmed for us that the quality of communication and trust responsibility to the health care providers. It is therefore critical
between physician and patient is the most important contribut- that after a complication or adverse event arises in a pediatric
ing factor in the patient’s decision to prosecute a medical mal- case, whenever possible the physician should speak openly with
practice suit. the parents about inappropriate feelings of guilt. The discussion
Several researchers have analyzed physician-patient communi- should cover possible or known causes or mechanisms of the
cation and its relationship to claims for damages for alleged pro- injury or death that are independent of any care rendered by the
fessional negligence. Beckman and colleagues studied 45 deposi- parents, including prenatal care or home care of a chronically ill
tion transcripts of plaintiffs in settled malpractice suits, focusing child. Similarly, the physician should make a point of explaining
on the question of why these plaintiffs decided to bring malprac- to adult patients and their families how and why adverse condi-
tice actions.9 These authors concluded that the process of care, tions arose, independent of any possible deficiencies in the qual-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 8 MINIMIZING THE RISK OF MALPRACTICE CLAIMS — 3
ity of care received at home or in patient compliance. Patients and Informed consent is merely an extension of good communication
their families are keenly sensitive to unintended inferences that practices, albeit one that is mandated by law.The tort of informed
blame for the bad outcome rests with them. consent is derived from the concept of battery—for example,
The principles of good communication are the same, whether unauthorized touching. Patients are deemed not to have consent-
an adverse event has occurred or not.They include the following: ed to a procedure unless they have been advised of all the risks
involved in it and all the alternatives to it. In most jurisdictions,
1. Content. Convey medical information in descriptive terms
the standard is objective rather than subjective. In other words,
that patients can understand, using illustrations, sketches, and
the risks and alternatives that must be disclosed are those that a
diagrams. Ask about the response to the therapeutic regimen.
“reasonable patient, in similar circumstances”—not necessarily
Provide counseling and instruction if no improvement is
the plaintiff—would regard as material to the decision whether to
observed. Inform the patient about specific steps in the exam-
undergo the surgery in question. With procedures for which the
ination or treatment plan.
statistical incidence of risks has been published or is known, the
2. Process. Ask patients whether they understand what they have
physician has a duty to quantify for the patient the likelihood of
been told; check the understanding by listening to the patient
the risk being realized. If the patient’s particular condition or sit-
after providing an explanation. Demonstrate respect for any
uation is such that the likelihood of the risk occurring is higher
cultural or socioeconomic differences that may be impeding
than average, the physician has the duty to so inform the patient.
the patient’s understanding.
Many physicians ignore another critical element in the
3. Emotional affect. Demonstrate concern and understanding of
required informed consent discussions: describing the range of
the patient’s complaints. Express empathy; use humor where
reasonable alternative procedures or modalities other than the
appropriate. Demonstrate awareness of the patient’s occupa-
procedure in question that are available to the patient. The haz-
tion, social circumstances, hobbies, or interests.
ard that such omissions entail is illustrated by a case in which the
4. Follow-up. Return telephone calls. Explain the protocol for
physician performed a transesophageal balloon dilatation of the
substitute or resident coverage, and introduce patients to
esophagus to address achalasia that had not responded to con-
other personnel who may be following their care. During
servative medical therapy. The risk of esophageal perforation was
longer hospitalizations, keep the patient and the family
disclosed as part of informed consent, and the procedure was per-
informed of the patient’s progress or treatment plan. Keep the
formed totally within the standard of care, but the patient suf-
referring physician promptly informed by providing treat-
fered perforation of the esophagus with serious permanent and
ment or discharge summaries. In the event of a patient’s
long-term disability. Although an alternative approach, via thora-
death, meet with the family to review and explain autopsy
cotomy, was known to be followed at other institutions, it was not
findings.
used at the defendant hospital, and the informed consent discus-
Further guidelines apply when an adverse outcome occurs. In the sion therefore did not include the surgical alternative as a dis-
hospital setting, prompt disclosure of an untoward or unexpect- closed option. The defendants were forced to settle the case for a
ed event that causes injury or harm is mandated by the Joint significant amount of money, even though there had been no neg-
Commission on the Accreditation of Healthcare Organizations ligence and the patient acknowledged that the risk of esophageal
(JCAHO). JCAHO standards require disclosure of unanticipated perforation had been thoroughly disclosed. A breach of informed
outcomes “whenever those outcomes differ significantly from the consent was easily established because one of the reasonable
anticipated outcome.” The responsibility to communicate lies alternatives was not disclosed to the patient.The argument that a
with both the attending physician and, in the case of a complica- reasonable person would probably have rejected the surgical
tion incident to surgery, the person accountable for securing con- alternative had it been disclosed was not a valid defense; nondis-
sent for the procedure. closure of a reasonable alternative, in and of itself, created strict
When possible, it may be advisable to invite other responsible liability.
caregivers to take part in the discussion of the adverse event with Some surgeons regard the informed consent discussion as an
the patient and the family. Consideration should also be given to inconvenient imposition on their time. However, the few minutes
inviting other persons who may be sources of support for the needed for this discussion pales in comparison with the time
patient and could benefit from the disclosure. During the discus- needed to defend a lawsuit involving a breach of informed con-
sion, express regret for the occurrence, without ascribing blame, sent, either as the central or an ancillary claim. In addition, given
fault, or neglect to oneself or any other caregiver. Describe the that the surgeon’s personal interaction with a patient may be sig-
decisions that led to the adverse event, including those in which nificantly limited in comparison with that of the primary care
the patient participated. Explain and outline the course of events, physician, obstetrician, gynecologist, or medical specialist, the
using factual, nonspeculative, nontechnical language, without informed consent discussion presents an important opportunity
admitting fault or liability or ascribing blame to anyone else. State for the surgeon to develop rapport and a positive relationship with
the nature of the mistake or error if one was made, and highlight the patient. Such rapport can be invaluable in the event of a later
the expected consequences and prognosis, if known. Outline the complication or adverse outcome. An effective informed consent
plan of corrective action with respect to the patient. In the event discussion may decrease the likelihood of a claim for a particular
that certain information is unknown at the time of the discussion adverse outcome if the patient remembers that the risk of its
(e.g., the etiology of the condition, suspected equipment mal- occurrence was disclosed and discussed.
function in the absence of controlled testing, or pending labora- Informed consent is not the consent form. The form is merely
tory test results), tell the patient and family that such information a piece of evidence documenting that informed consent occurred;
is currently unknown and offer to share the information with the critical factor is the content of the discussion. For the form to
them when it becomes available. be effective, it must cogently summarize the disclosures in a man-
ner that makes it difficult for the patient to later refute, in a “he
INFORMED CONSENT
said, she said” controversy, the version of the discussion that the
Effective informed consent can reduce the risk of litigation. physician may be rendering in the courtroom under oath.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 8 MINIMIZING THE RISK OF MALPRACTICE CLAIMS — 4
An effective informed-consent discussion based on custom scans are of relevance, be sure the printed copy is stapled and
and habit is essential because of the slow pace of the legal system. placed into the progress notes of the patient’s chart. A surgeon
In most jurisdictions, the statute of limitations for bringing claims who has provided the patient with a sketch to help explain an
involving adult patients is 2 years. By the time the defendant operative procedure should place the sketch in the patient’s chart
physician’s pretrial deposition is taken, another 1 to 3 years may and write the date on it. In one case involving an informed con-
have elapsed, and after that, even more time passes before the sent issue, the defense was able to produce a sketch of the opera-
conversation will have to be relayed under oath if the claim goes tion that the surgeon had made on the reverse side of a lab report
to trial. It is exceedingly rare that physicians can actually recall the in the patient’s chart, refuting the patient’s contention that no
informed consent discussion in question at the time of suit. explanation of the procedure had ever been given. If equipment
However, the content of the communication can be proved more malfunction is involved in an adverse outcome, such as a death in
reliably by means of custom and habit than by direct recollection, which a postmortem examination was conducted, insist that the
particularly when the elements of the discussion are corroborat- risk management office provide a secure place to store the speci-
ed with a comprehensive but clear form signed by the patient. men or equipment in question for later testing or use as a trial
In some cases, physicians encourage the showing of a patient exhibit. If an anomalous condition has contributed to an adverse
education video that explains the intended procedure. Such videos outcome in a death case, make sure the pathologist at autopsy at
should also communicate the risks of the procedure. The use of least photographs the abnormality if the specimen is not going to
such videos can provide additional evidence to support the be preserved for later use.
defense that the patient gave informed consent. Each version of If an untoward outcome or event occurs, document the event
the video should be labeled with the dates when it was routinely in the chart purely with facts. Avoid expressions of opinion or
used, and it should not be discarded when it is replaced with suggestions of blame of other health care providers. In the event
updated versions. The patient’s chart should reflect that the pa- relevant information becomes available at a later point, it can be
tient watched the video and had no questions after a review of its helpful to make a late entry in the chart, documenting the time of
contents. the entry.
The physician who will perform the procedure, not the nurse If one realizes that an error in documentation has been made
or resident who will assist at it, has the duty to secure the patient’s in the patient’s chart (e.g., inaccurate information recorded), do
consent. Information provided by other health care providers can not remove the page and start over and do not scratch out or
be used by the defense as evidence, however. “white out” the mistake.The appropriate way of handling such an
error is to draw a single line through the inaccurate information,
DOCUMENTATION
record the correct information, and initial and date the amend-
Along with effective communication techniques and informed ment. Clearly, a medical record should never be altered in an
consent protocols, good documentation practices can minimize a attempt to cover something up. In the event of a suit, this act
surgeon’s risk of becoming a defendant in a medical malpractice could lead to the loss of an otherwise defensible case.
suit, or at least provide a more effective defense if litigation is
EDUCATING AND INFORMING OFFICE STAFF
commenced. Although the purpose of keeping medical records is
to provide subsequent caregivers with important information rel- More than ever before, every practicing surgeon must recog-
evant to the patient’s condition and treatment, in the context of nize that his or her office staff must also be well informed and well
litigation, medical records are used to demonstrate what care was educated about malpractice issues. The Health Insurance
or was not rendered. A standard question that plaintiffs’ attorneys Portability and Accountability Act (HIPAA) of 1996, which
ask defendants at pretrial depositions is whether the defendant began taking effect in 2003, regulates the use of an individual’s
agrees with the adage, “If it is not documented, it wasn’t done.” protected health information and, for the first time, authorizes
Time and time again, otherwise defensible cases are compro- specific federal penalties if a patient’s right is violated. All practice
mised because of inadequate documentation, such as failure to employees must be trained in compliance with the law and must
document an order, the time an order was given, a critical tele- know how to deal with privacy requirements stated in the law.
phone call from the patient or patient’s family, a critical informal In-service training of office staff is pivotal to reducing the risk
consultation, or critical symptoms reported by a patient during of being sued. All office personnel should be well informed and
the course of an examination or clinic visit. educated on issues of confidentiality, including how to answer the
A current trend in tort reform legislation, designed to discour- phone, what kinds of conversations are inappropriate, and the
age frivolous suits, is to require that any claim being brought must giving out of medical information. Good patient relations is also
be accompanied by a certification of merit, which establishes that critical; many avoidable lawsuits have arisen simply because a
a qualified expert has reviewed the records and is supportive of member of the physician’s office staff was rude to a patient on the
the claim. If the chart is well documented in defensible cases, phone, or the patient waited too long to see the doctor without an
many reputable experts will be loath to give an opinion that sub- explanation. In the event that patients or family members call or
standard care was provided. On the other hand, absence of ade- write to express displeasure with service they received—whether
quate documentation sometimes prejudices expert case reviewers that service was provided by the surgeon, the resident, the clinic
in favor of the plaintiff, even though subsequent deposition testi- staff, or the nursing team—courtesy and common sense decree
mony may provide a cogent and defensible explanation for how that the dissatisfied customers be contacted and allowed to vocal-
and why the adverse event or complication occurred. ize their complaints, by telephone or in person.Willingness to lis-
Ensure that telephone conversations are documented. Cases ten to these persons indicates a genuine interest in improving the
have been saved in the courtroom simply because a resident who delivery of patient care and may well prevent some claims.
received a call jotted a short note of the patient’s complaint and
ADDITIONAL POINTERS
the advice given and pasted it in the patient’s chart. Keep log-
books of appointments, cancellations of appointments, and rea- Be vigilant for litigious patients; such individuals exist. They
sons for cancellations. If printed images of bedside ultrasound should receive the same high-quality medical care as any other
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 8 MINIMIZING THE RISK OF MALPRACTICE CLAIMS — 5
patient, but extra attention should go into documentation and at the time of pretrial depositions. Review the available records
informed consent. Avoid becoming paranoid, but inform the staff and prepare a confidential summary of the case; address this
of any concerns. Such patients may feel short-changed by the summary only to legal counsel, with no copies to anyone. If the
medical system, or they may be looking for any derogatory state- media is involved at the outset of the suit, under no circumstances
ments about another physician’s advice or treatment. Steer clear should the defendants attempt to be spokespersons on their own
of criticizing another physician. behalf; they should leave this task to others who are equipped to
With the enormous pressure on minimizing health care expen- determine how much information to provide to the media about
ditures, virtually all surgeons feel pressure to reduce length of stay the controversy.
and decrease the use of diagnostic tests and medications. These Defendants should find out the name of the lawyer who will be
constrictions should never influence patient care decisions. Cut- assigned to represent them and arrange an initial meeting to
ting corners may result in litigation. In dealing with health care familiarize the lawyer with the medical issues in the case. Defend-
plan denials, it can often be helpful to talk directly with the med- ants who conduct any medical research to assist themselves and
ical director. their counsel with the issues should do so with the understanding
that the research is in the context of communication with coun-
sel. Independent research conducted for the defendant’s own edi-
What Can Surgeons Do to Assist in Their Defense if They fication, not for communication with counsel, is discoverable by
Are Sued? the plaintiff. Defendants should take the time necessary to edu-
First, one should assemble all of the relevant records, phone cate their attorney on the medical issues involved so that the attor-
logs and messages, and e-mail correspondence or other notes and ney can gather more information effectively. Defendants can rec-
should cooperate fully with the claims representative of the insur- ommend and discuss with counsel certain fact-gathering tasks to
er and the representative of the hospital risk management team if be done by counsel on the defendants’ behalf. Both can begin
the hospital is involved in the case. Under no circumstances thinking about whom to engage as an outside expert to assist in
should one alter, amend, or discard records when a suit is initiat- identifying weak points or issues in the case before the defendant
ed. Do not discuss the facts of the case with any colleagues until submits to a deposition by the plaintiff’s lawyer. However, after
legal counsel is involved, because anyone involved in those dis- defendant and counsel have agreed on an expert, only counsel
cussions may be asked to repeat the substance of the conversation should approach or contact the expert.
References
1. Mello MM, Studdert DM, Brennan TA:The new Harvard Medical Practice Study III. N Engl J acteristics of physicians with obstetric malpractice
medical malpractice crisis. N Engl J Med 348: Med 325:245, 1991 claims experience. Obstet Gynecol 78:1050, 1991
2281, 2003 5. Hickson GB, Pichert JW, Federspiel CF, et al: 9. Beckman HB, Markakis KM, Suchman AL, et al:
2. Brennan TA, Sox CM, Burstin HR: Relation Development of an early identification and The doctor-patient relationship and malpractice.
between negligent adverse events and the out- response model of malpractice prevention. Law Arch Intern Med 154:1365, 1994
comes of medical malpractice litigation. N Engl J and Contemporary Problems 60:7, 1997
10. Levinson W, Roter DL, Mullooly JP, et al:
Med 335:1963, 1996 6. Entman SS, Glass CA, Hickson GB, et al: The Physician-patient communication: the relation-
3. Brennan TA, Leape LL, Laird NM, et al: relationship between malpractice claims history ship with malpractice claims among primary
Incidence of adverse events and negligence in and subsequent obstetric care. JAMA 272:1588, care physicians and surgeons. JAMA 277:553,
hospitalized patients. N Engl J Med 324:370, 1994 1997
1991 7. Sloan FA, Mergenhagen PM, Burfield WB, et al: 11. Hickson GB, Clayton EW, Githens PB, et al:
4. Localio AR, Lawthers AG, Brennan TA, et al: Medical malpractice experience of physicians: Factors that prompted families to file medical
Relations between malpractice claims and predictable or haphazard? JAMA 262:3291, 1989 malpractice claims following perinatal injuries.
adverse events due to negligence: results of the 8. Baldwin LM, Larson EH, Hart LG, et al: Char- JAMA 267:1359, 1992
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 9 ELEMENTS OF COST-EFFECTIVE CARE — 1
9 ELEMENTS OF COST-EFFECTIVE
NONEMERGENCY SURGICAL CARE
Robert S. Rhodes, M.D., F.A.C.S., and Charles L. Rice, M.D., F.A.C.S.
The citizens of industrialized nations generally enjoy a high level Surgery is a particularly suitable subject for cost-effectiveness
of health, and the positive correlation between life expectancy and analysis because surgical illnesses are usually of relatively short
per capita income is one of the best-known relationships in inter- duration, surgical outcomes are readily quantified, and surgical
national development.1 Yet many of these nations also face major costs often involve global fees. In what follows, we explore some
challenges in controlling the cost and improving the quality of basic principles of cost-effective surgical care and address some of
health care.The United States has attempted to control these costs the complex issues involved in defining such care.We define cost-
through price controls (in the Nixon era), prospective payment (in effectiveness as cost divided by net benefit, with the numerator
the Reagan era), and managed care (in the Clinton era), but none (cost) expressed in dollars and the denominator (net benefit)
of these measures have had any long-term success [see Table 1].2,3 expressed as beneficial outcomes minus adverse outcomes. Since
A consequence of the ongoing growth in health care expendi- cost-effectiveness is integrally related to quality of care issues, we
tures is that health care then increasingly competes with other consider recent changes in the concepts of quality, address the
social goals (e.g., education) for some of the same funds. The complex issues associated with cost, and examine the relation of
anguish of having to choose one social goal over another can be quality to cost. Perhaps most important, we also focus on specific
rationalized when the expenditures on the chosen goal produce skills and attributes that can help surgeons become more cost-
demonstrable improvements. Thus, if increased health spending effective.
generates measurably better health, it seems worthwhile, but if it
does not, it seems wasteful. In the United States, unfortunately,
the latter scenario appears to prevail. Even though the United Demise of “Appropriateness” as Indicator of Quality
States spends a larger fraction of its gross domestic product
DRAWBACKS OF TRADITIONAL VIEW OF QUALITY
(GDP) on health care than other industrialized nations do [see
Table 2], U.S. citizens seem less healthy—often by wide margins— To achieve cost-effective care, it is necessary first to develop a suit-
than citizens in other nations [see Table 3].4 Of further concern are able definition of quality—a task that is considerably more problem-
the data indicating that the greater U.S. spending is attributable atic than it seems.6,7 The traditional definition of quality focused on
largely to higher prices for health care goods and services.5 the appropriateness of the care provided, and the authority (in terms
Controlling health care costs and improving health care out- of knowledge) for such appropriateness was viewed as exclusively the
comes have multiple interwoven perspectives that range from the province of physicians. By the end of the 20th century, however, sev-
macrostructure of the health care system to the wide variety of eral factors had begun to erode appropriateness (and physician au-
individual patient-provider interactions. The relevance of these thority) as the traditional indicator of quality.
interactions is underscored by the fact that physician decision- One such factor was the realization that per capita health care
making accounts for 75% of overall health care costs. The pro- expenditure was not necessarily positively correlated with life
nounced impact of physicians’ choices on health care costs also expectancy. Another factor—one that directly challenged the
explains why those who pay the bills naturally seek to identify the authority of the physician as the arbiter of quality of care—was the
most cost-effective physicians. finding that some procedures have a relatively high incidence of
Expenditure Expenditure as
Year for Health Services U.S. Population Expenditure Percentage of
GDP ($ billion)
and Supplies (million) per Capita ($) GDP (%)
($ billion)
Year Canada France Germany Japan United Kingdom United States OECD Median
inappropriate indications. For instance, a Rand Corporation the intensity of local diagnostic testing and the number of invasive
study found that 32% of carotid endarterectomies, 17% of coro- cardiac procedures subsequently performed.18 Indeed, some
nary arteriograms, and 17% of upper GI endoscopies lacked communities seem to have distinct “practice signatures”—a find-
appropriate indications.8 In another study, one in six hysterec- ing that supports the idea that many medical decisions are based
tomies were deemed inappropriate.9 Caesarean section is also fre- on opinion rather than on evidence.19 It may be tempting to
quently performed for unclear indications. attribute such variations to the inherent potential conflict of inter-
A third factor was the differences in judgments of appropriate- est in a fee-for-service system, but in fact, economic incentives
ness often noted when decisions were made for groups rather than appear to have relatively little influence on physicians in this
for individuals.10 In addition, retrospective assessments often regard. Comparable variations in utilization rates exist among
judged appropriateness on the basis of outcome alone, without Veterans Health Administration medical facilities,20 as well as in
considering processes of care.11 countries that do not have fee-for-service reimbursement.
Yet another factor was the recognition of the great disparities in Whether the high utilization rates observed are too high or the
the frequency of surgical procedures among small geographic low utilization rates are too low is still a matter of debate.The pos-
areas.12-14 These frequency variations are procedure specific, and sibility that low frequency of use may reflect restricted access to
their degree is often related to the degree of consensus regarding care is a particular concern, given the association between varia-
indications.15 Procedures with highly specific indications (e.g., tion and the ratio of hospital beds to population.21 To date, stud-
repair of fractured hips, inguinal herniorrhaphy, and appendecto- ies that have attempted to find evidence supporting other possible
my) often exhibit little frequency variation, whereas procedures explanations of these variations (e.g., differences in disease inci-
with less definite indications (e.g., carotid endarterectomy, hys- dence and differences in the appropriateness of use) have not
terectomy, and coronary angiography) often exhibit a great deal of found such evidence.22 The current belief that the high utilization
variation.16 rates are too high is supported by findings of comparable health
The lack of consensus about the appropriateness of surgical status among patients from widely disparate areas of usage, which
interventions is often related to a lack of evidence. Indeed, a study have led to the conclusion that “marked variability in surgical
from the 1970s estimated that only about 15% of common med- practices and presumably in surgical judgment and philosophy
ical practices had documented foundations in any sort of medical must be considered to reflect absent or inadequate data by which
research.17 This conclusion does not necessarily mean that only to evaluate surgical treatment....”23
15% of care is effective, but it does raise concerns about the lack In addition to these concerns about selection and utilization of
of hard evidence for most care. surgical interventions, specific concerns have been raised about
Variations in procedure frequency also appear to be related to quality of care. For instance, studies suggested that as many as one
provider capacity (usually expressed as the number of hospital fourth of hospital deaths might be preventable,24 that one third of
beds per 1,000 persons): one study noted a close relation between hospital procedures might be exposing patients to unnecessary
United United
Canada France Germany Japan Kingdom States OECD Median
Infant mortality (per 1,000 live births) 5.3 4.3 4.5 3.2 5.8 7.1 5.0
difference between the true incidences and the initial clinical esti- Accordingly, it is incumbent on surgeons to know how decisions
mates indicates the potential for inaccuracy in surgeons’ estimation about technology acquisition contribute to excess capacity and cost
of outcomes. within the health care system. The process begins with providers
The results of this study seem relatively clear-cut, but they may be who, out of a compulsion to be the first to have a new technology, ac-
considerably less so when applied to other institutions. For instance, quire it before its value is fully known. Other providers, fearing to be
the authors calculated a savings of $447 per patient. However, costs left behind, then follow suit. If the new technology is successful, the
(and any savings therein) are likely to vary from one institution to an- capacity within a community can exceed the needs; if it is unsuccess-
other in conjunction with a number of factors, including surgeons’ ful, health care cost increases without any increase in benefit to the
differing estimates of the clinical likelihood of appendicitis, the avail- community. Competition among providers is advocated as a way of
ability of less expensive alternatives to in-hospital observation, and restraining health care costs, but when competition is driven by the
the use of the emergency department for triage. In this report, 53% technological imperative, it can contribute to inflationary increases in
of the patients studied had appendicitis, but in other studies, as few these same costs.
as 30% of patients with an admitting diagnosis of appendicitis even- Special challenges result from practice innovations that do not
tually underwent appendectomy.40 involve the introduction of new technology but, rather, involve the
Proper assessment of the literature also requires an awareness of application of existing technology in new ways.65 In this setting,
the distinction between relative and absolute risk reduction. For methodologic problems may prevent surgeons from appreciating
instance, a treatment that reduces the incidence of an undesired potential harm before the innovation has become widely dissemi-
outcome from 5% to 4% and a treatment that reduces it from nated. Laparoscopic cholecystectomy is a particularly good exam-
50% to 40% can both be said to achieve a 20% relative reduction ple of an innovation that diffused rapidly into surgical practice
in risk. Reporting effectiveness in terms of relative improvement before its safety had been fully assesssed. Although laparoscopic
can be misleading if the baseline outcome is ignored.41 Patients’ cholecystectomy is now relatively safe, the learning curve was asso-
participation in adjuvant cancer therapy (and their willingness to ciated with an increased number of bile duct injuries—an out-
tolerate side effects) may be affected more by absolute reductions come that might have been avoided had the procedure been intro-
in risk than by relative reductions. duced in a more systematic fashion.The following four questions,
Another potential pitfall in assessing evidence can arise when an formulated by the American College of Surgeons,66 should be
advance in diagnostic technology allows earlier symptomatic diag- asked whenever a new technology or an innovation in surgical care
nosis or a new or improved screening test allows diagnosis at an is being considered for introduction into widespread use:
asymptomatic stage of a disease. As a result of such developments, 1. Has the new technology been considered adequately tested for
studies intended to compare different treatments of the same dis- safety and efficacy?
ease may actually be comparing treatments of different stages of 2. Is the new technology at least as safe and effective as existing,
the disease process. Earlier diagnosis may appear to improve long- proven techniques?
term survival while in fact only serving to identify the condition for 3. Is the individual proposing to perform the new procedure fully
a longer time.The apparent extended survival with earlier diagno- qualified to do so?
sis is referred to as lead-time bias, and such bias can lead to over- 4. Is the new technology cost-effective?
estimation of disease prevalence.42
Further information on critical analysis of the medical literature EFFICIENT USE OF DIAGNOSTIC TESTING
is available elsewhere,19 particularly in the excellent series pro- Laboratory tests and imaging studies are responsible for a large
duced by the Evidence-Based Medicine Working Group.43-60 share of health care costs and account for much of the reported cost
A final argument for the value of critical literature analysis is variations. Traditionally, the value of a test rested on its sensitivity
physicians’ need to keep pace with patients’ growing access to (i.e., its ability to identify patients with a disease) and specificity (i.e.,
medical information. There are now more than 15,000 health- its ability to identify patients without a disease).67 However, the cost-
related Web sites,61 and it is estimated that tens of millions of effectiveness of a test also depends on disease prevalence. For instance,
adults find health information online. In addition, patients may get if a test with a 98% sensitivity and a 98% specificity is applied to a
information from completely unmonitored sources, such as dis- group of patients with a disease prevalence of 50% (i.e., a group in
ease-specific bulletin-boards. Given that at least some of this infor- which half the patients have the disease being tested for), 245 of
mation is inaccurate, misleading, or unconventional,62 it is vital every 500 patients tested (500 × 0.98 × 0.5) will have true positive
that surgeons be aware of what their patients may know or believe. results and five (500 × 0.02 × 0.5) will have false positive results. If,
Survey results published in 2003 suggest that patient use of the however, this same test is applied to 500 members of a population
Internet may be somewhat less than previous estimates suggested with a disease prevalence of 10%, 49 patients (500 × 0.98 × 0.1) will
and that further patient use may be dependent on subsequent have true positive results and nine (500 × 0.02 × 0.9) will have false
interactions with the physician.63 Issues of reimbursement for positive results.Thus, for any given sensitivity, the ratio of true pos-
Internet-based health care services also need to be resolved.64 itives to false positives increases with increasing prevalence of disease
in a given patient population. In the above example, the incidence of
TECHNOLOGY ASSESSMENT
false positives was 2.0% (5/245) in the first group and 18.4% (9/49)
The prevailing societal attitude that equates the latest with the in the second. Given that most tests are not 98% sensitive and 98%
best—the so-called technological imperative—creates consider- specific, the incidence of false positives in the real world is likely to
able pressure to acquire the newest equipment and techniques, be that much greater.This relation between disease prevalence and
even before their value is completely evident. With the explosive the incidence of false positives serves to establish a test’s value or
growth of technology in recent years, this behavior has been a utility and explains why a test may have relatively little value as a
major contributor to the rapid growth of health care costs. screening test in general practice (where the disease prevalence may
It is undeniable that many technological advances have improved be low) but may have relatively high value in a specialist’s practice
surgical care; however, not every new technology proves successful. (where referrals may increase the relative prevalence of the disease).
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 9 ELEMENTS OF COST-EFFECTIVE CARE — 5
An example of the role of test utility in clinical decision making Critical pathways, also referred to as practice guidelines, are
is found in the functional assessment of incidental adrenal mass- increasingly used to standardize treatments and are particularly
es.68 Physicians encountering such masses often feel compelled to helpful for high-volume diagnoses. Although criticized by some as
engage in an elaborate workup; however, in the absence of con- embodying a “cookie cutter” approach, they minimize variation by
crete signs and symptoms, measurement of specific hormone lev- displaying optimal goals for both patients and providers. Critical
els may be of little value. Close inspection of many other routine pathways have been developed by a number of groups and orga-
preoperative tests reveals that they, too, may have little value.69,70 nizations and are available commercially, through surgical soci-
As noted [see Demise of “Appropriateness” as Indicator of eties,81 and in focused publications.82 The Agency for Healthcare
Quality, above], increases in diagnostic testing tend to parallel Research and Quality (AHRQ) has also established practice
increases in clinically relevant downstream procedures.71 An guidelines, which are available online (http://www.ahrq.gov or
example is the known association between the intensity of diag- http://www.guideline.gov) or through evidence-based practice
nostic testing and the frequency of subsequent invasive cardiac centers. The guideline.gov site is part of the National Guideline
procedures.18 A consequence of this association is that increases in Clearinghouse and is a comprehensive repository for clinical prac-
the number of patients who undergo cardiac catheterization as a tice guidelines and related materials.
result of false positive screening tests also lead to increases in the Critical pathways, though valuable as explicit expressions of the
number of patients with negative findings who may have compli- processes of care, do have limitations. One is that the focus on qual-
cations of catheterization, because complications of catheteriza- ity and efficiency of care is often adopted after the decision has
tion occur just as frequently in patients with false positive indica- already been made to admit the patient or perform a procedure. A
tions as in those with true positives.The net effect is to flatten the second is that standardization does not automatically result in qual-
cost-benefit curve and steepen the cost-harm curve.29 Thus, the ity improvement. Accordingly, critical pathways must be consid-
relative frequency of false positives affects both the numerator and ered flexible and subject to modification on the basis of experience.
the denominator of cost-effectiveness. Indeed, critical pathways are perhaps best understood not as rigid
The possibility of a relative reduction in benefit coupled with a rel- rules but as ways of codifying experience that can help others avoid
ative increase in harm is the basis of the new relation between quali- mistakes. A third limitation is that some guidelines do not adhere
ty and cost. In the context of the appropriateness concept, the rela- to established methodologic standards.83-86 A great deal of addi-
tion between health care cost and quality was seen exclusively as tional information on pathway development, implementation, and
positive: increasing expenditure was considered to improve quality, troubleshooting is readily available in published sources.87,88
and vice versa. In the light of our current understanding, however,
COORDINATION OF CARE
differential effects on the cost-benefit and the cost-harm curves can
be seen to alter the relation of quality to cost [see Figure 1].72 By preventing duplication of tests and unnecessary delays, coor-
dination of care both improves patient satisfaction and saves
CLINICAL DECISION ANALYSIS
money. The most frequent causes of delay are scheduling of tests
Analysis of clinical decision making involves quantifying the (31%), followed by unavailability of postdischarge facilities (18%),
effect or impact of each option involved in a medical decision.The physician decision making (13%), discharge planning (12%), and
outcome of each decision thereby acquires a probability, and each scheduling of surgery (12%).89 The growing complexity of health
component of the decision tree carries an explicit assumption that care makes teamwork increasingly essential.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 9 ELEMENTS OF COST-EFFECTIVE CARE — 6
DISEASE MANAGEMENT
meaningfulness of a given functional status. For instance, patient
Comprehensive management of disease goes beyond coordina- A may not be able to walk as far as patient B, but whether patient
tion of care and emphasizes preventive measures. Disease man- A actually has a poorer quality of life depends on the context in
agement is most applicable to a relatively large group of patients which that poorer functional status is placed.96
with a given health problem within a given health system or prac- Calculation of QALYs is confounded by several factors.80,97 For
tice. Such management uses an explicit, systematic population- instance, estimates of the future value of an outcome measure may
based approach to identify patients at risk, intervene with specific vary with the circumstances prevailing at the time of assessment
programs of care, and measure clinical and other outcomes.90 (e.g., acute pain) or with the patient’s age (e.g., the elderly often
place great value on the ability to live independently).Thus, quality
of life may be more important than longevity.98 Calculation of
Analysis of Cost-Effectiveness QALYs may also be affected by gender, ethnicity, socioeconomic sta-
In simple terms, cost-effectiveness reflects the cost of a health tus, religious beliefs, and other factors that affect attitudes about
care intervention (usually expressed in dollars) in relation to out- health care.Adjusting outcome measures to account for health status
come. It is distinct both from the cost-benefit ratio, which mea- and severity of illness before treatment can also be difficult.99
sures return on investment (with both the numerator and the Still another factor confounding determination of QALYs is
denominator expressed in dollars), and from efficiency, which that patients, providers, and health care purchasers may have dif-
measures productivity (with outputs divided by inputs). Analysis ferent perspectives on the experiential, physiologic, and resource-
of cost-effectiveness, by definition, compares two approaches to a related dimensions of QALYs. These differences may be reflected
given problem, with the numerator reflecting any difference in cost in different views about which measure is best for judging the out-
come of a given intervention. Thus, the hospital administration is
and the denominator reflecting any difference in quality.The com-
likely to emphasize length of stay and cost, whereas the surgeon
parison can be between two interventions, between an interven-
and the patient are more likely to emphasize morbidity, mortality,
tion and no intervention, or between early and delayed treat-
and subsequent quality of life. When these various perspectives
ment.91 Beneficial changes in one component of the cost-effec-
disagree about the outcome of a decision (as when an outcome
tiveness ratio can be outweighed by adverse changes in the other,
deemed successful by a provider does not satisfy the patient), the
and vice versa. For example, a study of appendicitis noted that for disagreement further complicates the assessment of quality.
each 10% increase in diagnostic accuracy, there was a 14%
increase in the perforation rate.92 In this case, the cost (i.e., DETERMINATION OF COST
increased morbidity from perforation) might be the price paid for Definition and attribution of cost are also complex issues.
the benefit derived (i.e., greater diagnostic accuracy). Any savings Practice costs are relatively easy to identify. Hospital costs, howev-
achieved up front might be lost in the long run because of more er, are much more intricate; as has been well said, “cost is a noun
advanced or complicated illness. that never really stands alone.”100
MEASUREMENT OF QUALITY
A first step in unraveling the complexity of cost is to understand
the distinction between costs and charges. Charges reflect price
To calculate cost-effectiveness, it is necessary to understand the structure but are a poor reflection of actual costs. Costs can be calcu-
principles underlying the measurement of both quality and cost. lated as an aggregate fraction of charges, and this aggregate ratio is
Under the new concept of quality, the preferred outcome measure often relatively constant among institutions. Nevertheless, substantial
is health care–related quality of life, typically expressed in terms of variations exist among institutions regarding the relation between
quality-adjusted life years (QALYs),93,94 which reflect the length of charges and costs for specific goods and services. Such variations re-
time for which a patient experiences a given health status. There sult partly from differences in accounting systems and partly from
are several methods of quantifying QALYs.95 Some of these meth- contractual differences with payors. However, they also arise as a
ods include objective measures (e.g., functional status), whereas consequence of substantial differences in cost attribution, and these
others are based entirely on subjective estimates of well-being.The differences are evident even with the relatively standardized account-
objective measures emphasize patient-desired outcomes and the ing standards required by the Centers for Medicare and Medicaid
Variable Supply
Behavior of cost in relation to output Fixed Depreciation
or activity Semivariable Utilities
Semifixed Number of full-time equivalents per step in output
Services (CMS) (formerly the Health Care Financing Administra- cedure being offset by an increase in procedure volume and an
tion [HCFA]). For instance, data from 1996 indicated that best actual increase in aggregate costs. Given such results, it is under-
practice for expense per 100 minutes of OR time was $511, but the standable that patients, providers, purchasers, and investigators
national median was $938—a 46% variance.101 It is difficult to de- might all reach differing opinions about the value of new technol-
termine how much of this variation is due to differences in account- ogy. Similarly, the added costs of a complication in a single patient
ing and how much to differences in efficiency. can be considered with respect to the frequency of that complica-
To better understand cost behavior, it is useful to recognize that tion in the entire population undergoing a given treatment.109
health-related costs commonly fall into one of four general cate- Priorities for quality improvement efforts to prevent complications
gories [see Table 4]. For surgeons, the first two—the behavior of cost should consider both the incidence of the complication and its
in relation to output or activity and the traceability of costs—are per- independent contribution to resource use.
haps the most important.Within these general categories, there are Perspectives on cost-saving can vary among the different com-
several types of costs that are worth considering in further detail. ponents of the health care system. A 1996 consensus statement
Variable costs, such as supplies, change in a constant proportion- recommended adoption of better standards to improve the com-
al manner with changes in output; fixed costs do not change in re- parability of cost and quality.94,110,111 The panel advocated that cal-
sponse to changes in volume. Semivariable costs (e.g., utilities) in- culations be based on the perspective of society as a whole rather
clude elements of both fixed and variable costs; there is a fixed basic than on that of patients, providers, or purchasers. Otherwise, the
cost per unit of time and a direct, proportional relation between vol- panel concluded, costs incurred by patients or others, such as out-
ume and cost. Semifixed costs (also known as step costs) may patient medication or home care after hospital discharge, might be
change with changes in output, but the changes occur in discrete deemed irrelevant from the purchaser’s perspective.
steps rather than in a constant proportional manner. An example of A unilateral perspective may also disregard some outcomes. For
a semifixed cost is the number of full-time equivalents (FTEs) re- example, how soon patients return to work after an illness may mat-
quired for a particular output. If one FTE can produce 2,000 wid- ter little to a health maintenance organization (HMO) or a govern-
gets, every 2,000-unit change in widget output will be associated ment program but may matter a great deal to the patients them-
with a change in labor cost: for every 2,000-unit increment in out- selves, their employers, or the government agency responsible for
put, one more FTE is needed (with a concomitant increase in disability payments—and probably to most surgeons.
costs), and for every 2,000-unit decrement, one fewer FTE is need-
QUANTIFICATION OF COST-EFFECTIVENESS
ed (with a concomitant decrease in costs). Unless the step threshold
is attained, costs do not change. Thus, a semifixed cost might be Because it is a ratio, cost-effectiveness may be affected by
considered either a variable cost or a fixed cost, depending on the changes in either the numerator (cost) or the denominator (qual-
size of the steps relative to the range of output. Unfortunately, stan- ity) [see Table 5]. Thus, changes in cost-effectiveness can occur
dard protocols for reporting this information often are not avail- through either a relative reduction in cost or a relative improve-
able,102 and the lack of such protocols makes it more difficult to ment in quality. Moreover, quality improvements will be a func-
compare cost analyses of clinical interventions. tion of both the extent and the duration of the improvement.
Cost traceability is classified as direct or indirect. Examples of The various confounding factors notwithstanding, good data
direct costs are salaries, supplies, rents, and utilities; examples of are available on the relative cost-effectiveness of some common
indirect costs are depreciation and administrative costs associated medical interventions [see Table 6].112 The median medical inter-
with regulatory compliance. However, not all costs classified as vention cost is $19,000/year of life. The figure of $50,000/year of
indirect are necessarily indirect in all circumstances. In some situ- life saved has often been put forward as a threshold for cost-effec-
ations, they could be defined as direct costs, with the specific clas- tiveness; however, any such thresholds remain both arbitrary and
sification depending on the given cost objective. relative and are not necessarily indicative of an intervention’s soci-
One technique that can help clarify costs is the creation of a etal value. For instance, the Oregon state health plan prioritized
matrix in which cost type is plotted against cost traceability.Thus, benefits on the basis of broad input from stakeholders rather than
variable costs can be direct or indirect, and direct costs can be a stratified list of $/QALYs.113 Physician leadership is particularly
variable, semivariable, semifixed, or fixed. More often than not, crucial in this context because the majority of health care costs are
costs are categorized according to a decision maker’s specific related to the decision to provide care, not to the question of
needs. The subcategory to which a given cost is assigned, howev- which options for care should be selected.
er, often depends on whose point of view is assumed—the pur-
chaser, the provider, or the patient.103,104 A key point is that physi-
cians primarily affect costs via their impact on variable costs (e.g., Implications of Outcome Variations
fully variable or semifixed costs), yet these costs typically consti- Although it is human nature for each surgeon to believe that he
tute no more than 15% to 35% of hospital costs.104,105 or she is among the best, the data clearly show considerable vari-
The interval between the intervention and the point of mea- ation in resource use and outcomes among surgeons and among
surement can also affect estimates of cost-effectiveness.106,107 hospitals.114 These variations are often relatively large, sometimes
Whereas patients are likely to view outcomes over the long term, exceeding 200% or even 300%. Some of the discrepancies report-
providers and purchasers tend to focus on the short term (e.g., the ed can be accounted for by the natural variability of biologic
term of a health care contract). This difference in perspective processes, and some by differences in disease severity; however,
affects the calculation of QALYs, which, in turn, affects the deter- the majority of the variations are unexplained.
mination of cost-effectiveness. Health care purchasers are well aware of these variations and
It is also useful to distinguish between per-procedure costs at use claims data to create performance profiles of hospital and
the hospital level and aggregate procedure costs at the insurer physician costs and outcomes and to establish benchmarks toward
level. This distinction was clearly an issue with the advent of which providers are expected to strive.The potential problem with
laparoscopic cholecystectomy,108 which saw lower costs per pro- such benchmarks is that they tend to reflect an ideal or excep-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 9 ELEMENTS OF COST-EFFECTIVE CARE — 8
The initial cost of endarterectomy is offset by the high cost of care after a major
Carotid endarterectomy in asymptomatic stroke; the relative cost of surgical treatment increases substantially with
patients74 8,000 +0.25 increasing age, increasing perioperative stroke rate, and decreasing stroke
rate during medical management
Routine radiation therapy after conservative The ratio is heavily influenced by the cost of radiation therapy and the quality-
28,000 +0.35
surgery for early breast cancer186 of-life benefit that results from a decreased risk of local recurrence
Total hip arthroplasty for osteoarthritis of the 117,000 in The cost savings result from the high cost of custodial care associated with
+6.9
hip: 60-year-old woman187 cost savings dependency
Endoscopic versus open carpal tunnel Cost-effectiveness is very sensitive to a major complication such as median
195 +0.235
release188 nerve injury
tional patient population.115 Thus, efforts to meet the mandated some states publicly disclosed provider-specific data on outcomes
performance levels might actually increase the risk of adverse out- of cardiac surgery. Their intent was to educate the public regard-
comes in complicated patients who need more extensive care. ing the choice of health care providers. Although these efforts used
A significant limitation of practice profile comparisons is that more criteria than were available through DRGs alone,125,126 the
they cannot fully account for disease-severity factors that affect profiles remained highly controversial because they still did not
outcome. Adjustments for disease severity are difficult to make on adequately account for all the differences in case severity. Because
the basis of claims data because in many cases, the requisite data current severity adjustments may not reflect differences attribut-
either is not collected or is miscoded.116 Medical-record review is able to patient selection, surgeons operating on truly high-risk
much better at accounting for severity, but it is also significantly patients will, all other factors being equal, have poorer outcomes
more cumbersome and costly. Even with medical-record review, than surgeons operating on lower-risk patients. However, all other
the effects of comorbid conditions on cost and outcome can be factors may not be equal. If the latter group of surgeons operated
difficult to sort out; as a result, much of the cost variation will still on the former group’s patients, the outcomes might even be worse,
be unaccounted for.117 Moreover, some differences in cost and and if the former group operated on the latter group’s patients, the
length of stay are related to factors that are not under surgeons’ outcomes might even be better. Such patient selection among
direct control, such as patient age, patient gender, and various cul- practices is a well-recognized phenomenon.127
tural, ethnic, or socioeconomic factors extrinsic to the medical Public release of provider outcome data may also have unin-
care system.118-120 Selection bias may affect outcome reporting as tended consequences. For instance, it has been suggested that
well.121 High rates of functional health illiteracy can also have an publicizing provider outcomes creates incentives to reduce risk-
adverse effect on compliance (and hence on outcomes).122 adjusted mortality by avoiding high-risk patients.128,129 In a 1996
Current methods, therefore, can result in very different estimates study, although consumer guides containing provider-specific out-
of cost-effectiveness for the same intervention. Despite the short- come data appeared to improve quality of care, they also appeared
comings of these methods, it is likely that health care purchasers will to have limited credibility among cardiovascular specialists.129
continue to use claims data and medical record review to assess cost- Surveys also indicated that the data were of limited value to the
effectiveness.The issue, then, is not whether such assessments will be target audience (i.e., patients undergoing cardiac surgery).
made but rather to what extent they will be used and for what pur- The success of provider report cards in prompting quality
poses.The Leapfrog Group (http://www.leapfroggroup.org) has tak- improvement depends on several factors.130 The added value of
en the lead in this area.This organization increasingly focuses on the such reports is likely to result in an increase in their availability to
differences in cost and outcome evidence and uses these data to rec- the public.131 As examples, one Web site (http://www.healthgrades.
ommend referral patterns. A 1995 national survey found that 39% com) contains hospital specialty data on cardiac, orthopedic, neu-
of managed care organizations were moderately or largely influenced rologic, pulmonary, and vascular surgery; transplantation out-
in initial physician selection by the physician’s previous patterns of comes are available from the United Network for Organ Sharing
costs or utilization, and nearly 70% profiled their member physi- (http://www.unos.org). There are numerous other Web sites that
cians.123 At least one HMO recognized that practices with high focus on health care quality [see Table 7].
scores on service and quality indicators attracted significantly more In contrast to the equivocal results of payor-based efforts, physi-
new enrollees than practices with lower scores did.124 cian-based quality-improvement efforts have had unquestioned
A somewhat controversial step has been the distribution of success. Perhaps the most notable of these latter efforts is that ini-
provider outcomes directly to the public in the form of report tiated by the Northern New England Cardiovascular Disease
cards. In an early effort, HCFA (now CMS) calculated mortality Study Group, which has developed a multi-institutional regional
data for individual hospitals using a risk-adjustment model based model for the continuous improvement of surgical care.132 The
on DRGs. After many years, however, HCFA acknowledged the success of this group’s approach rests on several key characteris-
flaws in the associated mortality model and stopped releasing tics: there is no ambiguity of purpose, the data are not owned by
these data. Subsequently, both HCFA (using Medicare data) and any member or subgroup of members, members have an estab-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 9 ELEMENTS OF COST-EFFECTIVE CARE — 9
lished safe place to work, a forum is set up for discussion, and reg- effective change strategies include reminders, patient-mediated
ular feedback is provided. Using a systems approach, the group interventions, outreach visits, input from opinion leaders, and mul-
effected a 24% reduction in hospital mortality for cardiac surgery tifaceted activities. Specific factors reported to increase the proba-
and reduced variation in outcomes among group members. The bility of a practice change are peer interaction, commitment to
decrease in mortality was considerably greater than that reported change, and assessment of the results of change.133 Additional evi-
by HCFA and by state report cards for similar procedures. Despite dence suggests that improvement in care is more likely to occur
concerns that releasing such findings would lead to unfavorable with CME activity that is directly linked to processes of care.134-138
publicity, no such reaction occurred. It is noteworthy that the Indeed, many of these features of practice change were employed
process the group developed did not involve personal criticism or both in the model developed by the Northern New England
attempt to identify the proverbial bad apples.Three important con- Cardiovascular Disease Study Group and in the subsequent
clusions can be drawn from the results reported: (1) physician-ini- national study by the Society of Thoracic Surgeons, which used
tiated interventions are likely to be more effective than external process measures to improve outcomes from coronary artery
review in improving quality, (2) a systems approach to quality bypass graft (CABG) surgery.139
improvement is better than the bad-apple approach, and (3) it is The current interest in assessing surgeons’ performance is not
possible to conduct quality-improvement programs involving prac- new, nor is the plea for that assessment from surgeons. In the early
tice groups that might otherwise be viewed as competitors. years of the 20th century, Ernest A. Codman, a Boston surgeon,
Although self-assessment of quality and cost-effectiveness may crusaded for hospitals and surgeons to publicize their results; his
seem daunting, the most difficult step may be the willingness to efforts typically met with varying degrees of disinterest or even
initiate the process. Studies of practice change in relation to con- defensiveness.140 Today, in the early years of the 21st century, it is
tinuing medical education (CME) consistently emphasize that clear that efforts to profile surgeons, despite their methodologic
shortcomings, are unlikely to go away. Surgeons who respond to
such efforts dismissively or defensively (e.g., by attempting to
explain away any outcome variations simply by stating, “My
Table 6 Cost-Effectiveness of Common
patients are sicker”) will be forgoing the opportunity to reestablish
Surgical Interventions92 the authority of the medical profession on the issue of quality.
Surgeons who preemptively familiarize themselves with their own
Cost-Effectiveness outcome data, on the other hand, will be better positioned to
Intervention ($/QALY)
respond appropriately to external review.
Mammography and breast exam (versus exam One must accept from the outset that self-assessment is an
95,000
alone) annually for women 40–49 yr of age ongoing process akin to peeling an onion: initial steps inevitably
lead to deeper analyses. Even simple data charts may reveal
Mammography and breast exam (versus exam
alone) annually for women 40–64 yr of age
17,000 changes or patterns in a surgeon’s outcomes or resource con-
sumption that might not otherwise be obvious.141 Sometimes,
Postsurgical chemotherapy for premenopausal
18,000
merely standardizing a process is enough to improve outcomes sig-
women with breast cancer nificantly. With time, strategies for optimal practice emerge.142,143
An important concept in looking at outcome measures and
Bone marrow transplant and high (versus standard)
130,000 processes of care is that for any given outcome measure to be a
chemotherapy for breast cancer
valid index of improved quality, it should also be intimately relat-
Cervical cancer screening every 3 yr for women ed to the processes of care.30
≤ 0*
older than 65 yr
The NCQA accredits managed health care plans and develops and refines the Healthplan Employ-
National Committee for Quality Assurance (NCQA)
er Data and Information Set (HEDIS). Many of the measures involve screening (e.g., mammogra-
(www.ncqa.com)
phy) and/or prevention (e.g., smoking cessation).
FACCT is a national organization dedicated to improving health care by advocating for an account-
Foundation for Accountability (FACCT) (www.facct.org)
able and accessible system.
National Forum for Health Care Quality Measurement NQF is a private, not-for-profit membership organization created to develop and implement a na-
and Reporting (ww.nqf.org) tional strategy for health care quality measurement and reporting.
Leapfrog is composed of more than 140 public and private organizations that provide health bene-
The Leapfrog Group (www.leapfroggroup.org) fits. The group works with medical experts to identify problems and to propose solutions that it
believes will improve hospital safety. It represents more than 34 million health care consumers in
all 50 states.
The institute offers resources and services to help health care organizations make dramatic and
Institute for Healthcare Improvement (www.ihi.org)
long-lasting improvements that enhance outcomes and reduce costs.
This organization was created to build consumer demand by providing information on quality rat-
QualityCounts (www.qualitycounts.org) ings for medical groups and hospitals in its network; tips for choosing doctors or hospitals; and in-
formation on dealing with medical errors.
The Commonwealth Fund supports and publishes studies in the broad area of health care quality.
The Commonwealth Fund (www.cmwf.org)
The study results are available on its Web site.
The NPSF identifies and creates a core body of knowledge; identifies pathways to apply that
National Patient Safety Foundation (www.npsf.org) knowledge; develops and enhances the culture of receptivity to patient safety; and raises
public awareness and fosters communications about patient safety.
Agency for Healthcare Research and Quality AHRQ is a branch of the Department of Health and Human Services that focuses on funding and
(www.ahrq.org) reporting health services research. Its Web site is an excellent resource of knowledge.
A nonprofit advocacy organization active in both state (primarily New York) and national efforts to
Center for Medical Consumers (www.medicalconsumers.org) improve the quality of health care. Its Web site is regularly updated with articles on issues of
health care quality, including a report on volume-outcomes in carotid endarterectomy.
large patient populations, outcome comparisons can be highly prob- physician-initiated) alternatives do not emerge, then other, less
lematic when one is dealing with unusual or infrequent cases. More- desirable options are likely to be imposed.
over, the relative importance of hospital volume and surgeon volume
may vary with specific procedures: complex, team-dependent proce-
dures (e.g., CABG surgery) may be more dependent on hospital vol- Practical Issues in Improving Cost-Effectiveness
ume, whereas less complicated procedures may be more dependent The OR is a frequent target for improved efficiency, and specif-
on surgeon volume. In the Veterans Administration National Surgi- ic guidelines for achieving this end are available.158-160 Perceived
cal Quality Improvement Project’s large study of eight common sur- delays in room turnover are a common complaint, for which the
gical procedures, which used medical-record data rather than claims responsibility is variously assigned to nurses, anesthesiologists, and
data, no correlation could be established between institutional oper- surgeons themselves. Maintaining large inventories to satisfy indi-
ative volume and postoperative mortality.154 It remains unclear, vidual surgeon preferences also contributes to higher costs, and
therefore, whether practice makes perfect or perfect makes practice. the growth of minimally invasive surgery has added new dimen-
The announced thresholds for given procedures are also fraught sions to this challenge [see 1:1 Preparation of the Operating Room].161
with methodologic problems.155 Key issues in this setting include reusable versus disposable equip-
The empirical relation between surgical volume and outcome ment, the varying costs of different types of equipment used to
has led to proposals for regionalization of care.156 Regionalization accomplish the same task, and just-in-time inventory. Major pieces
has proved effective in trauma care, but the basis of the improved of equipment are often duplicated to allow similar cases to be per-
quality in this setting may be better systems of care, not higher vol- formed simultaneously in different rooms, but this duplication
ume per se.This view is consistent with the findings that not every often means that the equipment may be idle for relatively long
high-volume provider has better outcomes and not every low-vol- periods. More efficient use of such equipment reduces costs, but
ume provider has poor outcomes. Regionalization of care without it requires levels of cooperation and coordination among surgical
a solid understanding of the basis of the volume-outcome rela- staff members that can be hard to achieve.
tionship has the potential to create unintended or even adverse To improve efficiency, the surgical team must think of the OR
consequences for other types of care. Consequently, many believe less as a workshop and more as a factory. Surgeons, having been
that it is too soon to use these volume-outcome data as surrogates steeped in the view that they are the “captain of the ship,” often
for quality or as criteria for establishing policy.157 Nonetheless, the have a hard time embracing the view that all members of the sur-
pressure to reduce cost remains strong; if suitable (preferably gical team have interdependent goals for quality maintenance and
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 9 ELEMENTS OF COST-EFFECTIVE CARE — 11
cost reduction. However, these two perspectives are not mutually how effectively they can address the issues of quality and cost. In
exclusive. Successful team efforts have led to cost reductions in particular, it is essential that they address both variations in interven-
trauma care162,163 and to the use of protocols to guide ventilator tion rates and variations in outcomes. Medical decision making
weaning.164,165 Moreover, the relative contributions of individual must increasingly be evidence based. Financial constraints will place
and institutional cost-effectiveness are such that improving the growing pressure on payors to reimburse surgeons and hospitals
former may have little impact if the latter is not improved as well. only for those procedures with clear indications, suitably low mor-
Ambulatory surgical units are often heralded as a cost-saving bidity and mortality, or both.This has already occurred with lung re-
measure. However, the aggregate savings are likely to depend on duction surgery for end-stage chronic obstructive pulmonary disease
existing OR capacity and on specific payor issues.166 (COPD). Although this procedure was being performed more and
It is worthwhile for surgeons to familiarize themselves with the more frequently, there was little hard evidence indicative of long-
broader organizational efforts aimed at improving quality in term efficacy. As a result, HCFA announced that it would pay for
health care [see Table 7].167-169 Such efforts may indeed help the procedure only if it was performed as part of a clinical trial aimed
improve care significantly; however, the most meaningful at confirming such efficacy; other payors quickly followed suit.173
improvements in care are likely to arise from efforts initiated at the Only in the past few years did the results of an RCT clarify the role
grassroots level. of lung reduction surgery for COPD.174
Academic medical centers are no more immune to the current
changes in health care than nonacademic centers are. In fact, they
Ethical and Legal Concerns face special challenges.175 Teaching hospitals are under growing
Efforts to improve cost-effectiveness are often seen as forcing pressure to subsidize education and research from their clinical
health professionals to face conflicts between the ethic of patient incomes, even while reimbursement is being increasingly restrict-
advocacy, on one hand, and pressures to make clinical decisions for ed.176 A 1997 study examining the relation between National
societal purposes and on behalf of third parties, on the other. Institutes of Health awards and managed care penetration in aca-
Although resolving these tensions may seem difficult,170 the med- demic medical centers found the two to be inversely related.177
ical profession is no stranger to such potential conflicts. The vast Other studies indicated that increased competitiveness within
majority of physicians successfully avoid the temptations inherent health care markets seemed to hinder the capacity of academic
in fee-for-service care, and at least as many appear to avoid incen- health centers to conduct clinical research and foster the careers
tives to undertreat. Although some believe that evidence-based of young faculty members.178,179 Nevertheless, despite higher
practices derived from large populations may not be readily applic- costs, teaching hospitals continue to demonstrate better out-
able to individual patients, the rationale for this belief is not clear. comes, even for rather low-technology interventions.180,181
One area that frequently generates controversy is the high costs A concern for the future is that academic medical centers may
of the terminal stages of life, particularly among patients who lose the capacity for producing the evidence on which cost-effec-
require intensive care. To mitigate the dilemma faced by physi- tive practice must be based—circumstances that would be tanta-
cians involved in making life-ending decisions, increasing empha- mount to eating the proverbial seed corn.182
sis is being placed on patient self-determination. However, even It is curious that despite the frequently expressed concerns
when physicians and institutions make efforts to comply with the about quality, competition over price still appears to be a much
choices of patients or their families in the setting of terminal ill- more urgent issue than competition over quality is.183 It seems log-
ness, costs are not always reduced, nor are outcomes always ical, however, that at some point, concerns about how much is
improved.171 The actual savings may be small.172 being paid out will give way to questions about why something is
being paid for. Physicians are the only participants in the health
care system who have the knowledge and skills needed to address
The Future the challenges of identifying cost-effective care. If they can
Physicians undoubtedly have a role to play in the ongoing discus- respond constructively to these challenges, rather than simply
sion and debate on the future of the health care system in the United ignore or dismiss them, they stand a good chance of recapturing
States.The extent of their input in this debate is likely to depend on much of their lost status and autonomy.
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72. Stoline AM, Weiner JP: The New Medical
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31. Taubes G: Looking for evidence in medicine. Marketplace: A Physician’s Guide to the Health
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end points. Evidence-Based Medicine Working
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ELEMENTS OF CONTEMPORARY PRACTICE 9 ELEMENTS OF COST-EFFECTIVE CARE — 13
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85. Shaneyfelt TM, Mayo-Smith MF, Rothwangl J:
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276:1172, 1996 118. Rhodes RS, Sharkey PD, Horn SD: Effect of coronary artery bypass graft surgery. JAMA
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95. Velanovitch V: Using quality of life instruments to surgery: implications for managed health care.
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98. Eiseman B: Surgical decision making and elderly Clin Proc 60:880, 1985 health care delivery costs using clinical paths: a
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122. Williams MV, Parker RM, Baker DW, et al: Health Care Finance 21:48, 1995
99. Kreder HJ, Wright JG, McLeod R: Outcomes Inadequate functional health literacy among
studies in surgical research. Surgery 121:223, patients at two public hospitals. JAMA 274:1677, 144. Sosa JA, Bowman HM, Tielsch JM, et al: The
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Importance of hospital volume in the overall man-
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148. Pearce WH, Parker MA, Feinglass J, et al: The 161. Newman RM, Traverso LW: Cost-effective mini- States. N Engl J Med 340:928, 1999
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29:768, 1999 162. Taheri PA, Wahl WL, Butz DA, et al: Trauma ser- awards to US medical schools and managed care
149. Harmon JW,Tang DG, Gordon TA, et al: Hospital vice cost: the real story. Ann Surg 227:720, 1998 market penetration. JAMA 278:217, 1997
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150. Trends in the concentration of six surgical proce- JAMA 278:222, 1997
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N Engl J Med 340:488, 1999 on medical education and research. Ann Surg
153. Houghton A: Variance in outcome of surgical pro- 223:453, 1996
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© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 10 HEALTH CARE ECONOMICS: THE LARGER CONTEXT — 1
In another chapter [see ECP:9 Elements of Cost-Effective Non- rent reflection of a long-term trend in which health care costs in
emergency Surgical Care], we review the principles of cost-effective the United States have risen continuously since 1966 (the year in
surgical care and discuss the implications of such principles for which Medicare and Medicaid were implemented) [see Figure 1].
health care spending. Our primary focus there is on the interac- Economists differ on whether such spending represents a risk to
tion between an individual surgeon and an individual patient. In the overall economic well-being of the United States. Those who
this chapter, we explore some of the issues surrounding health care are concerned about both the amount that is spent on health care
spending on a larger (i.e., national) scale. Although the data pre- and the rate at which this amount is growing cite the following
sented come from the United States, many of the challenges iden- concerns:
tified are faced by other industrialized nations as well. We believe
1. In spending more on health care, society spends less on
that it is important for surgeons to have a broad understanding of
other goods and services—a process referred to as dis-
these issues, in particular because such concerns are increasingly
placement. Thus, health care consumes resources that
becoming the subject of political debate.
might otherwise have been allocated to services such as
education or public safety.
United States Health Care Expenditures 2. The health care market is imperfect; therefore, some health
care spending is inevitably wasteful [see ECP:9 Elements of
SPENDING LEVELS Cost-Effective Nonemergency Surgical Care].
3. The health care sector of the economy is so large—not only
In 2002, U.S. National Health Expenditures (NHE) amounted
in terms of the amounts of money involved but also in
to $1.6 trillion (approximately 14.9% of the gross domestic prod-
terms of the number of people employed—that short-term
uct [GDP]).1 According to data from the World Bank
changes in its growth rate (in either direction) necessarily
(http://www.worldbank.org/data/databytopic/GDP.pdf), if the cur-
exert substantial and painful economic effects.
rent level of U.S. health care spending were viewed as a separate
4. As costs increase, voluntary participation by employers in
economy, it would be the fourth largest economy in the world, sur-
the provision of health insurance to employees and retirees
passing the GDP of the United Kingdom. This level of spending
comes under increasing pressure, with the result that
translates into a per capita expenditure of $5,440, which surpass-
employers either shift more and more of the costs of insur-
es the per capita expenditure for the next highest-spending coun-
ance to employees or decide to stop providing health insur-
try, Switzerland, by almost 30%.
ance altogether.2
Between 2000 and 2002, the average annual growth rate for per
capita health care spending was 7.1%, a rate that, if sustained, A major concern about the considerable swings in the rate of
would result in a figure of $3.1 trillion (17.7% of the GDP) for growth is that it creates the appearance of a health care system in
total NHE by 2012 [see Table 1]. This high growth rate is the cur- constant crisis.3 One need look no further than the news stories in
National health expenditures (NHE) ($ billion) 1,309.4 (6.2%) 1,420.7 (8.5%) 1,553.0 (9.3%)
Hospital care expenditures ($ billion) 413.2 (4.0%) 444.3 (7.5%) 486.5 (9.5%)
Physician and clinical services expenditures 290.3 (6.4%) 315.1 (8.6%) 339.5 (7.7%)
($ billion)
Prescription drug expenditures ($ billion) 121.5 (17.1%) 140.8 (15.9%) 162.4 (15.3%)
Per capita NHE ($) 4,670 (5.2%) 5,021 (7.5%) 5,440 (8.3%)
Gross national product (GDP) ($ billion) 9,825 (5.7%) 10,082 (2.6%) 10,446 (3.6%)
4,000 In 1996, almost half (44.2%) of total NHE was accounted for
by just 15 conditions [see Table 2].8 Even a casual glance at this
3,200 short list of conditions reveals how many of them are potentially
avoidable; obvious examples include motor vehicle accidents,
chronic obstructive pulmonary disease, and respiratory malignan-
2,400
cies. These findings illustrate how public policy decisions (or the
lack of them) can result in costs that are attributed to the health
1,600 care system. Another study found that in 1998, 9.1% of total
NHE ($78.5 billion) was related to obesity and overweight—a
percentage comparable to that related to smoking.9
800
It is also noteworthy that a small fraction of the population
accounts for the majority of health care spending. An analysis of
0 data from the 1987 National Medical Expenditure Survey and the
1966 1970 1980 1990 2001
1996 Medical Expenditure Panel Survey revealed that for both
Year periods surveyed, 5% of the population accounted for more than
Figure 1 Shown is the increase in per capita national health
half (55%) of total spending and 10% of the population for near-
care spending between 1996 and 2001.2 ly 70%.10 One implication of these findings is that any efforts to
constrain health care spending that focus on the 90% of the pop-
ulation responsible for only one third of expenditures are unlikely
the press in the United States to read of bankrupt hospital systems to have a major impact.
on one hand and cases of excessive profit-taking on the other.
Those who do not hold this pessimistic view of current health Factors Influencing Demand for Health Care
care spending argue that the health care share of GDP has no nat-
ural limit and that the only issue is whether the value of health AGING OF POPULATION
care spending is higher or lower than that of the spending it dis-
places.4 Intrinsic to this argument is the notion that the appropri- Although many believe that the aging of the United States pop-
ateness of spending can be judged only by taking the long view. ulation is a key factor driving the increase in HCE, several studies
Proponents of this viewpoint assert that it is alarmist to be overly suggest otherwise. A 1992 study estimated that total NHE in 2030
concerned about short-term changes in the rate of growth and would be $16 trillion, reflecting an estimated average growth rate
maintain that over the long term, the current growth rate is sus- of 8.3% (a rate that proved to be remarkably close to the observed
tainable. According to this school of thought, it is health care increase over the subsequent decade).11 Only 0.5% of this $16 tril-
spending in the economy as a whole that ought to be the focus, lion could be attributed to the aging of the population. A subse-
not the fraction of the total cost borne by a specific sector.5 quent report estimated that less than 1 percentage point of the
Regardless of which perspective is closer to the truth, it is abun- annual growth through the 1990s could be accounted for by
dantly clear that to date, no approach by either the public or the aging.12 Studies involving the Canadian population13 and multiple
private sector has significantly reduced—much less reversed—the national populations14 reached similar conclusions.
rate at which health care spending is growing [see Figure 2].6 The implications of these findings for health policy are not
entirely clear. It has been argued, however, that if the gradual aging
SERVICES PURCHASED of the United States population over the coming three decades
Elsewhere [see ECP:9 Elements of Cost-Effective Nonemergency is accompanied by a change in practice patterns from those
Surgical Care], we discussed the appropriateness (or lack thereof)
of a variety of services purchased with health care dollars.We also
Change in Per Capita Private Health Spending (%)
+10
pointed out that the United States ranks well behind other indus-
trialized countries in a number of well-accepted indicators of a +8
population’s health.
However, we need not look beyond the United States for evi- +6
dence that increased health care expenditures are not invariably
associated with demonstrable improvements in health outcomes. +4
Several major studies have shown that patients treated in higher-
spending regions of the United States do not have either better +2
health outcomes or greater satisfaction with their care than
patients treated in lower-spending regions.7 One such study 0
reported that the differences in spending were largely attributable
to the higher frequency of physician visits, the tendency to consult -2
specialists more readily, the ordering of more tests, the perfor-
mance of more minor procedures, and the more extensive use of -4
1961 1965 1970 1975 1980 1985 1990 1995 2000
hospital and intensive care services in the higher-spending
Year
regions. The authors could find no evidence that these types of
increased utilization resulted in improved survival, better func- Figure 2 Depicted are the percentage changes in per capita pri-
tional status, or enhanced satisfaction with care. These findings vate health care spending between 1961 and 2000.6
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 10 HEALTH CARE ECONOMICS: THE LARGER CONTEXT — 3
200
PRESCRIPTION DRUGS
of Health Spending (%)
Spending on hospital services accounts for nearly a third Figure 3 Shown are the growth rates for major components of
(31.3%) of all NHE. Since 2001, growth in spending on hospital health care spending between 1991 and 2001. Data from the
services has slowed somewhat, though it continues to outpace infla- Centers for Medicare and Medicaid Services (www.cms.hhs.gov/
tion and growth in GDP.18 The current growth in hospital inpatient statistics/nhe/historical).
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 10 HEALTH CARE ECONOMICS: THE LARGER CONTEXT — 4
hence, increased spending).21 Although this relationship is not Minneapolis area but more than twice that amount ($8,414) in
uniform across all technologies, the data reinforce the increasing the Miami area.25 Despite the sizable difference in expenditures,
evidence that technological change is the key driver of increased the authors found no differences in outcomes on a risk-adjusted
health spending. basis. A strong case can be made that if no differences in quality,
From a policy perspective, it might be tempting to conclude access, or satisfaction can be demonstrated, much of the difference
that one way of constraining the growth of health care spending in spending may be unnecessary, inappropriate, or ineffective.
would be to restrain the introduction or dissemination of new It is unclear precisely what proportion of total health care
technologies. For political reasons, however, such a step might expenditures represents costs that are greater than the benefits
prove difficult, if not impossible, to implement. In a survey con- that result. Some authors argue the figure is at least one third,26
trasting the interest in new medical technologies demonstrated by but others doubt whether it is that high.27 No one, however, main-
Americans with that demonstrated by Europeans, Americans were tains that this figure is zero. Unfortunately, no system has yet been
found to be more interested in such technologies and to have high- devised that will eliminate such unproductive spending.
er expectations regarding medicine’s capacity for managing illness
COST OF REGULATION AND ADMINISTRATION
or disability.22 To curb Americans’ appetite for new technologies
would require a considerable change in public opinion and per- The United States health care system is notable for its bewil-
ception of the value of such technologies, extensive education of dering array of insurers and contracts.Virtually every physician in
the public regarding realistic expectations, or a willingness on the the United States has had to expend considerable time and effort
part of United States political leaders to impose such a restraint in on dealing with complicated, arcane, and apparently deliberately
the face of public opposition.The last scenario is difficult to imag- confusing rules and practices. As a reaction to this state of affairs,
ine, given current campaign financing. some critics of the system in the United States have asserted that
the adoption of a simplified Canadian-style single-payor health
FAILURE OF MARKET FORCES insurance system would yield large savings in administrative costs
Some economists—and a considerable number of politicians— that could then be used to expand coverage to those who are cur-
believe that unleashing market forces will suffice to constrain the rently uninsured.
cost of health care. It appears, however, that health care does not A 2003 study compared administrative health care costs in the
behave like other sectors of the economy, for a number of reasons. United States with those in Canada. In 1999, per capita health
For one thing, it is difficult for health care consumers to become administration costs amounted to $1,059 in the United States (for
fully informed. For another, health services have the characteris- a total cost of $294 billion), contrasted with $307 in Canada [see
tics of public goods. In addition, health insurance leads to the so- Table 3].28 The authors arrived at these figures by analyzing data
called moral-hazard effect. This term moral hazard warrants a from governments, hospitals, insurance companies, and physi-
brief discussion here. It originated with the purchase of fire insur- cians. They argued that much of the difference between the two
ance in the 19th century, when it was recognized that the owner countries was accounted for by the multiple sources of health cov-
of a property that was insured might have an incentive to incur a erage in the United States, as opposed to the single source in the
loss either by deliberately setting a fire (a moral hazard) or by not Canadian system.
taking steps to reduce the likelihood of fire.The implication of the In an editorial accompanying this report,29 Aaron raised three
moral hazard effect for health care spending is that those who are questions29: (1) Are the differences reported accurate? (2) Would
insured (or more generously insured) will tend to use more health the difference in administrative costs cover the costs for addi-
services. (There is an obvious contrast with automobile insur- tional services under universal coverage? (3) What are the impli-
ance: no one would argue that insured drivers are more likely to cations for the answers for health policy? Aaron argued that the
deliberately wreck their cars.) In the health care setting, such significance of the differences in administrative spending were
behavior is logical in economic terms because for fully insured exaggerated—first, because of the methodology used to compare
persons, the cost of additional health services is borne by all those purchasing power between the two currencies, and second,
who pay insurance premiums. As a consequence, there may be because the original analysis assumed that the relative compen-
substantial demand for services that are of only minimal benefit. sations of clinical and administrative employees were the same in
Because minimally beneficial services may cost as much as any the two countries. He further argued that there was no reason to
other service, the overall benefit derived may be vastly overshad- believe that any costs potentially saved by simplifying adminis-
owed by the cost. tration in the United States would be used to extend coverage.
A complete exposition of this important topic is beyond the Aaron was certainly no defender of the current U.S. system:
scope of this chapter. Further discussion may be found in two I look at the U.S. health care system and see an administrative
excellent texts on health economics.23,24 monstrosity, a truly bizarre mélange of thousands of payers with
payment systems that differ for no socially beneficial reason, as
well as staggeringly complex public systems with mind-boggling
Inefficiencies in Health Care administered prices and other rules expressing distinctions that
can only be regarded as weird.
INEFFECTIVE OR INAPPROPRIATE CARE
Nevertheless, he concluded, as have most other observers of the
In another chapter [see ECP:9 Elements of Cost-Effective Non- United States system, that the administrative structure of any
emergency Surgical Care], we explored a number of considerations nation’s health care system evolves from its political history and
related to either the delivery of services of limited or nonexistent institutions and that to be durable, a health care system must
value or the failure to employ services of demonstrated benefit. reflect prevailing political values.
The actual cost incurred by these factors is difficult to estimate but
is certainly large. In a study that compared utilization of medical COSTS OF MEDICAL INJURY
resources by Medicare beneficiaries in various regions of the The Institute of Medicine has produced two reports that have
United States, per capita spending in 1996 was $3,341 in the received considerable attention in both the scientific and the lay
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 10 HEALTH CARE ECONOMICS: THE LARGER CONTEXT — 5
Administrative Cost Category Total Cost Per Capita Total Cost Per Capita
($ billion) Cost ($) ($ billion) Cost ($)
press. The first, To Err Is Human,30 concluded that mistakes were ing.35 According to the CBO’s estimates, malpractice costs
frequently made in the health care system and that the conse- amounted to $24 billion in 2002, or less than 2% of overall nation-
quences of these mistakes were considerable in both human and al health spending; thus, even a 25% reduction in malpractice
economic terms. The second, Crossing the Quality Chasm,31 out- costs would lower health care costs by only about 0.4%. Because
lined steps that must be taken to ensure that patients are not of the political interests invested in the issue, however, malpractice
injured by the care intended to help them. Although the magni- liability is certain to remain the subject of public discussion for the
tude of the problem identified in the two reports has been vigor- foreseeable future.
ously debated, the existence of the problem is undeniable. A 2003
analysis based on a review of 7.5 million hospital discharge ab-
stracts from nearly 1,000 hospitals in 28 states documented siz- Implications for Surgeons
able variations in length of stay and expenditure related to medical In a now-classic article describing the consequences of contin-
injury.32 The authors concluded that despite this variability, med- ued population growth, Hardin first articulated the notion of the
ical injuries both pose significant risks for patients and result in tragedy of the commons36:
considerable cost to society. It is difficult to argue with the propo- Picture a pasture open to all. It is to be expected that each herds-
sition that systems for minimizing these risks and reducing the man will try to keep as many cattle as possible on the commons.
associated cost must be developed and implemented. Such an arrangement may work reasonably satisfactorily for cen-
turies because tribal wars, poaching, and disease keep the num-
COST OF MEDICAL MALPRACTICE
bers of both man and beast well below the carrying capacity of the
Physicians have long argued that the tort system of compensa- land. Finally, however, comes the day of reckoning, that is, the day
tion for alleged medical injuries or adverse outcomes is expensive, when the long-desired goal of social stability becomes a reality. At
punitive, and arbitrary. Furthermore, they assert that the threat of this point, the inherent logic of the commons remorselessly gen-
litigation induces them to practice defensive medicine. As a con- erates tragedy. As a rational being, each herdsman seeks to maxi-
mize his gain. [H]e asks, “What is the utility to me of adding one
crete example, a 2002 report from the American Academy of
more animal to my herd?”
Orthopaedic Surgeons indicated that concerns about liability had [T]he rational herdsman concludes that the only sensible
caused nearly half of the surgeons surveyed to alter their practice course for him to pursue is to add another animal to his herd. And
and nearly two thirds to order more diagnostic tests.33 another; and another.… But this is the conclusion reached by
The sharp rise in premiums for medical malpractice liability each and every rational herdsman sharing a commons.Therein is
insurance over the past several years has led many professional the tragedy. Each man is locked into a system that compels him
associations to lobby Congress and state legislatures for caps on to increase his herd without limit—in a world that is limited. Ruin
noneconomic damages, as well as for other changes in the tort lia- is the destination toward which all men rush, each pursuing his
bility system. Proponents of such changes point to the loss of own best interest in a society that believes in the freedom of the
access to care in the only level 1 trauma center in Las Vegas in commons. Freedom in a commons brings ruin to all.
2002; the difficulty of providing on-call surgical care to emergency The comparison with health care may seem far-fetched at first
rooms in Jacksonville, Florida, and in Mississippi in 2003; and the glance, but as practitioners continue to seek to maximize utility for
loss of neurosurgical services in the northern panhandle of West themselves or their patients, the eventual outcome—assuming that
Virginia in 2002. Concerned about continued increases, the the resources available for health care are, like the commons,
reform advocates cite the reduced rates of increase in premiums finite—may well turn out to be as tragic as the one described by
reported in states that have imposed caps on noneconomic losses Hardin. Surgeons can help avert this fate by helping to develop,
(e.g., California, Colorado, and Montana). and then adhering to, evidence-based approaches such as the one
Two reports cast doubt on these arguments, however. A study we outline elsewhere [see ECP:9 Elements of Cost-effective Non-
conducted by the General Accounting Office was unable to con- emergency Surgical Care], thereby minimizing the likelihood that
firm the existence of any widespread access problems that could procedures that are of limited value or whose benefit is less than
be attributed to concerns about malpractice premiums.34 A report their cost will be performed. The importance of one-on-one edu-
from the Congressional Budget Office (CBO) concluded that any cation in the context of surgical care must also be emphasized.
savings resulting from a federally imposed cap on damage awards Such education, by placing patient interests ahead of surgeon
would not have a significant impact on total health care spend- interests, truly defines professionalism.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
ELEMENTS OF CONTEMPORARY PRACTICE 10 HEALTH CARE ECONOMICS: THE LARGER CONTEXT — 6
References
1. Levit K, Smith C, Cowan C, et al: Health spending 12. Strunk BC, Ginsburg PB: Aging plays limited role 24. Zweifel P, Breyer F: Health Economics. Oxford
rebound continues in 2002. Health Aff (Millwood) in health care cost trends. Data Bulletin #23. University Press, New York, 1997
23:147, 2004 Center for Studying Health System Change, 25. Fisher ES, Wennberg DE, Stukel TA, et al: The
2. Altman SH,Tompkins CP, Eilat E, et al: Escalating Washington, D.C., September 2002, p 1 implications of regional variations in Medicare
health care spending: is it desirable or inevitable? 13. Barer ML, Evans RG, Hertzman C: Avalanche or spending, pt 1: the content, quality, and accessibil-
Health Aff (Millwood), Web Exclusives, 8 January glacier? Health care costs and demographic ity of care. Ann Intern Med 138:273, 2003
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26. Brook RH, Vaiana ME: Appropriateness of Care: A
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Reacting to Hyperturbulence. Organizational 27. Aaron HJ: Should public policy seek to control the
Hopkins University Press, Baltimore, 2002
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15. Reinhardt UE: Does the aging of the population (Millwood), Web Exclusives, 8 January 2003
Improving Performance. Huber GP, Glicks WH,
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(Millwood) 22:27, 2003 hlthaff.w3.28v1/DC1
4. Pauly MV: Should we be worried about high real
16. Francis DR: Healthcare costs are up: here are the 28. Woolhandler S, Campbell T, Himmelstein DU:
medical spending growth in the United States?
Health Aff (Millwood), Web Exclusives, 8 January culprits. Christian Science Monitor, December 15, Costs of health care administration in the United
2003 2003 States and Canada. N Engl J Med 349:768, 2003
http://content.healthaffairs.org/cgi/content/full/ 17. Heffler S, Smith S, Keehan S, et al: Health spend- 29. Aaron HJ: The costs of health care administration
hlthaff.w3.15v1/DC1 ing projections for 2002–2012. Health Aff in the United States and Canada—questionable
5. Chernew ME, Hirth RA, Cutler DM: Increased (Millwood), Web Exclusives, 7 February 2003 answers to a questionable question. N Engl J Med
spending on health care: how much can the United http://content.healthaffairs.org/cgi/content/full/ 349:801, 2003
States afford? Health Aff (Millwood) 22:15, 2003 hlthaff.w3.54v1/DC1
30. Committee on the Quality of Health Care in
6. Altman DE, Levitt L:The sad history of health care 18. Strunk BC, Ginsburg PB: Tracking health care America, Institute of Medicine: To Err Is Human:
cost containment as told in one chart. Health Aff costs: trends stabilize but remain high in 2002. Building a Safer Health System. Kohn LT, Corrigan
(Millwood), Web Exclusives, 23 January 2002 Health Aff (Millwood), Web Exclusives, 11 June JM, Donaldson MS, Eds. National Academy Press,
http://content.healthaffairs.org/cgi/content/full/ 2003 Washington, D.C., 1999
hlthaff.w2.83v1/DC1 http://content.healthaffairs.org/cgi/content/full/
hlthaff.w3.266v1/DC1 31. Committee on the Quality of Health Care in
7. Fisher ES, Wennberg DE, Stukel TA, et al: The America, Institute of Medicine: Crossing the
implications of regional variations in Medicare 19. Singer B, Manton KG: The effects of health Quality Chasm: A New Health System for the 21st
spending, part 2: Health outcomes and satisfaction changes on projections of health service needs for Century. National Academy Press, Washington,
with care. Ann Intern Med 138:288, 2003 the elderly population of the United States. Proc D.C., 2001
Natl Acad Sci USA 95:15618, 1998
8. Druss BG, Marcus SC, Olfson M, et al: The most 32. Zhan C, Miller MR: Excess length of stay, charges,
expensive medical conditions in America. Health 20. Shactman D, Altman SH, Eilat E, et al: The out-
and mortality attributable to medical injuries dur-
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9. Finkelstein EA, Fiebelkorn IC, Wang G: National 33. Medical malpractice insurance concerns—final
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report. American Academy of Orthopaedic Sur-
obesity: how much, and who’s paying? Health Aff tionship between technology availability and health
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(Millwood), Web Exclusives, 14 May 2003 care spending. Health Aff (Millwood), Web
http://content.healthaffairs.org/cgi/content/full/ Exclusives, 5 Nov 2003 34. US General Accounting Office: Medical malprac-
hlthaff.w3.219v1/DC1 http://content.healthaffairs.org/cgi/content/full/ tice: implications of rising premiums on access to
hlthaff.w3.537v1/DC2 health care. Publication No. GAO-03-836.Washing-
10. Singer B, Manton KG: The effects of health
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the elderly population of the United States. Proc are Americans in new medical technologies? A 35. Congressional Budget Office: Limiting tort liability
Natl Acad Sci USA 95:15618, 1998 multicountry comparison. Health Aff (Millwood) for medical malpractice. Washington, D.C., January
11. Burner ST, Waldo JR, McKusick DR: National 20:194, 2001 2004
health expenditures projections through 2030. 23. Rice T: The Economics of Health Reconsidered, 36. Hardin G: The tragedy of the commons. Science
Health Care Financ Rev 14(1):1, 1992 2nd ed. Health Administration Press, Chicago, 2002 162:1243, 1968
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREPARATION OF THE OR — 1
1 PREPARATION OF THE
OPERATING ROOM
Rene Lafrenière, M.D., C.M., F.A.C.S., Ramon Berguer, M.D., F.A.C.S., Patricia C. Seifert, R.N., Michael Belkin, M.D.,
F.A.C.S., Stuart Roth, M.D., Ph.D., Karen S.Williams, M.D., Eric J. De Maria, M.D., F.A.C.S., and Lena M. Napolitano,
M.D., F.A.C.S., for the American College of Surgeons Committee on Perioperative Care
Today’s operating room is a complex environment wherein a vari- during the operation, critical devices must be positioned so that
ety of health care providers are engaged in the sacred ritual of they can readily be brought into use for monitoring and life sup-
surgery, controlling and modifying nature’s complicated orchestra port. The supplies and instruments likely to be needed must be
of disease entities. In what follows, we discuss certain key aspects easily available. Effective communication must be in place among
of the OR environment—design, safety, efficiency, patient factors, the members of the OR team, the OR front desk, and the rest of
and the multidisciplinary team—with the aim of improving sur- the hospital. Built-in computer, phone, imaging, and video sys-
geons’ understanding and comprehension of this complex world. tems can enhance efficiency and safety by facilitating access to
In particular, we focus on emerging technologies and the special clinical information and decision-making support. Finally, the
OR requirements of the burgeoning fields of endovascular surgery design of the OR must facilitate cleaning and disinfection of the
and minimally invasive surgery. room as well as permit efficient turnover of needed equipment and
supplies for the next procedure.
A modern OR must include adequate storage space for imme-
General Principles of OR Design and Construction diately needed supplies. Equally important, it must include ade-
quate storage space for the multitude of equipment and devices
PHYSICAL LAYOUT
required in current surgical practice. All too often, storage space is
The basic physical design and layout of the OR have not changed inadequate, with the result that equipment and supplies must be
substantially over the past century. In the past few years, however, stored in hallways and in the ORs themselves, thereby creating
major changes have occurred in response to continuing technologi- obstructions and hazards for personnel and patients.
cal developments in the areas of minimally invasive surgery, intraop- The basic design of today’s OR consists of a quadrangular room
erative imaging, invasive nonsurgical procedures (e.g., endoscopic, with minimum dimensions of 20 × 20 ft. More often, the dimen-
endovascular, and image-guided procedures), patient monitoring, sions are closer to 30 × 30 ft to accommodate more specialized
and telemedicine. cardiac, neurosurgical, minimally invasive, or orthopedic proce-
The exact specifications for new construction and major remodel- dures. Smaller rooms, however, are generally adequate for minor
ing of ORs in the United States depend, first and foremost, on state surgery and for procedures such as cystoscopy and eye surgery.
and local regulations, which often incorporate standards published Ceiling height should be at least 10 ft to allow mounting of oper-
by the Department of Health and Human Services.1 The American ating lights, microscopes, and other equipment on the ceiling. An
Institute of Architects publishes a comprehensive set of guidelines for additional 1 to 2 ft of ceiling height may be needed if x-ray equip-
health care facility design that includes a detailed discussion of OR ment is to be permanently mounted.
design.2 The design of new ORs must also take into account recom-
VOICE, VIDEO, AND DATA COMMUNICATION
mendations generated by specialty associations and regulatory agen-
cies.3-6 Finally, there are numerous articles and books that can be The operating suite should be wired to provide two-way voice,
consulted regarding various aspects of OR design.7-11 video, and data communication between the OR and the rest of the
The architectural design process for modern ORs should in- health care facility. Teleconnection of the OR to other areas of the
clude knowledgeable and committed representatives from hospi- hospital (e.g., the pathology department, the radiology department,
tal clinical services, support services, and administration. Impor- the emergency department, conference rooms, surgeons’ offices, and
tant design considerations include the mix of inpatient and outpa- wet/dry laboratories) can greatly enhance both patient care and
tient operations, patient flow into and out of the OR area, the teaching by improving the exchange of crucial information while
transportation of supplies and waste materials to and from the keeping noncritical traffic out of the OR environment.Two-way au-
OR, and flexibility to allow the incorporation of new technologies. dio and video teleconferencing can improve surgical management by
This planning phase benefits greatly from the use of architectural facilitating proctoring of less experienced practitioners, real-time
drawings, flow diagrams, computer simulations, and physical consultation with experienced specialists or the scientific literature,
mockups of the OR environment. and immediate viewing of x-ray images, specimens, and histologic
For an operation to be successful, multiple complex tasks must findings. Archiving of visual data also permits efficient sharing of in-
be carried out, both serially and in parallel, while care is exercised formation with other practitioners, to the point where even the most
to ensure the safety of both the patient and OR personnel.To this complex operative situation can be experienced on a nearly firsthand
end, it is vital that the OR be designed so as to permit patients, OR basis. It is largely true that our newfound technological ability to
personnel, and equipment to move and be moved as necessary share the OR environment between institutions has greatly facilitat-
without being unduly hindered by overcrowding or by obstruction ed the rapid development of advanced laparoscopic surgical proce-
from cables, wires, tubes, or ceiling-mounted devices. Before and dures on a global level.The superior educational value of a shared
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREPARATION OF THE OR — 2
audio and visual environment for teaching and learning complex patients because conservation of body heat is critical in these
surgical procedures is now well established. patients. Generally, surgeons who are actively working and fully
gowned prefer a temperature of 18° C (64.4° F), but anesthesiol-
ACCOMMODATION OF NEW TECHNOLOGIES
ogists prefer 21.5° C (70.7° F).14
In developing the OR of the future, it is essential to remain Humidity in the OR is generally maintained at between 50%
abreast of new technologies and incorporate them as appropriate; and 60%; humidity greater than 60% may cause condensation on
however, this should be done in such a way as to make the OR cool surfaces, whereas humidity less than 50% may not suppress
environment simpler rather than more complicated and less inti- static electricity.
midating rather than more so. Any new technical development
LIGHTING
must undergo rigorous evaluation to ensure that the correct tech-
nology is introduced in the correct manner at the correct time.12 Well-balanced illumination in the OR provides a surgeon with a
Properly utilized, technology can greatly facilitate surgical man- clear view of the operative field, prevents eye strain, and provides ap-
agement. A potential example is the bar coding now seen in every propriate light levels for nurses and anesthesiologists. Much of our
facet of our daily lives. At a patient’s first office visit, he or she can factual knowledge of OR illumination has been gained through the
be given a bar code, which is entered into a computer. On the efforts of Dr.William Beck and the Illuminating Engineering Soci-
morning of surgery, the computer can give the patient a wake up ety.15,16 A general illumination brightness of up to 200 footcandles
call at 5:30 A.M. Upon arrival at the surgical center, the patient (ft-c) is desirable in new constructions.The lighting sources should
can be logged in by bar code. Each step in the process can be not produce glare or undesirable reflection.
tracked: how many minutes it took for the patient to get to the The amount of light required during an operation varies with
OR, how long it took for the anesthesiologist and the resident to the surgeon and the operative site. In one study, general surgeons
interview the patient in the preoperative holding area, and how operating on the common bile duct found 300 ft-c sufficient;
long it took to position the patient. Essentially, this process is a because the reflectance of this tissue area is 15%, the required
variation on patient tracking and data acquisition that minimizes incident light level would be 2,000 ft-c.17 Surgeons performing
variability with respect to data entry. Tracking information can coronary bypass operations require a level of 3,500 ft-c.17 Whether
also be displayed on a video monitor, so that the patient’s location changes in the color of light can improve discrimination of differ-
and current status within the surgical care process are available on ent tissues is unknown.
an ongoing basis. Another facet of OR lighting is heat production. Heat may be
produced by infrared light emitted either directly by the light
MAXIMIZATION OF EFFICIENCY IN DESIGN AND PROCESS
source or via energy transformation of the illuminated object.
With the proliferation of technology, the increased complexity of However, most of the infrared light emitted by OR lights can be
surgical procedures, and the ongoing advances in surgical capabili- eliminated by filters or by heat-diverting dichroic reflectors.
ties, surgery today is a highly involved undertaking. As the number
of potential processes and subprocesses in surgical care has in-
creased, so too has the potential for inefficiency. Often, the organiza- Basic Safety Concerns in the OR
tional tendency to keep doing things the way they have always been The OR presents a number of environmental hazards to both
done prevents necessary improvements from being made, even in surgical personnel and patients. Chemical hazards exist from the use
the face of significant pressure from corporate interests to improve of trace anesthetic gases, flammable anesthetic agents, various deter-
and simplify processes. Decreasing turnover time and increasing ef- gents and antimicrobial solutions, medications, and latex products.18
ficiency during procedures are essential and can be accomplished by Other ever-present physical hazards include electrical shock and
simplifying rather than complicating the processes involved. An ex- burns, exposure to radiation from x-ray equipment, and injuries
ample of such an approach was documented in a 2002 article caused by lasers.19 In addition to causing injury directly, the use of
demonstrating that the redesign of a neurosurgical operating suite lasers can expose OR personnel to papillomavirus in smoke plumes.20
simplified processes and procedures related to neurosurgical opera- Hazards that are less often considered include noise pollution21 and
tions, resulting in a 35% decrease in turnover time.13 In addition, light hazards from high-intensity illumination.22 The most effective
team efficiency was significantly increased, leading to further time way of minimizing the particular hazards in a given OR is to have an
savings. The time commitment required of the specialist and the active in-hospital surveillance program run by a multidisciplinary
team members to make the necessary changes was modest, but the team that includes surgeons.
presence of OR administrators, staff members, surgeons, and anes-
MINIMIZATION OF HAZARDS TO PATIENT
thesia personnel, all cooperating to make working conditions more
productive and rewarding for everyone, was deemed crucial to the Patient safety, the first order of business in the OR,23 begins
success of the experiment. with proper handling of patients and their tissues, which is partic-
ularly important where patients are in direct contact with medical
devices. It is imperative that physicians, nurses, and technicians
Environmental Issues in the OR protect patients from injuries caused by excessive pressure, heat,
abrasion, electrical shock, chemicals, or trauma during their time
TEMPERATURE AND HUMIDITY
in the OR. Equipment must be properly used and maintained
The ambient temperature of the OR often represents a com- because equipment malfunctions, especially in life-support or
promise between the needs of the patient and those of the staff; monitoring systems, can cause serious harm.
the temperature desired by staff itself is a compromise between
the needs of personnel who are dressed in surgical gowns and Anesthetic Considerations
those who are not. In Europe and North America, OR tempera- Surgery, by its very nature, makes demands on the body’s
tures range from 18° to 26° C (64.4° to 78.8° F). A higher tem- homeostatic mechanisms that, if unchecked, would be injurious.
perature is necessary during operations on infants and burn It is the role of the anesthesiologist to anticipate these demands,
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREPARATION OF THE OR — 3
compensate for them, and protect the patient by supporting the becomes supine, the blood flow becomes essentially uniform from
body’s own efforts to maintain homeostasis [see 1:3 Perioperative apex to base.29 During spontaneous ventilation in the supine posi-
Considerations for Anesthesia]. Patient protection demands that con- tion, the patient can compensate for the altered flow, but when he
cerned physicians understand the effects of their perioperative in- or she is anesthetized, paralyzed, and placed on positive pressure
terventions, both positive and negative, and act to minimize the ventilation, the weight of the abdominal contents prevents the pos-
unintended consequences. terior diaphragm from moving as freely as the anterior diaphragm,
Even with straightforward surgical procedures, issues related to thus contributing to a ventilation-perfusion mismatch.30
patient positioning can lead to unintended consequences. Gen- After the supine position, the lithotomy position is the next
eral, regional, and monitored anesthesia care render patients help- most common position for surgical procedures. Approximately
less to protect themselves from the stresses of an uncomfortable 9% of operations are conducted with the patient in the lithotomy
position. As the physician who renders the patient helpless, the position.26 Because the lithotomy position is basically a modifica-
anesthesiologist is responsible for protecting the patient from the tion of the supine position, there is still a risk of upper-extremity
results of the position. The surgeon, who chooses the position for neuropathy; however, the risk of lower-extremity neuropathy is sig-
the procedure that maximizes exposure and facilitates the opera- nificantly greater. The main hemodynamic consequence of the
tion, is responsible for the consequences of that choice. The OR lithotomy position is increased cardiac output secondary to the
team is responsible for procuring and maintaining whatever spe- gravity-induced increase in venous return to the heart caused by
cialized equipment is needed to position the patient properly.The elevation of the lower extremities above the level of the heart.28 Of
American Society of Anesthesiologists (ASA) Practice Advisory on greater concern is the effect on the lower extremity of the various
the Prevention of Perioperative Peripheral Neuropathies recom- devices used in positioning. Damage to the obturator, sciatic, lat-
mends that when practical, the patient should be placed in the eral femoral cutaneous, and peroneal nerves after immobilization
intended position before the procedure to see if it is comfortable.24 in the lithotomy position, though rare, has been reported.31,32 Such
If the position is uncomfortable when the patient is awake, it complaints account for only 5% of all closed claims for nerve dam-
should be modified until it is comfortable. age in the Closed Claims Data Base.25
The consequences of patient discomfort from positioning may Other patient positions can also lead to physiologic and neuro-
include postoperative myalgias, neuropathies, and compartment logic complications, including the lateral decubitus, prone, sitting,
syndromes. The greatest risk in the supine position, peripheral Trendelenburg, and reverse Trendelenburg positions.
neuropathy, arises from the positioning of the upper extremity.
MINIMIZATION OF OCCUPATIONAL INJURIES TO
The two most common peripheral neuropathies reported to the
HEALTH CARE TEAM
ASA Closed Claim Study as of 1999 were ulnar neuropathy and
brachial plexopathy.25 Approximately 28% of the closed claims for Work-related musculoskeletal injuries are a major cause of de-
peripheral neuropathy were for ulnar neuropathy and 20% for creased productivity and increased litigation costs in the United
brachial plexopathy.25 With regard to upper-extremity positioning, States.23 In the OR, occupational injuries can be caused by excessive
the ASA Practice Advisory recommends that the arms be abduct- lifting, improper posture, collision with devices, electrical or thermal
ed no more than 90°.24 The arms should also be positioned so as injury, puncture by sharp instruments, or exposure to bodily tissues
to decrease pressure on the postcondylar groove of the humerus. and fluids.Temporary musculoskeletal injuries resulting from poor
When the arms are tucked, the neutral position is recommended. posture (particularly static posture) or excessive straining are less
Prolonged pressure on the radial nerve in the spiral groove of the commonly acknowledged by members of the surgical team but oc-
humerus should be avoided. Finally, the elbows should not be cur relatively frequently during some operations.
extended beyond a comfortable range so as not to stretch the To reduce injuries from awkward posture and excessive strain-
median nerve. ing, OR devices should be positioned in an ergonomically desir-
Approximately 80% of surgical procedures are performed with able manner, so that unnecessary bending, reaching, lifting, and
patients in the supine position.26 Its ubiquity notwithstanding, the twisting are minimized. Visual displays and monitors should be
supine position has certain physiologic consequences for the placed where the surgical team can view them comfortably.
patient, including gravitational effects on both the circulatory sys- Devices that require adjustment during operations should be read-
tem and the pulmonary system.27 The most immediate hemody- ily accessible. Placement of cables and tubes across the OR work-
namic effect noted upon assumption of the supine position is space should be avoided if possible.The patient and the operating
increased cardiac output resulting from enhanced return of lower- table should be positioned so as to facilitate the surgeons’ work
extremity venous blood to the heart.28 If this effect were unop- while maintaining patient safety. Lifting injuries can be prevented
posed, systemic blood pressure would rise. This rise does not by using proper transfer technique and obtaining adequate assis-
occur, however, because baroreceptor afferent impulses lead to a tance when moving patients in the OR.
reflexive change in the autonomic balance, which decreases stroke
volume, heart rate, and contractility,29 thereby serving to maintain
blood pressure. Inhaled, I.V., and regional anesthetics all have the Equipment
capacity to blunt or abolish these protective reflexes, thus causing Modern surgery uses an ever-increasing number of devices in
hypotension in supine, anesthetized patients and necessitating the the OR to support and protect the patient and to assist the work
administration of additional fluids or, occasionally, pressors. of the surgical team [see Table 1]. All OR equipment should be eval-
Immediate effects of the supine position on the respiratory sys- uated with respect to three basic concerns: maintenance of patient
tem include cephalad and lateral shifting of the diaphragm and safety, maximization of surgical team efficiency, and prevention of
cephalad shifting of the abdominal contents, resulting in decreased occupational injuries.
functional residual capacity and total lung capacity.27,28 In addition,
ELECTROSURGICAL DEVICES
perfusion of the lung changes as the supine position is assumed.
When the patient is upright, the dependent portions of the lungs The electrosurgical device is a 500 W radio-frequency genera-
receive the bulk of the blood flow23; however, when the patient tor that is used to cut and coagulate tissue. Although it is both
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREPARATION OF THE OR — 4
Table 1 Devices Used in the OR evacuator should be attached to the laser to improve visualization,
reduce objectionable odor, and decrease the potential for papillo-
Anesthesia delivery devices
mavirus infection from the laser smoke plume.37
Ventilator
For support POWERED DEVICES
of patient Physiologic monitoring devices
Warming devices The most common powered device in the OR is the surgical
I.V. fluid warmers and infusers table. Central to every operation, this device must be properly
positioned and adjusted to ensure the safety of the patient and the
Sources of mechanical, electrical, and internal power,
including power tools and electrocautery, as well as laser efficient work of the surgical team. Manually adjustable tables are
and ultrasound instruments simple, but those with electrical controls are easier to manage. OR
Mechanical retractors table attachments, such as the arm boards and leg stirrups used to
Lights mounted in various locations position patients, must be properly maintained and secured to pre-
For support Suction devices and smoke evacuators
of surgeon
vent injuries to patients or staff. During transfer to and from the
Electromechanical and computerized assistive devices, such
as robotic assistants OR table, care must be taken to ensure that the patient is not
Visualization equipment, including microscopes, endoscopic injured and that life-support, monitoring, and I.V. systems are not
video cameras, and display devices such as video moni- disconnected. Proper transfer technique, personnel assistance, and
tors, projection equipment, and head-mounted displays
the use of devices such as rollers will help prevent musculoskeletal
Data, sound, and video storage and transmission equipment
injuries to the OR staff during this maneuver.
Diagnostic imaging devices (e.g., for fluoroscopy, ultrasonog-
raphy, MRI, and CT) Other powered surgical instruments common in the OR
include those used to obtain skin grafts, open the sternum, and
Surgical instruments, usually packaged in case carts before
each operation but occasionally stored in nearby fixed or
perform orthopedic procedures. Powered saws and drills can
mobile modules cause substantial aerosolization of body fluids, thereby creating a
Tables for display of primary and secondary surgical potential infectious hazard for OR personnel.38,39
For support instruments
of OR team
Containers for disposal of single-use equipment, gowns, VIEWING AND IMAGING DEVICES
drapes, etc.
Workplace for charting and record keeping OR microscopes are required for microsurgical procedures.
Communication equipment Floor-mounted units are the most flexible, whereas built-in micro-
scopes are best employed in rooms dedicated to this type of pro-
cedure.40 Microscopes are bulky and heavy devices that can cause
common and necessary in the modern OR, it is also a constant obstructions and collision hazards in the OR. All controls and dis-
hazard and therefore requires close attention.33 When in use, the plays must be properly positioned at or below the user’s line of
electrosurgical unit generates an electrical arc that has been asso- sight to allow comfortable and unobstructed viewing.
ciated with explosions.This risk has been lessened because explo- Today’s less invasive operations require more accurate intraop-
sive anesthetic agents are no longer used; however, explosion of erative assessment of the relevant surgical anatomy through the
hydrogen and methane gases in the large bowel is still a real—if use of x-ray, computed tomography, magnetic resonance imaging,
rare—threat, especially when an operation is performed on an and ultrasonography. Intraoperative fluoroscopy and ultrasonog-
unprepared bowel.34 Because the unit and its arc generate a broad raphy are most commonly used for this purpose. Intraoperative
band of radio frequencies, electrosurgical units interfere with ultrasonography requires a high-quality portable ultrasound unit
monitoring devices, most notably the electrocardiographic moni- and specialized probes. Depending on the procedure and the
tor. Interference with cardiac pacemaker activity also has been training of the surgeon, the presence of a radiologist and an ultra-
reported.35 sound technician may be required. The ultrasound unit must be
The most frequently reported hazard of the electrosurgical unit positioned near the patient, and the surgical team must be able to
is a skin burn. Such burns are not often fatal, but they are painful, view the image comfortably. In some cases, the image may be dis-
occasionally require skin grafts, and raise the possibility of litiga- played on OR monitors by means of a video mixing device.
tion.The burn site can be at the dispersive electrode, ECG moni- Dedicated open radiologic units are usually installed either in the
toring leads, esophageal or rectal temperature probes, or areas of OR proper or immediately adjacent to the OR to permit intraop-
body contact with grounded objects. The dispersive electrode erative imaging of the selected body area. As image-guided proce-
should be firmly attached to a broad area of dry, hairless skin, dures become more commonplace, OR designers will have to
preferably over a large muscle mass.34 accommodate such devices within the OR workplace in a user-
friendly manner.
LASERS
ADDITIONAL DEVICES
Lasers generate energy that is potentially detrimental. Lasers
have caused injuries to both patients and staff, including skin The use of sequential compression stockings (SCDs), with or
burns, retinal injuries, injuries from endotracheal tube fires, pneu- without additional medical anticoagulation, has become the stan-
mothorax, and damage to the colon and to arteries.36 Some design dard of care for the prevention of venous thromboembolism in the
changes in the OR are necessary to accommodate lasers. The OR majority of operations for which direct access to the lower extrem-
should not have windows, and a sign should be posted indicating ities is not required [see 6:6 Venous Thromboembolism].41 This is par-
that a laser is in use. The walls and ceiling in the room should be ticularly true in operations lasting more than 4 hours for which the
nonreflective. Equipment used in the operative field should be patient is in the lithotomy position. The pump often must be
nonreflective and nonflammable. The concentration of O2 and placed near the patient on the floor or on a nearby cart.The pres-
N2O in the inhaled gases should be reduced to decrease the pos- sure tubing from the stockings to the pump must be routed out of
sibility of fire. In addition, personnel should wear goggles of an the surgical team’s way to prevent hazards and enlargements, par-
appropriate type to protect the eyes from laser damage. A smoke ticularly during operations for which perineal access is required.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREPARATION OF THE OR — 5
Suction devices are ubiquitous in the OR, assisting the surgeon Table 2 ICRP-Recommended
in the evacuation of blood and other fluids from the operative Radiation Dose Limits43
field. A typical suction apparatus consists of a set of canisters on a
wheeled base that receive suction from a wall- or ceiling-mounted Dose Limit
source. The surgeon’s aspirating cannula is sterilely connected to
these canisters. Suction tubing is a common tripping hazard in the Occupational Public
OR, and the suction canisters fill rapidly enough to require repeat- 20 mSv/yr averaged over
ed changing. Effective dose 1 mSv/yr
defined periods of 5 yr
Portable OR lights or headlights are often used when the light-
ing provided by standard ceiling-mounted lights is insufficient or Annual equivalent dose in
Lens of the eye 150 mSv 15 mSv
when hard-to-see body cavities prove difficult to illuminate. Head-
Skin 500 mSv 50 mSv
lights are usually preferred because the beam is aimed in the direc-
Hands and feet 500 mSv —
tion the surgeon is looking; however, these devices can be uncom-
fortable to wear for prolonged periods. The fiberoptic light cord ICRP—International Commission on Radiological Protection mSv—millisievert
from the headset tethers the surgeon to the light source, which can
exacerbate crowding.
Units of Exposure
CASE CARTS AND STORAGE Radiation exposure is expressed in several ways. One of the
In the case cart system, prepackaged sterile instruments and most commonly used terms is the rad (radiation absorbed dose),
supplies for each scheduled operation are placed on a single open defined as the amount of energy absorbed by tissue (100 erg/g =
cart (or in an enclosed cart) and delivered from the central sterile 1 rad). In the Système International, the gray (Gy) is used in place
supply area to the OR before the start of the procedure. of the rad (1 Gy = 100 rad).The newest of the units in current use,
Instrument sets should be sterilized according to facility policy. It the millisievert (mSv), was introduced as a measure of the effec-
is not recommended that instrument sets be flash sterilized imme- tive absorbed dose to the entire body (accounting for different sen-
diately before use in order to avoid purchasing additional instru- sitivities of exposed tissues).The amount of radiation generated by
ment sets.42 Instruments that are used less frequently or are used the x-ray tube is determined by the energy generated by the beam,
as replacements for contaminated items can be kept in nearby which in turn is determined both by the number of x-ray photons
fixed or mobile storage modules for ready access when required. generated (measured in milliamperes [mA]) and by the power or
Replacements for frequently used items that may become conta- penetration of the beam (measured in kilovolts [kV]). Most mod-
minated (e.g., dissecting scissors and hemostats) should be sepa- ern fluoroscopes automatically balance mA levels against kV lev-
rately wrapped and sterile so that they are readily available if need- els on the basis of the contrast of the image so as to optimize image
ed during an operation. quality and minimize x-ray exposure.
Exposure of human beings to radiation is broadly categorized as
either public (i.e., environmental exposure of the general public)
The Endovascular OR or occupational. The International Commission on Radiological
The field of vascular surgery has rapidly expanded over the past Protection (ICRP) has established recommended yearly limits of
decade to encompass a wide variety of both established and in- radiation exposure for these two categories [see Table 2].43 A 2001
novative endovascular procedures that are new to the OR en- study determined that with appropriate protection, radiation
vironment. Such procedures include complex multilevel dia- exposure for busy endovascular surgeons fell between 5% and 8%
gnostic arteriography, balloon angioplasty (with and without of ICRP limits, whereas exposure for other OR personnel fell
stenting), and endoluminal grafting of aortic aneurysms. Many between 2% and 4%.44 Average radiation exposure for patients
of these procedures can be performed in the radiologic interven- undergoing endovascular aneurysm repair was 360 mSv/case
tion suite as well as in the cardiac catheterization laboratory. (range, 120 to 860).44
However, the sterile environment, the option of performing com-
Basic Safety Rules
bined open surgical and endovascular procedures, and the op-
portunity to provide one-stop diagnostic and therapeutic care A few simple rules and procedures can help ensure a safe envi-
make the OR the favored location for efficient and safe man- ronment for patients and OR staff. The simplest rule is to mini-
agement. Although most OR personnel are familiar with fluoro- mize the use of fluoroscopy. Inexperienced operators are notorious
scopic procedures as well as simple diagnostic arteriography, the for excessive reliance on fluoroscopy. Such overutilization results
development of a comprehensive and successful endovascular both from needing more time to perform endovascular maneuvers
program in the OR requires significant personnel training, than a more experienced surgeon would need and, more impor-
commitment of resources, and preparation. In what follows, we tant, from performing excessive and unnecessary (and frequently
review certain basic considerations in the evolution of such a unintentional) imaging between maneuvers.The use of pulsed flu-
program, focusing primarily on space and equipment. Tech- oroscopy and effective collimation of the images will also minimize
nical details of endovascular procedures are addressed in the dose of radiation administered. Minimal use of high-definition
more detail elsewhere [see 6:8 Fundamentals of Endovascular fluoroscopy and unnecessary cine runs (both of which boost radi-
Surgery]. ation output) are desirable. Most important, surgeons and OR
staff should maximize their working distance from radiation
RADIATION SAFETY sources. Radiation scatter drops off rapidly with increasing dis-
A detailed discussion of radiation physics and safety is beyond tance from the fluoroscope.
the scope of this chapter.There are, however, certain fundamental
Safety Equipment and Monitoring
concerns that should be emphasized here to ensure the safety of
patients and staff members. All OR personnel should wear protective lead aprons (0.25 to
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREPARATION OF THE OR — 6
0.5 mm in thickness). Wraparound designs are preferred because Table 3 Standard Equipment for
members of the OR team will invariably turn their backs to the Endovascular ORs
radiation source on occasion. The apron should include a thyroid
shield. High-level users must wear protective lead-containing lens-
Entry needle (16-gauge beveled)
es. A mobile shield (e.g., of lead acrylic) is a useful adjunct that Entry wire (J wire or floppy-tip wire)
may be employed to reduce exposure during cine runs. All per- Arterial sheath (5 Fr)
sonnel should wear radiation safety badges. Although these badges Catheters
afford no direct protection, they do allow direct monitoring of Diagnostic Multipurpose nonselective (pigtail, tennis racquet,
individual cumulative exposure on a monthly basis. arteriography straight, etc.)
Selective (cobra head, shepherd’s crook, etc.)
PHYSICAL LAYOUT Guide wires (floppy, steerable, angled, hydrophilic, etc.)
Contrast agent (nonionic preferred)
The design of the endovascular OR depends on the balance of Power injector
institutional and programmatic needs. For large institutions with a
significant endovascular volume, a dedicated endovascular OR Sheaths (various lengths and diameters)
may be desirable. Ideally, such a room would combine fixed ceil- Guide catheters
ing-mounted imaging equipment with a dedicated “floating” flu- Balloons (various lengths and diameters)
Balloon stent
Stents
oroscopy table. The main advantage of a dedicated endovascular angioplasty
Balloon expandable (various lengths and diameters)
OR is that it provides state-of-the-art imaging techniques and Self-expanding (various lengths and diameters)
capabilities in the OR setting; the main disadvantage is that it is Inflation device
relatively inflexible and is not useful for other procedures. For
many institutions, such a room may not be cost-effective. For- Large-caliber sheaths (12–24 Fr)
tunately, with careful design, a high-quality endovascular suite can Super-stiff guide wires
Endovascular Endovascular stent grafts
be set up that is flexible enough to allow both complex endovas- aneurysm Main body and contralateral iliac limb
cular procedures and conventional open vascular and nonvascular repair
Aortic and iliac extension grafts
operations to be performed. Such a room should be at least 600 Endovascular arterial coils
sq ft in area, with sufficient length and clearance for extension
tables and angiographic wires and catheters.
digital C-arms have increased dramatically. State-of-the-art
EQUIPMENT
portable C-arms are considerably less expensive than fixed sys-
tems ($175,000 to $225,000) while retaining many of their advan-
Imaging Equipment tages. The variable image intensifier size (from 6 to 12 in.) offers
There are two fundamental physical designs for OR imaging valuable flexibility, with excellent resolution at the smaller end and
equipment. The first is the fixed ceiling-mounted system that is an adequate field of view at the larger end.With some portable C-
also employed in catheterization laboratories and dedicated radio- arm systems, it is possible to vary the distance between the image
logic interventional suites. The second is a system using portable intensifier and the x-ray tube, as with a fixed system (see above).
C-arms with dedicated vascular software packages designed for Pulsed fluoroscopy, image collimation, and filtration are standard
optimal endovascular imaging. Each of these systems has advan- features for improving imaging and decreasing radiation exposure.
tages and disadvantages. Sophisticated software packages allow high-resolution digital sub-
Notable benefits of the fixed ceiling-mounted system include traction angiography, variable magnification, road mapping (i.e.,
higher power output and smaller focal spot size, resulting in the high- the superimposition of live fluoroscopy over a saved digital arteri-
est-quality images. Larger image intensifiers (up to 16 in.) make pos- ogram), and a number of other useful features. Improvements in
sible larger visual fields for diagnostic arteriograms; thus, fewer runs C-arm design allow the surgeon to use a foot pedal to select vari-
need be made, and injection of dye and exposure to radiation are re- ous imaging and recording modes as well as to play back selected
duced accordingly.The variable distance between the x-ray tube and images and sequences.
the image intensifier allows the intensifier to be placed close to the Unlike fixed systems, which require patients to be moved on a
patient if desired, thereby improving image quality and decreasing floating table to change the field of view, C-arm systems require the
radiation scatter. Fixed systems are accompanied by floating angiog- image intensifier to be moved from station to station over a fixed pa-
raphy tables, which allow the surgeon to move the patient easily be- tient. Although more cumbersome than fixed systems, the newest C-
neath the fixed image intensifier. It is generally accepted that such arms have increased mobility and maneuverability. Patients must be
systems afford the surgeon the most control and permit the most ef- placed on a special nonmetallic carbon fiber table.To provide a suffi-
fortless and efficient imaging of patients. cient field of view and permit panning from head to toe, the tables
Unfortunately, fixed ceiling-mounted systems are quite expen- must be supported at one end with complete clearance beneath. Al-
sive (typically $1 million to $1.5 million), and major structural though these tables do not flex, they are sufficient for most opera-
renovations are often required for installation in a typical OR. tions. Furthermore, they are mobile and may be replaced with con-
Perhaps more important for most ORs, however, is that these sys- ventional operating tables when the endovascular suite is being used
tems are not particularly flexible. The floating angiography tables for standard open surgical procedures.
and the immobility of the image intensifiers render the rooms
unsuitable for most conventional open surgical procedures. Interventional Equipment
Consequently, fixed imaging systems are generally restricted to The performance of endovascular procedures in the OR
high-volume centers where utilization rates justify the construc- requires familiarity with a wide range of devices that may be unfa-
tion of dedicated endovascular ORs. miliar to OR personnel, such as guide wires, sheaths, specialized
As endovascular procedures in the OR have become increas- catheters, angioplasty balloons, stents, and stent grafts [see Table 3].
ingly common, the imaging capability and versatility of portable In a busy endovascular OR, much of this equipment must be
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREPARATION OF THE OR — 7
Aortic Extender
Contralateral Leg
Trunk/Ipsilateral Leg
Iliac Extender
Figure 1 Shown are the component parts of a modular aortic stent graft.
stocked for everyday use, with the remainder ordered on a case-by- planted by less invasive endovascular alternatives.Today’s vascular
case basis. The expense of establishing the necessary inventory of surgery ORs must be prepared and equipped for a safe and effi-
equipment can be substantial and can place a considerable burden cient transition as this trend continues.
on smaller hospitals that are already spending sizable amounts on
stocking similar devices for their catheterization laboratories and
interventional suites. Fortunately, many companies are willing to The Laparoscopic OR
supply equipment on a consignment basis, allowing hospitals to
PHYSICAL LAYOUT
pay for devices as they are used.
With the advent of laparoscopy, it has become necessary to reeval-
Aortic Stent Grafts uate traditional OR concepts with the aim of determining how best
Endovascular repair of an abdominal aortic aneurysm (EVAR) to design a surgical environment suitable for the demanding require-
is the most common and important endovascular procedure per- ments of advanced minimally invasive surgical procedures.
formed in the OR [see 6:11 Repair of Infrarenal Abdominal Aortic As noted (see above), until the early 1990s, ORs were constructed
Aneurysms]. As of spring 2003, three EVAR devices had been in much the same way as they had been for nearly 100 years.The ef-
approved by the FDA for commercial use, with numerous others fect of the explosion in minimally invasive surgical procedures that
at various stages of the FDA approval process. All EVAR grafts are occurred in that decade, along with the demonstration that patients
expensive (> $10,000). Although busy hospitals may maintain an benefited from significantly reduced recovery times, was to force OR
inventory of devices, most grafts are ordered on a case-by-base personnel to move rapidly into a new age of technology, with little or
basis. The favored devices are configured as bifurcated aortoiliac no preparation. During the early days of laparoscopic surgery, sur-
grafts. Most such grafts are modular in design, comprising two geons noted significant increases in turnover time and procedural
main pieces [see Figure 1], though one unibody device has been down time.45 Adding to the problem was that the OR environment
approved. Nonbifurcated grafts connecting the aorta to a single was becoming increasingly cluttered as a consequence of the addi-
iliac artery are available for special circumstances. Grafts are con- tion of endoscopic video towers and other equipment.This equip-
structed of either polyester or polytetrafluoroethelyne (PTFE) ment often proved to be complicated to use and expensive to repair.
and have varying amounts of stent support. Proximal fixation is The increasing expenditure of money and time, coupled with an op-
accomplished in different ways, ranging from friction fit to the use erating environment that increasingly promoted confusion rather
of hooks and barbs. Various extension components for both ends than patient care, constituted a clear signal that the OR, as designed
of the graft are available; in many cases, these components are a century before, had been stretched beyond its capabilities and
necessary to complete the repair. needed to be redesigned.
Endovascular therapy is a rapidly evolving field within the dis- A key component of OR redesign for laparoscopic surgery is the
cipline of vascular surgery. Many operations traditionally per- placement of patient contact equipment on easily movable booms
formed as open surgical procedures are increasingly being sup- that are suspended from the ceiling.This arrangement makes rooms
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREPARATION OF THE OR — 8
easier to clean and thus speeds turnover. All patient contact equip-
ment and monitors are placed on these booms, and all other equip-
ment is moved to the periphery of the surgical suite, usually in a
nurse’s command and control center.Thus, control of all equipment
is at the fingertips of the circulating nurse, and the disruption and in-
convenience of manipulating equipment on carts is avoided.
Rearranging monitors is much simpler with the easily movable
booms than with carts, and there are no wires to trip OR person-
nel, because the wiring is done through the boom structure.
Furthermore, because the wiring moves with the equipment, there
is less risk that settings will be accidentally changed or wires
unplugged—and thus less wear and tear on equipment and staff.
The booms are easily moved to the periphery of the room, allow-
ing the room to be used for multispecialty procedures, including
non–minimally invasive procedures [see Figure 2].
LAPAROSCOPIC SURGICAL TEAM
In 1998, the first FDA-approved voice activation system, given the known inherent problems with surgeons’ voluntary self-
Hermes (Computer Motion, Santa Barbara, Calif.), was intro- reporting of infections occurring in the ambulatory surgical set-
duced into the OR. Designed to provide surgeons with direct ting.47 Each infection is estimated to increase total hospital stay by
access and control of surgical devices, Hermes is operated via an average of 7 days and add more than $3,000 in charges.
either a handheld pendant or voice commands from the surgeon. SSIs have been divided by the CDC into three broad categories:
The challenges of advanced laparoscopic surgery provide a fertile superficial incisional SSI, deep incisional SSI, and organ/space SSI
ground for demonstrating the benefits of voice activation [see Table [see Table 5 and 1:2 Prevention of Postoperative Infection].48 Factors
4]. Two-handed laparoscopic procedures make it very difficult for that contribute to the development of SSI include (1) those arising
a surgeon to control ancillary equipment manually, even if touch- from the patient’s health status, (2) those related to the physical
screens are sterile and within reach. environment where surgical care is provided, and (3) those result-
Voice activation gives surgeons immediate access to and direct ing from clinical interventions that increase the patient’s inherent
control of surgical devices, and it provides the OR team with crit- risk. Careful patient selection and preparation, including judi-
ical information. To operate a device, the surgeon must take cious use of antibiotic prophylaxis, can decrease the overall risk of
approximately 20 minutes to train the recognition system to his or infection, especially after clean-contaminated and contaminated
her voice patterns and must wear an audio headset to relay com- operations.
mands to the controller. The learning curve for voice control is
minimal (two or three cases, on average). Many devices can now HAND HYGIENE
be controlled by voice activation software, including cameras, light Hand antisepsis plays a significant role in preventing nosocomial
sources, digital image capture and documentation devices, print- infections.When outbreaks of infection occur in the perioperative pe-
ers, insufflators, OR ambient and surgical lighting systems, operat- riod, careful assessment of the adequacy of hand hygiene among OR
ing tables, and electrocauteries. personnel is recommended. U.S. guidelines recommend that agents
In the future, more and more devices will be accessible to the used for surgical hand scrubs should substantially reduce microor-
surgeon through simple voice commands, and the time will soon ganisms on intact skin, contain a nonirritating antimicrobial prepara-
arrive when telesurgical and telementoring capabilities will be an tion, possess broad-spectrum activity, and be fast-acting and persis-
integral part of the system.The voice interface will allow surgeons tent.49 In October 2002, the CDC published the most recent version
to interact with the world at large in such a way that the perfor- of its Guideline for Hand Hygiene in Health-Care Settings.50 The
mance of a surgical procedure is actively facilitated rather than Guideline’s final recommendations regarding surgical hand antisep-
interrupted. The OR will cease to be an environment of isolation. sis included the following:
• Surgical hand antisepsis using either an antimicrobial soap or
Infection Control in the OR an alcohol-based hand rub with persistent activity is recom-
Infection control is a major concern in health care in general, mended before donning sterile gloves when performing surgical
but it is a particularly important issue in the sterile environment of procedures (evidence level IB).
the OR, where patients undergo surgical procedures and are at sig- • When performing surgical hand antisepsis using an antimicro-
nificant risk for perioperative nosocomial infection. Even the best bial soap, scrub hands and forearms for the length of time rec-
OR design will not compensate for improper surgical technique or ommended by the manufacturer, usually 2 to 6 minutes. Long
failure to pay attention to infection prevention. scrub times (e.g., 10 minutes) are not necessary (evidence level
Surgical site infection (SSI) is a major cause of patient morbid- IB).
ity, mortality, and health care costs. In the United States, accord- • When using an alcohol-based surgical hand-scrub product with
ing to the Centers for Disease Control and Prevention (CDC), persistent activity, follow the manufacturer’s instructions.
about 2.9% of nearly 30 million operations are complicated by Before applying the alcohol solution, prewash hands and fore-
SSIs each year. This percentage may in fact be an underestimate, arms with a nonantimicrobial soap, and dry hands and fore-
arms completely. After application of the alcohol-based prod-
uct, allow hands and forearms to dry thoroughly before don-
ning sterile gloves.
Table 4 Benefits of Voice Activation
Technology in the Laparoscopic OR GLOVES AND PROTECTIVE BARRIERS
*National Nosocomial Infection Surveillance definition: a nonhuman-derived implantable foreign body (e.g., prosthetic heart valve, nonhuman vascular graft, mechanical heart, or
hip prosthesis) that is permanantly placed in a patient during surgery.
†
If the area around a stab wound becomes infected, it is not an SSI. It is considered a skin or soft tissue infection, depending on its depth.
ments is the implementation of the CDC’s universal precau- SSIs completely, but by sharing information and influencing sub-
tions,52 designed to prevent transmission of human immunodefi- sequent behavior, it is certainly possible to reduce their incidence.
ciency virus, hepatitis B virus, and other bloodborne pathogens. A 2002 study documented successful institution of a surveil-
These precautions involve the use of protective barriers (e.g., lance program after a period of high infection rates in an orthope-
gloves, gowns, aprons, masks, and protective eyewear) to reduce dic surgical department.54 This program contributed to a signifi-
the risk that the health care worker’s skin or mucous membranes cant reduction in SSI rates after elective hip and knee replacement
will be exposed to potentially infectious materials. Performance procedures and was successful in creating awareness of infection
standards for protective barriers are the responsibility of the FDA’s control practices among hospital staff members.
Center for Devices and Radiological Health. These standards
ANTIMICROBIAL PROPHYLAXIS
define the performance properties that these products must exhib-
it, such as minimum strength, barrier protection, and fluid resis- SSIs are established several hours after contamination.55
tance.The current CDC recommendation is to use surgical gowns Administration of antibiotics before contamination reduces the
and drapes that resist liquid penetration and remain effective bar- risk of infection but is subsequently of little value.56 Selective use
riers when wet. of short-duration, narrow-spectrum antibiotic agents should be
Compliance with universal precautions and barrier protection is considered for appropriate patients to cover the usual pathogens
notably difficult to achieve. A 2001 study, however, found that ed- isolated from SSIs [see Table 6]. Optimal surgical antimicrobial
ucational interventions aimed at OR personnel improved compli- prophylaxis is based on the following three principles: (1) appro-
ance significantly, particularly with regard to the use of protective priate choice of antimicrobial agent, (2) proper timing of antibiot-
eyewear and double-gloving. Furthermore, such interventions ic administration before incision, and (3) limited duration of
were associated with a reduced incidence of blood and body fluid antibiotic administration after operation.
exposure.53 Recommendations for antibiotic prophylaxis are addressed in
more detail elsewhere [see 1:2 Prevention of Postoperative Infection].
INFECTION SURVEILLANCE PROGRAMS
When a preoperative antibiotic is indicated, a single dose of thera-
Surveillance is an important part of infection control [see CP:7 peutic strength, administered shortly before incision, usually suf-
Infection Control in Surgical Practice]. The success of a surveillance fices.57 (The dose may have to be increased if the patient is morbidly
program depends on the ability of the infection control team to obese.58) A second dose is indicated if the procedure is longer than
form a partnership with the surgical staff. Creating a sense of own- two half-lives of the drug or if extensive blood loss occurs. Con-
ership of the surveillance initiative among the members of the sur- tinuation of prophylaxis beyond 24 hours is not recommended.
gical staff enhances cooperation and ensures that the best use is With respect to redosing of the antimicrobial agent in lengthy
made of the information generated. It is not possible to eliminate procedures, consistency is important but can be difficult to obtain.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREPARATION OF THE OR — 11
OR design can be helpful in this regard. In a 2003 study, signifi- nonwarmed patients but in only 13 (5%) of 277 warmed patients
cant improvement of intraoperative antibiotic prophylaxis in pro- (P = 0.001).Wound scores were also significantly lower in warmed
longed (> 4 hours) cardiac operations was achieved by employing patients (P = 0.007).
an automated intraoperative alert system in the OR, with alarms The safest and most effective way of protecting patients from
both audible and visible on the OR computer console at 225 min- hypothermia is to use forced-air warmers with specialized blankets
utes after administration of preoperative antibiotics.59 Intraop- placed over the upper or lower body. Alternatives include placing
erative redosing of antibiotics was significantly more frequent a warming water mattress under the patient and draping the
in the reminder group (68%) than in the control group (40%; patient with an aluminized blanket. Second-line therapy for main-
P < 0.0001).The use of an automatic reminder system in the OR taining normothermia is to warm all I.V. fluids. Any irrigation flu-
improved compliance with guidelines on perioperative antibiotic ids used in a surgical procedure should be at or slightly above
prophylaxis. body temperature before use. Radiant heating devices placed
above the operative field may be especially useful during opera-
NONPHARMACOLOGIC PREVENTIVE MEASURES
tions on infants. Use of a warmer on the inhalation side of the
Several studies have confirmed that certain nonpharmacologic anesthetic gas circuit can also help maintain the patient’s body
measures, including maintenance of perioperative normothermia temperature during an operation.
and provision of supplemental perioperative oxygen, are effica-
cious in preventing SSIs.60 Supplemental Perioperative Oxygen
Destruction by oxidation, or oxidative killing, is the body’s most
Perioperative Normothermia important defense against surgical pathogens. This defensive
A 1996 study showed that warming patients during colorectal response depends on oxygen tension in contaminated tissue. An
surgery reduced infection rates.61 A subsequent observational easy method of improving oxygen tension in adequately perfused
cohort study found that mild perioperative hypothermia was asso- tissue is to increase the fraction of inspired oxygen (FIO2). Supple-
ciated with a significantly increased incidence of SSI.62 A ran- mental perioperative oxygen (i.e., an FIO2 of 80% instead of 30%)
domized, controlled trial, published in 2001, was done to deter- significantly reduces postoperative nausea and vomiting and
mine whether warming patients before short-duration clean pro- diminishes the decrease in phagocytosis and bacterial killing usu-
cedures would have the same effect.63 In this trial, 421 patients ally associated with anesthesia and surgery. Oxygen tension in
scheduled to undergo clean (breast, varicose vein, or hernia) pro- wound tissue has been found to be a good predictor of SSI risk.64
cedures were randomly assigned either to a nonwarmed group or
Avoidance of Blood Transfusion
to one of two warmed groups (locally warmed and systemically
warmed). Warming was applied for at least 30 minutes before The association between blood transfusion and increased peri-
surgery. Patients were followed, and masked outcome assessments operative infection rates is well documented. In a 1997 study,
were made at 2 and 6 weeks. SSIs occurred in 19 (14%) of 139 geriatric hip fracture patients undergoing surgical repair who
received blood transfusion had significantly higher rates of peri-
operative infection than those who did not (27% versus 15%),
Table 6 Distribution of Pathogens Isolated and this effect was present on multivariate analysis.65 Another
from SSIs: National Nosocomial Infections 1997 study, involving 697 patients undergoing surgery for col-
Surveillance System, 1986–199648 orectal cancer, yielded similar findings: 39% of transfused
patients had bacterial infections, compared with 24% of non-
Percentage of Isolates* transfused patients, and the relative risk of infection was 1.6 for
Pathogen
transfusion of one to three units of blood and 3.6 for transfusion
1986–1989 1990–1996
of more than three units.66
(N=16,727) (N=17,671)
A large prospective cohort study published in 2003 evaluated
Staphylococcus aureus 17 20 the association between anemia, blood transfusion, and perioper-
Coagulase-negative staphylococci 12 14
ative infection.67 Logistic regression analysis confirmed that intra-
operative transfusion of packed red blood cells was an indepen-
Enterococcus species 13 12 dent risk factor for perioperative infection (odds ratio, 1.06; con-
fidence interval, 1.01 to 1.11; P > 0.0001). Furthermore, transfu-
Escherichia coli 10 8
sion of more than four units of packed red blood cells was associ-
Pseudomonas aeruginosa 8 8 ated with a 9.28-fold increased risk of infection (confidence inter-
val, 5.74 to 15.00; P < 0.0001).
Enterobacter species 8 7
Proteus mirabilis 4 3
Housekeeping Procedures
Klebsiella pneumoniae 3 3
FLOORS AND WALLS
Other Streptococcus species 3 3
Despite detailed recommendations for cleaning the OR [see
Candida albicans 2 3 Table 7],68 the procedures that are optimal to provide a clean envi-
ronment while still being cost-effective have not been critically
Group D streptococci (nonenterococci) — 2
analyzed.
Other gram-positive aerobes — 2 Only a few studies have attempted to correlate surface contam-
ination of the OR with SSI risk. In one study, for example, ORs
Bacteroides fragilis — 2
were randomly assigned to either a control group or an experi-
*Pathogens representing less than 2% of isolates are excluded. mental group.69 The control rooms were cleaned with a germici-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREPARATION OF THE OR — 12
Table 7 OR Cleaning Schedules are those cases in which a fresh traumatic wound is present or
gross spillage of GI contents occurs. Dirty or infected operations
Surgical lights and tracks include those in which bacterial inflammation occurs or in which
Fixed ceiling-mounted equipment pus is present.The infection rate may be as high as 40% in a con-
Furniture and mobile equipment, including wheels taminated or dirty operation.
OR and hall floors Fear that bacteria from dirty or heavily contaminated cases
Areas requiring daily Cabinet and push-plate handles could be transmitted to subsequent cases has resulted in the devel-
cleaning Ventilation grills opment of numerous and costly rituals of OR cleanup. However,
All horizontal surfaces there are no prospective studies and no large body of relevant data
Substerile areas
to support the usefulness of such rituals. In fact, one study found
Scrub and utility areas
no significant difference in environmental bacterial counts after
Scrub sinks
clean cases than after dirty ones.73 Numerous authorities have rec-
Ventilation ducts and filters ommended that there be only one standard of cleaning the OR
Recessed tracks after either clean or dirty cases.68,73,74 This recommendation is rea-
Areas requiring routinely Cabinets and shelves sonable because any patient may be a source of contamination
scheduled cleaning Walls and ceilings
caused by unrecognized bacterial or viral infection; more impor-
Sterilizers, warming cabinets, refrigerators, and
ice machines tant, the other major source of OR contamination is the OR
personnel.
Rituals applied to dirty cases include placing a germicide-
dal agent and wet-vacuumed before the first case of the day and soaked mat outside the OR door, allowing the OR to stand idle for
between cases; in the experimental rooms, cleaning consisted only an arbitrary period after cleanup of a dirty procedure, and using
of wiping up grossly visible contamination after clean and clean- two circulating nurses, one inside the room and one outside. None
contaminated cases. Both rooms had complete floor cleanup after of these practices has a sound theoretical or factual basis.
contaminated or dirty and infected cases. The investigators found Traditionally, dirty cases have been scheduled after all the clean
that bacterial colony counts obtained directly from the floors were cases of the day. However, this restriction reduces the efficiency
lower in the control rooms but that counts obtained from other with which operations can be scheduled and may unnecessarily
horizontal surfaces did not differ between the two OR groups. In delay emergency cases.There are no data to support special clean-
addition, wound infection rates were the same in the control ing procedures or closing of an OR after a contaminated or dirty
rooms and the experimental rooms and were comparable with operation has been performed.75 Tacky mats placed outside the
rates reported in other series. Another study found that floor dis- entrance to an OR suite have not been shown to reduce the num-
infectants decreased bacterial concentration on the floor for only ber of organisms on shoes or stretcher wheels, nor do they reduce
2 hours; colony counts then returned to pretreatment levels as per- the risk of SSI.76
sonnel walked on the floor.70 These investigators recommended
discontinuing routine floor disinfection.
Even when an OR floor is contaminated, the rate of redispersal Data Management in the OR
of bacteria into the air is low, and the clearance rate is high. It is In this era of capitated reimbursement and managed care, con-
unlikely, therefore, that bacteria from the floor contribute to SSI. tainment of health care costs is a prime concern; consequently,
Consequently, routine disinfection of the OR floor between clean OR efficiency has become a higher priority for many institutions.77
or clean-contaminated cases appears unnecessary. No OR environment can even function, let alone improve its effi-
According to CDC guidelines for prevention of SSI, when visi- ciency, without data. Data control every facet of the activities with-
ble soiling of surfaces or equipment occurs during an operation, in the OR environment. For evaluating procedural time, OR uti-
an Environmental Protection Agency (EPA)–approved hospital lization and efficiency, OR scheduling, infection rates, injury pre-
disinfectant should be used to decontaminate the affected areas vention, and other key measures of organizational function, it is
before the next operation.71 This statement is in keeping with the essential to have current, high-quality data.
OSHA requirement that all equipment and environmental sur- To obtain good data, it is necessary first to determine what
faces be cleaned and decontaminated after contact with blood or information is required. For example, assessment of OR utilization
other potentially infectious materials. Disinfection after a contam- and efficiency depends on how utilization is measured. Before an
inated or dirty case and after the last case of the day is probably a OR can meaningfully be measured against a target figure, it is nec-
reasonable practice, though it is not supported by directly perti- essary to know exactly how the organization calculates utilization
nent data.Wet-vacuuming of the floor with an EPA-approved hos- and how the parameters are defined.There is no accepted nation-
pital disinfectant should be performed routinely after the last oper- al standard. The future of the organization—not to mention the
ation of the day or night. jobs of the people who work there—may depend on how well it
understands and controls OR utilization.
DIRTY CASES
It is generally agreed that 80% to 85% is the maximum utiliza-
Operations are classified or stratified into four groups in relation tion level that an OR can be expected to reach. At higher utiliza-
to the epidemiology of SSIs [see 1:2 Prevention of Postoperative tion levels, the OR loses flexibility, and the hospital should con-
Infection].72 Clean operations are those elective cases in which the sider adding capacity. It is important that utilization of all OR
GI tract or the respiratory tract is not entered and there are no resources by the various sectors of the institution be reasonable
major breaks in technique.The infection rate in this group should and balanced, because higher OR utilization can be achieved only
be less than 3%. Clean-contaminated operations are those elective when this is the case. To improve the use of OR time, it is impor-
cases in which the respiratory or the GI tract is entered or during tant (1) to limit the number of ORs available to the number
which a break in aseptic technique has occurred.The infection rate required to achieve good utilization, (2) to have nurses rather than
in such cases should be less than 10%. Contaminated operations attending surgeons control access to the surgical schedule, (3) to
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREPARATION OF THE OR — 13
OR SCHEDULING
provide good scheduling systems that allow surgeons to follow
themselves, and (4) to maintain systems that enable and enforce For optimal OR utilization, it is important to have a system for
efficient turnover between cases.78 releasing OR time efficiently and appropriately. Surgical services
It has been estimated that 30% of all health care outlays are fill their OR time at different rates. In a 2002 study, the median
related to surgical expenditures.79 Thus, it is likely that in a cost- period between the time when a patient was scheduled for surgery
conscious, competitive environment, the OR will be a major and the day of the operation ranged from 2 to 27 days, depending
focus of change. Surgical costs are related to OR utilization, on the subspecialty.83 Whereas ophthalmologic surgeons might
inventory levels, operative volume, supply usage, and equipment schedule outpatient cases weeks beforehand, cardiac or thoracic
purchase, rental, and maintenance. Facility design also affects surgeons might book cases the day before the operation.
efficiency and thus the ability to reduce costs. All of these issues Consequently, it would not be logical to release allocated OR time
must be evaluated and monitored to ensure quality care at the for all services the same prespecified number of days before
lowest feasible cost.80 surgery.84 A better approach would be to predict, as soon as a case
Once good data are available, the issue then becomes how prac- is scheduled, which surgical service is likely to have the most
tices and procedures should change as a result. Although new underutilized OR time on the scheduled day of surgery. In prac-
information, by itself, can often affect behavior, true behavior tice, the OR information system would perform the forecasting
modification in the OR requires effective leadership from the and provide a recommendation to the OR scheduler. To produce
chiefs of surgery, anesthesia, and nursing, all of whom should reliable results, forecasting should be based on the previous 6
receive monthly performance reports. months of OR performance, with allowances made for vacations
and meeting-related down time.
DATA ACQUISITION
Perioperative costs can be reduced if cases are scheduled so that
The necessary data must be not only available but also acces- the workload evenly matches staffing schedules. Specifically, to
sible in a rapid and convenient manner. Total automation of minimize the cost per case, down time must be minimized.
OR data management is critical for ascertaining patterns, man- Appropriate choice of the day on which a patient will undergo
aging productivity and resources, and providing solid informa- surgery is the most important decision affecting OR labor costs.84
tional bases for future decisions. Only through automation
QUALITY IMPROVEMENT
tools can relevant, timely, and accurate statistical data be gen-
erated to facilitate problem solving, trend spotting, forecasting, The key to increased OR efficiency is increased productivity.
and revisioning.81 Standardization and streamlining of internal procedures reduces
A long-standing question in OR utilization was how many his- bottlenecks, and computerization speeds the flow of information
torical data points were necessary or ideal to make appropri- so that continuous improvement of the system becomes possible.
ate decisions regarding OR staffing via statistical methods. In a Before a desired improvement can be implemented, the proposed
2002 study, statistical analysis of 30 workdays of data yielded change must be tested quickly so that its effect can be determined.
staffing solutions that had, on average, 30% lower staffing costs This is accomplished by means of a collaborative effort, in which
and 27% higher staffing productivity than the existing staffing the group involved in the change learns how to plan, do, check
plans.82 The productivity achieved in this way was 80%, and this and act—the so-called PDCA cycle, which is a classic quality ini-
figure was not significantly improved by increasing the number tiative method. During the PDCA cycle, teams are encouraged to
of workdays of data beyond 180. These findings suggest that in share ideas and talk about various solutions. A change is tested
most OR environments, statistical methods of data acquisition quickly, and if it works, implementation is expanded and tested
and analysis can identify cost-lowering and productivity-enhanc- further. The importance of the changes that can be implemented
ing staffing solutions by using 30 days of OR and anesthesia is often secondary to the progress made in building collaboration
data. with fellow physicians and other health care professionals.84
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35:1117, 1990 in the operating room. Surg Clin North Am 76:161,
alerts in the operating room. Infect Control Hosp
39. Jewett DL, Heinsohn P, Bennett C, et al: Blood- 1996
Epidemiol 24:13, 2003
containing aerosols generated by surgical tech- 81. Mueller J, Marinari B, Kunkel S: Flipping assump-
60. Sessler DI, Akca O: Nonpharmacological preven-
niques: a possible infectious hazard. Am Ind Hyg tions and revisioning perioperative services. J Nurs
tion of surgical wound infections. Clin Infect Dis
Assoc J 53:228, 1992 Admin 25:22, 1995
35:1397, 2002
40. Patkin M: Ergonomics and the operating micro- 82. Epstein RH, Dexter F: Statistical power analysis to
61. Kurz A, Sessler DI, Lenhardt R: Perioperative nor-
scope. Adv Ophthalmol 37:53, 1978 estimate how many months of data are required to
mothermia to reduce the incidence of surgical
41. Walenga JM, Fareed J: Current status on new anti- identify operating room staffing solutions to
wound infection and shorten hospitalization.
coagulant and antithrombotic drugs and devices. reduce labor costs and increase productivity.
Study of Wound Infection and Temperature
Curr Opin Pulmon Med 3:291, 1997 Anesth Analg 94:640, 2002
Group. N Engl J Med 358:876, 1996
42. Mangram AJ, Horan TC, Pearson ML, et al: The 83. Dexter F,Traub RD: How to schedule elective sur-
62. Flores-Maldonado A, Medine-Escobedo CE,
Hospital Infection Control Practices Advisory gical cases into specific operating rooms to maxi-
Rios-Rodriguez HM, et al: Mild perioperative
Committee. Guideline for prevention of surgical mize the efficiency of use of operating room time.
hypothermia and the risk of wound infection. Arch
site infection, 1999. Am J Infect Control 27:98, Anesth Analg 94:933, 2002
Med Res 32:227, 2001
1999 84. Surgery teams make strides on OR delays. OR
63. Melling AC, Ali B, Scott EM, et al: Effects of pre-
43. Radiological Protection and Safety in Medicine: A Manager 14(1):1, 1998
operative warming on the incidence of wound
report of the International Commission of Radio- infection after clean surgery: a randomized con-
logical Protection. Annals of the ICRP 26:1, 1996 trolled trial. Lancet 358:876, 2001
44. Lipsitz EC, Veith FJ, Ohki T, et al: Does endovas- 64. Hopf HW, Hunt TK, West JM: Wound tissue oxy-
cular repair of aortoiliac aneurysms pose a radia- gen tension predicts the risk of wound infection in Acknowledgment
tion safety hazard to vascular surgeons? J Vasc Surg surgical patients. Arch Surg 132:997, 1997
32:702, 2000 65. Koval KJ, Rosenberg AD, Zuckerman JD, et al: Figure 1 Courtesy of W. L. Gore & Associates,
45. Patterson P: Turnover time: is all the study worth Does blood transfusion increase risk of infection Newark, Delaware.
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I BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 2 PREVENTION OF POSTOPERATIVE INFECTION — 1
2 PREVENTION OF POSTOPERATIVE
INFECTION
Jonathan L. Meakins, M.D., D.Sc., F.A.C.S., and Byron J. Masterson, M.D., F.A.C.S.
Remote sites of Skin Bowel Nature and site Size of Operating Operating
infection of operation inoculum team–related room–related
required to
Postpone elective Is the operation produce • Comportment • Traffic control
operation if possible. • Clean infection • Use of • Cleaning
Treat remote infection • Clean- impermeable • Air
appropriately. contaminated Varies in drapes and
• Contaminated different gowns
• Dirty or clinical • Surgical scrub
infected situations.
HOST
DEFENSE
BACTERIA MECHANISMS
SURGICAL
SITE
CONTROL OF SOURCES OF
BACTERIA
Endogenous bacteria are
Skin a more important cause of
SSI than exogenous bacte-
ria. In clean-contaminated,
Superficial contaminated, and dirty-
Subcutaneous
Incisional infected operations, the
Tissue
SSI
source and the amount of bacteria are functions of the patient’s
disease and the specific organs being operated on.
Operations classified as infected are those in which infected tis-
Deep Soft Tissue sue and pus are removed or drained, providing a guaranteed
(Fascia and Muscle) Deep Incisional
SSI
inoculum to the surgical site.The inoculum may be as high as 1010
bacteria/ml, some of which may already be producing an infec-
tion. In addition, some bacteria could be in the growth phase
Organ/Space Organ/Space rather than the dormant or the lag phase and thus could be more
SSI pathogenic.The heavily contaminated wound is best managed by
delayed primary closure. This type of management ensures that
the wound is not closed over a bacterial inoculum that is almost
Figure 2 Surgical site infections are classified into three cate-
gories, depending on which anatomic areas are affected.3 certain to cause a wound infection, with attendant early and late
consequences.
Patients should not have elective surgery in the presence of
remote infection, which is associated with an increased incidence
patient clinical status (three or more diagnoses on discharge).6
of wound infection.5 In patients with urinary tract infections,
The National Nosocomial Infection Surveillance (NNIS) study
wounds frequently become infected with the same organism.
reduced these four risk factors to three: wound classification,
Remote infections should be treated appropriately, and the oper-
duration of operation, and American Society of Anesthesiologists
ation should proceed only under the best conditions possible. If
(ASA) class III, IV or V.7,8 Both risk assessments integrate the
operation cannot be appropriately delayed, the use of prophylac-
three determinants of infection: bacteria (wound class), local envi-
tic and therapeutic antibiotics should be considered [see Sidebar
ronment (duration), and systemic host defenses (one definition of
Antibiotic Prophylaxis of Infection and Tables 2 through 4].
patient health status), and they have been shown to be applicable
Preoperative techniques of reducing patient flora, especially
outside the United States.9 However, the SENIC and NNIS
endogenous bacteria, are of great concern. Bowel preparation,
assessments do not integrate other known risk variables, such as
antimicrobial showers or baths, and preoperative skin decontami-
smoking, tissue oxygen tension, glucose control, shock, and main-
tenance of normothermia, all of which are relevant for clinicians
(though often hard to monitor and to fit into a manageable risk
assessment). Table 1 National Research Council
Classification of Operative Wounds 5
Bacteria
Nontraumatic
Clearly, without an No inflammation encountered
infecting agent, no infection Clean (class I) No break in technique
will result. Accordingly, Respiratory, alimentary, or genitourinary tract not
most of what is known entered
about bacteria is put to use Gastrointestinal or respiratory tract entered without
in major efforts directed at significant spillage
reducing their numbers by means of asepsis and antisepsis. The Appendectomy
principal concept is based on the size of the bacterial inoculum. Clean- Oropharynx entered
contaminated
Wounds are traditionally classified according to whether the (class II) Vagina entered
wound inoculum of bacteria is likely to be large enough to over- Genitourinary tract entered in absence of infected urine
whelm local and systemic host defense mechanisms and produce Biliary tract entered in absence of infected bile
an infection [see Table 1]. One study showed that the most impor- Minor break in technique
tant factor in the development of a wound infection was the num- Major break in technique
ber of bacteria present in the wound at the end of an operative Gross spillage from gastrointestinal tract
procedure.10 Another study quantitated this relation and provided Contaminated
(class III) Traumatic wound, fresh
insight into how local environmental factors might be integrated Entrance of genitourinary or biliary tracts in presence
into an understanding of the problem [see Figure 3].11 In the years of infected urine or bile
before prophylactic antibiotics, as well as during the early phases Acute bacterial inflammation encountered, without pus
of their use, there was a very clear relation between the classifica- Transection of “clean” tissue for the purpose of surgical
tion of the operation (which is related to the probability of a sig- Dirty and infected access to a collection of pus
nificant inoculum) and the rate of wound infection.5,12 This rela- (class IV) Traumatic wound with retained devitalized tissue, for-
tion is now less dominant than it once was; therefore, other fac- eign bodies, fecal contamination, or delayed treat-
ment, or all of these; or from dirty source
tors have come to play a significant role.6,13
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I BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 2 PREVENTION OF POSTOPERATIVE INFECTION — 5
50
ondary to the trauma of the shave and the inevitable small areas of
inflammation and infection. If hair removal is required,14,15 clip-
ping is preferable and should be done in the OR or the prepara-
tion room just before the operative procedure. Shaving, if ever per-
Clinical Wound Infection Rate (%)
40
formed, should not be done the night before operation.
In the past few years, the role of the classic bowel preparation [see
Table 5] has been questioned [see Discussion, Infection Prevention
30
in Bowel Surgery, below].16-20 The suggestion has been made that
selective gut decontamination (SGD) may be useful in major elec-
tive procedures involving the upper GI tract and perhaps in other
20 settings. At present, SGD for prevention of infection cannot be rec-
ommended in either the preoperative or the postoperative period.
When infection develops after clean operations, particularly
those in which foreign bodies were implanted, endogenous infect-
10
ing organisms are involved but the skin is the primary source of the
infecting bacteria. The air in the operating room and other OR
sources occasionally become significant in clean cases; the degree
0 of endogenous contamination can be surpassed by that of exoge-
0 1 2 3 4 5 6
nous contamination. Thus, both the operating team—surgeon,
Leg Wound Bacteria assistants, nurses, and anesthetists—and OR air have been report-
ed as significant sources of bacteria [see 1:1 Preparation of the
Dry Wound; Cephaloridine > 10 µg/ml
Operating Room]. In fact, personnel are the most important source
Dry Wound; Placebo of exogenous bacteria.21-23 In the classic 1964 study by the National
Academy of Sciences–National Research Council, ultraviolet light
Wet Wound;
Wound Fluid Hematocrit > 8%; Placebo (UVL) was efficacious only in the limited situations of clean and
ultraclean cases.5 There were minimal numbers of endogenous
Figure 3 The wound infection rate is shown here as a function of
bacteria, and UVL controlled one of the exogenous sources.
bacterial inoculum in three different situations: a dry wound with
an adequate concentration of antibiotic (cephaloridine > 10 µg/ml),
Clean air systems have very strong advocates, but they also have
a dry wound with no antibiotic (placebo), and a wet wound with no equally vociferous critics. It is possible to obtain excellent results
antibiotic (placebo, wound fluid hematocrit > 8%).11 in clean cases with implants without using these systems.
However, clean air systems are here to stay. Nevertheless, the pres-
ence of a clean air system does not mean that basic principles of
nation have been proposed frequently. These techniques, particu- asepsis and antisepsis should be abandoned, because endogenous
larly preoperative skin decontamination [see Sidebar Preoperative bacteria must still be controlled.
Preparation of the Operative Site], may have specific roles in The use of impermeable drapes and gowns has received con-
selected patients during epidemics or in units with high infection siderable attention. If bacteria can penetrate gown and drapes,
rates. As a routine for all patients, however, these techniques are they can gain access to the wound.The use of impermeable drapes
unnecessary, time-consuming, and costly in institutions or units may therefore be of clinical importance.24,25 When wet, drapes of
where infection rates are low. 140-thread-count cotton are permeable to bacteria. It is clear that
The preoperative shave is a technique in need of reassessment. some operations are wetter than others, but generally, much can
It is now clear that shaving the evening before an operation is asso- be done to make drapes and gowns impermeable to bacteria. For
ciated with an increased wound infection rate.This increase is sec- example, drapes of 270-thread-count cotton that have been water-
Route of
Antibiotic Dose
Administration
proofed are impermeable, but they can be washed only 75 times. with possible contamination. A longer duration, even of a clean
Economics plays a role in the choice of drape fabric because operation, represents increased time at risk for contamination.
entirely disposable drapes are expensive. Local institutional factors These points, in addition to pharmacologic considerations, sug-
may be significant in the role of a specific type of drape in the pre- gest that the surgeon should be alert to the need for a second dose
vention of SSI. of prophylactic antibiotics [see Sidebar Antibiotic Prophylaxis of
Infection].
PROBABILITY OF CONTAMINATION
Abdominal operation is another risk factor not found in the
The probability of contamination is largely defined by the NNIS risk assessment.6,8 Significant disease and age are addition-
nature of the operation [see Table 1]. However, other factors con- al factors that play a role in outcome; however, because the major
tribute to the probability of contamination; the most obvious is the concentrations of endogenous bacteria are located in the
expected duration of the operative procedure, which, whenever abdomen, abdominal operations are more likely to involve bacter-
examined, has been significantly correlated with the wound infec- ial contamination.
tion rate.6,10,12 The longer the procedure lasts, the more bacteria For some years, postoperative contamination of the wound has
accumulate in a wound; the sources of bacteria include the been considered unlikely. However, one report of SSI in sternal
patient, the operating team (gowns, gloves with holes, wet drapes), incisions cleaned and redressed 4 hours postoperatively clearly
the OR, and the equipment. In addition, the patient undergoing a shows that wounds can be contaminated and become infected in
longer operation is likely to be older, to have other diseases, and to the postoperative period.26 Accordingly, use of a dry dressing for
have cancer of—or to be undergoing operation on—a structure 24 hours seems prudent.
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I BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 2 PREVENTION OF POSTOPERATIVE INFECTION — 7
Oral Oral
Amoxicillin, 2.0 g 1 hr before procedure Clindamycin, 600 mg 1 hr before procedure
or
Dental procedures likely to cause Cephalexin or cefadroxil,† 2.0 g 1 hr before procedure
gingival bleeding; operations or
or instrumentation of the upper Azithromycin or clarithromycin, 500 mg 1 hr before procedure
respiratory tract Parenteral Parenteral
Ampicillin, 2.0 g I.M. or I.V. 30 min before procedure Clindamycin, 600 mg I.V. within 30 min before procedure
or
Cefazolin, 1.0 g I.M. or I.V. within 30 min before procedure
Oral
Amoxicillin, 2.0 g 1 hr before procedure
Vancomycin, 1.0 g I.V. infused slowly over 1 hr, beginning 1 hr
Gastrointestinal or genitourinary Parenteral before procedure; if risk of endocarditis is considered high,
operation; abscess drainage Ampicillin, 2.0 g I.M. or I.V. within 30 min before proce- add gentamicin, 1.5 mg/kg (to maximum of 120 mg) I.M. or
dure; if risk of endocarditis is considered high, add I.V. 30 min before procedure‡
gentamicin, 1.5 mg/kg (to maximum of 120 mg) I.M.
or I.V. 30 min before procedure‡
*Pediatric dosages are as follows: oral amoxicillin, 50 mg/kg; oral or parenteral clindamycin, 20 mg/kg; oral cephalexin or cefadroxil, 50 mg/kg; oral azithromycin or clarithromycin, 15 mg/kg;
parenteral ampicillin, 50 mg/kg; parenteral cefazolin, 25 mg/kg; parenteral gentamicin, 2 mg/kg; parenteral vancomycin, 20 mg/kg. Total pediatric dose should not exceed total adult dose.
†
Patients with a history of immediate-type sensitivity to penicillin should not receive these agents.
‡
High-risk patients should also receive ampicillin, 1.0 g I.M. or I.V., or amoxicillin, 1.0 g p.o., 6 hr after procedure.
Duration of Operation
lead to a reduced SSI rate, probably as a consequence of increased
In most studies,6,10,12 contamination certainly increases with tissue oxygen tension,33 though the value of this practice has been
time (see above).Wound edges can dry out, become macerated, or questioned.34 If the patient is not intubated, a mask, not nasal
in other ways be made more susceptible to infection (i.e., requir- prongs, is required.35
ing fewer bacteria for development of infection). Speed and poor
technique are not suitable approaches; expeditious operation is Barrier Function
appropriate. Inadequate perfusion may also affect the function of other
organs, and the resulting dysfunction will, in turn, influence the
Electrocautery patient’s susceptibility to infection. For example, ischemia-reper-
The use of electrocautery devices has been clearly associated fusion injury to the intestinal tract is a frequent consequence of
with an increase in the incidence of superficial SSIs. However, hypovolemic shock and bloodstream infection. Inadequate perfu-
when such devices are properly used to provide pinpoint coagu- sion of the GI tract may also occur during states of fluid and elec-
lation (for which the bleeding vessels are best held by fine for- trolyte imbalance or when cardiac output is marginal. In experi-
ceps) or to divide tissues under tension, there is minimal tissue mental studies, altered blood flow has been found to be associat-
destruction, no charring, and no change in the wound infection ed with the breakdown of bowel barrier function—that is, the
rate.30 inability of the intestinal tract to prevent bacteria, their toxins, or
both from moving from the gut lumen into tissue at a rate too
PATIENT FACTORS
fast to permit clearance by the usual protective mechanisms. A
variety of experimental approaches aimed at enhancing bowel
Local Blood Flow barrier function have been studied; at present, however, the most
Local perfusion can clinically applicable method of bowel protection is initiation of
greatly influence the devel- enteral feeding (even if the quantity of nutrients provided does
opment of infection, as is not satisfy all the nutrient requirements) and administration of
seen most easily in the ten- the amino acid glutamine [see 8:23 Nutritional Support].
dency of the patient with Glutamine is a specific fuel for enterocytes and colonocytes and
peripheral vascular disease to acquire infection of an extremity. As has been found to aid recovery of damaged intestinal mucosa and
a local problem, inadequate perfusion reduces the number of bac- enhance barrier function when administered either enterally or
teria required for infection, in part because inadequate perfusion parenterally.
leads to decreased tissue levels of oxygen. Shock, by reducing local
perfusion, also greatly enhances susceptibility to infection. Fewer Advanced Age
organisms are required to produce infection during or immediate- Aging is associated with structural and functional changes that
ly after shock [see Figure 4]. render the skin and subcutaneous tissues more susceptible to
To counter these effects, the arterial oxygen tension (PaO2) must infection. These changes are immutable; however, they must be
be translated into an adequate subcutaneous oxygen level (deter- evaluated in advance and addressed by excellent surgical tech-
mined by measuring transcutaneous oxygen tension)32; this, nique and, on occasion, prophylactic antibiotics [see Sidebar
together with adequate perfusion, will provide local protection by Antibiotic Prophylaxis of Infection]. SSI rates increase with aging
increasing the number of bacteria required to produce infection. until the age of 65 years, after which point the incidence appears
Provision of supplemental oxygen in the perioperative period may to decline.36
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I BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 2 PREVENTION OF POSTOPERATIVE INFECTION — 10
SURGEON-RELATED FACTORS *This agent should be used only for therapeutic purposes; it should not be used
for prophylaxis.
There are a limited number of ways in which the surgeon can
improve a patient’s systemic responses to surgery. Nevertheless,
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I BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 2 PREVENTION OF POSTOPERATIVE INFECTION — 11
Table 6 Effect of Surveillance and Feedback Shock has an influence on the incidence of wound infection [see
on Wound Infection Rates in Two Hospitals28 Figure 4]. This influence is most obvious in cases of trauma, but
there are significant implications for all patients in regard to main-
Period 1 Period 2* tenance of blood volume, hemostasis, and oxygen-carrying capac-
ity. The effect of shock on the risk of infection appears to be not
Number of wounds 1,500 1,447 only immediate (i.e., its effect on local perfusion) but also late
Hospital A
Wound infection rate 8.4% 3.7% because systemic responses are blunted as local factors return to
normal.
Number of wounds 1,746 1,939
Hospital B Advanced age, transfusion, and the use of steroids and other
Wound infection rate 5.7% 3.7%
immunosuppressive drugs, including chemotherapeutic agents,
*Periods 1 and 2 were separated by an interval during which feedback on wound infection are associated with an increased risk of SSI.41,42 Often, these fac-
rates was analyzed.
tors cannot be altered; however, the proper choice of operation,
the appropriate use of prophylaxis, and meticulous surgical tech-
ability of contamination but also in relation to host factors.6,7,9 nique can reduce the risk of such infection by maintaining patient
According to this study, patients most clearly at risk for wound homeostasis, reducing the size of any infecting microbial inocu-
infection are those with three or more concomitant diagnoses; lum, and creating a wound that is likely to heal primarily.
other patients who are clearly at risk are those undergoing a clean- Smoking is associated with a striking increase in SSI incidence.
contaminated or contaminated abdominal procedure and those As little as 1 week of abstinence from smoking will make a posi-
undergoing any procedure expected to last longer than 2 hours. tive difference.43
These last two risk groups are affected by a bacterial component, Pharmacologic therapy can affect host response as well.
but all those patients who are undergoing major abdominal pro- Nonsteroidal anti-inflammatory drugs that attenuate the pro-
cedures or lengthy operations generally have a significant prima- duction of certain eicosanoids can greatly alter the adverse
ry pathologic condition and are usually older, with an increased effects of infection by modifying fever and cardiovascular effects.
frequency of concomitant conditions. The NNIS system uses Operative procedures involving inhalational anesthetics result in
most of the same concepts but expresses them differently. In the an immediate rise in plasma cortisol concentrations.The steroid
NNIS study, host factors in the large study are evaluated in terms response and the associated immunomodulation can be modi-
of the ASA score. Duration of operation is measured differently fied by using high epidural anesthesia as the method of choice;
as well, with a lengthy operation being defined by the NNIS as pituitary adrenal activation will be greatly attenuated. Some
one that is at or above the 75th percentile for operating time. drugs that inhibit steroid elaboration (e.g., etomidate) have also
Bacterial contamination remains a risk factor, but operative site is been shown to be capable of modifying perioperative immune
eliminated.8 responses.
No Antibiotic Antibiotic
100
80
Wound Infection Rate (%)
60
40
20
0
Control 1 Hr Day 1 3 5 Control 1 Hr Day 1 3 5
Time of Inoculation
Determinant of Infection
Discussion
Antibiotic Prophylaxis of Surgical Site Infection
1950s to profound skepticism about prophylactic antibiotic use in
It is difficult to understand why antibiotics have not always pre- any operation.
vented SSI successfully. Certainly, surgeons were quick to appreci- The principal reason for the apparent inefficacy was inadequate
ate the possibilities of antibiotics; nevertheless, the efficacy of understanding of the biology of SSIs. Fruitful study of antibiotics
antibiotic prophylaxis was not proved until the late 1960s.11 and how they should be used began after physiologic ground-
Studies before then had major design flaws—principally, the work established the importance of local blood flow, maintenance
administration of the antibiotic some time after the start of the of local immune defenses, adjuvants, and local and systemic
operation, often in the recovery room. The failure of studies to perfusion.49
demonstrate efficacy and the occasional finding that prophylactic The key antibiotic study, which was conducted in guinea pigs,
antibiotics worsened rather than improved outcome led in the late unequivocally proved the following about antibiotics:
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I BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 2 PREVENTION OF POSTOPERATIVE INFECTION — 13
1. They are most effective when given before inoculation of bacte- use, anesthesia, and surveillance have reduced SSI rates in all cat-
ria. egories that were established by this classification [see Table
2. They are ineffective if given 3 hours after inoculation. 8].6,12,13,51
3. They are of intermediate effectiveness when given in between In 1960, after years of negative studies, it was said, “Nearly all
these times [see Figure 5].50 surgeons now agree that the routine use of prophylaxis in clean
operations is unnecessary and undesirable.”57 Since then, much
Although efficacy with a complicated regimen was demonstrat- has changed: there are now many clean operations for which no
ed in 1964,51 the correct approach was not defined until 1969.11 competent surgeon would omit the use of prophylactic antibiotics,
Established by these studies are the philosophical and practical particularly as procedures become increasingly complex and pros-
bases of the principles of antibiotic prophylaxis of SSI in all surgi- thetic materials are used in patients who are older, sicker, or
cal arenas11,50: that prophylactic antibiotics must be given preoper- immunocompromised.
atively within 2 hours of the incision, in full dosage, paren- A separate risk assessment that integrates host and bacterial
terally, and for a very limited period. These principles remain variables (i.e., whether the operation is dirty or contaminated, is
essentially unchanged despite minor modifications from innumer- longer than 2 hours, or is an abdominal procedure and whether the
able subsequent studies.52-56 Prophylaxis for colorectal operations patient has three or more concomitant diagnoses) segregates more
is discussed elsewhere [see Infection Prevention in Bowel Surgery, effectively those patients who are prone to an increased incidence
below]. of SSI [see Integration of Determinants of Infection, below]. This
approach enables the surgeon to identify those patients who are
PRINCIPLES OF PATIENT SELECTION
likely to require preventive measures, particularly in clean cases, in
Patients must be selected for prophylaxis on the basis of either which antibiotics would normally not be used.6
their risk for SSI or the cost to their health if an SSI develops (e.g., The prototypical clean operation is an inguinal hernia repair.
after implantation of a cardiac valve or another prosthesis). The Technical approaches have changed dramatically over the past 10
most important criterion is the degree of bacterial contamination years, and most primary and recurrent hernias are now treated
expected to occur during the operation. The traditional classifica- with a tension-free mesh-based repair. The use of antibiotics has
tion of such contamination was defined in 1964 by the historic become controversial. In the era of repairs under tension, there was
National Academy of Sciences–National Research Council study.5 some evidence to suggest that a perioperative antibiotic (in a sin-
The important features of the classification are its simplicity, ease gle preoperative dose) was beneficial.58 Current studies, however,
of understanding, ease of coding, and reliability. Classification is do not support antibiotic use in tension-free mesh-based inguinal
dependent on only one variable—the bacterial inoculum—and the hernia repairs.59,60 On the other hand, if surveillance indicates that
effects of this variable are now controllable by antimicrobial pro- there is a local or regional problem61 with SSI after hernia surgery,
phylaxis. Advances in operative technique, general care, antibiotic antibiotic prophylaxis (again in the form of single preoperative
dose) is appropriate. Without significantly more supportive data,
prophylaxis for clean cases cannot be recommended unless specif-
ic risk factors are present.
Data suggest that prophylactic use of antibiotics may contribute
Staphylococcal Lesions
to secondary Clostridium difficile disease; accordingly, caution
10
should be exercised when widening the indications for prophylax-
is is under consideration.62 If local results are poor, surgical prac-
Mean 24-Hour Lesion Diameter (mm)
can clearly be reduced by this regimen. No data suggest that fur- meager, resistant microbes have developed in every other situation
ther doses are required for prophylaxis. in which antibiotics have been utilized, and it is reasonable to
Fortunately, cefazolin is effective against both gram-positive expect that prophylaxis in any ecosystem will have the same result,
and gram-negative bacteria of importance, unless significant particularly if selection of patients is poor, if prophylaxis lasts too
anaerobic organisms are encountered.The significance of anaero- long, or if too many late-generation agents are used.
bic flora has been disputed, but for elective colorectal surgery,65 A rare but important complication of antibiotic use is
abdominal trauma,66,67 appendicitis,68 or other circumstances in pseudomembranous enterocolitis, which is induced most com-
which penicillin-resistant anaerobic bacteria are likely to be monly by clindamycin, the cephalosporins, and ampicillin [see 8:16
encountered, coverage against both aerobic and anaerobic gram- Nosocomial Infection].62 The common denominator among differ-
negative organisms is strongly recommended and supported by ent cases of pseudomembranous enterocolitis is hard to identify.
the data. Diarrhea and fever can develop after administration of single doses
Despite several decades of studies, prophylaxis is not always of prophylactic antibiotics. The condition is rare, but difficulties
properly implemented.52,54,68,69 Unfortunately, didactic education occur because of failure to make a rapid diagnosis.
is not always the best way to change behavior. Preprinted order
CURRENT ISSUES
forms70 and a reminder sticker from the pharmacy71 have proved
to be effective methods of ensuring correct utilization. The most significant questions concerning prophylaxis of SSIs
The commonly heard decision “This case was tough, let’s give already have been answered. An important remaining issue is the
an antibiotic for 3 to 5 days” has no data to support it and should proper duration of prophylaxis in complicated cases, in the setting
be abandoned. Differentiation between prophylaxis and therapeu- of trauma, and in the presence of foreign bodies. No change in the
sis is important. A therapeutic course for perforated diverticulitis criteria for antibiotic prophylaxis is required in laparoscopic pro-
or other types of peritoneal infection is appropriate. Data on casu- cedures; the risk of infection is lower in such cases.78,79 Cost fac-
al contamination associated with trauma or with operative proce- tors are important and may justify the endless succession of stud-
dures suggest that 24 hours of prophylaxis or less is quite ade- ies that compare new drugs in competition for appropriate clinical
quate.72-74 Mounting evidence suggests that a single preoperative niches.
dose is good care and that additional doses are not required. Further advances in patient selection may take place but will
require analysis of data from large numbers of patients and a dis-
Trauma Patients tinction between approaches to infection of the wound, which is
The efficacy of antibiotic administration on arrival in the emer- only a part of the operative field, and approaches to infections
gency department as an integral part of resuscitation has been directly related to the operative site. These developments will
clearly demonstrated.66 The most common regimens have been define more clearly the prophylaxis requirements of patients
(1) a combination of an aminoglycoside and clindamycin and (2) whose operations are clean but whose risk of wound or operative
cefoxitin alone. These two regimens or variations thereof have site infection is increased.
been compared in a number of studies.40,67,75 They appear to be A current issue of some concern is potential loss of infection
equally effective, and either regimen can be recommended with surveillance capability. Infection control units have been shown to
confidence. For prophylaxis, there appears to be a trend toward offer a number of benefits in the institutional setting, such as the
using a single drug: cefoxitin or cefotetan.55 If therapy is required following:
because of either a delay in surgery, terrible injury, or prolonged
1. Identifying epidemics caused by common or uncommon
shock, the combination of an agent that is effective against anaer-
organisms.23,26,56
obes with an aminoglycoside seems to be favored. Because amino-
2. Establishing correct use of prophylaxis (timing, dose, duration,
glycosides are nephrotoxic, they must be used with care in the
and choice).52,55,72
presence of shock.
3. Documenting costs, risk factors, and readmission rates.80,81
In many of the trauma studies just cited, antibiotic prophylaxis
4. Monitoring postdischarge infections and secondary conse-
lasted for 48 hours or longer. Subsequent studies, however, indi-
quences of infections.82-84
cated that prophylaxis lasting less than 24 hours is appropri-
5. Ensuring patient safety.85
ate.73,74,76 Single-dose prophylaxis is appropriate for patients with
6. Managing MRSA and VRE.86
closed fractures.77
S. aureus—in particular, MRSA—is a major cause of SSI.86
COMPLICATIONS
Cross-infection problems are a concern, in a manner reminiscent
Complications of antibiotic prophylaxis are few. Although data of the preantibiotic era. Hand washing (see below) is coming back
linking prophylaxis to the development of resistant organisms are into fashion, consistent with the professional behavior toward
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
I BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 2 PREVENTION OF POSTOPERATIVE INFECTION — 15
cross-infection characteristic of that era. At present, hard evidence tion in bacterial counts on clean skin.90 All variables considered,
is lacking, but clinical observation suggests that S. aureus SSIs are chlorhexidine gluconate followed by an iodophor appears to be
especially troublesome and destructive of local tissue and require the best option [see Table 9].
a longer time to heal than other SSIs do. When S. aureus SSIs The purpose of washing the hands after surgery is to remove
occur after cardiac surgery, thoracotomy, or joint replacement, microorganisms that are resident, that flourished in the warm, wet
their consequences are significant. Prevention in these settings is environment created by wearing gloves, or that reached the hands
important. When nasal carriage of S. aureus has been identified, by entering through puncture holes in the gloves. On the ward,
mupirocin may be administered intranasally to reduce the inci- even minimal contact with colonized patients has been demon-
dence of S. aureus SSIs.87 strated to transfer microorganisms.91 As many as 1,000 organisms
The benefits of infection surveillance notwithstanding, as the were transferred by simply touching the patient’s hand, taking a
business of hospital care has become more expensive and finan- pulse, or lifting the patient. The organisms survived for 20 to 150
cial control more rigid, the infection control unit is a hospital com- minutes, making their transfer to the next patient clearly possible.
ponent that many administrators have come to consider a luxury A return to the ancient practice of washing hands between each
and therefore expendable. Consequently, surveillance as a quality patient contact is warranted. Nosocomial spread of numerous
control and patient safety mechanism has been diminished. organisms—including C. difficile; MRSA, VRE, and other antibi-
It is apparent that SSIs have huge clinical and financial impli- otic-resistant bacteria; and viruses—is a constant threat.
cations. Patients with infections tend to be sicker and to undergo Hand washing on the ward is complicated by the fact that over-
more complex operations. Therefore, higher infection rates trans- washing may actually increase bacterial counts. Dry, damaged
late into higher morbidity and mortality as well as higher cost to skin harbors many more bacteria than healthy skin and is almost
the hospital, the patient, and society as a whole.With increasingly impossible to render even close to bacteria free. Although little is
early discharge becoming the norm, delayed diagnosis of postdis- known about the physiologic changes in skin that result from fre-
charge SSI and the complications thereof is a growing prob- quent washings, the bacterial flora is certainly modified by alter-
lem.82-84 Effective use of institutional databases may contribute ations in the lipid or water content of the skin. The so-called dry
greatly to identification of this problem.83 hand syndrome was the impetus behind the development of the
Clearly, the development of effective mechanisms for identify- alcohol-based gels now available.These preparations make it easy
ing and controlling SSIs is in the interests of all associated with the for surgeons to clean their hands after every patient encounter
delivery of health care.85 The identification of problems by means with minimal damage to their skin.
of surveillance and feedback can make a substantial contribution
to reducing SSI rates [see Table 6].12,85
Infection Prevention in Bowel Surgery
Hand Washing At present, the best method of preventing SSIs after bowel
surgery is, once again, a subject of debate. There have been three
The purpose of cleansing the surgeon’s hands is to reduce the
principal approaches to this issue, involving mechanical bowel
numbers of resident flora and transient contaminants, thereby
preparation in conjunction with one of the following three antibi-
decreasing the risk of transmitting infection. Although the proper
otic regimens55,92-97:
duration of the hand scrub is still subject to debate, evidence sug-
1. Oral antibiotics (usually neomycin and erythromycin),20,96
gests that a 120-second scrub is sufficient, provided that a brush
2. Intravenous antibiotics covering aerobic and anaerobic bowel
is used to remove the bacteria residing in the skin folds around the
flora,16,20,55,94,95 or
nails.88 The nail folds, the nails, and the fingertips should receive
3. A combination of regimens 1 and 2 (meta-analysis suggests that
the most attention because most bacteria are located around the
the combination of oral and parenteral antibiotics is best).97
nail folds and most glove punctures occur at the fingertips.
Friction is required to remove resident microorganisms which are The present controversy, triggered by a clinical trial,16 a
attached by adhesion or adsorption, whereas transient bacteria are review,20 and three meta-analyses, relates to the need for mechan-
easily removed by simple hand washing. ical bowel preparation,17-19 which has been a surgical dogma since
Solutions containing either chlorhexidine gluconate or one of the early 1970s.The increased SSI and leak rates noted have been
the iodophors are the most effective surgical scrub preparations attributed to the complications associated with vigorous bowel
and have the fewest problems with stability, contamination, and preparation, leading to dehydration, overhydration, or electrolyte
toxicity.89 Alcohols applied to the skin are among the safest known abnormalities.
antiseptics, and they produce the greatest and most rapid reduc- An observational study reported a 26% SSI rate in colorectal
Antifungal
Agent Mode of Action Comments
Activity
Chlorhexidine Cell wall disruption Fair Poor activity against tuberculosis-causing organisms; can
cause ototoxicity and eye irritation
Iodine/iodophors Oxidation and substitution by free iodine Good Broad antibacterial spectrum; minimal skin residual activi-
ty; possible absorption toxicity and skin irritation
Alcohols Denaturation of protein Good Rapid action but little residual activity; flammable
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
I BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 2 PREVENTION OF POSTOPERATIVE INFECTION — 16
All from SENIC index 1.0 3.6 8.9 17.2 27.0 4.1
surgery patients.98 Intraoperative hypotension and body mass have a major influence on outcome.
index were the only independent predictive variables. All patients One investigation demonstrated that silk sutures decrease the
underwent mechanical bowel preparation the day before operation number of bacteria required for infection.101 Other investigators
and received oral antibiotics and perioperative I.V. antibiotics. Half used a suture as the key adjuvant in studies of host manipula-
of the SSIs were discovered after discharge. Most would agree that tion,102 whereas a separate study demonstrated persistent suscep-
the protocol was standard. These and other results suggest that a tibility to wound infection days after shock.103 The common vari-
fresh look at the infectious complications of surgery—and of bowel able is the number of bacteria. This relation may be termed the
surgery in particular—is required. inoculum effect, and it has great relevance in all aspects of infec-
The recommended antibiotic regimen for bowel surgery con- tion control. Applying knowledge of this effect in practical terms
sists of oral plus systemic agents (see above).55 The approach to involves the following three steps:
mechanical bowel preparation, however, is open. Intuition would
1. Keeping the bacterial contamination as low as possible via asep-
suggest that the presence of less liquid and stool in the colon might
sis and antisepsis, preoperative preparation of patient and sur-
be beneficial and perhaps that a preoperative phosphate enema
geon, and antibiotic prophylaxis.
with 24 hours of fluid might make sense. It is hard to throw out
2. Maintaining local factors in such a way that they can prevent
30 years of apparent evidence on the basis of these three meta-
the lodgment of bacteria and thereby provide a locally unrecep-
analyses. These studies do, however, present data that cannot be
tive environment.
ignored. Protocols for bowel surgery in the modern era of same-
3. Maintaining systemic responses at such a level that they can
day admission, fast track surgery, and rapid discharge will require
control the bacteria that become established.
further study and clinical trials.
These three steps are related to the determinants of infection
and their applicability to daily practice.Year-by-year reductions in
Integration of Determinants of Infection wound infection rates, when closely followed, indicate that it is
The significant advances in the control of wound infection dur- possible for surgeons to continue improving results by attention to
ing the past several decades are linked to a better understanding of quality of clinical care and surgical technique, despite increasingly
the biology of wound infection, and this link has permitted the complex operations.5,13,28-30 In particular, the measures involved in
advance to the concept of SSI.2 In all tissues at any time, there will the first step (control of bacteria) have been progressively refined
be a critical inoculum of bacteria that would cause an infectious and are now well established.
process [see Figure 3].The standard definition of infection in urine The integration of determinants has significant effects [see Figures
and sputum has been 105 organisms/ml. In a clean dry wound, 105 3 and 4]. When wound closure was effected with a wound hemat-
bacteria produce a wound infection rate of 50% [see Figure 3].11 ocrit of 8% or more, the inoculum required to produce a wound
Effective use of antibiotics reduces the infection rate to 10% with infection rate of 40% was 100 bacteria [see Figure 3]. Ten bacteria
the same number of bacteria and thereby permits the wound to produced a wound infection rate of 20%. The shift in the number
tolerate a much larger number of bacteria. of organisms required to produce clinical infection is significant. It
All of the clinical activities described are intended either to is obvious that this inoculum effect can be changed dramatically
reduce the inoculum or to permit the host to manage the number by good surgical technique and further altered by use of prophylac-
of bacteria that would otherwise be pathologic. One study in tic antibiotics. If the inoculum is always slightly smaller than the
guinea pigs showed how manipulation of local blood flow, shock, number of organisms required to produce infection in any given set-
the local immune response, and foreign material can enhance the ting, results are excellent. There is clearly a relation between the
development of infection.99 This study and two others defined an number of bacteria and the local environment.The local effect can
early decisive period of host antimicrobial activity that lasts for 3 also be seen secondary to systemic physiologic change, specifically
to 6 hours after contamination.50,99,100 Bacteria that remain after shock. One study showed the low local perfusion in shock to be
this period are the infecting inoculum. Processes that interfere important in the development of an infection.99,100
with this early response (e.g., shock, altered perfusion, adjuvants, One investigation has shown that shock can alter infection rates
or foreign material) or support it (e.g., antibiotics or total care) immediately after its occurrence [see Figure 4].103 Furthermore, if
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
I BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 2 PREVENTION OF POSTOPERATIVE INFECTION — 17
the inoculum is large enough, antibiotics will not control bacteria. normal homeostasis in patients at risk is one of the great advances
In addition, there is a late augmentation of infection lasting up to of surgical critical care.104 The clearest improvements in this
3 days after restoration of blood volume. These early and late regard have come in maintenance of blood volume, oxygenation,
effects indicate that systemic determinants come into play after and oxygen delivery.
local effects are resolved.These observations call for further study, One group demonstrated the importance of oxygen delivery,
but obviously, it is the combined abnormalities that alter outcome. tissue perfusion, and PaO2 in the development of wound infec-
Systemic host responses are important for the control of infec- tion.105 Oxygen can have as powerful a negative influence on the
tion. The patient has been clearly implicated as one of the four development of SSI as antibiotics can.106 The influence is very
critical variables in the development of wound infection.6 In addi- similar to that seen in other investigations. Whereas a PaO2 equiv-
tion, the bacterial inoculum, the location of the procedure and its alent to a true fractional concentration of oxygen in inspired gas
duration, and the coexistence of three or more diagnoses were (FIO2) of 45% is not feasible, maintenance, when appropriate, of
found to give a more accurate prediction of the risk of wound an increased FIO2 in the postoperative period may prove an ele-
infection. The spread of risk is defined better with the SENIC mentary and effective tool in managing the inoculum effect.
index (1% to 27%) than it is with the traditional classification Modern surgical practice has reduced the rate of wound infec-
(2.9% to 12.6%) [see Table 10].The importance of the number of tion significantly. Consequently, it is more useful to think in terms
bacteria is lessened if the other factors are considered in addition of SSI, which is not limited to the incision but may occur any-
to inoculum. The inoculum effect has to be considered with where in the operative field; this concept provides a global objec-
respect to both the number of organisms and the local and sys- tive for control of infections associated with a surgical procedure.
temic host factors that are in play. Certain variables were found to Surveillance is of great importance for quality assurance. Reports
be significantly related to the risk of wound infection in three of recognized pathogens (e.g., S. epidermidis and group A strepto-
important prospective studies [see Table 10].6,10,12 It is apparent cocci) as well as unusual organisms (e.g., Rhodococcus [Gordona]
that the problem of SSI cannot be examined only with respect to bronchialis, Mycoplasma hominis, and Legionella dumoffii) in SSIs
the management of bacteria. Host factors have become much highlight the importance of infection control and epidemiology for
more significant now that the bacterial inoculum can be main- quality assurance in surgical departments.21-23,26,27 (Although
tained at low levels by means of asepsis, antisepsis, technique, and these reports use the term wound infection, they are really
prophylactic antibiotics.104 addressing what we now call SSI.) The importance of surgeon-
Important host variables include the maintenance of normal specific and service-specific SSI reports should be clear [see Table
homeostasis (physiology) and immune response. Maintenance of 6],12,13,107 and their value in quality assurance evident.
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tion of defense reactions of the skin to the primary wound infections through use of computer deci- crobial prophylaxis in colorectal surgery. Dis Colon
lodgment of bacteria. Br J Exp Pathol 38:79, 1957 sion analysis. Infect Control Hosp Epidemiol Rectum 32:121, 1989
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I BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 2 PREVENTION OF POSTOPERATIVE INFECTION — 19
94. Norwegian Study Group for Colorectal Surgery 99:1, 1986 of bacterial endocarditis: recommendations by the
Should antimicrobial prophylaxis in colorectal 103. Livingston DH, Malangoni MA: An experimental American Heart Association. JAMA 277:1794,
surgery include agents effective against both anaer- study of susceptibility to infection after hemorrha- 1997
obic and aerobic microorganisms? A double-blind, gic shock. Surg Gynecol Obstet 168:138, 1989 112. Durack DT: Prevention of infective endocarditis.
multicenter study. Surgery 97:402, 1985 N Engl J Med 332:38, 1995
104. Meakins JL: Surgeons, surgery and immunomod-
95. Song J, Glenny AM: Antimicrobial prophylaxis in ulation. Arch Surg 126:494, 1991 113. Prevention of bacterial endocarditis. Med Lett
colorectal surgery: a systematic review of random- Drugs Ther 43:98, 2001
ized controlled trials. Br J Surg 85:1232, 1998 105. Knighton D, Halliday B, Hunt TK: Oxygen as an
antibiotic: a comparison of the effects of inspired 114. Hayek LJ, Emerson JM, Gardner AMN: A place-
96. Condon RE, Bartlett JG, Greenlee H, et al: Efficacy oxygen concentration and antibiotic administra- bo-controlled trial of the effect of two preoperative
of oral and systemic antibiotic prophylaxis in colo- tion on in vivo bacterial clearance. Arch Surg baths or showers with chlorhexidine detergent on
rectal operations. Arch Surg 118:496, 1983 121:191, 1986 postoperative wound infection rates. J Hosp Infect
97. Lewis RT: Oral versus systemic antibiotic prophy- 10:165, 1987
106. Rabkin J, Hunt TK: Infection and oxygen.
laxis in elective colon surgery: a randomized study Problem Wounds: The Role of Oxygen. Davis JC, 115. Garner JS: CDC guidelines for the prevention and
and meta-analysis send a message from the 1990’s. Hunt TK, Eds. Elsevier, New York, 1987, p 1 control of nosocomial infections: guideline for pre-
Can J Surg 45:173, 2002 vention of surgical wound infections, 1985. Am J
107. Olson MM, Lee JT Jr: Continuous, 10-year wound Infect Control 14:71, 1986
98. Smith RL, Bohl JK, McElearney ST, et al: Wound infection surveillance: results, advantages, and
infection after elective colorectal resection. Ann unanswered questions. Arch Surg 125:794, 1990 116. Hamilton HW, Hamilton KR, Lone FJ: Preopera-
Surg 239:599, 2004 tive hair removal. Can J Surg 20:269, 1977
108. Oreskovich MR, Dellinger EP, Lennard ES, et al:
99. Miles AA, Miles EM, Burke J:The value and dura- 117. McDonald WS, Nichter LS: Debridement of bac-
Duration of preventive antibiotic administration
tion of defence reactions of the skin to the primary terial and particulate-contaminated wounds. Ann
for penetrating abdominal trauma. Arch Surg
lodgement of bacteria. Br J Exp Pathol 38:79, 1957 Plast Surg 33:142, 1994
117:200, 1982
100. Miles AA: The inflammatory response in relation 118. Edwards PS, Lipp A, Holmes A: Preoperative skin
109. Langely JM, Le Blanc JC, Drake J, et al: Efficacy of
to local infections. Surg Clin North Am 60:93, antiseptics for preventing surgical wound infec-
antimicrobial prophylaxis in placement of cere-
1980 tions after clean surgery. Cochrane Database Syst
brospinal fluid shunts: meta-analysis. Clin Infect
Rev 3:CD003949, 2004
101. Alexander JW, Alexander WA: Penicillin prophylax- Dis 17:98, 1993
is of experimental staphylococcal wound infec- 110. Forse RA, Karam B, MacLean LD, et al: Antibiotic
tions. Surg Gynecol Obstet 120:243, 1965 prophylaxis for surgery in morbidly obese patients.
Surgery 106:750, 1989
Acknowledgment
102. Polk HC Jr: The enhancement of host defenses
against infection: search for the holy grail. Surgery 111. Dajani AS,Taubert KA,Wilson W, et al: Prevention Figures 3 and 4 Albert Miller.
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1 Basic Surg Perioperative Considerations 3 PERIOPERATIVE CONSIDERATIONS FOR ANESTHESIA — 1
3 PERIOPERATIVE CONSIDERATIONS
FOR ANESTHESIA
Steven B. Backman, M.D.C.M., Ph.D., Richard M. Bondy, M.D.C.M., Alain Deschamps, M.D., Ph.D., Anne Moore, M.D.,
and Thomas Schricker, M.D., Ph.D.
Ongoing advancements in modern surgical care are being comple- operation. It is especially important not to abruptly discontinue
mented by alterations in anesthetic management aimed at providing medications that may result in withdrawal or rebound phenome-
maximum patient benefit. Since the early 1990s, anesthesia practice na (e.g., beta blockers, alpha agonists, barbiturates, and opioids).
has changed enormously—through the proliferation of airway de- With some medications (e.g., oral hypoglycemics, insulin, and cor-
vices, the routine employment of patient-controlled analgesia ticosteroids), perioperative dosage adjustments may be necessary
(PCA), the wider popularity of thoracic epidural anesthesia, the de- [see 8:10 Endocrine Problems]. Angiotensin-converting enzyme
velopment of computer-controlled devices for infusing short-acting (ACE) inhibitors have been associated with intraoperative
drugs, the growing use of quickly reversible inhalational drugs and hypotension and may be withheld at the discretion of the anesthe-
muscle relaxants, the availability of online monitoring of CNS func- siologist.3 Drugs that should be discontinued preoperatively in-
tion, and the increased application of transesophageal echocardiog- clude monoamine oxidase inhibitors (MAOIs) and oral anticoag-
raphy, to name but a few examples. Our aim in this chapter is to offer ulants [see Table 1].
surgeons a current perspective on perioperative considerations for Many surgical patients are taking antiplatelet drugs. Careful
anesthesia so as to facilitate dialogue between the surgeon and the consideration should be given to the withdrawal of these agents in
anesthesiologist and thereby help minimize patient risk.The primary the perioperative period [see Table 1] because of the possibility that
focus is on the adult patient: the special issues involved in pediatric discontinuance may lead to an acute coronary syndrome. If in-
anesthesia are beyond the scope of our review. In addition, the ensu- creased bleeding is a significant risk, longer-acting agents (e.g.,
ing discussion is necessarily selective; more comprehensive discus- aspirin, clopidogrel, and ticlopidine) can be replaced with non-
sions may be found elsewhere.1,2 steroidal anti-inflammatory drugs (NSAIDs) that have shorter
half-lives. Typically, these shorter-acting drugs are given for 10
days, stopped on the day of surgery, and then restarted 6 hours
Perioperative Patient Management after operation. Platelet transfusion should be considered only in
Preoperative medical evaluation is an essential component of the presence of significant medical bleeding.4
preoperative assessment for anesthesia. Of particular importance to The increasing use of herbal and alternative medicines has led
the anesthesiologist is any history of personal or family problems to significant morbidity and mortality as a consequence of unex-
with anesthesia. Information should be sought concerning dif- pected interactions with traditional drugs. Because many patients
ficulty with airway management or intubation, drug allergy, fail to mention such agents as part of their medication regimen
delayed awakening, significant postoperative nausea or vomiting during the preoperative assessment, it is advisable to question all
(PONV), unexpected hospital or ICU admission, and postdural patients directly about their use. Particular attention should be
puncture headache (PDPH). Previous anesthetic records may be given to Chinese herbal teas, which include organic compounds
requested. and toxic contaminants that may produce renal fibrosis or failure,
The airway must be carefully examined to identify patients at cholestasis, hepatitis, and thrombocytopenia. Specific recommen-
risk for difficult ventilation or intubation [see Special Scenarios, dations for discontinuance for many of these agents have been
Difficult Airway, below], with particular attention paid to teeth, developed [see Table 1].
caps, crowns, dentures, and bridges. Patients must be informed
about the risk of trauma associated with intubation and airway
management. Anesthetic options [see Choice of Anesthesia, below] Inpatient versus Outpatient Surgery
should be discussed, including the likelihood of postoperative ven- An ever-increasing number of operations are performed on an
tilation and admission to the hospital or the intensive care unit. ambulatory basis. Operations considered appropriate for an
When relevant, the possibility of blood product administration ambulatory setting are associated with minimal physiologic tres-
should be raised, and the patient’s acceptance or refusal of transfu- pass, low anesthetic complexity, and uncomplicated recovery.5,6
sion should be carefully documented. Postoperative pain man- The design of the ambulatory facility may impose limitations on
agement [see 1:5 Postoperative Pain] should be addressed, par- the types of operations or patients that can be considered for
ticularly when a major procedure is planned. The risks associat- ambulatory surgery. Such limitations may be secondary to avail-
ed with general or regional anesthesia should be discussed in an ability of equipment, recovery room nursing expertise and access
informative and reassuring manner; a well-conducted preopera- to consultants, and availability of ICU beds or hospital beds.
tive anesthesia interview plays an important role in alleviating Patients who are in class I or class II of the American Society of
anxiety. Anesthesiologists (ASA) physical status scale are ideally suited for
The medications the patient is taking can have a substantial ambulatory surgery; however, a subset of ASA class III patients
impact on anesthetic management. Generally, patients should may be at increased risk for prolonged recovery and hospital
continue to take their regular medication up to the time of the admission [see Table 2].
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1 Basic Surg Perioperative Considerations 3 PERIOPERATIVE CONSIDERATIONS FOR ANESTHESIA — 2
Potentiation of sympathomimetic
amines, possible hypertensive crisis
May prolong and intensify effects of Elective surgery: discontinue at least 2 wk in
Isocarboxazid Irreversible inhibition of mono- other CNS depressants advance; consider potential for suicidal
Phenelzine amine oxidase with the resultant Severe idiopathic hyperpyrexic reaction tendency—mental health specialist should
MAOIs Pargyline increase in serotonin, norepineph- with meperidine and possibly other be involved
Tranylcypromine rine, epinephrine, dopamine, and narcotics Emergency surgery: avoid meperidine;
octamine neurotransmitters
Selegiline Potential catastrophic interaction with consider regional anesthesia
tricyclic antidepressants, characterized
by high fever and excessive cerebral
excitation and hypertension
Premedication to produce anxiolysis, sedation, analgesia, addition, it is associated with a decreased incidence of sore throat
amnesia, and reduction of PONV and aspiration may be con- and does not require muscle paralysis for insertion. On the other
sidered for patients undergoing outpatient procedures, as it may hand, an LMA may not protect as well against aspiration.5,9,10
for those undergoing inpatient procedures. Such premedication The benefits of regional anesthesia [see Regional Anesthesia
should not delay discharge. Fasting guidelines [see Table 3] and Techniques, below] may include decreases in the incidence of aspi-
intraoperative monitoring standards for ambulatory surgery are ration, nausea, dizziness, and disorientation. Spinal and epi-
identical to those for inpatient procedures [see Patient dural anesthesia may be associated with PDPH and backache.
Monitoring, below]. Compared with spinal anesthesia, epidural anesthesia takes more
A number of currently used anesthetics (e.g., propofol and des- time to perform, has a slower onset of action, and may not pro-
flurane), narcotics (e.g., alfentanil, fentanyl, sufentanil, and duce as profound a block; however, the duration of an epidural
remifentanil), and muscle relaxants (e.g., atracurium, mivacuri- block can readily be extended intraoperatively or postoperatively
um, and rocuronium) demonstrate rapid recovery profiles. Ni- if necessary. Care should be exercised in choosing a local anes-
trous oxide also has desirable pharmacokinetic properties, but it thetic for neuraxial blockade: spinal lidocaine may be associated
may be associated with increased PONV. Titration of anesthetics with a transient radicular irritation; bupivacaine may be associat-
to indices of CNS activity (e.g., the bispectral index) may result in ed with prolonged motor block; and narcotics may produce pru-
decreased drug dosages, faster recovery from anesthesia, and ritus, urinary retention, nausea and vomiting, and respiratory
fewer complications.7,8 Use of a laryngeal mask airway (LMA) depression. Various dosing regimens have been proposed to min-
rather than an endotracheal tube is ideal in the outpatient setting imize these side effects.11-14
because lower doses of induction agent are required to blunt the Monitored anesthesia care [see Choice of Anesthesia, below]
hypertension and tachycardia associated with its insertion; in achieves minimal CNS depression, so that the airway and sponta-
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1 Basic Surg Perioperative Considerations 3 PERIOPERATIVE CONSIDERATIONS FOR ANESTHESIA — 3
Table 1 (continued)
Type of Drug Agent Pharmacologic Effects Adverse Effects Discontinuance Recommendations
Inhibition of platelet-activating
Ginkgo (Ginkgo factor Increased bleeding
Discontinue at least 36 hr in advance
biloba) Modulation of neurotransmitter May potentiate other platelet inhibitors
receptor activity
Increased bleeding
Ginger (Zingiber Potent inhibitor of thromboxane Discontinue at least 36 hr in advance
May potentiate effects of other
officinale) synthase
anticoagulants
Hypertension
Hypokalemia
Licorice (Glycyrrhiza
Edema
glabra)
Contraindicated in chronic liver and renal
insufficiency
Inhibits reuptake of serotonin, Possible interaction with MAOIs Discontinue on day of surgery; abrupt with-
St. John’s wort norepinephrine, and dopamine Evidence for reduced activity of drawal in physically dependent patients
(Hypericum by neurons cyclosporine, warfarin, calcium chan- may produce benzodiazepine-like with-
perforatum) Increases metabolism of some P- nel blockers, lidocaine, midazolam, drawal syndrome
450 isoforms alfentanil, and NSAIDs
ADP—adenosine diphosphate ETOH—ethyl alcohol GP—glycoprotein GABA—γ-aminobutyric acid MAOIs—monoamine oxidase inhibitors NSAIDs—nonsteroidal anti-inflammatory drugs
PT—prothrombin time PTT—partial thromboplastin time
Table 2—Association between Preexisting insensibility characterized by loss of consciousness, amnesia, anal-
Medical Conditions and Adverse Outcomes65 gesia, and muscle relaxation. This state may be achieved either
with a single anesthetic or, in a more balanced fashion, with a
combination of several drugs that specifically induce hypnosis,
Medical Condition Associated Adverse Outcome
analgesia, amnesia, and paralysis.
Congestive heart failure 12% prolongation of postoperative stay There is, at present, no consensus as to which general anesthet-
Hypertension Twofold increase in risk of intraoperative ic regimen best preserves organ function. General anesthesia is
cardiovascular events employed when contraindications to regional anesthesia are pres-
Asthma Fivefold increase in risk of postoperative ent or when regional anesthesia or monitored anesthesia care fails
respiratory events
to provide adequate intraoperative analgesia. In addition, there are
Smoking Fourfold increase in risk of postoperative
respiratory events
a few situations that specifically mandate general anesthesia and
Obesity Fourfold increase in risk of intraoperative
controlled ventilation: the need for abdominal muscle paralysis,
and postoperative respiratory events lung isolation, and hyperventilation; the presence of serious car-
Reflux Eightfold increase in risk of intubation- diorespiratory instability; and the lack of sufficient time to perform
related adverse events regional anesthesia. Alternatives to general surgery should be con-
sidered for patients who are susceptible to malignant hyper-
thermia, for those in whom intubation is likely to prove difficult or
of alcohol or drugs. Any factor that may complicate airway the risk of aspiration is high, and for those with pulmonary com-
management should be noted (e.g., trauma to the face or the promise that may worsen after intubation and positive pressure
neck, a beard, a short and thick neck, obesity, or a full stomach). ventilation.
When appropriate, blood samples should be obtained as soon as Regional anesthesia is achieved by interfering with afferent or
possible for typing and crossmatching, as well as routine blood efferent neural signaling at the level either of the spinal cord (neur-
chemistries and a complete blood count. Arrangements for post- axial blockade) or of the peripheral nerves. Neuraxial anesthesia
operative ICU monitoring, if appropriate, should be instituted (i.e., epidural or spinal administration of local anesthetics) is com-
early. monly employed as the sole anesthetic technique for procedures
Clear communication must be established between the surgical involving the lower abdomen and the lower extremities; it also pro-
team and anesthesia personnel so that an appropriate anesthetic vides effective pain relief after intraperitoneal and intrathoracic
management plan can be formulated and any specialized equip- procedures. Combining regional and general anesthesia has
ment required can be mobilized in the OR. The induction of become increasingly popular.16 Currently, some physicians are
anesthesia may coincide with resuscitation. Accordingly, the using neuraxial blockade as the sole anesthetic technique for pro-
surgical team must be immediately available to help with diffi- cedures such as thoracotomy and coronary artery bypass grafting,
cult I.V. access, emergency tracheostomy, and cardiopulmonary which are traditionally thought to require general anesthesia and
resuscitation. Patients in shock may not tolerate standard endotracheal intubation.17
anesthetics, which characteristically blunt sympathetic outflow.The Neuraxial blockade has several advantages over general anes-
anesthetic dose must be judiciously titrated, and definitive surgi- thesia, including better dynamic pain control, shorter duration of
cal treatment must not be unduly delayed by attempts to “get a paralytic ileus, reduced risk of pulmonary complications, and
line.” decreased transfusion requirements; it is also associated with a
decreased incidence of renal failure and myocardial infarction [see
1:5 Postoperative Pain].18-21 Contrary to conventional thinking,
Choice of Anesthesia however, the type of anesthesia used (general or neuraxial) is not
Anesthesia may be classified into three broad categories: (1) an independent risk factor for long-term cognitive dysfunction.22
general anesthesia, (2) regional anesthesia, and (3) monitored Neuraxial blockade is an essential component of multimodal reha-
anesthesia care. General anesthesia can be defined as a state of bilitation programs aimed at optimization of perioperative care
and acceleration of recovery.23,24
For short, superficial procedures, a wide variety of peripheral
Table 3—Fasting Recommendations* to nerve blocks may be considered.25 For procedures on the upper or
Reduce Risk of Pulmonary Aspiration66 lower extremity, an I.V. regional (Bier) block with diluted lidocaine
is often useful. Anesthesia of the upper extremity and shoulder
Ingested Material Minimum Fasting Period† (hr) may be achieved with brachial plexus blocks. Anesthesia of the
lower extremity may be achieved by blocking the femoral, obtura-
Clear liquids‡ 2 tor, and lateral femoral cutaneous nerves (for knee surgery) or the
Breast milk 4 ankle and popliteal sciatic nerves (for foot surgery). Anesthesia of
Infant formula 6 the thorax may be achieved with intercostal or intrapleural nerve
Nonhuman milk§ 6 blocks. Anesthesia of the abdomen may be achieved with celiac
Light meal¶ 8 plexus and paravertebral blocks. Anesthesia of the head and neck
*These recommendations apply to healthy patients undergoing elective procedures; they
may be achieved by blocking the trigeminal, supraorbital, supra-
are not intended for women in labor. Following the guidelines does not guarantee complete trochlear, infraorbitral, and mental nerves and the cervical plexus.
gastric emptying.
†
These fasting periods apply to all ages.
Local infiltration of the operative site may provide intraoperative
‡
Examples of clear liquids include water, fruit juices without pulp, carbonated beverages, as well as postoperative analgesia.
clear tea, and black coffee.
§
Because nonhuman milk is similar to solids in gastric emptying time, amount ingested
Unlike the data on neuraxial blockade, the data on peripheral
must be considered in determining appropriate fasting period. nerve blockade neither support nor discourage its use as a substitute
¶
A light meal typically consists of toast and clear liquids. Meals that include fried or fatty for general anesthesia. Generally, however, we favor regional tech-
foods or meat may prolong gastric emptying time. Both amount and type of foods ingested
must be considered in determining appropriate fasting period. niques when appropriate: such approaches maintain consciousness
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1 Basic Surg Perioperative Considerations 3 PERIOPERATIVE CONSIDERATIONS FOR ANESTHESIA — 5
Table 4—Postanesthetic Discharge index or the Patient State Index. These indices are used as mea-
Scoring System (PADSS)67 sures of hypnosis to guide the administration of anesthetics.28,29
See morphine
For perioperative Orthostatic hypotension, myocardial depression, dry mouth,
Meperidine analgesia: 0.5– 2 hr (oral); 1 hr 2–4 hr mild tachycardia, mydriasis, histamine release
0.1 NA 1.5 mg/kg I.V., (s.c., I.M.)
I.M., s.c. Attenuates shivering; to be avoided with MAOIs
Local anesthetic–like effect
See morphine
Remifentanil 250–300 1 µg/kg 0.25–0.4 µg/kg/min 3–5 min 5–10 min Awareness, bradycardia, muscle rigidity
Ideal for infusion; fast recovery, no postoperative analgesia
See morphine
Alfentanil 7.5–25 50–300 µg/kg 1.25–8.0 µg/kg/min 1–2 min 10–15 min Awareness, bradycardia, muscle rigidity
Fentanyl 75–125 5–30 µg/kg 0.25–0.5 µg/kg/min 5–15 min 30–60 min See morphine and alfentanil
secondary to intubation and surgery, thus improving intraopera- (by increasing the tone of the esophagogastric sphincter); it may
tive hemodynamic stability. Major drawbacks are hypotension and also possess antiemetic properties.
bradycardia; rebound hypertensive crises may be precipitated by In all patients at risk for aspiration who require general anesthesia,
their discontinuance.30,31 a rapid sequence induction is essential.This is achieved through ade-
quate preoxygenation, administration of drugs to produce rapid loss
Prevention of Aspiration of consciousness and paralysis, and exertion of pressure on the
Aspiration of gastric contents is an extremely serious complica- cricoid cartilage (the Sellick maneuver) as loss of consciousness oc-
tion that is associated with significant morbidity and mortality. curs to occlude the esophagus and so limit reflux of gastric contents
Fasting helps reduce the risk of this complication [see Table 3]. into the pharynx. An alternative is the so-called modified rapid se-
When the likelihood of aspiration is high, pharmacologic treat- quence induction, which permits gentle mask ventilation during the
ment may be helpful [see Table 7]. H2 receptor antagonists (e.g., application of cricoid pressure (thereby potentially reducing or abol-
cimetidine, ranitidine, and famotidine) and proton pump inhibitors ishing insufflation of gas into the stomach). The advantages of the
(e.g., omeprazole) reduce gastric acid secretion, thereby raising modified approach are that there is less risk of hypoxia and that there
gastric pH without affecting gastric volume or emptying time. is more time to treat cardiovascular responses to induction agents
Nonparticulate antacids (e.g., sodium citrate) neutralize the acid- before intubation. Regardless of which technique is used, considera-
ity of gastric contents. Metoclopramide promotes gastric empty- tion should be given to emptying the stomach via an orogastric or
ing (by stimulating propulsive GI motility) and decreases reflux nasogastric tube before induction.
Timing of
Agent Dose Administration Comments
before Operation
H2 receptor 1–3 hr
antagonists
Cimetidine 300 mg, p.o. Hypotension, bradycardia, heart block, increased airway resistance,
CNS dysfunction, reduced hepatic metabolism of certain drugs
Ranitidine 50 mg I.V. Bradycardia
Famotidine 20 mg I.V. Rare CNS dysfunction
Hypotension, apnea, antiemetic (low dose), sexual fantasies and hallucinations, convulsions
Propofol 1.0–2.5 mg/kg 90–100 5–10 ± seizures (rare), pain on injection, thrombophlebitis
Analgesia; increased BP, HR, CO; lacrimation and salivation; bronchial dilatation; elevated ICP
Ketamine 0.5–2 mg/kg 30 10–15 Dreaming, illusions, excitement
Preservation of respiration (apnea possible with high doses)
INDUCTION MAINTENANCE
Induction of general anesthesia is produced by administering Balanced general anesthesia is produced with a variety of drugs
drugs to render the patient unconscious and secure the airway. It to maintain unconsciousness, prevent recall, and provide analgesia.
is one of the most crucial and potentially dangerous moments for Various combinations of volatile and I.V. agents may be employed
the patient during general anesthesia. Various agents can be used to achieve these goals. The volatile agents isoflurane, desflurane,
for this purpose; the choice depends on the patient’s baseline med- and sevoflurane are commonly used for maintenance [see Table 9].
ical condition and fasting status, the state of the airway, the surgi- Nitrous oxide is a strong analgesic and a weak anesthetic agent that
cal procedure, and the expected length of the hospital stay. The possesses favorable pharmacokinetic properties. It cannot be used
agents most commonly employed for induction are propofol, sodi- as the sole anesthetic agent unless it is administered in a hyperbar-
um thiopental, ketamine, and etomidate [see Table 8]. The opioids ic chamber; it is usually administered with at least 30% oxygen to
alfentanil, fentanyl, sufentanil, and remifentanil are also used for prevent hypoxia. Nitrous oxide is commonly used in combination
this purpose; they are associated with a very stable hemodynamic with other volatile agents. All of the volatile agents can trigger
profile during induction and operation [see Table 6]. malignant hyperthermia in susceptible patients.
Volatile agents [see Table 9] may be employed for induction of The I.V. drugs currently used to maintain general anesthesia,
general anesthesia when maintenance of spontaneous ventilation whether partially or entirely, feature a short context-sensitive elim-
is of paramount importance (e.g., with a difficult airway) or when ination half-life; thus, pharmacologically significant drug accumu-
bronchodilation is required (e.g., with severe hyperreactive airway lation during prolonged infusion is avoided. Such agents (includ-
disease). Inhalation induction is also popular for ambulatory ing propofol, midazolam, sufentanil, and remifentanil) are typical-
surgery when paralysis is not required. Sevoflurane is well suited ly administered via computer-controlled infusion pumps that use
for this application because it is not irritating on inhalation, as population-based pharmacokinetic data to establish stable plasma
most other volatile agents are, and it produces rapid loss of con- (and CNS effector site) concentrations. Because of the extremely
sciousness. Sevoflurane has mostly replaced halothane as the agent rapid hydrolysis of remifentanil, its administration may be labor
of choice for inhalation induction because it is less likely to cause intensive, necessitating frequent administration of boluses and
dysrhythmias and is not hepatotoxic. constant vigilance. Its short half-life also limits its usefulness as an
Rocuronium 0.6–1.2 35–75 None Renal < 10%, hepatic > 70% Minimal histamine release
Vecuronium 0.08–0.1 45–90 Hepatic 30%–40% Renal 40%, hepatic 60% Prolonged paralysis (long-term use)
Cisatracurium 0.15–0.2 40–75 Hoffman elimination Renal 16%, hepatic 0% Negligible histamine release; laudanosine metabolite
analgesic in the postoperative period.To circumvent this problem, accident, preexisting pathophysiologic conditions (e.g., CNS disor-
various dosing regimens have been proposed in which the patient ders, hepatic insufficiency, and drug or alcohol ingestion), elec-
is switched from remifentanil to a longer-acting narcotic. trolyte abnormalities, acidosis, hypercarbia, hypoxia, hypothermia,
and hypothyroidism. As noted, the effects of narcotics and benzo-
NEUROMUSCULAR BLOCKADE
diazepines can be reversed with naloxone and flumazenil, respec-
The reversible paralysis produced by neuromuscular blockade tively. Physostigmine may be given to reverse the reduction in con-
improves conditions for endotracheal intubation and facilitates sciousness level produced by general anesthetics. Electrolyte, glu-
surgery. Neuromuscular blocking agents are classified as either cose, blood urea nitrogen, and creatinine levels should be mea-
depolarizing (succinylcholine) or nondepolarizing (pancuronium, sured; liver and thyroid function tests should be performed; and
rocuronium, vecuronium, atracurium, cisatracurium, and miva- arterial blood gas values should be obtained. Patients should be
curium) and may be further differentiated on the basis of chemi- normothermic. Unexplained failure to emerge from general anes-
cal structure and duration of action [see Table 10]. The blocking thesia warrants immediate consultation with a neurologist.
effect of nondepolarizing muscle relaxants is enhanced by volatile
drugs, hypothermia, acidosis, certain antibiotics, magnesium sul-
fate, and local anesthetics and is reduced by phenytoin and carba- Regional Anesthesia Techniques
mazepine. Patients with weakness secondary to neuromuscular Neuraxial (central) anesthesia techniques involve continuous or
disorders (e.g., myasthenia gravis and Eaton-Lambert syndrome) intermittent injection of drugs into the epidural or intrathecal space
may be particularly sensitive to nondepolarizing muscle relaxants. to produce sensory analgesia, motor blockade, and inhibition of
sympathetic outflow. Peripheral nerve blockade involves inhibition
EMERGENCE
of conduction in fibers of a single peripheral nerve or plexus (cer-
General anesthesia is terminated by cessation of drug adminis- vical, brachial, or lumbar) in the periphery. Intravenous regional
tration, reversal of paralysis, and extubation. During this period, anesthesia involves I.V. administration of a local anesthetic into a
close scrutiny of the patient is essential, and all OR personnel must tourniquet-occluded extremity. Perioperative pain control may be
coordinate their efforts to help ensure a smooth and safe emer- facilitated by administering local anesthetics, either infiltrated into
gence. In this phase, patients may demonstrate hemodynamic the wound or sprayed into the wound cavity.32,33 Procedures per-
instability, retching and vomiting, respiratory compromise, and, formed solely under infiltration may be associated with patient dis-
occasionally, uncooperative or aggressive behavior. satisfaction caused by intraoperative anxiety and pain.34
Reversal of neuromuscular blockade is achieved by administer-
CONTRAINDICATIONS
ing anticholinesterases such as neostigmine and edrophonium.
These drugs should be given in conjunction with a muscarinic Strong contraindications to regional (particularly neuraxial)
antagonist (atropine or glycopyrrolate) to block their unwanted anesthesia include patient refusal or inability to cooperate during
parasympathomimetic side effects. Neostigmine is more potent the procedure, elevated intracranial pressure, anticoagulation, vas-
than edrophonium in reversing profound neuromuscular block- cular malformation or infection at the needle insertion site, severe
ade. It is imperative that paralysis be sufficiently reversed before hemodynamic instability, and sepsis. Preexisting neurologic dis-
extubation to ensure that spontaneous respiration is adequate and ease is a relative contraindication.
that the airway can be protected. Reversal can be clinically verified
ANTICOAGULATION AND BLEEDING RISK
by confirming the patient’s ability to lift the head for 5 seconds.
Reversal can also be assessed by measuring muscle contraction in Although hemorrhagic complications can occur after any
response to electrical nerve stimulation. regional technique, bleeding associated with neuraxial blockade is
Causes of failure to emerge from anesthesia include residual the most serious because of its devastating consequences. Spinal
neuromuscular blockade, a benzodiazepine or opioid overdose, the hematoma may occur as a result of vascular trauma from place-
central anticholinergic syndrome, an intraoperative cerebrovascular ment of a needle or catheter into the subarachnoid or epidural
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1 Basic Surg Perioperative Considerations 3 PERIOPERATIVE CONSIDERATIONS FOR ANESTHESIA — 9
Heparin
I.V. ⇔ ⇑ min 4–6 hr
s.c. ⇔ ↑ 1 hr 4–6 hr
LMWH ⇔ ⇔ 2–4 hr 12 hr
Warfarin ⇑ ⇔ 2–6 days 4–6 days
Aspirin ⇔ ⇔ hr 5–8 days
Thrombolytic agents (t-PA, streptokinase) ⇔ ⇑ min 1–2 days
⇑ —clinically significant increase ↑—possibly clinically significant increase ⇔—clinically insignificant increase or no effect
LMWH—low-molecular-weight heparin t-PA—tissue plasminogen activator
Heparin
space. Spinal hematoma may also occur spontaneously, even in
the absence of antiplatelet or anticoagulant therapy. The actual There does not seem to be an increased risk of spinal bleeding
incidence of spinal cord injury resulting from hemorrhagic com- in patients receiving subcutaneous low-dose (5,000 U) unfrac-
plications is unknown; the reported incidence is estimated to be tionated heparin [see 6:6 Venous Thromboembolism] if the interval
less than 1/150,000 for epidural anesthesia and 1/220,000 for between administration of the drug and initiation of the procedure
spinal anesthesia.35 With such low incidences, it is difficult to is greater than 4 hours.39 Higher doses, however, are associated
determine whether any increased risk can be attributed to antico- with increased risk. If neuraxial anesthesia or epidural catheter
agulant use [see Table 11] without data from millions of patients, removal is planned, heparin infusion must be discontinued for at
which are not currently available. Much of our clinical practice is least 6 hours, and the partial thromboplastin time (PTT) should
based on small surveys and expert opinion. be measured. Recommendations for standard heparin cannot be
extrapolated to low-molecular-weight heparin (LMWH), because
Antiplatelet Agents the biologic actions of LMWH are different and the effects can-
There is no universally accepted test that can guide antiplatelet not be monitored by conventional coagulation measurements.
therapy. Antiplatelet agents can be divided into four major class- After the release of LMWH for general use in the United States
es: (1) aspirin and related cyclooxygenase inhibitors (nonsteroidal in 1993, more than 40 spinal hematomas were reported during a
anti-inflammatory drugs, or NSAIDs); (2) ticlopidine and selec- 5-year period. LMWH should be stopped at least 12 hours before
tive adenosine diphosphate antagonists; (3) direct thrombin regional blockade, and the first postoperative dose should be given
inhibitors (e.g., hirudin); and (4) glycoprotein IIb/IIIa inhibitors. no sooner than 4 hours afterward.37
Only with aspirin is there sufficient experience to suggest that at
clinical doses it does not increase the risk of spinal hematoma.36 COMPLICATIONS
Caution should, however, be exercised when aspirin is used in
Drug Toxicity
conjunction with other anticoagulants.37
Systemic toxic reactions to local anesthetics primarily involve
Oral Anticoagulants the CNS and the cardiovascular system [see Table 12]. The initial
Therapeutic anticoagulation with warfarin is a contraindication symptoms are light-headedness and dizziness, followed by visual
to regional anesthesia.38 If regional anesthesia is planned, oral war- and auditory disturbances. Convulsions and respiratory arrest
farin can be replaced with I.V. heparin (see below). may ensue and necessitate treatment and resuscitation.
*Recommended maximum dose can be given to healthy, middle-aged, normal-sized adults without toxicity.
Subsequent doses should not be given for at least 4 hr. Doses should be reduced during pregnancy.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surg Perioperative Considerations 3 PERIOPERATIVE CONSIDERATIONS FOR ANESTHESIA — 10
Recovery
The use of neuraxial analgesic adjuncts (e.g., opioids, cloni-
dine, epinephrine, and neostigmine) decreases the dose of local Admission to the postanesthetic care unit (PACU) is appropri-
anesthetic required, speeds recovery, and improves the quality of ate for patients whose vital signs are stable and whose pain is ade-
analgesia.The side effects of such adjuncts include respiratory depres- quately controlled after emergence from anesthesia. Patients
sion (with morphine), tachycardia (with epinephrine), hypoten- requiring hemodynamic or respiratory support may be admitted
sion (with clonidine), and nausea and vomiting (with neostigmine to the PACU if rapid improvement is expected and appropriate
and morphine). monitoring and personnel are available. Hemodynamic instability,
the need for prolonged respiratory support, and poor baseline
Neurologic Complications condition mandate admission to the ICU. Common complica-
The incidence of neurologic complications ranges from tions encountered in the PACU include postoperative pulmonary
2/10,000 to 12/10,000 with epidural anesthesia and from insufficiency, cardiovascular instability, acute pain, and nausea and
0.3/10,000 to 70/10,000 with spinal anesthesia.40 The most com- vomiting [see Table 13]. These complications are discussed in
mon serious complication is neuropathy, followed by cranial nerve greater detail elsewhere [see 8:4 Pulmonary Insufficiency, 8:2 Acute
palsy, epidural abscess, epidural hematoma, anterior spinal artery Cardiac Dysrhythmia, and 1:5 Postoperative Pain].
syndrome, and cranial subdural hematoma.Vigilance and routine
neurologic testing of sensory and motor function are of para-
mount importance for early detection and treatment of these Special Scenarios
potentially disastrous complications.
DIFFICULT AIRWAY
Transient neurologic symptoms The term transient neu- Airway management is a pivotal component of patient care
rologic symptoms (TNS) refers to backache with pain radiating because failure to maintain airway patency can lead to permanent
into the buttocks or the lower extremities after spinal anesthesia. It disability, brain injury, or death.The difficult airway should be man-
occurs in 4% to 33% of patients, typically 12 to 36 hours after the aged in accordance with contemporary airway guidelines, such as
resolution of spinal anesthesia, and lasts for 2 to 3 days.41 TNS has the protocols established by the ASA, to reduce the risk of adverse
been described after intrathecal use of all local anesthetics but is outcomes during attempts at ventilation and intubation. (The ASA
most commonly noted after administration of lidocaine, in the protocols may be accessed on the organization’s Web site: http://
ambulatory surgical setting, and with the patient in the lithotomy www.asahq.org/publicationsandservices/difficult%20airway.pdf.)
position during operation. Discomfort from TNS is self-limited The emphasis on preserving spontaneous ventilation and the focus
and can be effectively treated with NSAIDs. on awake intubation options are central themes whose importance
cannot be overemphasized.
Postdural Puncture Headache It is crucial that all patients who are undergoing difficult or pro-
Use of small-gauge pencil-point needles for spinal anesthesia is longed airway instrumentation be appropriately treated with topi-
associated with a 1% incidence of PDPH.The incidence of PDPH cal anesthesia, sedation, and monitoring so as to ensure adequate
after epidural analgesia varies substantially because the risk of ventilation and to attenuate, detect, and treat harmful neuroen-
inadvertent dural puncture with a Tuohy needle is directly depen- docrine responses that can cause myocardial ischemia, bron-
dent on the anesthesiologist’s training. PDPH is characteristically chospasm, and intracranial hypertension. Extubation is stressful as
aggravated by upright posture and may be associated with photo- well and may be associated with intense mucosal stimulation and
phobia, neck stiffness, nausea, diplopia, and tinnitus. Meningitis exaggerated glottic closure reflexes resulting in laryngospasm and,
should be considered in the differential diagnosis. Although possibly, pulmonary edema secondary to vigorous inspiratory
PDPH is not life-threatening, it carries substantial morbidity in efforts against an obstructed airway. Laryngeal incompetence and
the form of restricted activity. Medical treatment with bed rest, I.V. aspiration can also occur after extubation. Removal of an endotra-
fluids, NSAIDs, and caffeine is only moderately effective. An cheal tube from a known or suspected difficult airway should ide-
epidural blood patch is the treatment of choice: the success rate is ally be performed over a tube exchanger so as to facilitate emer-
approximately 70%. gency reintubation.
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1 Basic Surg Perioperative Considerations 3 PERIOPERATIVE CONSIDERATIONS FOR ANESTHESIA — 11
Alternatives to standard oral airways, masks, introducers, circuits), local or systemic inflammatory responses (either related
exchangers, laryngoscopes, and endotracheal tubes now exist that or unrelated to infection), transfusion reaction, hypermetabolic
offer more options, greater safety, and better outcomes. It would endocrinopathy (e.g., thyroid storm or pheochromocytoma), neu-
be naive to believe that any single practitioner could master every rologic catastrophe (e.g., intracranial hemorrhage), and reaction
new airway protocol and device. To keep up with technical and to or abuse of a drug.
procedural advances, university hospital program directors should Immediate recognition and treatment of a fulminant MH
consider incorporating technical skill laboratories and simulator episode are essential for preventing morbidity and mortality.
training sessions into their curricula. Therapy consists of discontinuing all triggers, instituting aggressive
cooling measures, giving dantrolene in an initial dose of 2.5 mg/kg,
MORBID OBESITY
and administering 100% oxygen to compensate for the tremen-
Morbid obesity represents the extreme end of the overweight dous increase in oxygen utilization and carbon dioxide production.
spectrum and is usually defined as a body-mass index higher than An indwelling arterial line, central venous access, and bladder
40 kg/m2 [see 5:7 Morbid Obesity].42 It poses a formidable chal- catheterization are indispensable for monitoring and resuscitation.
lenge to health care providers in the OR, the postoperative recov- Acidosis, hyperkalemia, and malignant dysrhythmias must be
ery ward, and the ICU.The major concerns in the surgical setting rapidly treated, with the caveat that calcium channel blockers are
are the possibility of a difficult airway, the increased risk of known contraindicated in this setting. Maintenance of adequate urine out-
or occult cardiorespiratory compromise, and various serious tech- put is of paramount importance and may be facilitated by the clin-
nical problems related to positioning, monitoring, vascular access, ically significant amounts of mannitol contained in commercial
and transport. Additional concerns are the potential for underly- dantrolene preparations. When the patient is stable and the surgi-
ing hepatic and endocrine disease and the effects of altered drug cal procedure is complete, monitoring and support are continued
pharmacokinetics and pharmacodynamics. For the morbidly in the ICU, where repeat doses of dantrolene may be needed to
obese patient, there is no such thing as minor surgery. prevent or treat recrudescence of the disease.
Initial management should be based on the assumptions that
MASSIVE TRANSFUSION
(1) a difficult airway is likely, (2) the patient will be predisposed to
hiatal hernia, reflux, and aspiration, and (3) rapid arterial desatu- Massive blood transfusion, defined as the replacement of a pa-
ration will occur with induction of anesthesia as a consequence of tient’s entire circulating blood volume in less than 24 hours, is asso-
decreased functional residual capacity and high basal oxygen con- ciated with significant morbidity and mortality. Management of
sumption. Often, the safest option is an awake fiberoptic intuba- massive transfusion requires an organized multidisciplinary team ap-
tion with appropriate topical anesthesia and light sedation.43 In proach and a thorough understanding of associated hematologic
expert hands, this technique is extremely well tolerated and can and biochemical abnormalities and subsequent treatment options.
usually be performed in less than 10 minutes. Morbidly obese Patients suffering from shock as a result of massive blood loss of-
patients often are hypoxemic at rest and have an abnormal alveo- ten require transfusions of packed red blood cells, platelets, fresh
lar-arterial oxygen gradient caused by ventilation-perfusion mis- frozen plasma, and cryoprecipitate to optimize oxygen-carrying ca-
matching. The combination of general anesthesia and the supine pacity and address dilutional and consumptive loss of platelets and
position exacerbates alveolar collapse and airway closure. clotting factors [see 8:3 Shock and 1:4 Bleeding and Transfusion].
Mechanical ventilation, weaning, and extubation may be difficult Transfusion of large amounts of blood products into a critically ill
and dangerous, especially in the presence of significant obstructive patient can lead to coagulopathies, hyperkalemia, acidosis, citrate in-
sleep apnea. Postoperative pulmonary complications (e.g., pneu- toxication, fluid overload, and hypothermia.45 Therapy should be
monia, aspiration, atelectasis, and emboli) are common. guided by vital signs, urine output, pulse oximetry, electrocardiogra-
Morbid obesity imposes unusual loading conditions on both phy, capnography, invasive hemodynamic monitoring, serial arterial
sides of the heart and the circulation, leading to the progressive blood gases, biochemical profiles, and bedside coagulation screens.
development of insulin resistance, atherogenic dyslipidemias, sys- Fluids should be administered through large-bore cannulas con-
temic and pulmonary hypertension, ventricular hypertrophy, and nected to modern countercurrent warming devices. Shed blood
a high risk of premature coronary artery disease and biventricular should be salvaged and returned to the patient whenever possible. In
heart failure. Perioperative cardiac morbidity and mortality are refractory cases, transcatheter angiographic embolization techniques
therefore significant problems. Untoward events can happen sud- should be considered for control of bleeding.
denly, and resuscitation is extremely difficult. Cardiorespiratory Newer hemostatic agents, such as aprotinin and recombinant
compromise may be attenuated by effective postoperative pain factor VIIa, should also be considered. Aprotinin is a serine pro-
control that permits early ambulation and effective ventilation. tease inhibitor with unique antifibrinolytic and hemostatic prop-
Surgical site infection and dehiscence may result in difficult reop- erties. It is used during surgery to decrease blood loss and trans-
eration and prolonged hospitalization. fusion requirements as well as to attenuate potentially harmful
inflammatory responses and minimize reperfusion injury.
MALIGNANT HYPERTHERMIA
Recombinant factor VIIa was originally approved for hemophili-
Malignant hyperthermia (MH) is a rare but potentially fatal acs who developed antibodies against either factor VIII or factor
genetic condition characterized by life-threatening hypermetabol- IX; it may prove useful for managing uncontrolled hemorrhage
ic reactions in susceptible individuals after the administration of deriving from trauma or surgery.
volatile anesthetics or depolarizing muscle relaxants.44 Abnormal
HYPOTHERMIA
function of the sarcoplasmic reticulum calcium release channel in
skeletal muscle has been identified as a possible underlying cause. Significant decreases in core temperature are common during
In making the diagnosis of MH, it is important to consider anesthesia and surgery as a consequence of exposure to a cold OR
other possible causes of postoperative temperature elevation. Such environment and of disturbances in normal protective thermoreg-
causes include inadequate anesthesia, equipment problems (e.g., ulatory responses. Patients lose heat through conduction, convec-
misuse or malfunction of heating devices, ventilators, or breathing tion, radiation, and evaporation, especially from large wounds and
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surg Perioperative Considerations 3 PERIOPERATIVE CONSIDERATIONS FOR ANESTHESIA — 12
during major intracavitary procedures. Moreover, effective vaso- cutaneous changes. Laryngeal edema can occur within minutes, in
constrictive reflexes and both shivering and nonshivering thermo- which case the airway should be secured immediately. Anaphylaxis
genesis are severely blunted by anesthetics.46 Neonates and the can mimic heart failure, asthma, pulmonary embolism, and ten-
elderly are particularly vulnerable. sion pneumothorax. Treatment involves withdrawing the offend-
Hypothermia may confer some degree of organ preservation ing substance and administering oxygen, fluids, and epinephrine,
during ischemia and reperfusion. For example, in cardiac surgery, followed by I.V. steroids, bronchodilators, and histamine antago-
hypothermic cardiopulmonary bypass is a common strategy for nists. Prolonged intubation and ICU monitoring may be required
protecting the myocardium and the CNS. Intentional hypother- until symptoms resolve. Appropriate skin and blood testing should
mia has also been shown to improve neurologic outcome and sur- be done to identify the causative agent.
vival in comatose victims of cardiac arrest. Perioperative hypother-
mia can have significant deleterious effects as well, however, PERIOPERATIVE DYSRHYTHMIAS
including myocardial ischemia, surgical site infection, increased In 2000, current scientific developments in the treatment of
blood loss and transfusion requirements, and prolonged anesthet- stroke and coronary artery disease were merged with the evolving
ic recovery and hospital stay. discipline of evidence-based medicine to produce the most com-
The sensation of cold is highly uncomfortable for the patient, prehensive set of resuscitation standards ever created: a 12-part
and shivering impedes monitoring, raises plasma catecholamine document from the American Heart Association entitled
levels, and exacerbates imbalances between oxygen supply and “Guidelines 2000 for Cardiopulmonary Resuscitation and
demand by consuming valuable energy for involuntary muscular Emergency Cardiovascular Care.” This document addresses a
activity. It is therefore extremely important to measure the wide array of key issues in both in-hospital and out-of-hospital
patient’s temperature and maintain thermoneutrality. Increasing resuscitation, including a recommendation for confirmation of
the ambient temperature of the OR and applying modern forced- tube position after endotracheal intubation and a warning about
air warming systems are the most effective techniques available. In the danger associated with unintentional massive auto-PEEP.
addition, all I.V. and irrigation fluids should be heated. After the As regards the impact the new guidelines have on management
patient has been transferred from the OR, aggressive treatment of of dysrhythmias, the dominant role of amiodarone is undeniably
hypothermia with these techniques should be continued as neces- the most visible and important development.50 Amiodarone is a
sary. Shivering may also be reduced by means of drugs such as complex, powerful, and broad-spectrum agent that inhibits almost
meperidine, nefopam, tramadol, physostigmine, ketamine,
all of the drug receptors and ion channels conceivably responsible
methylphenidate, and doxapram.47
for the initiation and propagation of cardiac ectopy, irrespective of
INTRAOPERATIVE AWARENESS underlying ejection fraction, accessory pathway conduction, or
anatomic substrate. It does, however, have potential drawbacks,
One of the goals of anesthesia is to produce a state of uncon-
such as its relatively long half-life, its toxicity to multiple organs,
sciousness during which the patient neither perceives nor recalls nox-
and its complicated administration scheme. Furthermore, amio-
ious surgical stimuli.When this objective is not met, awareness oc-
darone is a potent noncompetitive alpha and beta blocker, which
curs, and the patient will have explicit or implicit memory of
intraoperative events. In some instances, intraoperative awareness has important implications for anesthetized, mechanically venti-
develops because human error, machine malfunction, or technical lated patients who may be debilitated and experiencing volume
problems result in an inappropriately light level of anesthesia. In oth- depletion, abnormal vasodilation, myocardial depression, and
ers (e.g., when the patient is severely hemodynamically unstable or fluid, electrolyte, and acid-base abnormalities. That said, no other
efforts are being made to avoid fetal depression during cesarean sec- drug in its class has ever demonstrated a significant benefit in ran-
tion), the light level of anesthesia may have been intentionally cho- domized trials addressing cardiac arrest in humans.
sen. Regardless of the cause, intraoperative awareness is a terrifying Amiodarone is effective in both children and adults, and it can
experience for the patient and has been associated with serious long- be used for prophylaxis as well as treatment. The recommended
term psychological sequelae.48 Prevention of awareness depends on cardiac arrest dose is a 300 mg I.V. bolus. In less acute situations,
regular equipment maintenance, meticulous anesthetic technique, the initial 300 mg dose should be administered slowly over 15 to
and close observation of the patient’s movements and hemodynam- 20 minutes, and one or two additional boluses may be given sim-
ic responses during operation. CNS monitoring may reduce the risk ilarly. A loading regimen is then initiated, first at 1 mg/min for 6
of intraoperative awareness. hours and then at 0.5 mg/min for 18 hours.
The inclusion of vasopressin (antidiuretic hormone) as an alter-
ANAPHYLAXIS native to epinephrine in the revised ventricular tachycardia/ven-
Allergic reactions range in severity from mild pruritus and tricular fibrillation protocol represents another major change in
urticaria to anaphylactic shock and death. Inciting agents include drug therapy for advanced cardiac life support. Vasopressin is an
antibiotics, contrast agents, blood products, volume expanders, integral component of the hypothalamic-pituitary-adrenal axis
protamine, aprotinin, narcotics, induction agents, muscle relax- and the neuroendocrine stress response. The recommended dose
ants, latex,49 and, rarely, local anesthetic solutions. Many drug for an adult in fibrillatory arrest is 40 units in a single bolus. For
additives and preservatives have also been implicated. vasodilatory shock states associated with sepsis, hepatic failure, or
True anaphylaxis presents shortly after exposure to an allergen vasomotor paralysis after cardiopulmonary bypass, infusion at a
and is mediated by chemicals released from degranulated mast cells rate of 0.01 to 0.05 units/min may be particularly useful.
and basophils. Manifestations usually include dramatic hypoten- Vasopressin is neither recommended nor forbidden in cases of
sion, tachycardia, bronchospasm, arterial oxygen desaturation, and pulseless electrical activity or asystolic arrest.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surg Perioperative Considerations 3 PERIOPERATIVE CONSIDERATIONS FOR ANESTHESIA — 13
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epidural or spinal anaesthesia: results from 39. Horlocker TT, Wedel DJ: Neurological compli- 61. Vanderweghem JL, Depurreux M,Tielmans CH,
overview of randomised trials. BMJ 321:1493, cations of spinal and epidural anesthesia. Reg et al: Rapidly progressive interstitial renal fibro-
2000 Anesth Pain Med 25:83, 2000 sis in young women: association with summing
20. Beattie WS, Badner NH, Choi P: Epidural anal- 40. Loo CC, Dahlgren G, Irestedt L: Neurological regimen including Chinese herbs. Lancet
gesia reduces postoperative myocardial infarc- complications in obstetric regional anesthesia. 341:387, 1993
tion: a metaanalysis. Anesth Analg 93:853, 2001 Int J Obstet 9:99, 2000
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1 Basic Surg Perioperative Considerations 3 PERIOPERATIVE CONSIDERATIONS FOR ANESTHESIA — 14
62. Jadont M, Plaen JF, Cosyns JP, et al: Adverse Anesthesiology 90:896, 1999 Lippincott Williams & Wilkins, Philadelphia, p
effects from traditional Chinese medicine. 67. Chung F: A post-anesthetic discharge scoring 385
Lancet 347:892, 1995 system for home readiness after ambulatory 71. Compendium of Pharmaceuticals and Specialties,
63. Kao WF, Hung DZ, Lin KP: Podophylotoxin surgery. J Clin Anesth 7:500, 1995 Canadian Pharmacists Association. Webcom
intoxication: toxic effect of Bajiaolian in herbal 68. Reves JG, Glass PSA, Lubarsky DA: Nonbar- Limited, Toronto, 2002
therapeutics. Hum Exp Toxicol 11:480, 1992 biturate intravenous anesthetics. Anesthesia, 5th 72. Koblin DD: Mechanisms of action. Anesthesia,
64. Edzard E: Harmless herbs? A review of the ed. Miller RD, Ed. Churchill Livingstone Inc, 5th ed. Miller RD, Ed. Churchill Livingstone
recent literature. Am J Med 104:170, 1998 Philadelphia, 2000, p 228 Inc, Philadelphia, 2000, p 48
65. Chung F, Mezei G: Adverse outcomes in ambu- 69. Bailey PL, Egan TD, Stanley TH: Intravenous 73. Eger EE II: Uptake and distribution. Anesthesia,
latory anesthesia. Can J Anesth 46:R18, 1999 opioid anesthetics. Anesthesia, 5th ed. Miller 5th ed. Miller RD, Ed. Churchill Livingstone
66. ASA Task Force on Preoperative Fasting. RD, Ed. Churchill Livingstone Inc, Philadelphia, Inc, Philadelphia, 2000, p 74
Practice guidelines for preoperative fasting and 2000, p 273 74. Savarese JJ, Caldwell JE, Lien CA, et al: Pharma-
the use of pharmacologic agents to reduce the 70. Stoelting RK: Histamine and histamine receptor cology of muscle relaxants and their antagonists.
risk of pulmonary aspiration: application to antagonists. Pharmacology and Physiology in Anesthesia, 5th ed. Miller RD, Ed. Churchill
healthy patients undergoing elective procedures. Anesthetic Practice, 3rd ed. Stoelting RK, Ed. Livingstone Inc, Philadelphia, 2000, p 412
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1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 4 BLEEDING AND TRANSFUSION — 1
A surgeon is often the first person to be called when a patient expe- Even when a technical cause of bleeding has seemingly been ex-
riences ongoing bleeding.To treat such a patient appropriately, the cluded, the possibility often must be reconsidered periodically
surgeon must identify the cause or source of the bleeding. Causes throughout assessment. Patients who are either unresuscitated or un-
fall into two main categories: (1) conditions leading to loss of vascu- derresuscitated undergo vasospasm, which may cause tamponade of
lar integrity, as in a postoperative patient with an unligated vessel the bleeding point.1 As resuscitation proceeds, the catecholamine-
that is bleeding or a trauma patient with a ruptured spleen, and (2) induced vasospasm subsides and the bleeding may recur. For this
conditions leading to derangement of the hemostatic process. In reason, constant reassessment of the possibility of a technical cause of
this chapter, we focus on the latter category, which includes a broad bleeding is appropriate. Only when the surgeon is confident that a
spectrum of conditions ranging from aspirin-induced platelet dys- missed injury or unligated vessel is not the cause of the bleeding
function to von Willebrand disease (vWD) to disseminated in- should other potential causes be investigated.
travascular coagulation (DIC) and even to hemophilia.
Coagulopathies are varied in their causes, treatments, and prog-
noses. Our aim is not to obviate the hematologic tests required for Initial Assessment of
identification of rare congenital or acquired clotting abnormalities Potential Coagulopathy
but to outline effective management approaches to the coagu- The first step in assess-
lopathies surgeons see most frequently.The vast majority of these ment of a patient with a po-
coagulopathies can be diagnosed by means of a brief patient and tential coagulopathy is to
family history, a review of medications, physical examination, and draw a blood sample. The
laboratory studies—in particular, activated partial thromboplastin blood should be distributed
time (aPTT), prothrombin time (PT, commonly expressed as an in- into a tube containing eth-
ternational normalized ratio [INR]), complete blood count (CBC), ylenediaminetetraacetic
and D-dimer assay. acid (EDTA) (for a CBC) and a citrated tube (for coagulation
analysis).
At the same time, the patient’s temperature should be noted. Be-
Exclusion of Technical
cause coagulation is a chemical reaction, it slows with increasing
Causes of Bleeding
cold.2 Thus, a patient with a temperature lower than 35° C (95° F)
It is critical for the sur- clots more slowly and less efficiently than one with a temperature of
geon to recognize that the 37° C (98.6° F).3 The resulting coagulatory abnormality is what is
most common causes of known as a hypothermic coagulopathy. Upon receipt of the drawn
postoperative bleeding are specimen, the laboratory warms the sample to 37° C to run the co-
technical: an unligated vessel agulation assays (aPTT and INR). In a patient with a purely hy-
or an unrecognized injury is pothermic coagulopathy, this step results in normal coagulation
much more likely to be the parameters. Hypothermic patients should be actively rewarmed.4
cause of a falling hematocrit than either a drug effect or an endoge- Typically, such patients cease to bleed after rewarming, and no fur-
nous hemostatic defect. Furthermore, if an unligated vessel is treat- ther treatment is required. If the patient is normothermic and ex-
ed as though it were an endogenous hemostatic defect (i.e., with hibits normal coagulation values but bleeding continues, attention
transfusions), the outcome is likely to be disastrous. For these rea- should again be focused on the possibility of an unligated bleeding
sons, in all cases of ongoing bleeding, the first consideration must al- vessel or an uncontrolled occult bleeding source (e.g., the GI tract).
ways be to exclude a surgically correctable cause. Ongoing bleeding in conjunction with abnormal coagulation pa-
Ongoing bleeding may be surprisingly difficult to diagnose. rameters may have any of several underlying causes. In this setting,
Healthy young patients can usually maintain a normal blood pres- one of the most useful pieces of information to obtain is a personal
sure until their blood loss exceeds 40% of their blood volume and family history. A patient who has had dental extractions with-
(roughly 2 L). If the bleeding is from a laceration to an extremity, it out major problems or who had a normal adolescence without any
will be obvious; however, if the bleeding is occurring internally (e.g., history of bleeding dyscrasias is very unlikely to have a congenital or
from a ruptured spleen or an intraluminal GI source), there may be hereditary bleeding disorder.5 If there is a personal or family history
few physiologic signs [see 8:3 Shock]. For the purposes of the ensuing of a specific bleeding disorder, appropriate steps should be taken to
discussion, we assume that bleeding is known to have occurred or to diagnose and treat the disorder [see Discussion, Bleeding Disorders,
be occurring. below].
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1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 4 BLEEDING AND TRANSFUSION — 2
Patient has normal INR and aPTT Patient has normal INR and prolonged aPTT
T° is normal T° is low
Warm patient.
Platelet status or coagulation parameters are abnormal Platelet status and coagulation parameters are normal
Look for family history of specific bleeding disorder. DIC is not present.
Reconsider possibility of unligated vessel [see above, left].
Patient has increased INR and normal aPTT Patient has increased INR and prolonged aPTT
Consider drug effects (warfarin), hepatic failure, and If D-dimer level is elevated, assume DIC and
malnutrition. treat accordingly.
Give I.V. vitamin K or FFP as appropriate; treat cirrhosis-related If D-dimer level is normal, consider end-stage
variceal bleeding surgically. renal disease and multifactor deficiency.
Give FFP, and initiate directed therapy.
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1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 4 BLEEDING AND TRANSFUSION — 4
Measurement of
percoagulable state.10 It is likely that many of the thrombotic
Coagulation Parameters
complications are related to simple reversal of a needed anticoag-
ulant state. Protamine should also be used with caution in dia-
NORMAL INR,
betic patients. These persons sometimes become sensitized to
NORMAL aPTT
impurities in protamine through their exposure to similar impu-
Patients with a normal rities in insulin, and this sensitization may result in an anaphylac-
INR and aPTT who exhibit tic reaction.
ongoing bleeding may have It should be remembered that the aPTT does not accurately
impaired platelet activity. measure the anticoagulant activity of low-molecular-weight hep-
Inadequate platelet activity is frequently manifested as persistent arins. Because such heparins exert the greater proportion of their
oozing from wound edges or as low-volume bleeding. Such bleeding anticoagulant effect by potentiating antithrombin to inactivate fac-
is rarely the cause of exsanguinating hemorrhage, though it may be tor Xa rather than factor IIa, an assay that measures anti-Xa activi-
life-threatening on occasion, depending on its location (e.g., the ty is needed to measure the anticoagulant effect.This effect, howev-
head or the pericardium). Inadequate platelet activity may be attrib- er, like that of unfractionated heparin, is reversible by protamine. A
utable either to an insufficient number of platelets or to platelet dys- crucial point is that the administration of fresh frozen plasma (FFP)
function. In the absence of a major surgical insult, a platelet count of will not correct the anticoagulant effect of either unfractionated
20,000/mm3 or higher is usually adequate for normal coagulation.6,7 heparin or low-molecular-weight heparins. In fact, given that plas-
There is some disagreement regarding the absolute level to which ma contains antithrombin and that both unfractionated heparin
the platelet count must fall before platelet transfusion is justified in and low-molecular-weight heparins act by potentiating antithrom-
the absence of active bleeding. Patients undergoing procedures in bin, administration of FFP could actually enhance the heparins’ an-
which even capillary oozing is potentially life-threatening (e.g., ticoagulant effect.
craniotomy) should be maintained at a higher platelet count (i.e., A variety of direct thrombin inhibitors (e.g., bivalirudin [Hirulog]
> 20,000/mm3 ). Patients without ongoing bleeding who are not and lepirudin) are currently available in Europe, Asia, and North
specifically at increased risk for major complications from low-vol- America.11 Many of them cause prolongation of the aPTT. One
ume bleeding may be safely watched with platelet counts lower than disadvantage shared by most of the direct thrombin inhibitors is
20,000/mm3. that the effects are not reversible; if thrombin inhibition is no longer
Oozing in a patient who has an adequate platelet count and nor- wanted, FFP must be given to correct the aPTT. Because the in-
mal coagulation parameters may be a signal of platelet dysfunction. hibitor that is circulating but not bound at the time of FFP admin-
The now-routine administration of aspirin to reduce the risk of myo- istration will bind the prothrombin in the FFP, the amount of FFP
cardial infarction and stroke has led to a rise in the incidence of as- required to correct the aPTT may be greater than would be needed
pirin-induced platelet dysfunction. Aspirin causes irreversible plate- with a simple factor deficiency.
let dysfunction through the cyclooxygenase pathway; the effect of von Willebrand disease is frequently, though not always, associ-
aspirin can thus be expected to last for approximately 10 days.The ated with a slight prolongation of the aPTT. Its clinical expression
platelet dysfunction caused by other nonsteroidal anti-inflammatory is variable. Confirmation of the diagnosis can be obtained by test-
drugs (e.g., ibuprofen) is reversible and consequently does not last as ing for circulating factor levels. Platelet function analysis will also
long as that caused by aspirin. Newer platelet-blocking agents have show abnormal function. Correction is accomplished by adminis-
been found to be effective in improving outcome after coronary an- tering directed therapy (von Willebrand factor [vWF]) [see Discus-
gioplasty.8 These drugs function predominantly by blocking the sion, Bleeding Disorders, below], DDAVP, or cryoprecipitate.
platelet surface receptor glycoprotein (GP) IIb-IIIa, which binds Hemophilia may either cause spontaneous bleeding or lead to
platelets to fibrinogen. prolonged bleeding after a surgical or traumatic insult. As noted, he-
In patients with platelet dysfunction caused by an inhibitor of mophilia is rare in the absence of a personal or family history of the
platelet function, such as an elevated blood urea nitrogen (BUN) disorder.The most common forms of hemophilia involve deficien-
level, 1-desamino-8-D-arginine vasopressin (DDAVP) is capable of cies of factors VIII, IX, and XI (hemophilia A, hemophilia B, and he-
partially reversing the dysfunction.9 DDAVP has also been success- mophilia C, respectively). In contrast to depletion of natural antico-
ful in partially reversing aspirin-induced platelet dysfunction. agulants such as antithrombin and protein C [see 6:6 Venous
Less common causes of bleeding in patients with a normal INR Thromboembolism], depletion of procoagulant factors rarely gives rise
and a normal aPTT include factor XIII deficiency, hypofibrinogen- to significant manifestations until it is relatively severe.Typically, no
emia or dysfibrinogenemia, and derangements in the fibrinolytic laboratory abnormalities result from depletion of procoagulant fac-
pathway [see Discussion, Mechanics of Hemostasis, below]. tors until factor activity levels fall below 40% of normal, and clinical
abnormalities are frequently absent even when factor activity levels
NORMAL INR,
fall to only 10% of normal.This tolerance for subcritical degrees of
PROLONGED aPTT
depletion is a reflection of the built-in redundancies in the procoagu-
Patients with a normal lant pathways.
INR and an abnormal If hemophilia is suspected, specific factor analysis is indicated.
aPTT are likely to have a Appropriate therapy involves administering the deficient factor or
drug-induced coagulation factors [see Table 1]. Hemophiliac patients who have undergone ex-
defect. The agent most tensive transfusion therapy may pose a particular challenge: massive
commonly responsible is transfusions frequently lead to the development of antibodies that
unfractionated heparin. make subsequent transfusion or even directed therapy impossible.
Reversal of the heparin effect, if desired, can be accomplished by Accordingly, several alternatives to transfusion or directed factor
administering protamine sulfate. Protamine should be given with therapy (e.g., recombinant activated factor VII [rVIIa]) have been
caution, however, because it has been reported to induce a hy- developed for use in this population.
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1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 4 BLEEDING AND TRANSFUSION — 5
INCREASED INR,
degree of cerebral atrophy as a result of one of the more frequent
NORMAL aPTT
causes of cirrhosis—namely, alcoholism. As a result, the bridging
An increased INR in as- intracranial veins are more vulnerable to tears and more likely to
sociation with a normal bleed. Modest elevations of the INR in patients who are not ac-
aPTT is a more ominous tively bleeding, have not recently undergone operation, and are
finding in a patient with a not specifically at increased risk for life-threatening hemorrhage
coagulopathy. Any of a may be observed without correction.
number of causes, all cen- An elevated INR with a normal aPTT may also be a conse-
tering on factor deficiency, quence of warfarin administration. Such a coagulopathy is the re-
may be responsible. sult of a pure factor deficiency, and its degree is proportional to
Cirrhosis is arguably the most serious of the causes of an ele- the prolongation of the INR. Because warfarin acts by disrupting
vated INR. It is a major problem not so much because of the co- vitamin K metabolism, the coagulopathy may be corrected by giv-
agulopathy itself but because of the associated deficits in wound ing vitamin K [see Table 2].12 If the patient is actively bleeding, vi-
healing and immune function that result from the synthetic dys- tamin K should still be given, but the primary corrective measure
function and the loss of reticuloendothelial function. In all cases, should be to administer FFP in an amount proportional to the
factor replacement should be instituted with FFP. If the bleeding patient’s size and the relative increase in the INR. The INR
is a manifestation of the cirrhosis (as in variceal bleeding), emer- should subsequently be rechecked to ensure that replacement
gency portal decompression should be accomplished before the therapy is adequate.Vitamin K replacement therapy has two main
coagulopathy worsens. Management of cirrhotic patients who potential drawbacks: (1) if the patient is to be reanticoagulated
have sustained injuries is particularly troublesome because such with warfarin in the near future, dosing will be difficult because
patients are at disproportionately high risk for subdural hema- the patient will exhibit resistance to warfarin for a variable period;
toma. The reason this risk is so high is that in addition to their and (2) anaphylactic reactions have been reported when vitamin
pathologic autoanticoagulation, these patients often have some K is given I.V.
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1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 4 BLEEDING AND TRANSFUSION — 6
Table 2 Management of the Patient should be continued until the coagulation parameters are corrected
with an Increased INR12 and the bleeding stops.
DIC is a diffuse, disorganized activation of the clotting cascade
Indication Recommended Treatment within the vascular space. It may result either from intravascular
presentation of an overwhelming clotting stimulus (e.g., massive
INR above therapeutic range If no bleeding is present or surgery is crush injury or transfusion reaction) or from presentation of a mod-
but < 5.0 indicated, lower or hold next dose erate clotting stimulus in the context of shock. Different degrees of
INR > 5.0 but < 9.0 severity have been described. In the mildest form of DIC, accelera-
Patient has no significant In the absence of additional risk factors tion of the clotting cascade is seen, and microthrombi are formed in
bleeding for bleeding, withhold next 1–2 doses; the vascular space but are cleared effectively.Thus, mild DIC may
alternatively, withhold next dose and
give vitamin K, 1.0–2.5 mg (oral route
be little more than an acceleration of the clotting cascade that es-
is acceptable) capes recognition. In the moderate form of DIC, the microthrombi
Rapid reduction of INR Give vitamin K, 2.0–4.0 mg p.o.; expected are ineffectively lysed and cause occlusion of the microcirculation.
is required reduction of INR should occur within 24 hr This process is clinically manifested in the lungs as the acute respi-
ratory distress syndrome (ARDS), in the kidneys as renal failure,
INR > 9.0
Patient has no significant Give vitamin K, 3.0–5.0 mg p.o.; expected
and in the liver as hepatic failure.
bleeding reduction of INR should occur within 24 hr Neither mild DIC nor moderate DIC is what surgeons tradition-
Patient has serious bleeding Give vitamin K, 10 mg I.V., and FFP; further ally think of as DIC. Severe DIC arises when congestion of the mi-
or is overly anticoagulated vitamin K supplementation may be crovasculature with thrombi occurs, resulting in large-scale activa-
(INR > 20.0) required every 12 hr
tion of the fibrinolytic system to restore circulation.This fibrinolytic
Patient has life-threatening Prothrombin complexes may be indicated,
bleeding or is seriously along with vitamin K, 10 mg I.V. activity results in breakdown of clot at previously hemostatic sites of
overanticoagulated microscopic injury (e.g., endothelial damage) and macroscopic in-
jury (e.g., I.V. catheter sites, fractures, or surgical wounds). Bleed-
INCREASED INR,
ing and reexposure to tissue factor stimulate activation of factor VII
PROLONGED aPTT
with increased coagulation activity; thus, microthrombi are formed,
and the vicious circle continues.The ultimate manifestation of se-
Increases in both the INR vere DIC is bleeding from (1) fibrinolysis and (2) depletion (con-
and the aPTT may be the sumption) of coagulation factors.
most problematic finding of Several scoring systems have been devised to assess the severity
all. When both assays show of DIC. These scoring systems are most useful for distinguishing
increases, the patient is likely DIC from other causes of coagulopathy (e.g., hypothermia, dilu-
to have multiple factor defi- tion, or drug effects) [see Table 3].15
ciencies; possible causes in- DIC is a diagnosis of exclusion, largely because none of the vari-
clude DIC, severe hemodilution, and renal failure with severe ous treatment strategies tried to date have been particularly success-
nephrotic syndrome. However, when dramatic elevations of the ful. Heparin has been given in large doses in an attempt to break the
aPTT and the INR are observed in a seemingly asymptomatic pa- cycle by stopping the clotting, thus allowing clotting factor levels to
tient, the problem may lie not in the patient’s condition but in the return to normal. Antifibrinolytic agents (e.g., ε-aminocaproic acid)
laboratory analysis. If the tube in which the blood sample was placed have also been tried in an attempt to reduce fibrinolytic activity and
for these tests was not adequately filled, the results of the coagulation thus slow the bleeding that stimulates subsequent clot formation.
assays may be inaccurate. In such cases, the blood sample should be Antithrombotics (e.g., antithrombin and protein C) have been used
redrawn and the tests repeated. as well; improvements have been noted in laboratory measures of
Hemodilution and nephrotic syndrome result in a coagulopathy DIC but not in survival.
that is attributable to decreased concentration of coagulation pro- Currently, the most appropriate way of treating a patient with se-
teins. Dilutional coagulopathy may occur when a patient who is giv- vere DIC is to follow a multifaceted approach. First, the clotting
en a large volume of packed red blood cell (RBC) units is not also stimulus, if still present, should be removed: dead or devitalized tis-
given coagulation factors.13 Because of the tremendous redundan- sue should be amputated, abscesses drained, and suspect transfu-
cy of the hemostatic process, pure dilutional coagulopathy is rare. It sions discontinued. Second, hypothermia, of any degree of severity,
is considered an unlikely diagnosis until after one full blood volume should be corrected. Third, both blood loss (as measured by the
has been replaced (as when a patient requires 10 units of packed hematocrit) and clotting factor deficits (as measured by the INR)
RBCs to maintain a stable hematocrit). Nephrotic syndrome is as- should be aggressively corrected (with blood and plasma, respec-
sociated with loss of protein (coagulation proteins as well as other
body proteins) from the kidneys. Table 3 Coagulopathy (DIC) Score
Both hemodilution and nephrotic syndrome should be distin-
guished from DIC (which is a consumptive rather than a dilutional INR aPTT Platelets Fibrinogen D-dimer
process14), though on occasion this distinction is a difficult one to Score (sec) (sec) (1,000/mm3) (mg/dl) (ng/ml)
make. A blood sample should be sent for D-dimer assay. If the D-
dimer level is low (< 1,000 ng/ml), DIC is unlikely; if it is very high 0 < 1.2 < 34 > 150 > 200 < 1,000
(> 2,000 ng/ml) and there is no other clear explanation (e.g., a com- 1 > 1.2 > 34 < 150 < 200 < 2,000
plex unstable pelvic fracture), the diagnosis of DIC rather than dilu- 2 > 1.4 > 39 < 100 < 150 < 4,000
tion should be made.Treatment of dilutional coagulopathy should 3 > 1.6 > 54 < 60 < 100 > 4,000
be directed at replacement of lost factors. FFP should be given first, DIC—disseminated intravascular coagulopathy INR—international normalized
followed by cryoprecipitate, calcium, and platelets. Transfusion ratio aPTT—activated partial thromboplastin
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 4 BLEEDING AND TRANSFUSION — 7
Patients who are actively bleeding (e.g., those with GI hemor- An additional indication for transfusion is oxygen-carrying capac-
rhage) should receive transfusions up to a level sufficient to keep up ity that is insufficient to support necessary activities (e.g., wound
with blood loss. Coagulation factors must also be replaced as nec- healing, mobilization, and physical therapy).Typical manifestations
essary [see Measurement of Coagulation Parameters, Increased are light-headedness, tachycardia, and tachypnea either during the
INR, Prolonged aPTT, above]. Patients at high risk for active bleed- activity in question or at rest. Clearly, some degree of tachycardia is
ing (e.g., from massive liver injury) should receive transfusions up to be expected in any patient who has undergone a major operation
to a level at which, if bleeding occurs or recurs, enough reserve oxy- or sustained a serious injury.The key point with respect to sympto-
gen-carrying capacity is afforded to allow diagnosis and correction matic anemia is that patients who have physiologically compensat-
of the hemorrhage without significant compromise of oxygen deliv- ed for anemia must be distinguished from those whose health or re-
ery. In cases of major injury, we advocate a target hematocrit of covery is compromised by anemia, and only the latter group should
30%; however, this is not a fixed value but a rule-of-thumb figure receive transfusions.
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1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 4 BLEEDING AND TRANSFUSION — 8
Table 4 Blood Substitutes 81 decrease oxygen demand. Oxygen demand is directly proportional
to metabolic activity; that is, as metabolic rate increases, so too does
Product (Manufacturer) Source oxygen demand. Once unnecessary activity (e.g., assuming an up-
right posture or walking) has been eliminated, respiration becomes
PHP (Apex Bioscience) Pyridoxylated human hemoglobin conjugated an activity that requires a significant amount of energy. Mechanical
to polyoxyethylene
ventilation reduces the work of breathing and with it the oxygen re-
PEG-hemoglobin (Enzon) Bovine hemoglobin conjugated to quirements of the respiratory muscles. Even with full mechanical
polyethylene glycol ventilation, however, most patients continue to initiate breaths on
PolyHeme (Northfield Glutaraldehyde-polymerized pyridoxylated their own. This energy-requiring activity can be eliminated by ad-
Laboratories) human hemoglobin ministering a neuromuscular blocking agent, which dramatically re-
duces oxygen demand in essentially all skeletal muscle.The meta-
Glutaraldehyde-polymerized bovine
Hemopure (Biopure) hemoglobin bolic rate can be further reduced by inducing hypothermia. This
measure should be used with caution, however, because hypother-
Oxidized raffinose–crosslinked human mia in the absence of neuromuscular blockade results in uncontrol-
Hemolink (Hemosol) hemoglobin from expired stored blood
lable shivering, which actually increases the metabolic rate. In addi-
Oxygent (Alliance Emulsified perflubron
tion, trials addressing the use of hypothermia in head injury patients
Pharmaceutical) to reduce cerebral oxygen demand reported increased infection rates
in the hypothermic groups.
A completely different approach to the issue of the unacceptabil-
OBSERVATION OF ANEMIA
ity or unavailability of RBC transfusion involves the use of RBC
It has become standard practice to observe patients with low he- substitutes to augment oxygen-carrying capacity. A variety of differ-
moglobin concentrations that in the past would have triggered trans- ent substitutes are currently under investigation [see Table 4].18 None
fusion.The data currently available support this approach down to a have been approved for routine use by the United States Food and
hemoglobin concentration of 6 to 7 g/dl; below 6 g/dl, the data are Drug Administration, but several have demonstrated promise in
not sufficient to support observation alone. clinical trials. Without modification, the hemoglobin molecule is
There does come a hemoglobin level below which life is not pos- nephrotoxic. Accordingly, virtually all of the products now being
sible. Certain religions prohibit blood transfusion even when death studied depend on techniques for making an acellular hemoglobin
is the probable or certain consequence. Such prohibitions have molecule nontoxic for I.V. administration.
challenged the medical community to find techniques for support- Acellular blood substitutes clearly possess a number of advan-
ing life at lower and lower hemoglobin concentrations. In addition, tages, including greatly increased shelf life, reduced risk of viral
they have helped to define the limits beyond which a restrictive transmission, availability that is not limited by donor supply, re-
transfusion protocol may be fatal. duced or eliminated risk of incompatibility reactions, and—poten-
When RBC transfusion is not possible (whether for cultural rea- tially, at least—reduced cultural and religious objections.19 To what
sons or because compatible blood is unavailable), there are a num- extent this approach is suited to the treatment of anemia in surgical
ber of temporizing measures that can be used to support life. If oxy- patients should be clarified when the results of the trials now under
gen-carrying capacity cannot be increased, one option is simply to way are published.18
Discussion
Mechanics of Hemostasis CELLULAR COMPONENTS
Hemostasis is the term for the process by which cellular and plas-
Endothelium
ma components interact in response to vessel injury in order to
maintain vascular integrity and promote wound healing.The initial The endothelium has both procoagulant and anticoagulant
response to vascular injury (primary hemostasis) involves the re- properties.When vascular injury occurs, the endothelium serves as
cruitment and activation of platelets, which then adhere to the site of a nidus for recruitment of platelets, adhesion of platelets to the en-
injury. Subsequently, plasma proteins, in concert with cellular com- dothelial surface, platelet aggregation, migration of platelets across
ponents, begin to generate thrombin, which causes further activa- the endothelial surface, generation of fibrin, and expression of ad-
tion of platelets and converts fibrinogen to fibrin monomers that hesion molecule receptors (E-selectin and P-selectin). Exposure of
polymerize into a fibrin clot. The final step is the release of plas- collagen fibrils and release of vWF from the Weibel-Palade bodies
minogen activators that induce clot lysis and tissue repair. cause platelets to adhere to the cellular surface of the endothelium.
The cellular components of hemostasis include endothelium, The presence of interleukin-1β (IL-1β), tissue necrosis factor
white blood cells (WBCs), RBCs, and platelets.The plasma compo- (TNF), interferon-8 (IFN-8), and thrombin promotes expression
nents include a number of procoagulant and regulatory proteins of tissue factor (TF) on the endothelium.20,21 TF activates factors X
that, once activated, can accelerate or downregulate thrombin for- and VII, and these activated factors generate additional thrombin,
mation or clot lysis to facilitate wound healing. In normal individu- which increases both fibrin formation and platelet aggregation.
als, these hemostatic components are in a regulatory balance; thus, The endothelium also acts in numerous ways to downregulate co-
any abnormality involving one or more of these components can re- agulation.22 Heparan sulfate and thrombomodulin are both down-
sult in a pathologic state, whether of uncontrolled clot formation regulators of thrombin formation. In the presence of thrombin, the
(thrombosis) or of excessive bleeding (hemorrhage).These patholo- endothelium responds by (1) releasing thrombomodulin, which
gies can result from either hereditary defects of protein synthesis or forms a complex with thrombin to activate protein C; (2) producing
acquired deficiencies attributable to metabolic causes. endothelium-derived relaxing factor (i.e., nitric oxide23) and prosta-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 4 BLEEDING AND TRANSFUSION — 9
cyclin, which have vasodilating and platelet aggregation–inhibiting ef- two is that the intrinsic pathway requires no extravascular source for
fects, respectively; and (3) releasing tissue plasminogen activator (t-PA) initiation, whereas the extrinsic pathway requires an extravascular
or urokinase-type plasminogen activator (u-PA), either of which con- component (i.e., TF). This traditional depiction is useful in inter-
verts the zymogen plasminogen to an active form (i.e., plasmin) that preting coagulation tests, but it is not an accurate reflection of the
degrades fibrin and fibrinogen.20,24 Heparan sulfate, on the endothe- hemostatic process in vivo. Accordingly, our focus is not on this stan-
lium wall, forms a complex with plasma antithrombin to neutralize dard view but rather on the roles contact factors (within the intrinsic
thrombin.The endothelium is also the source of tissue factor pathway cascade) and TF play in coagulation. As noted, circulating plasma
inhibitor (TFPI), which downregulates TF-VIIa-Xa complexes. vWF is necessary for normal adhesion of platelets to the endotheli-
um. Plasma vWF also serves as the carrier protein for factor VIII,
Erythrocytes and Leukocytes preventing its neutralization by the protein C regulatory pathway.
The nonplatelet cellular components of blood play indirect roles Even in patients in whom laboratory tests strongly suggest a se-
in hemostasis. RBCs contain thromboplastins that are potent stimu- vere clotting abnormality (i.e., the aPTT is markedly prolonged),
lators of various procoagulant proteins. In addition, the concentra- contact factors do not play a significant role in the generation of
tion of RBCs within the bloodstream (expressed as the hematocrit) thrombin. However, contact factor activation does appear to play
assists in primary hemostasis by physically forcing the platelets to- secondary roles that are essential to normal hemostasis and tissue
ward the endothelial surfaces.When the RBC count is low enough, repair. Factor XII, prekallikrein, and high-molecular-weight kinino-
the absence of this force results in inadequate endothelium-platelet gen are bound to the endothelium to activate the bradykinin (BK)
interaction and a bleeding diathesis. pathway.The BK pathway exerts profibrinolytic effects by stimu-
Leukocytes have several functions in the hemostatic process.The lating endothelial release of plasminogen activators. It also stimu-
interaction between the adhesion molecules expressed on both leu- lates endothelial production of nitric oxide and prostacyclin, which
kocytes and endothelium results in cytokine production, initiation of play vital regulatory roles in vasodilation and regulation of platelet
inflammatory responses, and degradation of extracellular matrix to activation.29
facilitate tissue healing. In the presence of thrombin, monocytes ex- The key initiator of plasma procoagulant formation is the expres-
press TF, which is an integral procoagulant for thrombin generation. sion of TF on cell surfaces.21,30 TF activates factor VII and binds
Neutrophils and activated monocytes bind to stimulated platelets with it to form the TF-VIIa complex, which activates factors X and
and endothelial cells that express P-selectin. Adhesion and rolling of IX. Factor Xa also enhances its own production by activating factor
neutrophils, mediated by fibrinogen and selectins on the endotheli- IX, which in turn activates factor X to form factor Xa. Factor Xa
um, appear to facilitate vessel integrity but may also lead to inflam- also produces minimal amounts of thrombin by cleaving the pro-
matory responses.25,26 Lymphocytes also adhere to endothelium via thrombin molecule. The thrombin generated from this process
adhesion molecule receptors and appear to be responsible for cy- cleaves the coagulation cofactors V and VIII to enhance production
tokine production and inflammatory responses. of the factor complexes IX-VIIIa (intrinsic tenase) and Xa-Va (pro-
thrombinase), which catalyze conversion of prothrombin to throm-
Platelets bin [see Figure 2].31
The roles platelets play in hemostasis and subsequent fibrin for- Thrombin has numerous functions, including prothrombotic
mation rest on providing a phospholipid surface for localizing pro- and regulatory functions. Its procoagulant properties include cleav-
coagulant activation. Activation of platelets by agonists such as ing fibrinogen, activating the coagulation cofactors V and VIII, in-
adenosine triphosphate (ATP), adenosine diphosphate (ADP), epi- ducing platelet aggregation, inducing expression of TF on cell sur-
nephrine, thromboxane A2 , collagen, and thrombin causes platelets faces, and activating factor XIII. In cleaving fibrinogen, thrombin
to undergo morphologic changes and degranulation. Degranulation causes the release of fibrinopeptides A and B (fibrin monomer).
of platelets results in the release of procoagulants that promote fur- The fibrin monomer undergoes conformational changes that ex-
ther platelet adhesion and aggregation (e.g., thrombospondin, vWF, pose the α and β chains of the molecule, which then polymerize
fibrinogen, ADP, and ATP), vasodilation (e.g., serotonin), and sur- with other fibrin monomers to form a fibrin mesh. Activated factor
face expression of P-selectin, which induces cellular adhesion. Plate- XIII cross-links the polymerized fibrin (between the α chains and
let degranulation also results in the release of β-thromboglobulin, the γ chains) to stabilize the fibrin clot and delay fibrinolysis.
platelet factor 4 (which has antiheparin properties), various growth
factors, coagulation procoagulants, and calcium as well as the for- Fibrin(ogen)olysis
mation of platelet microparticles. Plasminogen activator inhibitor–I Plasminogen is the primary fibrinolytic zymogen that circulates in
(PAI-I) released from degranulated platelets neutralizes the fibri- plasma. In the presence of t-PA or u-PA (released from the endothe-
nolytic pathway by forming a complex with t-PA. lium), plasminogen is converted to the active form, plasmin. Plasmin
Upon exposure to vascular injury, platelets adhere to the exposed cleaves fibrin (or fibrinogen) between the molecule’s D and E do-
endothelium via binding of vWF to the GPIb-IX-V complex.27 mains, causing the formation of X,Y, D, and E fragments.The sec-
Conformational changes in the GPIIb-IIIa complex on the activated ondary function of the fibrinolytic pathway is the activation by u-PA
platelet surface enhance fibrinogen binding, which results in of matrix metalloproteinases that degrade the extracellular matrix.32
platelet-to-platelet interaction (i.e., aggregation).The phospholipid
surface of the platelet membranes anchors activated IXa-VIIIa and Regulatory Factors
Xa-Va complexes, thereby localizing thrombin generation.28 In persons with normal coagulation status, downregulation of
hemostasis occurs simultaneously with the production of procoagu-
PLASMA COMPONENTS lants (e.g., activated plasma factors, stimulated endothelium, and
stimulated platelets). In addition to their procoagulant activity, both
Procoagulants
thrombin and contact factors stimulate downregulation of the coag-
Traditional diagrams of the coagulation cascade depict two dis- ulation process. Thrombin forms a complex with endothelium-
tinct pathways for thrombin generation: the intrinsic pathway and bound thrombomodulin to activate protein C, which inhibits factors
the extrinsic pathway.The premise for the distinction between the Va and VIIIa. The thrombin-thrombomodulin complex also regu-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 4 BLEEDING AND TRANSFUSION — 10
VII VIII
Platelet TF
Aggregation VIIIa
IXa
XIIIa V
VIII IXa AT
AT
TF-VIIa Va aPC
AT Xa
V
XIII TFPI Thrombomodulin
VIIIa PS
IX X
PC
Thrombin Thrombin
IXa Xa
Xa
Va
Fibrinogen Va AT
II II
Platelet
lates the fibrinolytic pathway by activating a circulating plasma pro- sickle-cell anemia) have been reported to lead to thrombosis, but
tein known as thrombin-activatable fibrinolysis inhibitor (TAFI), usually not to major bleeding.
which appears to suppress conversion of plasminogen to plasmin.33 Inherited platelet membrane receptor defects are relatively com-
Contact factors are known to be required for normal surface-depen- mon. Of these, vWD is the one that most frequently causes bleeding.40
dent fibrinolysis, and there is some evidence that contact factor defi- The condition is characterized by vWF abnormalities, which may
ciencies can lead to thromboembolism. Another plasma protein re- take three forms: vWF may be present in a reduced concentration
sponsible for regulation of fibrinolysis is α2-antiplasmin, which binds (type I vWD), dysfunctional (type II vWD), or absent altogether
to circulating and bound plasmin to limit breakdown of fibrin. (type III). Diagnosis of vWD is based on a combination of the patient
Circulating downregulating proteins include antithrombin (a history (e.g., previous mucosal bleeding) and laboratory parameters
serine protease inhibitor of activated factors—especially factors [see Laboratory Assessment of Bleeding, below]. It is necessary to
IXa, Xa, and XIa—and thrombin31), proteins C and S (regulators identify the correct type or subtype of vWD: some treatments (e.g.,
of factors VIIIa and Va34), C1 inhibitor (a regulator of factor XIa), DDAVP) are contraindicated in patients with type IIb vWD.41
TFPI (a regulator of the TF-VIIa-Xa complex35), and α2-macro- Less common receptor defects include Glanzmann thrombas-
globulin (a thrombin inhibitor—the primary thrombin inhibitor in thenia (a defect in the GPIIb-IIIa complex), Bernard-Soulier syn-
neonates36). Limitation of platelet activation occurs secondarily as a drome (a defect in the GPIb-IX complex), and Scott syndrome (a
result of decreased levels of circulating agonists and endothelial re- defect in the platelet’s activated surface that promotes thrombin
lease of prostacyclin [see Figure 2]. formation); other agonist receptors on the platelet membrane may
be affected as well.42,43 Intracellular platelet defects are relatively
rare but do occur; examples are gray platelet syndromes (e.g., alpha
Bleeding Disorders granule defects), Hermansky-Pudlak syndrome, dense granule de-
fects,Wiskott-Aldrich syndrome, and various defects in intracellular
INHERITED COAGULOPATHIES
production and signaling (involving defects of cyclooxygenase syn-
Numerous congenital abnormalities of the coagulation system have thase and phospholipase C, respectively).43
been identified. In particular, various abnormalities involving plasma Numerous pathologic states are also associated with deficiencies
proteins (e.g., hemophilia and vWD), platelet receptors (e.g., Glanz- or defects of plasma procoagulants. Inherited sex-linked deficiencies
mann thrombasthenia and Bernard-Soulier syndrome), and en- of factor VIII (i.e., hemophilia A) and factor IX (i.e., hemophilia B
dothelium (e.g., telangiectasia) have been described in detail. For the and Christmas disease) are relatively common.44-46 The clinical pre-
sake of brevity, we will refer to abnormal protein synthesis resulting in sentations of hemophilia A and hemophilia B are similar: hemar-
a dysfunctional coagulation protein as a defect and to abnormal protein throses are the most common clinical manifestations, ultimately
synthesis resulting in decreased protein production as a deficiency. leading to degenerative joint deformities. Spontaneous bleeding may
Most of the coagulation defects associated with endothelium are also occur, resulting in intracranial hemorrhage, large hematomas in
closely related to thrombosis or atherosclerosis. Defects or deficien- the muscles of extremities, hematuria, and GI bleeding. Factor XI
cies of thrombomodulin,TFPI, and t-PA, albeit rare, are associated deficiency is relatively common in Jewish persons but rarely results
with thrombosis.37,38 Vascular defects (e.g., hemorrhagic telangiec- in spontaneous bleeding.47,48 Such deficiency may result in bleeding
tasias) may carry an increased risk of bleeding as a consequence of after oral operations and trauma; however, there are a number of
dysfunctional fibrinolysis, concomitant platelet dysfunction, or co- major procedures (e.g., cardiac bypass surgery) that do not result in
agulation factor deficiencies.39 postoperative bleeding in this population.49
Defects or deficiencies of RBCs and WBCs have other primary Inherited deficiencies of the other coagulation factors are very
clinical manifestations that are not related to hemostasis. Alter- rare. Factor XIII deficiencies result in delayed postoperative or
ations in the physical properties of blood (e.g., decreased blood posttraumatic bleeding. Congenital deficiencies of factor V, factor
flow from increased viscosity, polycythemia vera, leukocytosis, and VII, factor X, prothrombin, and fibrinogen may become apparent
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 4 BLEEDING AND TRANSFUSION — 11
in the neonatal period (presenting, for example, as umbilical stump bin, but cross-breeding has produced a number of new venoms with
bleeding); later in life, they result in clinical presentations such as different hemostatic consequences.The clinical presentation of co-
epistaxis, intracranial bleeding, GI bleeding, deep and superficial agulopathies associated with snakebites generally mimics that of
bruising, and menorrhagia. consumptive coagulopathies.63
Defects or deficiencies in the fibrinolytic pathway are also rare Drug-induced factor deficiencies are common, particularly as a
and are most commonly associated with thromboembolic events. result of anticoagulant therapy.The most commonly used anticoag-
α2-Antiplasmin deficiencies and primary fibrin(ogen)olysis are rare ulants are heparin and warfarin. Heparin does not cause a factor
congenital coagulopathies with clinical presentations similar to those deficiency; rather, it accelerates production of antithrombin, which
of factor deficiencies. In primary fibrin(ogen)olysis, failure of regula- inhibits factor IXa, factor Xa, and thrombin, thereby prolonging
tion of t-PA and u-PA leads to increases in circulating plasmin levels, clot formation.Warfarin reduces procoagulant potential by inhibit-
which result in rapid degradation of clot and fibrinogen.50,51 ing vitamin K synthesis, thereby reducing carboxylation of factor
VII, factor IX, factor X, prothrombin, and proteins C and S. Newer
ACQUIRED COAGULOPATHIES
drugs that may also cause factor deficiencies include direct thrombin
A wide range of clinical conditions may cause deficiencies of the inhibitors (e.g., lepirudin and bivalirudin64) and fibrinogen-degrad-
primary, secondary, or fibrinolytic pathways. Acquired coagulopa- ing drugs (e.g., ancrod65).
thies are very common, and most do not result in spontaneous Isolated acquired factor deficiencies are relatively rare. Clinically,
bleeding. (DIC is an exception [see below].) they present in exactly the same way as inherited factor deficiencies,
As noted, coagulopathies related to the endothelium are primari- except that there is no history of earlier bleeding. In most cases,
ly associated with thrombosis rather than bleeding.There are a num- there is a secondary disease (e.g., lymphoma or an autoimmune
ber of disorders that may cause vascular injury, including sickle-cell disorder) that results in the development of antibody to a procoag-
anemia, hemolytic-uremic syndrome, and thrombotic thrombocyto- ulant (e.g., factor V, factor VIII, factor IX, vWF, prothrombin, or
penic purpura. fibrinogen).66-68
Acquired platelet abnormalities, both qualitative (i.e., dysfunc-
tion) and quantitative (i.e., decreases in absolute numbers), are com- Disseminated Intravascular Coagulation
mon occurrences. Many acquired thrombocytopathies are attribut- DIC is a complex coagulation process that involves activation of
able to either foods (e.g., fish oils, chocolate, red wine, garlic, and the coagulation system with resultant activation of the fibrinolytic
herbs) or drugs (e.g., aspirin, ibuprofen, other nonsteroidal anti- pathway and deposition of fibrin; the eventual consequence is the
inflammatory drugs, ticlopidine, various antibiotics, certain antihista- multiple organ dysfunction syndrome (MODS).69 The activation
mines, and phenytoin).52-56 Direct anti–platelet receptor drugs (e.g., occurs at all levels (platelets, endothelium, and procoagulants), but it
abciximab and eptifibatide) block the GPIIb-IIIa complex, thereby is not known whether this process is initiated by a local stimulus or a
preventing platelet aggregation.57 Thrombocytopenia can be prima- systemic one. It is crucial to emphasize that DIC is an acquired dis-
ry or secondary to a number of clinical conditions. Primary bone order that occurs secondary to an underlying clinical event (e.g.,
disorders (e.g., myelodysplastic or myelophthisic syndromes) and a complicated birth, severe gram-negative infection, shock, major
spontaneous bleeding may arise when platelet counts fall below head injury, polytrauma, severe burns, or cancer. As noted [see Mea-
10,000/mm3. Thrombocytopenia can be associated with immune surement of Coagulation Parameters, Increased INR, Prolonged
causes (e.g., immune thrombocytopenic purpura or thrombotic aPTT, above], there is some controversy regarding the best approach
thrombocytopenic purpura) or can occur secondary to administra- to therapy, but there is no doubt that treating the underlying cause
tion of drugs (e.g., heparin). Acquired platelet dysfunction (e.g., ac- of DIC is paramount to patient recovery.
quired vWD) that is not related to dietary or pharmacologic causes DIC is not always clinically evident: low-grade DIC may lack
has been observed in patients with immune disorders or cancer. clinical symptoms altogether and manifest itself only through labo-
Acquired plasma factor deficiencies are common as well. Patients ratory abnormalities, even when thrombin generation and fibrin
with severe renal disease typically exhibit platelet dysfunction (from deposition are occurring. In an attempt to facilitate recognition of
excessive amounts of uremic metabolites), factor deficiencies as- DIC, the disorder has been divided into three phases, distinguished
sociated with impaired synthesis or protein loss (as with increased on the basis of clinical and laboratory evidence. In phase I DIC,
urinary excretion), or thrombocytopenia (from diminished throm- there are no clinical symptoms, and the routine screening tests (i.e.,
bopoietin production).58,59 Patients with severe hepatic disease com- INR, aPTT, fibrinogen level, and platelet count) are within normal
monly have impairment of coagulation factor synthesis, increases limits.70 Secondary testing (i.e., measurement of antithrombin, pro-
in circulating levels of paraproteins, and splenic sequestration of thrombin fragment, thrombin-antithrombin complex, and soluble
platelets. fibrin levels) may reveal subtle changes indicative of thrombin gen-
Hemodilution from massive RBC transfusions can occur if more eration. In phase II DIC, there are usually clinical signs of bleeding
than 10 packed RBC units are given within a short period without around wounds, suture sites, I.V. sites, or venous puncture sites,
plasma supplementation. Immunologic reactions to ABO/Rh mis- and decreased function is noted in specific organs (e.g., lung, liver,
matches can induce immune-mediated hypercoagulation. Acquired and kidneys). The INR is increased, the aPTT is prolonged, and
multifactorial deficiencies associated with extracorporeal circuits the fibrinogen level and platelet count are decreased or decreasing.
(e.g., cardiopulmonary bypass, hemodialysis, and continuous ven- Other markers of thrombin generation and fibrinolysis (e.g., D-
ovenous dialysis) can arise as a consequence of hemodilution of dimer level) show sizable elevations. In phase III DIC, MODS is
circuit priming fluid or activation of procoagulants after exposure observed, the INR and the aPTT are markedly increased, and fib-
to thrombogenic surfaces.60-62 Thrombocytopenia can result from rinogen and D-dimer levels are markedly depressed. A peripheral
platelet destruction and activation caused by circuit membrane ex- blood smear would show large numbers of schistocytes, indicating
posure, or it can be secondary to the presence of heparin antibody. RBC shearing resulting from fibrin deposition.
Animal venoms can be either procoagulant or prothrombotic. The activation of the coagulation system seen in DIC appears to
The majority of the poisonous snakes in the United States (rattle- be primarily caused by TF. The brain, the placenta, and solid tu-
snakes in particular) have venom that works by activating prothrom- mors are all rich sources of TF. Gram-negative endotoxins also in-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 4 BLEEDING AND TRANSFUSION — 12
Table 5 Tests of Platelet Function The CBC (including platelet count and differential count), the
INR, and the aPTT tests should be the primary laboratory tests for
Product (Manufacturer) Method differentiating coagulopathies [see Figure 3].
Platelet count and platelet function should be considered as inde-
Measures time required to occlude pendent values [see Figure 4]. Patients with congenital thrombocy-
PFA-100 (Dade Behring) aperture after exposure to platelet
agonists at shear rates topathies often have normal platelet counts; therefore, assessment of
platelet function is required as well. Historically, the bleeding time
hemoSTATUS (Medtronic) Measures activated clotting time; platelet- has been used to assess platelet function.This test is grossly inade-
activating factor is the platelet agonist
quate, in that it may yield normal results in as many as 50% of
AggreStat (Centocor)
Measures changes in voltage (impedance) patients with congenital thrombocytopathies.72,73 Numerous rapid
after addition of platelet agonist
tests of platelet function are currently available that can be used to
Thromboelastograph Measures changes in the viscoelastic screen for platelet defects; these tests can and should be included in
(Haemascope) properties of clotting blood induced by the diagnostic approach to the bleeding patient [see Table 5].73-75
a rotating piston
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16. Weitzel JN, Sadowski JA, Furie BC, et al: Surrepti- 37. Juhan-Vague I,Valadier J, Alessi MC, et al: Deficient haemostasis during major orthopaedic surgery. Br J
tious ingestion of a long-acting vitamin K antagonist/ tPA release and elevated PA inhibitor levels on patients Anaesth 82:503, 1999
rodenticide, brodifacoum: clinical and metabolic stud- with spontaneous recurrent DVT. Thromb Haemost
57:67, 1987 62. Konrad C, Markl T, Schuepfer G, et al:The effects of
ies of three cases. Blood 76:2555, 1990 in vitro hemodilution with gelatin, hydroxyethyl starch,
17. Hébert PC, Wells G, Blajchman MA, et al: A multi- 38. Korninger C, Lechner K, Niessner H, et al: Impaired and lactated Ringer’s solution on markers of coagula-
center, randomized, controlled clinical trial of trans- fibrinolytic capacity predisposes for recurrence of ve- tion: an analysis using SONOCLOT. Anesth Analg
fusion requirements in critical care. Transfusion Re- nous thrombosis.Thromb Haemost 52:127, 1984 88:483, 1999
quirements in Critical Care Investigators, Canadian 39. Shovlin CL: Molecular defects in rare bleeding disor- 63. Boyer LV, Seifert SA, Clark RF, et al: Recurrent and
Critical Care Trials Group. N Engl J Med 340:409, ders: hereditary hemorrhagic telangiectasia. Thromb persistent coagulopathy following pit viper envenoma-
1999 Haemost 78:145, 1997 tion. Arch Intern Med 159:706, 1999
18. Maxwell RA, Gibson JB, Fabian TC, et al: Resuscita- 40. Sadler JE, Mannucci PM, Berntop E, et al: Impact, di- 64. Eriksson BI, Kalebo P, Ekman S, et al: Direct throm-
tion of severe chest trauma with four different hemo- agnosis, and treatment of von Willebrand’s disease. bin inhibition with rec-hirudin CGP 39393 as pro-
globin-based oxygen-carrying solutions. J Trauma 49: Thromb Haemost 84:160, 2000 phylaxis of thromboembolic complications after total
200, 2000 41. Mannucci PM: Desmopressin: a nontransfusional hip replacement.Thromb Haemost 72:227, 1994
19. Creteur J, Sibbald W, Vincent JL: Hemoglobin solu- form of treatment for congenital and acquired bleed- 65. Sherman DG, Atkinson RP, Chippendale T, et al:
tions—not just red blood cell substitutes. Crit Care ing disorders. Blood 72:1449, 1988 Intravenous ancrod for treatment of acute ischemic
Med 28:3025, 2000 42. Weiss HJ: Congenital disorders of platelet function. stroke: the STAT study: a randomized controlled trial.
20. Mantovani A, Sozzani S,Vecchi A, et al: Cytokine acti- Semin Thromb Hemost 17:228, 1980 Stroke Treatment with Ancrod Trial. JAMA 282:
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1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 4 BLEEDING AND TRANSFUSION — 15
2395, 2000 factor deficiencies. Clin Lab Haematol 20:179, 1998 78. Jeroukhimov I, Jewelewicz D, Zaias J, et al: Early injec-
66. Oleksowicz L, Bhagwati N, DeLeon-Fernandez M: 72. Lind SE:The bleeding time does not predict surgical tion of high-dose recombinant factor VIIa decreases
Deficient activity of von Willebrand’s factor-cleaving bleeding. Blood 77:2547, 1991 blood loss and prolongs time from injury to death in
protease in patients with disseminated malignancies. experimental liver injury. J Trauma 53:1053, 2002
73. Mammen EF, Comp PC, Gosselin R, et al: PFA-
Cancer Res 59:2244, 1999 79. Schreiber MA, Holcomb JB, Hedner U, et al:The ef-
100™ System: A new method for assessment of plate-
fect of recombinant factor VIIa on noncoagulopathic
67. Francis JL, Biggerstaff J, Amirkhosravi A: Hemostasis let dysfunction. Semin Thromb Hemost 24:195, 1998
pigs with grade V liver injuries. J Am Coll Surg
and malignancy. Semin Thromb Hemost 24:93, 1998 74. Speiss BD: Coagulation function in the operating 196:691, 2003
68. Amirkhosravi M, Francis JL: Coagulation activation room. Anesth Clin North Am 8:481, 1990
80. Cartmill M, Dolan G, Byrne JL, et al: Prothrombin
by MC28 fibrosarcoma cells facilitates lung tumor for- 75. LeForce WR, Bruno DS, Kanot WP, et al: Evaluation complex concentrate for oral anticoagulant reversal in
mation.Thromb Haemost 73:59, 1995 of the Sonoclot analyzer for the measurement of plate- neurosurgical emergencies. Br J Neurosurg 14:458,
69. Williams EC, Moshen DF: Disseminated intravas- let function in whole blood. Am Clin Lab Sci 22:30, 2000
cular coagulation. Hematology: Basic Principles and 1992
81. Winslow RM: Blood substitutes. Adv Drug Deliv Rev
Practice. Hoffman R, Benz EJ Sr, Shattil SJ, et al, Eds. 76. Martinowitz U, Kenet G, Segal E, et al: Recombinant 40:131, 2000
Churchill-Livingstone, New York, 1995, p 1758 activated factor VII for adjunctive hemorrhage control
70. Muller-Berghaus G, ten Cate H, Levi M: Dissemi- in trauma. J Trauma 51:431, 2001
nated intravascular coagulation: clinical spectrum and 77. Lynn M, Jerokhimov I, Jewelewicz D, et al: Early use
established as well as new diagnostic approaches. of recombinant factor VIIa improves mean arterial Acknowledgments
Thromb Haemost 82:706, 1999 pressure and may potentially decrease mortality in ex-
71. Lawrie AS, Kitchen S, Purdy G, et al: Assessment of perimental hemorrhagic shock: a pilot study. J Trauma Figures 1, 3, and 4 Marcia Kammerer.
Actin FS and Actin FSL sensitivity to specific clotting 52:703, 2002 Figure 2 Seward Hung.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE PAIN — 1
5 POSTOPERATIVE PAIN
Henrik Kehlet, M.D., Ph.D., F.A.C.S. (Hon.)
Thoracic Abdominal
Give systemic opioids with Give epidural local Give epidural local Give incisional/
NSAIDs. anesthetic–opioid combination anesthetic–opioid intraperitoneal local
with systemic NSAIDs or combination (add NSAIDs anesthetic with
Consider epidural or COX-2 inhibitors if
COX-2 inhibitors. systemic NSAIDs or
local anesthetic–opioid analgesia is insufficient).
If this combination is not COX-2 inhibitors.
combination If this combination is not
available, give systemic
opioids with NSAIDs or available, give systemic
COX-2 inhibitors. opioids with NSAIDs or
Consider cryoanalgesia. COX-2 inhibitors.
Gynecologic
Peripheral
Give epidural local anesthetics Give incisional local anesthetic Give intrathecal local anesthetic
with systemic NSAIDs and systemic opioids with plus morphine and systemic
or NSAIDs or COX-2 inhibitors. NSAIDs or COX-2 inhibitors
Give systemic opioids with Consider peripheral nerve or
NSAIDs. blockade.
Give a peripheral nerve block
(single dose or continuous)
with systemic NSAIDs or
COX-2 inhibitors.
Consider continuous epidural
local anesthetic–opioid
combination in high-risk patients
Prostatectomy with systemic NSAIDs.
given to obtain the documented synergistic-additive effect. Cryo- morphine combination will provide effective analgesia for the
analgesia is useful because it is moderately effective, easy to per- first 8 to 16 hours, after which NSAIDs or COX-2 inhibitors may
form, free of significant side effects, and relatively inexpensive. be added. The use of peripheral nerve blocks is gaining more
Paravertebral blocks are also effective but necessitate continuous popularity and may be continued postoperatively.15,16 Acetamin-
infusion. Acetaminophen is recommended as a basic analgesic ophen is provided as a basic analgesic for multimodal analgesia.
for multimodal analgesia. After arthroscopic joint procedures, instillation of a local anes-
Pain after cardiac operation with sternotomy is less severe, and thetic and an opioid analgesic (e.g., morphine) provides effective
systemic opioids plus NSAIDs are recommended. The combined early postoperative pain relief.
regimen of epidural local anesthetics and opioids is recommended During superficial procedures, systemic opioids combined with
when more effective pain relief is necessary, and it may reduce car- NSAIDs or COX-2 inhibitors should suffice. Acetaminophen is
diopulmonary morbidity.13 provided as a basic analgesic for multimodal analgesia.
ABDOMINAL
PROCEDURES Treatment Modalities
Pain after major and up-
PSYCHOLOGICAL
per abdominal operations is
INTERVENTIONS
severe, and a combined reg-
imen of epidural local anes- Individuals differ consid-
thetics and opioids is rec- erably in how they respond
ommended because it has to noxious stimuli; much of
proved to be very effective and to have few and acceptable side ef- this variance is accounted
fects.11,12,14 Furthermore, the epidural regimen will reduce postop- for by psychological factors. Cognitive, behavioral, or social inter-
erative pulmonary complications and ileus, as compared with treat- ventions should be used in combination with pharmacologic ther-
ment with systemic opioids. Systemic NSAIDs or COX-2 inhibitors apies to prevent or control acute pain, with the goal of such inter-
are added when needed. Acetaminophen is recommended as a ventions being to guide the patient toward partial or complete self-
basic analgesic for multimodal analgesia. control of pain.17,18 Sophisticated psychological techniques, such
After gynecologic operations,12 systemic opioids plus NSAIDs or as biofeedback and hypnosis therapy, are not applicable to a busy
COX-2 inhibitors are recommended except in patients in whom surgical unit, but simple psychological techniques are a valuable
more effective pain relief is desirable. In such patients, the combined part of good medical practice.
regimen of epidural local anesthetics and opioids is preferable. Acet- Psychological preparation in patients with postoperative pain
aminophen is recommended as a basic analgesic for multimodal has been demonstrated to shorten hospital stay and reduce post-
analgesia. operative narcotic use [see Table 2].19 Psychological techniques
Pain following prostatectomy is usually not severe and may be should be combined with pharmacologic or other interventions,
treated with systemic opioids combined with NSAIDs or COX-2 but care must be taken to ensure that the pharmacologic treat-
inhibitors and acetaminophen. However, blood loss and throm- ment does not compromise the mental function necessary for the
boembolic complications are reduced when epidural local anesthet- success of the planned psychological intervention.
ics are administered.This method is therefore recommended intra-
SYSTEMIC OPIOIDS
operatively and continued in selected high-risk patients for pain
relief after open prostatectomy and transurethral resection. In low- The terminology associated with the pharmacology of the opi-
risk patients, systemic opioids with NSAIDs or COX-2 inhibitors oids is confusing, to say the least. Opiate is an appropriate term
and acetaminophen alleviate postoperative pain. for any alkaloid derived from the juice of the plant (i.e., from
opium). The proper term for the class of agents, whether exoge-
PERIPHERAL
nous, endogenous, natural, or synthetic, is opioid.
PROCEDURES
After vascular proce-
dures, postoperative pain
control is probably best
achieved with epidural Table 2—Psychological Preparation
local anesthetic–opioid mix- of Surgical Patients
tures, combined with sys-
temic NSAIDs or COX-2 inhibitors. Acetaminophen is recom- Procedural information—Give a careful and relevant description
mended as a basic analgesic for multimodal analgesia. This regi- of what will take place
men will be effective, and the increase in peripheral blood flow Sensory information—Describe the sensations that will be experienced
either during or after the operation
that is documented to occur with epidural local anesthetics may
lower the risk of graft thrombosis. Pain treatment information—Outline the plan for administering
sedative and analgesic medication, and encourage patients to
Pain relief after major joint procedures (e.g., hip and knee communicate concerns and discomforts
operations)12 may involve an epidural regimen in high-risk Instructional information—Teach patients postoperative exercises,
patients because such regimens have been shown to reduce such as leg exercises, and show them how to turn in bed or move so
thromboembolic complications and intraoperative blood loss and that pain is minimal
to facilitate rehabilitation. The severe pain noted after knee Reassurance—Reassure those who are mentally, emotionally, or
physically unable to cooperate that they are not expected to take an
replacement is probably best treated with epidural local anes- active role in coping with pain and will still receive sufficient analgesic
thetics combined with opioids. Otherwise, for routine manage- treatment
ment, a single intrathecal dose of a local anesthetic–low-dose
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE PAIN — 5
Prototypical Ligand
Receptor Type Physiologic Actions
Endogenous Exogenous
Mechanisms of Action pharmacodynamic data are available. Use of this agent is recom-
mended; it may be given orally, intravenously, or intramuscularly
Opioids produce analgesia and other physiologic effects by
[see Table 5].
binding to specific receptors in the peripheral and central nervous
system [see Table 3]. These receptors normally bind a number of
Meperidine Detailed and sufficient pharmacokinetic and
endogenous substances called opioid peptides. These receptor-
pharmacodynamic data on meperidine are available. It is less suit-
binding interactions mediate a wide array of physiologic effects.20
able than morphine as an analgesic because its active metabolite,
Five types of opioid receptors and their subtypes have been dis-
covered: mu, delta, kappa, epsilon, and sigma receptors. Most normeperidine, can accumulate, even in patients with normal
commonly used opioids bind to mu receptors. The mu1 receptor renal clearance, and this accumulation can result in CNS excita-
is responsible for the production of opioid-induced analgesia, tion and seizures.20 Other agents should be used before meperi-
whereas the mu2 receptor appears to be related to the respiratory dine is considered. Like morphine, meperidine can be given oral-
depression, cardiovascular effects, and inhibition of GI motility ly, intravenously, or intramuscularly.
commonly seen with opioids. In studies from 2001 and 2004, Side Effects
investigators were able to obtain a reduction in the GI side effects
of morphine with a specific peripherally acting mu antagonist By depressing or stimulating the CNS, opioids cause a number
without interfering with analgesia.21,22 of physiologic effects in addition to analgesia.The depressant effects
The demonstration of the existence of peripheral opioid recep- of opioids include analgesia, sedation, and altered respiration and
tors has given rise to studies investigating the effect of administer- mood; the excitatory effects include nausea, vomiting, and miosis.
ing small opioid doses at the surgical site. Unfortunately, incision- All mu agonists produce a dose-dependent decrease in the
al opioid administration has no significant beneficial effect23; how- responsiveness of brain-stem respiratory centers to increased car-
ever, intra-articular administration does yield a modest benefit.24 bon dioxide tension (PCO2).This change is clinically manifested as
The relation between receptor binding and the intensity of the an increase in resting PCO2 and a shift in the CO2 response curve.
resultant physiologic effect is known as the intrinsic activity of an Agonist-antagonist opioids have a limited effect on the brain stem
opioid. Most of the commonly used opioid analgesics are agonists. and appear to elicit a ceiling effect on increases in PCO2.
An agonist produces a maximal biologic response by binding to its Opioids also have effects on the GI tract. Nausea and vomiting
receptor. Other opioids, such as naloxone, are termed antagonists are caused by stimulation of the chemoreceptor trigger zone of the
because they compete with agonists for opioid receptor binding medulla. Opioids enhance sphincteric tone and reduce peristaltic
sites. Still other opioids are partial agonists because they produce contraction. Delayed gastric emptying is caused by decreased
a submaximal response after binding to the receptor. (An excellent motility, increased antral tone, and increased tone in the first part
example of a submaximal response produced by partial agonists is of the duodenum. Delay in passage of intestinal contents because
buprenorphine’s action at the mu receptor.) of decreased peristalsis and increased sphincteric tone leads to
Drugs such as nalbuphine, butorphanol, and pentazocine are greater absorption of water, increased viscosity, and desiccation of
known as agonist-antagonists or mixed agonist-antagonists.20 bowel contents, which cause constipation and contribute to post-
These opioids simultaneously act at different receptor sites: their operative ileus. Opioids also increase biliary tract pressure. Finally,
action is agonistic at one receptor and antagonistic at another [see opioids may inhibit urinary bladder function, thereby increasing
Table 4]. The agonist-antagonists have certain pharmacologic the risk of urinary retention.
properties that are distinct from those of the more common mu Several long-acting, slow-release oral opioids are currently avail-
agonists: (1) they exhibit a ceiling effect and cause only submaxi- able, but their role (in particular, their safety) in the setting of
mal analgesia as compared with mu agonists, and (2) administra- moderate to severe postoperative pain remains to be established.
tion of an agonist-antagonist with a complete agonist may cause a In addition, modern principles of treatment increasingly empha-
reduction in the effect of the complete agonist.20 size the use of opioid-sparing analgesic approaches to enhance
recovery (see below).
Agents
EPIDURAL AND SUBARACHNOID OPIOIDS
Morphine Morphine is the opioid with which the most clin-
ical experience has been gained. Sufficient pharmacokinetic and Opioids were first used in the epidural and subarachnoid space
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE PAIN — 6
Receptor Type
Opioid
Mu Kappa Delta Sigma
Agonists
Morphine Agonist — — —
Meperidine (Demerol) Agonist — — —
Hydromorphone (Dilaudid) Agonist — — —
Oxymorphone (Numorphan) Agonist — — —
Levorphanol (Levo-Dromoran) Agonist — — —
Fentanyl (Duragesic) Agonist — — —
Sufentanil (Sufenta) Agonist — — —
Alfentanil (Alfenta) Agonist — — —
Methadone (Dolophine) Agonist — — —
Agonist-Antagonists
Buprenorphine (Buprenex) Partial agonist — — —
Butorphanol (Stadol) Antagonist Agonist Agonist —
Nalbuphine (Nubain) Antagonist Partial agonist Agonist —
Pentazocine (Talwin) Antagonist Agonist Agonist —
Dezocine (Dalgan) Partial agonist — — Agonist
Antagonists
Naloxone (Narcan) Antagonist Antagonist Antagonist Antagonist
in 1979. Since that time, they have become the mainstay of post- solubility of an opioid determines its access to the dorsal horn via
operative management for severe pain. Epidural opioids may be (1) diffusion through the arachnoid granulations and (2) diffusion
administered in a single bolus or via continuous infusions. They into spinal radicular artery blood flow.
are usually combined with local anesthetics in a continuous Subarachnoid opioids should be used when the required dura-
epidural infusion to enhance analgesia.14 tion of analgesia after surgery is relatively short. When protracted
analgesia is required, epidural administration is preferred; repeat-
Mechanisms of Action ed injections may be given through epidural catheters, or contin-
Opioids injected into the epidural or subarachnoid space cause uous infusions may be used. Smaller doses of subarachnoid opi-
segmental (i.e., selective, spinally mediated) analgesia by binding oids are generally required to produce analgesia. Ordinarily, no
to opioid receptors in the dorsal horn of the spinal cord.25 The more than 0.1 to 0.25 mg of morphine should be used. These
lipid solubility of an opioid, described by its partition coefficient, doses, which are about 10% to 20% of the size of comparably
predicts its behavior when introduced into the epidural or sub- effective epidural doses, provide reliable pain relief with few side
arachnoid space. Opioids with low lipid solubility (i.e., hydrophilic effects.26 Fentanyl has also been extensively used in the subarach-
opioids) have a slow onset of action and a long duration of action. noid space in a dose range of 6.25 to 50 µg. Pain relief after
Opioids with high lipid solubility (i.e., lipophilic opioids) have a administration of subarachnoid fentanyl is as potent but not as
quick onset of action but a short duration of action.Thus, the lipid prolonged as analgesia after administration of morphine.
moderate to severe postoperative pain because of the advanta- this setting,58,59 and the investigators concluded that these drugs
geous physiologic effects it exerts and the reduction in postopera- were therefore contraindicated in CABG patients. The larger
tive morbidity it brings about. question is whether these drugs should also be contraindicated for
perioperative use, or at least used with caution, in high-risk car-
CONVENTIONAL NSAIDS AND COX-2 INHIBITORS
diovascular patients who are undergoing procedures other than
NSAIDs are minor analgesics that, because of their anti-inflam- CABG. At present, the data are insufficient to allow any conclu-
matory effect, may be suitable for management of postoperative sions, but in my view, until more information is available, it may
pain associated with a significant degree of inflammation (e.g., be prudent to avoid perioperative use of COX-2 inhibitors in all
bone or soft tissue damage).46 They may, however, have central high-risk cardiovascular patients (i.e., those with uncontrolled
analgesic effects as well and thus may have analgesic efficacy after hypertension, previous myocardial infarction, heart failure, or pre-
all kinds of operations. Conventional NSAIDs inhibit both COX- vious cerebral vascular disorders). In other patients, however, peri-
1 and COX-2. Selective COX-2 inhibitors, which do not inhibit operative administration of selective COX-2 inhibitors may be jus-
COX-1, have the potential to achieve analgesic efficacy compara- tified if the advantageous effects appear to outweigh the potential
ble to that of conventional NSAIDs but with fewer side effects [see (low) risk of complications.
Table 8].47-49 Finally, the already quite low risk of NSAID-induced asthma may
Only a few of the NSAIDs may be given parenterally.The data be further reduced by the use of selective COX-2 inhibitors.48,49
now available on the use of NSAIDs for postoperative pain are Peripheral (i.e., surgical site) administration of NSAIDs may
insufficient to allow definitive recommendation of any agent or have a slight additional analgesic effect in comparison with sys-
agents over the others, and selection therefore may depend on temic administration,60 but further data on safety are required.
convenience of delivery, duration, and cost.46 It is clear, however, Acetaminophen also possesses anti-inflammatory capability,
that these agents may play a valuable role as adjuvants to other both peripherally and centrally. Its analgesic effect is somewhat
analgesics; accordingly, they have been recommended as basic (about 20% to 30%) weaker than those of conventional NSAIDs
analgesics for all operations in low-risk patients. All of the NSAIDs and COX-2 inhibitors; however, it lacks the side effects typical of
have potentially serious side effects: GI and surgical site hemor- these agents.61-63 Combining acetaminophen with NSAIDs may
rhage, renal failure, impaired bone healing and asthma. The endo- improve analgesia, especially in smaller and moderate-sized oper-
scopically verified superficial ulcer formation seen within 7 to 10
days after the initiation of NSAID therapy is not seen with selec-
tive COX-2 inhibitor treatment in volunteers. The clinical rele-
vance of these findings for perioperative treatment remains to be
established, however, given that acute severe GI side effects
(bleeding, perforation) are extremely rare in elective cases.
Because prostaglandins are important for regulation of water
and mineral homeostasis by the kidneys in the dehydrated patient,
perioperative treatment with NSAIDs, which inhibit prostaglandin
synthesis, may lead to postoperative renal failure. So far, specific
COX-2 inhibitors have not been demonstrated to be less nephro-
toxic than conventional NSAIDs.48-51 Although little systematic
evaluation has been done, extensive clinical experience with NSAIDs
suggests that the renal risk is not substantial.51 Nonetheless, con-
ventional NSAIDs and COX-2 inhibitors should be used with
caution in patients who have preexisting renal dysfunction.
Although conventional NSAIDs prolong bleeding time and
inhibit platelet aggregation, there generally does not seem to be a
clinically significant risk of increased bleeding. However, in some
procedures for which strict hemostasis is critical (e.g., tonsillectomy,
cosmetic surgery, and eye surgery), these drugs have been shown to
increase the risk of bleeding complications and should therefore be
replaced with COX-2 inhibitors, which do not inhibit platelet
aggregation.52,53 The observation that prostaglandins are involved in
bone and wound healing has given rise to concern about potential
side effects in surgical patients. Although there is experimental evi-
dence that both conventional NSAIDs and COX-2 inhibitors can
impair bone healing,54-57 the clinical data available at present are
insufficient to document wound or bone healing failure with these
drugs.This is a particularly important issue for future study, in that
many orthopedic surgeons remain reluctant to use NSAIDs.
Currently, there is widespread concern about the increased risk
of cardiovascular complications associated with long-term treat-
Figure 1 Illustrated is the procedure for performing cryoanalge-
ment with selective COX-2 inhibitors. Generally, such side effects sia in a thoracotomy. The intercostal nerve in the thoracotomy
have appeared after 1 to 2 years of treatment. In the past few years, space is isolated, together with the two intercostal nerves above the
however, two studies of patients undergoing coronary artery space and the two below it, and the cryoprobe is applied to the
bypass grafting (CABG) found that the risk of cardiovascular nerves for 45 seconds. The probe is then defrosted and reapplied to
complications was increased significantly (two- to threefold) in the nerves for 45 seconds.The analgesia obtained lasts about 30 days.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE PAIN — 10
offer major advantages over single-modality regimens, whether by The potential of combination regimens is especially intriguing
maintaining or improving analgesia, by reducing side effects, or by with respect to the concept of perioperative opioid-sparing anal-
doing both.77,78 Combinations of epidural local anesthetics and gesia.The use of one or several nonopioid analgesics in such regi-
morphine,14,27 of NSAIDs and opioids,46,77,78 of NSAIDs and mens may enhance recovery, in that the concomitant reduction in
acetaminophen,61,62 of acetaminophen and opioids,63 of aceta- the opioid dosage will lead to decreased nausea, vomiting, and
minophen and tramadol,66 and of a selective COX-2 inhibitor and sedation.80-84 Both the adverse events associated with postopera-
gabapentin79 have been reported to have additive effects. At pres- tive opioid analgesia and the relatively high costs of such analgesia
ent, information on other combinations (involving ketamine, argue for an opioid-sparing approach.85,86 Another argument that
clonidine, glucocorticoids, and other agents) is too sparse to allow has been advanced is that the introduction of the JCAHO pain ini-
firm recommendations; however, multimodal analgesia is tiative may precipitate increased use of opioids (and thereby an
undoubtedly promising, and multidrug combinations should cer- increased risk of side effects), though it is not certain that this will
tainly be explored further. be the case.87,88
Perception of Pain
Trauma
Capillary
Muscle
Segmental Reflexes:
Increased Skeletal Muscle Tension
Decreased Chest Compliance
More Nociceptive Input
Increased Sympathetic Tone
Decreased Gastric Mobility
IIeus, Nausea, Vomiting
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE PAIN — 12
Discussion
Physiologic Mechanisms of Acute Pain injury tissue, thereby generating smooth muscle spasm, which am-
The basic mechanisms of acute pain are (1) afferent transmis- plifies the sensation.
sion of nociceptive stimuli through the peripheral nervous system POSTINJURY CHANGES IN PERIPHERAL AND
after tissue damage, (2) modulation of these injury signals by con- CENTRAL NERVOUS SYSTEMS
trol systems in the dorsal horn, and (3) modulation of the ascend-
ing transmission of pain stimuli by a descending control system After an injury, the afferent nociceptive pathways undergo phys-
originating in the brain [see Figure 2].89-92 iologic, anatomic, and chemical changes.91,92 These changes
include increased sensitivity on the part of peripheral nociceptors,
PERIPHERAL PAIN RECEPTORS AND NEURAL as well as the growth of sprouts from damaged nerve fibers that
TRANSMISSION TO SPINAL CORD become sensitive to mechanical and alpha-adrenergic stimuli and
eventually begin to fire spontaneously. Moreover, excitability may
Peripheral pain receptors (nociceptors) can be identified by
be increased in the spinal cord, which leads to expansion of recep-
function but cannot be distinguished anatomically. The respon-
tive fields in dorsal horn cells. Such changes may lower pain
siveness of peripheral pain receptors may be enhanced by endoge-
thresholds, may increase afferent barrage in the late postinjury
nous analgesic substances (e.g., prostaglandins, serotonin,
state, and, if normal regression does not occur during convales-
bradykinin, nerve growth factor, and histamine), as well as by
cence, may contribute to a chronic pain state.91
increased efferent sympathetic activity.89 Antidromic release of
Neural stimuli have generally been considered to be the main
substance P may amplify the inflammatory response and thereby
factor responsible for initiation of spinal neuroplasticity; however,
increase pain transmission.The peripheral mechanisms of visceral
it now appears that such neuroplasticity may also be mediated by
pain still are not well understood90 —for example, no one has yet
cytokines released as a consequence of COX-2 induction.92
explained why cutting or burning may provoke pain in the skin but
Improved understanding of the mechanisms of pain may serve as
not provoke pain in visceral organs. Peripheral opioid receptors
a rational basis for future drug development and may help direct
have been demonstrated to appear in inflammation on the periph- therapy away from symptom control and toward mechanism-spe-
eral nerve terminals, and clinical studies have demonstrated that cific treatment.94
there are analgesic effects from peripheral opioid administration In experimental studies, acute pain behavior or hyperexcitabili-
during arthroscopic knee surgery.93 ty of dorsal horn neurons may be eliminated or reduced if the
Somatic nociceptive input is transmitted to the CNS through afferent barrage is prevented from reaching the CNS. Preinjury
A-delta and C fibers, which are small in diameter and either neural blockade with local anesthetics or opioids can suppress
unmyelinated or thinly myelinated. Visceral pain is transmitted excitability of the CNS; this is called preemptive analgesia.
through afferent sympathetic pathways; the evidence that afferent Because similar antinociceptive procedures were less effective in
parasympathetic pathways play a role in visceral nociception is experimental studies when applied after injury, timing of analgesia
inconclusive.90 seems to be important in the treatment of postoperative pain;
DORSAL HORN CONTROL SYSTEMS AND MODULATION however, a critical analysis of controlled clinical studies that com-
OF INCOMING SIGNALS
pared the efficacy of analgesic regimens administered preopera-
tively with the efficacy of the same regimens administered postop-
All incoming nociceptive traffic synapses in the gray matter of eratively concluded that preemptive analgesia does not always pro-
the dorsal horn (Rexed’s laminae I to IV). Several substances may vide a clinically significant increase in pain relief.95,96 Nonetheless,
be involved in primary afferent transmission of nociceptive stimuli it is important that pain treatment be initiated early to ensure that
in the dorsal horn: substance P, enkephalins, somatostatin, neu- patients do not wake up with high-intensity pain. As long as the
rotensin, γ-aminobutyric acid (GABA), glutamic acid, angiotensin afferent input from the surgical wound continues, continuous
II, vasoactive intestinal polypeptide (VIP), and cholecystokinin treatment with multimodal or balanced analgesia may be the most
octapeptide (CCK-8).91 From the dorsal horn, nociceptive infor- effective method of treating postoperative pain.95,97
mation is transmitted through the spinothalamic tracts to the
hypothalamus, through spinoreticular systems to the brain stem
and reticular formation, and finally to the cerebral cortex. Effects of Pain Relief
sity for the stress response in modern anesthesiology and surgery greater extent than a local anesthetic regimen would.22 Another
has been questioned.28 Thus, concern about the detrimental effects explanation may be inadequate study design in some cases: most
of operative procedures (e.g., myocardial infarction, pulmonary studies to date have focused on the effects of a single factor (i.e.,
complications, and thromboembolism) that cannot be attributed epidural analgesia) on overall postoperative morbidity, which is
solely to imperfections in surgical technique has led to the hypoth- probably too simplistic an approach, given that overall postopera-
esis that the unsupported continuous injury response may instead tive outcome is known to be determined by multiple factors.103,104
be a maladaptive response that erodes body mass and physiologic Besides postoperative pain relief, reinforced psychological prepa-
reserve.28,98 Because neural stimuli play an important role in releas- ration of the patient, reduction of stress by performing neural
ing the stress response to surgical injury, pain relief may modify this blockade or opting for minimal invasive procedures, and enforce-
response, but this modulation is dependent on the mechanism of ment of early oral postoperative feeding and mobilization may all
action of the pain treatment modality employed.28 play a significant role in determining outcome.103,104 Prevention of
Alleviation of pain through antagonism of peripheral pain medi- intraoperative hypothermia, avoidance of fluid overloading, and
ators (i.e., through use of NSAIDs) has no important modifying avoidance of hypoxemia may be important as well.103,104
effect on the response to operation.22,30 The effects of blockade of Therefore, although adequate pain relief is obviously a prereq-
afferent and efferent transmission of pain stimuli by means of uisite for good outcome, the best results are likely to be achieved
regional anesthesia have been studied in detail.22,31 Spinal or by combining analgesia with all the aforementioned factors in a
epidural analgesia with local anesthetics prevents the greater part multimodal rehabilitation effort.103,104 Observations from patients
of the classic endocrine metabolic response to operative proce- undergoing a variety of surgical procedures suggest that such a
dures in the lower region of the body (e.g., gynecologic and uro- multimodal approach may lead to significant reductions in hospi-
logic procedures and orthopedic procedures in the lower limbs) tal stay, morbidity, and convalescence.103,104 Admittedly, these pre-
and improves protein economy; however, this effect is consider- liminary observations require confirmation by randomized or
ably weaker in major abdominal and thoracic procedures, proba- multicenter trials. The role of the acute pain service105 and the
bly because of insufficient afferent neural blockade. The modify- effect of establishing a postoperative rehabilitation unit should be
ing effect of epidural analgesia on the stress response is most pro- assessed as well.
nounced if the neural blockade takes effect before the surgical
insult.The optimal duration of neural blockade for attenuating the TOLERANCE, PHYSICAL DEPENDENCE, AND ADDICTION
hypermetabolic response has not been established, but it should Continued exposure of an opioid receptor to high concentra-
include at least the initial 24 to 48 hours.22,31 tions of opioid will cause tolerance. Tolerance is the progressive
Alleviation of postoperative pain through administration of decline in an opioid’s potency with continuous use, so that higher
epidural-intrathecal opioids has a smaller modifying effect on the and higher concentrations of the drug are required to cause the
surgical stress response, in comparison with the degree of pain same analgesic effect. Physical dependence refers to the produc-
relief it provides22,31; furthermore, it does not provide efferent sym- tion of an abstinence syndrome when an opioid is withdrawn. It is
pathetic blockade. Systemic administration of opioids, either ac- defined by the World Health Organization as follows106:
cording to a fixed administration regimen or according to a demand-
based regimen, has no important modifying effect on the stress A state, psychic or sometimes also physical, resulting from interactions
between a living organism and a drug, characterized by behavioural
response.22 The effects of pain relief by acetaminophen, tramadol,
and other responses that always include a compulsion to take the drug
cryoanalgesia, or TENS on the stress response have not been estab- on a continuous or periodic basis in order to experience its psychic
lished but probably are of no clinical significance. Further studies effects, and sometimes to avoid discomfort from its absence.
aimed at defining the effects of multimodal analgesia on the sur-
gical stress response are required. This definition is very close to the popular conception of addic-
tion. It is important, however, to distinguish addiction (implying
POSTOPERATIVE MORBIDITY compulsive behavior and psychological dependence) from toler-
The effects of nociceptive blockade and pain relief on postop- ance (a pharmacologic property) and from physical dependence
erative morbidity remain to be defined, except with respect to (a characteristic physiologic effect of a group of drugs). Physical
intraoperative spinal or epidural local anesthetics in lower-body dependence does not imply addiction. Moreover, tolerance can
procedures, about which the following four conclusions can be occur without physical dependence; the converse does not appear
made.22,99 First, intraoperative blood loss is reduced by about to be true.
30%. Second, thromboembolic and pulmonary complications are The possibility that the medical administration of opioids could
reduced by about 30% to 40%. Third, when epidural local anes- result in a patient’s becoming addicted has generated much debate
thetics are continuously administered (with or without small doses about the use of opioids. In a prospective study of 12,000 hospi-
of opioids) to patients undergoing abdominal or thoracic proce- talized patients receiving at least one strong opioid for a protract-
dures, pulmonary infectious complications appear to be reduced ed period, there were only four reasonably well documented cases
by about 40%.30 Fourth, the duration of postoperative ileus is of subsequent addiction, and in none of these was there a history
reduced14,31; this effect may be of major significance, in that reduc- of previous substance abuse.107 Thus, the iatrogenic production of
tion of ileus allows earlier oral nutrition,31 which has been demon- opioid addiction may be very rare.
strated to improve outcome.
CONCLUSION
The impact of continuous epidural analgesia on postoperative
outcome after major operations remains the subject of some debate. The choice of therapeutic intervention for acute postoperative
Three large randomized trials from 2001 and 2002 found no pos- pain is determined largely by the nature of the patient’s problem,
itive effects except for improved pulmonary outcome.100-102 One the resources available, the efficacy of the various treatment tech-
explanation for these negative findings may be the use of a pre- niques, the risks attendant on the procedures under consideration,
dominantly opioid-based epidural analgesic regimen, which would and the cost to the patient.108 Whereas trauma has been the sub-
hinder the normal physiologic responses supporting recovery to a ject of intensive research, the mechanisms of the pain associated
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE PAIN — 14
with trauma and surgical injury and the optimal methods of reliev- morbidity, will stimulate more surgeons to turn their attention to
ing such pain have received comparatively little attention from sur- this area. Effective control of postoperative pain, combined with a
geons. It is to be hoped that our growing understanding of basic high degree of surgical expertise and the judicious use of other
pain mechanisms and appropriate therapy, combined with the perioperative therapeutic interventions within the context of mul-
promising data supporting the idea that adequate inhibition of timodal postoperative rehabilitation, is certain to improve surgical
surgically induced nociceptive stimuli may reduce postoperative outcome.
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J Surg 186:472, 2003 Acknowledgments
70. Dahl JB, Mathiesen O, Møiniche S: Prospective pre-
medication: an option with gabapentin and related 89. Kidd BL, Urban LA: Mechanisms of inflammatory Figure 1 Carol Donner.
drugs? Acta Anaesthesiol Scand 48:1130, 2004 pain. Br J Anaesth 87:3, 2001 Figure 2 Dana Burns Pizer.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 1
Postoperative care is an integral part of complete surgical man- dures. Physicians should become acquainted with the costs of the
agement. For a patient undergoing an elective operation, such various treatments and medications at their institution. Choices
care should be thought of within the context of perioperative made on the basis of both efficacy and expense will become increas-
care: that is, it should be considered as part of a continuum that ingly common as hospital systems adapt to the changing health care
ranges from evaluating and preparing the patient for a surgical environment.
procedure to minimizing the stress of the procedure to promot-
ing a return to health after the procedure.
As a result of ongoing surgical and anesthetic advances and the Postoperative Monitoring
growing application of minimally invasive surgical techniques, In the postoperative period, many patients return to the same
many procedures that once necessitated hospitalization are now room they occupied preoperatively. Some, however, require more
commonly performed in day surgical units. Other procedures advanced monitoring and care and will require admission to a
are proving to be amenable to a fast track surgical approach, monitored telemetry bed, an intermediate care unit, or a surgical
in which postoperative care focuses on minimizing postoperative critical care unit.
pain, enhancing mobility and exercise capacity, and encouraging The selection of postoperative monitoring is guided by a thor-
enteral intake. Such programs typically reduce the length of stay ough understanding of the patient’s preoperative status and medical
after a major procedure to 1 to 4 days. history, the diagnosis that led to the operation, the operation per-
In what follows, we focus on postoperative management of formed, and the circumstances of the operative procedure.The vital
more seriously ill patients undergoing major operations, for whom signs that are commonly monitored on a surgical ward include tem-
outpatient and fast track approaches generally are not well suited. perature, pulse rate, blood pressure, respiratory rate, urine output
Such patients may include those with comorbid conditions that (hourly or at some other interval), weight (daily), and fluid intake
prolong recovery, those who have sustained intraoperative com- and output. These can generally be obtained at intervals of 2 to 4
plications, and those who are undergoing emergency operations. hours. If more frequent monitoring or nursing care (e.g., frequent
These patients are heavy users of hospital resources but benefit suctioning) is required, admission to an intermediate care unit may
greatly from medical care available in the modern hospital setting be advisable. On a telemetry ward, continuous cardiac monitoring
(e.g., ventilatory support, continuous monitoring, and an exten- can be provided for patients who have significant cardiopulmonary
sive pharmacopoeia). A portion of this care is provided in the disease or for those at risk for perioperative myocardial infarction or
recovery room or the intensive care unit, and its efficient delivery dysrhythmia. In a CCU, additional monitoring is provided, includ-
depends on collaboration among physicians from several different ing both noninvasive and invasive monitoring with arterial lines,
disciplines.The surgeon brings balanced surgical judgment to this continuous monitoring of central venous pressure (CVP) and right-
setting and interacts frequently with the patient and the family. sided pulmonary arterial pressures via Swan-Ganz catheterization,
continuous monitoring of arterial oxygen saturation via pulse oxi-
metry, measurement of end-tidal carbon dioxide tension, and elec-
Postoperative Orders trocardiographic monitoring [see 8:26 CardiopulmonaryMonitoring].
The direction that postoperative management of a seriously ill Recommended criteria for ICU admission and discharge have been
patient will take is outlined in the surgeon’s postoperative orders [see formulated.4 When resources are limited, such guidelines may be use-
Sidebar Sample Postoperative Orders].Through this document, the ful in resolving triage difficulties, but each institution and each unit will
nursing staff is informed of (1) the diagnosis, (2) the operation per- have to develop its own approach to this sometimes thorny problem.
formed, and (3) the patient’s condition. Monitoring measures are Controversy continues regarding what level of monitoring is
listed, and the therapeutic measures to be employed (analgesia, most appropriate for each patient. In many hospitals, requests for
antibiotics, wound care, I.V. fluid administration, and the handling ICU beds exceed the number of available critical care beds, and
of tubes, catheters, and drains) are detailed. Evidence-based analyses triage of patients is necessary. This sometimes means moving
indicate that certain common therapies are indeed valuable (e.g., patients from the ICU before their primary physician feels they
inhaled oxygen1,2), whereas others either are not of proven benefit are ready for transfer, canceling or delaying operative procedures,
(e.g., intermittent positive-pressure breathing [IPPB] and room and providing less than the requested level of postoperative mon-
humidification) or are indicated only in selected situations (e.g., for itoring for some patients. The increased use of intermediate or
gastritis, which is appropriate only in patients who are undergoing step-down units has provided some relief in these difficult situa-
mechanical ventilation or who have coagulopathies3). tions, but appropriate allocation of resources continues to be a
Some uniformity in the postoperative orders is valuable because major issue in postoperative bed selection. It has been argued
it allows a decrease in the floor stock of medications and increases that in some clinical circumstances, our ability to monitor disease
the nursing staff’s experience with specific medications and proce- may have outpaced our ability to intervene therapeutically.5 A
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 2
consensus conference sponsored by the National Institutes of abnormalities that are the most serious and potentially the most
Health in 1983 concluded that although the care provided in immediately life threatening are hypokalemia and hyperkalemia.
ICUs appears beneficial, the only area in which improved out- These abnormalities must be corrected rapidly; multiple potassi-
come could be documented was coronary care.6 Acceptable um measurements to confirm this correction are required.
indications for admission to CCUs and invasive monitoring Abnormal levels of sodium and chloride should be corrected over
with arterial lines and pulmonary arterial catheters have been a period of days.
proposed; they include myocardial infarction, shock, drug Serum calcium measurements reflect total serum calcium.
overdose, major cardiovascular surgery, acute respiratory dis- Only the ionized fraction of serum calcium is active, however,
tress syndrome (ARDS), and other forms of respiratory failure and thus, total serum calcium levels are not reliable indicators of
that call for mechanical ventilation[see 8:26 Cardiopulmonary the need for calcium administration.8 However, after parathyroid
Monitoring].7 operation, measurements of calcium levels are valuable because
The laboratory tests that are often obtained postoperatively the other factors that affect the level of ionized calcium are usu-
may be thought of as another form of postoperative monitoring. ally unchanged.
Although such tests can be valuable, they are infrequently used Coagulation studies are overused preoperatively and are
to make important clinical judgments. Technological develop- unnecessary postoperatively, except to monitor anticoagulation
ments have made it possible for the nursing staff to monitor therapy or to evaluate the bleeding patient. Arterial blood gas
blood gas pressures, pH, and other biochemical indices at the measurements are useful in ventilated or hypoxic patients but
bedside. For example, finger-stick blood glucose measurements should be used judiciously.
are indicated in insulin-resistant patients and should be obtained
every 6 hours (see below). Hematocrits should be obtained post-
operatively only if serious bleeding is suspected.The white blood Postoperative Pain Relief
cell count routinely increases after the stress of operation and is Despite the considerable progress that has been made in
therefore of little diagnostic value during the first few days after understanding the pathophysiology of pain,9 routine pain man-
operation.Thrombocytopenia routinely accompanies major trau- agement is often unsatisfactory.10 Many hospitals have estab-
ma, massive transfusion, and major operative procedures (e.g., lished pain services that improve quality of care and optimize
cardiac bypass operation); platelet counts are necessary only if relief of pain,11,12 which is a prerequisite for optimal recovery.13
the patient shows evidence of bleeding. Treatment of postoperative pain actually begins before the
In healthy individuals with normal renal function, serum elec- procedure, as the health care team educates the patient about the
trolyte levels are usually well maintained despite major stress. In events that will occur before, during, and after the procedure.
these patients, infrequent measurements of serum electrolytes Classic studies demonstrated that such an educational approach
are appropriate (every 2 or 3 days). By contrast, in patients with reduced patients’ requirements for analgesics and diminished
an underlying chronic disease, such as renal or hepatic disease or their perception of pain.14
an illness that routinely results in electrolyte derangement, fre- Preemptive anesthesia reduces the sensation of pain before the
quent measurements of electrolytes are indicated.The electrolyte creation of the incision, thereby significantly decreasing pain per-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 3
Levorphanol 2–3 mg q. 4 hr 2–3 mg S.C. q. 4–6 hr Optimal I.V. dose has not been established
Methadone 5–20 mg q. 3–4 hr 2.5–10.0 mg S.C., I.M., or I.V. q. 3–4 hr Excellent I.V.-to-oral bioavailability, 1:2 mg
Acetaminophen
15–60 mg q. 3–6 hr 15–60 mg S.C., I.M., or I.V. q. 4 hr —
with codeine
Propoxyphene 32–65 mg q. 4 hr — —
ception in the postoperative period. Techniques utilizing epidu- Systemic medications used for postoperative pain relief
ral anesthesia15 or major field block16 achieve a greater reduction include opioids, nonsteroidal anti-inflammatory drugs
in perceived pain than general anesthesia does, and they greatly (NSAIDs), and other nonnarcotic agents [see Table 1]. Surgeons
reduce the need for postoperative analgesics while enhancing are currently moving away from systemic opioids: in addition to
postdischarge activity. Epidural anesthesia and other regional their well-recognized capacity for inducing respiratory depres-
techniques are being applied more frequently, now that a num- sion, opioids prolong ileus and increase nausea and vomiting.
ber of trials have found them to be superior to general anesthe- Regional anesthesia coupled with NSAID administration
sia.17 In the case of epidural anesthesia, the catheter can be used appears to yield better results in terms of patient recovery.18
to provide sustained pain relief for several days after operation. On occasion, however, systemically administered narcotics are
This approach is particularly useful in patients who have under- still the best available choice. Studies addressing postoperative
gone operations on the lower abdomen or the lower extremities: pain have shown that most cases of severe pain are not uniform-
it can lead to earlier mobilization and return of bowel function ly relieved by the current practice of narcotic prescription.
after operation, thereby shortening hospital stay.18 According to one study, physicians prescribe inadequate doses of
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 4
Acetylated salicylate
Aspirin 325–650 mg q. 4 hr — —
Nonacetylated salicylates
Diflunisal Loading dose, 1,000 mg,
— FDA indications: pain, OA, and RA
then 500–1,000 mg/day
Propionic acids
FDA indications: RA, OA, pain, and
Ibuprofen 400–800 mg t.i.d.–q.i.d. —
dysmenorrhea
Acetic acids
Nonopioid FDA indications: RA, OA, ankylosing spondy-
analgesics Indomethacin 25 mg b.i.d. or t.i.d. I.V. used to close PDA
litis, acute painful shoulder, and gout
Oxicam
Piroxicam 20 mg/day — FDA indications: OA and RA
Fenamates
FDA indications: pain, dysmenorrhea, RA,
Meclofenamate 50 mg q. 4 hr —
and OA
COX-2 inhibitors
Rofecoxib 12.5–25.0 mg/day — FDA indications: OA, pain, and dysmenorrhea
narcotic analgesics for patients with moderate or severe pain, and tion was exaggerated. (Addiction usually does not develop unless
nurses give only 40% to 50% of the amount prescribed.19 In this narcotics are prescribed regularly for more than 2 weeks.)
study, the effective dose of narcotic required for pain relief was NSAIDs, though safer than narcotics, have side effects of their
underestimated, the fear of respiratory depression was high, the own. In particular, they inhibit prostaglandin synthesis, thereby
duration of action was overestimated, and the danger of addic- decreasing inflammation. This prostaglandin inhibition may
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 5
Table 2 Guidelines for I.V. In patients who require continued postoperative volume resus-
citation, hypotonic fluids, even at an increased rate, are not
Patient-Controlled Analgesia
appropriate. Isotonic fluid is required to maintain adequate
intravascular volume. Administration of 5% dextrose in lactated
Basal Demand Lockout Ringer solution at the rate of 150 ml/hr provides about six times
Drug (Concentration) Dosage Dosage Interval
as much intravascular volume resuscitation as the usual mainte-
Morphine (1–2 mg/ml) 0–0.5 mg/hr 0.5–3.0 mg 5–12 min nance regimen. Adjustments in volume should be guided by care-
Meperidine (10 mg/ml) 0–5 mg/hr 5–30 mg 5–12 min ful monitoring of urine output, pulse rate, and BP. A common
Fentanyl (10–20 µg/ml) 0–5 µg/hr 10–20 µg 5–10 min error in postoperative fluid therapy is to order hypotonic fluids at
Hydromorphone 0–0.1 mg/hr 0.1–0.5 mg 5–10 min an increased rate of administration (i.e., 150 ml/hr of 5% dex-
(0.2–0.5 mg/ml) trose in 0.5 N saline) after determining, on the basis of physical
Oxymorphone (0.25 mg/ml) — 0.2–0.4 mg 8–10 min examination findings (i.e., tachycardia, decreased BP, and
Methadone (1 mg/ml) 0–0.5 mg/hr 0.5–2.5 mg 8–20 min decreased urine output in the appropriate clinical situation), that
Nalbuphine (1 mg/ml) — 1–5 mg 5–10 min
a patient is relatively hypovolemic. Because fluid losses into the
interstitium are isotonic, isotonic fluid replacement is indicated.
exacerbate renal insufficiency; for this reason, NSAIDs should be In addition, the use of isotonic fluids is important because of
used with caution in patients with preexisting renal dysfunction. the presence of elevated levels of antidiuretic hormone (ADH)
Other side effects include GI bleeding, inhibition of platelet and other counterregulatory hormones. In a normal, unstressed
aggregation, and prolonged bleeding time. person, free-water loading (e.g., the drinking of several glasses of
Patient-controlled analgesia (PCA) represents an important water) results in a fall in ADH levels and excretion of very dilute
advance in pain management [see 1:5 Postoperative Pain].20-22 This urine by the kidney, thus allowing the serum sodium and osmo-
modality has gained widespread acceptance because it provides lality to return to normal. Various stressful stimuli, including
improved pain control and greater patient satisfaction, which are operative procedures, result in an inability to lower ADH levels
attributable both to more expedient administration of the drug and an inability to excrete free water.23-25 The administration of
and to more consistent plasma levels. PCA generally takes the hypotonic fluid, with its free-water content, can lead to hypona-
form of intermittent drug doses administered on demand, with a tremia in postoperative patients and others with elevated levels of
minimal required interval between doses (the lockout interval). A counterregulatory stress hormones. The resultant hyponatremia
constant background infusion (basal dosage) may be given to may cause significant morbidity and mortality.26,27 The use of iso-
supplement the intermittent dose, but it should be used cau- tonic fluid prevents this problem. In uncomplicated elective pro-
tiously so as not to induce respiratory depression. The narcotics cedures of brief duration (e.g., hernia repair, cholecystectomy,
most commonly used for PCA are morphine, meperidine, and and uncomplicated bowel surgery), the stress response is short-
fentanyl. Methadone is rarely given in this setting because of its lived and the patient can be switched to maintenance fluids 24
slow onset and long duration of action [see Table 2]. Nalbuphine, hours after operation. Patients who undergo operation under
though possessing narcotic analgesic properties of its own, is gen- local anesthesia do not experience a stress response and general-
erally used for its antagonist properties, which act against side ly need little, if any, fluid.
effects such as pruritus. Other side effects seen with patient-con- Once recovery from a major insult has begun, the capillary leak
trolled analgesia are nausea, vomiting, sweating, and the afore- closes and fluid is mobilized from the periphery into the vascular
mentioned respiratory depression. space. At this point, the fluid orders should be changed to main-
tenance rates or lower and from isotonic resuscitation fluid to
hypotonic saline. An important sign that the capillary leak has
Management of Fluid Imbalance, Electrolyte
reversed is the return of a brisk urine output. Such spontaneous
Abnormalities, and Acid-Base Disorders
diuresis is a significant marker of the patient’s recovery. It is asso-
Postoperative fluid therapy is guided by the patient’s overall ciated with a fall in levels of ADH, aldosterone, steroids, cate-
preoperative condition, the preoperative diagnosis, and the cir- cholamines, and other counterregulatory hormones and with a
cumstances of the operative procedure. The presence of cardiac, rise in atrial natriuretic factor.28,29 The use of diuretics in an
pulmonary, renal, or hepatic disease will affect the type and rate attempt to “diurese off” excess fluid masks this physiologic
of fluid required postoperatively. Similarly, peritonitis, the septic response; therefore, diuretics should be reserved for use in
response, or other conditions that affect the patient’s volume sta- patients who have inadequate renal or cardiac function and
tus and peripheral capillary permeability will influence the should be administered only after the capillary leak has reversed,
approach to fluid therapy. In an adequately hydrated patient who so as not to cause intravascular volume depletion.
has undergone a minor procedure with minimal blood loss and Several I.V. fluids are commonly employed for maintenance
for whom the postoperative recovery period is expected to be and resuscitation [see Table 3]. Crystalloids are the fluids of choice
short, maintenance fluid administration alone is adequate. for perioperative fluid replacement. The use of colloid solutions
Maintenance requirements for a 70 kg patient are normally about offers no clear advantages in perioperative care, and their very
100 ml/hr of 5% dextrose in one-half normal saline, with approx- high cost makes it difficult to justify their use in the majority of
imately 20 mEq/L of potassium added. By contrast, in a patient surgical patients.30-32 A meta-analysis of 30 randomized, con-
with bowel obstruction, small bowel infarction, and bowel perfo- trolled trials comparing albumin to either no albumin or crystal-
ration, maintenance fluid administration alone is inadequate. In loid in critically ill patients with hypovolemia, burns, or hypoal-
these patients, reequilibration and fluid loss from the intravascu- buminemia found strong evidence suggesting that use of albumin
lar space continue for many hours after operation; consequently, may increase mortality.33
resuscitation must be continued postoperatively, and as much as In the first 24 hours after operation, potassium supplementa-
7 to 10 L of crystalloid may have to be given over 24 hours to tion is unnecessary in most patients. Potassium levels in I.V. flu-
maintain adequate perfusion. ids should be adjusted according to serum potassium levels.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 6
Unfortunately, the serum potassium level provides an extremely concentration by increasing cardiac output, provided that
inaccurate estimate of total body potassium. A profound deple- intravascular volume is adequate. Older patients with coronary
tion may exist despite serum potassium levels in the low to nor- artery disease are more likely to suffer deleterious effects if their
mal range.The long-term use of diuretics such as furosemide and intravascular volume, their hemoglobin concentration, or both
the thiazides is commonly associated with low body stores of are low, because such patients have a limited ability to augment
potassium. Patients undergoing nutritional repletion will also cardiac output under these circumstances.
tend to have low serum potassium levels. If the patient has ques- Standard monitoring of volume status includes vital signs,
tionable renal function, potassium should be withheld until a mental status, and urine output. Because of the effects of gener-
serum level is available. If renal function is normal and urine out- al anesthesia, unrecognized intravascular volume depletion may
put is not compromised, we add 20 mEq/L of potassium to the develop. If a Foley catheter has been inserted, a decrease in the
I.V. fluids after the first 24 postoperative hours. urine output can be an early sign of such depletion. Hypovolemia
with depletion of the intravascular compartment should not be
FLUID IMBALANCE
confused with changes in total body water, which may or may not
Patients who undergo uncomplicated elective procedures usu- occur in hypovolemia. If body weight is used to assess total body
ally experience relatively inconsequential abnormalities of their water content, it is possible to assume that a patient is “fluid over-
intravascular volume. However, patients who undergo lengthy or loaded” because of an elevated body weight, though in fact the
complicated procedures or have abnormalities of intravascular intravascular volume has been depleted and the patient is under-
volume preoperatively are more likely to manifest abnormalities perfused and hypovolemic.This is a common scenario in patients
of circulating volume and should be evaluated carefully in the who have sustained significant losses of intravascular volume and
postoperative period to assess their intravascular volume status blood with resulting shock, capillary leakage, and fluid accumu-
and tissue perfusion. lation in the interstitium and the intracellular compartment.34
It has been demonstrated that the volume status of an individual
Hypovolemia patient, especially if he or she has unstable vital signs or is critically
Hypovolemia is a decrease in the effective intravascular vol- ill in the ICU, cannot be easily estimated by means of clinical as-
ume, caused by losses incurred either externally (e.g., hemor- sessment alone.35,36 The use of invasive monitoring is therefore im-
rhage or loss of transcellular fluid) or internally (e.g., transcapil- portant in determining the status of the intravascular compartment
lary leakage of fluid into traumatized tissue). Oxygen delivery and and the ability of the body to maintain tissue perfusion.The use of a
tissue perfusion are dependent on the ability to generate an ade- pulmonary arterial catheter to determine cardiac filling pressures
quate cardiac output in the presence of hemoglobin that is suffi- and cardiac output usually allows a more accurate assessment of the
ciently saturated (arterial oxygen saturation [SaO2] more than patient’s intravascular volume status. In patients who are relatively
90%, arterial oxygen tension [PaO2] more than 60 mm Hg). An stable hemodynamically but manifest signs of a contracted intravas-
inadequate intravascular volume can lead to poor perfusion either cular volume (e.g., low urine output, increased heart rate, low or
because of a lowered preload that results in a depressed cardiac borderline blood pressure, depressed mental status, poor capillary
output or because of a low hemoglobin concentration (e.g., from refill), an isotonic fluid challenge should be administered. At least
bleeding).Younger patients usually tolerate a lowered hemoglobin 500 and preferably 1,000 ml of lactated Ringer solution or normal
5% Plasma protein Equal to Equal to 145 0 <2 0 12.5 g protein 33 Colloid, expensive
fraction (250 ml) plasma plasma
*Reflects sample cost to pharmacy at the University of North Carolina at Chapel Hill School of Medicine. Actual cost to the patient is likely to be significantly higher.
D5LR—5% dextrose in lactated Ringer solution D5NS—5% dextrose in normal saline solution D51/ 2 NS—5% dextrose in one-half normal saline solution D51/ 4 NS—5% dextrose in
one-quarter saline solution D5W—5% dextrose in water
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 7
saline solution should be given rapidly and the patient’s response concentration of sodium relative to the amount of free water in
evaluated. If the vital signs normalize and the urine output rises, the the intravascular compartment. The serum sodium concentra-
patient is assumed to be responding to volume loading. Further ob- tion is not related to the volume state of the intravascular com-
servation will determine whether the patient requires more isotonic partment. Patients may be normovolemic, hypovolemic, or hyper-
fluid administration. If the patient does not respond to the initial volemic in the presence of hyponatremia.
bolus of fluid or has significant renal or cardiopulmonary dysfunc- In the postoperative setting, hyponatremia usually results from
tion, it is generally more prudent to employ invasive monitoring an excess of free water. This occurs when hypotonic fluid is
with a pulmonary arterial catheter to determine the status of the in- administered to patients whose ADH levels cannot fall because
travascular compartment.The use of diuretics in this setting should of the stress of operation or injury. In these patients, the free
be limited to patients who have known severe cardiopulmonary water administered as hypotonic fluid cannot be eliminated
dysfunction or advanced renal disease with a known dependency through the kidney, and hyponatremia results. In most cases, the
on diuretics.The administration of a diuretic to a patient with in- stress subsides in 24 to 48 hours and the ADH levels fall, which
travascular volume depletion can result in further depletion of the allows the kidney to correct the free-water excess. Patients who
intravascular volume despite the production of urine. continue to be ill or under stress and those who have poor renal
Other techniques useful in the assessment of a patient’s vol- function may experience difficulty in correcting the free-water
ume status include measurement of sodium in the urine sedi- excess. Significant morbidity and mortality can occur if the
ment, cardiac echocardiography, and the determination of serum serum sodium concentration falls below 120 mEq/L.26,27
lactate levels. None of these techniques is entirely accurate or Hyponatremia in the postoperative setting is best avoided by
practical.The response to a fluid bolus remains a practical means means of appropriate I.V. fluid management, including the use of
of assessing the status of the intravascular compartment. Failure isotonic fluid in the immediate postoperative period.
to respond to one or more fluid boluses should prompt further The treatment of hyponatremia depends on the serum sodium
evaluation, including invasive monitoring if indicated. concentration and how long it took serum sodium to reach that
level. Intravascular volume deficits, if present, should be correct-
Fluid Overload ed first. Patients who have chronically depressed serum sodium
Fluid overload in the postoperative surgical patient is reported concentrations will tolerate slow correction with isotonic fluid
to occur with varying frequency and has been associated with (e.g., lactated Ringer solution or normal saline solution). Patients
inferior outcomes.37 The degree to which a patient may become who experience an acute, rapid falloff of their serum sodium con-
“overloaded” with fluid is determined by the patient’s preopera- centration or those who are symptomatic require correction with
tive status, age, and existing cardiopulmonary, renal, or hepatic hypertonic (3%) saline over 24 to 48 hours.
disorders; the length of the operative procedure; the fluids
administered; and the presence or absence of infection and Hypernatremia Hypernatremia reflects a relative deficien-
inflammatory mediators. Although it is generally accepted that cy of free water compared with sodium. Under normal circum-
patients who require large amounts of fluid and who gain weight stances, hypernatremia stimulates thirst, and the intake of free
in the postoperative period are likely to have a less favorable out- water returns the serum sodium concentration to normal. Hyper-
come, it is difficult to separate the effect of large-volume resusci- natremia may develop in patients who are unable to regulate fluid
tation from the circumstances that prompt such therapy, most intake (e.g., obtunded patients) or do not have their fluids replaced
commonly shock, a septic response, or both. appropriately. This is especially likely in patients with large free-
Judicious use of fluids in the perioperative period and the water losses such as sweat and insensible losses. Patients with dia-
application of the principles of invasive monitoring outlined betes insipidus (e.g., as a result of head injury) develop hyperna-
above generally allow appropriate volume resuscitation without tremia because of large (> 10 L/day) losses of very dilute urine.
precipitating pulmonary edema or congestive heart failure. It Treatment of hypernatremia consists of providing adequate
should be recognized, however, that in patients who sustain volumes of free water to correct the deficit. Serum sodium con-
shock or manifest a septic response (with or without bacterial centration is a good indicator of the adequacy of replacement. In
infection), fluid will leak from the intravascular compartments the case of diabetes insipidus, treatment with desmopressin ace-
and total body anasarca will develop. The resultant increase in tate, either parenterally or by the nasal route, in concert with care-
body weight associated with an increased requirement for fluid ful fluid management will generally alleviate the hypernatremia.
infusion will give the impression that the patient is receiving
excessive amounts of fluid. Although this may be the case, it is Disorders of Potassium Concentration
generally difficult to determine intravascular volume status in Hypokalemia Hypokalemia may have a number of causes
more seriously ill patients through simple observation alone.35,36 in the postoperative patient. Chronic use of diuretics, poor nutri-
The value of invasive monitoring in the ICU should again be tion with total body potassium depletion, and GI losses are all
emphasized. Patients suspected of being “fluid overloaded” associated with varying degrees of hypokalemia. Among the most
should be carefully evaluated by an experienced clinician, and if common causes is alkalosis, which brings about a shift of potas-
they do not respond to preliminary measures to correct their vol- sium into the intracellular compartment.
ume status, they should undergo invasive monitoring. Since the serum potassium level does not accurately reflect the
total body potassium pool, hypokalemia at levels of 3 mEq/L or
ELECTROLYTE ABNORMALITIES
less is associated with severe total body potassium depletion
(usually in excess of 100 mEq). Such patients may require ECG
Disorders of Sodium Concentration monitoring and should receive I.V. potassium and have levels
Hyponatremia Hyponatremia is caused by excess free measured frequently to monitor their progress. Correction of the
water in the intravascular space [see 8:7 Disorders of Water and underlying cause of the problem is important. Potassium should
Sodium Balance]. The serum sodium concentration is not an be given only if there is reliable urine flow, however, as danger-
accurate measure of total body sodium but rather reflects the ously high potassium levels may result in anuric patients. Our
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 8
metabolic acidosis related to inadequate tissue perfusion; the net Management of Tubes and Drains
effect of this measure is a temporary elevation of serum pH asso- Guidelines for the perioperative use of tubes and drains should
ciated with an increase of CO2 production. Bicarbonate combines be developed on the basis of scientific data. For the most part,
with hydrogen ions to form carbonic acid and, subsequently, water current practices in this regard are not rigorously formulated and
and CO2. It should be noted that this increased CO2 production tested but are simply passed on to surgical trainees on little basis
can result in a worsening of intracellular acidosis if minute venti- other than surgical tradition. With the development of evidence-
lation is not increased to allow elimination of the excess CO2. based medicine, these approaches are being evaluated and chal-
Furthermore, exogenous bicarbonate eliminates the utility of lenged. As a result, this aspect of surgical care is evolving.
measuring the base deficit and may worsen oxygen delivery by
NASOGASTRIC TUBES
causing an adverse shift in the oxygen dissociation curve.
Traditionally, nasogastric tubes were routinely used in all
Metabolic Alkalosis patients undergoing GI surgery. In the past decade, however, the
Metabolic alkalosis is most often caused by a loss of hydrogen value of this routine practice for elective surgical patients has
ions from the GI tract (e.g., through vomiting or nasogastric suc- been questioned. A 1995 meta-analysis of 26 trials that included
tion) or in the urine (e.g., as a result of diuretic therapy).The loss 3,964 patients concluded that nasogastric tubes are unnecessary
of hydrogen ions is associated with the liberation of bicarbonate, in elective surgical patients and may even add to debility [see Table
as shown in the following equation: 4].43 Nasogastric decompression is appropriate on a selective
basis for any patient in whom severe nausea, vomiting, or gastric
CO2 + H2O → H2CO3 → H+ + HCO3– distention develops [see Figure 1]. Moreover, it is indicated in
Hypokalemia can result in metabolic alkalosis by causing a shift of patients with intestinal obstruction or those with severe pro-
hydrogen ions into the cell in exchange for potassium. Although longed ileus, usually related to intra-abdominal sepsis.
perceived as extracellular metabolic alkalosis, this is in fact an intra-
FINE, PLIABLE FEEDING TUBES
cellular metabolic acidosis because of the hydrogen ion shift.
Prompt repletion of potassium in the hypokalemic patient can min- The introduction of the Dobbhoff tube by Dobbie and
imize the effect of these changes. Metabolic alkalosis can also result Hoffmeister allowed routine intubation past the pylorus for feed-
from contraction of the extracellular volume.This contraction alka- ing.44 The Dobbhoff tube is a highly flexible No. 8 polyurethane
losis occurs when the lost fluid contains chloride but little or no bi- tube with two distal side holes and a mercury-weighted tip. A
carbonate, as occurs with diuretic therapy. steel wire is used to stent the tube during placement and is
Of particular significance in the postoperative period is the removed after the tube is positioned.The Dobbhoff tube and the
development of hypokalemic, hypochloremic metabolic alkalosis Entriflex tube (a similar tube with a thin, elongated distal seg-
associated with the loss of significant amounts of gastric secre- ment) are placed in a manner similar to that of a nasogastric tube
tions. This can occur either through nasogastric suction or with [see Figure 1]. Once in the stomach, the tube can be advanced
repeated vomiting. Patients develop intravascular volume con- under fluoroscopic guidance into the duodenum. Alternatively,
traction in addition to alkalosis and hypochloremia as they lose the tube can be allowed to pass spontaneously through the
volume and HCl.This development is associated with an increase pylorus by placing the patient in the right lateral decubitus posi-
in sodium and water retention in the kidney, mediated by ADH tion and allowing enough slack externally. The use of metoclo-
and aldosterone. The volume deficit, hypochloremia, and pramide can sometimes facilitate passage into the duodenum. A
hypokalemia all result in increased bicarbonate absorption by the radiograph should always be obtained before the initiation of
kidney. Paradoxical aciduria will result as bicarbonate reabsorp- feedings through a nasoenteric small-bore catheter [see Figure 2].
tion, together with sodium and potassium retention, leads to an These tubes can pass easily into the trachea even in intubated
increased hydrogen ion concentration in the urine. Treatment of patients and can cause a pneumothorax or a pneumonic process
hypokalemic, hypochloremic metabolic alkalosis is directed at if feedings are given without radiographic confirmation that the
decreasing the fluid losses, if possible, and providing significant location of the tip is correct.45,46
amounts of volume, potassium, and chloride.
LONG INTESTINAL TUBES
Chloride repletion is important because chloride is the only
reabsorbable anion in this setting. If adequate chloride is not Long intestinal tubes (e.g., the Cantor tube and the Miller-Ab-
given, electroneutrality in the distal nephron can be maintained bott tube) are occasionally used in patients with partial small-
only by the excretion of hydrogen ions. Since the patient is vol- bowel obstruction early after operation, although mechanical bowel
ume contracted, no excess sodium ions are available for excre- obstruction usually necessitates early operation. Use of long intes-
tion, and hypokalemia precludes the excretion of potassium ions. tinal tubes should be reserved for selected patients who are not
Bicarbonate is being reabsorbed avidly at this time.Thus, as sodi- candidates for early reoperation. Because movement distally is
um is reabsorbed in the hypovolemic state, hydrogen ions will of dependent on peristalsis, these tubes are of little value in patients
necessity be excreted in the urine. If chloride is provided in ade- with paralytic ileus. The Cantor tube is made of silicone-coated
quate amounts, it will be reabsorbed with sodium, thus obviating polyvinyl chloride and has a small balloon tip.The tip is filled with
excretion of hydrogen ion (or potassium ions if they are available) mercury, passed through the nose, and allowed to advance into the
to maintain electroneutrality. small intestine either passively or under fluoroscopic guidance;
Metabolic alkalosis can be divided into two varieties: saline there, it will aspirate fluid and gas. Removal of the tube is accom-
responsive and saline resistant. Saline-responsive metabolic alka- plished by pulling approximately 30 cm of tube out of the nose every
losis is generally caused by GI losses or by diuresis, whereas 1 or 2 hours and either taping or clamping it to prevent slippage.
saline-resistant metabolic alkalosis is usually a consequence of
BILIARY DRAINAGE CATHETERS
either severe hypokalemia or an edematous state such as cirrho-
sis. Patients with the saline-responsive variety generally respond Biliary tract drains include cholecystostomy tubes, percuta-
well to volume expansion with sodium chloride. neous drains of the biliary tract placed under fluoroscopic con-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 10
trol, T tubes, and endoscopically placed nasobiliary tubes. or thyroid surgery.50 Postoperative drainage does, however,
Cholecystostomy tubes may be placed with the help of local anes- reduce serum formation and other wound problems after mas-
thesia in patients with advanced medical problems who cannot tectomy.51 Postmastectomy wound drainage can be managed on
tolerate general anesthesia and formal cholecystectomy. Patients an outpatient basis and thus need not hinder or delay discharge.
in whom dissection would be technically difficult and associated
FOLEY CATHETERS
with a high risk of complications can also be treated by cholecys-
tostomy tube placement. Ultrasonographically guided percuta- Foley catheters are routinely used after operation to drain the
neous cholecystostomy tube placement has gained acceptance for urinary bladder [see Figure 3]. Bladder catheterization alleviates
patients who are not considered good candidates for operation. the patient’s discomfort and allows precise monitoring of urine
The use of T tubes is generally limited to operative exploration output.When interpreted in the appropriate clinical situation, few
or repair of the common bile duct (CBD). In most cases, the CBD measurements are more valuable than urine output. However,
is explored for the presence of stones. The duct is then closed placement of a Foley catheter can lead to a number of complica-
around the T-shaped end of the tube to stent the duct. The long tions, the most common of which is urinary tract infection.
end of the T tube is then brought out of an incision, sutured to the Among general surgery patients, the overall infection rate is
skin, and attached to a drainage bag. The exit site should be cho- 10%, and 26% of these infections occur secondary to urinary
sen to allow direct percutaneous access into the distal CBD tract infections52; for example, 49% of orthopedic infections and
should this become necessary for later stone extraction or duct 75% of urologic and medical infections are related to urinary
manipulation. A T tube usually drains most of the bile produced tract infections. The distal urethra is usually colonized with bac-
(600 to 700 ml daily) initially. A decrease in the volume of bile teria. Even one catheterization of the bladder will result in urinary
drained indicates patency of the distal duct and free flow into the tract infection in 1% of ambulatory patients.52 Infection will
duodenum. At 7 to 10 days after the operation, a cholangiogram develop within 3 to 4 days of catheterization in 95% of patients
is obtained to assess the patency of the CBD and look for stones. managed with indwelling catheters and open drainage systems.52
I.V. antibiotics should be administered during cholangiography. A A variety of organisms can cause urinary tract infection.
normal cholangiogram shows no stones; a patent, nondilated Escherichia coli is by far the most common pathogen, although
CBD without leakage; and free flow of contrast medium into the other Enterobacteriaceae are also common. Staphylococci, strep-
duodenum.The tube can be removed by gentle withdrawal; alter- tococci, and enterococci also frequently cause urinary tract infec-
natively, the tube is clamped, and if the patient continues to do tion. Dysuria can be a symptom of urinary tract infection; how-
well, it is removed on an outpatient basis after 1 to 2 weeks. If the ever, infection may often present only as fever or a septic
cholangiogram is abnormal, the T tube should be left to drain and response. Diagnosis is based on microscopic examination of the
the problem addressed either through the tract of the T tube or by urine and urine culture [see 8:16 Nosocomial Infection]. Urinary
means of endoscopic retrograde cholangiopancreatography. tract infection can be prevented by (1) avoiding nonessential
Nasobiliary tubes are placed at the time of endoscopic evalua- catheterization, (2) allowing only trained personnel to insert
tion of the biliary tree, usually to alleviate CBD obstruction. catheters, (3) using meticulous aseptic technique to avoid intro-
These tubes are left to drain by gravity and can otherwise be duction of bacteria, (4) adequately securing the catheter after
managed in much the same fashion as nasoenteric tubes. insertion so it does not move in and out of the urethra and the
bladder, (5) maintaining proper drainage, and (6) removing the
DRAINS catheter at the earliest possible opportunity.
Various tubes and associated devices have been used to drain Few controlled studies have been published that address the
purulent materials, blood, or serum from body cavities. These optimal duration of bladder catheter drainage. One study sug-
include Penrose drains (very soft rubber tubes with a gauze gests that such drainage should be limited to about 3 days after a
wick), closed suction drains (e.g., Jackson-Pratt or Hemovac major low-rectal operation and to about 1 day after other types of
drains), and sump drains (multiple-lumen tubes that draw air colon operations.53 Epidural drug administration in the postop-
into one interior lumen and fluid from a companion tube). erative period should not be an indication for bladder drainage
Controlled clinical trials in elective surgical patients indicate that beyond 24 hours.54
routine use of drains does not improve outcome for patients
undergoing cholecystectomy,47 laminectomy,48 colon surgery,49 Antinausea Prophylaxis
Postoperative nausea and vomiting are common problems and
Table 4 Meta-analysis of 26 Clinical Trials of are best treated pharmacologically unless intestinal obstruction
Selective versus Routine Nasogastric Decompression43 or severe ileus exists. For example, H2-receptor antagonists and
dexamethasone have been shown to be effective if given periop-
eratively. Droperidol may also be effective, and a 1999 random-
Selective Routine
Decompression Decompression P ized trial suggested that supplemental oxygen may also reduce
nausea and vomiting.2
Total no. of patients 1,986 1,978 — The use of local and regional anesthetic techniques reduces
patient exposure to agents such as nitrous oxide, which predis-
Patients with complications 833 1,084 < 0.03
poses to nausea. Administration of NSAIDs instead of a narcotic
Patients with pneumonia 53 119 < 0.0001 also reduces the incidence of this complication.
Patients with atelectasis 44 94 0.001
Ambulation and Nutrition
Patients with fever 108 212 0.02
Traditional postoperative care generally included bed rest,
Time to oral feeding (days) 3.53 4.59 0.04
which is now considered undesirable in that it increases muscle
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 11
a c
Straight Catheter
b c
Figure 3 The Foley catheter is the primary type of catheter utilized for long-term bladder catheterization (a). If the bladder is
to be catheterized a single time, however, a straight catheter without a balloon is used. When difficulty is encountered in passing
a Foley catheter (often in men with an enlarged prostate gland), a curved-tip catheter, or coudé catheter, can often be passed by
experienced personnel. The smallest-diameter catheter that will accomplish the task should be selected (16 French to 24 French
for adult men, 16 French to 26 French for adult women). Before insertion, the balloon at the end of the Foley catheter should be
tested, the patient’s genital area cleansed, and the tip of the catheter well lubricated. In men, the penis should be held erect and
the catheter inserted into the meatus and advanced gently until urine returns (b). In women, the labia should be gently spread,
the urethral meatus located, and the catheter gently inserted until urine returns. In both men and women, once urine returns,
the catheter is then advanced a little farther to ensure that the balloon does not lie in the urethra. The balloon is inflated by the
injection of 5 to 10 ml of saline solution through the balloon port. After insertion is completed, the exterior portion of the
catheter is taped to the patient’s thigh (c). Once it is no longer necessary, the catheter should be removed. Removal consists of
deflating the balloon and then withdrawing the catheter as gently as possible.
RESPIRATORY COMPLICATIONS
al status.73 The surgeon should be alert for the presence of angina,
cardiac valve disease, and arrhythmias, including heart block, ven- Pulmonary complications are common after operative proce-
tricular arrhythmias, and supraventricular tachycardia.74,75 dures. In one study, dependent atelectasis (3.4% of lung vol-
Hypertension in the postoperative period frequently occurs ume) developed in 100% of patients 5 to 10 minutes after
secondary to pain or hypoxia. Initial treatment, therefore, consists administration of anesthesia78; 1 hour later, atelectasis was pres-
of administering adequate analgesia to control pain and ensuring ent in 90% of the patients, and 24 hours after operation, it was
adequate oxygenation. Once pain is alleviated and hypoxia cor- present in 50%. Up to 40% of obese patients show evidence of
rected, drug treatment may be considered. A variety of agents are basal pulmonary atelectasis on initial postoperative x-ray.79
available for the treatment of hypertension [see Table 5].76,77 The Postoperative respiratory complications include atelectasis, aspi-
physician should generally become familiar with one or two med- ration pneumonia, and other pneumonias. A variety of factors con-
ications and use them with confidence rather than try to master tribute to the development of these complications, and various ap-
a large number of them. proaches have been used to prevent and treat them. For example,
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 14
abdominal incisions cause pain, which limits the patient’s activity to rib cage breathing.80 This shift begins to reverse after 24 hours.
and shifts predominantly abdominal breathing to chest wall breath- However, the placement of the incision can influence the risk of
ing. Fluoroscopy of the diaphragm after operation has demonstrat- postoperative respiratory compromise. For example, lower abdom-
ed reduced diaphragmatic movement, with a shift from abdominal inal and transverse incisions are associated with a lower rate of com-
Onset Mechanism
Drug Administration Side Effects Indications/Contraindications
of Action of Action
plications and a lower rate of respiratory compromise than longitu- to 23%.93 Approximately one third of deaths occur in the first
dinal or midline incisions.81 Other factors that increase the risk of hour after embolism; however, as many as 90% of patients survive
postoperative pulmonary complications include age, underlying dis- long enough to be evaluated and for therapeutic intervention to
ease, malnutrition, and chronic obstructive pulmonary disease with be considered. Aggressive early anticoagulation therapy is associ-
subsequent colonization.82,83 ated with 90% survival. Up to 95% of pulmonary emboli origi-
A variety of preoperative, intraoperative, and postoperative respi- nate in the deep veins of the leg; a small percentage originate in
ratory treatments are available that may be valuable in preventing se- pelvic veins and at other sites. There have been reports of pul-
rious postoperative pulmonary complications. Preoperative treat- monary emboli originating in veins of the upper extremities, but
ment with incentive spirometry and chest physical therapy has been such cases are exceedingly uncommon.
studied and appears to be of some value in improving patients’ over- Dyspnea is the most common symptom of pulmonary
all pulmonary status in preparation for operation.84 Smoking should embolism and is usually of sudden onset. Dyspnea can be tran-
be discontinued, and underlying pulmonary infection such as bron- sient. The most common physical finding is tachypnea. Rales are
chitis or pneumonia should always be treated and operation delayed present in 50% of cases. Circulatory collapse characterized by
if possible because the ciliary paralysis that occurs with the use of shock or syncope occurs in 20% of patients with pulmonary
anesthetics has the potential for causing a severe pneumonia after embolism and correlates with larger emboli. Although most
operation. patients with pulmonary embolism are hypoxemic, a PaO2 greater
Routine respiratory therapy is frequently used postoperatively than 80 mm Hg was found in 10% of patients in the urokinase-
to prevent pulmonary complications. Routine therapeutic mea- streptokinase pulmonary embolus trial.The chest x-ray, although
sures include administration of bronchodilator aerosol or ultra- it may be abnormal, is commonly nondiagnostic.The most com-
sonic mist aerosol, IPPB, incentive spirometry, and oxygen ther- mon abnormalities evident on the electrocardiogram are T wave
apy. However, some studies have questioned the value of many of inversion, nonspecific ST segment elevation or depression, and
these respiratory treatments.85,86 One study demonstrated that a sinus tachycardia.Ventilation-perfusion scans are frequently valu-
hospital-wide effort to reduce the use of specific respiratory ther- able in ruling out pulmonary embolism in a patient with a clear
apy services did not adversely affect patient outcome.87 For chest x-ray, but some data cast doubt on the utility of a ventila-
example, administration of beta agonists was successfully tion-perfusion scan result of low or intermediate probability.93,94
switched from air-driven aerosols to handheld nebulizers.The use If the lung scan is equivocal, pulmonary angiography should be
of IPPB was almost completely eliminated, and treatment by performed. Pulmonary arterial pressures are routinely elevated in
incentive spirometry was reduced by 55%. The decrease in the patients with significant pulmonary embolism. The role of spiral
use of incentive spirometry occurred in the late postoperative CT in the detection of pulmonary embolism has not yet been
period, when, studies suggest, it is no longer of value. In patients fully defined; its specificity is good, but its sensitivity is poor as a
at high risk, such as those undergoing upper abdominal opera- consequence of its inability to detect subsegmental emboli.95
tion, respiratory therapy is most beneficial when performed in the Treatment of pulmonary embolism is supportive and includes
immediate postoperative period. Patients treated with incentive administration of oxygen, adequate maintenance of fluid resusci-
spirometry return more rapidly to preoperative pulmonary lung tation, and rapid I.V. anticoagulation. If heparin is used, it is given
volumes than do untreated patients.84 In this study, use of ultra- in an 80 U/kg bolus, then infused at a rate of 18 U/kg/hr.96 The
sonic nebulization was also decreased markedly, whereas oxygen partial thromboplastin time (PTT) is then adjusted according to a
therapy was retained at about the same level.87 Aerosol ultrason- nomogram.97 Low-molecular-weight heparin can be used for pro-
ic nebulization and mist aerosol are of little or no value. phylaxis and treatment of both deep vein thrombosis (DVT) and
Early mobilization after operation is believed to improve the pa- pulmonary embolism.98 Patients who cannot receive heparin99 or
tient’s overall respiratory status. In several studies, early mobilization other forms of prophylaxis or who exhibit continued or recurrent
appeared to be as effective in improving overall respiratory status as signs and symptoms of pulmonary embolus should be strongly
chest physical therapy.88,89 Early mobilization (i.e., turning every 2 considered for vena caval filter placement.100 Some patients may
hours) in coronary artery bypass patients was shown to decrease the benefit from thrombolytic therapy administered early, but this
incidence of atelectasis and pneumonia significantly. In high-risk option is generally not available for postoperative patients.101
patients, routine postoperative prophylactic chest physical therapy
has been shown to decrease the frequency of pulmonary infection Deep Vein Thrombosis
significantly.90 However, in a study of children undergoing cardiac Some degree of DVT develops in approximately 30% of
procedures, chest physical therapy had no effect on the develop- patients after abdominal or thoracic procedures and in up to 80%
ment of pulmonary atelectasis.91 of patients after hip procedures [see 6:6 Venous Thromboembolism].
Atelectasis indicates pulmonary dysfunction and may also Some reviews suggest that routine prophylaxis is justified in all
presage pneumonia. Postoperative pneumonia is an extremely seri- surgical patients who are at high risk for DVT (e.g., those older
ous complication and is a major cause of mortality on surgical ser- than 40 years, obese patients, patients with malignant disease,
vices. Factors that increase the risk of postoperative pneumonia in- patients with prior DVT or pulmonary embolism, or patients
clude advanced age, gram-negative bacterial infection, emergency undergoing long, complicated operative procedures). Low-dose
operation, use of a ventilator, and postoperative peritonitis. unfractionated heparin (5,000 units subcutaneously every 12
hours) should be given until the patient is ambulatory. Increasing
THROMBOEMBOLISM
the frequency of administration does not decrease the incidence
of emboli but does increase the risk of hemorrhagic complica-
Pulmonary Embolism tions.The addition of dihydroergotamine to heparin may improve
Pulmonary embolism is the most common fatal acute pul- efficacy, but the risk associated with its vasoconstrictor effects
monary disorder in hospitalized patients [see 6:6 Venous Throm- may outweigh its potential benefits. Dextran in an initial dose of
boembolism]. In the United States, pulmonary embolism occurs in 10 ml/kg appears to be equally effective in decreasing the risk of
more than 250,00 patients each year92; mortality ranges from 8% pulmonary embolism but is more expensive. Dextran 70 and dex-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 16
tran 40 appear to be equally efficacious. External pneumatic complications, which include hemolytic transfusion reactions,
compression and gradient elastic stockings can also be employed nonhemolytic transfusion reactions, and transmission of infection
to prevent DVT. (e.g., hepatitis, AIDS, cytomegalovirus, and herpesvirus). In
Findings from several reviews suggest that mortality from pul- addition, blood transfusion itself may be a significant immuno-
monary embolism is decreasing and that effective prophylaxis with depressant.112-115 In the past, it was typically considered reason-
either subcutaneous heparin or pneumatic compression devices able to order a blood transfusion when the hematocrit measured
can decrease the risk of DVT and pulmonary embolism.102-104 30% or less. Today, however, there are few, if any, situations in
To achieve optimal results, prophylaxis must be started before the which this practice should be followed. For example, in a young
operative procedure begins. healthy patient who has no other disease and is expected to con-
tinue to improve, hematocrits in the low to middle 20s are accept-
CENTRAL VENOUS CATHETER COMPLICATIONS
able. This restrictive approach to red blood cell transfusion is as
Central venous catheters, arterial catheters, and triple-lumen effective as, and possibly superior to, a liberal transfusion
catheters may be associated with such complications as perfora- approach in ICU patients.116 In addition, patients with a variety
tion of the vascular system, thrombi, and infection. In one study, of other chronic diseases that lead to persistently low hematocrits
complications related to initial catheter placement occurred in (e.g., chronic renal insufficiency) have been safely observed at rel-
5.7% of patients, sepsis occurred in 6.5%, and mechanical com- atively low hematocrit levels without transfusion.
plications occurred in 9%.105,106 Complications of catheter place- Alternatives to transfusion include autologous donation,
ment are hemorrhage and pneumothorax. The most common hemodilution, cell-saving techniques, oxygen-carrying solutions
late mechanical complications are major venous thrombosis and (both perfluorocarbon-based and hemoglobin-based), and
nursing mishaps. Central venous thrombophlebitis and sepsis recombinant erythropoietin. Autologous donation, hemodilution,
usually necessitate immediate removal of the central venous and cell saver techniques require considerable advanced planning
catheter and antibiotic therapy. In some patients with Silastic and are not cost-effective for widespread use. Perfluorocarbon-
catheters, treatment with I.V. antibiotics and anticoagulants and based and hemoglobin-based oxygen-carrying solutions are, at
careful monitoring for potential exploration and drainage of present, still investigational.117 Recombinant erythropoietin has
perivascular infection or vein excision may be indicated.105 Other been used in anemic medical patients since 1989 and in surgical
studies have shown that administration of antibiotics through the patients since 1997.118 The indications and end points for its use
indwelling catheter is effective. In one study of catheter-associat- have not yet been fully defined.
ed infections, 18 patients (86%) were cured without removal of
DIABETES MELLITUS
the catheter. Absolute indications for catheter removal are lack of
defervescence and continued positive blood cultures despite The diabetic patient presents a series of management problems
antibiotic therapy.106 An effective method of assessing catheter in the postoperative period. Careful management of blood glu-
contamination in patients with central lines in place is routine cose levels is necessary to avoid hypoglycemia or hyperglycemia
catheter exchange and culture [see 8:16 Nosocomial Infection]. with associated complications such as diabetic ketoacidosis and
Studies have shown a direct link between catheter infection and dehydration secondary to glycosuria. Diabetes has a significant
contamination of the site.To avoid mechanical complications, an negative impact on wound healing. For patients whose disease is
x-ray should be obtained after insertion of any central line to doc- managed by diet alone, additional measures are usually unneces-
ument its position.The catheter should be evaluated every 2 to 7 sary. In the postoperative period, careful monitoring, including
days to ensure that it has not migrated or been displaced. finger-stick glucose measurements every 6 hours, is appropriate,
with a sliding scale of regular insulin administered as needed. In
UPPER GASTROINTESTINAL BLEEDING
patients who are receiving oral hypoglycemic agents, the medica-
Before the advent of routine administration of antacids, life- tion should be discontinued on the day before operation, and
threatening upper GI bleeding was a common problem in patients insulin should be given as needed for hyperglycemia. Patients who
undergoing major stress, particularly in those with head injury, require insulin should be given a dextrose infusion and one half of
burns, or multiple trauma. A number of agents have been used for the total daily dose of insulin as regular insulin the morning of the
prophylaxis, including antacids, sucralfate, H2 receptor antago- operation. Glucose is administered throughout the operation, as
nists, and proton pump inhibitors.The antacid regimen for bleed- guided by measured glucose levels. In patients who require major
ing prophylaxis is 30 to 60 ml by nasogastric tube every 1 to 2 operations and massive fluid administration, blood glucose should
hours to maintain gastric pH above 4. According to one study, be measured frequently during operation, and insulin should be
sucralfate may also be effective for bleeding prophylaxis.107 By given I.V. as needed. Postoperatively, glucose levels in some
comparison, H2 receptor antagonists have not proved to be more patients will be well controlled by administration of insulin on a
effective than antacids in preventing major upper GI bleed- sliding scale based on finger-stick glucose monitoring.
ing.108,109 Agents that elevate gastric pH may increase the risk of Shock, major trauma, or extremely prolonged operations can
nosocomial pneumonia by favoring gastric colonization.110 Proton lead to hypoperfusion of the skin and subcutaneous tissue. In
pump inhibitors significantly reduce rebleeding rates and offer an these patients, subcutaneous administration of insulin is inappro-
alternative to H2 receptor antagonists.111 With adequate prophylax- priate and dangerous. Instead, monitoring in the ICU, with fre-
is, the incidence of massive upper GI bleeding is essentially zero. quent glucose measurements, and treatment with I.V. insulin
should be undertaken. Dextrose should be included in postoper-
POSTOPERATIVE TRANSFUSION AND ANEMIA
ative administration of fluids.
A decreased hematocrit and relative anemia occur very com-
OTHER ENDOCRINE COMPLICATIONS
monly after major operative procedures. In patients with these
conditions, blood transfusion is often considered [see 1:4 Bleeding Another postoperative endocrine complication is hypothy-
and Transfusion]. It is important, however, to avoid unnecessary roidism, which usually occurs in the elderly. Hypothyroidism is
transfusions because of the potential for transfusion-associated frequently associated with (1) a low temperature and (2) a low
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 17
comes into focus, it can be compared with the new limitations spent in 1988, compared with $15 billion in 1999. Between 1980
and needs that may have resulted from the illness or injury that and 1997, home health care costs increased from $842/recipient
necessitated the hospitalization. One should always remember to $6,595/recipient.121
that functioning well in the hospital setting and being indepen-
dent at home, work, or school can be dramatically different. Extended Care Facilities
A number of options are available for acute care placement for Extended care facilities, such as rest homes, nursing homes,
those patients who have special care needs after discharge [see and rehabilitation centers, are often very successful in maximizing
Table 7]. They fall into two categories: in-home care and extend- a patient’s potential for independence. They offer more intensive
ed care facilities. skilled therapies than are offered by home health agencies and
provide supervision and assistance with activities of daily living
In-Home Care that can be difficult for working family members to provide. Re-
In-home care consists of home health services, private duty habilitation facilities are distinguished from skilled nursing facili-
nurses, and community resources such as Meals on Wheels and ties primarily by the amount of activity an individual patient can
transportation services. For patients who can be discharged endure. The standard amount of activity for a rehabilitation cen-
home but require assistance or support, home health services ter is 3 to 4 hours a day, though this need not be constant activi-
represent an excellent alternative to continued hospitalization. ty. Physical therapists, occupational therapists, and speech thera-
Home health agencies can provide skilled nursing care, assistance pists can assist in making judgments about a patient’s endurance,
in the home (homemakers or aides), physical therapy services, potential, and goals for independence.
speech therapy services, occupational therapy services, and med- Patients who require assistance with convalescence that cannot be
ical social worker support [see Table 8]. These patients must be provided in their home setting are most often referred to a rest home
otherwise independent, as home health agencies do not provide facility.This is a relatively cost-effective alternative and is generally
long periods of custodial care. Patients who require greater assis- an intermediate step before the patient returns to a home setting.
tance must therefore either hire private duty nurses or consider Patients who require a higher level of care than that provided in
an extended care facility as an alternative after discharge. either a rest home or through home health care require admission
Home health agencies charge per service per visit. Charges for to a nursing home. A nursing home is either an intermediate care
skilled therapies, such as skilled nursing, occupational therapy, and facility or a skilled nursing facility. At an intermediate care facility,
physical therapy, may cost up to $100 a visit or an hour.These fees registered nurses or licensed practical nurses are on duty for at least
are comparable to those charged in acute care facilities. Charges for 4 hours a day to tend to patients’ special medical needs; addition-
nonskilled assistance range from a few dollars an hour to as high as al care is provided full time by trained staff who are not registered
$15 an hour. Services offered through home health providers are or practical nurses. Patients who require round-the-clock care from
time limited under Medicare and Medicaid rules. either a registered nurse or a licensed practical nurse must be
The use of home health services has increased dramatically admitted to a skilled nursing facility. Such patients include those
over the past decade. Medicare data indicate that $2.1 billion was who are potentially unstable or who may have a special need such
Approximate
Facility Insurance Coverage Services Offered
Daily Cost ($)
Medicaid
Rest home 40–60* Convalescent care
Private payment plans
Medicaid
Skilled nursing, 4 hr a day
Private payment plans
Intermediate care facility 85–135* Other skilled services (e.g., physical and occupational therapy) only
Medicare will cover skilled services on contractual basis
but not room and board
Medicaid
Medicare (for 100 days) Skilled nursing, 24 hr a day
Skilled nursing facility 100–150* Other skilled services (e.g., physical and occupational therapy) only
Some insurance plans
on contractual basis; some provide in-house physical therapy
Private payment plans
Medicare
All skilled services (physical, occupational, and speech therapy) pro-
Medicaid
Rehabilitation facility 800–1,000 vided in-house
Some insurance plans
Intensive therapy provided 3–5 hr a day
Private payment plans
*Includes only room and board; additional fees required for therapies and medications.
Prices reflect average cost in 1998 based on semiprivate room rates.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 19
tient physical therapy at a local hospital or clinic may be a good imum. Nursing homes and rehabilitation facilities have no such
option to enable the patient to live at home. This option, howev- mandate, however. They set aside a limited number of beds for
er, requires extensive family support to provide transportation to Medicare and Medicaid patients, but these tend to be in high
therapy and care in the home. demand and may represent a resource drain for these facilities.
Patients who are not eligible for Medicare can sometimes be
Services for Indigent Patients enrolled in Medicaid programs. Patients who are not eligible for
Patients without insurance and with no available financial Medicaid assistance will have to spend their private funds until
resources can present a difficult problem for discharge planners. they qualify for Medicaid. In general, adults are eligible for
Most home health agencies are mandated to set aside funds for Medicaid if they are disabled, have dependent children, or have
indigent clients, but the services provided tend to be the bare min- inadequate financial resources.
References
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1 Basic Surgical and Perioperative Considerations 6 ROUTINE POSTOPERATIVE MANAGEMENT — 21
52. Sobel JD, Kaye D: Urinary tract infections. Principles 77. Halpern NA, Goldberg M, Neely C, et al: Postopera- 100. Greenfield LJ, Peyton R, Crute S, et al: Greenfield
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53. Benoist S, Panis Y, Denet C, et al: Optimal duration 20:1637, 1992 bolism. Am J Surg 163:375, 1992
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55. Kovacevich GJ, Gaich SA, Lavin JP, et al:The preva- Anaesth Intensive Care 13:399, 1985 boembolism in general surgical patients: a meta-
lence of thromboembolic events among women with 80. Ford GT, Whitelaw WA, Rosenal TW, et al: Di- analysis. Ann Surg 208:227, 1988
extended bed rest prescribed as part of the treatment aphragm function after upper abdominal surgery in 104. Geerts WH, Heit JA, Clagett GP, et al: Prevention of
for premature labor or preterm premature rupture of humans. Am Rev Respir Dis 127:431, 1983 venous thromboembolism. Chest 119(1 suppl):132S,
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56. Convertino VA, Goldwater DJ, Sandler H: Effects of monary function after transverse or midline incision 105. Wang EE, Prober CG, Ford-Jones L, et al:The man-
orthostatic stress on exercise performance after in patients with obstructive pulmonary disease. In- agement of central intravenous catheter infections.
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57. Kehlet H, Mogensen T: Hospital stay of 2 days after 82. Lawrence VA, Dhanda R, Hilsenbeck SG, et al: Risk 106. Verghese A,Widrich WC, Arbeit RD: Central venous
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58. Yeung RS, Buck JR, Filler RM: The significance of 83. Mitchell CK, Smoger SH, Pfeifer MP, et al: Multi- 107. Borrero E, Ciervo J, Chang JB: Antacid vs sucralfate
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17:347, 1982 tive pulmonary complications following general elec- abdominal aortic surgery: a randomized trial in 50
59. Galicier C, Richet H: A prospective study of postop- tive surgery. Arch Surg 133:194, 1998 patients. Arch Surg 121:810, 1986
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Control 6:487, 1985 of incentive spirometry on pulmonary volumes after lactic therapy for stress ulcer bleeding: a reappraisal.
60. Locker D, Norwood SH,Torma MJ, et al: A prospec- laparotomy. Acta Anaesthesiol Belg 33:203, 1982 Ann Intern Med 106:562, 1987
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61. Trowbridge PE: A randomized study of cholecystec- treatment of postoperative atelectasis following ab- 110. Driks MR, Craven DE, Celli BR, et al: Nosocomial
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stet 155:171, 1982 86. Pontoppidan H: Mechanical aids to lung expansion compared with antacids or histamine type 2 blockers.
62. Soper DE: Delayed hemolytic transfusion reaction: a in non-intubated surgical patients. Am Rev Respir N Engl J Med 317:1376, 1987
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Sci 19:267, 1983 55:1113, 1983
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65. Bernard GR, Vincent JL, Laterre PF, et al: Efficacy 89. Castillo R, Haas A: Chest physical therapy: compara- et al: Blood transfusions and prognosis in colorectal
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115. Fong Y, Karpeh M, Mayer K, et al: Association of pe-
66. Slotman GJ, Jed EH, Burchard KW: Adverse effects 90 Connors AF Jr, Hammon WE, Martin RJ, et al: rioperative transfusions with poor outcome in resec-
of hypothermia in postoperative patients. Am J Surg Chest physical therapy: the immediate effect on oxy- tion of gastric adenocarcinoma. Am J Surg 167:256,
149:495, 1985 genation in acutely ill patients. Chest 78:559, 1980 1994
67. Valeri CR, Cassidy G, Khuri S, et al: Hypothermia- 91. Reines HD, Sade RM, Bradford BF, et al: Chest 116. Hebert PC, Wells G, Blajchman MA, et al: A multi-
induced reversible platelet dysfunction. Ann Surg physiotherapy fails to prevent postoperative atelecta- center, randomized, controlled clinical trial of trans-
205:175, 1987 sis in children after cardiac surgery. Ann Surg fusion requirements in critical care. N Engl J Med
68. Luna GK, Maier RV, Pavlin EG, et al: Incidence and 195:451, 1982 340:409, 1999
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29:605, 1998 thromboembolism. JAMA 279:458, 1998 cell transfusion. Curr Opin Hematol 8:405, 2001
70. Ku J, Brasel KJ, Baker CC, et al: Triangle of death: 94. Bone RC: Ventilation/perfusion scan in pulmonary 119. Freedman VA, Berkman LF, Rapp SR, et al: Family
hypothermia, acidosis, and coagulopathy. N Horizons embolism: “the emperor is incompletely attired” (ed- networks: predictors of nursing home entry. Am J
7:61, 1999 itorial). JAMA 263:2794, 1990 Public Health 84:843, 1994
71. Lee TH, Marcantonio ER, Mangione CM, et al: Der- 95. Garg K: CT of pulmonary thromboembolic disease. 120. Naylor MD, Brooten D, Campbell R, et al: Compre-
ivation and prospective validation of a simple index Radiol Clin North Am 40:111, 2002 hensive discharge planning and home follow-up of
for prediction of cardiac risk of major noncardiac hospitalized elders: a randomized clinical trial. JAMA
surgery. Circulation 100:1043, 1999 96. Hirsh J,Warkentin TE, Raschke R, et al: Heparin and
low-molecular-weight heparin: mechanisms of ac- 281:613, 1999
72. O’Kelly B, Browner WS, Massie B, et al:Ventricular tion, pharmacokinetics, dosing considerations, moni- 121. Social Security Bulletin. Annual statistical supple-
arrhythmias in patients undergoing noncardiac toring, efficacy, and safety. Chest 114:489S, 1998 ment, 1997. Annu Stat Suppl Soc Secur Bull, Dec
surgery. JAMA 268:217, 1992 1997, p 1
97. de Groot MR, Buller HR, ten Cate JW, et al: Use of a
73. Fleisher LA, Eagle KA: Lowering cardiac risk in non- heparin nomogram for treatment of patients with ve-
cardiac surgery. N Engl J Med 345:1677, 2001 nous thromboembolism in a community hospital.
74. Pritchett ELC: Management of atrial fibrillation. N Thromb Haemost 80:70, 1998
Engl J Med 326:1264, 1992 98. Hirsh J, Warkentin TE, Shaughnessy SG, et al: He- Acknowledgments
75. Salerno DM, Anderson B, Sharkey P, et al: Intra- parin and low-molecular-weight heparin: mecha-
venous verapamil for treatment of multifocal atrial nisms of action, pharmacokinetics, dosing, monitor- Figures 1a, 3 Tom Moore.
tachycardia with and without calcium pretreatment. ing, efficacy, and safety. Chest 119:64S, 2001 Figures 1b, 1c, 2 Courtesy of Samir M. Fakhry, M.D.
Ann Intern Med 107:623, 1987 99. Laster J, Cikrit D, Walker N, et al: The heparin-in- The authors wish to thank Ms. Eva Powell, M.S.W.,
76. Calhoun DA, Oparil S: Treatment of hypertensive duced thrombocytopenia syndrome: an update. for her invaluable contributions to the section on hos-
crisis. N Engl J Med 323:1177, 1990 Surgery 102:763, 1987 pital discharge planning.
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 1
Small or superficial wound that will heal Fresh, acute wound with viable wound
secondarily within 2 weeks margins, limited bacterial contamination,
and no unusual problems with foreign
Example: bodies or hemorrhage
Puncture wounds
Superficial abrasions Examples:
Secondary healing: Dog-bite wounds
Clean and dress the wound and allow it Kitchen-knife wounds
to heal. Surgical wounds
Primary closure:
Proceed immediately to consideration of
method of wound closure.
Choices:
Direct approximation
Skin graft
Flap (local or distant)
Simplest method possible in a given situation is preferred.
Provide general or local anesthesia as needed; prepare
wound for closure.
Wound with edges in proximity Wound edges cannot be Wound edges cannot be
approximated; wound contains no approximated, and a skin graft
Close wound by direct denuded bones, cartilage, nerve, or is not possible or desirable
approximation. tendon; and a skin graft is cosmetically
Consider use of drains. and functionally acceptable Utilize a flap for wound closure.
Consider use of drains.
Apply a skin graft.
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 3
Acute wound with Acute wound with questionably Acute or neglected wound with
uncontrollable hemorrhage viable tissue or extreme excessive bacterial contamination
contamination with foreign bodies
Example: Example:
Wound in a hemophiliac Examples: Human-bite wounds
Tertiary closure: Wounds with embedded road tar Tertiary closure:
Pack or wrap wound tightly until Wounds with severely contused Debride and irrigate wound and
bleeding is controlled; then tissue initiate dressing changes with
proceed with closure. Tertiary closure: antibacterial cream until bacterial count
Proceed with debridement of foreign is < 105/g tissue; then proceed with
bodies and necrotic tissue, and initiate closure.
dressing changes until wound is clean;
then proceed with closure.
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 4
are particularly prone to cellulitis, and antibiotics are indicated by staphylococci or streptococci, and gram-positive coverage is
when such extremities are wounded. Stool-contaminated wounds generally indicated. The presence of crepitus or a foul smell sug-
and human-bite wounds are considered infected from the mo- gests a possible anaerobic infection. Initial antibiotic choices are
ment of infliction and must be treated with antibiotics [see 3:2 made empirically; more specific antibiotic treatment can be insti-
Soft Tissue Infection].4,5 As a rule, dog-bite wounds are less severely tuted when the results of bacterial culture and sensitivity studies
contaminated with bacteria; however, a 1994 meta-analysis sug- become available.
gested that prophylactic antibiotics are probably beneficial in this
setting.6 In addition, antibiotic prophylaxis is often indicated for
wounds with extensive amounts of devitalized tissue (e.g., farm Timing of Wound
injuries). Closure
When antibiotic prophylaxis is called for, the agent or agents The goal of acute wound
to be used should be selected on the basis of the bacterial species management should be a
believed to be present. Staphylococcus aureus, α-hemolytic strep- closed, healing wound.The
tococci, Eikenella corrodens, Haemophilus species, and anaerobes first issue to address is the
are often cultured from human-bite wounds.4,5 To cover these timing of closure.The choices
species, a broad-spectrum antibiotic or combination of antibi- are (1) primary closure,
otics should be administered; amoxicillin-clavulanate, a β-lacta- that is, to close the wound at the time of initial presentation; (2)
mase inhibitor, is a common choice. secondary closure, that is, to allow the wound to heal on its own;
Pasteurella multocida is the most common infecting organism and (3) tertiary closure, that is, to close the wound after a period of
in cat-bite wounds. P. multocida is also common in dog-bite secondary healing.The proper choice depends on how the follow-
wounds, though α-hemolytic streptococci and S. aureus are ing questions are answered:
frequently isolated as well.6,7 For cat-bite wounds, penicillin
alone usually suffices, whereas for dog-bite wounds, a broad- 1. Must the wound be closed, or will secondary healing pro-
spectrum agent (e.g., penicillin-clavulanate) is preferable. Muti- duce an acceptable result?
lating injuries that are caused by farm equipment are often con- 2. If closure is required,
taminated with a mixture of gram-positive organisms and gram- a. Can hemorrhage be easily controlled?
negative organisms, though not always excessively so.8 When b.Can all necrotic material and foreign bodies be clearly
antibiotics are indicated for such injuries, broad-spectrum cover- identified and excised?
age is appropriate. c. Is excessive bacterial contamination present?
The anatomic location of a wound may also suggest whether oral
Normal healing can proceed only if tissues are viable, the
flora, fecal flora, or some less aggressive bacterial contaminant is
wound contains no foreign bodies, and tissues are free of excessive
likely to be present. A Gram stain can provide an early clue to the
bacterial contamination.
type of bacteria present as well.The choice of prophylactic antibiot-
ic to be given is ultimately based on the clinician’s best judgment re- SMALL OR SUPERFICIAL WOUNDS
garding which agent or combination of agents will cover the
Superficial wounds involving only the epidermis and a portion
pathogens likely to be present in the wound on the basis of the in-
of the dermis will frequently heal secondarily within 1 to 2 weeks.
formation available.
In such wounds, the functional and aesthetic results of secondary
Antibiotics are clearly indicated if cellulitis is present when an
healing are generally as good as or better than those obtained by
injured patient is first seen.The presence of infection suggests that
primary or tertiary closure. For puncture wounds, secondary
there has been a significant delay between wounding and presenta-
healing is preferred because it diminishes the likelihood of infec-
tion for treatment. Routine soft tissue infections are usually caused
tion and produces an aesthetically acceptable scar. For wounds on
concave surfaces such as the medial canthal region and the na-
solabial region, secondary healing generally yields excellent aes-
Table 2—Immunization Schedule* thetic results.9
ACUTE WOUNDS
Tetanus-Prone Non–Tetanus-Prone
History of Tetanus Wounds Wounds WITHOUT BACTERIAL
Immunization CONTAMINATION,
(Doses)
Td† TIG Td† TIG FOREIGN BODIES,
OR NECROTIC TISSUE
Unknown or < 3 Yes Yes Yes No
3 or more No‡ No No§ No If wound closure is re-
quired, primary closure is
Note: The only contraindication to tetanus and diphtheria toxoids for the wounded patient is
a history of neurologic or severe hypersensitivity reaction to a previous dose. Local side preferred if it is feasible: it
effects alone do not preclude continued use. If a systemic reaction is suspected to represent eliminates the need for extensive wound care; the wound reaches
allergic hypersensitivity, postpone immunization until appropriate skin testing is performed.
If a contraindication to a tetanus toxoid–containing preparation exists, consider passive its final, healed state more quickly; and it minimizes patient discom-
immunization against tetanus for a tetanus-prone wound. fort. However, a wound with foreign bodies or necrotic tissue that
*Modified from the recommendations of the Centers for Disease Control and Prevention.
†
For children younger than 7 yr, diphtheria and tetanus toxoids and pertussis vaccine cannot be removed by irrigation or debridement, or a wound with
adsorbed (or diphtheria and tetanus toxoids adsorbed, if pertussis vaccine is contraindicated) excessive bacterial contamination, should not be closed primarily
is preferable to tetanus toxoid alone. For persons 7 yr of age and older, Td is preferable to
tetanus toxoid alone. (see below), nor should wounds in which hemostasis is incomplete.
‡
§
Yes, if more than 5 yr since last dose. Hematomas,10 necrotic tissue,11 and foreign bodies12 promote the
Yes, if more than 10 yr since last dose.
Td—tetanus and diphtheria toxoids adsorbed (for adult use) growth of bacteria and provide a mechanical barrier between healing
TIG—tetanus immune globulin (human) tissues.
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 5
ACUTE WOUNDS WITH High-velocity missiles such as bullets are rendered sterile by the
EXCESSIVE BLEEDING explosion required for their propulsion; therefore, deeply embedded
Hemorrhage can be readily bullets can often be left safely where they have lodged. Center-fire ri-
controlled in most wounds fle bullets and .44 magnum pistol bullets carry a large amount of ki-
with pressure, cauterization, netic energy and can produce extensive tissue damage.Wounds cre-
or ligation. Occasionally, as ated by such high-velocity missiles may have to be debrided to
with a patient with a bleed- permit excision of necrotic tissue. The mechanism of injury may
ing diathesis, primary wound suggest the possibility of a foreign body within the wound that is not
closure is precluded by inadequate hemostasis. In such cases, the immediately apparent. If a radiopaque material, such as metal or
wound should be packed or wrapped tightly and elevated if the leaded glass, is being looked for, radiographs may detect its pres-
anatomic site of the wound allows.The wound should then be re- ence. For less opaque materials, xeroradiography, magnified radi-
examined within 24 hours to determine whether hemostasis is suf- ographs, and computed tomographic scans are sometimes diagnos-
ficient to allow safe closure. If bleeding within a wound occurs after tically useful.18
closure, the course of action depends on the size of the resulting
hematoma. Small hematomas, which will be resorbed, can be ig- Identification and Debridement of Necrotic Tissue
nored. Larger hematomas, which provide a significant barrier to The necrotic tissue in most wounds can be identified and surgi-
healing, require drainage. cally debrided at initial presentation. In some wounds, there may
be a significant amount of tissue of questionable viability. If the
ACUTE WOUNDS WITH amount of questionable material precludes acute debridement,
FOREIGN BODIES OR dressing changes may be initiated.When all tissue has been identi-
NECROTIC TISSUE fied as viable or necrotic, and when the necrotic tissue has been
debrided surgically or by means of dressing changes, the wound
Foreign Bodies can be closed.
Most foreign bodies can Sometimes, a flap of tissue may be of questionable viability. Signs
be easily removed from that suggest whether tissue is viable include color, bright-red arteri-
wounds manually or de- olar bleeding, and blanching on pressure followed by capillary refill.
brided surgically. Patients injured in motorcycle accidents, however, A flap can also be evaluated acutely by administering up to 15
frequently slide along asphalt pavements for long distances at high mg/kg of fluorescein intravenously and observing the flap for fluo-
speeds, with the result that many small fragments of asphalt become rescence under an ultraviolet lamp after 10 to 15 minutes have
embedded in and beneath the skin. Exploding gunpowder also elapsed.19 Viable tissue fluoresces. Flap tissue that is thought to be
causes many small pieces of foreign material to be embedded with- devascularized, on the basis of physical examination or fluorescein
in the skin. These foreign bodies are often difficult to extract, but examination, should be debrided. If the viability of a segment of tis-
they should be removed as soon as possible after the injury. High- sue is in doubt, it may be sewn back in its anatomic location and al-
pressure irrigation with saline will remove many foreign bodies. Sur- lowed to define itself as viable or nonviable over time.
gical debridement or vigorous scrubbing with a wire brush may be In burn wounds, it is impossible to assess the extent of final tissue
required for the removal of more firmly embedded foreign material. damage at presentation because the injury can worsen during the first
If too much time elapses between injury and treatment, the embed- few days after the burn.20 Closure of the burn wound is often delayed
ded material is gradually covered and encapsulated by advancing until the depth of the injury can be more precisely defined [see 7:14
epithelium and thereby becomes sealed within the dermis. In such Rehabilitation of the Burn Patient].
instances, surgical dermabrasion is necessary for the removal of the Another type of wound in which the severity of the injury may
foreign material.13,14 not be readily apparent is the crush injury. With a crush injury,
Foreign materials such as paint, oil, and grease are sometimes there may not be an external laceration, even though tissue damage
inadvertently injected subcutaneously under pressure (600 to may be extensive.The primary concern is whether muscle damage
12,000 psi) by the spray guns used for painting, automotive body in the fascial compartments is severe enough to induce swelling suf-
work, or industrial purposes.15,16 On initial examination, the in- ficient to compromise the vascularity of the muscle. If pulses are di-
jury may appear deceptively benign in that a punctate entry minished or paresthesias are developing, the pressure within the
wound draining foreign material is often the only sign of injury fascial compartment is clearly excessive, and fasciotomies are indi-
other than edema. Nevertheless, these wounds must be treated cated. In less clear-cut cases, intracompartmental pressures may be
aggressively if extensive tissue loss is to be avoided.With some in- assessed by percutaneous placement of catheters or wicks into the
jected materials, radiographs are useful for demonstrating the ex- fascial compartments.The catheters or wicks are attached to pres-
tent of distribution. The involved area, which is frequently the sure monitors or transducers. An intracompartmental pressure
hand, should be incised, and as much of the foreign material as greater than 40 mm Hg indicates that capillary filling pressure has
possible should be surgically debrided (preferably, if the hand is been exceeded and muscle perfusion is compromised.The fascial
involved, by a surgeon who specializes in hand injuries). Because compartment must then be released to prevent ischemic muscle
the foreign material is often widely distributed in the soft tissues, damage; the fasciotomies must be performed on an emergency ba-
extensive incisions may be necessary. Antibiotics and tetanus pro- sis. If the degree of damage is not severe enough to necessitate fas-
phylaxis are also recommended.The ultimate prognosis is at least ciotomy, the injured part should be elevated and dressed in a mild-
partially determined by the type of material injected: paint is asso- ly compressive dressing to limit edema formation. If there is muscle
ciated with a particularly poor prognosis, whereas water is associ- damage, the possibility of crush syndrome with renal damage
ated with a good one.17 Early aggressive therapy does not rule out caused by rhabdomyolysis must be considered. If myoglobin is
the possibility of amputation, especially if the injected material is found in the urine, diuresis should be induced, and the urine
notably caustic. should be alkalinized.
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1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 6
ACUTE OR NEGLECTED Once bacterial control has been accomplished, the wound can
WOUNDS WITH BACTERIAL be closed. In one series, tertiary closure was successful in more
CONTAMINATION than 90% of cases when bacterial counts in tissue had diminished
to less than 10 5/g.38
An infected wound is de-
An alternative to either primary closure or dressing changes in
fined as one with bacterial
these patients is delayed primary closure, a technique developed
concentrations greater than
empirically during wartime.39 Saline-soaked gauze is packed into
105 organisms/g tissue.21,22
the wound at the time of injury, and the wound is reexamined after
β-Hemolytic streptococci
several days. If the wound appears clean, the wound edges are then
are an exception to this rule and can produce clinical infections in
approximated. If the wound appears to be contaminated at follow-
lower concentrations.23 It is often difficult to assess the degree of
up, dressing changes are instituted.This approach limits the infec-
bacterial contamination of a wound solely through visual inspection.
tion rate in potentially contaminated wounds.
Ideally, quantitative cultures are ordered so that precise informa-
When infection develops after closure of a wound, treatment in-
tion about the type and numbers of bacteria present can be ob-
volves removal of some or all of the sutures and initiation of dressing
tained. The rapid slide technique typically yields bacterial counts
changes, often with use of topical antibacterials [see Dressings, be-
within 1 hour.24 If this information cannot be obtained, the clini-
low]. Any cellulitis surrounding the wound is treated with systemic
cian must rely on more empirical information.
antibiotics [see 3:2 Soft Tissue Infection].
The age of the wound is one factor correlated with the degree of
bacterial contamination.The initial 6 to 8 hours after wounding has Surgical Wounds
been referred to as the golden period because closure can usually be
The American College of Surgeons has divided operative wounds
accomplished safely during this period. In a clinical study in a civil-
into four major categories [see Table 3].The likelihood of infection af-
ian setting, most wounds less than 5 to 6 hours old were contaminat-
ter any surgical procedure is correlated with the category of
ed with fewer than 105 bacteria/g tissue and therefore could be safely
wound.40 Wounds in classes I and II have low infection rates, where-
closed primarily.25 Experimental data suggest that bacteria trapped
as wounds in class IV have infection rates as high as 40%.
within the fibrinous exudate that forms over a wound’s surface cause
the infections seen in wounds closed after 6 to 8 hours.26,27 The bac- Wounds Resulting from Wild-Animal Bites:
teria proliferate after wounding and generally take 6 to 8 hours to Special Considerations
reach levels of 105/g tissue. The longer wounds remain open, the
Rabies prophylaxis must be considered for bite wounds from
greater the likelihood that they will become infected.25
high-risk wild animals such as skunks, raccoons, foxes, coyotes, and
The location of the injury is also significant. Lacerations of the
bats.41 Rabies is generally not a risk in bite wounds from rodents,
face, which has an abundant blood supply, are more likely to resist
rabbits, pets, and domestic animals unless the animal is acting un-
bacterial proliferation (and to do so for a longer time) than injuries
usually aggressive and is salivating excessively. If there is any possi-
to less adequately perfused areas, such as the lower extremities.28
bility that the biting animal has rabies and the animal is available, it
Immune status is also important. A wound is less likely to become
should be watched for symptoms of rabies for 10 days. If the biting
infected in a young, healthy person than in an elderly, debilitated
animal can be killed and examined, rabies can be confirmed or ex-
patient or a person receiving immunosuppressive medication.29
cluded by means of an immunofluorescent antibody study of its
The mechanism of injury can suggest whether a wound may be-
brain. If rabies is confirmed or if the biting animal is not available
come infected and what species of bacteria are most likely to be pres-
for examination and rabies is suspected, the patient should be treat-
ent in the wound [see Antibiotic Prophylaxis, above].Wounds with a
ed with both rabies immune globulin and human diploid cell vac-
high degree of bacterial contamination (e.g., human-bite wounds)
cine. Specific schedules for administration appear elsewhere [see
generally should not be closed.
3:2 Soft Tissue Infection].
An infected wound can sometimes be excised to produce a fresh,
With snakebite wounds, the possibility of envenomation must be
less contaminated wound. A 1997 study of human facial bites re-
considered. The poisonous snakes native to the United States are
ported successful wound closure when extensive debridement was
coral snakes and three species of pit vipers—namely, rattlesnakes,
performed before closure and patients were treated with antibiotics
copperheads, and water moccasins.42-44 The pit vipers can be identi-
for 1 week.30 An alternative approach to a contaminated wound is to
close it over a drain and administer topical and systemic antibiotics;
this approach has yielded low infection rates in some series.31,32 Table 3—Classification and Infection
In situations in which the nature of the injury precludes com-
plete wound excision or in which there is cellulitis of surrounding
Rates of Operative Wounds
tissues, dressing changes should be initiated. The use of certain
Infection Rate
topical agents will lead to a decreased bacterial count. Silver sulfa- Classification
(%)
Wound Characteristics
diazine (Silvadene) is used frequently because its antibacterial
spectrum is broad, it is comfortable for the patient, and it does not Clean (class I) 1.5–5.1
Atraumatic, uninfected; no entry of
commonly lead to metabolic problems such as those seen with GU, GI, or respiratory tract
other agents, such as mafenide (Sulfamylon) or silver nitrate.33,34 Minor breaks in sterile technique;
Clean-contaminated
Silver sulfadiazine may also optimize the rate of epithelialization.35 (class II)
7.7–10.8 entry of GU, GI, or respiratory
Parenteral antibiotics are not useful for killing bacteria in the tract without significant spillage
wound itself, because they do not penetrate the wound directly.36 Traumatic wounds; gross spillage
Contaminated
In experiments on animals, parenteral antibiotics have proved use- (class III)
15.2–16.3 from GI tract; entry into infected
tissue, bone, urine, or bile
ful for controlling bacteria within wounds when used in conjunc-
tion with proteolytic enzymes such as Travase.26,37 This combina- Dirty (class IV) 28.0–40.0
Drainage of abscess; debridement
tion of treatments has not been widely used clinically. of soft tissue infection
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 7
fied by the pit between the eye and nostril on each side of the head, areas.44 The venom is a neurotoxin that produces severe local pain.
the vertical elliptic pupils, the triangular shape of the head, the sin- Neurologic signs usually develop within 15 minutes and consist of
gle row of caudal plates, and the characteristic fang marks they in- muscle pain and cramps starting in the vicinity of the bite.The ab-
flict when they bite. Coral snakes have rounder heads and eyes and dominal muscles frequently become involved. Other symptoms that
lack fangs; they are identified by their characteristic color pattern, may develop are vomiting, tremors, increased salivation, paresthe-
consisting of red, yellow, and black vertical bands. Patients bitten by sias, hyperreflexia, and, with severe envenomation, shock. In sen-
any of the pit vipers must be examined for massive swelling and pain, sitive individuals, paralysis, hemolysis, renal failure, or coma may be
which, along with fang marks, suggest envenomation.The pain and seen.Treatment of black widow envenomation includes parenteral
swelling generally develop within 30 minutes of the bite, although 10% calcium gluconate, parenteral methocarbamol, and one dose
they may take up to 4 hours to become manifest. Secondary local of parenteral antivenin.
signs, such as erythema, petechiae, ecchymoses, and bullae, some-
times appear; if envenomation is extensive, systemic signs, such as
disseminated intravascular coagulation (DIC), bleeding, shock, Method of Wound
acute respiratory distress syndrome, and renal failure, may also be Closure
seen. Patients bitten by coral snakes, on the other hand, show no ob- When a wound is ready
vious local signs when envenomation has occurred. Consequently, to be closed, the appropri-
the physician must look for systemic signs, such as paresthesias, in- ate type of wound closure
creased salivation, fasciculations of the tongue, dysphagia, difficulty must be chosen. The types
in speaking, visual disturbances, respiratory distress, convulsions, of wound closure are (1)
and shock.These symptoms may not develop until several hours af- direct approximation, (2)
ter the bite. skin graft (autograft), (3)
No local care is necessary for coral snake bite wounds; however, a local flap, and (4) distant flap. In general, the simplest method
variety of techniques have been used for local care of pit viper bite possible in a given situation is preferred.
wounds. Some groups have advocated surgical approaches, such as
DIRECT WOUND APPROXIMATION
early incision with suction and wound excision, whereas others have
suggested topical application of ice or use of tourniquets to limit the The most common surgical problem is the deep, relatively
spread of venom. None of these treatments have been shown to pro- acute traumatic or surgical wound that is suitable for primary clo-
vide a definite benefit.At present, topical application of ice is discour- sure by direct approximation of the edges of the wound. In this
aged because it is more likely to lead to secondary injuries than to setting, the goal is to provide the best possible chance for uncom-
benefit the patient.Tight tourniquets cannot be left in place for long plicated healing.
periods without risking damage to the extremity; however, loose Adequate general or local anesthesia is an extremely important
tourniquets that slow lymphatic drainage may be of some value. Ex- first step. If local anesthesia is indicated, as for small traumatic in-
cision of the bite wound may be effective if it is performed within 1 to juries, 0.5% or 1.0% lidocaine (Xylocaine) is generally injected di-
2 hours of injury.To reduce the incidence of unintentional injuries, rectly into the wounded tissues. Although other local anesthetic
excision should be performed only by persons with medical training. agents can be used, lidocaine is the most popular choice because it
Antivenin is indicated if pain and swelling are substantial enough acts quickly, it rarely provokes allergic reactions, and it provides lo-
to suggest extensive envenomation. It should be administered only cal anesthesia for the 1 to 2 hours required for most wound closures.
if it is clearly necessary because it is of equine origin and frequently Epinephrine in a dilution of 1:100,000 or 1:200,000 is often used
produces serum sickness. Antivenin is almost never required for in combination with the lidocaine. Epinephrine prolongs the effec-
copperhead bites but is more commonly needed for rattlesnake tiveness of the anesthetic, increases the anesthetic dose that can be
bites.45 When indicated, it should be administered as soon as possi- safely used, and aids hemostasis.47 Lower concentrations of epi-
ble because it is less effective when given after signs of envenoma- nephrine can be effective, but it becomes unstable if stored for long
tion have become severe. periods at low concentrations. Traditionally, epinephrine has not
Whenever there is any suggestion of envenomation, a battery of been used in the fingers and toes out of concern that it might in-
tests, including hematocrit, fibrinogen level, coagulation studies, duce vasospasm, which could result in loss of one or more digits. In
platelet count, urinalysis, and serum chemistry values, should be the first half of 2001, this guideline was questioned by a prospective
performed.These tests should be repeated every 8 to 24 hours to study in which a series of digital blocks with epinephrine resulted in
evaluate any venom-induced changes.With severe envenomation, no reported morbidity.48 In reviewing the literature, the authors of
decreased fibrinogen levels, coagulopathies, and bleeding may be the study could not identify a single case in which local anesthesia
seen, as may myoglobinuria. alone resulted in digital loss. An experimental study from 1985 sug-
Envenomation is also a consideration with the bites of brown gested that the use of epinephrine is associated with a higher inci-
recluse spiders and black widow spiders.44 The brown recluse spider dence of infection49; however, this association has not been noted
has a violin-shaped mark on its dorsum; is found in dark, dry clinically.
places; and is nocturnal.The symptoms of the bite may range from The maximum safe doses of lidocaine traditionally cited are 4
minor irritation to extreme tenderness associated with edema and mg/kg without epinephrine and 7 mg/kg with epinephrine.The up-
erythema; the tenderness, erythema, and edema generally do not per limit of the maximum safe dose has been questioned. During li-
develop until 2 to 8 hours after the bite. In more severe cases, tissue posuction procedures, up to 35 mg/kg of lidocaine has been admin-
necrosis can develop in as little as 12 hours, although more often istered in a 0.1% solution containing epinephrine in a 1:1,000,000
the area of necrosis does not demarcate itself for weeks. Severe sys- dilution without reaching toxic drug levels.50,51 Given that some of
temic reactions, including hemolysis and DIC, have been reported. the anesthetic is aspirated in the course of a liposuction procedure,
The tissue necrosis resulting from the bite of the brown recluse can caution should be exercised in extrapolating this finding to other
be minimized by the use of dapsone.46 The black widow often has a types of procedures. The pain involved in injecting the local anes-
red hourglass mark on its abdomen and lives in dark, dry, protected thetic can be minimized by using a small-caliber needle, warming
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 8
the drug, injecting the drug slowly, using the subcutaneous rather done-iodine,79,80 and a sterile field is created by using sterile drapes.
than the intradermal route (even though the rate of onset is thereby Skin preparation limits contamination of the wound by bacteria
slowed),52 providing counterirritation, and buffering the agent with from adjacent skin. The wound is surgically debrided of any for-
sodium bicarbonate to limit its acidity.53 eign bodies or necrotic material to limit the chances of postopera-
Topical local anesthetics have been gaining in popularity. TAC tive infection.81 If the wound edges are beveled and adequate local
(a solution of 0.5% tetracaine, 1:2,000 adrenaline [epinephrine], tissue is available, the wound edges should be excised by means of
and 11.8% cocaine) has been demonstrated to be as effective as in- incisions perpendicular to the skin.
jectable anesthetics when applied topically to an open wound, es- Although wound closure can usually proceed in a straightforward
pecially in the face or scalp.54,55 Concerns have been expressed manner, special caution is necessary in certain situations. When a
about the possible toxicity of the cocaine, and efforts have been wound crosses tissues with different characteristics, such as at the
made to identify alternative topical agents. Topical 5% lidocaine vermilion border of the lip, at the eyebrow, or at the hairline of the
with 1:2,000 epinephrine,56 topical 4% lidocaine with 0.1% epi- scalp, great care must be taken to align the damaged structures accu-
nephrine and 0.5% tetracaine,57 0.48% bupivicaine with 1:26,000 rately. Injured nerves or ducts should generally be repaired at the
norepinephrine,58 and 3.56% prilocaine with 0.10% phenyl- time of wound closure. In acute wounds, it is generally best to avoid
ephrine59 have all been demonstrated to be equivalent to TAC. more complex tissue rearrangements such as a Z-plasty or W-plasty.
EMLA (a eutectic mixture of lidocaine and prilocaine) has been Actual reconstructive surgery in the face of trauma is rarely indicated
used to induce local anesthesia in intact skin, often before venous [see 3:7 Surface Reconstruction Procedures]. Direct approximation of
cannulation,60 and it has been evaluated in open wounds as well.61 wounds does not always produce a uniform or aesthetically desirable
EMLA is a more effective local anesthetic than TAC for open result, particularly in extensive wounds, wounds lying outside nor-
wounds of the lower extremity. To induce sufficient anesthesia to mal skin folds or creases, wounds in children older than 2 years,
be useful, however, EMLA must be in contact with the skin for 1 wounds in the sternal and deltoid regions, U-shaped wounds,
to 2 hours. wounds with beveled edges, or wounds in regions of thick oily skin,
Hair may be clipped to facilitate exposure and wound closure, such as the tip of the nose, where scars are often less acceptable.
if necessary. Close shaving should be avoided, however, because it Wounds heal optimally when two perpendicular, well-vascularized
potentiates wound infections.62 Clipping of eyebrows should also wound edges are approximated in a tension-free manner.
be avoided because they may not grow back. An ideal method of wound closure would support the wound
The next step is to irrigate the wound with a high-pressure (≥ 8 until it had nearly reached full strength (i.e., about 6 weeks), would
psi) spray to decrease the number of bacteria in the wound.63-65 A not induce inflammation, would not induce ischemia, would not
pressurized irrigation device is preferred, but if none is available, penetrate the epidermis and predispose to additional scars, and
high-pressure irrigation may be performed by using (1) a 30 to 50 would not interfere with the healing process in any way. No existing
ml syringe and a 19-gauge needle or catheter or (2) a flexible bag of method of wound closure accomplishes all of these goals: some sort
intravenous 0.9% saline attached to tubing and a 19-gauge catheter of compromise is virtually always necessary.
with a pressure device.63 Low-pressure irrigation and scrubbing of
the wound with a saline-soaked sponge have not been demonstrated Materials for Wound Closure
to decrease the incidence of wound infections.65,66 Irrigants that have Materials available for wound closure are sutures, staples, tapes,
been demonstrated to be nontoxic to tissues include 0.9% saline67 and tissue adhesives. Of these, sutures are most commonly used. Ab-
and Pluronic F-68,68,69 though lactated Ringer solution is also ac- sorbable sutures, such as those made of plain or chromic catgut,
ceptable. Pluronic F-68 has surfactant properties that improve polyglactin 910 (Vicryl), polyglycolic acid (Dexon), polyglyconate
wound cleansing without damaging tissues. Antibiotics are some- (Maxon), or polydioxanone (PDS), are generally used for dermis,
times added to irrigation solutions to increase their effectiveness fat, muscle, or superficial fascia. Nonabsorbable sutures, such as
at killing bacteria. Solutions of 1% neomycin sulfate and 2% those made of nylon, Ethibond, or polypropylene (Prolene), are
kanamycin sulfate, which do not kill fibroblasts in culture,70 have most commonly used either for the skin (in which case they are re-
limited toxicity to tissues.There is some evidence71 that antibiot- moved) or for deeper structures that require prolonged wound sup-
ic supplements are more effective than saline solution in de- port, such as the fascia of the abdominal wall or tendons.
creasing bacterial counts in contaminated wounds. The suture should be as small in diameter as possible while still
There are a number of solutions that should never be placed on a being able to maintain approximation.The decision to remove skin
wound. Povidone-iodine scrub and soaps containing hexachloro- sutures or staples involves balancing of optimal cosmesis with the
phene are especially damaging to normal tissues.67,72,73 Chlorhexi- need for wound support. Optimal cosmesis demands early removal
dine, which is found in various brands of soaps, has also been demon- of sutures, before inflammation can develop and before epithelial-
strated to impede the healing process.74,75 Alcohol is toxic to tissues ization can occur along the suture tracts. An epithelialized tract will
and should not be placed in wounds.76 A 0.5% solution of sodium develop around a suture or staple that remains in the skin for more
hypochlorite (Dakin solution) has been demonstrated to be toxic to than 7 to 10 days; after removal of the stitch, the tract will be re-
fibroblasts, to impair neutrophil function, and to slow epithelializa- placed by an unwanted scar.82 On the other hand, it takes a number
tion in open wounds.70,77 A 0.25% solution of acetic acid has been of weeks for the wound to gain significant tensile strength, and early
demonstrated to kill fibroblasts in culture and to slow epithelializa- removal of wound support can lead to dehiscence of wounds sub-
tion in open wounds.70 Hydrogen peroxide has been shown to kill fi- ject to substantial tension.Wounds on the face and wounds along
broblasts in culture and to cause histologic damage to tissues.67,70 skin tension lines (e.g., incisions for thyroidectomy) are subject to
Even standard hand soap can induce some tissue damage that is visi- limited tension, and sutures can be removed from these areas rela-
ble on histologic examination.67,76 The dictum “Don’t put in a wound tively early. Sutures are generally removed at day 4 or 5 from the face
what you wouldn’t put in your eye” is a valid guideline.78 and generally by day 7 from other areas where skin tension is limited.
After adequate anesthesia has been achieved, hair has been Sutures should remain longer in wounds subject to a greater
clipped, and the wound has been irrigated, the tissue surrounding amount of stress, such as wounds in the lower extremities and
the wound is prepared with an antibacterial solution such as povi- wounds closed under tension. Sutures also remain longer in
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 9
wounds in persons with healing limitations, such as malnutrition. Deeper fascial layers that contribute to the structural integrity of ar-
Less aesthetically pleasing consequences may have to be accepted eas such as the abdomen or the chest should be closed as a separate
in these cases. layer to prevent hernias or other structural deformities.
One way of sustaining skin wound support while avoiding un- If there appears to be a potential risk of fluid collecting in an
wanted scars from skin sutures is to use buried dermal sutures. Syn- unclosed subcutaneous space, drains are a more suitable alterna-
thetic materials, such as Vicryl, Dexon, PDS, or Maxon, are prefer- tive than subcutaneous stitches. In addition to preventing the ac-
able to chromic or plain catgut because the former are absorbed by cumulation of blood or serum in the wound, suction drains also
simple hydrolysis with little inflammatory response, whereas the aid in the approximation of tissues.They are particularly useful in
latter provoke an active cellular inflammatory response that slows aiding tissue approximation under flaps. Most drains—especially
the healing process. Buried dermal sutures are often used in con- those made of silicone rubber—are relatively inert. However, all
junction with either tapes (e.g., SteriStrips) or fine epidermal su- drains tend to potentiate bacterial infections and should be re-
tures to aid in precise epidermal alignment. moved from a wound as soon as possible.97
Closure with staples is more rapid than suture closure, although Drains can usually be safely removed when drainage reaches
approximation may not be as precise.83 Tape is easy to apply, is levels of 25 to 50 ml/day. If a seroma develops after drain re-
comfortable for the patient, and leaves no marks on the skin.84-86 moval, intermittent sterile aspirations followed by application of
However, patients may inadvertently remove tapes, and approxima- a compressive dressing are indicated. In the unusual case in
tion is less precise with tapes alone than with sutures. Furthermore, which drainage is persistent and refractory to intermittent aspi-
wound edema tends to cause inversion of taped wound edges. Sup- rations, a drain may be reintroduced. In unusual cases with pro-
plemental dermal sutures can enhance the precision of the closure longed drainage, drains have been left in place for weeks to avoid
achieved with staples or tapes. the development of a seroma.98
Cyanoacrylate tissue adhesives, used by surgeons for over 30 Occasionally, despite a surgeon’s best efforts, a closed wound
years, are strong, reasonably flexible, and biocompatible.When will dehisce. Dehiscence usually results from tension combined
these compounds first became available, isobutyl cyanoacrylate with local and systemic factors. Local factors include poor surgical
and trifluoropropyl cyanoacrylate were placed between wound technique and tissue damage by trauma, prior surgery, or radia-
edges to hold them together. Adhesives used in this way created tion—or, in the case of the abdomen, increased intra-abdominal
a mechanical barrier to healing and increased wound inflamma- pressure. Systemic factors include malnutrition, obesity, and con-
tion and infection rates. This use of cyanoacrylate tissue adhe- current use of medications such as steroids or chemotherapeutic
sives was abandoned relatively quickly.87 Since then, cyanoacry- agents. If the dehiscence is noted within 6 to 8 hours and it involves
lates have been applied topically to intact skin at the edge of wounds only skin and superficial tissues, the wound can be reclosed or, al-
to hold injured surfaces together. Contact with open wounds is care- ternatively, allowed to heal secondarily with dressing changes. De-
fully avoided to limit toxicity. Hystoacryl Blue (n-butyl-2-cyanoacry- hiscence of deeper structures such as the abdominal fascia can be a
late) has been used extensively with good clinical results.88 It creates more serious problem. Fascial dehiscence in the abdomen is often
limited wound strength during the first day after injury and should heralded by serosanguineous discharge between sutures on days 5
not be used in wounds subject to stress.89 to 8. Fascial separation of less than a few centimeters can be treated
Octylcyanoacrylate is stronger than Hystoacryl Blue. A prospec- expectantly; if the dehiscence is larger, reoperation for fascial reclo-
tive, randomized trial in Canada90 compared octylcyanoacrylate to sure should be performed if the patient’s condition permits.
sutures for wound closure.There were few cases of dehiscence, and
SKIN GRAFTS
the aesthetic results of wounds assessed 3 months after closure
were similar to those obtained with sutures. As would be expected, If a wound can be directly
octylcyanoacrylate closures were faster for the surgeon and less approximated without ex-
painful to the patient. Octylcyanoacrylate was not used in deep cessive tension or distortion
wounds that penetrated fascia, and the authors also specifically rec- of normal structures, that is
ommended against its use on the hands and over joints where ei- almost always the method
ther washing or repetitive motion might lead to premature removal of choice. If a wound is so
of the adhesive.90 extensive that direct ap-
Fibrin glue has been utilized to improve the adherence and take proximation is impossible, skin grafts should be considered [see 3:7
of skin grafts91,92; it has also been used with a limited number of su- Surface Reconstruction Procedures]. However, skin grafts cannot be used
tures to close wounds subjected to limited tension (e.g., bleph- to close injuries that involve bone denuded of periosteum, cartilage
aroplasty incisions93) and to curtail seroma formation under flaps.94 denuded of perichondrium, tendon denuded of paratenon, and
Although fibrin glue is helpful in these settings, it is not strong nerve denuded of perineurium. Skin grafts will not heal over large
enough to be usable alone for the closure of wounds subject to even areas (> 1.0 to 1.5 cm2 ) of denuded bone, cartilage, nerve, or ten-
limited tension. Autologous fibrin can be produced from plasma, don, because these structures are relatively, if not totally, avascular,
though the process is sufficiently laborious to discourage routine use. and blood vessels are not present to revascularize the graft. For such
Homologous fibrin has been available in Europe for some time. As a wounds, flaps must be considered (see below).
result of its superb safety record, homologous fibrin has been ap- Skin grafts vary in thickness, from very thin split-thickness grafts
proved by the Food and Drug Administration for general use in the that incorporate the epidermis and only a small portion of the der-
United States. mis to full-thickness grafts that incorporate the entire dermis.
The old surgical principle that dead space should be closed or (There are further variations within these two classifications.) The
obliterated seems to call for the closure of subcutaneous tissues. nature of the graft affects how readily the graft takes. Thin full-
However, studies in both laboratory animals and humans have dem- thickness skin grafts from areas such as the eyelid, the retroauricu-
onstrated that multiple layers of closure contribute to an increased lar area, or the medial surface of the upper arm take more reliably
incidence of infection.95,96 Therefore, sutures should be avoided than thicker ones from other areas. Similarly, thin split-thickness
whenever possible in subcutaneous fat, which cannot hold them. grafts take more reliably than thicker ones. Grafts that incorporate
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 10
most or all of the dermis maximally inhibit wound contraction. ed wound.They do not require as vascular a wound bed as grafts
The ability to inhibit wound contraction is not dependent on the do, because they maintain their blood supply after transfer and do
absolute thickness of the graft; rather, it is related to the amount of not depend on revascularization for survival. Flaps are indicated
deeper dermis the graft contains.99 for wounds containing denuded bone, cartilage, tendon, or nerve
Skin grafting produces a second wound at the donor site. All that cannot be closed by direct approximation. Flaps may be used in
donor sites for full-thickness grafts must be closed independently some situations in which skin grafts are also a possible choice be-
either by direct wound approximation or by application of an addi- cause they may provide tissue with desirable characteristics such as
tional graft. Donor sites for split-thickness grafts generally heal sec- bulk or a more natural appearance. Flaps that include bone or mus-
ondarily. Donor sites for thicker grafts tend to heal more slowly; cle may also be indicated for functional purposes. Any flap creates at
donor sites for very thick split-thickness grafts may require grafting least some functional or aesthetic deficit, a consideration when de-
for adequate closure. ciding what type of flap should be used.When feasible, use of lo-
Skin grafts can be meshed and expanded like a pantograph.This cal flaps is generally preferred because they usually require a less
technique increases the area that can be covered and facilitates complex operation and because local tissue is generally the most
drainage of fluid through the resulting interstices. Meshed grafts natural-looking substitute for the wounded tissue. Sometimes,
conform well to irregular surfaces. However, the aesthetic result of a however, specific tissue requirements mandate use of distant flaps.
meshed graft is usually less satisfactory than that of an intact, un- A flap can be classified as either random or axial. A random flap is
meshed skin graft, especially if the meshed graft is expanded widely. supplied with blood from the subdermal plexus but has no specific
Wound contraction is increased with an expanded meshed skin blood vessel supplying it. An axial flap must be supplied by a specif-
graft, which can be a problem around flexion and extension creases ic, predictable blood vessel. Generally, a flap that includes large
near joints. amounts of tissue or specialized tissue such as muscle or bone is con-
A suitable donor site should provide a good color match for the structed as an axial flap. The most complex distant flap is an axial
wounded tissue and be as inconspicuous as possible.100 Because hu- one that requires microvascular anastomoses of the primary blood
mans are relatively symmetrical, the ideal graft tissue in terms of vessels of the flap to appropriate recipient vessels in surrounding tis-
color and texture match is tissue from the contralateral structure. sue [see 3:7 Surface Reconstruction Procedures].
However, this type of graft is often impractical because the donor The blood supply to the flap must not be impaired by poor de-
site is frequently too conspicuous. In general, skin anywhere above sign, kinking of the vascular pedicle, pressure from an ill-placed dress-
the clavicles resembles facial skin; the retroauricular and supraclav- ing, poor patient positioning, or hematoma formation. Drains are
icular regions and the scalp are relatively inconspicuous donor sites frequently placed under flaps both to encourage tissue approxima-
for facial wounds. The buttocks and upper thighs are preferred tion and to prevent collection of blood and serum under the flap.
donor sites for wounds of the trunk or the extremities. Flaps will retain their color, texture, hair-bearing characteristics, and
Grafts will not take if bacterial contamination is excessive,101 if a sebaceous activity regardless of the recipient site. Sensibility and per-
seroma or hematoma develops between the graft and the wound spiration return to some extent between 6 weeks and 3 months after
site, or if shearing occurs between the graft and the wound site. In- flap transfer. With certain axial flaps, sensibility and other neural
fected wounds and wounds in which bleeding is inadequately con- functions are preserved from the outset. In children, flaps are also
trolled should not be grafted. Compressive, immobilizing dressing durable and have normal growth potential.
techniques and elevation can help prevent shearing and limit sero-
ma formation. A graft must be protected to some extent until it
reaches maturity, usually 6 months after placement.102 Such mea- Dressings
sures are especially important for lower-extremity grafts, which may Different types of dressings perform different functions. There-
be more susceptible to trauma and dependent edema. fore, for any wound, the purpose a dressing is to serve must be
The color of grafted skin generally changes after transfer and is carefully considered before the dressing is applied.
usually darker than it appeared in situ.103 Hair is transferred only Partial-thickness injuries, such as abrasions and skin graft donor
with full-thickness or very thick split-thickness skin grafts. In sites, heal primarily by epithelialization and are best treated with
thicker split-thickness skin grafts, sebaceous activity is lost ini- dressings that maintain a warm, moist environment.106,107 A variety
tially but resumes within 3 months. In the interim, the graft must of dressings can accomplish this goal, including biologic dressings
be lubricated with skin creams. Sensibility in skin grafts is more (e.g., allograft,108 amnion,109 or xenograft110), synthetic biologic
like that of the recipient site than that of the area from which the dressings (e.g., Biobrane111), hydrogel dressings, and dressings of
graft was taken.104 Perspiration returns with sensibility, and its semipermeable or nonpermeable membranes (e.g., Op-Site or
pattern also is determined by that of the recipient site.104 Full- Duoderm).107 These dressings need not be changed as long as they
thickness skin grafts have normal growth potential when they are remain adherent. Small, superficial wounds also heal readily when
placed during the early years of life, but the growth of split-thick- dressed with Xeroform or Scarlet Red; these dressings are often
ness skin grafts is limited.105 Skin grafts can be remarkably changed with greater regularity.112 The traditional approach to par-
durable after complete healing and can be used effectively even tial-thickness injuries has been to apply gauze, often impregnated
on the soles of the feet. with a petrolatum-based antimicrobial such as bismuth tribromo-
phenate (Xeroform), and to allow it to dry. Heat lamps have been
FLAPS
used to accelerate the drying process.With this method, the gauze
Like skin grafts, flaps al- provides a matrix that facilitates scab formation.
low coverage of a wound A scab, which consists of dried fibrin, blood cells, and wound
that cannot be satisfactorily exudate, will protect a wound and limit desiccation and bacterial
closed primarily; again, the invasion. Epithelial cells advancing beneath a scab, however, must
cost is a secondary wound at debride the scab-wound interface enzymatically to migrate across
the donor site. Flaps can be the wound surface beneath the scab.113 Epithelialization is there-
used to close any uninfect- fore slower under a scab than it would be under an occlusive dress-
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1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 11
ing. Thus, wounds covered with a scab tend to cause the patient wound or absorb fluid but instead facilitates drainage through itself
more discomfort than wounds covered with occlusive dressings as to the overlying layers of the dressing. Materials with these charac-
well. teristics include Xeroflo, a fine-meshed gauze impregnated with a
For wounds containing necrotic tissue, foreign bodies, or other hydrophilic substance, and N-terface, a synthetic fine-meshed
debris, wet-to-dry dressings are preferred. In this approach, saline- gauze.The dressing layer directly over the contact layer should be
soaked, wide-meshed gauze dressings are applied, allowed to dry, absorptive and capable of conveying exudate or transudate away
and then changed every 4 to 6 hours. Granulation tissue (including from the wound surface. Wide-meshed gauze facilitates capillary
necrotic tissue and other debris) and wound exudate become incor- action and drainage.117 Such absorptive layers must not be allowed
porated within the wide-meshed gauze; thus, a debriding effect is to become soaked, because if they do, exudate collects on the
produced when the gauze is removed.114,115 The disadvantage of this wound surface, and maceration and bacterial contamination may
type of dressing is that some viable cells are damaged by the de- occur.The outermost dressing layer is a binding layer, the purpose
bridement process.Wet-to-wet dressing changes, in which the saline of which is to fix the dressing in place. Tape is most commonly
is not allowed to dry, minimize tissue damage but do not produce as used as a binding layer, though elastic wraps or other materials
much debridement. Enzymatic agents (e.g., Travase, Santyl, and may sometimes be used instead.
Accuzyme) can debride wounds effectively and are a reasonable al- With sutured wounds, dressings are required only until
ternative to wet-to-dry or wet-to-wet dressings for wounds contain- drainage from the wound ceases.With nondraining wounds, dress-
ing necrotic tissue.116 ings may be removed after 48 hours, by which time epithelial cells
Virtually any type of dressing change will lower the bacterial will have sealed the superficial layers of the wound. An alternative
count in infected wounds; however, application of antibacterial method of treating minimally draining incisional wounds is to ap-
agents, which directly affect the infecting bacteria, generally de- ply an antibacterial ointment. Such ointments are occlusive and
creases the bacterial count more quickly than other dressing-change maintain a sterile, moist environment for the 48 hours required for
regimens. Silver sulfadiazine is frequently used because in addi- epithelialization.
tion to its broad antibacterial spectrum and low incidence of side Some physicians use occlusive dressings for incisional wounds.
effects, it has the secondary benefits of maintaining the wound in These dressings, as mentioned, create a warm, moist, sterile envi-
a moist state and speeding epithelialization.33 ronment that is optimal for epithelialization. Some of these are
For wounds with exposed tendons or nerves, it is particularly transparent, allowing observation of the wound.The disadvantage
important to maintain a moist environment to prevent desiccation of most of these dressings is their limited absorptive capacity, allow-
of the exposed vital structures. Although the biologic and mem- ing drainage from the wound to collect under the dressing.
brane dressings mentioned accomplish this, they are difficult to use In certain small wounds in areas that are difficult to dress, such
on deep or irregular wounds and wounds with a great deal of as the scalp, it may be reasonable to forgo a synthetic dressing and
drainage. Consequently, wet-to-wet dressings or dressings includ- simply allow a scab to form on the wound surface.
ing creams that contain agents such as silver sulfadiazine are often Some novel approaches to wound management have been de-
used. veloped since the latter part of the 1990s. One such approach in-
For sutured wounds, the purpose of a dressing is to prevent bac- volves the use of skin substitutes, such as Alloderm, Integra, and
terial contamination, protect the wound from trauma, manage any Apligraf. Alloderm and Integra contain only dermal elements,
drainage, and facilitate epithelialization. One approach is to use a whereas Apligraf and others contain cellular components, includ-
dressing with multiple layers, each of which serves a different pur- ing epithelium.The cellular elements most likely do not remain in
pose. The contact layer immediately adjacent to the wound must the wound for long, but they are thought to provide cytokines that
be sterile and nontoxic. An ideal contact layer does not stick to the may stimulate the healing process in the short term.
Discussion
Physiology of Wound Healing lation and norepinephrine from the sympathetic nervous system.
Phylogenetically, humans have lost the ability of many lower Prostaglandins, such as prostaglandin F2α (PGF2α), and thrombox-
animals, such as planaria and salamanders, to regenerate special- ane A2 are also involved. As the vessels contract, platelets adhere to
ized structures in most of their tissues. Although the wound-heal- the collagen exposed by damage to the blood vessel endothelium
ing process differs slightly from tissue to tissue, the process is sim- and form a plug. Platelet aggregation during the hemostatic process
ilar throughout the body. The result in almost all tissues is scar, results in the release of cytokines and other proteins from the alpha
the so-called glue that repairs injuries. The goal of acute wound granules of the cytoplasm of platelet cells.These cytokines include
management is to facilitate the body’s innate tendency to heal so platelet-derived growth factor (PDGF), transforming growth fac-
that a strong but minimally apparent scar results. Generally, how- tor–β (TGF-β), transforming growth factor–α (TGF-α), basic fi-
ever, the normal wound-healing process cannot be accelerated. broblast growth factor (bFGF, also called fibroblast growth factor 2
The physiology of wound healing is usually described in phases [FGF2]), platelet-derived epidermal growth factor (PD-EGF), and
[see Figure 1]. Although each of these phases will be discussed as a platelet-derived endothelial cell growth factor (PD-ECGF). Some
separate entity, the phases blend without distinct boundaries. of these cytokines have direct effects early in the healing process,
and others are bound locally and play critical roles in later aspects of
HEMOSTASIS
healing.
Most wounds extend into the dermis, injuring blood vessels and The extrinsic coagulation cascade is stimulated by a tissue factor
resulting in bleeding.This process stimulates vasoconstriction in the released from the injured tissues and is essential for clot formation.
injured vessels, mediated by epinephrine from the peripheral circu- The intrinsic cascade is triggered by exposure to factor XII and is
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1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 12
Figure 1 Depicted are the phases of wound healing. In the early phases (top, left), platelets adhere to collagen exposed by
damage to blood vessels to form a plug.The intrinsic and extrinsic coagulation cascades generate fibrin, which combines
with platelets to form a clot in the injured area. Initial local vasoconstriction is followed by vasodilatation mediated by hista-
mine, PGE 2 , PGI 2 , serotonin, and kinins. Neutrophils are the predominant inflammatory cells (a polymorphonucleocyte is
shown here). In the migratory phase (top, right), fibrin and fibronectin are the primary components of the provisional
wound matrix. Additional inflammatory cells, as well as fibroblasts and other mesenchymal cells, migrate into the wound
area. Gradually, macrophages replace neutrophils as the predominant inflammatory cells. Angiogenic factors induce the
development of new blood vessels as capillaries. Epithelial cells advance across the wound area from the basal layer of the
epidermis.The fibrin-platelet clot may dehydrate to form a scab. In the proliferative phase (bottom, left), the advancing
epithelial cells have covered the wound area. New capillaries form.The wound’s strength grows as a result of steadily
increasing production of collagen and glycosaminoglycans by fibroblasts. Collagen replaces fibrin. Myofibroblasts induce
wound contraction. In the late phase (bottom, right), scar remodeling occurs.The overall level of collagen in the wound
plateaus; old collagen is broken down as new collagen is produced.The number of cross-links between collagen molecules
increases, and the new collagen fibers are aligned so as to provide a gradual increase in wound tensile strength. New capil-
laries combine to form larger vessels.The epithelium is healed, although it never quite regains its normal architecture.
not essential. Both coagulation cascades generate fibrin, which acts INFLAMMATION
with platelets to form a clot in the injured area [see 1:4 Bleeding and Tissue damage at the site of injury stimulates the inflammatory
Transfusion]. In a large wound, the superficial portion of this clot response.This response is most prominent during the first 24 hours
may dehydrate over time to produce a scab. after a wound is sustained. In clean wounds, signs of inflammation
In addition to contributing to hemostasis, fibrin is the primary dissipate relatively quickly, and few if any inflammatory cells are seen
component of the provisional matrix that forms in the wound dur- after 5 to 7 days. In contaminated wounds, inflammation may per-
ing early healing. Fibrin becomes coated with vitronectin from the sist for a prolonged period. The signs of inflammation, originally
serum and fibronectin derived from both serum and aggregating described by Hunter in 1794, include erythema, edema, heat, and
platelets. Fibronectins are a class of glycoproteins that facilitate the pain.
attachment of migrating fibroblasts as well as other cell types to The signs of inflammation are generated primarily by changes in
the fibrin lattice.118 By influencing cellular attachment, fibronectin the 20 to 30 µm diameter venules on the distal side of the capillary
is a key modulator of the migration of various cell types in the bed. In the first 5 to 10 minutes after wounding, the skin blanches as
wound.119,120 In addition, the fibrin-fibronectin lattice binds vari- a result of the vasoconstriction that contributes to hemostasis.The
ous cytokines released at the time of injury and serves as a reser- initial vasoconstriction is followed by vasodilatation, which generates
voir for these factors in the later stages of healing.121 the characteristic erythema. The vasodilatation is mediated by (1)
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1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 13
vasodilator prostaglandins such as PGE2 and prostacyclin, released (4) kinins, the release of which is stimulated by the coagulation cas-
by injured cells; (2) histamine, released by mast cells and possibly by cade; and possibly by other factors as well. As the blood vessels di-
platelets to a lesser degree; (3) serotonin, also released by mast cells; late, the endothelial cells lining the microvenules tend to contract
and separate from one another, resulting in increased vascular per-
meability. Serum migrates into the extravascular space, giving rise to
Table 4—Involvement of Cytokines edema. Inflammatory cells initially adhere loosely to endothelial
in Wound-Healing Functions cells lining the capillaries and roll along the endothelial surface of
the vessels.The inflammatory cells eventually adhere to the vessel
Wound-Healing Function Cytokines Involved wall, in a process mediated by the β2 class of integrins, and subse-
PDGF
quently transmigrate into the extravascular space.122 Chemo-
Neutrophil chemotaxis
IL-1 attractants stimulate the migration of inflammatory cells to the in-
jured area. As monocytes migrate from the capillaries into the
PDGF extravascular space, they transform into macrophages in a process
Macrophage chemotaxis TGF-β mediated by serum factors and fibronectin.123-125 After migration,
IL-1
the inflammatory cells must be activated before they can perform
EGF their biologic functions.
Fibroblast chemotaxis PDGF Neutrophils are the predominant inflammatory cell in the wound
TGF-β during the 2 to 3 days after wounding, but macrophages eventually
EGF become the predominant inflammatory cell in the wound. Because
PDGF monocytes are present in the serum in much lower numbers than
IGF neutrophils, it is not unexpected that they are rarely seen in the
Fibroblast mitogenesis TGF-β wound area initially. After appearing in the wound, both neutrophils
TGF-α and macrophages engulf damaged tissue, digesting them in lyso-
IL-1 somes. After neutrophils phagocytose damaged material, they
TNF-α cease to function and often release lysosomal contents, which can
EGF contribute to tissue damage and a prolonged inflammatory re-
Acidic and basic FGF (FGF1 and FGF2) sponse. Inflammatory cells and liquefied tissue are the constituents
TGF-β of pus, which may or may not be sterile, depending on whether bac-
Angiogenesis, endothelial cell
chemotaxis, mitogenesis
TGF-α teria are present. Unlike neutrophils, macrophages survive after
TNF-α phagocytosing bacteria or damaged material.The shift in predomi-
VEGF nant inflammatory cell type within the wound from neutrophils to
PD-ECGF macrophages is at least in part due to macrophages’ extended life
EGF span. Macrophage-specific chemoattractants may also selectively at-
Basic FGF (FGF2) tract macrophages into the wound.
Epithelialization
TGF-β In addition to phagocytosis, macrophages are capable of secreting
TGF-α matrix metalloproteinases (MMPs) that break down damaged tis-
KGF
IGF
EGF
Basic FGF (FGF2)
Table 5—Cell Sources of Cytokines
Collagen synthesis PDGF
TGF-β Cell Type Cytokines
IL-1
EGF
TNF-α
PDGF
Platelet
TGF-β
Basic FGF (FGF2)
TGF-α
PDGF
Fibronectin synthesis
TGF-β FGF
EGF PDGF
TGF-β
Basic FGF (FGF2)
Macrophage TGF-α
PDGF
Proteoglycan synthesis IL-1
TGF-β
TNF-α
IL-1
IGF-1
Basic FGF (FGF2)
Wound contraction TGF-β
TGF-β Lymphocyte
IL-2
EGF
FGF
PDGF Endothelial cell
Scar remodeling, collagenase PDGF
TGF-β
stimulation
IL-1 TGF-α
TNF-α Epithelial cell PDGF
EGF—epidermal growth factor—FGF—fibroblast growth factor—IGF—insulinlike growth TGF-β
factor—IL-1—interleukin-1—KGF—keratinocyte growth factor—PD-ECGF—platelet-derived
endothelial cell growth factor—PDGF—platelet-derived growth factor—TGF—transforming Smooth muscle cell PDGF
growth factor—TNF—tumor necrosis factor—VEGF—vascular endothelial growth factor—
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1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 14
sue; they are also a primary source of cytokines that mediate other When epithelial cells migrating from two areas meet, contact inhi-
aspects of the healing process. Experimental studies have demon- bition prevents further migration.The cells making up the epithelial
strated that neutrophils are not essential to normal healing,126 monolayer then differentiate into basal cells and divide, eventually
whereas macrophages are necessary.127 These additional macro- yielding a neoepidermis consisting of multiple cell layers. Epithelial-
phage functions—especially their role as a cytokine source—most ization progresses both from wound edges and from epithelial
likely are what make them essential. appendages. Epithelial advancement is facilitated by adequate de-
MIGRATORY PHASE bridement and decreased bacterial counts, as well as by the flattening
of rete pegs in the dermis adjacent to the wound area.The epithelium
Many substances attract fibroblasts and other mesenchymal cells never returns to its previous state.The new epidermis at the edge of
into the wound during the migratory phase, including many of the the wound remains somewhat hyperplastic and thickened, whereas
cytokines118,128-130 [see Table 4]. It is not known which of them are the epidermis over the remainder of the wound is thinner and more
most active biologically at different points after wounding. The fi- fragile than normal.True rete pegs do not form in the healed area.
broblasts migrate along the scaffold of fibrin and fibronectin, as
mentioned.This migration involves the upregulation of integrin re- PROLIFERATIVE PHASE AND COLLAGEN SYNTHESIS
ceptor sites on the cell membranes, which allows the cells to bind at The proliferative phase of wound healing usually begins approx-
different sites in the matrix and pull themselves through the scaffold. imately 5 days after wounding. During this phase, the fibroblasts
Migration through the provisional matrix is also facilitated by syn- that have migrated into the wound begin to synthesize proteogly-
thesis of MMPs, which help cleave a path for the cells. Additional cy- cans and collagen, and the wound gains strength. Until this point,
tokines stimulate the proliferation of mesenchymal cells important in fibrin has provided most of the wound’s strength. Although a small
the wound-healing process once these cells have been attracted amount of collagen is synthesized during the first 5 days of the heal-
into the wound area131,132 [see Table 4]. ing process,139 the rate of collagen synthesis increases greatly after
the fifth day. Wound collagen content continually increases for 3
Angiogenesis
weeks, at which point it begins to plateau.140
Angiogenesis is also initiated in the migratory phase during the Although there are at least 18 types of collagen, the ones of pri-
first 2 or 3 days after wounding. Before revascularization of the in- mary importance in skin are type I, which makes up 80% to 90% of
jured area, the wound microenvironment is hypoxic and is character- the collagen in skin, and type III, which makes up the remaining
ized by high lactic acid levels and a low pH. Angiogenic factors stim- 10% to 20%. A higher percentage of type III collagen is seen in em-
ulate the process of neovascularization. Some of the more potent bryologic skin and in early wound healing. A critical aspect of colla-
angiogenic factors are derived from platelets and macrophages133,134 gen synthesis is the hydroxylation of lysine and proline moieties
[see Tables 4 and 5]. New vessels develop from existing vessels as cap- within the collagen molecule. This process requires specific en-
illaries.The capillaries grow from the edges of the wound toward ar- zymes as well as oxygen, vitamin C, α-ketoglutarate, and ferrous
eas of inadequate perfusion within the provisional wound matrix, iron, which function as cofactors. Hydroxyproline, which is found
where lactate levels are increased and tissue oxygen tension is low. almost exclusively in collagen, serves as a marker of the quantity of
The generation of new vessels involves both migration and prolifera- collagen in tissue. Hydroxylysine is required for covalent cross-link
tion of cells. Both cellular activities are modulated by the angiogenic formation between collagen molecules, which contributes greatly to
cytokines. A key aspect of endothelial cell migration is the upregula- wound strength. Deficiencies in oxygen or vitamin C or the sup-
tion of the α-β3 integrin binding domain that facilitates the binding pression of enzymatic activity by corticosteroids may lead to under-
of the endothelial cells to the matrix. Migrating endothelial cells pro- hydroxylated collagen incapable of generating strong crosslinks.
duce plasminogen activator, which catalyzes the breakdown of fibrin, Underhydroxylated collagen is easily broken down. After collagen
as well as MMPs, which help create paths through the matrix for the molecules are synthesized by fibroblasts, they are released into the
developing blood vessels.When the budding capillaries meet other extracellular space.There, after enzymatic modification, they align
developing capillaries, they join and blood flow is initiated. As the
wounded area becomes more vascularized, the capillaries consoli-
800
date to form larger blood vessels.
Tensile Strength (g/mm2)
Epithelialization
600
Epithelialization of skin involves the migration of cells from the
basal layer of the epidermis across the denuded wound area.135 This
migratory process begins approximately 24 hours after wounding. 400
The migrating cells develop bands 40 to 80 Å wide that can be seen
with electron microscopy and stained with antiactin antibodies.
About 48 hours after wounding, the basal epidermal cells at the 200
wound edge enlarge and begin to proliferate, producing more migra-
tory cells. If the normal basement membrane is intact, the cells sim-
0
ply migrate over it; if it is not, they migrate over the provisional fibrin- 1 2 3 4 5 6 7 8 9 10 11 12
fibronectin matrix.136 As migration is initiated, desmosomes that link Weeks after Wounding
epithelial cells together and hemidesmosomes that link the cells to
the basement membrane disappear.137 Migrating cells express inte- Figure 2 The tensile strength of skin wounds begins to increase
gradually about 3 weeks after wounding.The collagen elaborated early
grins on their cell membranes that facilitate migration. As they mi-
in the healing process is replaced by stronger collagen that is aligned
grate, they secrete additional proteins that become part of the new
along the lines of stress in the tissue. Closer bonding and a greater
basement membrane, including tenascin,138 vitronectin, and collagen number of cross-links between fibers augment the wound’s tensile
types I and V. In addition, they generate MMPs to facilitate migra- strength.The process of collagen replacement and scar remodeling
tion, as noted. continues for years.248
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1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 15
themselves into fibrils and fibers that give the wound strength. Ini- nia repair, or many orthopedic procedures is based on the time
tially, the collagen molecules are held together by electrostatic cross- required for increased tensile strength.
links as fibrils form.These cross-links are subsequently replaced by
more stable covalent bonds.The covalent bonds form between ly- Role of Cytokines in Wound Healing
sine and lysine, between lysine and hydroxylysine, and between hy-
droxylysine and hydroxylysine141; the strongest cross-links form be- Wounding stimulates specific cellular activities in a consistent
tween hydroxylysine and hydroxylysine. manner that is reproducible from wound to wound. Many, if not all,
Proteoglycans, also synthesized during the proliferative phase of of these cellular activities appear to be mediated by cytokines.The
healing, consist of a protein core linked to one or more glycos- predictability with which cellular activities start and stop after
aminoglycans. Dermatan sulfate, heparin, heparan sulfate, keratan wounding suggests that the cytokines mediating them are released
sulfate, and hyaluronic acid are the more common proteoglycans. in a closely regulated fashion; however, the details of this process
The biologic effects of proteoglycans are less well understood than have not yet been elucidated.
those of collagen.They generally anchor specific proteins in certain Numerous cytokines are known to be capable of mediating the
locations and affect the biologic activity of target proteins. Heparin major biologic activities involved in wound healing [see Table 4].
is an important cofactor of bFGF during angiogenesis. Other pro- Most of these activities can be mediated by more than one factor,
teoglycans most likely facilitate the alignment of collagen mole- and researchers have not yet been able to determine which factors
cules into fibrils and fibers. are the most important stimulants of wound-healing functions in
vivo. One possible explanation for the duplication in mediating
Wound Contraction functions is that factors with similar activities may act at different
Collagen has no contractile properties, and its synthesis is not times in the course of the wound-healing process.
required for wound contraction. During the proliferative phase, Cytokines are produced by platelets, macrophages, lymphocytes,
myofibroblasts appear in the wound and probably contribute to endothelial cells, epithelial cells, and smooth muscle cells [see Table
its contraction.142 Myofibroblasts are unique cells that resemble 5]. Some cytokines, such as PDGF, are produced by several cell
normal fibroblasts and may be derived from them.They have con- types,147-150 whereas others, such as interleukin-2 (IL-2), are pro-
voluted nuclei, vigorous rough endoplasmic reticula, and microfil- duced by only one cell type.151,152 The cell of origin is a key variable
ament bundles 60 to 80 Å in diameter.These microfilaments can that determines the time at which a factor will be present after
be stained with antiactin and antimyosin antibodies. Many au- wounding. Platelets, for example, release PDGF,147 TGF-β,153 and
thorities believe that the myofibroblasts pull the wound together epidermal growth factor (EGF),154 and it would be expected that
from the edges of the wound; however, others believe, on the basis these cytokines would be found in a wound soon after injury. Fac-
of observations in collagen lattices, that it is the fibroblasts within tors produced by several different cell types may be released by indi-
the center of the wound that generate the force of wound contrac- vidual cell types at different times. For example, PDGF148,149 and
tion.To date, this issue has not been resolved.TGF-β is a potent TGF-β,155 which are produced by both platelets and macrophages,
stimulant of wound contraction in experimental models.143 might be released by platelets soon after wounding and by macro-
The wound edges are pulled together at a rate of 0.60 to 0.75 phages at a later stage in the healing process.
mm/day. The rate of contraction varies with tissue laxity. Con- The names of cytokines are frequently misleading. In many cas-
traction is greatest in anatomic sites where there is redundant tis- es, they derive from the first known cell of origin or from the first
sue. Wound contraction generally continues most actively for 12 function discovered (or hypothesized) for the factor. As a result, a
to 15 days or until wound edges meet. polyfunctional factor may have a name implying that it has only one
function, a factor produced by multiple cell types may have a name
LATE PHASE: SCAR REMODELING
suggesting that it is produced by a single cell type, or a factor’s name
Approximately 3 weeks after wounding, scar remodeling be- may lay claim to a capability that the factor does not have. For ex-
comes the predominant feature of the healing process. Collagen ample,TGF-β received its name because it was originally believed
synthesis is downregulated, and the wound becomes less cellular as to be capable of transforming normal cells into malignant ones. Al-
apoptosis occurs. During this phase, there is continual turnover of though it is now known that TGF-β does not have this capability,
collagen molecules as old collagen is broken down and new colla- the name has not been altered.
gen is synthesized along lines of stress.144,145 Collagen breakdown is Cytokines are also a promising tool in the biologic modification
mediated by several MMPs, found in scar tissue as well as in nor- of the wound-healing process. Early experimental work was done
mal connective tissues.146 At least 25 MMPs that affect different with small quantities of factors extracted from biologic sources
substrates have been identified.The more common of these include (e.g., platelets). Currently, recombinant technology can provide
MMP-1 (collagenase-1), MMP-2 (gelatinase A), and MMP-3
(stromelysin-1). The activity of these collagenolytic enzymes is Table 6—Factors Impairing Wound Healing
modulated by several tissue inhibitors of metalloproteinases
(TIMPs). During this phase, there is little net change in total Local Systemic
wound collagen,144 but the number of cross-links between collagen
strands increases. Infection Malnutrition
The realigned, highly cross-linked collagen is much stronger than Foreign bodies Cancer
the collagen produced during the earlier phases of healing.The re- Ischemia/hypoxia Diabetes mellitus
sult is a steady, gradual growth in wound tensile strength that con- Venous insufficiency Uremia
Toxins (e.g., spider venom) Jaundice
tinues for 6 to 12 months after wounding [see Figure 2]. Scar tissue
Previous trauma Old age
never reaches the tensile strength of unwounded tissue, however. Radiation Systemic corticosteroids
The rate of gain in tensile strength begins to plateau at 6 weeks Cigarette smoking Chemotherapeutic agents
after injury.The common clinical recommendation that patients Alcoholism
avoid heavy lifting or straining for 6 weeks after laparotomy, her-
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 16
large quantities of highly purified material that can be used clinical- days after grafting, the graft’s vascular supply appears nearly nor-
ly. It has been experimentally demonstrated that many of the cy- mal on dye injection studies.173
tokines are capable of accelerating wound healing in normal and Lymphatic channels begin to develop 4 to 5 days after grafting,
healing-impaired models. TGF-β has markedly increased wound- and the lymphatic system gradually matures until it, too, is nearly
breaking strength in incisional wounds in rats soon after wound- normal after 21 days.175 Epithelial cells and fibroblasts remain dor-
ing.156 bFGF has increased the strength of incisional wounds when mant for 3 days after placement of a skin graft and subsequently
injected on day 3 after wounding.157 EGF has accelerated the clo- proliferate.176 The epithelium remains hyperplastic for 6 weeks.177
sure of partial-thickness wounds in pigs when applied topically,158 By 7 to 8 days after grafting, fibroblasts are more plentiful in the
and it has accelerated collagen accumulation in a wound chamber graft than in the surrounding skin, and new collagen is being synthe-
model.159 PDGF has accelerated healing in incisional wounds in sized.176,177 Collagenolytic activity develops simultaneously and ac-
rats when administered in a slow-release vehicle at the time of tually exceeds collagen synthesis for 2 weeks, leading to a net loss in
wounding.160 Cytokines have also been observed to reverse healing graft collagen. However, during the third week after grafting, the net
deficits produced by diabetes,161 steroids,162 doxorubicin,163 and ra- amount of collagen starts to increase as the rate of collagen synthesis
diation164 in experimental models. begins to exceed the rate of collagenolysis. Active collagen synthesis
The positive results of these experimental studies encouraged continues for at least 20 weeks.102
the use of cytokines in clinical trials in humans. In an early human
study, EGF accelerated the healing of skin graft donor sites.165 In
another study, it was applied topically to chronic nonhealing Disturbances of Wound Healing
wounds in an uncontrolled group of patients and was considered Healing does not always occur in a straightforward, undisturbed
to contribute to improved healing in the majority.166 Autogenous fashion. Both local and systemic factors can interfere with healing.
platelet extracts have been used on chronic nonhealing wounds as Local factors include infection, foreign bodies, tissue hypoxia, ve-
well, with good results.167 In a better-controlled study, recombi- nous insufficiency, local toxins, mechanical trauma, irradiation, and
nant human PDGF-bb accelerated healing when applied topically cigarette smoking. Systemic factors include malnutrition, cancer,
to pressure sores in a randomized, double-blind, placebo-con- diabetes mellitus, uremia, jaundice, old age, corticosteroids, chemo-
trolled fashion.168 In another carefully controlled, randomized, therapeutic agents, and alcoholism. Several of these local and sys-
prospective study, bFGF was also demonstrated to be efficacious temic factors [see Table 6] will be discussed in more detail.
as a topical wound-healing supplement for pressure sores.169
LOCAL FACTORS
PDGF-bb has been demonstrated to be efficacious and has been
approved for use on diabetic ulcers.170 It is being marketed as be-
Infection
caplermin (Regranex).
It is not known which factors will be most effective as healing ad- The body maintains a symbiotic relationship with bacteria.
juvants in either normal or impaired healing states. It would seem Normal dry skin contains up to 1,000 bacteria/g,4 and saliva con-
logical that addition of a combination of factors in a sequence mimick- tains 100 million bacteria/ml.178 The bacterial population is kept
ing that characteristic of normal healing would produce optimal ef- in control by several mechanisms. Invasion is mechanically limit-
fects when healing is unimpaired.When healing is impaired, it would ed by an intact stratum corneum in the skin and intact oral mu-
seem logical to augment the quantity of whatever factors are lacking cosa.5 Sebaceous secretions contain bactericidal and fungicidal
or present at reduced levels. However, much work remains to be fatty acids that modulate bacterial proliferation.179 Edema dilutes
done—first, to determine which factors are most critical in normal these fatty acids, making edematous areas more infection prone.
states and, second, to determine which factors are lacking in im- Lysozymes in skin hydrolyze bacterial cell membranes, further
paired states so that the best use can be made of the recombinant limiting bacterial proliferation.180 The immune system augments
factors now available. local barriers to infection.
Infection occurs when the number or virulence of bacteria ex-
ceeds the ability of local tissue defenses to control them. Generally,
Physiology of Skin Graft Healing as mentioned, infection exists when bacteria have proliferated to lev-
Although the physiology of skin graft healing is similar to that els beyond 105 organisms/g tissue (β-hemolytic streptococci being
of open wound healing, differences arise because the wound is the only exception). At this level, bacteria overwhelm host defenses
covered by the graft and because the graft has its own intrinsic ar- and proliferate in an uncontrolled fashion.This number was defined
chitectural nature. Initially, fibrin holds the graft on the recipient by studies performed at the United States Army Institute of Surgical
site. The strength of attachment increases rapidly for the first 8 Research and elsewhere.21,181-183 Local factors such as impaired cir-
hours after graft placement, after which the rate of increase tapers culation or radiation injury increase the risk of infection. Systemic
off slightly.171 For the first 48 hours, the graft survives by serum diseases such as diabetes, AIDS, uremia, and cancer also increase
imbibition172: plasmalike fluid is absorbed by the graft, which in- the susceptibility to wound infection.
creases in weight by up to 30% during this period.The absorbed
fluid supports only minimal metabolic activities and maintains Hypoxia and Smoking
cellular viability until revascularization occurs. After approximate- Delivery of oxygen to healing tissues is critical for prompt wound
ly 48 hours, new blood vessels begin to grow into the graft from repair. Oxygen is necessary for cellular respiration as well as for hy-
the recipient site.173 It is not known whether a new vascular net- droxylation of proline and lysine residues. Adequate tissue oxygena-
work grows within the graft or whether vessels from the recipient tion requires an adequate circulating blood volume,184 adequate
site simply connect with existing vessels in the graft. Skin graft cardiac function, and adequate local vasculature.Vascular disorders
revascularization probably involves a combination of these two may be systemic, as in peripheral vascular disease, or localized,
processes.174 Blood flow in the graft reaches nearly normal levels caused by scarring from trauma or prior surgery.Wound healing in
approximately 7 days after grafting.The vascular system continues ischemic extremities is directly correlated with transcutaneous oxy-
to mature, with smaller vessels merging into larger ones. By 21 gen tension.185 Hyperbaric oxygen has been used in the treatment
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1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 17
of many types of wounds in which tissue hypoxia may impair heal- by limiting the supply of critical amino acids required for synthesis of
ing. Anemia, however, is not associated with impaired healing un- collagen and other proteins. Collagen synthesis essentially stops in the
less the anemia is severe enough to limit circulating blood volume.186 absence of protein intake,199 resulting in impaired healing.200,201 Argi-
Smoking can impair tissue oxygenation. Smoking stimulates nine and glutamine appear to be particularly important amino acids.
vasoconstriction acutely and contributes to the development of ath- Cystine residues are found along the nonhelical peptide chain associ-
erosclerosis and vascular disease over time.187-189 Approximately 3% ated with procollagen; in the absence of these cystine residues, proper
to 6% of cigarette smoke is carbon monoxide, which binds to he- alignment of peptide chains into a triple helix is inhibited.202
moglobin, producing carboxyhemoglobin. Smokers have carboxy- Carbohydrates and fats provide energy for healing, and wound
hemoglobin levels between 1% and 20%.190 Carboxyhemoglobin healing slows when carbohydrate or fat stores are limited. As an al-
limits the oxygen-carrying capacity of the blood, increases platelet ternative energy source, protein is broken down instead of contrib-
adhesives,191 and produces endothelial changes.192,193 uting primarily to tissue growth.203 Fatty acids are also vital compo-
nents of cell membranes.
Irradiation Several vitamins are essential for normal healing. As mentioned,
Irradiation damages the DNA of cells in exposed areas. Some vitamin C is a necessary cofactor for hydroxylation of lysine and pro-
cells die, and others are rendered incapable of undergoing mitosis. line during collagen synthesis. The ability of fibroblasts to produce
When radiation is administered therapeutically, doses are fraction- new, strongly cross-linked collagen is diminished if vitamin C is defi-
ated and tangential fields are used to limit damage to normal cells cient. Clinically, existing scars dissolve because collagenolytic activity
while maximizing damage to tumor cells. Despite such techniques, continues without adequate compensatory collagen synthesis, and
normal cells are damaged by irradiation. new wounds fail to heal.Vitamin C deficiency is also associated with
Radiation therapy initially produces inflammation and desqua- impaired resistance to infection.203 Because vitamin A is essential for
mation in a dose-dependent fashion.194 After a course of irradiation, normal epithelialization, proteoglycan synthesis, and normal immune
healing ensues if surrounding normal tissues have not been ir- function,204-206 healing is impaired when vitamin A is deficient.Thi-
reparably damaged. Additional cells must migrate into the treated amine deficiency has also been associated with impaired healing.207
area for adequate healing to occur. Fibroblasts migrating into irradi- Vitamin D, required for normal calcium metabolism, is needed for
ated tissue are often abnormal because of irradiation.These cells are bone healing. Exogenous vitamin E impairs wound healing in rats,
characterized by multiple vacuoles, irregular rough endoplasmic most likely by influencing the inflammatory response in a cortico-
reticulum, degenerating mitochondria, and cytoplasmic crystalline steroid-like manner.208
inclusion bodies. Increased levels of inflammatory mediators con- The minerals necessary for normal healing include the trace ele-
tribute to an abnormal healing response. Collagen is synthesized to ment zinc, a necessary cofactor for DNA polymerase and reverse
an abnormal degree in irradiated tissue, causing characteristic fibro- transcriptase. Because zinc deficiency can result in an inhibition of
sis.The media of dermal blood vessels in irradiated areas thickens cellular proliferation and deficient granulation tissue formation209
and some blood vessels become occluded, resulting in a decrease in and healing,210 zinc replacement should be given if a deficiency is
the total number of blood vessels. Superficial telangiectasias may be diagnosed. Pharmacologic overdosing with zinc does not accelerate
seen.The epidermis becomes thinned, and changes in pigmentation wound healing and can have detrimental effects.210
often develop. Irradiated skin is dry because of damage to seba- Correction of generalized malnutrition requires refeeding. The
ceous and sweat glands, and it has little hair.The epidermal base- amount of food ingested in the immediate preoperative period may
ment membrane is abnormal, and nuclear atypia is common in have a greater influence than the overall degree of malnutrition, pos-
keratinocytes. sibly by inducing positive nitrogen balance.211 A prospective, ran-
Abnormal healing is predictable after wounding of previously ir- domized study of patients undergoing total parenteral nutrition pri-
radiated tissue. Decreased vascularity and increased fibrosis limit the or to surgery demonstrated a significant reduction in postoperative
ability of platelets and inflammatory cells to gain access to wounds morbidity and mortality.212
in the area.The quantity of cytokines released is therefore limited in
wounds in irradiated tissue.This relative cytokine deficiency causes Cancer
impairment of virtually all cellular aspects of healing. Damaged fi- Impaired wound healing associated with cancer has been dem-
broblasts and keratinocytes in the area may not respond normally to onstrated experimentally213 and is often noted clinically. Cancer-
wound-healing stimulants. In addition, irradiated tissue is predis- bearing hosts may have impaired healing for a variety of reasons.
posed to infection, which can further slow the healing process. Cancer-induced cachexia, manifest as weight loss, anorexia, and as-
Clinically, impaired healing is manifest by a higher rate of com- thenia, significantly limits healing. Cachexia is a result of either de-
plications when an operation is performed on irradiated tissue.195 creased caloric intake, increased energy expenditure, or both.
Vitamin A has been used to reverse the healing impairment caused Decreased oral intake may be due to anorexia or mechanical fac-
by radiation therapy.196 Difficult wounds in irradiated tissue can of- tors.Anorexia is mediated through as yet imperfectly defined circulat-
ten be managed surgically by bringing a new blood supply to the ing factors. Changes in taste perception, hypothalamic function, and
area with flaps from nonirradiated areas. tryptophan metabolism may contribute to anorexia.Tumors in the
gastrointestinal tract can produce obstruction and generate fistulae
SYSTEMIC FACTORS
that limit nutrient absorption. Other cancers generate peptides such
as gastrin and vasoactive intestinal polypeptide (VIP) that alter tran-
Malnutrition sit times and interfere with absorption of nutrients.
Adequate amounts of protein, carbohydrates, fatty acids, vitamins, Cancers alter host metabolism in dysfunctional ways as well.
and other nutrients are required for wounds to heal. Malnutrition Glucose turnover may be increased, sometimes leading to glucose
frequently contributes to suboptimal healing.197 In experimental intolerance. The effect of increased glucose use is higher energy
studies,198 a loss of 15% to 20% of lean body mass has been associated needs.214 Protein catabolism may be accelerated. Protein break-
with a decrease in wound-breaking strength and a decrease in colonic down in muscle is increased, as is hepatic utilization of amino acids.
bursting pressure. Hypoproteinemia inhibits proper wound healing Such changes in protein metabolism produce a net loss of plasma
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 18
protein. Unlike malnourished patients, cancer patients may not be This impaired healing results from derangements in cellular func-
able to alter their metabolism to rely on fat for most energy needs. tion induced by steroids. A primary feature of wounds in steroid-
In tumor-bearing animals, fat accumulates, while other, more vital treated individuals is a deficiency in inflammatory cell function. As
tissues are broken down for energy. In addition, vitamin C may be discussed, inflammatory cells, particularly macrophages, mediate
taken up preferentially by some tumors, limiting availability of the essentially all aspects of healing through cytokines. By diminishing
vitamin for hydroxylation of proline and lysine moieties in collagen. the supply of cytokines, steroids and other immunosuppressive
All of these metabolic changes contribute to a negative energy bal- agents profoundly impair all aspects of healing. Macrophage migra-
ance and inefficient energy use. tion, fibroblast proliferation, collagen accumulation, and angiogen-
Cancer patients may be relatively anergic, most likely because of esis are among the processes diminished by steroid administration.
abnormal inflammatory cell activity. Macrophages do not migrate Sandberg237 demonstrated that the effects of steroids on healing are
or function normally in cancer patients. Inflammatory cell dysfunc- most pronounced when the drug is administered several days before
tion may limit the availability of cytokines required for healing and or after wounding.
may also predispose to infection. All aspects of steroid-induced healing impairment other than
Impaired healing must be anticipated in cancer patients be- wound contraction can be reversed by supplemental vitamin A.The
cause of the many alterations in metabolism and immune func- recommended dose is 25,000 IU/day. Topical vitamin A has also
tion. It has been suggested that vitamin A can improve healing in been found effective for open wounds.238 Anabolic steroids and
tumor-bearing mice,215 but this effect has not been demonstrated growth hormone–releasing factor have also reversed steroid-
in humans. induced healing impairments.
Old Age Chemotherapeutic Agents
The elderly heal less efficiently than younger persons. DuNuoy Chemotherapeutic agents impair healing primarily through inhi-
and Carrell,216 who studied patients injured during World War I, bition of cellular proliferation. Many agents have been examined in
demonstrated that wounds in 20-year-old patients contracted more experimental models, and virtually all agents impair healing.239 Ni-
rapidly than those in 30-year-old patients. In a blister epithelializa- trogen mustard, cyclophosphamide, methotrexate, BCNU (carmus-
tion model,217 younger patients also healed more rapidly than older tine), and doxorubicin are the most damaging to the healing process.
patients. Another study218 found that wound disruption occurred Most chemotherapeutic regimens use a combination of agents,
with less force in the elderly. compounding their deleterious effects. Clinical trials with chemo-
therapeutic agents have not been associated with as high an inci-
Diabetes dence of complications as might be anticipated from experimental
Diabetes mellitus is also associated with impaired healing. In a evidence.The timing of drug administration as well as the doses uti-
prospective study of 23,649 surgical wounds,219 the risk of infection lized may explain this apparent contradiction. Doxorubicin, for ex-
was five times greater in diabetic patients than in nondiabetic pa- ample, is a more potent inhibitor of wound healing when delivered
tients. This impairment has been demonstrated experimentally in preoperatively than postoperatively.240
several models.220-222 A major contributor to this phenomenon is
the impaired inflammatory response associated with hyperglycemia. Jaundice and Liver Failure
Diabetes is associated with impaired granulocyte chemotaxis,223 Liver dysfunction most likely impairs healing through the direct
phagocytic function,224-226 and humoral and cellular immunity. In effect of hyperbilirubinemia and through metabolic impairments,
addition, diabetes is associated with a microangiopathy that can such as hypoalbuminemia and hypoprothrombinemia, that develop
limit blood supply to the healing wound, particularly in older dia- when the synthetic functions of the liver are impaired.The effect of
betic patients.227 Diabetic neuropathy impairs sensation, classically obstructive jaundice on wound healing has been examined experi-
in a stocking or glove nerve distribution in extremities. Although mentally by several investigators. Bayer and Ellis241 demonstrated de-
this neuropathy does not limit healing directly, it can diminish an creased wound-breaking strength in abdominal wounds in rats with
individual’s ability to protect himself or herself from trauma.The di- obstructive jaundice. In jaundiced animals with gastric wounds, angio-
abetes-induced impairment in healing may be reduced by tight genesis was subjectively diminished, but wound-breaking strength
control of blood sugar levels with insulin.228-230 was normal. Arnaud and coworkers242 demonstrated impaired heal-
ing with obstructive jaundice,242 but Greaney and associates243 could
Uremia not duplicate their results in a similar model. Greaney did show di-
Uremia has been associated with impaired healing, partially as a minished collagen accumulation, however, in the wounds of jaundiced
direct effect of urea and partially as the result of coexisting malnu- animals. In humans, Ellis and Heddle244 noted an increased incidence
trition. This healing impairment has been demonstrated experi- of wound dehiscence and hernias in patients undergoing surgery for
mentally in both incisional skin wounds and intestinal anastomoses relief of obstructive jaundice, although others have disagreed.
in rats231 and in an implantable Gore-Tex wound-healing model in Clinicians must be aware of both local and systemic factors that
humans.232 This impairment may be ameliorated by regular dialysis. can influence healing in an individual patient and take appropriate
measures, whenever possible, to improve chances for optimal healing.
Alcoholism
HYPERTROPHIC SCARS AND KELOIDS
In mice chronically fed alcohol, cellular ingrowth and collagen
accumulation were diminished in a sponge model.233 The events involved in normal healing begin and end in a
controlled fashion, producing flat, unobtrusive scars. Healing is a
Steroids and Immunosuppression biologic process, and as with all biologic processes, it may occur to
Adrenocortical steroids inhibit all aspects of healing. In incision- a greater or lesser degree. Disturbances that diminish healing have
al wounds, steroids slow the development of breaking strength234; in already been discussed. Excessive healing can result in a raised,
open wounds healing secondarily, they impede wound contrac- thickened scar with both functional and cosmetic complications.
tion235,236 and epithelialization. If the scar is confined to the margins of the original wound, it is
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
1 Basic Surgical Perioperative Considerations 7 ACUTE WOUND CARE — 19
called a hypertrophic scar.245 Keloids extend beyond the confines frequently in dark-skinned people. Hypertrophic scars generally
of the original injury, so that the original wound often can no develop soon after injury, whereas keloids may develop up to a
longer be distinguished. year after an injury. Hypertrophic scars may subside in time,
Certain patients and certain wounds are at higher risk for abnor- whereas keloids rarely do. Hypertrophic scars are more likely to
mal scarring. Dark-skinned persons and patients between the ages be associated with a contracture across a joint surface.
of 2 and 40 are at higher risk for the development of hypertrophic Keloids and hypertrophic scars result from a net increase in the
scars or keloids.Wounds in the presternal or deltoid area, wounds quantity of collagen synthesized by fibroblasts in the wound area.
that cross skin tension lines, and wounds in thicker skin have a The fibroblasts within keloids may be different in terms of their bio-
greater tendency to heal with a thickened scar. Some parts of the logic responsiveness from those within normal dermis. Although
body, such as the genitalia, the eyelids, the palms of the hands, and many theories have been suggested, the etiology of keloids and hy-
the soles of the feet, almost never develop abnormal scars. pertrophic scars is unknown. Treatment of hypertrophic scars and
Certain patient and wound characteristics increase the relative keloids has included surgical excision, steroid injection, pressure gar-
likelihood of developing a hypertrophic scar as opposed to a ke- ments, topical Silastic gel, radiation therapy, and combinations of
loid.246 Keloids are more likely than hypertrophic scars to be fa- these approaches.The absence of a uniform treatment program ac-
milial. Hypertrophic scars are more likely to be seen in light- curately suggests that no specific treatment is predictably effective
skinned people; both hypertrophic scars and keloids occur more for these lesions.247
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of zinc deficiency on nucleic acids, collagen, and healing of rat skin wounds. Ann Surg 161:293, 1965
noncollagenous protein of the connective tissue. J 229. Weringer EJ, Kelso JM,Tamai IY, et al: Effects of in-
Lab Clin Med 82:951, 1973 sulin on wound healing in diabetic mice. Acta En-
210. Haley JV: Zinc sulfate and wound healing. J Surg docrinol 99:101, 1982
Res 27:168, 1979 230. Yue DK, McLennan S, Marsh M, et al: Effects of
experimental diabetes, uremia, and malnutrition on Acknowledgments
211. Windsor JA, Knight GS, Hill GL:Wound healing re-
sponse in surgical patients: recent food intake is wound healing. Diabetes 36:295, 1987
more important than nutritional status. Br J Surg 231. Colin JF, Elliot P, Ellis H:The effect of uremia upon Figure 1 Carol Donner.
75:135, 1988 wound healing: an experimental study. Br J Surg Figure 2 Janet Betries.
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2 HEAD AND NECK 1 HEAD AND NECK DIAGNOSTIC PROCEDURES — 1
Head and neck surgery deals with a wide range of pathologic con- esophagus. The pharynx is subdivided into the nasopharynx, the
ditions affecting the upper aerodigestive tract and the endocrine oropharynx, and the hypopharynx.
organs of the head and neck. As in other areas of the body, the
causes of these conditions can be inflammatory, infectious, con- Nasopharynx
genital, neoplastic, or traumatic. This chapter discusses the diag- The nasopharynx extends from the posterior choanae to the
nostic approach to head and neck disorders, with particular inferior surface of the soft palate. Malignancies of the nasophar-
attention to cancer. ynx can present as nasal obstruction, epistaxis, tinnitus,
headache, diminished hearing, and facial pain.
Anatomic Considerations Oropharynx
The head and neck can be conceptualized by dividing it into The oropharynx extends from the junction of the hard and soft
the following segments: (1) nasal cavity and paranasal sinuses, (2) palates and the circumvallate papillae to the valleculae. It includes the
oral cavity, (3) pharynx, (4) larynx, (5) salivary glands, and (6) soft palate and uvula, the base of the tongue, the pharyngoepiglottic
thyroid [see Figure 1]. and glossoepiglottic folds, the palatine arch (which includes the ton-
sils and the tonsillar fossae and pillars), the valleculae, and the later-
NASAL CAVITY AND PARANASAL SINUSES
al and posterior oropharyngeal walls. Carcinomas of the oropharynx
The nasal vault and paranasal sinuses are a complex labyrinth can present as pain, sore throat, dysphagia, and referred otalgia.
of interconnected cavities. These cavities are lined with mucous
membranes and are normally well aerated. The nasal vault itself Hypopharynx
is divided into two equal halves by the nasal septum. There are The hypopharynx extends from the superior border of the
three paired turbinates in the nasal cavity, which further subdi- hyoid bone to the inferior border of the cricoid cartilage. It includes
vide the nasal vault from cephalad to caudal, creating the superi- the pyriform sinuses, the hypopharyngeal walls, and the post-
or, middle, and inferior meatuses. cricoid region (i.e., the area of the pharyngoesophageal junction).
The ethmoid sinus is the most complicated of the paranasal Malignancies of the hypopharynx can present as odynophagia,
sinuses; it is also known as the ethmoid labyrinth [see Figure 2]. dysphagia, hoarseness, referred otalgia, and excessive salivation.
The maxillary sinus lies within the body of the maxilla and is the
LARYNX
largest of the paranasal sinuses. The frontal sinus lies within the
frontal bone and is divided into two asymmetrical halves by an The larynx is subdivided into the supraglottis, the glottis, and
intersinus septum. The sphenoid sinus lies posterior to the nasal the subglottis [see Figure 3]. It consists of a framework of carti-
cavity and superior to the nasopharynx. It too is an asymmetri- lages that are held together by extrinsic and intrinsic musculature
cally paired structure that is divided by an intersinus septum.The and lined with a mucous membrane that is topographically
sphenoid sinus remains the most dangerous sinus to manipulate arranged into two characteristic folds (the false and true vocal
surgically because of the surrounding vital structures (i.e., the cords). Neoplasms of the larynx can present as hoarseness, dysp-
carotid artery, the optic nerve, the trigeminal nerve, and the vid- nea, stridor, hemoptysis, odynophagia, dysphagia, and otalgia.
ian nerve).
Tumors within the nasal vault or the paranasal sinuses present Supraglottis
as nasal airway obstruction, epistaxis, pain, and nasal discharge. The supraglottis extends from the tip of the epiglottis to the
They can originate in any of the paranasal sinuses or the nasal junction between respiratory and squamous epithelium on the
cavity proper and often remain silent or are mistakenly treated as floor of the ventricle (the space between the false and true cords).
an infectious or inflammatory condition, with a consequent delay Carcinomas of the supraglottis can present as sore throat,
in the diagnosis. odynophagia, dysphagia, and otalgia.
ORAL CAVITY Glottis
Anatomically, the oral cavity extends from the vermilion bor- The space between the free margin of the true vocal cords is
der to the junction of the hard and soft palates and the circum- the glottis.This structure is bounded by the anterior commissure,
vallate papillae. It includes the lips, the buccal mucosa, the upper the true vocal cords, and the posterior commissure. The most
and lower alveolar ridges, the retromolar trigones, the oral tongue common symptom of carcinoma of the glottis is hoarseness.
(anterior to circumvallate papillae), the hard palate, and the floor
of the mouth. Subglottis
The subglottis extends from the junction of squamous and res-
PHARYNX
piratory epithelium on the undersurface of the true vocal cords
The pharynx is a tubular structure extending from the base of (approximately 5 to 10 mm below the true vocal cords) to the
the skull to the esophageal inlet. Superiorly, it opens into the nasal inferior edge of the cricoid cartilage. The most common symp-
and oral cavities; inferiorly, it opens into the larynx and the tom of carcinoma of the subglottis is hoarseness.
1
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2 HEAD AND NECK 1 HEAD AND NECK DIAGNOSTIC PROCEDURES — 2
Superior Concha
Falx Cerebri
Middle Concha
Pharyngeal Orifice
of Auditory Tube
Inferior Concha
Straight Sinus
Oral Part
of Tongue
Sublingual Fold
Pharyngeal Recess
Pharyngeal Part
of Tongue
Salpingopharyngeal Fold
Hyoid Bone
Oral Part of Pharynx
Laryngeal Part
of Pharynx
Vocal Fold
Thyroid Cartilage
Figure 1 The anatomic structures of
Esophagus the head and neck are shown.
Frontal Sinus
Ethmoid Sinuses
Turbinate Ostium
Bones
Maxillary
Sinus
Nasal
Airway Figure 2 The paranasal
sinuses are shown.
usually provides only a working diagnosis.The head and neck sur- 60º, and 90º), which allow for visualization of structures that are in-
geon must then proceed in a stepwise fashion to further clarify the accessible by simple anterior rhinoscopy. Rigid nasal endoscopy is
diagnosis and, in the case of neoplasm, to perform an accurate staging. especially useful for visualizing deeper structures and structures that
Radiographic techniques allow the head and neck surgeon to vi- are not in a straight axis from the nasal aperture.
sualize the mass and determine its characteristics (i.e., to differenti-
ate between solid and cystic lesions), as well as determine its
anatomic associations. Ultrasonography, magnetic resonance imag- Indirect Laryngoscopy
ing, and computed tomography each provides a unique view of the Indirect laryngoscopy has been used since the 1800s for visualiz-
pathology in question and thereby helps narrow the differential di- ing the pharynx and larynx. In this technique, the head light source
agnosis. Acquisition of a tissue specimen for cytologic or histologic illuminates the mirror, which in turn illuminates the laryngophar-
analysis, or both, is the next step. Fine-needle aspiration (FNA) is ynx [see Figure 5].The patient is seated in the sniffing position and
often utilized at this stage in the workup, provided that the location protrudes the tongue while a warmed laryngeal mirror is intro-
of the mass lends itself to a safe procedure. If the lesion is located duced firmly against the soft palate in the midline to elevate the
deep in the neck near vital structures, image-guided FNA can be at- uvula out of the field (gently, so as not to elicit the gag reflex).The
tempted before resorting to an open biopsy. If the lesion is on a mu- image seen on the mirror can be used to assess vocal cord mobility,
cosal surface of the upper aerodigestive tract, an endoscopic biopsy as well as to inspect for a mass or foreign body of the larynx or phar-
is performed. Often, a panendoscopic procedure is performed at ynx.This technique can be performed rapidly and is inexpensive.
this point to accurately map the lesion, obtain a tissue specimen,
and, in patients with cancer, assess the rest of the upper aerodiges-
tive tract for a synchronous primary tumor. Endoscopic Procedures
After a histologic diagnosis has been made and correlated with Endoscopic evaluation of the upper aerodigestive tract is cru-
the imaging information, the patient and physician can have a com- cial in establishing a definitive diagnosis. The equipment used
prehensive discussion of the pathology, the stage of the disease, and consists of both rigid and flexible laryngoscopes, bronchoscopes,
the selection of therapy. and esophagoscopes. Many of these techniques can be performed
in the office setting, providing the surgeon with an array of meth-
ods for gaining the information necessary for a working diagnosis
Nasal Diagnostic Procedures and, in some cases, for performing a therapeutic intervention.
Operative endoscopy is performed to obtain a definitive diagno-
ANTERIOR RHINOSCOPY
sis, to stage tumors, and to rule out synchronous lesions.There is
Using a variety of different light sources that provide both illu- no substitute for thorough examination and biopsy of a lesion
mination and coaxial vision, the head and neck surgeon can view with the patient under general anesthesia. Regardless of the endo-
the nasal vault through a nasal speculum [see Figure 4].This tech- scopic method used, an adequate biopsy specimen must be
nique is performed both before and after nasal decongestion, with obtained for a histologic diagnosis.
particular attention to mucosal color, edema, and discharge and
FLEXIBLE RHINOLARYNGOSCOPY
the effect of vasoconstriction. Limited visualization of the nasal
septum, the turbinates, and the vault is also possible with this Flexible rhinolaryngoscopy is currently one of the most com-
technique. monly used techniques for visualizing the nasal cavity, the sinus-
es, the pharynx, and the larynx. The technique utilizes a small-
RIGID NASAL ENDOSCOPY
caliber flexible endoscope and can be performed in an office set-
The rigid nasal endoscope comes with a variety of lens angles (0º, ting [see Figure 6]. Before the procedure, the patient’s nasal cavity
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2 HEAD AND NECK 1 HEAD AND NECK DIAGNOSTIC PROCEDURES — 4
Epiglottis ESOPHAGOSCOPY
Infraglottic
Rigid Esophagoscopy
Cricoid
Cartilage Space Rigid esophagoscopy can be used to treat a variety of problems,
including foreign bodies, hemorrhage (e.g., from esophageal
varices), and endobronchial tumors. Rigid esophagoscopes [see Fig-
ure 8] are used with the patient under general anesthesia.The pa-
Trachea tient is placed in the supine position with the neck extended. The
esophagoscope is then passed along the right side of the tongue,
with the endoscopist using the left hand to cradle the instrument.
The right hand is used for stabilization of the proximal end of the
Figure 3 Cross-sectional anatomy of the larynx is shown. scope, suctioning, and insertion of instruments through the lumen
of the esophagoscope. The lip of the esophagoscope is positioned
anteriorly for manipulation of the epiglottis and visualization of the
is decongested and anesthetized for maximum visualization and pyriform sinus and the arytenoids.The scope is then passed along
minimal discomfort. In the procedure, the examiner threads the the pyriform sinus into the cricopharyngeus (i.e., the superior
end of the scope into the nasal aperture along the floor of the esophageal valve). The left thumb is then used to advance the in-
nasal cavity. As the scope is advanced, the examiner can visualize strument down the esophagus. If no major lesions are noted on in-
the nasal cavity proper for any evidence of lesions or masses. sertion of the esophagoscope, a careful inspection of the mucosa
Once the scope approaches the nasopharynx, it is directed inferi- should be made during withdrawal of the instrument.
orly and advanced slowly, allowing direct visualization of the
entire pharynx and larynx.
DIRECT LARYNGOSCOPY
The flexible fiberoptic bronchoscope is usually used with local The term panendoscopy refers to the combination of direct
anesthesia and sedation in a monitored setting (e.g., an operating laryngoscopy (with or without microscopic assistance), esopha-
suite). After local anesthesia and decongestion of the nasal vault goscopy, and bronchoscopy. Together, these three procedures
with topical tetracaine and 1% phenylephrine, the flexible scope is provide a complete examination of the entire upper aerodigestive
gently passed along the nasal floor into the nasopharynx, where tract. In cancer patients, this combination of procedures allows
the tip of the scope is angled inferiorly to permit visualization of the examiner to create a detailed map of the tumor, as well as to
the pharynx.The instrument is then advanced slowly into the glot- rule out synchronous primary tumors.
tis (between the true vocal folds) and into the tracheobronchial
tree. After a visual inspection of the airway has been completed, a Biopsy Procedures
specimen can be retrieved by means of brush biopsy, broncho-
alveolar lavage, or a biopsy forceps. FINE-NEEDLE ASPIRATION
Rigid Bronchoscopy FNA is often used to make an initial tissue diagnosis of a neck
Rigid bronchoscopy [see Figure 9] is performed with the patient mass. The advantages of this technique include high sensitivity
under general anesthesia. The patient is placed in the supine posi- and specificity; however, 5% to 17% of FNAs are nondiagnostic.
tion with the neck hyperextended. The bronchoscope is then Another advantage of FNA is speed: If a cytologist or a patholo-
passed along the right side of the tongue, with the endoscopist gist is available, diagnosis can often be made within minutes of
using the left hand to cradle the instrument.The instrument is ini- the biopsy.
tially held almost vertically until it reaches the posterior pharyngeal FNA is performed with a 10 ml syringe with an attached 21-
wall, at which point it is slowly guided into a more horizontal posi- to 25-gauge needle. Larger needles are more likely to result in
tion.While advancing the scope, the endoscopist cradles the instru- tumor seeding.The patient is positioned to allow for optimal pal-
ment with the fingers of the left hand, providing guidance and pro- pation of the mass. The skin overlying the mass is prepared with
tecting the patient’s lips and teeth. Once the tip of the epiglottis is a sterile alcohol prep sponge. Local anesthesia is not necessary.
The mass is grasped and held in a fixed and stable position. The
needle is introduced just under the skin surface. As the needle is
advanced, the plunger of the syringe is pulled back, to create suc-
tion. Once the mass is entered, multiple passes are made without
exiting the skin surface; this maneuver is critical in maximizing
specimen yield. After the final pass is completed, the suction on
the syringe is released and the needle withdrawn from the skin. If
a cyst is encountered, it should be completely evacuated and the
fluid sent for cytologic analysis.
A drop of aspirated fluid is placed on a glass slide. A smear is
made by laying another glass slide on top of the drop of fluid and
pulling the slides apart to spread the fluid. Fixative spray is then
applied. Alternatively, wet smears are placed in 95% ethyl alcohol
and treated with the Papanicolaou technique and stains.
FNA has several advantages over excisional biopsy. An FNA
requires only an office visit, with minimal loss of time from work
for the patient. In contrast, excisional biopsy is commonly per-
formed in an operating room, so the patient must undergo pre-
operative testing. Patients with a significant medical history may
require formal medical clearance. An excisional biopsy exposes
Figure 6 A small-caliber flexible laryngoscope is used for rhino- the patient to the risks of anesthesia, postoperative wound infec-
laryngoscopy. tion, and tumor seeding.
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2 HEAD AND NECK 1 HEAD AND NECK DIAGNOSTIC PROCEDURES — 6
a b
Figure 7 Shown are (a) normal vocal folds directly visualized via (b) a rigid laryngoscope.
ULTRASOUND-GUIDED FNA neck. Palpable masses in the neck [see 2:3 Neck Mass] can be
Ultrasonographic guidance of FNA enables the surgeon to ob- assessed for changes in size, for association with other local struc-
tain a cytologic specimen of deeper or nonpalpable masses that are tures, and for character (i.e., solid, cystic, or complex). Applica-
not amenable to standard FNA. Real-time imaging of the needle’s tions of ultrasonography include assessment of masses such as
passage allows the surgeon to plot a more accurate trajectory and thyroglossal duct cysts, branchial cleft cysts, cystic hygromas, sali-
avoid underlying vital structures. Furthermore, it provides an image vary gland tumors, abscesses, carotid body tumors, vascular
of the mass, allowing its characterization as solid, cystic, or hetero- tumors, and thyroid masses. Additionally, ultrasonography com-
geneous.With cystic or complex masses, it is imperative to place the bined with FNA and cytologic evaluation can provide both a
tip of the needle into the wall to increase specimen yield. detailed visual description and an accurate cytologic evaluation of
masses in the neck [see Ultrasound-Guided FNA, above].
CT-GUIDED FNA
COMPUTED TOMOGRAPHY
CT-guided FNA is most commonly employed to diagnose poor-
ly accessible or deep-seated lesions of the head and neck. Like ultra- A CT scan with intravenous contrast is often the first-line
sound-guided FNA, CT-guided FNA provides visualization of the imaging technique used to evaluate a mass of the neck and to as-
needle as it is passed through the tissue and into the underlying sess for pathologic adenopathy. CT has proved to be an effective
structures, thus allowing a more accurate needle trajectory and method for primary staging of tumors and lymph nodes. Addition-
avoidance of underlying vital structures. Additionally, visual guid- ally, it has been shown to be effective in studying capsular pene-
ance of the needle greatly increases the likelihood of obtaining a tration and extranodal extension. It is clearly superior to MRI in
specimen from the mass rather than the surrounding tissues. evaluating bone cortex erosion, given that MRI cannot assess
bone cortex status at all. CT scans are also widely used for post-
treatment surveillance in cancer patients.
Imaging Procedures
MAGNETIC RESONANCE IMAGING
Because many of the deep structures of the head and neck are
inaccessible to either direct evaluation by palpation or indirect MRI avoids exposing the patient to radiation and provides the
evaluation via endoscopy, further information must be obtained investigator with superior definition of soft tissue. For example,
by radiography. Imaging procedures such as CT, MRI, ultra- MRI can differentiate mucous membrane from tumor, as well as
sound, and positron emission tomography (PET) scanning per- detect neoplastic invasion of bone marrow. In patients with nasal
mit the diagnosis and analysis of pathologic conditions affecting cavity tumors, MRI can distinguish between neoplastic, inflam-
these deep structures, including the temporal bone, skull base, matory, and obstructive processes. MRI is also valuable in assess-
paranasal sinuses, soft tissues of the neck, and larynx. ing the superior extent of metastatic cervical lymphadenopathy
(i.e., intracranial extension). A disadvantage of MRI is its limited
ULTRASONOGRAPHY
ability to show bone detail; it therefore cannot detect invasion of
Ultrasonography is a safe and inexpensive method of gaining bone cortex by a neoplasm. Furthermore, an MRI scan is signif-
high-resolution real-time images of the structures of the head and icantly more expensive than a CT scan.
Figure 9 (a) Rigid bronchoscopes incorporate stainless-steel tubes of varying length and
diameter. The beveled distal end of this Hopkins bronchoscope facilitates mobilization of the
epiglottis during intubation; the side ports permit ventilation and use of suction catheters.
(b) Illumination is provided by fiberoptic rods that are inserted into the bronchoscope.
POSITRON EMISSION TOMOGRAPHY False negative scans occur when tumor deposits are very small
PET scanning is a functional imaging technique that measures (i.e., 3 to 4 mm or less in diameter). Thus, micrometastases are
tissue metabolic activity through the use of radioisotopically not reliably detected using an FDG-PET image. Furthermore, a
tagged cellular building blocks, such as glucose precursors. A false negative scan can occur if the PET scan is performed too
range of physiologic tracers has been developed for PET imag- soon after radiation therapy.
ing, with the glucose analogue 2-deoxy-2-[(18)F]fluoro-D-glu- The role of PET imaging in head and neck oncology is rapid-
cose (FDG) the most commonly used. FDG has a half-life of 110 ly expanding. Currently, the majority of PET imaging used in
minutes. Once given to the patient, FDG is taken up by glucose head and neck oncology is FDG based. FDG-PET is actively
transporters and is phosphorylated by hexokinase to become being used to look for unknown primary lesions and second pri-
FDG-6-phosphate (FDG-6-P). Further metabolism of FDG-6- maries, to stage disease before therapy, to detect residual or
P is blocked by the presence of an extra hydroxyl moiety, which recurrent disease after surgery or radiation therapy, to assess the
allows FDG-6-P to accumulate in the cell and serve as a marker response to organ preservation therapy, and to detect distant
for glucose metabolism and utilization. metastases. Because false positive and false negative PET scans
Because neoplastic cells have higher rates of glycolysis, localized do occur, accurate interpretation of PET scans requires a thor-
areas of increased cellular activity on PET scans may represent neo- ough understanding of the potential confounding factors.
plastic tissue. In this respect, PET is very different from CT and MRI,
PET/CT
which depict tissue structure rather than tissue metabolic activity.
Because FDG is nonspecifically accumulated in glycolytically PET/CT is essentially an FDG-PET scan that has been coreg-
active cells, it demarcates areas of inflammation as well as neo- istered with a simultaneous CT scan to allow the radiologist to
plastic tissue, which can lead to a false positive scan. Muscular precisely correlate the area of increased cellular activity with the
activity during the scan can also lead to areas of increased uptake anatomic structure. This technique removes some of the guess-
in nonneoplastic tissue. Furthermore, healing bone, foreign body work involved with interpreting an area of increased activity on a
granulomas, and paranasal sinus inflammation can produce false simple PET scan and provides the physician with a morphologic
positive results. correlate for the area of increased uptake.
Recommended Reading
AJCC Cancer Staging Manual, 5th ed. Lippincott Cummings C: Otolaryngology Head and Neck Cancer Institute, National Institutes of Health, 2004.
Raven, Philadelphia, 1997 Surgery, 3rd ed. Mosby – Year Book St. Louis, 1998 http://seer.cancer.gov/
Bailey B: Head and Neck Surgery – Otolaryngology, Som P: Head and Neck Imaging, 4th ed. Mosby, St. Acknowledgments
3rd ed. Lippincott Williams & Wilkins, Philadelphia, Louis, 2003 Figure 1 Tom Moore.
2001 Surveillance Epidemiology and End Results. National Figures 2 and 3 Alice Y. Chen.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 2 ORAL CAVITY LESIONS — 1
Diagnosis is probable
Infectious •Torus: intervention only if Treat with local Observe; repeat biopsy
•Viral: symptomatic treatment, antivirals if denture fit affected excision. if changes noted.
patient is immunocompromised •Cyst: observation or
•Bacterial: antibiotics excision
•Fungal: antifungals, usually topical (systemic •Fibroma: observation or
for persistent infection) excision
•Oral hairy leukoplakia or unusual infection: •Odontogenic cyst:
rule out HIV infection, refer patient to excision or debridement;
infectious disease specialist tooth extraction for
Noninfectious dentigerous cyst
•Aphthous ulcer: symptomatic treatment,
topical anti-inflammatories
•Traumatic ulcer: symptomatic treatment
•Autoimmune: symptomatic treatment, topical
or systemic steroids
•Necrotizing sialometaplasia: observation,
biopsy to rule out cancer
Diagnosis is uncertain
Perform biopsy.
Treat specific malignancy.
Minor salivary gland malignancy Mucosal melanoma Squamous cell carcinoma Kaposi sarcoma
Stage with CT, MRI, or PET. Stage with CT, MRI, PET, or Consider referral to medical
Assess with CT or MRI.
Perform wide local excision. panendoscopy. oncologist or infectious
Perform wide local excision.
•Clinically positive neck: •Stage 1 and 2: surgery disease specialist.
•Clinically positive neck: neck dissection.
•Clinically negative neck: consider neck dissection. or irradiation Rule out systemic disease.
selective neck dissection if tumor is •Clinically negative neck: •Stage 3 and 4: surgery with If asymptomatic, observe;
high grade. consider selective neck postoperative irradiation if symptomatic, consider
dissection. Perform neck dissection local or systemic treatment.
Consider postoperative irradiation for
Consider postoperative as indicated.
high-grade tumor or perineural spread.
irradiation.
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2 HEAD AND NECK 2 ORAL CAVITY LESIONS — 4
Infectious
Viral
Herpes simplex
Herpes zoster
Cytomegalovirus
Herpangina
Hand, foot, and mouth disease
Oral hairy leukoplakia (Epstein-Barr virus)
Bacterial Buccal
Mycobacterial infection Mucosa Oral
Syphilis Tongue
Gingivostomatitis
Fungal
Inflammatory Candidiasis
lesions Coccidioidomycosis Lower Floor of
Alveolus Mouth
Noninfectious
Recurrent aphthous stomatitis
Traumatic ulcer
Lip
Autoimmune disorders
Behçet syndrome
SLE Figure 1 Depicted are the major anatomic subsites of the oral
Wegener granulomatosis cavity.
Sarcoidosis
Amyloidosis
Pemphigus and pemphigoid cranial nerves should be examined, with particular attention
Pyogenic granuloma focused on the trigeminal, facial, and hypoglossal nerves.
Necrotizing sialometaplasia
Lichen planus
Investigative Studies
Mucocele
Ranula The history and physical
Tumorlike
lesions Tori examination should narrow
Fibroma down the differential diag-
Odontogenic cysts nosis and lead to a working
Benign diagnosis. If a benign local
Squamous papilloma process (e.g., aphthous sto-
Minor salivary gland neoplasms matitis, traumatic ulcer, or viral infection) is suspected, no fur-
Ameloblastoma ther investigation, other than reevaluation, may be needed. If the
Hemangioma lesion persists or progresses, further investigation is warranted.
Granular cell tumor
Brown tumor LABORATORY TESTS
Neuroma, schwannoma, neurofibroma
Laboratory studies are usually not beneficial in the initial
Osteoma, chondroma
Neoplasms Malignant
workup of oral cavity lesions. If a connective tissue disease is sus-
Squamous cell carcinoma pected, serologic tests [see Table 2] and referral to a rheumatolo-
Verrucous carcinoma gist or another appropriate specialist may be considered.
Minor salivary gland malignancies
IMAGING
Mucoepidermoid carcinoma
Adenoid cystic carcinoma The value of advanced imaging with computed tomography,
Polymorphous low-grade adenocarcinoma magnetic resonance imaging, or both in the management of oral
Mucosal melanoma cavity lesions has not been firmly established. Accordingly, judg-
Kaposi sarcoma ment must be exercised. There is evidence to suggest that early
Lymphoma
oral cavity malignancies can be managed without either CT or
Osteosarcoma
MRI. Nevertheless, many clinicians obtain these studies in all
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 2 ORAL CAVITY LESIONS — 5
cases of malignancy and in most cases of suspected malignancy. bacterial, or viral infection is suspected, a small portion of a spec-
CT and MRI can help assess the size and location of the lesion imen may be sent separately for culture. If there is an associated
and determine the degree to which surrounding structures are neck mass [see 2:3 Neck Mass], fine-needle aspiration (FNA) may
involved. In patients with oral cavity carcinoma, imaging facili- be performed to rule out metastatic disease. In general, FNA is
tates the staging of tumors and the planning of treatment. In not useful for biopsy of oral lesions: incisional biopsy is often tech-
patients with cervical metastases, physical examination augment- nically easier and provides more tissue.
ed by MRI and CT has a better diagnostic yield than physical
EXAMINATION UNDER ANESTHESIA AND PANENDOSCOPY
examination alone. Bone-window CT scans are particularly help-
ful for assessing invasion of the mandible, the maxilla, the cervi- In patients with oral carcinoma, examination under anesthesia
cal spine, and the base of the skull. CT scans are highly sensitive (EUA) and panendoscopy may be performed either before or
and specific for detecting mandibular invasion.2,3 MRI provides during operation to assess the extent of the primary tumor and
better soft tissue delineation than CT, with fewer dental artifacts, identify any synchronous tumors. Both EUA and panendoscopy
and therefore is particularly valuable for assessing malignancies of are commonly performed in the operating room with the patient
the tongue, the floor of the mouth, and the salivary glands. Loss under general anesthesia. Panendoscopy involves endoscopic
of the usual marrow enhancement on T1-weighted MRI images examination of the larynx, the oropharynx, the hypopharynx, the
suggests bone invasion, though this is not a specific finding. Chest esophagus, and, occasionally, the nasopharynx. As a rule, assess-
x-ray, CT, or both may be employed to search for lung metastases ment of the tumor and neck is more accurately performed when
or a second primary tumor. the patient is relaxed under a general anesthetic. With improved
Positron emission tomography (PET) is playing an increasing- imaging techniques and the wider availability of office endo-
ly important role in the workup of patients with head and neck scopes, the role of panendoscopy is decreasing.
carcinoma or mucosal melanoma. PET is useful for confirming
the presence of a malignancy, as well as for assessing cervical and
distant metastases4-6; it is particularly valuable for detecting recur- Diagnosis and
rent or persistent disease.7 Drawbacks include frequent false pos- Management of Specific
itive results with active inflammation, high cost, and limited avail- Oral Cavity Lesions
ability. In addition, the quality of the PET images obtained and
INFLAMMATORY LESIONS
the level of technical experience available vary considerably
among institutions. Although broad guidelines have been devel-
oped for certifying physicians in the use of PET, the specific Infectious
expertise needed for optimal imaging of the complexities of the Viral stomatitis may be caused by a number of different virus-
head and neck is not easily acquired. es, including herpes simplex virus (type 1 or type 2), varicella-
zoster virus, and coxsackievirus [see Figures 2a and 2b].8 It is most
BIOPSY
common in children and immunocompromised patients. The
For oral cavity lesions that are suggestive of malignancy or are lesions of viral stomatitis are generally vesicular, occur in the oral
probably of neoplastic origin, biopsy is usually required. A brief cavity and the oropharynx, and erupt over the course of several
observation period to allow reevaluation, with biopsy withheld, days to form painful ulcers. Eruption may be preceded by local
may be warranted if a response to therapy or spontaneous resolu- symptoms (e.g., burning, itching, or tingling) or systemic symp-
tion is possible. The potential morbidity associated with a biopsy toms (e.g., fever, rash, malaise, or lymphadenopathy). The diag-
done in a previously irradiated region should be considered in nosis is usually established by the history and the physical exami-
deciding whether biopsy is advisable. Specimens are usually sent nation and may be confirmed by means of biopsy or viral culture.
to the pathologist in 10% buffered formalin, but there are notable Treatment of viral stomatitis primarily involves managing
exceptions. If a lymphoma is suspected, specimens should be sent symptoms with oral rinses, topical anesthetics, hydration, and
without formalin for genetic testing and flow cytometry. If an antipyretics. Systemic antiviral medications may shorten the
autoimmune disease is suspected, special tests requiring immuno- course of herpetic stomatitis and are indicated in immunocom-
fluorescence are indicated, and specimens should be sent either promised patients.9
fresh or in Michel solution. In addition, if fungal, mycobacterial, Candidiasis is a common fungal infection of the oral cavity [see
Figures 2c and 2d]. Candida albicans is the species most common-
ly responsible; however, other Candida species can cause this con-
Table 2 Serologic Tests for Diagnosing Connective dition as well, with C. glabrata emerging as a growing problem in
immunocompromised hosts. Factors predisposing to oral candi-
Tissue Disease
dal infection include immunosupression, use of broad-spectrum
antibiotics, diabetes, prolonged use of local or systemic steroids,
Connective Tissue Disease Serologic Tests
and xerostomia.10 Oral candidiasis presents in several different
CBC, antinuclear antibody, anti–double- forms [see Table 3], of which pseudomembranous candidiasis
SLE
stranded DNA antibody, anti-Smith antibody (thrush) is the most common. This form is characterized by
white, curdlike plaques on the oral mucosa that may be wiped off
Antinuclear antibody, rheumatoid factor, anti-
Sjögren syndrome Ro (SS-A), and anti-La (SS-B) antibodies (with difficulty) to leave an erythematous, painful base (the
Auspitz sign). Widespread oral and pharyngeal involvement is
cANCA, serum creatinine level, urine common.The diagnosis is based on the clinical appearance of the
Wegener granulomatosis microscopy
lesion and on evaluation of scrapings with the potassium hydrox-
Sarcoidosis Serum calcium and ACE levels ide (KOH) test. Culture is generally not useful, because Candida
ACE—angiotensin-converting enzyme cANCA—cytoplasmic antineutrophil cytoplasmic is a common commensal oral organism.11
antibodies CBC—complete blood count SLE—systemic lupus erythematosus Ideally, initial management of oral candidiasis is aimed at
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 2 ORAL CAVITY LESIONS — 6
a b
c d
Figure 2 Shown are infectious lesions of the oral cavity: (a) primary herpes stomatitis of
the buccal mucosa and soft palate; (b) primary herpes stomatitis of the tongue (in the
same patient as in frame a); (c) oral candidiasis (pseudomembranous form); and (d) oral
candidiasis (erythematous form).
reversing the underlying condition, though this is not always pos- ulcers are the most common [see Table 4].9 The diagnosis is made
sible. Treatment typically involves either topically administered on the basis of the history and the physical examination; biopsy is
antifungal agents or, if infection is severe or topical therapy fails, reserved for lesions that do not heal or that grow in size.
systemically administered antifungals. Patients who are immuno- Numerous therapies have been tried for recurrent aphthous
compromised or have xerostomia may benefit from long-term stomatitis, most with only minimal success. The majority of aph-
prophylaxis. thous ulcers heal within 10 to 14 days and require no treatment;
however, patients with severe symptoms may require medical
Noninfectious intervention. Temporary pain relief can be obtained with topical
Recurrent aphthous stomatitis Aphthous stomatitis is a anesthetic agents (e.g., viscous lidocaine). Tetracycline oral sus-
common idiopathic ulcerative condition of the oral cavity [see pension and antiseptic mouthwashes have also been used, with
Figures 3a and 3b].The ulcers are typically painful and may occur varying success.9 Topical steroids are the mainstay of therapy and
anywhere in the oral cavity and the oropharynx but are rarely may shorten the duration of the ulcers if applied during the early
found on the hard palate, the dorsal tongue, and the attached gin- phase.11 These agents may be applied either in a solution (e.g.,
giva.9 Affected patients often have a history of lesions, beginning dexamethasone oral suspension, 0.5 mg/5 ml) or in an ointment
before adolescence. There are three different clinical presenta- (e.g., fluocinolone or clobetasol). Ointments work much better in
tions of recurrent aphthous stomatitis, of which minor aphthous the oral cavity than creams or gels do. Systemic steroids are indi-
cated when the number of ulcers is large or when the outbreak
has persisted for a long time.
Table 3 Clinical Presentation of Oral Candidiasis
Necrotizing sialometaplasia Necrotizing sialometaplasia
is a rare benign inflammatory lesion of the minor salivary glands
Type of Oral Candidiasis Presentation
that resembles carcinoma clinically and histologically and is read-
White, curdlike plaques on oral mucosa that ily mistaken for it [see Figure 3c].12 This condition most common-
Pseudomembranous when wiped off (with difficulty) leave erythe- ly develops in white males in the form of a deep, sudden ulcer of
matous, painful base
the hard palate.The presumed cause is ischemia of the minor sali-
Thick white plaques on oral mucosa that can- vary glands resulting from infection, trauma, surgery, irradiation,
Hyperplastic not be rubbed off or irritation caused by ill-fitting dentures.9 Biopsy is usually nec-
Red, atrophic areas on palate or dorsum of essary to rule out squamous cell carcinoma or a minor salivary
Erythematous tongue gland malignancy. Review of the tissue by a pathologist well versed
Cracking and fissuring at oral commissures
in head and neck pathology is essential. Characteristic histologic
Angular cheilitis
findings include coagulation necrosis of the salivary gland acini,
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 2 ORAL CAVITY LESIONS — 7
a b c
d e f
g h i
Figure 3 Shown are noninfectious inflammatory lesions of the oral cavity: (a) minor apthous ulcer of the lower lip; (b)
minor apthous ulcer of the upper lip; (c) necrotizing sialotmetaplasia of the hard palate; (d) resolution of necrotizing
sialometaplasia without treatment (in the same patient as in frame c); (e) pyogenic granuloma of the upper alveolus;
(f) reticular lichen planus involving the buccal mucosa; (g) lichen planus of the lateral tongue; (h) pemphigus vulgaris of
the oral cavity, with an erythematous base after rupture of bullae (involving the left lateral tongue, the buccal mucosa, and
the lip); and (i) traumatic ulcer of the tongue secondary to dental trauma.
ductal squamous metaplasia, preservation of the lobular architec- tant is the recommended treatment.The classic presentation is in
ture, and a nonmalignant appearance of squamous nests.12,13 a pregnant woman, and hormonal influences may have an addi-
Lesions resolve without treatment within 6 to 10 weeks [see tional influence on recurrence.
Figure 3d].
Lichen planus Lichen planus is a common immune-medi-
Pyogenic granuloma A pyogenic granuloma is an aggrega- ated inflammatory mucocutaneous disease [see Figures 3f and 3g].15
tion of proliferating endothelial tissue [see Figure 3e] that occurs Clinically, idiopathic lichen planus is indistinguishable from
in response to chronic persistent irritation (e.g., from a calculus lichenoid drug reaction. The reticular form of lichen planus is the
or a foreign body) or trauma.10 The lesion appears as a raised, most common one and presents as interlacing white keratotic stri-
soft, sessile or pedunculated mass with a smooth, red surface that ae on the buccal mucosa, the lateral tongue, and the palate.15
bleeds easily and can grow rapidly.14 Surface ulceration may Lichen planus is usually bilateral, symmetrical, and asympto-
occur, but the ulcers are not invasive. The gingiva is the most matic.16 The symptomatic phases may wax and wane, with erythe-
common location, but any of the oral tissues may be involved. matous and ulcerative changes being the primary signs. Cutaneous
Conservative excision with management of the underlying irri- lesions occur less frequently and appear as small, violaceous, pru-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 2 ORAL CAVITY LESIONS — 8
ritic papules.The diagnosis is generally made on the basis of the his- helpful in establishing the diagnosis. Circulating antibodies may be
tory and the physical examination; biopsy is not always necessary. present in either condition but are more common in pemphigus.
For asymptomatic lesions, no treatment is required other than Serologic tests may suffice to establish the diagnosis, without any
observation.17 For painful lesions, which are more common with need for biopsy. Management involves administration of immuno-
the erosive form of the disease, either topical or systemic steroids suppressive agents, often in conjunction with a dermatologist.
are appropriate.17 There is some controversy regarding the risk of
malignant transformation; however, long-term follow-up is still Traumatic ulcer Trauma (e.g., from tooth abrasion, tooth
recommended.16,18 The main risk posed by lichen planus may be brushing, poor denture fit, or burns) is a common cause of oral
the masking effect that the white striae cause, which can prevent mucosal ulceration [see Figure 3i]. The ulcers usually are painful
the clinician from observing the early leukoplakic and erythro- but typically are self-limited and resolve without treatment.Topical
plakic changes associated with epithelial dysplasia. anesthetic agents may be beneficial if pain is severe enough to limit
oral intake.
Ulcer from autoimmune disease Oral ulcers may be the
first manifestation of a systemic illness.The most common oral mani-
festation of systemic lupus erythematosus (SLE) is the appearance Tumorlike Lesions
of painful oral ulcers in women of childbearing age. Patients with
TORUS MANDIBULARIS AND TORUS PALATINUS
Behçet disease present with the characteristic triad of painful oral
ulcers, genital ulcers, and associated iritis or uveitis. Patients with Palatal and mandibular tori are benign focal overgrowths of cor-
Crohn disease or Wegener granulomatosis frequently manifest oral tical bone [see Figures 4a and 4b].10 They appear as slow-growing,
ulceration during the course of the illness. These disorders should asymptomatic, firm, submucosal bony masses developing on the
be managed in conjunction with a rheumatologist. lingual surface of the mandible or the midline of the hard palate.14
Mucous membrane pemphigoid and pemphigus vulgaris are When these lesions occur on the labial or buccal aspect of the
chronic vesiculobullous autoimmune diseases that frequently affect mandible and the maxilla, they are termed exostosis.20 Torus
the oral mucosa [see Figure 3h]. In mucous membrane pemphigoid, mandibularis tends to occur bilaterally, whereas torus palatinus
the antibodies are directed at the mucosal basement membrane, arises as a singular, often lobulated mass in the midline of the hard
resulting in subepithelial bullae.16 These bullae rupture after 1 to 2 palate. Surgical management is required only if the tori are inter-
days to form painful ulcers, which may heal over a period of 1 to 2 fering with denture fit.
weeks but often do not display a predictable periodicity. Oral pain
MUCOCELE AND MUCOUS RETENTION CYST
is often the chief complaint, but there may be undetected ocular
involvement that can lead to entropion and blindness. A mucocele is a pseudocyst that develops when injury to a
Pemphigus vulgaris is a more severe disease than mucous mem- minor salivary gland duct causes extravasation of mucous, sur-
brane pemphigoid. In this condition, the antibodies are directed at rounding inflammation, and formation of a pseudocapsule [see
intraepithelial adhesion molecules, leading to the formation of Figures 4c and 4d].14 Mucoceles are soft, compressible, bluish or
intraepithelial bullae.9 The blisters are painful and easily ruptured translucent masses that may fluctuate in size.They are most com-
and tend to occur throughout the oral cavity and the pharynx.19 The monly seen on the lower lip but also may develop on the buccal
Nikolsky sign (i.e., vesicle formation or sloughing when a lateral mucosa, anterior ventral tongue, and floor of the mouth. Only
shearing force is applied to uninvolved oral mucosa or skin) is pres- very rarely do they involve the upper lip; masses in the upper lip,
ent in both pemphigus and pemphigoid. In most cases, biopsy with even if they are fluctuant, should be assumed to be neoplastic,
pathologic evaluation (including immunofluorescence studies) is developmental, or infectious. Treatment involves excision of the
mucocele and its associated minor salivary gland.
A ranula (from a diminutive form of the Latin word for frog)
Table 4 Clinical Presentation of Aphthous Stomatitis is a mucocele that develops in the floor of the mouth as a conse-
quence of obstruction of the sublingual duct,16 secondary either
to trauma or to sublingual gland sialoliths. If the ranula extends
Type of Aphthous Presentation Time to
Ulcer Resolution through the mylohyoid muscle into the neck, it is referred to as a
plunging ranula. A plunging ranula may present as a submental
Multiple painful, well-demarcated or submandibular neck mass. Imaging helps delineate the extent
ulcers, < 1.0 cm in diameter, are
noted, with yellow fibrinoid base and
of the mass and may confirm the presence of a sialolith. The
Minor surrounding erythema; typically 7–10 days, with- recommended treatment is excision of the ranula with removal
involve mobile mucosa, with tongue, out scarring
of the sublingual gland and often the adjacent submandibular
palate, and anterior tonsillar pillar the
most common sites gland. Marsupialization is an option but is associated with a rela-
tively high recurrence rate.21
Ulcers, often multiple, may range in A mucous retention cyst (salivary duct cyst) is usually the result
size from a few millimeters to 3 cm
and may penetrate deeply with ele- of partial obstruction of a salivary gland duct accompanied by
Major (Sutton 4–6 wk, with
disease)
vated margins; typically involve
scarring
mucous accumulation and ductal dilatation [see Figure 4e].21 It is
mobile mucosa, with tongue, palate,
and anterior tonsillar pillar the most
a soft, compressible mass that may occur at any location in the oral
common sites cavity where minor salivary glands are present.Treatment involves
surgical excision with removal of the associated minor salivary
Small (1–3 mm) ulcers occur in
“crops” but are still limited to mov- gland.
Herpetiform able mucosal surfaces; gingival 1–2 wk
involvement, if present, is caused by FIBROMA
extension from nonkeratinizing
crevicular epithelium A fibroma is a hyperplastic response to inflammation or trau-
ma [see Figures 4f and 4g].22 It is a pedunculated soft or firm mass
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 2 ORAL CAVITY LESIONS — 9
a b c
d e f
g h
Figure 4 Shown are tumorlike lesions of the oral cavity: (a) torus mandibularis, with
bilateral bony protuberances on the lingual surface of the mandible; (b) mandibular
exostosis, with a unilateral bony protuberance on the labial-buccal surface of the
mandible; (c) mucocele of the lip (note the bluish hue of the cystic lesion; cf. frame e);
(d) mucocele of the floor of the mouth associated with the sublingual gland (ranula);
(e) mucous retention cyst of the lower lip (presenting much like mucocele, but appear-
ing more transparent); (f) fibroma of the hard palate resulting from denture trauma;
(g) fibroma of the lower lip; and (h) dentigerous cyst (a unilocular radiolucency sur-
rounding the crown of an unerupted tooth, with no bone destruction).
with a smooth mucosal surface that may be located anywhere in pressure resorption and to inflammation caused by retained ker-
the mouth. Such lesions are managed with either observation or atin. Management involves either excision or debridement and
local excision. creation of a well-ventilated and easily maintained cavity.24
ODONTOGENIC CYST
Neoplastic Lesions
A dentigerous cyst is an epithelium-lined cyst that, by defini-
BENIGN
tion, is associated with the crown of an unerupted tooth [see
Figure 4h]. Such cysts cause painless expansion of the mandible
or the maxilla. Treatment involves enucleation of the cyst and its Squamous Papilloma
lining and extraction of the associated tooth.23 Squamous papilloma is one of the most common benign neo-
An odontogenic keratocyst is a squamous epithelium–lined plasms of the oral cavity [see Figures 5a and 5b].13 It usually pre-
cyst that produces keratin. Bone resorption occurs secondary to sents as a solitary, slow-growing, asymptomatic lesion, typically
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 2 ORAL CAVITY LESIONS — 10
a b c
d e
f
Figure 5 Shown are benign neoplasms of the oral cavity: (a) squamous papil-
loma of the frenulum; (b) squamous papilloma of the ventral tongue; (c) pleo-
morphic adenoma of the hard palate; (d) pleomorphic adenoma of the hard
palate on coronal CT (note the soft tissue thickening along the left hard palate,
with no bone erosion or destruction); (e) ameloblastoma of the left angle and
ramus of the mandible (a multilocular radiolucency); and (f) ameloblastoma on
CT, with a soft tissue mass in the left mandible and erosion of the lingual plate
of the mandible.
a b c
d e f
g
Figure 6 Shown are malignant lesions of the oral cav-
ity: (a) polymorphous low-grade adenocarcinoma of
the hard palate (raised, erythematous lesion);
(b) extensive squamous cell carcinoma of the tongue,
the alveolar ridge, and the floor of the mouth; (c) squa-
mous cell carcinoma of the right floor of the mouth,
with mandibular invasion on CT scan; (d) squamous
cell carcinoma of the lip (ulcerative lesion); (e) squa-
mous cell carcinoma of the floor of the mouth (exo-
phytic lesion); (f) squamous cell carcinoma of the hard
palate; and (g) squamous cell carcinoma of the retro-
molar trigone.
developing many years later; regional recurrence is uncommon.36 have nodal metastases at presentation.42 Tumors thicker than 5
The survival rate for adenoid cystic carcinoma is relatively high mm are associated with an increased likelihood of nodal metas-
(approximately 80%) at 5 years but decreases dramatically over tases at presentation.44
the subsequent 10 to 15 years.36,40 Various factors predictive of No formal staging system has been developed for mucosal mela-
poor survival have been identified [see Table 5].40 noma. The diagnosis is made by means of biopsy and immunohis-
tochemical staining (e.g., for HMB-45 antigen, Melan-A, or S-100
Mucosal Melanoma protein). Any suspicious pigmented lesion in the oral cavity should
After the sinonasal region, the oral cavity is the site at which undergo biopsy to rule out melanoma. Amalgam tattoos are com-
mucosal melanoma most often occurs in the head and neck.41 mon in the oral cavity and can often be diagnosed on the basis of
Within the oral cavity, mucosal melanoma is most frequently
found involving the upper alveolus and the hard palate.42 It is
most common in men, usually developing in the sixth decade of
life.42 No specific risk factors or premalignant lesions have been Table 5 Poor Prognostic Factors for Minor
identified. There may, however, be an increased risk among cer- Salivary Gland Malignancies
tain subsets of East Asian patients.
Advanced disease at time of diagnosis
Oral mucosal melanoma typically appears as a flat or nodular
Positive nodes
pigmented lesion, frequently associated with ulceration. Amela-
High-risk histologic type (i.e., high-grade malignancies such as high-
notic melanoma is, fortunately, rare.43 Patients usually seek med- grade mucoepidermoid carcinoma, adenocarcinoma, carcinoma ex
ical attention at an advanced stage of the disease, when pain pleomorphic adenoma, and adenoid cystic carcinoma)
develops or when they notice a change in the fit of their dentures. Positive margins
Early asymptomatic lesions are usually identified incidentally by Male sex
either a physician or a dentist. Approximately 25% of patients
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2 HEAD AND NECK 2 ORAL CAVITY LESIONS — 13
Table 9 American Joint Committee on Cancer Table 11 Five-Year Carcinoma Survival Rates for
Staging System for Head and Neck Cancer Oral Cavity Subsites
(70%–80%) of alveolar ridge carcinomas occur on the lower alve- treatment planning and conformal radiotherapy have led to
olus, often in areas of leukoplakia.51 improved dosimetry with external beam radiotherapy, which has
Oral cavity carcinoma is generally classified according to the limited the perceived value of brachytherapy in our practice.
staging system developed by the American Joint Committee on The decision regarding which treatment is presented to a
Cancer [see Tables 8 and 9].52 Staging is based on clinical examina- patient as the first option is often determined by factors other
tion and diagnostic imaging.The diagnosis is made on the basis of than the extent of the tumor. Patient factors to be considered
biopsy and immunohistochemical staining (e.g., for cytokeratin include desires and wishes, age, medical comorbidities, and per-
and epithelial membrane antigen). formance status. Disease factors to be considered include tumor
Squamous cell carcinoma of the oral cavity is usually managed grade and stage; extent of invasion; primary site; the presence
with surgery, radiation therapy, or a combination of the two; and degree of nodal or distant metastasis; and previous treat-
chemotherapy is used primarily for palliation of incurable disease. ment. It is often helpful to discuss each case at a multidiscipli-
For localized disease without bone invasion, the cure rate for radi- nary treatment planning conference in order to develop a ranked
ation therapy is comparable to that of surgery.48 Advanced tumors list of options.
of the oral cavity are best managed with both surgery and irradia- Squamous cell carcinoma of the oral cavity tends to spread to
tion. Traditionally, in North America, oral cavity cancer is treated regional lymph nodes in a relatively predictable fashion. The pri-
primarily with surgery, and postoperative radiotherapy is added if mary levels of metastatic spread from oral cavity carcinoma
the disease is advanced or if there are pathologic features indica- includes level I through III nodes and, less frequently, level IV
tive of a high risk of recurrence (i.e., positive margins on micros- nodes53-55; metastases to level V are infrequent.53,55 The likelihood
copy; extensive perineural or intravascular invasion; two or more that cervical node metastases will develop varies depending on
positive nodes or positive nodes at multiple levels; or nodal capsu- the location of the primary tumor in the oral cavity and on the
lar extension). North American practice is reflected in the guide- stage of the tumor. Cervical metastases from carcinomas of the
lines developed by the American Head and Neck Society (www. lip or the hard palate usually occur only in advanced disease8;
headandneckcancer.org/clinicalresources/docs/oralcavity.php). however, cervical metastases from carcinomas of any of the other
Postoperative radiation, if indicated, should be started 4 to 6 oral cavity subsites are common at presentation [see Table
weeks after surgery. The total radiation dose depends on the clin- 10].8,11,48,50,51,53,56,57 Larger tumors carry a higher risk of cervical
ical and pathologic findings; the usual range is between 50 and 70 metastasis.
Gy, administered over 5 to 8 weeks. Brachytherapy can be used as The clinically positive neck is usually managed with either a
an adjunct when close or positive margins are noted. Advances in radical or a modified radical neck dissection, depending on the
extent of the disease. Some studies have found that for N1 and
some N2a patients, a comparable control rate can be achieved
Table 10 Incidence of Nodal Metastases* at with a selective neck dissection encompassing levels I through IV,
Presentation in Oral Cavity Subsites with postoperative radiation therapy added when indicated.58,59
The clinically negative neck can occasionally be managed with
Oral Cavity Subsite Incidence of Metastases observation alone, with treatment initiated only when nodal
metastases develop. Alternatively, the nodal basins at risk can be
Lip 10%
managed prophylactically by means of either surgery or radiation
Tongue 30%–40% therapy (involving levels I through III and, possibly, IV). The
rationale for prophylactic neck management is that treatment
Floor of mouth 50%
initiated while metastases are still occult is thought to be more
Alveoli 28%–32% effective than treatment initiated after the disease has progressed
Buccal mucosa 40%–52%
to the point where it is clinically detectable. For this reason,
many clinicians advocate prophylactic neck dissection for
*Clinically detectable or occult. patients with oral cavity carcinomas who are at moderate
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 2 ORAL CAVITY LESIONS — 15
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2000 neck. Head Neck 24:247, 2002
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II squamous cell cancer of the oral cavity. Arch
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1986 Presentation, treatment, and outcome of oral cavi- 69. Casiglia JW, Woo S: Oral manifestations of HIV
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Oral Pathol Oral Radiol Endod 86:42, 1998 Principles and Practice of Head and Neck Figure 1 Tom Moore.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 3 NECK MASS — 1
3 NECK MASS
Barry J. Roseman, M.D., and Orlo H. Clark, M.D., F.A.C.S.
Formulate initial diagnostic impressions Perform physical examination of head and neck
Look for
• Asymmetry • Signs of trauma • Skin changes
• Movement of mass on deglutition • Bruit
• Vocal changes
Diagnosis is probable, and Diagnosis is uncertain, or further Attempt to determine source of mass, and assess
further diagnostic investigation information is needed or desired its physical characteristics. Examine the following
is unnecessary areas in detail:
• Cervical lymph nodes • Skin • Thyroid
Consider investigative studies: • Salivary glands • Oral cavity and oropharynx
Biopsy: Fine-needle aspiration (FNA) • Larynx and hypopharynx • Nasal cavity and
is preferred method. nasopharynx
Imaging studies: Not routinely called
for, but ultrasonography, CT, MRI,
arteriography, angiography, and
plain x-rays are sometimes helpful.
Consultation with a head and neck
radiologist is desirable.
Primary neoplasm
These include
• Lymphoma • Thyroid cancer • Upper
aerodigestive tract cancer • Soft tissue sarcoma
• Skin cancer
Treat with surgery, radiation therapy, and/or
chemotherapy, as appropriate.
Metastatic tumor
Table 2—Classification of Cervical Lymph Nodes resent metastatic cancer. Multiple regions of enlarged lymph
nodes are usually a sign of systemic disease (e.g., lymphoma,
Level Nodes
tuberculosis, or infectious mononucleosis), whereas solitary
nodes are more often due to malignancy. Firm, rubbery nodes are
Submental nodes typical of lymphoma. Low cervical nodes are more likely to con-
I tain metastases from the thyroid or a primary source other than
Submandibular nodes
the head and neck, whereas upper cervical nodes are more likely
II Upper internal jugular chain nodes to contain metastases from the head and neck.
The submental and submandibular nodes (level I) are palpat-
III Middle internal jugular chain nodes
ed bimanually. Metastases to level I are commonly from the lips,
IV Lower internal jugular chain nodes the oral cavity, or the facial skin.The three levels of internal jugu-
lar chain nodes (levels II, III, and IV) are best examined by gen-
Spinal accessory nodes tly rolling the sternocleidomastoid muscle between the thumb
V
Transverse cervical nodes and the index finger. Level II and level III lymph nodes are com-
mon sites for lymph node metastases from primary cancers of the
VI Tracheoesophageal groove nodes oropharynx, the larynx, and the hypopharynx. Metastases in level
IV lymph nodes can arise from cancers of the upper aerodigestive
tract, cancers of the thyroid gland, or cancers arising below the
and the paranasal sinuses, especially when these areas cannot be clavicle (Virchow’s node). Nodal metastases in the posterior tri-
adequately visualized with more standard techniques. angle (level V) can arise from nasopharyngeal and thyroid cancers
The examination should begin with inspection for asymmetry, as well as from squamous cell carcinoma or melanoma of the pos-
signs of trauma, and skin changes. One should ask the patient to terior scalp and the pinna of the ear. The tracheoesophageal
swallow to see if the mass moves with deglutition. Palpation groove nodes (level VI) or control nodes are then palpated.
should be done both from the front and from behind. Ausculta-
tion is performed to detect audible bruits. One should also ask Skin
about the patient’s voice, changes in which may suggest either a Careful examination of the scalp, the ears, the face, the oral
laryngeal tumor or recurrent nerve dysfunction from locally inva- cavity, and the neck will identify potentially malignant skin
sive thyroid cancer. lesions, which may give rise to lymph node metastases.
During the physical examination, one should be thinking about
the following questions: What structure is the neck mass arising Thyroid Gland
from? Is it a lymph node? Is the mass arising from a normally The thyroid gland is first observed as the patient swallows; it is
occurring structure, such as the thyroid gland, a salivary gland, a then palpated and its size and consistency assessed to determine
nerve, a blood vessel, or a muscle? Or is it arising from an abnor- whether it is smooth, diffusely enlarged, or nodular and whether
mal structure, such as a laryngocele, a branchial cleft cyst, or a one nodule or several are present. If it is unclear whether the mass
cystic hygroma? Is the mass soft, fluctuant, easily mobile, well- is truly thyroid, one can clarify the point by asking the patient to
encapsulated, and smooth? Or is it firm, poorly mobile, and fixed swallow and watching to see whether the mass moves. Signs of
to surrounding structures? Does it pulsate? Is there a bruit? Does superior mediastinal syndrome (e.g., cervical venous engorge-
it appear to be superficial, or is it deeper in the neck? Is it attached ment and facial edema) suggest retrosternal extension of a thy-
to the skin? Is it tender? roid goiter. Elevation of the arms above the head often causes
The following areas of the head and neck are examined in such signs in a patient with a substernal goiter (a positive
some detail. Pemberton sign).The larynx and trachea are examined, with spe-
cial attention to the cricothyroid membrane, over which Delphian
Cervical Lymph Nodes nodes can be palpated.These nodes can be a harbinger of thyroid
Enlarged lymph nodes are by far the most common neck mass- or laryngeal cancer.
es encountered. The cervical lymphatic system consists of inter-
connected groups or chains of nodes that parallel the major neu- Major Salivary Glands
rovascular structures in the head and neck. The skin and mucos- Examination of the paired parotid and submandibular glands
al surfaces of the head and neck all have specific and predictable involves not only palpation of the neck but also an intraoral exam-
nodes associated with them. The classification of cervical lymph ination to inspect the duct openings. The submandibular glands
nodes has been standardized to comprise six levels [see Table 2 and are best assessed by bimanual palpation, with one finger in the
Figure 1]. Accurate determination of lymph node level on physi- mouth and one in the neck. They are normally lower and more
cal examination and in surgical specimens not only helps estab- prominent in older patients. The parotid glands are often palpa-
lish a common language among clinicians but also permits com- ble in the neck, though the deep lobe cannot always be assessed.
parison of data among different institutions. A mass in the region of the tail of the parotid must be distin-
The location, size, and consistency of lymph nodes furnish guished from enlarged level II jugular nodes. The oropharynx is
valuable clues to the nature of the primary disease. Other physi- inspected for distortion of the lateral walls. The parotid (Sten-
cal characteristics of the adenopathy should be noted as well, sen’s) duct may be found opening into the buccal mucosa, oppo-
including the number of lymph nodes affected, their mobility, site the second upper molar.
their degree of fixation, and their relation to surrounding anatom-
ic structures. One can often establish a tentative diagnosis on the Oral Cavity and Oropharynx
basis of these findings alone. For example, soft or tender nodes The lips should be inspected and palpated. Dentures should be
are more likely to derive from an inflammatory or infectious con- removed before the mouth is examined. The buccal mucosa, the
dition, whereas hard, fixed, painless nodes are more likely to rep- teeth, and the gingiva are then inspected. The patient should be
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 3 NECK MASS — 5
Occipital Nodes
Facial Nodes
(Buccal Nodes) Sternocleidomastoid
Muscle
Juguloomohyoid Node
Internal Jugular Chain of Nodes
(Deep Lateral Cervical Nodes) Jugular Trunk
Anterior Superficial
Cervical Nodes
(Anterior Jugular Nodes)
Supraclavicular Nodes
II
Figure 1 Cervical lymph nodes can be classified into six levels (inset) on the basis of
I
their location in the neck.1
VI III
IV
asked to elevate the tongue so that the floor of the mouth can be fully inspected and palpated.
examined and bimanual inspection performed. The tongue The hard palate is examined by gently tilting the patient’s head
should be inspected both in its normal position in the mouth and backward, and the soft palate is inspected by gently depressing the
during protrusion. tongue with a tongue blade. The movement of the palate is
Most of the oropharyngeal contents are easily visualized if the assessed by having the patient say “ahh.”
tongue is depressed. Only the anterior two thirds of the tongue The tonsils are then examined. They are usually symmetrical
is clearly visible on examination, however. The base of the but may vary substantially in size. For example, in young patients,
tongue is best visualized by using a mirror. In most persons, the hyperplastic tonsils may almost fill the oropharynx, but in adult
tongue base can be palpated, at the cost of some discomfort to patients, this is an uncommon finding. Finally, the posterior pha-
the patient.The ventral surface of the tongue must also be care- ryngeal wall is inspected.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 3 NECK MASS — 6
negative FNA results should not be considered the end point of ing for the primary site in metastatic disease from an unknown
any search and do not rule out cancer.) source.
Several studies have shown FNA to be approximately 90% Arteriography is useful mainly for evaluating vascular lesions
accurate in establishing a definitive diagnosis. Lateral cystic neck and tumors fixed to the carotid artery. Angiography is helpful for
masses that collapse on aspiration usually represent hygromas, evaluating the vascularity of a mass, its specific blood supply, or
branchial cleft cysts, or cystic degeneration of a metastatic papil- the status of the carotid artery, but it provides very little informa-
lary thyroid cancer. Fluid from these masses is sent for cytologic tion about the physical characteristics of the mass. Plain radi-
examination. If a palpable mass remains after cyst aspiration, a ographs of the neck are rarely helpful in differentiating neck mass-
biopsy of the solid component should be done; the morphology of es, but a chest x-ray can often confirm a diagnosis (e.g., in patients
the cells will be better preserved. with lymphoma, sarcoidosis, or metastatic lung cancer). A chest x-
If an extensive physical examination has been completed and ray is also important in any patient with a new diagnosis of can-
the FNA is not diagnostic, one may have to perform an open cer to determine if pulmonary metastases are present. It is also an
biopsy to obtain a specimen for histologic sections and microbio- essential component of preoperative evaluation for any patient
logic studies. It is estimated that open biopsy eventually proves older than 40 years.
necessary in about 10% of patients with a malignant mass. In an It is important to communicate with the radiologist: an experi-
open biopsy, it is important to orient skin incisions within the enced head and neck radiologist may be able to offer the sur-
boundaries of a neck dissection; the incisions can then, if neces- geon valuable guidance in choosing the best diagnostic test in a
sary, be extended for definitive therapy or reexcised if reoperation specific clinical scenario. Furthermore, providing the radiologist
subsequently proves necessary. Crossing incisions should never be with a detailed clinical history facilitates interpretation of the
situated over vessels. images.
A case in which lymphoma and metastatic squamous cell car-
cinoma are diagnostic possibilities constitutes a special situation.
FNA alone is often incapable of determining the precise histolog- Management of Specific
ic subtype for lymphoma, but it is usually capable of distinguish- Disorders
ing a lymphoproliferative disease from metastatic squamous cell
INFLAMMATORY AND INFEC-
carcinoma.This is a crucial distinction, in that the two neoplasms
TIOUS DISORDERS
are treated in drastically different ways.
If a lymphoma is suspected, FNA is typically followed by open Acute infection of the neck
biopsy, frozen-section confirmation, and submission of fresh tis- (cervical adenitis) is most often
sue to the pathologist. The intact node is placed in normal saline the result of dental infection,
and sent directly to the pathologist for analysis of cellular content tonsillitis, pharyngitis, viral upper respiratory tract infection, or
and nodal architecture and identification of lymphocyte markers. skin infection. Lymph node enlargement is a frequent finding that
If, however, metastatic squamous cell carcinoma is suspected, may reflect any of a number of infectious disorders. The most
FNA usually suffices for establishing the diagnosis and formulat- common cause of this symptom is an acute infection of the mouth
ing a treatment plan, which often includes chemotherapy and or pharynx. In this situation, the enlarged lymph nodes are usual-
radiation initially. In this setting, performing an open biopsy can ly just posterior and inferior to the angle of the mandible. Signs of
lead to significant wound healing complications; there is no need acute infection (e.g., fever, malaise, and a sore mouth or throat)
to incur this risk when FNA is all that is necessary to initiate treat- are usually present. A constitutional reaction, tenderness of the
ment. cervical mass, and the presence of an obvious infectious source
confirm the diagnosis. Treatment should be directed toward the
IMAGING
primary disease and should include a monospot test for infectious
Diagnostic imaging should be used selectively in the evaluation mononucleosis.
of a neck mass; imaging studies should be performed only if the Neck masses may also derive from subcutaneous abscesses,
results are likely to affect subsequent therapy. Such studies often infected sebaceous or inclusion cysts, or multiloculated carbun-
supply useful information about the location and characteristics cles (most often occurring in the back of the neck in a patient with
of the mass and its relation to adjacent structures. Diagnostic diabetes mellitus). The physical characteristics of abscesses make
imaging is particularly useful when a biopsy has been performed recognition of these problems relatively straightforward.
and a malignant tumor identified. In such cases, these studies can On occasion, primary head and neck bacterial infections can
help establish the extent of local disease and the presence or ab- lead to infection of the fascial spaces of the neck. A high index of
sence of metastases. suspicion is required in this situation: such infections are some-
Ultrasonography of the neck reliably differentiates solid masses times difficult to diagnose. Aggressive treatment with antibiotics
from cystic ones and is especially useful in assessing congenital and drainage of closed spaces is indicated to prevent overwhelm-
and developmental cysts. It is a valuable noninvasive technique for ing fasciitis.
vascular lesions and clearly delineates thyroid and parathyroid Various chronic infections (e.g., tuberculosis, fungal lym-
abnormalities. CT is also useful for differentiating cysts from solid phadenitis, syphilis, cat-scratch fever, and AIDS) may also involve
neck lesions and for determining whether a mass is within or out- cervical lymph nodes. Certain chronic inflammatory disorders
side a gland or nodal chain. In addition, CT scanning can delin- (e.g., sarcoidosis) may present with cervical lymphadenopathy as
eate small tongue-base or tonsillar tumors that have a minimal well. Because of the chronic lymph node involvement, these con-
mucosal component. MRI provides much the same information ditions are easily confused with neoplasms, especially lym-
as CT. T2-weighted gadolinium-enhanced scans are particularly phomas. Biopsy is occasionally necessary; however, skin tests and
useful for delineating the invasion of soft tissue by tumor: serologic studies are often more useful for establishing a diagno-
endocrine tumors are often enhanced on such scans. PET scan- sis. Treatment of these conditions is primarily medical; surgery is
ning is useful in the staging of many cancers, as well as in search- reserved for complications.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 3 NECK MASS — 8
PRIMARY MALIGNANT
paranasal sinuses, the nasopharynx, the floor of the mouth, the
NEOPLASMS
tongue, the palate, the tonsils, the piriform sinus, the hypophar-
ynx, or the larynx are best managed by an experienced head and
Lymphomas
neck oncologic surgeon in conjunction with a radiation therapist
Cervical adenopathy is one of and a medical oncologist.
the most common presenting
symptoms in patients with Soft Tissue Sarcomas
Hodgkin and non-Hodgkin lym- Malignant sarcomas are not common in the head and neck.The
phoma. The nodes tend to be softer, smoother, more elastic, sarcomas most frequently encountered include the rhabdomyosar-
and more mobile than nodes containing metastatic carcinoma coma seen in children, fibrosarcoma, liposarcoma, osteogenic sar-
would be. Rapid growth is not unusual, particularly in non- coma (which usually arises in young adults), and chondrosarcoma.
Hodgkin lymphoma. Involvement of extranodal sites, particularly The most common head and neck sarcoma, however, is malignant
Waldeyer’s tonsillar ring, is often seen in patients with non- fibrous histiocytoma (MFH). MFH is seen most frequently in the
Hodgkin lymphoma; enlargement of these sites may provide a clue elderly and extremely rarely in children, but it can arise at any age.
to the diagnosis. The diagnosis is usually suggested by FNA, then It is often difficult to differentiate pathologically from other entities
confirmed via excisional biopsy of an intact lymph node. The (e.g., fibrosarcoma). MFH can occur in the soft tissues of the neck
precise histologic subtype cannot be determined by FNA alone. or involve the bone of the maxilla or the mandible. The preferred
Open biopsy must ultimately be done and fresh tissue must be sub- treatment is wide surgical resection; adjuvant radiation therapy and
mitted for analysis by histology, immunochemistry, and electron chemotherapy are being studied in clinical trials.
microscopy. Rhabdomyosarcoma, usually of the embryonic form, is the most
Lymphoma is treated by means of radiation therapy, common form of sarcoma in children. It generally occurs near the
chemotherapy, or both, depending on the disease’s pathologic orbit, the nasopharynx, or the paranasal sinuses. The diagnosis is
type and clinical stage. confirmed by biopsy. A thorough search for distal metastases is
made before treatment—consisting of a combination of surgical
Thyroid Cancer resection, radiation therapy, and chemotherapy—is begun.
The approach to suspected thyroid cancer differs in some
respects from the approach to benign thyroid disease. The opera- Skin Cancer
tion of choice for papillary thyroid cancer that is occult (< 1 cm Basal cell carcinomas are the most common of the skin malig-
in diameter) and confined to the thyroid gland and for follicular nancies [see 3:4 Skin Lesions]. These lesions arise in areas that have
thyroid cancer that is minimally invasive (i.e., exhibiting only cap- been extensively exposed to sunlight (e.g., the nose, the forehead,
sular invasion) is thyroid lobectomy; the prognosis is excellent. the cheeks, and the ears).Treatment consists of local resection with
The procedure of choice for papillary, follicular, Hürthle cell, and adequate clear margins. Metastases are rare, and the prognosis is
medullary thyroid cancer is total or near-total thyroidectomy excellent. Inadequately excised and neglected basal cell carcinomas
(when it can be done safely) [see 2:7 Thyroid and Parathyroid may ultimately spread to regional lymph nodes and can cause exten-
Procedures]. Patients who present with thyroid nodules and have a sive local destruction of soft tissue and bone. For example, basal cell
history of radiation exposure or a family history of thyroid cancer carcinoma of the medial canthus may invade the orbit, the ethmoid
should also undergo total or near-total thyroidectomy because sinus, and even the brain. Periauricular basal cell carcinoma can
about 40% of them will have at least one focus of papillary thy- spread across the cartilage of the ear canal or into the parotid gland.
roid cancer. Total thyroidectomy decreases recurrence and per- Squamous cell carcinoma also arises in areas associated with
mits the use of iodine-131 (131I) to scan for and treat residual dis- extensive sunlight exposure; the lower lip and the pinna are the
ease; it also makes serum thyroglobulin and calcitonin assays most common sites. Unlike basal cell carcinoma, however, squa-
more sensitive for diagnosing recurrent or persistent differentiat- mous cell carcinoma tends to metastasize regionally and distally.
ed thyroid tumors of follicular or parafollicular cell origin. This tumor must also be excised with an adequate margin.
Patients with medullary thyroid cancer should undergo meticu- Melanoma is primarily classified on the basis of depth of inva-
lous elective (prophylactic) or therapeutic bilateral central neck dis- sion (as quantified by Clark level or Breslow thickness), location,
section. All patients with medullary thyroid cancer should be and histologic subtype, although the prognosis is closely related to
screened for ret proto-oncogene mutations on chromosome 10, as the thickness of the tumor [see Metastatic Tumors, Metastatic
well as for pheochromocytoma. Therapeutic modified neck dissec- Melanomas, below]. In addition to the typical pigmented, irregu-
tion is indicated for all patients with thyroid cancer and palpable larly shaped skin lesions [see 3:4 Skin Lesions], malignant mel-
nodes laterally. Prophylactic modified neck dissection is indicated for anoma may also arise on the mucous membranes of the nose or
patients with medullary thyroid cancer and either primary tumors the throat, on the hard palate, or on the buccal mucosa.The treat-
larger than 1.5 cm or evidence of central neck node involvement. ment of choice is wide surgical resection. Radiation therapy,
Patients with anaplastic thyroid cancer are probably best treat- chemotherapy, and immunotherapy may also be considered.
ed with a combination of chemotherapy and radiation therapy, in
conjunction with the removal of as much of the neoplasm as can METASTATIC TUMORS
safely be excised. Most patients with thyroid lymphoma should Any surgeon who is manag-
receive chemotherapy, radiation therapy, or both. ing patients with head and neck
cancers must have a thorough
Upper Aerodigestive Tract Cancer understanding of neck dissec-
Deciding on the optimal therapeutic approach to tumors of the tions and should have sufficient
aerodigestive tract (i.e., surgery, radiation therapy, or some com- training and experience to per-
bination of the two) generally requires expertise beyond that of form these operations in the
most general surgeons. Therefore, cancers involving the nose, the appropriate clinical circumstances.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 3 NECK MASS — 11
Classification of Neck Dissections the larynx are treated with lateral neck dissection. If extranodal
There are two classification systems for neck dissections. The extension or the presence of multiple levels of positive nodes is
first is based on the indications and goals of surgery. An elective (or confirmed by the pathologic findings, the patient should receive
prophylactic) neck dissection is done when the neck is clinically adjuvant bilateral neck radiation for 4 to 6 weeks after operation.
negative (that is, when no abnormal lymph nodes are palpable or
Metastatic Adenocarcinomas
visible on radiographic imaging). A therapeutic neck dissection is
done to remove all palpable and occult disease in patients with Adenocarcinoma in a cervical node most frequently represents
suspicious lymph nodes discovered via physical examination or a metastasis from the thyroid gland, the salivary glands, or the GI
CT scanning. tract.The primary tumor must therefore be sought through endo-
The second system is based on the extent and type of dissec- scopic and radiologic study of the bronchopulmonary tract, the GI
tion. Comprehensive neck dissections include the classic radical tract, the genitourinary tract, the salivary glands, and the thyroid
neck dissection, as well as the modified radical (or functional) gland. Other possible primary malignancies to be considered
neck dissection [see Figure 3]. In a radical neck dissection, the ster- include breast and pelvic tumors in women and prostate cancer in
nocleidomastoid muscle, the internal and external jugular veins, men.
the spinal accessory nerve, and the submaxillary gland are If the primary site is controlled and the patient is potentially
removed, along with all lymph node–bearing tissues. The modi- curable or if the primary site is not found and the neck disease is
fied radical or functional neck dissection is a modification of the the only established site of malignancy, neck dissection is the
radical neck dissection in which the lymphatic tissue from these appropriate treatment. Postoperative adjuvant radiation may also
areas is removed but the functional structures are preserved. be considered. If the patient has thyroid cancer and palpable
Selective neck dissections involve the removal of specific levels of nodes, lateral neck dissection and ipsilateral central neck dissec-
lymph nodes [see Figure 1]. The rationale for selective dissections tion are recommended.
is that several head and neck cancers consistently metastasize to Overall survival is low—about 20% at 2 years and 9% at 5
specific localized lymph node regions.The following are examples years—except for patients with papillary or follicular thyroid can-
of selective neck dissections: suprahyoid neck dissection (levels I cer, who have a good prognosis.Two factors associated with a bet-
and II); supraomohyoid neck dissection (levels I, II, and III); lat- ter prognosis are unilateral neck involvement and limitation of dis-
eral neck dissection (levels II, III, and IV); and posterolateral neck ease to lymph nodes above the cricoid cartilage.
dissection (levels II, III, IV, and V).
Metastatic Melanomas
Metastatic Squamous Cell Carcinomas If the patient has a thin melanoma (Breslow thickness < 1 mm;
The basic principle in the management of metastatic squamous Clark level I, II, or III), full-thickness excision with 1 cm margins
cell carcinoma is to treat all regional lymph node groups at high- should be done. Intermediate-thickness melanomas (Breslow
est risk for metastases by means of surgery or radiation therapy, thickness 1 to 4 mm; Clark level IV) have a definable risk of
depending on the clinical circumstances. Selective lymph node lymph-node spread and thus are staged with lymphatic mapping
dissection can be performed along with wide excision of the pri- and sentinel lymph node (SLN) biopsy [see 3:6 Lymphatic
mary tumor at the time of initial operation. For example, carcino- Mapping and Sentinel Lymph Node Biopsy] in addition to wide exci-
mas of the oral cavity are treated with supraomohyoid neck dis- sion with at least 1.5 to 2 cm margins. All patients with interme-
section, and carcinomas of the oropharynx, the hypopharynx, and diate-thickness melanomas and positive SLNs and all melanoma
patients with palpable lymph nodes should undergo modified
neck dissection for adequate local disease control. Because these
Contents Removed tumors may metastasize to nodes in the parotid region, superficial
Platysma Muscle in Classic Radical parotidectomy is often included in the neck dissection, particular-
Neck Dissection ly in the case of melanoma located on the upper face or the ante-
Internal Jugular Vein rior scalp. Consultation with a medical oncologist is indicated for
Carotid Artery all patients with intermediate-thickness or thick (Breslow thick-
ness > 4 mm; Clark level V) melanomas; immunotherapy or
Contents Removed chemotherapy may be considered. Radiation therapy is often con-
in Modified Neck sidered in patients with extensive local or nodal disease.
Dissection
Metastases from an Unknown
Primary Malignancy
Management of patients with
an unknown primary malignan-
cy is challenging for the surgeon.
Sternocleidomastoid It is helpful to know that when
Muscle cervical lymph nodes are found
to contain metastatic squamous
cell carcinoma, the primary tumor is in the head and neck about
90% of the time. Typically, such patients are found to have squa-
mous cell carcinoma on the basis of FNA of an abnormal cervical
lymph node; this finding calls for an exhaustive review of systems
Figure 3 Cross section of the neck shows the structures removed as well as a detailed physical examination of the head and neck.
in a classic radical neck dissection (right) and in a modified radi- If no primary tumor is identified, the patient should undergo
cal neck dissection (left).3 endoscopic evaluation of the nasopharynx, the hypopharynx, the
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 3 NECK MASS — 12
esophagus, the larynx, and the tracheobronchial tree under gener- nose, the oral cavities, and the sinuses. An ophthalmologic exam-
al anesthesia. Biopsies of the nasopharynx, the tonsils, and the ination is also required. If physical examination and radiographic
hypopharynx often identify the site of origin (though there is some studies find no evidence of metastases, modified neck dissection
debate on this point). If the biopsies do not reveal a primary should be performed on the involved side.
source of cancer, the preferred treatment is unilateral neck dissec- Metastatic adenocarcinoma in a cervical lymph node with no
tion, followed by radiation therapy directed toward the neck, the known primary tumor is discussed elsewhere [see Metastatic
entire pharynx, and the nasopharynx. In 15% to 20% of cases, the Adenocarcinomas, above].The most common primary sites in the
primary cancer is ultimately detected. Overall 5-year survival in head and neck are the salivary glands and the thyroid gland. The
such cases ranges from 25% to 50%. possibility of an isolated metastasis from the breast, the GI tract, or
If a malignant melanoma is found in a cervical lymph node but the genitourinary tract must also be rigorously investigated. If no
no primary tumor is evident, the patient should be asked about primary site is identified, the patient should be considered for pro-
previous skin lesions, and a thorough repeat head and neck exam- tocol-based chemotherapy and radiation therapy, directed accord-
ination should be done, with particular attention to the scalp, the ing to what the primary site is most likely to be in that patient.
References
1. Fabian RL: Benign and malignant diseases of 2. Cohen JI: Benign neck masses. Boie’s Funda- 3. Coleman JJ III, Sultan MR: Tumors of the head
the head and neck. Current Practice of Surgery. mentals of Otolaryngology: A Textbook of Ear, and neck. Principles of Surgery, 6th ed.
Levine BA, Copeland EM III, Howard RJ, et al, Nose and Throat Disease, 6th ed. Adams GL, Boie Schwartz SI, Shires GT, Spencer FC, Eds.
Eds. Churchill Livingstone, New York, 1993, vol LR Jr, Hilger PA, Eds. WB Saunders Co, McGraw-Hill Book Co, New York, 1994, p 595
2, sect VII, chap 1 Philadelphia, 1989
Recommended Reading
Beenken SW, Maddox WA, Urist MM: Workup of a poorly differentiated adenocarcinoma of unknown pri- Philadelphia, 1989, p 83
patient with a mass in the neck. Adv Surg 28:371, mary tumor site of the neck. Semin Oncol 20:279, Nguyen TD, Malissard L, Theobald S, et al: Advanced
1995 1993 carcinoma of the larynx: results of surgery and radio-
Byers RM: Neck dissection: concepts, controversies Hoffman HT, Karnell LH, Funk GF, et al: The therapy without induction chemotherapy (1980–1985):
and technique. Semin Surg Oncol 7:9, 1991 National Cancer Database report on cancer of the a multivariate analysis. Int J Radiat Oncol Biol Phys
Chandler JR, Mitchell B: Branchial cleft cysts, sinuses head and neck. Arch Otolaryngol Head Neck Surg 36:1013, 1996
and fistulas. Otolaryngol Clin North Am 14:175, 1981 124:951, 1998 Shah JP, Medina JE, Shaha AR, et al: Cervical lymph
Clark O, Duh QY: Textbook of Endocrine Surgery. Jossart GH, Clark OH:Well-differentiated thyroid can- node metastasis. Curr Probl Surg 30:1, 1993
WB Saunders Co, Philadelphia, 1997 cer. Curr Probl Surg 31:933, 1994 Spiro RH: Management of malignant tumor of the
Clark O, Duh QY, Perrier N, et al: Endocrine Tumors. Lee NK, Byers RM, Abbruzzese JL, et al: Metastatic salivary glands. Oncology 12:671, 1998
BC Decker Inc, Hamilton, Ontario, Canada, 2003 adenocarcinoma to the neck from an unknown prima- Van den Brekel MW, Castelijns JA: Surgery of lymph
Clark OH, Noguchi S: Thyroid Cancer Diagnosis and ry source. Am J Surg 162:306, 1991 nodes in the neck. Semin Roentgenol 35:42, 2000
Treatment. Quality Medical Publishing, St Louis, McGuirt WF: Diagnosis and management of masses Wu HS, Young MT, Ituarte P, et al: Death from thy-
2000 in the neck, with special emphasis on metastatic dis- roid cancer of follicular cell origin. J Am Coll Surg
Davidson BJ, Spiro RH, Patel S, et al: Cervical metas- ease. Oncology 4:85, 1990 191:600, 2000
tases of occult origin: the impact of combined modal- Moley JF, De Beneditti MK: Patterns of nodal metas-
ity therapy. Am J Surg 168:195, 1994 tases in palpable medullary thyroid carcinoma: recom-
Delbridge L, Guinea AL, Reeve TS: Total thyroidecto- mendations for extent of node dissection. Ann Surg
my for bilateral benign multinodular goiter: effect of 225:880, 1999 Acknowledgment
changing practice. Arch Surg 134:1385, 1999 Montgomery WW: Surgery of the neck. Surgery of the
Hainsworth JD: Poorly differentiated carcinoma and Upper Respiratory System, 2nd ed. Lea & Febiger, Figures 1 through 3 Tom Moore.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 4 ORAL CAVITY PROCEDURES — 1
Preoperative Evaluation
sues and result in a significant functional disturbance. In such
Oral cavity procedures are commonly performed to treat malig- cases, a flap reconstruction must be considered. In select cases,
nancies. Tumors should be assessed preoperatively to allow accu- pedicled flaps may be appropriate. Often, particularly with larger
rate staging of the disease and to facilitate planning of definitive or more complicated defects, free flaps provide the best recon-
treatment. In most cases, an examination under anesthesia with structive result. Free tissue reconstruction has the advantage of
endoscopy and biopsy is required to stage the primary tumor and allowing the surgeon to reconstruct the defect with the exact tis-
to look for synchronous second primary tumors. Except in the sue components that were excised, including bone and skin. In
case of very superficial lesions, computed tomography plays an addition, free flaps can be reinnervated to achieve a sensate
important role in preoperative planning. In selected cases, plain reconstruction.
radiographs (e.g., Panorex views) may be useful in evaluating the If the planned surgical procedure involves resection of part of
mandible.When the lesion is located in the tongue, magnetic res- the maxilla or the mandible, appropriate dental consultation
onance imaging may provide additional information about the should be obtained. If a postoperative splint, obturator, or dental
extent of the primary tumor. prosthesis is to be placed, it is critical that dental impressions be
Wide surgical margins are necessary for adequate treatment of obtained before operation. Thyroid function should be tested in
primary squamous cell carcinoma of the head and neck. A mar- all patients who have a history of radiation therapy to the neck to
gin of 1 to 2 cm should be achieved whenever possible, ideally confirm that they are euthyroid.
with frozen-section control. Current evidence clearly indicates In cooperative patients, small primary lesions of the oral cavi-
that overall patient outcome improves when clear margins are ty can sometimes be excised with local anesthesia; however, gen-
obtained. eral anesthesia with adequate relaxation is required in the major-
Nodal metastases are common with oral cavity tumors. Accord- ity of cases.The route of intubation must be carefully considered
ingly, patients should be assessed for cervical adenopathy both for each patient. When the planned resection is extensive and
clinically and radiographically. A chest x-ray should be obtained in when significant postoperative edema is anticipated, a tracheos-
all cases. CT or MRI can provide valuable information regarding tomy should be performed. Patients with bulky lesions should
the nodal status of the neck. In patients with advanced disease, a undergo tracheostomy under local anesthesia before general
more extensive search for distant metastases should be conducted, anesthesia is induced.When a tracheostomy is not planned, naso-
including a CT scan of the chest. In some circumstances, com- tracheal intubation is often desirable.
bining CT with positron emission tomography (PET) may be When the excision is limited to the oral cavity, perioperative
useful. antibiotics are generally unnecessary. When a graft, a flap, or
packing is employed, however, perioperative I.V. administration
of antibiotics is advisable. In all cases in which the neck is
Operative Planning entered, perioperative antibiotics are recommended. The oral
Surgical management of the neck is an evolving field. In gen- cavity can be prepared preoperatively with chlorhexidine and a
eral, if the risk of occult metastasis is greater than 20% to 25%, a toothbrush.
selective neck dissection [see 2:6 Neck Dissection] is recommend- A nasogastric feeding tube should be inserted whenever it is
ed, particularly if postoperative radiation therapy is not planned. believed that the patient may have a problem maintaining oral
Whenever there is clinical evidence of nodal disease, treatment of nutrition postoperatively. Patients who undergo primary closure
the neck must be included in operative planning. or split-thickness skin grafting or whose surgical wound is allow-
The oral cavity is a major component of a number of impor- ed to heal by secondary intention may be allowed clear liquids
tant functions, including speech and swallowing. Reconstruction in 24 to 48 hours and a pureed diet by postoperative day 3;
of the anticipated surgical defect must be carefully planned to they can often tolerate a soft diet within 1 week. Patients who
achieve the best results. Several basic considerations must be kept undergo flap reconstruction will have to be fed via a nasogastric
in mind. Tongue mobility and sensation must be maintained to tube until they have healed to the point where they can resume
the extent possible. Maintenance of mandibular continuity (espe- oral intake.
cially in the anterior segment of the mandible) is vital for ensur- Patients should be advised to maintain oral hygiene postoper-
ing postoperative oral competence. Separation of the nasal cavity atively by means of frequent irrigation and rinses with either nor-
from the oral cavity is critical for the oral phase of swallowing and mal saline or half-strength hydrogen peroxide.Teeth may be gent-
speech. Maintenance of the gingivobuccal and gingivolabial sul- ly cleaned with a soft toothbrush until healing has occurred.
cus is important for oral function and the fitting of dentures.
As a rule, oral cavity defects should be closed primarily when-
ever possible. Primary closure has the advantage of using sensate Anterior Glossectomy
tissue similar in form to the tissue that was excised. With experi-
OPERATIVE PLANNING
ence and careful judgment, the surgeon can usually determine
when a defect is too large for primary closure or when primary Either orotracheal or nasotracheal intubation may be appro-
closure is likely to cause distortion and tethering of adjacent tis- priate, depending on the surgical approach and the extent of the
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 4 ORAL CAVITY PROCEDURES — 2
neous flaps from the radial forearm, the anterior lateral thigh, or
the lateral arm are well suited to reconstruction in this area.
Pedicled flaps (e.g., myocutaneous flaps from the pectoral mus-
cle) are also used in this setting, but they are bulkier and harder
to contour to the defects.
If a mandibulotomy was made, it is repaired with the previ-
ously contoured plate. The lip-splitting incision is closed in three
layers (mucosa, muscle, and skin). Great care must be taken to
ensure accurate realignment of the vermilion border and the
orbicularis oris muscle.
Alternative Procedure: Laser Vaporization
Very superficial and premalignant lesions of the tongue may be
vaporized by using a CO2 laser. The desired depth of tissue
destruction for leukoplakia is approximately 1 to 2 mm.
TROUBLESHOOTING
TROUBLESHOOTING
Careful dissection directly onto the duct and stone usually
serves to prevent inadvertent injury to the lingual nerve.
COMPLICATIONS
OPERATIVE PLANNING
OPERATIVE TECHNIQUE
be removed by excising the infrastructure of the maxilla.The line sal flap that is wrapped over the cut bony edge of the palate. The
of transection is continued through the nasal process of the max- mucosal cut is connected around the maxillary tuberosity to the
illa medially and downward through the piriform aperture. Later- gingivolabial sulcus incision that was made earlier.
ally, the cut extends to the zygomatic process of the maxilla and The hard palate is then cut with a power saw. Once all the bone
around the posterolateral aspect of the sinus. cuts are complete, an osteotome may be used to connect them if
If the pterygoid plates are to be preserved, they are cut free by necessary.The remaining soft tissue attachments are divided along
placing a curved osteotome along the posterior wall of the sinus and the posterior hard palate with curved Mayo scissors. The surgical
sharply dividing the plates from the sinus wall. If the pterygoid defect is packed to control bleeding. Bleeding from the internal
plates, part of the pterygoid musculature, or both are to be resected, maxillary artery is controlled by ligatures or ligating clips.
the soft tissue attachments are cut sharply with curved Mayo scis-
sors once the entire maxillary specimen has been mobilized. Step 3: Reconstruction
The line of transection in the maxillary alveolus can run All sharp spicules of bone are debrided.The flap of hard palate
between two teeth if a suitable gap is evident. In the majority of mucosa is brought up over the cut bony edge of the palate and held
cases, however, it is advisable to extract a tooth and make the cut in place with several Vicryl sutures.The anterior and posterior cut
through the extraction site. A power saw is used, and the cut is edges of the soft palate are reapproximated with absorbable sutures.
connected to the transection line through the nasal process of the A split-thickness skin graft, 0.014 to 0.016 in. thick, is har-
maxilla and the piriform aperture. The hard palate mucosa is vested and used to line the raw undersurface of the cheek flap.
then incised lateral to the proposed cut in the hard palate bone to The skin graft is sutured to the mucosal edge of the cheek flap
preserve a flap of mucosa that can be used to cover the raw cut with 3-0 chromic sutures. Superiorly, the graft is not sutured but
bony edge of the palate. This incision is made with a needle-tip draped into position and retained by a layer of Xeroform packing
electrocautery and carried down to the bone of the hard palate. and strip gauze coated with antibiotic ointment. Gentle pressure
It should extend from the maxillary tuberosity posteriorly to the is applied to the packing so that it conforms to the defect. The
cut bone in the maxillary alveolus anteriorly, with care taken to previously fabricated dental obturator is placed to support the
obtain adequate mucosal margins. The mucosa is elevated for a packing and to close the oral cavity from the nasal cavity. In a
short distance over the hard palate bone to create a short muco- dentulous patient, the obturator may be wired to the remaining
b c
Figure 6 Maxillectomy. Radiographic assessment helps determine the required extent of resection. Depicted
are (a) medial maxillectomy, (b) subtotal maxillectomy without orbital exenteration, and (c) total maxillectomy
with orbital exenteration.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 4 ORAL CAVITY PROCEDURES — 8
teeth; in an edentulous patient, it may be temporarily fixed in mucosa area. The graft is sutured to the cut edge of the buccal
place with two screws placed in the remaining hard palate. mucosa with 4-0 chromic catgut. Xeroform and strip gauze coat-
The skin incisions are closed in two layers, with interrupted ed with antibiotic ointment are gently packed into the defect to
absorbable sutures used for the deep layers and nonabsorbable secure the skin graft. The previously fabricated dental obturator
monofilament sutures for the skin. If a lip-splitting incision was is wired to the remaining teeth to hold the packing in place.
made, care must be taken to ensure exact reapproximation of the
TROUBLESHOOTING
orbicularis oris and the vermilion border.
If the infraorbital rim was resected, it should be reconstructed to If a lip-splitting incision is planned, lip contraction can be re-
yield good aesthetic results. A split calvarial bone graft may be used duced and vermilion border realignment improved by employing a
for this purpose when there is adequate soft tissue coverage for the stair-step lip incision and a Z-plasty. A single intraoperative steroid
bone grafts available.When soft tissue coverage is inadequate or the dose reduces facial edema without compromising wound healing.
orbital floor must be reconstructed, an osteocutaneous radial fore- Retention of the obturator is aided by the band of scar tissue that
arm or scapular flap may be employed with excellent results. forms at the junction of the mucosa and the skin graft. Covering the
cut edge of the hard palate bone with mucosa eliminates pain
Alternative Procedure: Peroral Partial Maxillectomy caused by pressure from the obturator on thinly covered bone.
The oral cavity is exposed with cheek retractors. An incision is If more than a small area of the floor of the orbit is resected, it
made in the gingivobuccal sulcus and the mucosa of the hard should be repaired to prevent enophthalmos. Epiphoria is un-
palate, with care taken to maintain adequate margins; a monopo- common; when it occurs, it is related to scarring of the nasolac-
lar electrocautery, set to use the cutting current, is suitable for this rimal duct. Identifying the duct and transecting it obliquely should
purpose. Incisions are made circumferentially through all the soft reduce the incidence of this complication.
tissues up to the anterior wall of the maxilla and the hard palate.
POSTOPERATIVE CARE
The infraorbital nerve should be preserved if it is not involved
with the disease process. A nasogastric tube is placed at the end of the procedure. Many
The cut in the hard palate mucosa should be made lateral to patients are able to begin a liquid diet and advance to a soft diet
the planned cuts in the hard palate bone to create a mucosal flap, within a few days after operation. A soft diet should be continued
which will be used to cover the cut bony edge of the hard palate. for at least 2 weeks. Oral rinses and flushes with normal saline or
If necessary, teeth may be extracted to allow the surgeon to make half-strength hydrogen peroxide should be performed at least
bone cuts through tooth sockets while preserving adjacent teeth. four times daily and after meals.
The bone is cut with a high-speed power saw, and an osteotome The obturator and the packing may be removed from the cav-
is used to divide any remaining bony attachments and deliver the ity in 7 to 10 days. The obturator should be replaced to maintain
specimen. If the mucosa remaining in the maxillary antrum is not oral competence. The prosthodontist makes a final obturator
diseased, it need not be removed. once healing is complete and the cavity has stabilized. Facial inci-
A split-thickness skin graft, 0.014 to 0.016 in. thick, is harvest- sions are cleaned twice daily and coated with antibiotic ointment.
ed from the anterolateral thigh and used to reline the raw buccal Facial sutures are removed 5 to 7 days after operation.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 4 ORAL CAVITY PROCEDURES — 9
COMPLICATIONS the retromolar trigone, and it may lead to anesthesia of the lower
The main complications of maxillectomy are as follows: lip as a consequence of the need to divide both mental nerves.
1. Enophthalmos and hypophthalmos, which create a cosmet- Technical aspects of visor flap creation are summarized elsewhere
ic deformity. [see Anterior Glossectomy, Operative Technique, Step 1, above].
2. Infraorbital nerve injury, which results in anesthesia or pares-
thesia of the ipsilateral cheek and upper lip. On occasion, the Step 2: Resection
infraorbital nerve may have to be sacrificed as part of the If a plate is to be used in the reconstruction of the mandible, a
planned resection. template and a reconstruction plate are shaped and conformed to
3. Epiphoria, caused by scarring of the nasolacrimal duct. the mandible before resection. The segment of mandible to be
4. Difficult retention of the dental prosthesis, which can usually resected is marked. The plate is applied to the buccal cortex of
be prevented by careful preoperative evaluation and appropri- the mandible, and screw holes are predrilled in the mandible for
ate choice of reconstructive method. In select cases, free tissue gauging of depth. The plate is then set aside until needed for
reconstruction without a dental prosthesis may be optimal. reconstruction.
Mucosal incisions are made around the lesion with the electro-
cautery, with care taken to maintain adequate surgical margins.The
Mandibulectomy mandibular segment to be removed is cut with a high-speed sagittal
OPERATIVE PLANNING
saw.The lingual nerve and the hypoglossal nerve are preserved if pos-
sible. Muscle attachments to the resected mandibular segment are
General anesthesia with muscle relaxation is essential for all sharply divided, allowing the surgical specimen to be delivered [see
types of mandibulectomy. Either orotracheal or nasotracheal intu- Figure 8].
bation is appropriate, depending on the surgical approach and the
extent of the planned resection. A tracheostomy should be per-
formed whenever significant postoperative swelling or airway
compromise is anticipated. Skin incisions should be marked
before the endotracheal tube is taped in place.
Preoperative radiographic evaluation is essential for planning
the surgical approach and determining the extent of the proposed
resection. For lesions without radiographic or clinical evidence of
bone invasion, a marginal mandibulectomy is often appropriate.
This procedure may also be performed to obtain adequate surgi-
cal margins for lesions that are in close proximity to the mandible.
When the lesion is small, it is occasionally possible to perform
marginal mandibulectomy via the transoral route. For more ex-
tensive lesions and those that show evidence of bone invasion, a
segmental mandibulectomy is required.
The patient should be supine in a 20° reverse Trendelenburg
position. Perioperative antibiotics should be administered.
OPERATIVE TECHNIQUE
Step 1: Exposure
Wide exposure for access to primary tumors of the oral cavity
and the mandible may be achieved by means of either a lower-
cheek flap or a visor flap.The former is often preferable, in that it
allows resection of the primary and ipsilateral lymph nodes.
To create a lower-cheek flap, a lip-splitting incision is made
through the full thickness of the lower lip and carried down through
the chin tissues to the periosteum of the anterior mandible [see Figure
7].This incision may be made straight through the mental subunit
with a Z-plasty placed at the mental crease; alternatively, it may be
made around the mental subunit.The incision is continued vertically
to approximately the level of the thyrohyoid membrane, then extend-
ed laterally to the mastoid along a skin crease.The transverse compo-
nent of the incision should be made at least two fingerbreadths below
the mandible to prevent injury to the marginal mandibular nerve.
The cheek flap is fully developed by incising the oral mucosa along
the gingivolabial sulcus while maintaining adequate surgical margins
around the lesion.The periosteum of the mandible is then elevated
and the cheek flap retracted to expose the mandible.
A visor flap [see Figure 3] has the advantage of not requiring a Figure 8 Mandibulectomy. The segment to be removed is cut
lip-splitting incision, and it provides adequate exposure for lesions with a high-speed saw, with care taken to preserve the lingual
of the anterior oral cavity. However, it is inadequate for exposing and hypoglossal nerves if possible, and the muscle attachments
lesions posterior to the middle third of the tongue or in the area of to the segment are sharply divided to free the surgical specimen.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 4 ORAL CAVITY PROCEDURES — 10
In some cases, only a marginal mandibulectomy of the lingual or most patients will need to be fed through this tube until their inci-
alveolar cortex of the mandible is necessary.The bone is cut with a sions are healed. A soft diet should be continued for 6 weeks. Oral
high-speed saw in such a way that the cuts are rounded off and lack rinses and flushes with normal saline or half-strength hydrogen per-
sharp angles, which are prone to fracturing. Once the bone cuts are oxide should be performed at least four times a day and after meals.
made, an osteotome may be used to free the specimen. Facial incisions are cleaned twice a day and coated with anti-
biotic ointment. Facial sutures are removed 5 to 7 days after
Step 3: Reconstruction
operation.
When a marginal mandibulectomy has been performed, a plate is
sometimes needed to support the mandible.This is especially likely TROUBLESHOOTING
to be the case for a patient with a thin edentulous mandible, in which Contouring the reconstruction plate to the mandible before
the remaining bone cannot withstand the forces of mastication. resecting the mandibular segment will prevent malocclusion and
When the anterior mandible has been resected, it must be recon- enhance cosmetic results. Preserving the lingual nerve and the
structed with vascularized bone. Any of several free flaps may be hypoglossal nerve, when possible, will improve postoperative
employed, depending on the tissue requirements for the planned re- swallowing and speech. The marginal mandibular nerve should
construction. Free tissue flaps from the fibula, the scapula, or the il- be identified and protected as well. If a lip-splitting incision is
iac crest can provide bone that is suitable for mandibular recon- used, performing a stair-step lip incision and a Z-plasty reduces
struction, as well as soft tissue that is suitable for reconstruction of lip contraction and improves vermilion border realignment.
accompanying mucosal and cutaneous defects.
After lateral mandibular resections, good results can be achieved COMPLICATIONS
by using mandibular reconstruction plates with suitable soft tissue The main complications of mandibulectomy are as follows:
reconstruction.There is a significant risk of plate failure, however,
especially in dentulous patients. In many cases, replacing the resect- 1. Malocclusion, caused by inaccurate repair of the resected
ed portion of the mandible with vascularized bone—especially if the mandibular segment.
defect is longer than a few centimeters—yields better long-term re- 2. Plate failure or fracture, which can be reduced by recon-
sults than using a reconstruction plate alone. structing bony defects larger than 1 to 2 cm with revascular-
ized bone.
POSTOPERATIVE CARE
3. Oral incompetence, caused by inadequate reconstruction of
A nasogastric tube is placed at the end of the surgical procedure; anterior mandibular defects.
Selected Readings
Baurmash H: Submandibular salivary stones: current Johnson JT, Leipzig B, Cummings CW: Management Spiro RH, Gerold FP, Strong EW: Mandibular
management modalities. J Oral Maxillofac Surg 62:369, of T1 carcinoma of the anterior aspect of the tongue. “swing” approach for oral and oropharyngeal tumors.
2004 Arch Otolaryngol 106:249, 1980 Head Neck 3:371, 1981
Brown JD:The midface degloving procedure for nasal, Lanier DM: Carcinoma of the hard palate. Surgery of Stern SJ, Geopfert H, Clayman G, et al: Squamous cell
sinus and nasopharyngeal tumors. Otolaryngol Clin the Oral Cavity. Bailey BJ, Ed. Year Book Medical carcinoma of the maxillary sinus. Arch Otolaryngol
North Am 34:1095, 2001 Publishers, Chicago, 1989, p 163 Head Neck Surg 119:964, 1993
Brown JS, Kalavrezos N, D’Sousa J, et al: Factors that Leipzig B, Cummings CW, Chung CT, et al: Carcinoma Wald RM, Calcaterra TC: Lower alveolar carcinoma:
influence the method of mandibular resection in the segmental v. marginal resection. Arch Otolaryngol
of the anterior tongue. Ann Otol Rhinol Laryngol
management of oral squamous cell carcinoma. Br J 109:578, 1983
Oral Maxillofac Surg 40:275, 2002 91:94, 1982
Galloway RH, Gross PD, Thompson SH, et al: Patho- Osguthorpe JD, Weisman RA: “Medial maxillectomy”
genesis and treatment of ranula: report of three cases. J for lateral nasal neoplasms. Arch Otolaryngol Head
Oral Maxillofac Surg 47:299, 1989 Neck Surg 117:751, 1991
Hussain A, Hilmi OJ, Murray DP: Lateral rhinotomy Schramm VL, Myers EN, Sigler BA: Surgical manage- Acknowledgment
through nasal aesthetic subunits: improved cosmetic ment of early epidermoid carcinoma of the anterior
outcome. J Laryngol Otol 116:703, 2002 floor of the mouth. Laryngoscope 90:207, 1980 Figures 1 through 8 Alice Y. Chen.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 5 PAROTIDECTOMY — 1
5 PAROTIDECTOMY
Leonard R. Henry, M.D., and John A. Ridge, M.D., Ph.D., F.A.C.S.
Anatomic Considerations
the surgeon faces the operative field. A small cottonoid sponge is
The parotid (“near the ear”) gland, the largest of the salivary placed in the external auditory canal, where it remains for the
glands, occupies the space immediately anterior to the ear, over- duration of the procedure to prevent otitis externa from blood
lying the angle of the mandible. It drains into the oral cavity via clots in the external auditory canal. The skin is painted with an
Stensen’s duct, which enters the oral vestibule opposite the upper antiseptic agent. A single perioperative dose of an antibiotic is
molars. The gland is invested by a strong fascia and is bounded administered.
superiorly by the zygomatic arch, anteriorly by the masseter, pos- The patient is draped in a fashion that permits the operating
teriorly by the external auditory canal and the mastoid process, team to see all of the muscle groups innervated by the facial
and inferiorly by the sternocleidomastoid muscle. The masseter nerve. To this end, we employ a head drape that incorporates
muscle, the styloid muscles, the posterior belly of the digastric the endotracheal tube and hose. This drape secures the airway,
muscle, and a portion of the sternocleidomastoid muscle lie deep keeps the tube from interfering with the surgeon, and permits
to the parotid. Terminal branches of the external carotid artery, rotation of the head without tension on the endotracheal tube.
the facial vein, and the facial nerve are found within the gland. The skin of the upper chest and neck is widely painted and
Parasympathetic innervation to the parotid is via the otic gan- draped with a split sheet to allow additional exposure in the
glion, which gives fibers to the auriculotemporal branch of the unlikely event that a neck dissection or a tracheostomy becomes
trigeminal nerve. Sympathetic innervation to the gland originates necessary. The nose, the lips, and the eyes are covered with a
in the sympathetic ganglia and reaches the auriculotemporal nerve sterile transparent drape that allows observation of movement
by way of the plexus around the middle meningeal artery.1 during the procedure and permits access to the oral cavity (if
The facial nerve trunk exits the stylomastoid foramen and desired) [see Figure 1].
courses toward the parotid. Once inside the gland, it commonly
bifurcates into superior (temporal-frontal) and inferior (cervico-
marginal) divisions before giving rise to its terminal branches.The Operative Technique
nerve branching within the parotid can be quite complex, but the
common patterns are well known and their relative frequencies STEP 1: INCISION AND SKIN FLAPS
well established.2,3 The portion of the parotid gland lateral to the The incision is planned so as to permit excellent exposure with
facial nerve (about 80% of the gland) is designated as the super- good cosmetic results. It begins immediately anterior to the ear,
ficial lobe; the portion medial to the facial nerve (the remaining continues downward past the tragus, curves back under the ear
20%) is designated as the deep lobe. Deep-lobe tumors often pre- (staying close to the earlobe), and finally turns downward to
sent clinically as retromandibular or parapharyngeal masses, with descend along the sternocleidomastoid muscle [see Figure 1].
displacement of the tonsil or soft palate appreciated in the throat. Either all or part of this incision may be used, depending on cir-
cumstances. The incision is marked before draping. Skin creases
typically help conceal the resulting scar.
Operative Planning Skin flaps are then created to expose the parotid gland. A tack-
Obtaining informed consent for parotidectomy entails dis- ing suture is placed within the dermis of the earlobe so that it can
cussing both the features and the potential complications of the be retracted posteriorly. Skin hooks are used to apply vertical trac-
procedure. It is appropriate to address the possibility of facial tion.The anterior flap is created superficial to the parotid fascia to
nerve injury, but in doing so, the surgeon should not neglect afford access to the appropriate dissection plane.Vertically orient-
other, far more common sequelae, such as cosmetic deformity, ed blunt dissection minimizes the risk of injury to the distal
earlobe numbness, and Frey syndrome. Even conditions that are branches of the facial nerve [see Figure 2].The face is observed for
expected beforehand may prove distressing or debilitating for the muscle motion. The flap is raised until the anterior border of the
patient. The risk of complications such as nerve injury is greater gland is identified. The facial nerve branches are rarely encoun-
in cases involving reoperation or resection of malignant or deep- tered during flap elevation until they emerge from the parenchy-
lobe tumors.The overwhelming majority of parotid tumors, how- ma of the parotid. If muscle movement occurs, the flap has been
ever, are benign and lateral to the facial nerve. Accordingly, in more than adequately developed. The anterior flap is retracted
what follows, we focus primarily on superficial parotidectomy, with a suture through the dermis.
referring to variants of the procedure where relevant. The posterior-inferior skin flap is then elevated in a similar
Excellent lighting, correctly applied traction and countertrac- manner. Careful dissection is performed to define the relation-
tion, adequate exposure, and clear definition of the surgical anato- ship of the parotid tail to the anterior border of the sternocleido-
my are essential in parotid surgery. The use of magnifying loupes mastoid. During this portion of the procedure, the great auricu-
and headlights is recommended. General anesthesia without mus- lar nerve is identified coursing cephalad and superficial to the
cle relaxation should be employed. sternocleidomastoid muscle. Uninvolved branches of this nerve
The patient is placed in the supine position, with the head ele- should be preserved if possible to prevent postoperative numb-
vated and turned away from the side undergoing operation and ness of the earlobe.4,5 The parotid tail is dissected away from the
with the neck slightly extended. The table is positioned to allow sternocleidomastoid muscle. Vertical traction is applied to the
the first assistant to stand directly above the patient’s head, while gland surface with clamps to facilitate exposure.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 5 PAROTIDECTOMY — 2
Troubleshooting
tumors may displace the nerve from its normal location. For
A favorable skin crease, if available, may be used for the inci- appropriate and safe exposure of the nerve trunk, it is necessary to
sion to improve the postoperative cosmetic result; however, it is mobilize several centimeters of the parotid, thereby creating a
important to keep the incision a few millimeters from the earlobe trough rather than a deep hole. Small arteries run superficial and
itself. A wound at the junction of the earlobe with the facial skin parallel to the facial nerve; these must be divided. Use of the elec-
will distort the earlobe and create a visible contour change. An trocautery this close to the nerve is potentially hazardous. Bleeding
incision behind the tragus may lead to similar problems. is typically minor but nonetheless must be controlled.
STEP 2: IDENTIFICATION OF FACIAL NERVE Retrograde Approach
Once the flaps have been developed and retracted, the next As noted, when the main trunk cannot be exposed, the most
step is to identify the facial nerve. Usually, the nerve may be iden- common alternative method of identifying the facial nerve is to
tified either at its main trunk (the antegrade approach) or at one find a peripheral branch and then dissect proximally toward the
of the distal branches, with subsequent dissection back toward main trunk.Which branch is sought may depend on factors such
the main trunk (the retrograde approach). For a lateral parotidec- as the surgeon’s level of comfort with the relevant anatomy and
tomy, our preference is to identify the main trunk first (unless it known consistency or inconsistency of the nerve branch’s loca-
is thoroughly obscured by tumor or scar). tion. Often, in this setting, tumor bulk is the deciding factor.
The anatomic relationships between the nerve branches and
Antegrade Approach various landmarks can be exploited for more efficient identifica-
The dissection plane is immediately anterior to the cartilage of tion. For example, the marginal mandibular branch of the facial
the external auditory canal. The gland is mobilized anteriorly by nerve characteristically lies below the horizontal ramus of the
means of blunt dissection. To reduce the risk of a traction injury, mandible.7 Often, the facial vein can be traced toward the parotid
tissue is spread in a direction that is perpendicular to the incision or the submandibular gland; the nerve branch can then be found
and thus parallel to the direction of the main trunk of the nerve coursing perpendicular and superficial to the vein. The buccal
[see Figure 3].The nerve trunk can usually be located underlying a branch of the facial nerve has a typical location in the so-called
point about halfway between the tip of the mastoid process and buccal pocket—the area inferior to the zygoma and deep to the
the ear canal. In addition, there are several anatomic landmarks superficial musculoaponeurotic layer, which contains the buccal
that facilitate identification of the nerve, including the tragal point- fat pad and Stensen’s duct in addition to the buccal branch.7 The
er, the posterior belly of the digastric muscle, and the tympa- zygomatic branch of the facial nerve lies roughly 3 cm anterior
nomastoid suture. Of these, the tympanomastoid suture is closest to the tragus, and the temporal-frontal branch lies at the mid-
to the main trunk of the facial nerve.6 The clinical utility of this point between the outer canthus of the eye and the junction
landmark is limited, however, because the tympanomastoid suture of the ear’s helix with the preauricular skin.7 Nerve branches to
is not easily appreciated in every case. In addition, deep-lobe the eye should be dissected with particular care: even transient
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 5 PAROTIDECTOMY — 3
area of the tumor are retracted to allow exposure of the deep por-
tion of the gland and facilitate resection. Traction injury to the
nerve may still result in transient facial weakness.
Troubleshooting
Complete superficial parotidectomy with full dissection of all
facial nerve branches is seldom necessary, though in some cases,
it is mandated by tumor size or histologic findings. Removal of
the entire superficial lobe with the intention of gaining a larger
lateral margin is rarely useful, because the closest margin is usu-
ally where the tumor is nearest the facial nerve. Even temporary
paresis of the temporal-frontal branch of the facial nerve may
have devastating consequences, and dissection near this branch is
usually unnecessary in treating a benign tumor in the parotid tail.
Any close margins remaining after nerve-preserving cancer treat-
ment can be addressed by means of postoperative radiation ther-
apy, usually with excellent results.11
The question of whether to sacrifice the facial nerve almost
invariably arises in the setting of malignancy. In our view, this
measure is seldom necessary. Benign tumors tend to displace the
nerve, not invade it. Sacrifice of the nerve probably does not
enhance survival.12,13 Although the issue remains the subject of
debate, it is our practice, like that of others,14 to sacrifice only
those branches intimately involved with tumor. Repair, if feasi-
Figure 4 Parotidectomy. Dissection of the gland parenchyma is ble, should be performed [see Complications, Facial Nerve
carried out over the branches of the facial nerve to minimize the Injury, below].
risk of nerve injury. Each division of the substance of the gland
should reveal more of the facial nerve. STEP 4: DRAINAGE AND CLOSURE
idectomy,15-18 depending on the extent of the resection and the exploration so that either the continuity of the nerve can be con-
location of the tumor. Fortunately, permanent paralysis is uncom- firmed or the injury to the nerve can be identified and repaired if
mon, occurring in fewer than 5% of cases.17,19 possible.When the surgeon is certain that the nerve is intact, facial
Nerve monitoring has been advocated to reduce the incidence nerve dysfunction can be managed without reoperation, in antic-
of facial nerve injury. To date, however, no randomized trial has ipation of recovery21; however, this may take many months.
demonstrated that intraoperative facial nerve monitoring or Management of enduring facial nerve paralysis (from any
nerve stimulators yield any significant reduction in the incidence cause) is beyond the scope of our discussion and constitutes a sur-
of facial nerve paralysis. Indeed, indiscriminate use of nerve gical subspecialty in itself.21
monitoring and nerve stimulators may imbue the surgeon with a
GUSTATORY SWEATING (FREY SYNDROME)
false sense of security and cause him or her to pay insufficient
attention to the appearance of nerve tissue. Transient nerve dys- Gustatory sweating, or Frey syndrome, occurs in most patients
function may follow inappropriate (or even appropriate and after parotidectomy; it has been seen after submandibular gland
unavoidable) trauma to or traction and pressure on nerve trunks. resection as well. The symptom complex includes sweating, skin
Nerve monitoring does not prevent such problems; moreover, it warmth, and flushing after chewing food and is caused by cross-
adds to the cost of the procedure and increases operating time.20 innervation of the parasympathetic and sympathetic fibers sup-
Some, in fact, have suggested that nerve stimulators may actual- plying the parotid gland and the overlying skin.The reported inci-
ly increase transient dysfunction. Accordingly, our use of nerve dence of Frey syndrome varies greatly, apparently depending on
stimulators is selective. the sensitivity of the test used to elicit it. When Minor’s starch
The management of facial nerve injury depends on when the iodine test is employed, the incidence of Frey syndrome may
injury is discovered and on how sure the surgeon is of the reach 95% at 1 year after operation.22 Fortunately, the majority of
anatomic integrity of the nerve. If the injury is discovered intra- patients exhibit only subclinical findings, and only a small fraction
operatively, it should be repaired if possible. Primary repair— complain of debilitating symptoms.22 Most symptomatic patients
performed with interrupted fine permanent monofilament are adequately treated with topical antiperspirants; eventually,
sutures under magnification21—is preferred if sufficient nerve is however, they tend to become noncompliant with such measures,
available for a tension-free anastomosis. If both transected nerve preferring simply to dab the face with a napkin while eating.22
ends are identified but tension-free repair is not feasible, inter- Despite the relatively low incidence of clinically significant Frey
position nerve grafts may be used. Sensory nerves harvested from syndrome, there is an extensive literature addressing prevention
the neck (e.g., the great auricular nerve) are often employed for and treatment of this condition.9,19,23-30
this purpose. If the nerve is injured (or deliberately sacrificed) in
SIALOCELE (SALIVARY FISTULA)
conjunction with treatment of malignancy, use of nerve grafts
from distant sites may be indicated.21 Sialocele, or salivary fistula, has been reported to occur after 1%
If unexpected facial nerve dysfunction is identified in the to 15% of parotidectomies.9,31 Although this condition is general-
postanesthesia care unit and if the surgeon is unsure of the ly minor and self-limited, it may nonetheless be embarrassing for
anatomic integrity of the nerve (ideally, a rare occurrence), the the patient. We believe that the incidence of sialocele can be
patient should be returned to the operating room for wound reduced by maintaining closed suction drainage for 5 to 7 days (to
a b
Figure 5 Parotidectomy. Shown is drainage and closure after parotidectomy. (a) A closed suction drain is
placed in the operative bed and loosely tacked to the sternocleidomastoid muscle. (b) Interrupted monofila-
ment sutures are used for the skin. Bacitracin is applied. No additional dressings are used.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 5 PAROTIDECTOMY — 6
facilitate adhesion of the skin flaps to the underlying parotid (as well as alleviating Frey syndrome).24-28,39,40 All of these meth-
parenchyma). Postparotidectomy salivary fistula is usually attrib- ods have limitations or drawbacks that have kept them from being
utable to gland disruption rather than to duct transection and widely applied and accepted.
therefore tends to resolve without difficulty.32 Compression dress-
ings are generally effective.31 Anticholinergic agents have been
used in this setting as well.33-36 Low-dose radiation,37 completion Outcome Evaluation
parotidectomy, and tympanic neurectomy38 have all been em- With proper surgical technique, superficial or partial superficial
ployed in refractory cases. parotidectomy can be performed safely and within a reasonable
operating time. Blood transfusions should be required only in very
COSMETIC CHANGES
rare cases. Given adequate exposure, good knowledge of the rele-
Parotidectomy creates a hollow anterior and inferior to the ear, vant anatomy, limited trauma to the nerve, and appropriate use of
which may extend behind the mandible and may reach a signifi- closed suction drains (see above), complications should be
cant size in patients with large or recurrent tumors. This cosmetic uncommon. Although patients may tolerate parotidectomy on an
change is a necessary feature of the procedure, not a complication; outpatient basis, we prefer to keep them in the hospital overnight.
nonetheless, it should be discussed with the patient before opera- Patients should be able to leave the hospital with minimal pain,
tion. Many augmentation methods, using a wide variety of tech- comfortable with their drain care, by the morning of postopera-
niques, have been devised for improving postoperative appearance tive day 1.
References
1. Berkovitz BKG, Moxham BJ: A Textbook of Head 15. Witt RL: Facial nerve monitoring in parotid sur- parotidectomy. Arch Facial Plast Surg 5:109, 2003
and Neck Anatomy.Year Book Medical Publishers, gery: the standard of care? Otolaryngol Head Neck
30. Beerens AJ, Snow GB: Botulinum toxin A in the
Inc, Chicago, 1988 Surg 119:468, 1998
treatment of patients with Frey syndrome. Br J
2. Davis BA, Anson BJ, Budinger JM, et al: Surgical 16. Reilly J, Myssiorek D: Facial nerve stimulation and Surg 89:116, 2002
anatomy of the facial nerve and the parotid gland postparotidectomy facial paresis. Otolaryngol
based upon a study of 350 cervico-facial halves. Head Neck Surg 128:530, 2003 31. Wax M, Tarshis L: Post-parotidectomy fistula. J
Surg Gynecol Obstet 102:385, 1956 Otolaryngol 20:10, 1991
17. Dulguerov P, Marchal F, Lehmann W: Post-
3. Bernstein L, Nelson RH: Surgical anatomy of the parotidectomy facial nerve paralysis: possible etio- 32. Ananthakrishnan N, Parkash S: Parotid fistulas: a
extraparotid distribution of the facial nerve. Arch logic factors and results with routine facial nerve review. Br J Surg 69:641, 1982
Otolaryngol 110:177, 1984 monitoring. Laryngoscope 109:754, 1999 33. Cavanaugh K, Park A: Postparotidectomy fistulas:
4. Hui Y, Wong DSY, Wong LY, et al: A prospective 18. Bron LP, O’Brien CJ: Facial nerve function after a different treatment for an old problem. Int J
controlled double-blind trial of great auricular parotidectomy. Arch Otolaryngol Head Neck Surg Pediatr Otorhinolaryngol 47:265, 1999
nerve preservation at parotidectomy. Am J Surg 123:1091, 1997
34. Vargas H, Galati LT, Parnes SM: A pilot study
185:574, 2003 19. Debets JMH, Munting JDK: Parotidectomy for evaluating the treatment of postparotidectomy
5. Christensen NR, Jacobsen SD: Parotidectomy: parotid tumours: 19-year experience from the sialoceles with botulinum toxin type A. Arch
preserving the posterior branch of the great auric- Netherlands. Br J Surg 79:1159, 1992 Otolaryngol Head Neck Surg 126:421, 2000
ular nerve. J Laryngol Otol 111:556, 1997 20. Terrell JE, Kileny PR, Yian C, et al: Clinical out-
35. Guntinas-Lichius O, Sittel C: Treatment of post-
6. De Ru JA, van Benthem PPG, Bleys RLAW, et al: come of continuous facial nerve monitoring during
parotidectomy salivary fistula with botulinum
Landmarks for parotid gland surgery. J Laryngol primary parotidectomy. Arch Otolaryngol Head
Neck Surg 123:1081, 1997 toxin. Ann Otol Rhinol Laryngol 110:1162, 2001
Otol 115:122, 2001
21. Shindo M: Management of facial nerve paralysis. 36. Chow TL, Kwok SP: Use of botulinum toxin type
7. Peterson RA, Johnston DL: Facile identification of
the facial nerve branches. Clin Plast Surg 14:785, Otolaryngol Clin North Am 32:946, 1999 A in a case of persistent parotid sialocele. Hong
1987 Kong Med J 9:293, 2003
22. Linder TE, Huber A, Schmid S: Frey’s syndrome
8. Salame K, Ouaknine GER, Arensburg B, et al: Mi- after parotidectomy: a retrospective and prospec- 37. Shimms DS, Berk FK, Tilsner TJ, et al: Low-dose
crosurgical anatomy of the facial nerve trunk. Clin tive analysis. Laryngoscope 107:1496, 1997 radiation therapy for benign salivary disorders. Am
Anat 15:93, 2002 23. Bonanno PC, Palaia D, Rosenberg M, et al: Pro- J Clin Oncol 15:76, 1992
9. Leverstein H, van der Wal JE, Tiwari RM, et al: phylaxis against Frey’s syndrome in parotid 38. Davis WE, Holt GR, Templer JW: Parotid fistula
Surgical management of 246 previously untreated surgery. Ann Plast Surg 44:498, 2000 and tympanic neurectomy. Am J Surg 133:587,
pleomorphic adenomas of the parotid gland. Br J 24. Ahmed OA, Kolhe PS: Prevention of Frey’s syn- 1977
Surg 84:399, 1997 drome and volume deficit after parotidectomy 39. Kerawala CJ, McAloney N, Stassen LF:
10. Woods JE: Parotidectomy: points of technique for using the superficial temporal artery fascial flap. Br Prospective randomized trial of the benefits of a
brief and safe operation. Am J Surg 145:678, 1983 J Plast Surg 52:256, 1999
sternocleidomastoid flap after superficial parot-
11. Garden AS, El-Naggar AK, Morrison WH, et al: 25. Bugis SP, Young JEM, Archibald SD: Stern- idectomy. Br J Oral Maxillofac Surg 40:468, 2002
Postoperative radiotherapy for malignant tumors ocleidomastoid flap following parotidectomy.
Head Neck 12:430, 1990 40. Chao C, Friedman DC, Alford EL, et al: Acellular
of the parotid gland. Int J Radiat Oncol Biol Phys dermal allograft prevents post-parotidectomy soft
37:79, 1997 26. Jeng SF, Chien CS: Adipofascial turnover flap for tissue defects: a preliminary experience. Int Online
12. Renehan AG, Gleave EN, Slevin NJ, et al: Clinico- facial contour deformity during parotidectomy.
J Otorhinolaryngol Head Neck Surg 2(5):1, 1999
pathological and treatment-related factors influ- Ann Plast Surg 33:439, 1994
encing survival in parotid cancer. Br J Cancer 27. Govindaraj S, Cohen M, Genden EM, et al: The
80:1296, 1999 use of acellular dermis in the prevention of Frey’s
13. Magnano M, Gervasio CF, Cravero L, et al:Treat- syndrome. Laryngoscope 111:1993, 2001
ment of malignant neoplasms of the parotid gland. 28. Nosan DK, Ochi JW, Davidson TM: Preservation
Acknowledgment
Otolaryngol Head Neck Surg 121:627, 1999 of facial contour during parotidectomy. Oto-
14. Spiro JD, Spiro RH: Cancer of the parotid gland: laryngol Head Neck Surg 104:293, 1991 The authors wish to thank Veronica Levin for her assis-
role of 7th nerve preservation. World J Surg, 27: 29. Sinha UK, Saadat D, Doherty CM, et al: Use of tance in the preparation of this chapter.
863, 2003 AlloDerm implant to prevent Frey syndrome after Figures 1a, 2b, 3, 4 Tom Moore.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 6 NECK DISSECTION — 1
6 NECK DISSECTION
Miriam N. Lango, M.D., Bert W. O’Malley, Jr., M.D., F.A.C.S., and Ara A. Chalian, M.D.
Preoperative Evaluation
rent; are deeper than 6 mm; involve the ear, the temple, or the
In the majority of cases, cancer in the neck is a metastasis from classic H zone; occur in an immunocompromised patient; or are
a primary lesion in the upper aerodigestive tract, though me- poorly differentiated—have a significant occult metastatic rate,
tastases from skin, thyroid, and salivary gland neoplasms are ranging from 20% to 60%. The presence of cervical metastases
also encountered. Lymphomas often present as cervical reduces 5-year survival to about 32%,3 which suggests that early
lymphadenopathy. intervention for high-risk cutaneous lesions, involving regional
When a patient presents with a suspicious lesion in the neck, a lymphadenectomy, sentinel lymph node (SLN) biopsy, or irradi-
careful history and physical examination should be performed, ation of at-risk lymph node basins, may be warranted.
along with a thorough evaluation of the aerodigestive tract aimed
at locating the source of possible metastatic disease. Fine-needle Salivary Gland Neoplasms
aspiration (FNA) of the neck mass should then be done to deter- With salivary gland neoplasms [see 2:2 Oral Cavity Lesions],
mine whether the mass is malignant. FNA can often differentiate the incidence of cervical metastases is related to the histopathol-
between epithelial and lymphoid malignancies, and this differen- ogy as well as the size of the tumor. The most aggressive salivary
tiation will guide subsequent workup. The reported sensitivity of gland lesions are squamous cell carcinoma, carcinoma ex pleo-
FNA ranges from 92% to 98%; the reported specificity, from morphic adenoma, adenocarcinoma, and salivary ductal carcino-
94% to 100%.1,2 ma. Patients with these lesions often have cervical metastases at
If FNA reveals the presence of atypical lymphoid cells, an exci- presentation that warrant a therapeutic neck dissection [see Table
sional lymph node biopsy should be performed to supply the 1]. How best to manage occult cervical salivary gland metastatic
pathologist with a large enough sample to allow full typing of the disease is controversial. The occult metastatic rate for aggressive
tissue. An excisional biopsy may also be performed if the FNA is lesions ranges from 25% to 45%. For such lesions, a selective
negative or indeterminate, the surgeon suspects a malignancy, neck dissection is typically incorporated into the surgical
and the rest of the physical examination yields negative results. approach.4
Routine excisional biopsy of neck masses for diagnostic purposes
is not recommended, however, because it may result in tumor Metastatic Well-Differentiated Thyroid Cancer
spillage into the wound and complicate subsequent definitive Cervical lymph node metastases are present in 10% to 15% of
resection. patients with well-differentiated thyroid carcinoma. The impact
Once the presence of an epithelial malignancy is established, of nodal metastases on local recurrence and survival has not been
the primary site of the lesion must be determined if it is not established. Other factors (e.g., age, sex, tumor extent, and dis-
apparent on initial physical examination. Imaging studies (e.g., tant metastases) appear to have a greater effect on prognosis.
computed tomography and magnetic resonance imaging) may be Nevertheless, in the presence of clinically apparent nodal disease,
helpful in locating the source of a cervical metastasis. Positron a formal neck dissection is advised: so-called cherry-picking oper-
emission tomography (PET) detects lesions with increased meta- ations or limited lymph node excisions result in higher rates of
bolic activity but has the limitation of being unable to detect recurrence.5
lesions smaller than 1 cm in diameter. Primary lesions greater
than 1 cm in diameter usually are easily identified on physical Squamous Cell Carcinoma of the Upper Aerodigestive Tract
examination and other imaging studies; thus, PET scans are of With upper aerodigestive tract squamous cell carcinomas, the
limited value in this setting. In any patient with metastatic cervi- incidence of cervical metastases is related to the site of the pri-
cal adenopathy thought to originate in the upper aerodigestive mary lesion, the size of the tumor, the degree of differentiation,
tract, panendoscopy and biopsy with general anesthesia are the depth of invasion, and a number of other factors. A signifi-
mandatory for locating and characterizing the primary source of cant proportion of head and neck cancer patients who harbor
the tumor and ruling out the presence of synchronous lesions. clinically silent primary tumors of the base of the tongue, the
The most common occult primary sites are the base of the tonsils, or the nasopharynx initially present with cervical
tongue, the tonsils, and the nasopharynx. In 5% to 10% of adenopathy [see Table 1]. These sites lack anatomic barriers that
patients who present with a metastatic node, the primary lesion is limit tumor spread and are supplied by rich lymphatic networks
never found despite extensive workup. that facilitate metastasis. In contrast, patients with glottic and lip
cancers are more likely to present early, without clinical
INCIDENCE AND IMPACT OF NECK METASTASES
adenopathy.
The presence of cervical metastases negatively affects progno-
Cutaneous Squamous Cell Carcinoma sis and has been associated with increased recurrence rates and
The incidence of cervical metastases is governed by many fac- reduced disease-free and overall survival.The presence of clinical
tors. Cervical metastases from cutaneous squamous cell carcino- adenopathy decreases survival by 50%. Metastatic tumors that
mas are rare, occurring in 2% to 10% of cases. However, certain rupture the lymph node capsule—a process known as extracap-
lesions—those that are greater than 2 cm in diameter; are recur- sular spread (ECS)—are biologically more aggressive. Patients
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 6 NECK DISSECTION — 2
Table 1 Incidence of Cervical Metastases in the nasopharynx; it also applies to metastases from major salivary
Selected Head and Neck Cancers gland and sinonasal malignancies but not to metastases from
cutaneous or thyroid malignancies, which use an alternate staging
system.
Tumor Incidence of Cervical Adenopathy
The purpose of staging is to characterize the tumor burden of
Cutaneous squamous cell carcinoma 2%–10% an individual patient. Accordingly, an effective staging system
should incorporate factors known to have prognostic and thera-
Salivary gland malignancies
peutic significance, thereby facilitating planning of therapy and
Mucoepidermoid carcinoma (high-
30%–70% appropriate patient counseling. In addition, it should attempt to
grade)
8% standardize reporting so that meaningful cross-institutional com-
Adenoid cystic carcinoma
25% parisons can be obtained. A staging system ideally should also be
Malignant mixed tumor
46%
Squamous cell carcinoma simple to apply while still incorporating biologically important
50%
Salivary duct carcinoma factors that permit accurate patient stratification in prospective
40%
Acinic cell carcinoma clinical trials. Precise characterization and differentiation of tu-
Metastatic well-differentiated thyroid mors facilitate identification of those patients who are most like-
10%–15%
cancer ly to benefit from treatment.
Squamous cell carcinoma of upper
The TNM staging system does not include a number of fac-
aerodigestive tract tors that are known to have an impact on prognosis, such as the
Alveolar ridge 30% presence or absence of ECS and the pattern of lymphatic spread.
Hard palate 10% Nonanatomic factors (e.g., comorbidity, immune status, and nu-
Oral tongue 30% tritional status) have a strong impact on survival as well but are
Anterior pillar/retromolar trigone 45% also not incorporated in the current staging system. In general,
Floor of mouth 30% TNM staging has been found inadequate for use in clinical
Soft palate 44%
trials.12
Tonsillar fossa 76%
Tongue base 78%
The limitations of clinical staging of the neck are well de-
Bilateral 20% scribed.The addition of imaging to clinical examination improves
diagnostic sensitivity but not specificity. Imaging is particularly
useful after chemoradiation because of the difficulty of clinical
who have palpable cervical lymphadenopathy with ECS manifest examination in this setting. Pathologic review of neck specimens
a 50% decrease in survival compared with those who have pal- remains the gold standard for anatomic staging. The addition of
pable cervical lymphadenopathy without ECS.6 In addition, ultrasound-guided FNA of neck nodes yields enhanced diagnos-
about 50% of clinically negative, pathologically positive neck tic accuracy in cases where the neck is clinically negative but the
specimens exhibit ECS. Clinically negative, pathologically posi- radiologic findings are positive. This approach is employed to
tive, and ECS-positive specimens are associated with a high risk select patients for neck dissection in a number of centers, partic-
of regional recurrence and distant metastases.7-9 The presence of ularly in Europe; whether it provides more accurate staging than
ECS in lymph node metastases may in fact be the single most alternative methods, such as SLN biopsy, remains to be deter-
important prognostic factor in patients with head and neck can- mined. Results from the First International Conference on
cer. Identification of this patient subset may be the most impor- Sentinel Node Biopsy in Mucosal Head and Neck Cancer
tant benefit of elective neck dissection, in that it allows these revealed that SLN biopsy of the clinically negative neck has a sen-
patients to be offered adjuvant therapy. Nonrandomized studies sitivity comparable to that of a staging neck dissection.13 In gen-
have found that both disease-specific and overall survival are sig- eral, imaging modalities appear to be neither sufficiently sensitive
nificantly improved when these high-risk patients are treated nor sufficiently specific in the evaluation of the clinically negative
with adjuvant postoperative chemoradiation.10 However, ran- neck. Uptake of 2-deoxy-3 [18F] fluoro-D-glucose, as measured
domized clinical trials are needed to confirm the clinical benefits by PET scans, is undetectable in small foci of cancer in the clin-
of adjuvant chemoradiation in this setting. ically negative neck.14
Whereas anatomic and pathologic factors (e.g., ECS) have Proper staging is important for stratification of patients into
long been known to predict tumor behavior, it is only compara- risk categories on the basis of tumor biology, so that high-risk
tively recently that the impact of comorbidity has been well char- patients may be appropriately selected for clinical trials or offered
acterized.When patients are stratified by tumor stage, those with adjuvant therapy and other patients may be spared unnecessary
comorbidities fare worse. In fact, the impact of comorbidity on treatment. Until accurate methods of assessing the clinically neg-
overall survival is greater than that of tumor stage or treatment ative neck are developed, selective neck dissection will be per-
type.10,11 In addition, comorbidity is associated with both formed to treat the neck when the occult metastatic rate is
increased frequency and increased severity of surgical complica- expected to be higher than 20%.
tions.These factors may be important in treatment selection and
patient counseling. To date, comorbidity has not been incorpo- INDICATIONS FOR NECK DISSECTION
rated into clinical staging of head and neck cancer patients. The classic indication for neck dissection is for treatment of
metastatic carcinoma in the neck, most frequently deriving from
STAGING OF NECK CANCER
a mucosal site in the upper aerodigestive tract. Over time, the
Staging of the neck for metastatic squamous cell carcinomas of indications for neck dissection have changed. With wider use of
the head and neck is based on the TNM classification formulated chemoradiation therapy for head and neck cancer, treatment of
by the American Joint Committee on Cancer (AJCC) [see 2:2 metastatic disease in the neck has become increasingly nonsurgi-
Oral Cavity Lesions]. The N classification applies to cervical cal. Currently, neck dissections are considered either therapeutic
metastases from all upper aerodigestive tract mucosal sites except (performed to treat palpable disease in the neck) or elective (per-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 6 NECK DISSECTION — 3
Operative Planning
CHOICE OF PROCEDURE
In the presence of multiple pathologically positive lymph nodes went a planned neck dissection. Tumor cells were present in the
or evidence of ECS, adjuvant therapy is indicated.19 Accordingly, neck specimens of 25% of patients with complete and 39% of
selective neck dissection may be viewed as a diagnostic as well as patients with incomplete clinical responses. No patients with
a therapeutic procedure. To date, however, no randomized clini- complete pathologic responses experienced regional recurrence,
cal trials have demonstrated that selective neck dissection with whereas 20% of patients with pathologically positive neck dis-
adjuvant treatment as needed is better than so-called watchful section specimens experienced nonsalvageable regional recur-
waiting with regard to prolonging survival in patients who present rences. In addition, planned neck dissection led to reduced rates
without evidence of cervical metastatic disease. Therefore, it of regional recurrence in patients treated with chemoradiation.
is not yet possible to justify the added cost and morbidity of elec- The authors suggested that all patients presenting with N2 or
tive neck dissection in patients without evidence of metastatic dis- N3 cervical lymphadenopathy should undergo planned neck
ease. SLN mapping may facilitate pathologic staging in this set- dissection, regardless of clinical response to chemoradiation
ting and spare low-risk patients from unnecessary interventions; therapy.
however, its sensitivity and specificity for this purpose are still The required extent of planned neck dissection after chemora-
under investigation. diation is still under investigation. Neck dissection after chemora-
The growing focus on preservation of function and limitation diation carries significant morbidity in the form of severe soft tis-
of morbidity has led some surgeons to promote the use of selec- sue fibrosis and increased spinal accessory nerve injury. Pathologic
tive neck dissection to treat node-positive neck tumors. review of comprehensive neck specimens after chemoradiation
Although retrospective studies have suggested that a selective reveals that in patients with oropharyngeal cancer, levels I and V
neck dissection may be adequate in carefully selected node-pos- are rarely involved in the absence of radiographic abnormalities,23
itive patients,20 the effectiveness of this approach is still which suggests that a planned selective dissection involving levels
unproven, and its application remains subject to individual sur- II through IV may be sufficient for cases of oropharyngeal cancer
gical judgment. treated with chemoradiation. This more limited approach un-
doubtedly causes less morbidity, but additional data are required
Extended Neck Dissection to assess its oncologic efficacy.
Extended neck dissections can be combined with selective Typically, management of the neck is determined in part by
or comprehensive neck dissections to remove additional nodal management of the primary tumor. Early neck dissection for
basins, such as the suboccipital and retroauricular nodes. These bulky nodal disease before nonsurgical treatment of the primary
groups of nodes, which are located in the upper posterior neck, lesion is a controversial practice. Bulky cervical adenopathy is
are the first-echelon nodal basins for posterior scalp skin can- unlikely to exhibit a complete pathologic response to nonsurgical
cers. The retroauricular nodes lie just posterior to the mastoid treatment. A patient who requires dental extractions before radi-
process, and the suboccipital nodes lie near the insertion of the ation therapy may undergo a neck dissection at the same time,
trapezius muscle into the inferior nuchal line. Cancers of the proceeding to radiation therapy 7 to 10 days after operation.
anterior scalp, the temple, and the preauricular skin drain to peri- Early neck dissection decreases the tumor burden, thereby allow-
parotid lymph nodes; these lymph nodes are removed in con- ing lower adjunctive doses of radiation to be delivered to the neck.
junction with a parotidectomy [see 2:5 Parotidectomy]. Retro- Thus, it is possible that early neck dissection for bulky resectable
pharyngeal nodes may be removed in the treatment of selected cervical adenopathy can reduce the expected morbidity of
cancers originating in the posterior pharynx, the soft palate, or planned postchemoradiation neck dissection.There is limited evi-
the nasopharynx. A mediastinal lymph node dissection may be dence in the literature that such an approach is feasible in certain
combined with a neck dissection in the treatment of metastatic circumstances24; however, it is recommended that significant
thyroid carcinomas. delays in initiating treatment to the primary site be avoided
because such delays may ultimately have a negative impact on
NECK DISSECTION AFTER CHEMORADIATION
survival.
The indications for neck dissection have been significantly
RECONSTRUCTION AND RECURRENCE AFTER NECK
affected by the increasing use of organ preservation protocols for
DISSECTION
the treatment of head and neck cancer. Nasopharyngeal carcino-
mas, which are uniquely radiosensitive, are generally treated with The use of microvascular free tissue transfer to reconstruct
irradiation, with or without chemotherapy; neck dissection is surgical defects in the head has allowed surgeons to resect large
reserved for patients who experience an incomplete response and tumors with large margins while simultaneously achieving
for patients with bulky cervical lesions. Similarly, patients with improved functional results. Preservation of vascular—and,
early nodal disease (N0 or N1) treated according to organ preser- occasionally, neural—structures during neck dissection may
vation protocols may undergo nonsurgical therapy. For patients facilitate the reconstructive process. Typically, several vessels,
who have advanced neck disease (N2 or N3) or who respond including an artery and one or two veins, are required for inflow
incompletely to therapy, a planned posttreatment neck dissection and outflow into a free flap. The facial artery, the retro-
is recommended because surgical salvage of so-called neck fail- mandibular vein, and the external jugular vein, which are pre-
ures is rarely successful.21 As a rule, the planned neck dissection served during level I and level II dissection, are the vessels that
should be done within 6 weeks of the completion of chemoradi- are most frequently used for flap revascularization. If these ves-
ation therapy: if it is delayed past the 6-week point, progressive sels are unavailable as a consequence of high-volume neck dis-
soft tissue fibrosis may develop, resulting in difficult surgical dis- ease, the superior thyroid artery and the transverse artery, with
section, increased postoperative morbidity, and, potentially, companion veins, are suitable substitutes. To date, there is no
tumor progression. evidence in the literature that preservation of vascular structures
A 2003 study highlighted the need for planned neck dissection in the neck predisposes patients to regional recurrence. Cau-
after definitive chemoradiation for N2 or N3 nodal disease.22 In tion must, however, be exercised in the setting of pathologic
this study, 76 patients presenting with N2 or N3 disease under- lymphadenopathy.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 6 NECK DISSECTION — 5
a b c
d e f
Figure 2 Illustrated are incisions used for neck dissections. Incision design is a critical element of operative plan-
ning. Incisions are chosen with the aims of optimizing exposure of relevant neck levels and minimizing morbidity. The
incisions depicted in (a) and (b) are useful for selective neck dissections. For the more extensive exposure required in
a radical or modified radical neck dissection, a deeper half-apron style incision (c) may be used, or a vertical limb
may be dropped from a mastoid-submental incision (d); the latter incision is less reliable and may break down, expos-
ing vital structures such as the carotid. The incision depicted in (e) is also useful for selective neck dissections. The
Macfee incision (f) provides limited exposure and results in persisent lymphedema in the bipedicled skin flap.
Internal Carotid
Artery
External
Carotid
Artery
Facial
Artery
Digastric
Muscle
Spinal Lingual
Accessory Artery
Nerve
Hypoglossal
Nerve
Occipital Artery
Mylohyoid
Internal Jugular Muscle
Vein
Hyoid Bone
Ansa Hypoglossi
Superior
Thyroid Hyoglossal
Artery Muscle
Carotid Sheath
Common Carotid
Artery
Vagus Nerve
Figure 3 Depicted are the key anatomic relationships in levels I and II that must be kept in
mind in performing a neck dissection. View is of the right neck.
muscle. It then loops around the external carotid artery at the ori- placed along the lymphatic pedicle until there is no evidence of
gin of the occipital artery and ascends to the skull base between clear or turbid fluid on the Valsalva maneuver. Care is taken to
the external carotid artery and the internal jugular vein. Often, avoid inadvertent injury to the vagus nerve or the phrenic nerve,
the hypoglossal nerve is surrounded by a plexus of small veins, which course through this region.
branching off the common facial vein. Bleeding in this region
places the hypoglossal nerve at risk.The jugular vein, located just Step 4: Mobilization of Supraclavicular Fat Pad (“Bloody
posterior to the external carotid artery and the hypoglossal nerve, Gulch”)
may be isolated and doubly suture-ligated at this point. The fascia overlying the supraclavicular fat pad is incised, and
Frequently, the spinal accessory nerve is identified just lateral and the supraclavicular fat pad is bluntly retracted superiorly so as to
posterior to the internal jugular vein, proceeding posteriorly into free the tissues from the supraclavicular fossa. If transverse cervi-
the sternocleidomastoid muscle. cal vessels are encountered, they are clamped and ligated as nec-
In a radical neck dissection, the sternocleidomastoid muscle essary. Fascia is left on the deep muscles of the neck, which also
and the spinal accessory nerve are transected at this point and ele- envelop the brachial plexus and the phrenic nerve.
vated off the splenius capitis and the levator scapulae to the
trapezius posteriorly. The anterior edge of the trapezius is skele- Step 5: Dissection and Removal of Specimen
tonized from the occiput to the clavicle. The accessory nerve is Attention is then turned to the posterior aspect of the neck. Fat
again transected where it penetrates the trapezius. and lymphatic tissues are retracted anteriorly with Allis clamps,
and the specimen is dissected off the deep muscles of the neck
Step 3: Control of Internal Jugular Vein Inferiorly; Ligation of with a blade. Again, a layer of fascia is left on the deep cervical
Lymphatic Pedicle musculature: stripping fascia off the deep cervical musculature
The sternal and clavicular heads of the sternocleidomastoid results in denervation of these muscles, which adds to the mor-
muscle are transected and elevated to expose the anterior belly of bidity associated with accessory nerve sacrifice. Once the speci-
the omohyoid muscle.The soft tissue overlying the posterior belly men is mobilized beyond the phrenic nerve, the cervical nerves
of the omohyoid muscle is dissected, clamped, and ligated as nec- (C1–C4) may be divided. The specimen is peeled off the carotid
essary. The omohyoid muscle is then transected, and the jugular artery and removed.
vein, the carotid artery, and the vagus nerve are exposed. The
jugular vein is isolated and doubly suture-ligated. Care is taken Step 6: Closure
not to transect the adjacent vagus nerve and carotid artery. The The neck incision is closed in layers over suction drains.
lymphatic tissues in the base of the neck adjacent to the internal
MODIFIED RADICAL NECK DISSECTION
jugular vein are clamped and suture-ligated 1 cm superior to the
clavicle. If a chyle leak is encountered, a figure-eight stitch is The incision is made and flaps elevated as in a radical neck dis-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 6 NECK DISSECTION — 7
vein, which lies in close proximity to the nerve superiorly. Tissue include the presence of a sucking sound in the neck, a mill-wheel
posterior to the accessory nerve is grasped and freed from the murmur over the precordium, ECG changes, and hypotension.
deep muscles of the neck, the digastric muscle superiorly, and the Predisposing factors include elevation of the head of the bed and
sternocleidomastoid muscle posteriorly.The tissue included in so- spontaneous breathing, which increase negative intrathoracic
called level IIb is passed beneath the spinal accessory nerve and pressure and thus promote entry of air into the venous system.
incorporated into the main specimen. Injury to the internal jugular vein is more difficult to control when
The sternocleidomastoid muscle is retracted, and the fascia it occurs distally in the neck or chest at the junction with the sub-
posterior to the internal jugular vein is incised. Dissection is car- clavian vein. For this reason, ligation of the internal jugular vein in
ried down to the deep cervical musculature and cervical nerves, radical and modified radical neck dissections is typically per-
which form the floor of the dissection. The specimen is retracted formed 1 cm superior to the clavicle.
anteriorly. A layer of fascia is left on the deep cervical musculature Opalescent or clear fluid in the inferior neck suggests the pres-
and the cervical nerves to preserve innervation of the deep mus- ence of a chyle fistula. Chyle fistulas generally can be prevented
cles of the neck and protect the phrenic nerve as it courses over by clamping and ligating the lymphatic pedicle at the base of the
the anterior scalene muscle. neck.Those fistulas that occur are repaired at the time of the neck
The specimen is peeled off the internal jugular vein and dissection.There is no benefit in isolating individual lymphatic ves-
removed. Dissection too far posteriorly behind the vein may result sels, because these structures are fragile, do not hold stitches, and
in injury to the vagus nerve or the sympathetic trunk and predis- are prone to tearing. A figure-eight stitch is placed along the lym-
poses to postoperative thrombosis of the vein. Ligation of internal phatic pedicle until there is no evidence of clear or turbid fluid
jugular vein branches should be done without affecting the caliber on the Valsalva maneuver. Care must be taken not to inadvertently
of the vein or giving the vessel a “sausage link” appearance, which injure the vagus nerve or the phrenic nerve during repair of a chyle
would create turbulent flow patterns predisposing to thrombosis. leak.
Overall, gentle dissection around all vessels, with care taken to
POSTOPERATIVE
avoid pulling-related trauma, minimizes the risk of endothelial
injury. Dissection behind the internal jugular vein may result in The best treatment of postoperative complications such as
injury to the vagus nerve or the sympathetic trunk. hematoma and chyle leak is prevention. Hematomas, once pre-
A level IV dissection may be facilitated by retracting the omo- sent, are best managed by promptly returning the patient to the
hyoid muscle inferiorly or by dividing it for additional exposure. OR for evacuation. Management of postoperative leakage of chyle
The tissue inferior to the omohyoid is mobilized and delivered depends on the volume of the leak. Low-volume leaks may be
with the main specimen. The lymphatic pedicle is clamped and managed with packing, wound care, and nutritional supplemen-
ligated. Care is taken to look for leakage of chyle, particularly tation with medium-chain triglycerides.
when a level IV dissection is performed on the left. Wound complications (e.g., infection, flap necrosis, and carotid
artery exposure or rupture) share certain interrelated causative
Levels II to IV factors. Poor nutritional status, advanced tumor stage at presen-
When level I is spared, a smaller incision suffices for exposure. tation, hypothyroidism, and preoperative radiation therapy have
Subplatysmal flaps are raised superiorly to the level of the sub- all been associated with wound complications. After chemoradia-
mandibular gland. The inferior flap is raised, exposing the anteri- tion therapy, the use of smaller incisions and more limited dissec-
or edge of the sternocleidomastoid muscle. Dissection proceeds tion of soft tissues may lower the incidence of postoperative
just inferior to the submandibular gland until the posterior belly of wound problems, including persistent lymphedema and soft tis-
the digastric muscle is identified. The digastric muscle is skele- sue fibrosis. Conversely, poor planning of skin incisions may
tonized posteriorly to the sternocleidomastoid muscle and anteri- increase the likelihood of wound complications such as wound
orly to the omohyoid muscle, which forms the anterior limit of the breakdown, skin flap loss, and exposure of vital structures.Wound
dissection. The rest of the neck dissection proceeds as described complications predispose to carotid artery rupture, the most cat-
for a selective neck dissection involving levels I through IV. astrophic complication of neck dissection.
In some case, severe edema after planned neck dissections in
patients previously treated with chemoradiation may cause respi-
Complications ratory decompensation that necessitates tracheotomy. Postopera-
tive internal jugular vein thrombosis is not uncommon despite
INTRAOPERATIVE
preservation at the time of surgery,25 and it may exacerbate
Most intraoperative complications may be prevented by means edema. Impaired venous outflow predisposes to increased
of careful surgical technique, coupled with a thorough under- intracranial pressure.26 This may be a greater concern in patients
standing of head and neck anatomy. Injury to the internal jugular who require bilateral neck dissections. If a radical neck dissection
vein may occur either proximally or distally. Uncontrolled proxi- is performed on one side, the internal jugular vein must be pre-
mal bleeding endangers adjacent critical structures, such as the served on the other, or else the neck dissections must be staged.
carotid artery and the hypoglossal nerve.The bleeding may be ini- These problems are further exacerbated when the patient has
tially controlled with pressure, followed by a methodical search for undergone chemoradiation therapy before operation.
the bleeding source. Internal jugular vein lacerations can often be Most neck dissections result in some degree of temporary
repaired with 5-0 nylon sutures; if a laceration cannot be repaired, shoulder dysfunction. Patients in whom nerve-sparing procedures
the vein must be ligated. Occasionally, a laceration extends up to are performed can expect function to return within 3 weeks to 1
the skull base, and the vessel cannot be controlled with clamping year, depending on the procedure performed. Shoulder dysfunc-
and ligation. In these cases, it is acceptable to pack the jugular tion and pain are exacerbated when nerves supplying the deep
foramen for hemostasis. muscles of the neck are also sacrificed. All patients benefit from
It is important to gain distal control of the internal jugular vein physical therapy, which preserves full range of motion in the
before repair to prevent air embolism. Harbingers of air embolism shoulder while function returns.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 6 NECK DISSECTION — 9
References
1. Wakely PE Jr, Kneisl JS: Soft tissue aspiration 2001 Head Neck Surg 123:917, 1997
cytopathology. Cancer 90:292, 2000 11. Chen AY, Matson LK, Roberts D, et al: The sig- 20. Andersen PE, Warren F, Spiro J, et al: Results of
2. Carroll CM, Nazeer U, Timon CI: The accuracy nificance of comorbidity in advanced laryngeal selective neck dissection in management of the
of fine-needle aspiration biopsy in the diagnosis cancer. Head Neck 23:566, 2001 node-positive neck. Arch Otolaryngol Head Neck
of head and neck masses. Ir J Med Sci 167:149, 12. Weymuller EA Jr: Clinical staging and operative Surg 128:1180, 2002
1998 reporting for multi-institutional trials in head and 21. Narayan K, Crane CH, Kleid S, et al: Planned
3. Kraus DH, Carew JF, Harrison LB: Regional neck squamous cell carcinoma. Head Neck neck dissection as an adjunct to the management
lymph node metastasis from cutaneous squamous 19:650, 1997 of patients with advanced neck disease treated
cell carcinoma. Arch Otolaryngol Head Neck 13. Ross GL, Shoaib T, Soutar DS, et al: The First with definitive radiotherapy: for some or for all?
Surg 124:582, 1998 International Conference on Sentinel Node Head Neck 21:606, 1999
4. Spiro RH: Management of malignant tumors of Biopsy in Mucosal Head and Neck Cancer and 22. McHam SA, Adelstein DJ, Rybycki LA, et al:
the salivary glands. Oncology (Huntingt) 12:671, adoption of a multicenter trial protocol. Ann Surg Who merits a neck dissection after definitive
1998 Oncol 9:406, 2002 chemoradiotherapy for N2-N3 squamous cell
5. Shaha AR: Management of the neck in thyroid 14. Civantos FJ, Gomez C, Duque C, et al: Sentinel head and neck cancer? Head Neck 25:791, 2003
cancer. Otolaryngol Clin North Am 31:823, 1998 node biopsy in oral cavity cancer: correlation with 23. Doweck I, Robbins KT, Mendenhall WM, et al:
6. Alvi A, Johnson JT: Extracapsular spread in the PET scan and immunohistochemistry. Head Neck level-specific nodal metastases in oropha-
clinically negative neck (N0): implications and Neck 25:1, 2003 ryngeal cancer: is there a role for selective neck
outcome. Otolaryngol Head Neck Surg 114:65, 15. Jacobs JR, Arden RL, Marks SC, et al: Carotid dissection after definitive radiation therapy? Head
1996 artery reconstruction using superficial femoral Neck 25:960, 2003
7. Myers JN, Greenberg JS, Mo V, et al: arterial grafts. Laryngoscope 104(6 pt 1):689, 24. Sohn HG, Har-El G: Neck dissection prior to
Extracapsular spread: a significant predictor of 1994 radiation therapy for squamous cell carcinoma of
treatment failure in patients with squamous cell 16. Adams GL, Madison M, Remley K, et al: Preoper- tongue base. Am J Otolaryngol 23:138, 2002
carcinoma of the tongue. Cancer 92:3030, 2001 ative permanent balloon occlusion of internal 25. Leontsinis TG, Currie AR, Mannell A: Internal
8. Johnson JT, Wagner RL, Myers EN: A long-term carotid artery in patients with advanced head and jugular vein thrombosis following functional neck
assessment of adjuvant chemotherapy on out- neck squamous cell carcinoma. Laryngoscope dissection. Laryngoscope 105:169, 1995
come of patients with extracapsular spread of cer- 109:460, 1999 26. Lydiatt DD, Ogren FP, Lydiatt WM, et al:
vical metastases from squamous carcinoma of the 17. Bocca E, Pignataro O, Oldini C, et al: Functional Increased intracranial pressure as a complication
head and neck. Cancer 77:181, 1996 neck dissection: an evaluation and review of 843 of unilateral radical neck dissection in a patient
9. Jose J, Coatesworth AP, Johnston C, et al: cases. Laryngoscope 94:942, 1984 with congenital absence of the transverse sinus.
Cervical node metastases in squamous cell carci- 18. Shah JP, Candela FC, Poddar AK: The patterns Head Neck 13:359, 1991
noma of the upper aerodigestive tract: the signifi- of cervical lymph node metastases from squa-
cance of extracapsular spread and soft tissue mous carcinoma of the oral cavity. Cancer
deposits. Head Neck 25:451, 2003 66:109, 1990
10. Hathaway B, Johnson JT, Piccirillo JF, et al: 19. Pitman KT, Johnson JT, Myers EN: Effectiveness
Acknowledgment
Chemoradiation for metastatic SCCA: role of of selective neck dissection for management of
comorbidity. Laryngoscope 111(11 pt 1):1893, the clinically negative neck. Arch Otolaryngol Figures 1 through 3 Tom Moore.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 7 THYROID AND PARATHYROID PROCEDURES — 1
Thyroid Cartilage tumor should be sacrificed and allowed to remain attached to the
Sternohyoid thyroid. Separation of the sternohyoid muscle from the sternothy-
Muscle roid muscle provides better exposure of the operative field. The
middle thyroid veins should be cleaned of adjacent tissues to pre-
vent any injury to the recurrent laryngeal nerve when these veins
are ligated and divided. It is always safest to mobilize tissues par-
Sternocleidomastoid allel to the recurrent laryngeal nerve.
Muscle
Platysma Step 3: Division of Isthmus
When a thyroid lobectomy is to be performed, the isthmus
of the thyroid gland is usually divided with Dandy or Colodny
clamps at an early point in dissection to facilitate the subsequent
mobilization of the thyroid gland.The thyroid tissue that is to re-
main is oversewn with a 2-0 silk ligature.To minimize the chance
of invasion into the trachea or to avoid a visible mass in patients
with compensatory thyroid hypertrophy, thyroid tissues should
not be left anterior to the trachea.
Suprasternal Notch
Upper Parathyroid Cricothyroid lage. Such dissection is necessary only when laryngeal mobi-
Gland Muscle lization is performed to relieve tension on the tracheal anasto-
mosis after tracheal resection.
Step 5: Identification of Recurrent Laryngeal Nerves and
Lower Parathyroid Glands
External When the thyroid lobe is further mobilized, the lower para-
Laryngeal
thyroid gland is usually seen; this gland is almost always located
Nerve
anterior to the recurrent laryngeal nerve and is usually located
inferior to where the inferior thyroid artery crosses the recurrent
laryngeal nerve [see Figure 6].The carotid sheath is retracted lat-
Small Artery erally, and the thyroid gland is retracted anteriorly and medial-
and Vein in ly.This retraction puts tension on the inferior thyroid artery and
Berry's consequently on the recurrent laryngeal nerve, thereby facilitat-
Ligament ing the identification of the nerve.The recurrent laryngeal nerve
is situated more medially on the left (running in the tracheo-
esophageal groove) and more obliquely on the right. Dissection
should proceed cephalad along the lateral edge of the thyroid.
Fatty and lymphatic tissues immediately adjacent to the thyroid
gland are swept from it with a peanut sponge on a clamp, and
Recurrent small vessels are ligated. No tissue should be transected until
Laryngeal one is sure that it is not the recurrent laryngeal nerve.
Nerve (with
Vas Nervorum) Troubleshooting The upper parathyroid glands are usual-
ly situated on each side of the thyroid gland at the level where the
Figure 4 The recurrent laryngeal nerve enters the cricothyroid
recurrent laryngeal nerve enters the cricothyroid muscle [see Fig-
muscle at the level of the cricoid cartilage, first passing through
Berry’s ligament.2
ure 6]. Because the recurrent laryngeal nerve enters the cricothy-
roid muscle at the level of the cricoid cartilage, the area cephalad
to the cricoid cartilage is relatively safe.
sutures, devices such as the Harmonic Scalpel (Ethicon Endo- The right and left recurrent laryngeal nerves must be pre-
Surgery, Inc.), the Ligasure Precise (Valleylab), and the Hem-o-lok served during every thyroid operation. Although both nerves
clip (Weck Closure Systems) may be used to control vessels. enter at the posterior medial position of the larynx in the cri-
The tissues posterior and lateral to the superior pole that have cothyroid muscle, their courses vary considerably. The right re-
not already been mobilized can now be easily swept by blunt current laryngeal nerve takes a more oblique course than the
dissection away from the thyroid gland medially and anteriorly left recurrent laryngeal nerve and may pass either anterior or
and away from the carotid sheath laterally. The upper parathy-
roid gland is often identified at this time at the level of the
cricoid cartilage.
Superior Laryngeal
Troubleshooting It is essential to keep from injuring the Nerve
Internal Laryngeal
external laryngeal nerve. This nerve is the motor branch of the
Nerve
superior laryngeal nerve and is responsible for tensing the vocal
cords; it is also known as the high note nerve or the Amelita
Galli-Curci nerve. In about 80% of patients, the external laryn- External Laryngeal
geal nerve runs on the surface of the cricothyroid muscle; in Nerve
about 10%, it runs with the superior pole vessels; and in the
remaining 10%, it runs within the cricothyroid muscle. Given Superior Site for Ligating
that this nerve is usually about the size of a single strand of a spi- Thyroid Artery Vessels
der web, one should generally try to avoid it rather than to iden- and Vein
tify it. Injury to the external laryngeal nerve occurs in as many as
10% of patients undergoing thyroidectomy. The best ways of
preventing such injury are (1) to provide gentle traction on the
thyroid gland in a caudal and lateral direction and (2) to ligate
the superior pole vessels directly on the capsule of the upper pole
individually and low on the thyroid gland rather than to cross-
clamp the entire superior pole pedicle.
The internal laryngeal nerve is the sensory branch of the
superior laryngeal nerve; it provides sensory innervation to the
posterior pharynx. Injury to this nerve can result in aspiration.
Because the internal laryngeal nerve typically is cephalad to the
area of dissection during thyroidectomy and runs cephalad to Figure 5 The superior pole vessels should be individually identi-
the lateral portion of the thyroid cartilage, it usually is at risk fied and ligated low and laterally on the thyroid gland to minimize
only when the surgeon dissects cephalad to the thyroid carti- the chances of injury to the external laryngeal nerve.2
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 7 THYROID AND PARATHYROID PROCEDURES — 4
reason to be concerned about permanent hypoparathyroidism, follicular cancer who have undergone total or near-total thy-
whereas a high level (> 4.5 mg/dl) should prompt concern about roidectomy appear to benefit from radioactive iodine scanning
permanent hypoparathyroidism. and therapy. (It is necessary to discontinue L-thyroxine for 6 to
The surgical clips are removed on postoperative day 1, and tis- 8 weeks and L-triiodothyronine for 2 weeks before scanning.)
sue adhesive or Steri-Strips are applied to prevent tension on the Those considered to be at low risk (age < 45 years, tumor con-
healing wound. (If Steri-Strips are used, they are removed on day fined to the thyroid and not invasive, and tumor diameter < 4
10.) Patients usually are discharged on the first day, are given a cm) may receive radioactive iodine on an outpatient basis in a
prescription for thyroid hormone (L-thyroxine, 0.1 to 0.2 mg/day dose of approximately 30 mCi. Those who are considered to be
orally) if the procedure was more extensive than a thyroid lobec- at high risk should receive approximately 100 to 150 mCi.
tomy, and are told to take calcium tablets for any tingling or mus- Long-term (20-year) mortality is about 4% in low-risk patients
cle cramps. Patients with papillary, follicular, or Hürthle cell can- and about 40% in high-risk patients. Serum thyroglobulin lev-
cer should receive enough L-thyroxine to keep their serum levels els should be determined before and after discontinuance of
of thyroid-stimulating hormone (TSH) below 0.1 mIU/ml. On thyroid hormone; such levels are very sensitive indicators of per-
postoperative day 10, the pathology is reviewed, and further man- sistent thyroid disease after total thyroidectomy.
agement is discussed in the light of the pathologic findings. In
patients with thyroid cancer, values for serum calcium,TSH, and
thyroglobulin are obtained; in patients with coexisting hyper- Parathyroidectomy
parathyroidism, values for serum calcium, phosphorus, and
OPERATIVE PLANNING
parathyroid hormone (PTH) are obtained.
The preparation for parathyroidectomy is the same as that for
COMPLICATIONS
thyroidectomy. Patients who have profound hypercalcemia (serum
The following are the most significant complications of calcium ≥ 12.5 mg/dl) or mild to moderate renal failure should be
thyroidectomy. vigorously hydrated and given furosemide before operation. On
1. Injury to the recurrent laryngeal nerve. Bilateral injury to the rare occasions, such patients require additional treatment—for ex-
recurrent laryngeal nerve may result in vocal cord paresis and ample, administration of diphosphonates, mithramycin, or calci-
stridor and may have to be treated with a tracheostomy. tonin. Any electrolyte abnormalities (e.g., hypokalemia) should be
corrected.
2. Hypoparathyroidism.This complication may arise as the result
We recommend either bilateral exploration or focused explo-
of removal of, injury to, or devascularization of the parathyroid
ration with intraoperative PTH assay for most patients undergoing
glands. As noted [see Operative Technique, above], we recom-
initial operations for primary sporadic hyperparathyroidism. The
mend leaving parathyroid glands on their own vascular pedi-
latter approach can be taken only when the abnormal gland has
cle; however, if one is concerned about possible devasculariza-
been identified by sestamibi scanning. For patients with familial pri-
tion of a parathyroid, biopsy should be performed on the
mary hyperparathyroidism or secondary hyperparathyroidism,
gland to confirm its identity and then autotransplanted in 1 ×
bilateral exploration is recommended because most of these pa-
1 mm pieces into separate pockets in the sternocleidomastoid
tients have multiple abnormal parathyroid glands.
muscle.
Preoperative localization studies (e.g., ultrasonography, MRI,
3. Bleeding. Postoperative bleeding can be life threatening in that sestamibi scanning, and CT scanning) are generally unnecessary:
it can compromise the airway. Any postoperative respiratory they provide useful information in about 75% of patients, but they
distress can be thought of as attributable to a neck hematoma are often not considered cost-effective, because an experienced sur-
until proved otherwise. Most bleeding occurs within four hours geon can treat hyperparathyroidism successfully 95% to 98% of the
of operation, and virtually all occurs within 24 hours. time. Such studies are, however, essential when reoperation for per-
4. Injury to the external laryngeal nerve [see Operative Tech- sistent or recurrent hyperparathyroidism is indicated and when a
nique, above]. focused approach with intraoperative PTH assay is to be used.We
5. Infection.This complication is quite rare after thyroidectomy. do not believe that using the gamma probe is any better than pre-
Any patient with acute pharyngitis should not undergo this operative sestamibi scanning. All patients requiring reoperation
procedure. should undergo direct or indirect laryngoscopy before operation
6. Seroma. Most seromas are small and resorb spontaneously; for evaluation of vocal cord function.
some must be aspirated.
7. Keloid. Keloid formation after thyroidectomy is most com- OPERATIVE TECHNIQUE
mon in African-American patients and in patients with a his-
tory of keloids. Steps 1 through 4
8. There are a number of miscellaneous complications that are Steps 1, 2, 3, and 4 of a parathyroidectomy are virtually iden-
somewhat less common. tical to steps 1, 2, 4, and 5 of a thyroidectomy (see above), and
essentially the same troubleshooting considerations apply.
OUTCOME EVALUATION
Most patients can return to work or full activity in 1 to 2 Troubleshooting About 85% of people have four parathy-
weeks. Patients with benign lesions who have undergone hemi- roid glands, and in about 85% of these persons, the parathyroids
thyroidectomy may or may not require thyroid hormone; those are situated on the posterior lateral capsule of the thyroid. Nor-
with multinodular goiter, thyroiditis, or occult papillary cancer mal parathyroid glands measure about 3 × 3 × 4 mm and are light
typically do, whereas those with follicular adenoma typically do brown in color. The upper parathyroid glands are more posterior
not. Patients who have undergone total or near-total thyroidec- (i.e., dorsal) and more constant in position (at the level of the
tomy will require thyroid hormone. Patients with papillary or cricoid cartilage) than the lower parathyroid glands, which typi-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 7 THYROID AND PARATHYROID PROCEDURES — 7
cally are more anteriorly placed (on the posterior-lateral surface anterior-superior mediastinum. In all, about 15% of parathyroid
of the thyroid gland). Both the upper and the lower parathyroid glands are found within the thymus. If an upper parathyroid
glands are supplied by small branches of the inferior and superi- gland cannot be located, one should look not only far behind the
or thyroid arteries in most patients. About 15% of parathyroid thyroid gland superiorly but also in a paraesophageal position
glands are situated within the thymus gland, and about 1% are down into the posterior mediastinum. A thyroid lobectomy or
intrathyroidal. Other abnormal sites for the parathyroid glands thyroidotomy should be done on the side where fewer than two
are (1) the carotid sheath, (2) the anterior and posterior medias- parathyroid glands have been located and no abnormal parathy-
tinum, and (3) anterior to the carotid bulb or along the pharynx roid tissue has been identified. The carotid sheath and the area
(undescended parathyroids). posterior to the carotid, as well as the retroesophageal area, should
The upper parathyroid glands are usually lateral to the re- also be explored. In rare cases, there may be an undescended para-
current laryngeal nerve at the level of Berry’s ligament; their thyroid tumor anterior to the carotid bulb.
position makes them generally easier to preserve during thyroid- Although we do not recommend routine biopsy of more than
ectomy and easier to find during both parathyroid and thyroid one normal-appearing parathyroid gland, we do recommend bi-
surgery. When the upper parathyroids are not found at this site, opsy (not removal) and marking of all normal parathyroid glands
they often can be found in the tracheoesophageal groove or in the that have been identified when no abnormal parathyroid tissue
posterior mediastinum along the esophagus. The lower parathy- can be found.When four normal parathyroid glands are found in
roid glands are almost always situated anterior to the recurrent the neck, the fifth (abnormal) parathyroid gland is usually in the
laryngeal nerves and caudal to where the recurrent laryngeal nerve mediastinum.The surgeon’s responsibility is to make sure during
crosses the inferior thyroid artery; they may be surrounded by parathyroidectomy that the elusive parathyroid adenoma is not
lymph nodes. When the lower parathyroids are not found at this in or removable through the cervical incision used for the initial
site, they usually can be found in the anterior mediastinum (typ- operation and to minimize complications.The risk of permanent
ically in the thymus or the thymic fat). hypoparathyroidism or injury to the recurrent nerve should be
less than 2%.
Step 5: Parathyroid Resection
Abnormal parathyroid glands are removed. In about 80% of Step 6: Closure
patients with primary hyperparathyroidism, one parathyroid Closure is essentially the same for parathyroidectomy as for
gland is abnormal; in about 15%, all glands are abnormal (dif- thyroidectomy.
fuse hyperplasia); and in about 5%, two or three glands are abnor-
COMPLICATIONS
mal and one or two normal. Parathyroid cancer occurs in about
1% of patients with primary hyperparathyroidism. About 50% of The complications of parathyroidectomy are similar to those
patients with parathyroid cancer have a palpable tumor, and most of thyroidectomy but occur less often. Patients with a very high
exhibit profound hypercalcemia (serum calcium ≥ 14.0 mg/dl). serum alkaline phosphatase level and osteitis fibrosa cystica are
prone to profound hypocalcemia after parathyroidectomy. In
Troubleshooting In some patients, parathyroid tumors and such patients, both serum calcium and serum phosphorus lev-
hyperplastic parathyroid glands are difficult to find. If this is the els are low. In contrast, patients with hypoparathyroidism exhib-
case, the first step is to explore the sites where parathyroids are it low serum calcium levels but high serum phosphorus levels.
usually located, near the posterolateral surface of the thyroid
OUTCOME EVALUATION
gland. (About 80% of parathyroid glands are situated within 1
cm of the point where the inferior thyroid artery crosses the Outcome considerations are essentially the same as for
recurrent laryngeal nerve.) When a lower gland is missing from thyroidectomy. The patient should have a normal voice and be
the usual location, it is likely to be found in the thymus; this pos- normocalcemic. The overall complication rate should be less
sibility can be confirmed by mobilizing the thymus from the than 2%.
References
1. Henry JF, Audiffret J, Denizot A, et al: The nonrecur- Recommended Reading cology. Daly JM, Cady B, Low DW, Eds. CV Mosby Co,
rent inferior laryngeal nerve: review of 33 cases, includ- St. Louis, 1993, p 41
ing two on the left side. Surgery 104:977, 1988 Chen H, Sokol LJ, Udelsman R: Outpatient minimally Gordon LL, Snyder WH, Wians JR, et al: The validity of
2. Clark OH: Endocrine Surgery of the Thyroid and Para- invasive parathyroidectomy: a combination of sestamibi- quick intraoperative hormone assay: an evaluation of sev-
thyroid Glands.WB Saunders Co, Philadelphia, 2003 spect localization, cervical block anesthesia, and intraop- enty-two patients based on gross morphology criteria. Sur-
3. Cady B, Rossi R: Surgery of thyroid gland. Surgery of erative parathyroid hormone assay. Surgery 126:1016, gery 126:1030, 1999
the Thyroid and Parathyroid Glands. Cady B, Rossi R, 1999
Irvin GL, Molinari AS, Figuero C, et al: Improved success
Eds.WB Saunders Co, Philadelphia, 1991 Clark OH:Total thyroidectomy and lymph node dissection rate in reoperative parathyroidectomy with intraoperative
for cancer of the thyroid. Mastery of Surgery, 2nd ed. Ny- PTH assay. Ann Surg 229:874, 1999
hus LM, Baker RJ, Eds. Little, Brown and Co, Boston,
Acknowledgment Tezelman S, Shen W, Shaver JK, et al: Double parathyroid
1992, p 204
adenomas: clinical and biochemical characteristics before
Figures 1 through 7 Tom Moore. Clark OH:Total thyroid lobectomy. Atlas of Surgical On- and after parathyroidectomy. Ann Surg 218:300, 1993
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 8 PAROTID MASS — 1
8 PAROTID MASS
Ashok R. Shaha, M.D., F.A.C.S.
There are three major salivary glands in the human body—the Nonneoplastic The causes of nonneoplastic masses include
parotid gland, the submandibular gland, and the sublingual congenital, granulomatous, infectious or inflammatory, and non-
gland—of which the parotid gland is the largest. In addition, there inflammatory conditions. Some congenital lesions (e.g., heman-
are approximately 600 to 800 minor salivary glands distributed gioma or vascular malformation) present as a vague swelling in the
throughout the entire upper aerodigestive tract, starting from the parotid region that has been present since childhood. One con-
lip and extending to the lower end of the esophagus and up to the genital lesion, a first branchial cleft cyst, presents as a mass inferi-
pulmonary alveoli. Almost half of these minor salivary glands are or to the cartilaginous ear canal, with a cyst tract that can be either
on the hard palate. Accordingly, any mass on the hard palate medial or lateral to the facial nerve and may even divide the trunk
should be considered a minor salivary gland tumor until proved of the nerve. This cyst is most commonly noted in the second
otherwise.1 through fourth decades in life.
The majority of salivary gland tumors originate in the parotid Granulomatous diseases are frequently manifested by an
gland. Approximately 75% to 80% of parotid tumors are asymptomatic, gradual enlargement of a lymph node within the
benign.2,3 In the evaluation and surgical treatment of parotid gland; often, they cannot be readily distinguished from neoplasms.
tumors, it is essential to maintain awareness of the possibility of In sarcoidosis, salivary gland involvement may cause duct obstruc-
temporary or permanent facial nerve injury [see Discussion, Prin- tion, pain associated with the duct, xerostomia, or enlargement of
ciples of Facial Reanimation, below]. Because surgery necessarily the gland. The diagnosis is supported by chest x-rays that show
entails some risk of an injury to this structure or its branches, as bilateral hilar adenopathy and by elevated levels of angiotensin-
well as because most parotid masses do not give rise to significant converting enzyme (ACE).
symptoms, many patients with parotid tumors may find the As noted (see above), infectious or inflammatory diseases
prospect of surgical therapy difficult to accept. involving the parotid, unlike neoplasms, tend to give rise to pain in
their early stages. Most such inflammatory conditions begin with
diffuse enlargement of one or more salivary glands. Although
Clinical Evaluation parotitis is generally unilateral, it may be bilateral if a systemic
causative condition is involved, and other salivary glands may be
HISTORY
affected as well.The pain reported may be related to the presence
Evaluation of a parotid mass begins of a stone in the salivary duct or to diffuse obstructive parotitis.
with a good clinical history. The most Chronic parotitis may lead to recurrent infection and inflamma-
important question is, how long has the tion.When recurrent swelling of the salivary gland does occur, it is
mass been present? If local pain and directly related to eating and increased salivation.
swelling of recent onset (i.e., within the Sialadenosis is a noninflammatory, nonneoplastic condition of
past few days) are reported, infection or unknown origin that is characterized by diffuse enlargement of the
obstruction is the likely cause. If the mass has been present for a salivary gland, with no discrete mass or inflammation.
longer period (i.e., weeks to months), a neoplasm is more likely.
Unfortunately, the presentations of some nonneoplastic condi- Lymphoepithelial Lymphoepithelial lesions may be divided
tions resemble those of neoplasms, and distinguishing one type of into lymphocytic infiltrative diseases and lymphomas. In many
condition from the other can be challenging. Thus, the history cases, patients with lymphocytic infiltrative diseases (e.g., Mikulicz
should continue with further questions focusing on local or sys- disease, sicca complex, and Sjögren syndrome) have had their
temic signs and symptoms, the presence of swelling or other mass- conditions for long periods, and they may feel that they have
es in the salivary glands, and previous medical conditions (includ- always been chubby, when in fact they have had chronic enlarge-
ing skin cancer). ment of both parotid glands. In patients with Sjögren syndrome,
malignant transformation to high-grade lymphoma is known to
Classification
occur. Lymphoepithelial cysts are benign cystic lesions that may
Major salivary gland masses can be classified as nonneoplastic, arise from lymph nodes or from lymphoid aggregates in the sali-
lymphoepithelial, or neoplastic.4 vary gland. These lesions may be associated with HIV infection.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 8 PAROTID MASS — 2
Approach to Evaluation
of a Parotid Mass
Primary lymphoma of the salivary gland is uncommon, occur- The most common presentation of a parotid mass, whether
ring in fewer than 5% of patients with parotid masses.5 Suggestive benign or malignant, is an asymptomatic swelling in the preauric-
clinical features include (1) the development of a parotid mass in ular or retromandibular region. Occasionally, patients present with
a patient with a known history of malignant lymphoma, (2) the metastases to the intraparotid or periparotid lymph nodes. There
occurrence of a parotid mass in a patient with an immune disor- are approximately 17 to 20 lymph nodes in the substance of the
der (e.g., Sjögren syndrome, rheumatoid arthritis, or AIDS), (3) parotid and along its tail, and there may be a smaller number of
the presence of a parotid mass in a patient with a previous diag- lymph nodes within the deep lobe of the gland. These lymph
nosis of benign lymphoepithelial lesion, (4) the finding of multiple nodes may be directly affected by metastatic tumors originating
masses in one parotid gland or of masses in both parotid glands, from the anterior scalp or the temporal, periocular, or malar
and (5) the association of a parotid mass with multiple enlarged regions. Especially with elderly patients, it is extremely crucial to
cervical lymph nodes unilaterally or bilaterally.6 obtain a detailed history of any previously excised skin lesions,
some of which may have been squamous cell carcinomas (SCCs)
Neoplastic Neoplastic masses may be present for years with- that metastasized to the periparotid nodes. Generally, such metas-
out causing any symptoms. Benign salivary tumors are more com- tasis involves multiple superficial lymph nodes and presents as dif-
mon in younger persons, whereas malignant parotid lesions are fuse enlargement of the parotid parenchyma. With the massive
more common in the fifth and sixth decades of life.7 The classic involvement of the parotid gland, facial nerve palsy is not uncom-
presentation of a benign parotid tumor is that of an asymptomatic mon in this setting.The majority of metastases to the parotid gland
parotid mass that has been present for months to years. Benign derive from cutaneous SCC or melanoma; however, metastatic
neoplasms of the parotid include pleomorphic adenoma, basal cell spread from the lung, the breast, and the kidney also is known to
adenoma, myoepithelioma,Warthin tumor, oncocytoma, and cystad- occur.13
enoma. The observation of rapid growth in a long-standing pleo- The location of the parotid mass is a very important diagnostic
morphic adenoma is suggestive of malignant transformation. In a factor. The classic presentation of a benign mixed tumor is as a
2005 study of 94 patients with pleomorphic adenoma, malignant marblelike lesion in the parotid gland—a firm, mobile mass that
transformation to carcinoma was documented in 8.5% of cases.8 commonly originates in the superficial portion of the gland and
Rapid tumor growth, metastasis to lymph nodes, deep fixation, generally is not fixed to the deeper structures or to the skin.
and facial nerve weakness are all strongly suggestive of malignant Parotid tumors that originate in the deep lobe may present as a
disease and are indicators of a poor prognosis.9 Although pain is vague, diffuse swelling behind the angle of the mandible; more
more often experienced by patients with benign conditions, it is also often, however, they present as a swelling of the parapharyngeal
reported by some patients with infiltrative malignant tumors. In area accompanied by medial displacement of the tonsil or the soft
the latter patients, pain is another indicator of a poor prognosis.10 palate.
The presence of facial nerve palsy should raise the index of sus- Although physical examination of a parotid mass is a simple
picion for malignancy. Occasionally, patients present with classic process in itself, it should be accompanied by a thorough evalua-
Bell palsy. This condition is usually of viral origin, and most pa- tion of the head and neck that includes a detailed examination of
tients recover over time. If Bell palsy persists, however, further in- the oral cavity and the oropharyngeal, nasopharyngeal, hypopha-
vestigation is required, including imaging studies to rule out any ryngeal, and laryngopharyngeal areas. Occasionally, a tumor of the
obvious parotid lesion. Facial palsy occurring in association with oropharynx presents as cervical lymphadenopathy or as metastat-
parotitis and anterior uveitis is known as Heerfordt syndrome and ic disease in the tail of the parotid. In such cases, it may be diffi-
is often seen in patients with sarcoidosis. cult to determine whether the patient has a primary salivary gland
tumor or a metastatic lesion. The presence of any suspicious
PHYSICAL EXAMINATION
pathologic condition in the oropharynx or the base of the tongue
The physical examination should focus on the extent of the dis- is an indication for appropriate endoscopy and biopsy of the sus-
ease in the parotid, the neck, and the parapharynx; the localized pected primary site.
effects of the tumor (including trismus); and the motor or senso- Physical findings suggestive of malignancy include a large and
ry deficits resulting from neural invasion. fixed mass, facial nerve weakness, lymph node metastasis, and
The mass is palpated to determine whether it is painless or skin involvement; patients with advanced parotid malignancies
painful; whether it is soft, firm, hard, or cystic; and whether it is may present with trismus. Whereas patients with benign parotid
mobile or fixed to deep tissue or skin.The skin of the scalp, the ear, tumors rarely exhibit facial nerve weakness, approximately 12%
and the face is examined for lesions. The neck is palpated for to 15% of patients with parotid malignancies have facial nerve
adenopathy. In the oral cavity, the ducts are examined for dis- dysfunction at presentation.14 The most common causes of facial
charge or saliva after the glands are milked.The pharyngeal wall is nerve weakness in this setting are adenoid cystic carcinoma,
examined for deviation, and the jaw is examined for trismus. poorly differentiated carcinoma, and SCC. Primary SCC of the
The parotid occupies a large area, starting from the zygoma and parotid is quite rare, and a diagnosis of SCC in the gland should
extending to the upper portion of the neck and behind the lead one to suspect that a tumor has metastasized to the parotid
mandible to what is commonly called the tail of the parotid. lymph nodes. Before the diagnosis of primary SCC of the paro-
Occasionally, the parotid tissue extends behind the earlobe, in tid is made, high-grade mucoepidermoid carcinoma and metasta-
which case it may be misdiagnosed preoperatively as a nonsalivary tic SCC must be excluded.
pathologic condition. Accessory parotid tissue is present along The presence of cervical lymph node metastasis may direct
Stenson’s duct in approximately 21% of persons.11 Patients some- one’s attention to the parotid mass, though only about 20% of per-
times present with a tumor (most commonly, a benign mixed sons with parotid malignancies actually have clinically apparent
tumor) of this accessory tissue.12 Attempts to excise such masses cervical lymph node metastases at the time of initial presenta-
locally must be avoided, because of the high risk of injury to tion.10 The parotid tumors most commonly associated with
branches of the facial nerve. metastatic disease to the lymph nodes at presentation are high-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 8 PAROTID MASS — 4
grade mucoepidermoid carcinoma, poorly differentiated carcino- uate the ductal arrangements in patients with chronic sialoadeni-
ma, and SCC. Lymph node metastases may also derive from high- tis. Currently, however, sialography is rarely used, both because
grade adenocarcinomas or malignant mixed tumors. there is a significant possibility of an infectious flare-up and
Some patients are totally asymptomatic, with the only signifi- because the study actually yields only minimal information. In the
cant physical finding being a mass visible through the open mouth, early 1980s, CT sialography became popular for a time; however,
which is suggestive of either a deep-lobe parotid tumor or a para- it was quite a complicated procedure, and clinicians eventually
pharyngeal tumor.The majority of parotid tumors develop within found that the information it yielded could easily be obtained from
the superficial lobe of the parotid—not surprisingly, given that spiral (helical) CT. Occasionally, surface-coil MRI may be helpful
between 80% and 90% of the parotid tissue is superficial to the for evaluating parotid masses deriving from subcutaneous process-
facial nerve. However, a significant minority of parotid masses— es. Sialoendoscopy has generated considerable interest, especially
about 10%—are found within the deep lobe. Most deep-lobe in Europe and Germany17; however, this sophisticated technology
parotid tumors are benign, in which case surgical treatment gen- has not yet entered everyday practice. Although sialoendoscopy
erally consists of a superficial parotidectomy with dissection and may be of some value in the assessment of salivary stone disease
preservation of the facial nerve, followed by removal of the tumor. or chronic sialectasis, it is rarely performed in the United States at
Occasionally, however, malignant deep-lobe parotid tumors do present, and its eventual role in the evaluation of parotid masses
occur. Such tumors frequently involve the facial nerve, and surgi- remains to be determined.
cal treatment may require sacrifice of the facial nerve in select cir- For a classic benign mixed tumor presenting in the form of a
cumstances. Most patients who have undergone surgical treat- small nodule in the superficial lobe of the parotid gland, imaging
ment of a malignant deep-lobe tumor will require postoperative is not required.
radiation therapy. Currently, the role of positron emission tomography (PET) in
the initial evaluation of a parotid mass remains undefined. This
modality may, however, be of some value in the evaluation of sus-
Investigative Studies pected recurrent parotid cancers, lymph node metastases, or dis-
The majority of parotid masses can tant metastases.
easily be evaluated with a careful history
FINE-NEEDLE ASPIRATION BIOPSY
and a thorough physical examination.
Nevertheless, it sometimes happens that Routine use of FNA biopsy in the evaluation of a parotid mass
even after these measures have been car- [see Table 1] continues to be controversial. One reason for the
ried out, there remains some clinical controversy is that cytologic evaluation is difficult. Another is
uncertainty regarding whether the patho- that the extent of surgical treatment can easily be defined by
logic process is of parotid or of nonsali- means of the clinical assessment. The main argument against
vary origin. A number of nonsalivary tumors (e.g., neurofibromas, routine use of FNA biopsy is based on the standard approach to
lipomas, lymphadenopathies, metastatic cutaneous lesions, and most parotid masses, which is a superficial parotidectomy that
lymphomas) are known to present in the parotid region on occa- includes identification and preservation of the facial nerve.
sion. These tumors may be difficult to evaluate clinically, and fur- Nevertheless, FNA biopsy can be quite helpful, especially for the
ther diagnostic studies may therefore be required. purposes of preoperative consultation with patients regarding
the suspected pathologic process and the extent of surgical ther-
IMAGING
apy. FNA biopsy has an overall accuracy that exceeds 90%,18,19
Generally, parotid masses are imaged with either computed and it is considered a good investigational tool as long as it is
tomography or magnetic resonance imaging.15 CT is superior to used in the appropriate clinical context.
MRI for evaluation of the bony structures, whereas MRI may be In the case of a classic benign mixed tumor, which presents as
more helpful in distinguishing between inflammatory conditions a mobile, confined, superficial nodule in the parotid gland, FNA
and salivary neoplasms. CT scanning is indicated in patients with biopsy is not required for further treatment. However, in cases
diffuse enlargement of the parotid gland, tumor extension beyond where the clinical picture is not definitive and one cannot deter-
the superficial lobe, facial nerve weakness, trismus, or deep-lobe mine whether the pathologic process is of parotid origin or not,
parotid tumors that are difficult to evaluate clinically. If the parotid FNA biopsy is extremely important. Besides distinguishing be-
mass appears to be fixed to the deeper structures, it is appropriate tween benign and malignant conditions, FNA biopsy can also
to proceed with CT to evaluate the extent and parapharyngeal distinguish between salivary and nonsalivary processes [see Table
extension of the disease. MRI is indicated in patients with facial
nerve paralysis. Occasionally, it may be necessary to perform both
CT and MRI. Both imaging methods are helpful and accurate in
distinguishing deep-lobe parotid tumors from other parapharyn- Table 1 Uses of FNA Biopsy in Evaluation
geal masses. They are also useful for evaluating suspicious lymph of Parotid Mass
nodes and the periphery of the mass (specifically with respect to
determining whether the lesion is encapsulated or has irregular To identify suspected malignancy
To diagnose metastatic carcinoma
borders).
To identify suspected lymphoma
Ultrasonography can be useful for determining the location of To distinguish between salivary and nonsalivary lesions
the lesion and for guiding fine-needle aspiration (FNA) biopsy. In To facilitate conservative management of Warthin tumor or pleomorphic
the past, technetium-99m scanning was commonly employed for adenoma in a poor-risk patient
the diagnosis of oncocytoma and Warthin tumor.16 To confirm preoperatively suspected malignancy in a patient with facial
Various other diagnostic studies are available for evaluation of palsy
To evaluate bilateral tumors
parotid masses. At one time, sialography was commonly employed
to assess patients with suspected salivary stones, as well as to eval-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 8 PAROTID MASS — 5
100
Percent
Regional lymph node metastases
Deep-lobe cancer 50
Gross residual tumor after resection
Recurrent tumor after resection
Invasion of facial nerve by tumor
25
Neck Dissection
Overall, about 20% of patients with malignant parotid tumors 0 5 10
present with clinically detectable cervical lymphadenopathy
(cN+).10 There is wide agreement that these patients require either Time (Years)
a comprehensive or a modified neck dissection [see 2:6 Neck
Dissection], depending on the extent of the disease, but there con- Stage I, II Stage I, II with RT
tinues to be controversy regarding the management of patients
with salivary malignancies who have no clinically detectable cervi- Stage III, IV Stage III, IV with RT
cal lymphadenopathy (cN0). In one study, approximately 14% of
the patients were in cN+ status; however, approximately 12% were Figure 1 Depicted is the impact of postoperative radiation therapy
in cN0 status but presented with pathologically positive nodes (RT) on overall outcome for patients with stage I or II tumors and
(pN+).28 In view of the low frequency of occult metastasis in the patients with stage III or IV tumors.
group as a whole, the investigators generally did not recommend
routine elective treatment of the neck. They did find that certain
RADIATION THERAPY
histologic grades were associated with a higher incidence of
metastatic disease to the neck nodes: the incidence of occult Patients who present with advanced-stage (stage III or IV) dis-
metastasis was about 49% in patients with high-grade lesions, ease, a large primary tumor, close margins, perineural spread, soft
compared with 7% in those with intermediate-grade or low-grade tissue extension, facial nerve dysfunction, or cervical lymph node
lesions. In addition, the incidence of having occult metastatic dis- metastasis invariably require postoperative radiation therapy [see
ease was more than 20% in patients with tumors larger than 4 cm, Table 7].31,32 In general, this means that postoperative radiation
compared with 4% in those with smaller tumors. therapy is indicated for all patients except those with T1 or T2
The incidence of lymph node metastasis is affected not only by malignant tumors of low-grade histology and clear margins.Thus,
the size and histologic grade of the tumor but also by the histologic the decision whether to employ such therapy depends largely on
type, the primary tumor stage, the presence of facial nerve palsy, the intraoperative findings and the final pathology report. A 1990
the patient’s age, the extraparotid extension of the disease, and the analysis showed that postoperative radiation therapy had a major
degree of perilymphatic invasion.29 In a multivariate analysis, the impact on overall outcome in patients with stage III or IV tumors
variables that showed the highest correlation with the incidence of but conferred no statistically significant benefit on patients with
lymph node metastasis were the histologic type (i.e., adenocarci- stage I or II tumors [see Figure 1].33
noma, undifferentiated carcinoma, high-grade mucoepidermoid Currently, there is substantial interest in the potential role of
carcinoma, SCC, or salivary duct carcinoma) and the T stage.30 neutron therapy as a primary treatment modality for parotid
Thus, elective neck dissection may be considered in patients malignancies, especially advanced inoperable parotid cancers and
with advanced-stage primary tumors, those whose tumors are of adenoid cystic carcinomas. A group from the University of
high histologic grades, and those whose tumors are of certain spe- Washington demonstrated that neutron therapy exerted a benefi-
cific histologic types. A selective neck dissection may be performed cial effect when used as the sole treatment of advanced parotid
to remove the lymph nodes of the submandibular triangle, level II, cancers.34 Although these results are extremely promising, the
level III, and the upper part of level V for the purposes of staging.29 patients treated with this modality clearly experienced an
However, a comprehensive neck dissection that encompasses lev- increased incidence of complications. Nevertheless, for patients
els I through V may be necessary in patients who present with clin- with inoperable parotid cancer, neutron therapy may be the best
ically obvious cervical metastases. option currently available.
Discussion
Implications of Histopathologic Classification of Parotid World Health Organization.36 The most common types of parotid
Gland Cancer tumor are mucoepidermoid carcinoma, adenoid cystic carcinoma,
Alhough considerable controversy and debate continue to sur- adenocarcinoma, malignant mixed tumor, acinic cell carcinoma,
round the histopathologic classification of malignant parotid and primary SCC [see Figure 2].
tumors, most clinicians currently prefer either the classification As noted (see above), primary SCC of the parotid gland is quite
system of the Armed Forces Institute of Pathology35 or that of the rare, and most diagnoses of parotid SCC represent skin cancer
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 8 PAROTID MASS — 8
References
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13. Batsakis JG, Bautina E: Metastases to major salivary noma: external validation using the nationwide Oncol Biol Phys 27:235, 1993
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Neck Surg 9:90, 2001 tion in parotid carcinoma. Bull NY Acad Med 36. Seifert G, Sobin LH: The World Health Organiza-
15. Rabinov JD: Imaging of salivary gland pathology. 62:862, 1986 tion’s histological classification of salivary gland
Radiol Clin North Am 38:1047, 2000 27. Heller KS, Attie JN, Dubner S: Accuracy of frozen tumors: a commentary on the second edition. Can-
16. Higashi T, Murahashi H, Ikuta H, et al: Identifica- section in the evaluation of salivary tumors. Am J cer 70:379, 1992
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technetate. Clin Nucl Med 12:796, 1987 28. Armstrong JG, Harrison LB, Thaler HT, et al: The carcinoma of salivary gland origin. Head Neck Surg
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aspiration biopsy cytology of major salivary glands. gland. ORL J Otorhinolaryngol Relat Spec 63:123, cinoma of the major and minor salivary glands. Int
Acta Cytol 29:503, 1985 2001 J Oral Maxillofac Surg 17:190, 1988
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127:56, 2001 41. Spiro RH: Distant metastasis in adenoid cystic car-
20. Shaha AR, Webber C, DiMaio T, et al: Needle aspi- cinoma of salivary origin. Am J Surg 174:495, 1997
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multicenter study. J Oral Maxillofac Surg 59:263,
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guided biopsy in the evaluation of focal lesions and 43. Pillsbury HC, Fisch U: Extratemporal facial nerve
diffuse swelling of the parotid gland. Br J Oral 32. Harrison LB, Armstrong JG, Spiro RH, et al:
Postoperative radiation therapy for major salivary grafting and radiotherapy. Arch Otolaryngol 105:
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22. Gross M, Ben-Yaacov A, Rund D, et al: Role of 44. McGuirt WF, McCabe BF: Effect of radiation ther-
open incisional biopsy in parotid tumors. Acta Oto- 33. Armstrong JG, Harrison LB, Spiro RH, et al:
Malignant tumors of major salivary gland origin: a apy on facial nerve cable autografts. Laryngoscope
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matched-pair analysis of the role of combined sur-
23. AJCC Cancer Staging Manual, 6th edition. gery and postoperative radiotherapy. Arch Otolaryn- 45. Conley J, Baker DC: Hypoglossal-facial nerve anas-
Springer-Verlag, New York, 2002 gol Head Neck Surg 116:290, 1990 tomosis for reinnervation of the paralyzed face. Plast
24. Vander Poorten VL, Balm AJ, Hilgers FJ, et al: The 34. Laramore GE, Krall JM, Griffin TW, et al: Neutron Reconstr Surg 63:63, 1979
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parotid carcinoma. Cancer 85:2057, 1999 gland tumors: final report of an RTOG-MRC ran- lyzed eyelid with the enhanced palpebral spring or
25. Vander Poorten VL, Hart AA, van der Laan BF, et domized clinical trial. Radiation Therapy Oncology the gold weight: modern replacements for tarsor-
al: Prognostic index for patients with parotid carci- Group. Medical Research Council. Int J Radiat rhaphy. Facial Plast Surg 16:325, 2000
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 1 BREAST COMPLAINTS — 1
1 BREAST COMPLAINTS
D. Scott Lind, M.D., F.A.C.S., Barbara L. Smith, M.D., Ph.D., F.A.C.S., and Wiley W. Souba, M.D., Sc.D., F.A.C.S.
Given that approximately one of every two women will consult a benign or malignant.To this end, knowledge of the main risk fac-
health care provider for a breast-related complaint during her life- tors for breast cancer is essential: prompt identification of the
time,1 all clinicians should have a fundamental understanding of patients at highest risk for malignancy allows the physician to take
the evaluation and management of breast disorders. Although an appropriately vigorous approach from the beginning of the
most breast complaints do not result in a diagnosis of cancer, the diagnostic workup.
heightened public awareness of breast cancer—currently, the Various factors that place women at increased risk for breast
most common malignancy affecting women in the United carcinoma have been identified [see Table 2].4 These risk factors
States2—can induce significant anxiety and a sense of urgency in include increasing age; mutations in breast cancer risk genes
women who present with symptoms suggestive of a breast disor- (including BRCA1 and BRCA2, PTEN, and p53) and other fac-
der. Accordingly, any woman presenting with a breast complaint tors related to a family history of breast cancer5; hormonal and
should receive a comprehensive evaluation. reproductive factors, including early menarche, late menopause,
Unfortunately, it is becoming more and more difficult for prac- nulliparity, the absence of lactation,6 and the use of exogenous
titioners to stay current with the increasingly complex manage- hormones4,7-12; environmental factors, including diet and the
ment of breast disease. Breast problems still are often written lifestyle characteristic of developed Western nations13-15; certain
about in a manner that is more disease-focused than patient man- pathologic findings within breast tissue, including previous breast
agement–focused—an approach that we believe is of limited clin- cancer and various premalignant lesions16-18; and certain non-
ical utility. In this chapter, we outline the evaluation and manage- breast malignancies, including ovarian and endometrial carcino-
ment of the most common clinical presentations of breast disease, mas. There are also a number of molecular markers that can be
and we discuss specific breast disease problems in a manner clin- correlated with prognosis, including estrogen receptor (ER) status
ically relevant to the practicing surgeon. and HER-2/neu gene amplification.19
Most breast problems Recognition of risk factors facilitates appropriate screening and
encountered by practicing clinical management of individual patients. It must be recognized,
surgeons fall into six gener- however, that in many women in whom breast cancer develops,
al categories, which are as- known risk factors for breast carcinoma are entirely absent. The
sociated with varying de- absence of these risk factors should not prevent full evaluation or
grees of risk for breast can- biopsy of a suspicious breast lesion.
cer [see Table 1]. With some
BREAST CANCER SCREENING
presentations, such as a
dominant mass in a post- In the absence of a specific breast complaint, patients at risk for
menopausal woman, the breast cancer may be identified through screening. The three
index of suspicion for malignancy is high and the workup should main methods of breast cancer screening are breast self-examina-
be prompt and relatively straightforward. With other breast pres- tion (BSE), clinical breast examination (CBE), and screening
entations, such as a tender breast thickening in a premenopausal
woman, benign disease is much more likely. It is important to rec-
ognize, however, that any of these presentations can be associated Table 1 Common Presenting Symptoms of
with a malignancy, and thus, all of them warrant a complete eval- Breast Disease
uation. In fact, it is the evaluation of the usually benign symptoms
that places the greatest demands on the physician’s clinical judg- Symptom Likelihood of Risk of Missed
ment.When such symptoms are the main presenting complaint of Malignancy Malignancy
a breast cancer, their seemingly benign nature may be mislead-
Palpable mass Highest Lowest
ingly reassuring and delay the diagnosis of malignancy. Missed or
Abnormal mammogram ↑
delayed diagnosis of breast cancer is currently a major cause of with normal breast
malpractice claims and plaintiff awards.3 examination
Vague thickening or
nodularity
Risk Factors for Breast Cancer Nipple discharge
Breast pain ↓
The fundamental task facing a physician seeing a patient with
Breast infection Lowest Highest
a breast complaint is to determine whether the abnormality is
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 1 BREAST COMPLAINTS — 2
Work up patient:
• History, with particular attention to risk factors for breast cancer
• Physical examination
• Imaging studies (e.g., mammography)
Initiate evaluation of specific breast problem.
High-risk patients
without symptons
tives, with age at diagnosis recorded if available. Similarly, any fam- Investigative Studies
ily history of ovarian or other cancers (particularly those that devel-
IMAGING
oped when the relative was young) should be recorded, along with
age at diagnosis. Any personal history of cancer should be record-
ed, with particular attention paid to breast, ovarian, and endome- Mammography
trial cancers. Previous exposure to radiation, especially in the area Diagnostic mammography is the first imaging study em-
of the chest wall, should be noted. Admittedly, it is not always pos- ployed to evaluate breast abnormalities. Diagnostic, as opposed to
sible to obtain complete and precise family history data, whether screening, mammography is performed when a breast abnormal-
because of time constraints or because of family issues such as pre- ity is already present; it is a more comprehensive examination and
mature deaths, small family size, and distant or broken families. consists of multiple specialized images (e.g., magnification views
It is difficult for practicing surgeons to stay current with the or spot compression views). Diagnostic mammography includes a
explosive growth of knowledge related to the genetics of breast mammogram of the contralateral breast to rule out synchronous,
cancer. Researchers have identified two genes—BRCA1 and nonpalpable lesions whenever a woman older than 35 years pre-
BRCA2—that are associated with an inherited predisposition to sents with a palpable breast mass or other specific symptoms.
breast and ovarian cancers. Specific founder mutations in BRCA1 Approximately 4% to 5% of breast cancers occur in women
and BRCA2 are found within certain ethnic groups (e.g., younger than 40 years, and about 25% occur in women younger
Ashkenazi Jews).26 Tests are commercially available that detect than 50 years.
mutations in these genes. Whether to pursue genetic testing and Mammography fails to detect 10% to 15% of all palpable
how to interpret the results are complex issues. Accordingly, clin- malignant lesions, and its sensitivity is particularly decreased in
icians should consider consulting a professional genetics coun- women with lobular carcinoma or radiographically dense breast
selor if the option is available. tissue. Therefore, a negative mammogram should not influence
Finally, as with any surgical patient, an overview of the general the decision to perform a biopsy of a clinically palpable lesion.The
medical history should be obtained that includes current medica- purpose of mammography is to look for synchronous lesions or
tions, allergies, tobacco and alcohol use, previous surgical proce- nonpalpable calcifications surrounding the palpable abnormality,
dures, medical problems, and a brief social history. not to determine whether to perform a biopsy of the palpable
lesion.
PHYSICAL EXAMINATION
conserving surgery. In addition, it appears that MRI can distin- with indistinct walls or intracystic solid components are more like-
guish between a locally recurrent tumor and surgical scarring or ly to be associated with carcinoma, and therefore, either image-
radiation-induced change after lumpectomy and radiation, guided or excisional biopsy is warranted.
though the technology may not provide reliable readings until 18
months or more after surgery or the completion of radiation ther- Solid Masses
apy. The utility of MRI for screening of young high-risk women If a discrete mass in the breast is believed to be solid, either on
with mammographically dense breast tissue is being explored.28 the basis of ultrasonographic findings or because attempts at aspi-
Nuclear medicine studies, such as sestamibi scintimammogra- ration yield no fluid, a tissue diagnosis is necessary to rule out
phy and positron emission tomography (PET), remain primarily malignancy. Physical examination alone is insufficient: it correct-
investigational tools. At present, there is no proven role for ther- ly identifies masses as malignant in only 60% to 85% of cases.29
mography or xerography in the evaluation of breast problems. Furthermore, experienced examiners often disagree on whether
biopsy is needed for a particular lesion: in one study, four sur-
BIOPSY
geons unanimously agreed on the necessity of biopsy for only 11
In the past, the preferred biopsy method for nonpalpable mam- (73%) of 15 palpable masses that were later shown by biopsy to
mographically detected lesions was needle-localized surgical biop- be malignant.Tissue diagnosis may be accomplished by means of
sy.This procedure is initially performed in the breast imaging suite, FNA biopsy, core-needle biopsy, or open surgical biopsy [see 3:5
where a wire is placed in the breast adjacent to the imaged abnor- Breast Procedures].
mality.The patient is then transferred to the OR, where the surgeon
uses the wire as a guide to removal of the abnormality. A mammo- Phyllodes tumor The phyllodes tumor is a rare fibro-
gram of the excised lesion is performed to confirm its removal. epithelial breast lesion that clinically mimics a fibroadenoma.
Wire-guided diagnostic surgical procedures have now been largely Most phyllodes tumors present as palpable, solitary, well-defined,
supplanted by stereotactic and ultrasound-guided percutaneous mobile, and painless breast masses.With the widespread availabil-
core biopsy techniques, which are less invasive, less expensive, and ity of screening mammography, an increasing number of these
more expedient.With any of these approaches, however, it is impor- tumors are being discovered mammographically. Large phyllodes
tant to verify that the interpretation of the imaging abnormality is tumors may be associated with visible venous dilation in the skin
in concordance with the pathologic analysis of the specimen. overlying the tumor. Palpable axillary lymph nodes are encoun-
Follow-up should be based on the pathologic findings and on the tered in 20% of patients with phyllodes tumors, but histologic evi-
appearance of the abnormality on breast imaging. dence of malignancy is encountered in fewer than 5% of axillary
lymph node dissections for clinically positive nodes. The non–
tumor-containing palpable nodes are enlarged as a result of ne-
Management of Specific crosis of the primary tumor.
Breast Problems Tumors are classified histologically as low, intermediate, or
high grade on the basis of five criteria: stromal cellularity, stromal
PALPABLE MASS
atypia, the microscopic appearance of the tumor margin (infiltrat-
The workup and man- ing, effacing, or bulging), mitoses per 10 high-power fields, and
agement of a discrete breast the macroscopic size of the tumor. Structural31 and cytogenetic32
mass are governed by the studies of constituent cells have demonstrated similarities
age of the patient, the phys- between fibroadenomas and phyllodes tumors, and there is evi-
ical characteristics of the pal- dence that certain fibroadenomas develop into phyllodes tumors.
pable lesion, and the patient’s medical history. The likelihood of FNA is usually nondiagnostic, primarily because of the difficulty
malignancy is greater when the patient is 40 years of age or older, of obtaining adequate numbers of stromal cells for cytogenic
when the mass has irregular borders, or when skin dimpling or analysis. Although most phyllodes tumors have minimal metasta-
enlarged axillary nodes are present. A prebiopsy mammogram is tic potential, they have a proclivity for local recurrence and should
indicated for women older than 35 years and for those younger be excised with at least a 1 cm margin. Local recurrence has been
than 35 years who have a strong family history of premenopausal correlated with excision margins but not with tumor grade or
breast cancer. size.33 The most common site of metastasis from malignant phyl-
lodes tumors is the lungs (via the hematogenous route).
Cystic Masses The diagnosis of phyllodes tumor should be considered in all
Cysts are a common cause of dominant breast lumps, particu- patients with a history of a firm, rounded, well-circumscribed,
larly in premenopausal women. Ultrasonography is useful in dif- solid (i.e., noncystic) lesion in the breast. Simple excisional biop-
ferentiating cystic from solid lesions. Sonographically, simple cysts sy should be performed if aspiration fails to return cyst fluid or if
tend to be oval or lobulated and anechoic, with well-defined bor- ultrasonography demonstrates a solid lesion. Because phyllodes
ders. For asymptomatic simple cysts, no further intervention is tumors mimic fibroadenomas, they are often enucleated or
required. For symptomatic cysts, fine-needle aspiration (FNA) is excised with a close margin. If an adequate margin is not obtained
appropriate. If the aspirate is not bloody, the fluid should not be after examination of the permanent section, the patient should
sent for cytologic analysis, because it is unlikely to yield a diagno- undergo reexcision to obtain wider margins and avoid a 15% to
sis of cancer. If the aspirate is bloody, it should be sent for cyto- 20% recurrence rate. If a simple excision cannot be accomplished
logic examination. Women should be followed for 4 to 6 weeks without gross cosmetic deformity or if the tumor burden is too
after FNA to determine whether the cyst has recurred. If a simple large, a simple mastectomy should be performed. Radiation ther-
cyst recurs after aspiration, it should be excised. Fewer than 20% apy may have a role in the management of patients with chest wall
of simple cysts recur after a single aspiration, and fewer than 9% invasion. Chemotherapy, which is reserved for patients with
recur after two or three aspirations.29 Additional cysts subse- metastatic disease, is based on guidelines for the treatment of sar-
quently develop in more than 50% of patients.30 Complex cysts comas, rather than breast adenocarcinomas.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 1 BREAST COMPLAINTS — 7
ABNORMAL SCREENING
MAMMOGRAM
Table 3 American College of Radiology Breast
Imaging Reporting and Data System (BIRADS)
The increased use of
screening mammography
Category Assessment Description/Recommendation
has led to a dramatic rise in
the number of nonpalpable Additional imaging evaluation
0 Additional imaging recommended
breast lesions that call for required
tissue acquisition. General- Nothing to comment on; routine
ly, 5% to 10% of all screen- 1 Negative finding
screening recommended
ing mammograms are abnormal, and 10% of women with abnor-
Negative mammogram, but
mal mammograms have breast cancer.34 Currently, an abnormal interpreter may wish to describe
2 Benign finding
screening mammogram is the most common initial presentation a finding; routine screening
for women with breast cancer. In the Breast Imaging Reporting recommended
and Data System (BIRADS), developed by the American College Very high probability of benignity;
of Radiology, six different assessments (numbered 0 through 5) 3 Probably benign finding short-interval follow-up suggest-
are used in the interpretation of a screening mammogram [see ed to establish stability
Table 3].35 Women with either a negative or a benign assessment Probability of malignancy; biopsy
4 Suspicious abnormality should be considered
(category 1 or 2) should undergo routine screening mammogra-
phy in 1 to 2 years. Women with a possibly benign assessment 5 Abnormality highly sugges- High probability of cancer; appro-
(category 3) should undergo a repeat study in 6 months, at which tive of malignancy priate action should be taken
time the mammographic abnormality is assessed for stability.
In general, whenever the radiologist states that a lesion identi-
fied on mammography is suspicious, a tissue diagnosis should be NIPPLE DISCHARGE
obtained by means of either open needle-localized biopsy or Nipple discharge is a
mammographically guided stereotactic core-needle biopsy [see common breast complaint,
3:5 Breast Procedures]. Findings especially suggestive of malignan- occurring in approximately
cy include the presence of a localized soft tissue mass within the 20% to 25% of women.37 It
breast that either is new or has changed in size or appearance, may be classified as physio-
architectural distortion with irregular borders producing a stel- logic discharge, pathologic
late-appearing lesion, and clustered microcalcifications, with or discharge, or galactorrhea.
without a new or changed mass or architectural distortion. Although the actual inci-
dence of malignancy in women with nipple discharge is low, this
VAGUE THICKENING OR
complaint produces significant anxiety among women because of
NODULARITY
the fear that it may be a harbinger of breast cancer. Galactorrhea
Normal breast texture is can be a complex diagnostic challenge for the clinician; a thorough
often heterogeneous, particu- history, a focused physical examination, and appropriately chosen
larly in premenopausal wo- investigative studies are required for diagnosis.
men. Consequently, vague Nipple discharge should be evaluated with respect to its dura-
thickenings or tender or non- tion, character (i.e., bloody, nonbloody, or milky), location (i.e.,
tender areas of nodularity are unilateral or bilateral), and precipitating factors (i.e., whether it is
frequently detected by the spontaneous or expressed). Because endocrine disorders (e.g.,
patient or the clinician. It is important to distinguish this vague breast hypothyroidism and hyperprolactinemia) can produce galactor-
thickening or nodularity from a discrete or dominant breast mass. A rhea, symptoms indicative of these conditions (e.g., lethargy, con-
dominant breast mass is defined as a discrete lump that is distinctly dif- stipation, cold intolerance, and dry skin) should be looked for.
ferent from the surrounding breast tissue. Overall, approximately 10% The patient should also be questioned about symptoms of an
of dominant breast masses are malignant.The incidence of cancer in intracranial mass, such as headache, visual field disturbances, and
a dominant breast mass increases with age: in women 55 years of age amenorrhea.
or older, more than 30% of masses are malignant.36 Numerous medications are associated with galactorrhea, includ-
In clinical practice, the first step in evaluating a nodular area is ing various antidepressants (e.g., fluoxetine, buspirone, alprazo-
to compare it with the corresponding area of the opposite breast. lam, and chlorpromazine). Other classes of drugs associated with
Symmetrical tender nodularity—for example, in the upper outer nipple discharge include antihypertensives, H2-receptor antago-
quadrant of both breasts—is rarely pathologic. These areas often nists, and antidopaminergic medications (e.g., metoclopramide).
represent fibrocystic changes that may resolve with time and thus A focused physical examination is the next step in the evalua-
should be followed clinically. Asymmetrical areas of vague thicken- tion of nipple discharge; obviously, a detailed breast examination
ing in premenopausal women should be reexamined after one or is essential. If nipple discharge is not immediately apparent, the
two menstrual cycles. If the asymmetrical thickening persists, the clinician should attempt to elicit the discharge by gently squeez-
possibility of malignancy is increased, and biopsy should be per- ing the nipple. The clinician should then attempt to determine
formed.Women 35 years of age or older who have not had a mam- whether the discharge is limited to a single duct or involves mul-
mogram in the past 6 months should undergo mammography to tiple ducts. Attention should also be paid to any physical findings
rule out synchronous lesions. The accuracy of a negative FNA suggestive of endocrine imbalance, such as thyromegaly (hypothy-
biopsy in the presence of a vague thickening (as opposed to a dis- roidism) or visual field deficits (prolactinoma).
crete mass) is questionable; therefore, open biopsy is generally Nipple discharge is physiologic during pregnancy, developing
required for adequate sampling. as early as the second trimester and sometimes continuing for as
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 1 BREAST COMPLAINTS — 8
BREAST PAIN
long as 2 years post partum. Therefore, evaluation of nipple dis-
charge in women of childbearing years should include a pregnan- Breast pain, or mastal-
cy test. Elevated thyroid stimulating hormone (TSH) levels asso- gia, is one of the most com-
ciated with hypothyroidism can increase prolactin secretion and mon symptoms for which
produce galactorrhea. Accordingly, women with nipple discharge women seek medical atten-
should undergo thyroid function testing. When the level of suspi- tion. At present, the causes
cion for a prolactinoma is sufficiently high, the serum prolactin of breast pain are poorly
level should be checked. If the serum prolactin level is elevated, understood. Although pain
MRI of the head (i.e., of the sella turcica) is indicated to deter- is not usually a presenting
mine whether a prolactin-secreting pituitary tumor is present. symptom for breast cancer, it still warrants a comprehensive eval-
Mammography is the first imaging study performed to evalu- uation. The elements of the history that are important in the eval-
ate nipple discharge. It may reveal nonpalpable masses or micro- uation of breast pain are the location, character, severity, and tim-
calcifications that necessitate biopsy. Because most pathologic ing of the pain. Breast pain occurring in a predictable pattern just
causes of nipple discharge are located close to the nipple, magni- before the menstrual cycle is called cyclical mastalgia and is prob-
fication views of the retroareolar region may help identify the ably hormonally mediated. Notably, however, several studies have
underlying condition.The absence of any mammographic abnor- shown no differences in circulating estrogen levels between women
malities, however, should not lead to a false sense of security; fur- with mastalgia and pain-free control subjects. It has been postulat-
ther evaluation is still required. ed that in women with breast pain, progesterone levels may be
The role of exfoliative cytology in the management of nonlac- decreased or prolactin release may be increased in response to thy-
tational galactorrhea is unclear. Although cytology can be diag- rotropin-releasing factor hormone.39 Although histologic findings
nostic of cancer, its utility is limited by its low sensitivity.The high consistent with cysts, apocrine metaplasia, and ductal hyperplasia
false negative rate mandates further evaluation when the findings have been noted in the breasts of women with mastalgia, there is
from cytology are negative or nondiagnostic. Discharge that is no convincing evidence that any of these pathologic changes actu-
bloody, unilateral, and spontaneous is more likely to yield a diag- ally cause breast pain.
nosis of cancer. Mammography and physical examination usually yield normal
Ductography, or galactography, consists of mammography per- results in patients with breast pain. The likelihood of malignancy
formed after the offending lactiferous duct has been cannulated is increased when a patient with mastalgia is postmenopausal and
and filled with a contrast agent. It can be performed only when not taking estrogens or when the pain is associated with skin
active discharge is present and when the secreting duct can be changes or palpable abnormalities; however, these situations are
identified and accessed. Not infrequently, ductography is techni- uncommon.
cally impossible, or else the images are uninterpretable as a con- For most women with breast pain, treatment consists of reliev-
sequence of incomplete ductal filling or contrast extravasation. ing symptoms and reassuring the patient that the workup has not
Solitary papillomas, the most common cause of abnormal nipple identified an underlying breast carcinoma. Nonsteroidal anti-
discharge, typically appear as a ductal cutoff or filling defect on inflammatory drugs and supportive bras are helpful. Several
ductography. Unfortunately, a normal ductogram does not lifestyle interventions have been proposed as effective breast pain
exclude a pathologic condition, and as with a normal mammo- treatments. Dietary recommendations, such as avoidance of meth-
gram, further evaluation is still required. ylxanthines (found in coffee, tea, and sodas), are not evidence
Advances in endoscopic technology have made visualization based.40 However, oral ingestion of evening primrose oil has been
and biopsy of the mammary ducts possible.38 Flexible fiberoptic reported to produce significant or complete pain relief in about
ductoscopy [see 3:5 Breast Procedures] may permit direct identifi- 50% of women with cyclic mastalgia.41
cation and treatment of pathologic conditions affecting the ducts. For the rare patients who have severe pain that does not
At present, this technology is available only at a few centers, and respond to conservative measures, administration of hormones or
as with all new technologies, there is a learning curve associated drugs may be appropriate. Danazol has been successful against
with its use. Further experience with ductoscopy is required to breast pain and should be considered the first-line agent, though
determine its precise role in the evaluation and management of its androgenic effects may be troubling to many women.42
nipple discharge. Bromocriptine (a prolactin antagonist) and tamoxifen have also
After a thorough history, a focused physical examination, and been used to treat mastalgia.43 Pharmacotherapy for mastalgia is
appropriate diagnostic studies, pathologic nipple discharge that contraindicated in patients who are trying to become pregnant.
persists should be treated surgically. Operative therapy can resolve
BREAST INFECTION OR
the discharge and provide a diagnosis. Excision of a duct or ducts
INFLAMMATION
can usually be performed with the patient under local anesthesia
supplemented with intravenous sedation (so-called monitored Breast infections can be
anesthesia care [MAC]). The traditional surgical management of divided into two general
pathologic nipple discharge is a central duct excision, which effec- categories: (1) lactational
tively removes all of the central lactiferous ducts and sinuses, infections and (2) chronic
thereby preventing further discharge [see 3:5 Breast Procedures]. subareolar infections asso-
Single-duct excision, or microdochectomy, can be performed ciated with duct ectasia.
when the offending duct is clearly identified.The advantage of this Both cellulitis and abscess-
latter procedure is that it conserves breast tissue and causes only es may occur in lactating women, either during weaning or when
minimal deformity; the nipple-areola complex remains intact, so engorgement occurs. In the absence of an abscess, breast infec-
that the patient retains the ability to breast-feed. The main disad- tions are treated by (1) giving oral antibiotics that cover gram-pos-
vantage of single-duct excision is that the discharge may be more itive cocci, (2) applying warm packs to the breast, and (3) keep-
likely to recur than it would be after central duct excision. ing the breast emptied. Weaning is not necessary, because the
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 1 BREAST COMPLAINTS — 9
infant is not adversely affected by nursing from an infected For women with a previous diagnosis of breast cancer, surveil-
breast.44 A diagnosis of mastitis in a nonlactating woman must be lance protocols are described elsewhere [see Management of the
viewed with suspicion, and the possibility of inflammatory breast Patient with Breast Cancer, Follow-up after Treatment, below]. For
cancer must be excluded. Inflammatory breast cancer is a clini- women with lobular carcinoma in situ (LCIS) or a family history
copathologic variant of breast cancer that is clinically character- of breast carcinoma, surveillance should include twice-yearly phys-
ized by the rapid onset of an erythema, edema, and increased tem- ical examinations. Mammography should be performed annually
perature in the breast, with or without a palpable mass.The diag- after the diagnosis of LCIS or atypical hyperplasia. For women
nosis is made by means of a skin biopsy; the pathologic hallmark with a family history of breast cancer, mammography should be
is tumor cell invasion of the dermal lymphatics. performed annually, beginning at least 5 years before the earliest
Once a breast abscess forms, however, surgical drainage is nec- age at which cancer was diagnosed in a relative and in any case no
essary. Because of the network of fibrous septa within the breast, later than the age of 35 years.49 For women who carry BRCA1 or
breast abscesses in lactating women rarely form fluctuant masses. BRCA2 mutations and other women from families with an auto-
The clinical picture of breast erythema, tenderness, fever, and somal dominant pattern of breast cancer transmission, annual
leukocytosis establishes the diagnosis. General anesthesia is usual- mammographic screening should begin at least 10 years before the
ly required for optimal abscess drainage because of the tenderness earliest age at which the cancer was diagnosed in a relative and no
of the affected area and the amount of manipulation necessary to later than 25 years of age.49
break up the loculated abscess cavity. As with any abscess, a cul- Long-term results of prophylactic mastectomy in high-risk
ture should be performed and the cavity should be packed open. women indicate that breast cancer risk was reduced by at least
Nonlactational infections of the breast often present as chronic 90% in women at high or very high risk who underwent this pro-
relapsing infections of the subareolar ducts associated with cedure, compared with women who did not, with risk predicted
periductal mastitis or duct ectasia.These infections usually involve by the Gail model.50 Mathematical modeling suggests that pro-
multiple organisms, including skin anaerobes.45 Retraction or phylactic mastectomy could translate into improved survival for
inversion of the nipple, subareolar masses, recurrent periareolar women at very high risk if it confers a 90% reduction in risk.51
abscesses, or a chronic fistula to the periareolar skin may result, as There is, however, no clear consensus on the indications for risk
may palpable masses and mammographic changes that mimic reduction surgery; the benefits of prophylactic mastectomy must
carcinoma. In the acute phase of infection, treatment entails inci- be weighed against the irreversibility and psychosocial conse-
sion, drainage, and administration of antibiotics that cover skin quences of the procedure.
organisms, including anaerobes. In cases of repeated infection, the Chemoprevention may be defined as the use of nutrients or
entire subareolar duct complex should be excised after the acute pharmacologic agents to augment physiologic mechanisms that
infection has completely resolved, with antibiotic coverage pro- protect against the development of malignancy. Chemopreventive
vided during the perioperative period.Whether drain placement is strategies are designed either to block the initiation of the carcino-
necessary remains debatable. Even after wide excision of the sub- genic process or to prevent (or reverse) the progression of the pre-
areolar duct complex and intravenous antibiotic coverage, infec- malignant cell to an invasive cancer.52 Chemoprevention began
tions recur in some patients; excising the nipple and the areola can with the development of the antiestrogen tamoxifen. The efficacy
treat these.46 of tamoxifen in ER-positive breast cancer patients was recognized
early on, but its chemopreventive potential was not established
HIGH-RISK PATIENTS
until some time later.
Despite significant prog- The first—and still the most extensive—study to be published
ress in management, at on breast cancer chemoprevention was the National Surgical
least one third of women Adjuvant Breast and Bowel Project (NSABP) P-1 trial, in which
with breast cancer will ulti- women at increased risk for breast cancer were randomly assigned
mately die of their disease. to receive either tamoxifen, 20 mg/day, or placebo.53 Increased
This harsh reality has led to risk was determined on the basis of (1) age greater than 60 years,
efforts aimed at providing (2) a 5-year predicted incidence of breast cancer of at least 1.66%
primary prevention to high- (determined according to Gail’s criteria), or (3) a personal histo-
risk women. Genetic testing and the use of mathematical models ry of lobular carcinoma in situ. After a median follow-up of 55
have significantly improved our ability to define breast cancer risk. months, the overall risk of breast cancer was decreased by 49% in
The Gail model,47 which relies on data from the Breast Cancer the tamoxifen group, and the risk of noninvasive breast cancer was
Detection Demonstration Project, and the Claus model,48 which decreased by 50%. The reduction in breast cancer risk was limit-
relies on data from the Cancer and Steroid Hormone Project, are ed to ER-positive breast cancers. Several adverse side effects were
two of the tools that have been used to make this determination. noted in the tamoxifen group, the most worrisome of which were
At present, there are three treatment options for women at high a threefold increase in the incidence of endometrial cancer, a
risk for breast cancer: (1) close surveillance, (2) prophylactic mas- higher incidence of deep vein thrombosis and pulmonary
tectomy, and (3) chemoprevention with tamoxifen or other agents embolism, and a higher incidence of stroke. Although two subse-
in the setting of a clinical trial. Currently, no evidence-based con- quent trials, one from the United Kingdom54 and one from Italy,55
clusions can be made as to which of these management strategies did not confirm these findings, the Food and Drug Administra-
is superior. Research involving high-risk women includes few ran- tion (FDA) found the results of the NSABP P-1 trial to be com-
domized controlled trials, and many reports are based on uncon- pelling enough to warrant approval of tamoxifen as a chemopre-
trolled studies of selected populations with varying degrees of ventive agent in high-risk women.
breast cancer risk. Although most women at high risk choose the Concerns about the side effects of tamoxifen have generated
option of close surveillance, the growing body of data on chemo- interest in the use of selective estrogen receptor modulators
prevention and prophylactic mastectomy may increase selection (SERMs) as chemopreventive agents.56 It appears possible that
of the other two options. such so-called designer estrogens may have fewer side effects than
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 1 BREAST COMPLAINTS — 10
tamoxifen while reducing the rate of new breast cancers and low- Table 4 American Joint Committee on Cancer
ering the incidence of osteoporosis and cardiovascular disease. TNM Clinical Classification of Breast Cancer
One of the SERMs, raloxifene, has been approved by the FDA for
the treatment of postmenopausal osteoporosis and is known also TX Primary tumor cannot be assessed
to exert beneficial effects on lipid profiles. Unlike tamoxifen, ralox- T0 No evidence of primary tumor
ifene appears not to have stimulatory effects on the endometrium. Tis Carcinoma in situ; intraductal carcinoma, lobular
Moreover, the Multiple Outcomes of Raloxifene Evaluation carcinoma in situ, or Paget disease of nipple with
no associated tumor*
(MORE) trial found that fewer breast cancers were noted in
T1 Tumor ≤ 2.0 cm in greatest dimension
women treated with raloxifene than would have been expected
T1mic: microinvasion ≤ 0.1 cm in greatest dimension
without such treatment.57 T1a: tumor > 0.1 cm but ≤ 0.5 cm in greatest
On the basis of findings from osteoporosis trials, the NSABP dimension
incorporated raloxifene into an extensive multi-institutional che- T1b: tumor > 0.5 cm but ≤ 1.0 cm in greatest
moprevention trial that began enrolling patients in 1999. The dimension
T1c: tumor > 1.0 cm but ≤ 2.0 cm in greatest
Study of Tamoxifen and Raloxifene (STAR) trial is a random- dimension
Primary
ized, double-blind trial whose purpose is to compare the effec- tumor (T) T2 Tumor > 2.0 cm but ≤ 5.0 cm in greatest dimension
tiveness of raloxifene with that of tamoxifen in postmenopausal T3 Tumor > 5.0 cm in greatest dimension
women at increased risk for breast cancer. Entry criteria are sim- T4 Tumor of any size with direct extension to (a) chest
ilar to those for the NSABP P-1 study. A total of 22,000 post- wall† or (b) skin
menopausal high-risk women will be randomly assigned to T4a: extension to chest wall
T4b: edema (including peau d'orange) or ulcera-
receive either tamoxifen, 20 mg/day orally, or raloxifene, 60 tion of the skin of the breast or satellite skin
mg/day orally, for 5 years. nodules confined to the same breast
A number of newer agents may possess some capacity for T4c: both of the above (T4a and T4b)
breast cancer chemoprevention. Aromatase inhibitors, which have T4d: inflammatory carcinoma‡
been used as second-line therapies after tamoxifen in cases of
advanced breast cancer, may exert chemopreventive effects by NX Regional lymph nodes cannot be assessed
inhibiting parent estrogens and their catechol metabolites, there- (e.g., previously removed)
by preventing cancer initation.58 In addition, gonadotropin-releas- Regional N0 No regional lymph node metastasis
ing hormone agonists, monoterpenes, isoflavones, retinoids, rexi- lymph N1 Metastasis to movable ipsilateral axillary lymph node(s)
nodes (N) N2 Metastasis to ipsilateral axillary lymph node(s) fixed
noids, vitamin D derivatives, and inhibitors of tyrosine kinase to each other or to other structures
are all undergoing evaluation in clinical or preclinical studies N3 Metastasis to ipsilateral internal mammary lymph
with a view to assessing their potential chemopreventive activity. node(s)
Whether any of these compounds will play a clinically useful role
in preventing breast cancer remains to be seen. pNX Regional lymph nodes cannot be assessed (not
removed for pathologic study or previously removed)
pN0 No regional lymph node metastasis
Management of Breast pN1 Metastasis to movable ipsilateral axillary lymph node(s)
Cancer pN1a: only micrometastasis (none > 0.2 cm in
greatest dimension)
STAGING pN1b: metastasis to lymph node(s), any > 0.2 cm
in greatest dimension
In patients with newly Pathologic pN1bi: metastasis in 1 to 3 lymph nodes, any
diagnosed breast cancer, it classification > 0.2 cm and all < 2.0 cm in greatest
of lymph dimension
is important to determine nodes (pN)
pN1bii: metastasis to 4 or more lymph nodes,
the overall extent of disease any > 0.2 cm and all < 2.0 cm in greatest
before embarking on defin- dimension
itive therapy. This process, referred to as clinical staging, includes pN1biii: extension of tumor beyond the capsule
of a lymph node metastasis < 2.0 cm in
(1) physical examination to identify any areas of palpable disease greatest dimension
in the breasts or the axillary and supraclavicular nodes, along with pN1biv: metastasis to a lymph node ≥ 2.0 cm in
a detailed clinical history to identify symptoms that may suggest greatest dimension
metastatic disease; (2) imaging studies, including mammography, pN2 Metastasis to ipsilateral axillary lymph node(s) fixed
to each other or to other structures
chest x-ray, and sometimes bone scans or CT scans of the chest,
pN3 Metastasis to ipsilateral internal mammary lymph
the abdomen, or the head; and (3) laboratory studies, including a node(s)
complete blood count (CBC) and liver function tests.
The extent of preoperative staging should be guided by the size
MX Presence of distant metastasis cannot be assessed
and other characteristics of the primary tumor and by the Distant
M0 No distant metastasis
patient’s history and physical examination. The majority of pa- metastasis
(M) M1 Distant metastasis present (includes metastasis to
tients with breast cancer present with early stage I or II disease ipsilateral supraclavicular lymph nodes)
and a low probability of metastatic disease; therefore, extensive
testing adds cost without offering much benefit. For patients with * Paget disease associated with a tumor is classified according to the size of the tumor.
stage I or II disease, mammography and routine preoperative †The chest wall includes ribs, the intercostal muscles, and the serratus anterior, but not the
pectoral muscle.
blood work should be performed before definitive surgical thera- ‡Inflammatory carcinoma is a clinicopathologic entity characterized by diffuse brawny
py is initiated; further imaging studies should be reserved for induration of the skin of the breast with an erysipeloid edge, usually without an underlying
palpable mass. Radiologically, there may be a detectable mass and characteristic thickening
patients who have abnormal test results or clinical symptoms that of the skin over the breast. This clinical presentation is attributable to tumor embolization of
suggest metastatic disease (e.g., bone pain). For patients with dermal lymphatics with engorgement of superficial capillaries.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 1 BREAST COMPLAINTS — 11
higher-stage disease at presentation, the use of additional staging Table 5 American Joint Committee on
studies should be guided by the patient’s clinical situation. Cancer Staging System for Breast Cancer
Changes in American Joint Committee on Cancer Breast
Cancer Staging System Stage T N M
A number of evidence-based changes to the sixth edition of the Stage 0 Tis N0 M0
American Joint Committee on Cancer (AJCC) TNM staging sys-
tem for breast cancer were adopted for use in tumor registries in Stage I T1 N0 M0
January 2003 [see Tables 4 and 5].59 These changes reflected grow- T0 N1 M0
ing use of sentinel lymph node (SLN) biopsy and of immunohis- Stage IIA T1 N1 M0
tochemical and molecular technologies to detect nodal metas- T2 N0 M0
tases. They also included quantitative criteria for distinguishing
T2 N1 M0
micrometastases from isolated tumor cells and specific identifiers Stage IIB
T3 N0 M0
for recording the use of SLN biopsy, immunohistochemical stain-
ing, and molecular biologic techniques. In addition, the classifica- T0 N2 M0
tion of lymph node status was modified to include the number of Stage IIIA
T1 N2 M0
affected axillary lymph nodes, and changes were made to the clas- T2 N2 M0
sification of level III axillary lymph nodes and lymph nodes out- T3 N1, N2 M0
side of the axilla.These modifications of the staging system should Stage IIIB T4 N0, N1, N2 M0
bring standardization to the collection of important clinicopatho-
logic information. Stage IIIC Any T N3 M0
Mastectomy versus Limited Surgery chest wall (as in a woman with a local recurrence of a breast car-
Several randomized prospective studies have documented that cinoma that was treated with radiation therapy). Although there
segmental resection (lumpectomy), axillary dissection, and post- are some clinical data supporting the use of repeat local excision
operative irradiation of an intact breast result in disease-free and without further irradiation to treat local recurrence after radiation
overall survival rates equal to those of modified radical mastecto- therapy, most authorities favor mastectomy.65
my.60-63 Although most women with stage I and II breast can- When resection of the primary tumor to clean margins would
cers—indeed, most women with breast cancer—are candidates render the appearance of the remaining breast tissue cosmetically
for breast conservation therapy [see Table 6], some still require or unacceptable, mastectomy may be preferable. This is likely to be
desire mastectomy. When a patient is eligible for limited surgery, the case, for example, in patients with large primary tumors rela-
the decision between mastectomy and breast conservation with tive to their breast size: resection of the primary tumor would
radiation therapy is made on the basis of patient and physician remove a substantial portion of the breast tissue. Another exam-
preference, access or lack of access to radiation therapy, and the ple is patients with multiple primary tumors, who would have not
presence or absence of contraindications to breast conservation. only an increased risk of local recurrence but also poor cosmetic
results after multiple wide excisions. Patients with superficial cen-
Contraindications to breast conservation Patients for tral lesions, including Paget disease, are eligible for wide excision
whom mastectomy is still clearly the treatment of choice fall into (including the nipple and the areola) followed by radiation thera-
four broad categories: (1) those in whom radiation therapy is con- py, provided that clean margins are obtained. The survival and
traindicated, (2) those in whom lumpectomy would have an local recurrence rates in these patients are equivalent to those
unacceptable cosmetic result, (3) those for whom local recurrence in other groups of patients undergoing lumpectomy and radia-
is a concern, and (4) those high-risk patients in whom surgical tion.66-68 In many cases, the cosmetic results of this procedure are
prophylaxis is appropriate [see Management of Specific Breast preferable to those of immediate reconstruction, and there is
Problems, High-Risk Patients, above]. always the option to reconstruct the nipple and areola later.
Radiation therapy may be contraindicated for any of several Patients who are at high risk for local recurrence often choose
reasons. Some patients choose not to undergo radiation therapy, mastectomy as primary therapy. Features of primary tumors that
either because it is inconvenient or because they are concerned are associated with higher local recurrence rates after limited
about potential complications (including the induction of second
malignancies). Some patients simply do not have access to radia-
tion therapy, either because they live in a rural area or because
they have physical conditions that make daily trips for therapy Table 6 Determinants of Patient Eligibility for
onerous. Time and travel issues related to weeks-long courses of Lumpectomy and Radiation Therapy
conventional radiotherapy have led to studies investigating partial-
Primary tumor ≤ 5 cm (may be larger in selected cases)
breast or limited-field irradiation after breast-conserving sur-
Tumor of lobular or ductal histology
gery.64 Data from randomized prospective trials are required Any location of primary within breast if lumpectomy to clean margins
before this technique can be recommended in women with early- (including central lesions) will yield acceptable cosmetic results
stage breast cancer. Other patients have medical or psychiatric Clinically suspicious but mobile axillary nodes
disorders that would make it extremely difficult for them to com- Tumor either positive or negative for estrogen and progesterone
ply with the daily treatment schedule. Still others have specific receptors
medical contraindications to radiation therapy, including preg- Any patient age
nancy, collagen vascular disease, or previous irradiation of the
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 1 BREAST COMPLAINTS — 12
surgery and radiation include gross residual disease after lumpec- because radiation can produce capsular contracture in patients
tomy, multiple primary tumors within the breast, an extensive undergoing prosthetic reconstruction.
intraductal component, large tumor size, lymphatic vessel inva- Prosthetic reconstruction involves the use of an implant to
sion, and lobular histologic findings.69 restore the breast contour. It is technically the simplest type of
In practice, obtaining tumor-free margins is probably the most reconstruction but can still result in complications such as con-
critical factor in decreasing the risk of local recurrence. The diffi- tracture, infection, and rupture, which may necessitate further
culty of obtaining microscopically clean margins in tumors with surgery. Autologous reconstruction involves the transfer of the
an extensive intraductal component and in lobular carcinomas patient’s own tissue to reconstruct the breast.Tissue from various
may account for the higher local recurrence rates sometimes seen sites (e.g., the transverse rectus abdominis and the latissimus
with these tumors. Histologic analysis of mastectomy specimens dorsi) has been used for breast reconstruction. Skin-sparing mas-
from patients with tumors with an extensive intraductal compo- tectomy with immediate reconstruction consists of resection of the
nent has shown a high rate of multifocality within ipsilateral breast nipple-areola complex, any existing biopsy scar, and the breast
tissue; this residual disease is thought to be the nidus for local parenchyma, followed by immediate reconstruction.The generous
recurrence.70 skin envelope that remains optimizes the cosmetic result after
The long-term benefits of choosing mastectomy to reduce local breast reconstruction. The procedure is oncologically safe and
recurrences are not clear. Whereas the appearance of distant does not lead to an increase in the incidence of local recurrence.73
metastases typically heralds incurable and ultimately fatal disease,
local recurrence after breast conservation appears to have little, if Radiation Therapy
any, impact on overall survival. Prospective, randomized trials Current radiation therapy regimens consist of the delivery of
have had difficulty showing a statistically significant reduction in approximately 5,000 cGy to the whole breast at a dosage of
survival in women who have had a local recurrence after limited approximately 200 cGy/day, along with, in most cases, the deliv-
surgery and radiation. It has been suggested that additional fol- ery of an additional 1,000 to 1,500 cGy to the tumor bed, again
low-up may eventually confirm reduced survival in some patients at a dosage of 200 cGy/day. Axillary node fields are not irradiated
with local recurrences. Still, most of the evidence suggests that unless there is evidence that the patient is at high risk for axillary
local recurrences are not the source of subsequent distant metas- relapse—namely, multiple (generally more than four) positive
tases. It is worthwhile to keep in mind, however, that even if mas- lymph nodes, extranodal extension of tumor, or bulky axillary dis-
tectomy to prevent local recurrence does not actually improve sur- ease (i.e., palpable nodes several centimeters in diameter). Be-
vival, it may nevertheless provide significant benefit by reducing cause the combination of surgical therapy and radiation therapy
patient anxiety, the amount of follow-up testing required, and the increases the risk of lymphedema of the arm, it is appropriate only
need for subsequent treatment. when there is sufficient risk of axillary relapse to justify the
increased complication rate. As a rule, supraclavicular node fields
Options for axillary staging The histologic status of the are irradiated only in patients with multiple positive axillary
axillary nodes is the single most important predictor of outcome nodes, who are at increased risk for supraclavicular disease. The
in breast cancer. Traditionally, axillary dissection has been a rou- role of prophylactic irradiation of the internal mammary nodes
tine part of the management of breast cancer. It has been used to remains controversial.
guide subsequent adjuvant therapy and provide local control, and Postmastectomy radiation therapy involves the delivery of radi-
it may have contributed a small overall benefit in terms of sur- ation to the chest wall after mastectomy; it is mainly reserved for
vival.71 Unfortunately, axillary dissection can be associated with patients with T3 or T4 primary tumors or multiple positive lymph
sensory morbidities and lymphedema. nodes. Such therapy is recommended particularly when there are
SLN biopsy is a minimally invasive, less morbid, and quite multiple positive axillary lymph nodes: significant axillary disease
accurate method of detecting or ruling out occult lymph node predicts higher rates of chest wall recurrence after mastectomy.
metastasis [see 3:6 Lymphatic Mapping and Sentinel Lymph Node Two series74,75 have suggested that postmastectomy radiation ther-
Biopsy]. It is based on the principle that the SLN is the first node apy significantly improves survival in premenopausal women with
to which the tumor spreads; thus, if the SLN is tumor free, the any positive axillary nodes.
patient can be spared the morbidity of an axillary dissection. Irradiation of the breast or chest wall is generally well tolerated:
There is a learning curve associated with this technique, however, most women experience only minor side effects, such as transient
and discussion continues as to the most appropriate way of inte- skin erythema, mild skin desquamation, and mild fatigue. Because
grating it into general practice.72 SLN biopsy identifies an a small amount of lung volume is included in the irradiated fields,
increased number of patients with micrometastases, with some there is usually a clinically insignificant but measurable reduction
identified by immunohistochemical staining alone. Treatment of in pulmonary function. In addition, because the heart receives
patients who have only micrometastases to axillary nodes remains some radiation when the left breast or left chest wall is treated,
a topic of debate, addressed in an ongoing clinical trial of SLN there may be a slightly increased risk of future myocardial infarc-
biopsy by the American College of Surgeons Oncology Group. tion.There is also a 1% to 2% chance that the radiation will induce
a second malignancy (sarcoma, leukemia, or a second breast carci-
Breast reconstruction after mastectomy Advances in noma). These radiation-induced malignancies appear after a long
reconstructive techniques have made breast reconstruction lag time, generally 7 to 15 years or longer.
increasingly popular [see 3:5 Breast Procedures]. Reconstruction may
be done either at the time of the mastectomy (immediate recon- Systemic Drug and Hormone Therapy
struction) or later (delayed reconstruction). In the past, recon- Despite the success of surgical treatment and radiation therapy
struction was generally delayed for 1 to 2 years after mastectomy; in achieving local control of breast cancer, distant metastases still
now, it is most often performed immediately after mastectomy. In develop in many patients. Various drugs and hormones have
general, immediate reconstruction should be reserved for patients therefore been used to treat both measurable and occult metasta-
who are not likely to require postoperative adjuvant therapies, tic disease. Now that many clinical trials have demonstrated a sur-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 1 BREAST COMPLAINTS — 13
vival benefit, more and more women are receiving adjuvant cyto- most of whom had large or palpable lesions or comedo histology.
toxic chemotherapy. It became clear in early trials that multiple- The prognosis for DCIS continues to be very favorable in rela-
agent (or combination) chemotherapy was superior to single- tion to that for invasive breast cancers. In theory, there is no
agent chemotherapy.76,77 It also became clear that chemotherapy potential for metastatic disease with a purely in situ lesion. In
and hormone therapy were limited in their ability to control large practice, however, axillary node metastases continue to be found
tumor masses, though on occasion, patients with large tumor in 1% to 2% of patients thought to have pure DCIS, presumably
masses showed dramatic partial responses or even complete arising from a small area of invasion that was missed on patho-
responses to therapy. logic evaluation.
With the goal of eradicating breast cancer metastases while DCIS is believed to be a true anatomic precursor of invasive
they are still microscopic, systemic therapy is now administered in breast cancer.There are at least two lines of evidence that support
a so-called adjuvant setting—that is, when there is no evidence of this conclusion. First, when DCIS is treated with biopsy alone
distant metastases but there is sufficient suspicion that metastasis (usually because it was missed on the initial biopsy and not found
may have occurred. Until the late 1980s, adjuvant chemotherapy until subsequent review), invasive carcinoma develops in 25%
was given primarily to women who had axillary node metastases to 50% of patients at the site of the initial biopsy; all these tumors
but no other evidence of disease. In node-positive premenopausal appear within 10 years and are of ductal histology. Second, when
women, adjuvant chemotherapy appeared to be significantly DCIS recurs locally after breast conservation, invasive ductal
more beneficial than adjuvant hormone therapy. In node-positive carcinoma appears in about 50% of patients. The true relation-
postmenopausal women, on the other hand, hormone therapy ship between DCIS and invasive ductal carcinoma awaits a
appeared to be as beneficial as chemotherapy and less toxic. better understanding of the molecular biology of breast cancer
This approach to adjuvant systemic therapy changed in 1988, development.
when the NCI issued a clinical alert stating that there was suffi- The consequence of the view that DCIS is a precursor of inva-
cient evidence of benefit to allow recommendation of adjuvant sive cancer is that treatment is required once the diagnosis is
chemotherapy or hormone therapy for even node-negative breast made. Treatment options for DCIS are similar to those for inva-
cancer patients.78 By that time, a number of studies had shown sive breast cancer [see Figure 1]; however, it should be remem-
that adjuvant chemotherapy could improve survival in node- bered that although the risk of local recurrence is greater after
negative breast cancer patients.79-81 A consensus conference of breast conservation for DCIS than after mastectomy, the likeli-
experts in the field suggested that such therapy be reserved for hood of metastatic disease is very small. Wide excision to micro-
node-negative women with primary tumors larger than 1 cm in scopically clean margins followed by radiation therapy has
diameter.82 In 1992, a meta-analysis that reviewed the treatment become an accepted alternative to mastectomy. Smaller areas of
of 75,000 women in 133 randomized clinical trials of adjuvant DCIS, particularly of low to intermediate nuclear grade, are
therapy for breast cancer concluded that in node-negative pre- increasingly treated with wide excision without radiation.85 If
menopausal women, overall long-term survival was 20% to 30% clean margins cannot be obtained or if the cosmetic result is
higher in those who received chemotherapy than in those who did expected to be poor after excision to clean margins, mastectomy
not.83 This benefit also appeared to extend to postmenopausal should be performed.The NSABP B-17 study,86 which examined
women between 50 and 60 years of age. A 1998 overview of the the role of radiation in the treatment of DCIS, found that the
use of adjuvant tamoxifen in randomized trials demonstrated that addition of radiation therapy to wide excision reduced the recur-
in women with ER-positive tumors, those given tamoxifen for 5 rence rate at 43 months after operation by approximately half,
years had a 47% reduction in tumor recurrence and a 26% reduc- from 16.4% with wide excision alone to 7.0% with wide excision
tion in mortality, compared with those women who were given and radiation.The report also suggested that the addition of radi-
placebo.84 In this analysis, the effects of tamoxifen on recurrence ation therapy might reduce the incidence of invasive recurrences.
and survival were independent of age and menopausal status. Most patients in whom DCIS is identified mammographically
Tamoxifen did not appear to improve survival, however, in can choose between mastectomy and wide excision with or with-
women with ER-negative tumors. These results, together with out radiation, either of which yields excellent long-term survival.
data on the efficacy of tamoxifen for chemoprevention, have led Given the lack of any significant difference in survival between the
to increased use of tamoxifen for premenopausal women and for two options, the patient must weigh her feelings about the risk of
women with small tumors. a local, possibly invasive, recurrence after breast conservation
against her feelings about the cosmetic and psychological effects
TREATMENT OF NONINVASIVE CANCER
of mastectomy. Mastectomy remains a reasonable treatment even
for patients with very small DCIS lesions if the primary concern
Ductal Carcinoma in Situ is to maximize local control of the cancer. Breast reconstruction
Before mammographic screening was widely practiced, ductal after mastectomy for DCIS is an option that is open to most such
carcinoma in situ (DCIS) was generally identified either as a pal- patients.
pable lesion (usually with comedo histology) or as an incidental Axillary dissection is not usually performed in conjunction
finding on a biopsy performed for another lesion. With the with lumpectomy for DCIS, because the probability of positive
increasing use of mammography, DCIS is accounting for a grow- nodes is low: it increases morbidity and expense while providing
ing proportion of breast cancer cases. The diagnosis of DCIS is little prognostic information. On the other hand, low axillary dis-
now made in 6.6% of all needle-localized breast biopsies and section is often included in mastectomy for DCIS: a level I axil-
1.4% of breast biopsies for palpable lesions. About 30% of all lary dissection adds little morbidity to a mastectomy, and many
mammographically detected malignancies are DCIS.17 surgeons believe that dissection must be carried into the low axil-
It was recognized early on that DCIS had a very favorable la to ensure that the entire axillary tail of the breast is removed.
prognosis compared with other forms of breast cancer: long-term In some patients with areas of mammographically detected
survival approached 100% after treatment with mastectomy. DCIS lesions measuring less than 2.5 cm in diameter, it may be
Axillary lymph nodes were positive in only 1% to 2% of patients, possible to omit radiation therapy, particularly if the lesions do
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 1 BREAST COMPLAINTS — 14
DCIS is low to intermediate nuclear grade DCIS is low to intermediate nuclear grade and DCIS is high nuclear grade
and < 2.5 cm on mammography or biopsy > 2.5 cm but < 5 cm on mammography or biopsy
Treatment choices are
Treatment choices are Treatment choices are • Simple mastectomy ± reconstruction
• Simple mastectomy ± reconstruction • Simple mastectomy ± reconstruction • Wide excision
• Wide excision • Wide excision
Patient undergoes simple Patient undergoes Patient undergoes Patient undergoes simple Patient undergoes
mastectomy reconstruction wide excision wide excision mastectomy reconstruction wide excision
Margins are negative, and total Margins are negative, and Margins are positive Margins are negative
extent of DCIS is found to be total extent of DCIS is found
< 2.5 cm to be > 2.5 cm but < 5 cm Perform simple mastectomy Irradiate breast, and follow up.
± reconstruction. For high-grade lesions that are < 0.5 cm,
Irradiate breast, and follow up, or Irradiate breast and follow up. consider omitting radiation therapy.
follow up only.
not have comedo histology. Omission of radiation therapy is a factors; it may be additive with other risk factors [see Risk Factors
complex decision that should be based on the individual patient’s for Breast Cancer, above]. Because the two breasts are at equal risk
histology, the presence or absence of other risk factors, the pres- for future carcinoma, unilateral mastectomy is inappropriate.
ence or absence of contraindications to radiation therapy, and the Appropriate treatment options include (1) careful observation
degree to which the patient is willing to accept a higher local coupled with physical examination two or three times annually
recurrence rate. This option is probably best pursued in the con- and mammograms annually, (2) prophylactic bilateral simple
text of a clinical trial. mastectomies with or without reconstruction, and (3) chemopre-
There are certain patients with DCIS for whom mastectomy vention with tamoxifen or participation in chemoprevention trials
remains the preferred treatment, such as those who have lesions with other agents. Most patients choose the first option, but there
larger than 5 cm in diameter. Some surgeons would also include are some patients for whom prophylactic mastectomy is still
in this category those who have comedo lesions larger than 2.5 cm preferable, either because of anxiety or because of concurrent risk
and those who present with palpable DCIS. In these patients, the factors.
local recurrence rate after breast conservation, even in conjunc- Management of tumors that contain LCIS mixed with invasive
tion with radiation therapy, remains high. As many as half of these carcinoma of either lobular or ductal histology is dictated primar-
recurrences will contain invasive cancer with metastatic potential. ily by the features of the invasive carcinoma. Staging is not affect-
These also are the DCIS patients who are at highest risk for pos- ed by the presence of LCIS.
itive axillary nodes. For this reason, an axillary node sampling is
TREATMENT OF INVASIVE CANCER
often performed in conjunction with the mastectomy.
Although the optimal treatment regimen for breast cancer con-
Lobular Carcinoma in Situ tinues to be the subject of active investigation, there is at least a
LCIS, also referred to as lobular neoplasia, does not have the partial consensus regarding current treatment options for the var-
same clinical implications as DCIS, invasive ductal carcinoma, or ious stages of breast cancer.
invasive lobular carcinoma. It is now generally accepted that LCIS
is a predictor of increased risk of subsequent invasive breast car- Early-Stage Invasive Cancer
cinoma rather than a marker of the site at which the subsequent Local treatment In patients with stage I or II breast cancer,
carcinoma will arise. Most of the carcinomas that develop after a lumpectomy to microscopically clean margins combined with
biopsy showing LCIS are of ductal histology.87 The increased risk axillary dissection and radiation therapy [see Figure 2] appears to
of subsequent carcinoma is equally distributed between the breast yield approximately the same long-term survival rates as mastec-
undergoing biopsy and the contralateral breast and is thought to tomy. Patients undergoing lumpectomy and radiation are, howev-
be between 20% and 25% in patients with LCIS and no other risk er, at risk for local recurrence in the treated breast, as well as for
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 1 BREAST COMPLAINTS — 15
the development of a new primary tumor in the remaining breast adjuvant therapy are probably outweighed by its risks. Tamoxifen
tissue. Local recurrences can generally be managed with mastec- therapy is being reconsidered for women with such low-risk
tomy; overall survival is equivalent to that of women who under- tumors, given the data on the efficacy of this agent for both treat-
went mastectomy at the time of initial diagnosis.There may, how- ment and prevention of breast cancers. In premenopausal women,
ever, be a significant cost to the patient in terms of anxiety about adjuvant therapy should consist of combination chemotherapy,
recurrence, as well as the morbidity and potential mortality asso- with hormone therapy reserved for clinical trials; in postmeno-
ciated with undergoing a second surgical procedure. pausal women, hormone therapy (generally consisting of tamox-
On the other hand, patients who choose mastectomy as their ifen, 10 mg twice daily) is the first-line treatment. However, the
initial surgical treatment face the psychological consequences of idea that menopause should be an absolute cutoff point for con-
losing a breast. Although they are at lower risk for local recurrence sideration of chemotherapy is being reassessed. For healthy post-
than patients who choose lumpectomy, axillary node dissection, menopausal women, particularly those between 50 and 60 years
and radiation, their overall survival does not seem to be signifi- of age, the decision between hormone therapy and chemotherapy
cantly improved. Each physician and each patient must weigh the plus hormone therapy is made on an individual basis and takes
inconvenience and potential complications of radiation therapy into account the woman’s overall health and the specifics of her
and the risk of local recurrence against the value of breast preser- tumor.
vation, keeping in mind that the choice between procedures In cases of node-positive disease, combination chemotherapy is
appears to have no significant effect on survival. used for premenopausal women and for healthy postmenopausal
women up to 60 years of age or even older. Hormone therapy is
Adjuvant therapy It is generally agreed that adjuvant generally the treatment of choice in postmenopausal women who
chemotherapy, adjuvant hormone therapy, or both should be con- are older than 60 years and in poor health, particularly those with
sidered for all women with tumors larger than 1 cm in diameter, ER-positive tumors. Renewed interest is being expressed in other
even those with negative axillary lymph nodes. For patients with hormonal manipulations, such as oophorectomy and chemical
tumors that have a very favorable prognosis (i.e., that are smaller castration, for premenopausal women who are at high risk for
than 1 cm or have a favorable histology), the potential benefits of metastatic disease.88
Look for positive nodes. If clean margins are not obtained, perform mastectomy (see left).
If clean margins are obtained, look for positive nodes.
No positive nodes are Positive nodes are found No positive nodes are found
found
Administer radiation therapy. If primary
If primary tumor is < 1 cm, tumor < 1 cm, follow up. If primary
follow up. If primary tumor is Nodes are unfavorable, there are Nodes are favorable, and there are tumor ≥ 1 cm, administer adjuvant
≥ 1 cm, administer adjuvant > 4 positive nodes, or there is < 4 positive nodes chemotherapy and/or hormone
chemotherapy and/or extracapsular extension therapy if tumor is ER positive and
hormone therapy if tumor follow up.
is estrogen receptor (ER) Administer adjuvant chemotherapy
Administer adjuvant chemotherapy and/or hormone therapy if patient (Note: chemotherapy may precede
positive. Then, if tumor is > 5
(hormone therapy if patient is is ER positive. Consider chest wall radiation therapy.)
cm, irradiate chest wall and
postmenopausal). Consider bone irradiation.
follow up; if tumor is ≥ 1 cm
marrow transplantation.
but ≤ 5 cm, follow up.
Mastectomy patients Limited surgery patients Mastectomy patients Limited surgery patients
Irradiate chest wall and Irradiate breast and axilla If tumor is > 5 cm, irradiate chest Irradiate breast and follow up.
axilla and follow up. and follow up. wall and follow up; if tumor is
≤ 5 cm, follow up.
breast cancer is nearly linear over the first 10 years after treatment. tive local therapies in the management of highly selected pa-
Recurrence becomes less likely after the first decade, but it con- tients with breast cancer is being investigated. The need for
tinues at a significant rate through the second decade and beyond. axillary dissection continues to be questioned, and more and
In patients who have undergone limited surgery and radiation more, the features of the primary tumor, rather than axillary
therapy, radiation-induced breast and chest wall malignancies node status, are being used to establish the prognosis and deter-
begin to appear 7 or more years after treatment and continue to mine the need for adjuvant therapy. Trials of SLN biopsy are un-
appear for at least 20 years after treatment. der way. Data are also being accumulated on the clinical signifi-
Unfortunately, there is little in the way of evidence-based guid- cance of micrometastatic and molecular amounts of tumor in
ance to help the clinician determine the optimal posttreatment the SLN.
surveillance strategy for breast cancer patients. As a result, prac- Many ongoing trials of chemotherapy for breast cancer focus on
tice patterns vary considerably with respect to the use of follow- increasing the efficacy of treatment through dose intensification.
up tests in this population. Exhaustive posttreatment testing does Very high dose chemotherapy, in conjunction with administration
not seem warranted in early-stage breast cancer patients. There is of growth factor or autologous bone marrow transplantation, is
no evidence to support the use of routine bone scans, CT, PET being assessed in the hope that higher-dose chemotherapeutic reg-
brain imaging, and serum tumor markers in asymptomatic pa- imens will improve response rates and duration of response.
tients after treatment for early-stage disease. The use of such The early results from studies of bone marrow transplantation
intensive surveillance is based on the presumption that detecting have been somewhat disappointing: median survival is prolonged
disease recurrence at its earliest stage would offer the best chance by only 7 to 10 months beyond what is achievable with more stan-
of cure, improved survival, or, at least, improved quality of life. dard chemotherapy.92 There is, however, a small but significant
Given that the majority of recurrences are detected by patients group of long-term survivors who remain free of disease for more
themselves, educating patients about the symptoms of recurrent than 5 years after undergoing bone marrow transplantation to
disease is likely to be a more effective strategy. treat breast cancer with 10 or more positive lymph nodes at initial
Follow-up of early stage breast cancer patients should include a presentation.Trials of improved bone marrow transplantation reg-
thorough history and physical examination and mammography. imens continue in the hope that the toxicity and cost of the treat-
For patients treated with breast conservation, annual mammogra- ment can be reduced and the number of long-term survivors
phy is appropriate, beginning after any acute radiation reaction increased.
has resolved (generally 6 to 9 months after completion of radia- Immune therapy using antibodies to HER-2/neu protein, alone
tion therapy). For patients treated with mastectomy, mammogra- or in conjunction with chemotherapy, is being evaluated for
phy should be continued on an annual basis for the contralateral tumors that overexpress the oncogene HER-2/neu. At present,
breast. Physical examination and review of symptoms are general- there is no definitive evidence that the biologic therapies and
ly performed at 3- to 6-month intervals for the first 5 years after immune therapies now available are of significant value in the
completion of therapy, though these intervals have not yet been treatment of breast cancer. These types of therapy continue to be
tested in a prospective fashion. actively explored.
Although there has been little debate about the value of early Even more exciting than the prospect of improved therapy is
detection of a local recurrence within the treated breast or of a the concept of chemoprevention [see Management of Specific
new primary tumor in either breast, there has been a great deal of Breast Problems, High-Risk Patients, above]. Positive results of tri-
debate about the value of early detection of metastatic disease. als using tamoxifen for chemoprevention have raised hopes that
Two prospective, randomized trials addressed this issue. In one, a many breast cancers can be prevented and have increased interest
group of breast cancer patients was intensively followed with in identifying additional agents that can reduce breast cancer risk
blood tests every 3 months and with chest x-rays, bone scans, and with minimal side effects. These results underscore the impor-
liver ultrasonography annually.90 There was no difference in sur- tance of understanding breast cancer risk factors (including gene
vival or quality of life between this group and the control group, mutations) for better identification of women who might benefit
and metastatic disease was diagnosed, on average, less than 1 from chemoprevention. Ultimately, improved comprehension of
month earlier in the intensively followed group than in the control the pathophysiologic mechanisms of breast carcinogenesis is
group. In the second study, a group of breast cancer patients essential to the development of biologically based methods for the
received chest x-rays and bone scans every 6 months for 5 years.91 prevention and treatment of breast cancer.
Pulmonary and bone metastases were detected significantly earli-
MULTIDISCIPLINARY BREAST CANCER CARE
er in this group than in the control group, but there was no
improvement in survival. This study demonstrated that early Contemporary management of breast cancer demands a mul-
detection of metastatic disease could be achieved with short-inter- tidisciplinary approach involving several specialists, including sur-
val screening, but given current therapeutic options, early detec- geons, radiation oncologists, medical oncologists, radiologists, and
tion had no beneficial effect on survival. Both studies concluded pathologists. It is essential that each specialist have a working
that at present, there is no role for routine imaging studies in the knowledge of the others’ disciplines as they relate to breast cancer
follow-up of breast cancer patients and that imaging studies should care. This team of physicians, in consultation with the patient,
be ordered only as prompted by clinical findings. determines the selection and timing of individual treatments.This
process is greatly simplified when the physicians concerned are
FUTURE DIRECTIONS IN TREATMENT
able to coordinate their visits with the patient, thereby both saving
Breast cancer management is constantly evolving. The trend time for the patient and facilitating decision making among the
continues to be toward less extensive and less invasive surgical various specialists. A number of centers have established multidis-
interventions, without compromising patient outcomes. Ongoing ciplinary breast centers that allow a patient to see all the special-
trials are examining the need for radiation therapy after lumpec- ists in a single visit while also allowing the physicians to consult
tomy for tumors in elderly women or tumors consisting of pure with each other in reviewing the clinical data, imaging studies, and
DCIS. In addition, the use of percutaneous extirpative and abla- pathology and in determining treatment options.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 1 BREAST COMPLAINTS — 18
Patient education is also becoming more and more critical in shifting of a larger proportion of cancer care to the outpatient set-
the management of breast cancer. Patients are increasingly being ting also necessitates the use of other support services, such as vis-
asked to participate in decision making, and as hospital stays for iting nurses, social workers, and outpatient infusion services. How
breast cancer treatments become shorter, patients are also being best to coordinate these complex services while maintaining a
asked to participate more actively in their own care.To participate focus on the problems and needs of the individual patient remains
effectively, patients must be educated about the advantages and one of the major challenges faced by physicians caring for patients
disadvantages of the various aspects of cancer management. The with breast cancer.
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total mastectomy and lumpectomy with or with- therapy and chemotherapy in node-positive pre- lobular carcinoma in situ. Breast Cancer Res 5:
out irradiation in the treatment of breast cancer. menopausal women with breast cancer. N Engl J 258, 2003
N Engl J Med 320:822, 1989 Med 337:956, 1997 88. Scottish Cancer Trials Breast Group: Adjuvant
63. Fisher B, Anderson S, Bryant J, et al:Twenty-year 76. Bonadonna G, Valagussa P, Tancini G, et al: ovarian ablation versus CMF chemotherapy in
follow-up of a randomized trial comparing total Current status of Milan adjuvant chemotherapy premenopausal women with pathological stage II
mastectomy, lumpectomy, and lumpectomy plus trials for node-positive and node-negative breast breast carcinoma: the Scottish trial. Lancet
irradiation for the treatment of invasive breast cancer. J Natl Cancer Inst Monogr 1:45, 1986 341:1293, 1993
cancer. N Engl J Med 347:1233, 2002 89. Buzdar AU: Breast cancer in men. Oncology
77. Fisher B, Redmond C, Fisher E, et al: Systemic
64. Wallner P, Arthur D, Bartelink H, et al; workshop adjuvant therapy in treatment of primary opera- (Huntingt) 17:1361, 2003
participants: Workshop on partial breast irradia- ble breast cancer: NSABP experience. J Natl 90. GIVIO Investigators: Impact of follow-up testing
tion: state of the art and the science. Bethesda, Cancer Inst Monogr 1:35, 1986 on survival and health-related quality of life in
MD, December 8–10, 2002. J Natl Cancer Inst breast cancer patients. JAMA 271:1587, 1994
96:175, 2004 78. Clinical Alert from the National Cancer Institute.
Department of Human Services, National 91. Del Turco MR, Palli D, Cariddi A, et al: National
65. Newman LA, Washington TA: New trends in Cancer Institute, National Institutes of Health, Research Council Project on Breast Cancer
breast conservation therapy. Surg Clin North Am May 16, 1988 Follow-up. Intensive diagnostic follow-up after
83:841, 2003 treatment of primary breast cancer: a randomized
79. Fisher B, Costantino J, Redmond C, et al: A ran-
66. Harris JR, Hellman S, Kinne DW: Limited domized trial evaluating tamoxifen in the treat- trial. JAMA 271:1593, 1994
surgery and radiotherapy for early breast cancer. ment of patients with node-negative breast cancer 92. Peters WP: High-dose chemotherapy and autolo-
N Engl J Med 313:1365, 1985 who have estrogen-receptor-positive tumors. N gous bone marrow support for breast cancer.
67. Clarke DH, Le M, Sarrazin D, et al: Analysis of Engl J Med 320:479, 1989 Important Advances in Oncology. DeVita VT Jr,
local regional relapses in patients with early breast 80. Fisher B, Redmond C, Dimitrov NV, et al: A ran- Hellman S, Rosenberg SA, Eds. JB Lippincott
cancers treated by excision and radiotherapy: domized clinical trial evaluating sequential metho- Co, Philadelphia, 1991, p 135
experience of the Institut Gustave Roussy. Int J trexate and fluorouracil in the treatment of pa-
Radiat Oncol Biol Phys 11:137, 1985 tients with node-negative breast cancer who have
68. Fisher B, Wolmark N: Limited surgical manage- estrogen-receptor-negative tumors. N Engl J Med
ment for primary breast cancer: a commentary on 320:473, 1989 Acknowledgments
the NSABP reports. World J Surg 9:682, 1985 81. Mansour EG, Gray R, Shatila NH, et al: Efficacy
69. Schnitt SJ: Risk factors for local recurrence in of adjuvant chemotherapy in high-risk node-neg- Figure 1 Marcia Kammerer.
patients with invasive breast cancer and negative ative breast cancer. N Engl J Med 320:485, 1989 Figures 2 through 4 Talar Agasyan.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 2 SOFT TISSUE INFECTION — 1
Soft tissue infections are a diverse group of diseases that involve Table 2], as well as about any host factors that may increase their
the skin and underlying subcutaneous tissue, fascia, or muscle. susceptibility to infection and limit their ability to contain it. It is
Such infections may be localized to a small area or may involve a particularly important that they be questioned about specific clin-
large portion of the body. They may affect any part of the body, ical scenarios associated with unusual pathogens, such as an ani-
though the lower extremities, the perineum, and the abdominal mal bite (associated with Pasteurella multocida), a human bite
wall are the most common sites of involvement. Some soft tissue (Eikenella corrodens), chronic skin disease (Staphylococcus aureus),
infections are relatively harmless if treated promptly and ade- saltwater exposure (Vibrio vulnificus), and freshwater exposure
quately; others can be life-threatening even when appropriately (Aeromonas hydrophila).
treated.The symptoms and signs range from subtle or nonspecif- Physical examination usually reveals erythema, tenderness, and
ic indicators (e.g., pain, localized tenderness, and edema without induration. Vesicular lesions and honey-colored crusted plaques
fever) to obvious features (e.g., necrosis, blistering, and crepitus are seen in patients with impetigo. Intense, sharply demarcated
associated with systemic toxicity). erythema is characteristic of erysipelas. A tender, swollen erythe-
Soft tissue infections were first defined as such slightly more than matous papule, often containing a visible hair shaft, is indicative
a century ago. In 1883, Fournier described a gangrenous infection of folliculitis. A single painful, tender, indurated, erythematous
of the scrotum that continues to be associated with his name.1 In skin nodule suggests a furuncle, and the presence of multiple
1924, Meleney documented the pathogenic role of streptococci in inflammatory nodules with sinus tracts is consistent with a car-
soft tissue infection.2 Shortly thereafter, Brewer and Meleney buncle. Cellulitis in association with a decubitus ulcer or an
described progressive polymicrobial postoperative infection of the ischemic leg ulcer frequently signals a polymicrobial infection
muscular fascia with necrosis3 (though the term necrotizing fasciitis with gram-negative organisms. An erythematous linear streak,
was not introduced until more than 25 years later4).The association characteristic of lymphangitis, usually indicates a superficial infec-
between toxic-shock syndrome and streptococcal soft tissue infec- tion secondary to Streptococcus pyogenes; associated lymphade-
tion was delineated as this disease reemerged in the 1980s.5 nopathy may be present as well.
Various classification systems and eponyms are used to describe Patients with necrotizing soft tissue infections often complain
specific forms of soft tissue infection [see Discussion, Etiology and of severe pain that is out of proportion to their physical findings.
Classification of Soft Tissue Infection, below]. In our view, howev- Compared with patients who have nonnecrotizing infections, they
er, it is more important to develop a common approach to the are more likely to have fever, bullae, or blebs [see Figure 1]; signs
diagnosis and treatment of these conditions than to refine the of systemic toxicity; hyponatremia; and leukocytosis with a shift in
minor details of classification. For therapeutic purposes, the pri- immature forms. Physical findings characteristic of a necrotizing
mary consideration is to distinguish between necrotizing soft tis- infection include tenderness beyond the area of erythema, crepi-
sue infections and nonnecrotizing infections. Nonnecrotizing soft tus, cutaneous anesthesia, and cellulitis that is refractory to antibi-
tissue infections involve one or both of the superficial layers of the otic therapy.6 Tenderness beyond the borders of the erythematous
skin (epidermis and dermis) and the subcutaneous tissue, and area is an especially important clinical clue that develops as the
they usually respond to antibiotic therapy alone. Necrotizing soft infection in the deeper cutaneous layers undermines the skin.
tissue infections may involve not only the skin, the subcutaneous
tissue, and the superficial fascia but also the deep fascia and mus-
cle, and they must be treated with urgent surgical debridement. At Table 1 Common Soft Tissue Infections
times, it is difficult to distinguish between these two categories of
infection, especially when obvious clinical signs of necrotizing soft
Pyoderma
tissue infection are absent. Impetigo
In this chapter, we review diagnosis and management of the Erysipelas
main soft tissue infections seen by surgeons, including both super- Folliculitis
ficial infections (e.g., pyoderma, animal and human bites, and cel- Furuncles and carbuncles
lulitis) and necrotizing infections involving superficial and deep Superficial infections Infections developing in damaged skin
tissues [see Table 1]. Animal bites
Human bites
Cellulitis
Clinical Evaluation Nonnecrotizing
Necrotizing
The diagnosis of soft tissue infection is usually made on the
basis of the history and the physical examination. Patients typi- Necrotizing fasciitis
cally seek medical attention because of pain, tenderness, and ery- Deep necrotizing Myonecrosis
cutaneous infections Gas gangrene
thema of recent onset. They should be asked about environmen-
Metastatic gas gangrene
tal factors that may have disrupted the normal skin barrier [see
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 2 SOFT TISSUE INFECTION — 2
NONNECROTIZING INFECTION
Patient has one or more obvious clinical Patient has no obvious signs of
signs of necrotizing soft tissue infection necrotizing soft tissue infection
Patient has WBC count > 15,000/mm3, Patient has WBC count ≤ 15,000/mm3
disproportionate pain, bullae or blebs, and does not have disproportionate pain,
or refractory cellulitis bullae or blebs, or refractory cellulitis
Perform MRI.
Table 3 I.V. Antibiotic Dosages for Adult nonviable tissue does not necessitate debridement if the sur-
Patients with Necrotizing Soft Tissue Infection rounding tissues are viable. It is sometimes helpful to perform an
and Normal Renal Function exploratory incision over an area beyond the limits of debride-
ment when it is uncertain whether necrosis is undermining viable
skin. If no necrotizing infection is found, the incision may be
Ampicillin-sulbactam 3 g q. 6 hr closed primarily.
Imipenem-cilastatin 500–1,000 mg q. 6 hr
Reexploration should be routinely performed within 24 to 36
Single agents Meropenem 1 g q. 8 hr
Piperacillin-tazobactam 3.375 g q. 6 hr
hours to ensure that all necrotic tissue has been debrided. De-
Ticarcillin-clavulanate 3.1 g q. 6 hr bridement is repeated as necessary until the infection is controlled.
If repeated debridement does not control infection, if there are
Aerobic/facultative coverage persistent, fulminant infections of the extremities, or if an extrem-
Ampicillin 2 g q. 6 hr
Cefotaxime 1–2 g q. 8 hr
ity remains nonfunctional after debridement has been completed,
Ceftazidime 1 g q. 8 hr amputation can be lifesaving. Amputation is most often required
Agents used in Cefuroxime 1.5 g q. 8 hr for patients with clostridial myonecrosis and for diabetic patients
combination Ciprofloxacin 400 mg q. 12 hr with necrotizing fasciitis.15 In two large series of patients with
regimens Gentamicin 1.7 mg/kg q. 8 hr necrotizing soft tissue infections, the incidence of amputation was
Vancomycin 1 g q. 12 hr
Anaerobic coverage approximately 15% to 25%.12,13
Clindamycin 900 mg q. 8 hr Patients with necrotizing soft tissue infections involving the peri-
Metronidazole 500 mg q. 6 hr neum and perirectal areas may need a diverting colostomy to pre-
vent tissue contamination resulting from defecation and to control
local infection. Overall, this measure is required in fewer than
important to ensure that the dosage is high enough to achieve ade- 25% of cases.13
quate serum concentrations.13,14 Once the results of intraoperative After debridement, the exposed areas should be treated with
culture and antimicrobial sensitivity testing become available, 0.9% normal saline wet-to-dry dressings. Once the initial infec-
antibiotic therapy is adjusted accordingly. This adjustment can be tion has been controlled and debridement is no longer necessary,
challenging, in that all of the pathogens identified must be treated. dressing changes can often be performed at the bedside after suf-
I.V. antimicrobial therapy is continued until operative debride- ficient analgesics have been given to achieve adequate pain man-
ment is complete, there is no further evidence of infection in the agement. Patient-controlled analgesia is frequently useful early
involved tissues, and signs of systemic toxicity have resolved. in the course of treatment. Propofol or ketamine can be given
Topical antiseptic agents (e.g., Dakin solution and Burrow solu- in the intensive care unit to facilitate pain control during dressing
tion) may help control infection that progresses despite adequate changes.
debridement and I.V. antibiotics. Topical application of myco- Early enteral or parenteral nutritional support should be insti-
statin powder may help control progressive fungal infection.When tuted to optimize recovery. Nutritional support should begin once
patients are able to resume oral intake, they can often be switched resuscitation is complete, the infection is adequately controlled,
from I.V. to oral antimicrobial therapy. and the signs of sepsis have resolved. Because it frequently proves
Operative Treatment necessary to return the patient to the operating room, enteral
feeding tubes should be placed beyond the pylorus so that enter-
The most critical factors for reducing mortality from necrotiz- al nutrition can be provided without interruption. Alternatively,
ing soft tissue infections are early recognition and urgent opera- parenteral nutrition may be employed.
tive debridement.12,13,15,18 The extent of debridement depends on Once the localized infection is under control and the patient is
intraoperative findings and cannot be accurately predicted before recovering, the exposed soft tissues should be covered. This is
operation. Operative intervention serves to limit tissue damage by
removing necrotic tissue, which serves as a nidus for infection.
Thorough exploration is necessary to confirm the diagnosis of Table 4 Organisms Causing Necrotizing
necrotizing soft tissue infection and determine the degree of Soft Tissue Infection
involvement. Aggressive, widespread debridement of all apparent
necrotic, infected tissue is essential; antibiotics will not penetrate Gram-positive
dead tissues.The underlying necrosis of subcutaneous tissues, fas- Group A Streptococcus
cia, and muscle typically extends beyond the obvious limits of Enterococcus species
cutaneous involvement. Operative debridement should therefore Staphylococcus aureus
be continued until viable tissue is reached. The presence of arter- Group B Streptococcus
ial bleeding generally indicates that tissues are viable; in the Bacillus species
absence of arterial bleeding, tissues are nonviable even if venous Aerobes
Gram-negative
bleeding is present.With deep necrotizing infections, debridement Escherichia coli
of the necrotic fascia and muscle may create large skin flaps that Pseudomonas aeruginosa
are poorly perfused. It is best to preserve as much viable skin and Enterobacter cloacae
Klebsiella species
subcutaneous tissue as possible because these tissues can be
Serratia species
essential for later coverage of the wound. Nonviable skin, howev- Acinetobacter calcoaceticus
er, should be resected. Vibrio vulnificus
Wound drainage or exudate should be submitted for Gram
staining, as well as for aerobic, anaerobic, and fungal cultures and Bacteroides species
antimicrobial sensitivity testing. Fasciotomy is rarely required. Anaerobes Clostridium species
Peptostreptococcus species
The presence of subcutaneous gas extending beyond areas of
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 2 SOFT TISSUE INFECTION — 6
genes. Most cases are preceded by influenzalike symptoms. Infection Folliculitis Folliculitis is an infection of the hair follicle that
extends through the dermal lymphatic vessels and is typically man- is typically caused by S. aureus. It is characterized by a painful,
ifested by a tender, pruritic, intensely erythematous, sharply demar- tender, erythematous papule with a central pustule. A shaft of hair
cated, and raised plaque. Patients complain of pain, often in con- is often seen in the center of the pustule. Shaving, plucking, wax-
junction with high fever, increased skin warmth, and leukocytosis. ing, heat and humidity, the use of corticosteroids or antibiotics,
Lymphangitis and lymphadenopathy are sometimes present as well. immunosuppression, and occlusion of the skin by clothing, adhe-
The leg is the most common site of involvement, but erysipelas may sives, or plastics may predispose to folliculitis.20 Single or multiple
also occur on the face, the arms, and the upper thighs. lesions may occur in the skin of any hair-bearing area. If the pus-
The factors predisposing to the development of erysipelas of tule ruptures, superficial erosion often ensues. Infection that prin-
the extremity include local conditions such as tinea pedis (ath- cipally involves the deeper part of the hair follicle is characterized
lete’s foot), leg ulcers, and venous stasis dermatitis.23 Erysipelas by a tender, swollen papule without an associated pustule at the
tends to be more common in the presence of associated condi- skin surface.
tions such as lymphedema, diabetes mellitus, alcoholism, immu- In rare cases, folliculitis is caused by pathogens other than S.
nocompromise, and obesity,21,23 and it is more likely to recur in aureus, such as Pseudomonas aeruginosa, Klebsiella species, Entero-
patients with these associated diseases and in those whose under- bacter species, Proteus species, yeasts, and fungi. Pseudomonas fol-
lying skin conditions are inadequately treated. Erysipelas recurs in liculitis usually results from exposure to inadequately chlorinated
10% of patients within 6 months of their first episode and in 30% water in swimming pools, hot tubs, or whirlpools. Patients with
within 3 years.23 this infection have multiple papular or pustular lesions on the
The standard antibiotic treatment for uncomplicated erysipelas back, the buttocks, and the extremities, along with fever and
is penicillin, which is effective in at least 80% of cases. Oral and malaise appearing 6 hours to 3 days after exposure.22,24 Organ-
intravenous antibiotic regimens are equally efficacious. Amoxi- isms may be cultured either from the pustules or from the infect-
cillin appears to work as well as penicillin. Patients with erysipelas ed water. Klebsiella, Enterobacter, and Proteus species can cause fol-
of the lower extremity should be placed on bed rest, and the liculitis in patients receiving long-term antibiotic therapy for acne
involved leg should be elevated to reduce edema and pain. Once vulgaris.21 Yeast folliculitis and fungal folliculitis tend to occur in
the patient is able to resume normal activities, he or she should be immunocompromised patients.21
fitted with elastic stockings, which help reduce the recurrence of In most patients, folliculitis resolves spontaneously within 7 to
edema and lower the risk of lymphedema. For patients with tinea 10 days.22 Topical therapy with clindamycin, erythromycin, or
pedis, a topical antifungal agent is used to treat the infection and mupirocin ointments or benzoyl peroxide in combination with
prevent recurrence. warm soaks may accelerate resolution [see Table 5]. Isotretinoin
can be used to treat gram-negative folliculitis. Gentamicin cream
may be helpful in drying out the pustular lesions in patients with
Pseudomonas folliculitis.
Table 5 Topical and Oral Antibiotic Agents In patients with refractory or disseminated follicular infections,
oral antibiotic therapy is indicated. When S. aureus is considered
Used for Superficial Soft Tissue Infections*
the most likely pathogen, dicloxacillin, erythromycin, cephalexin,
cefadroxil, or clindamycin may be given; oral ciprofloxacin is indi-
Mupirocin ointment (2%), applied to affected area t.i.d.†
cated for the treatment of gram-negative folliculitis [see Table 5].
Erythromycin ointment (2%), applied to affected area b.i.d.†
Elimination of predisposing factors is important for reducing the
Clindamycin gel or lotion (1%), applied to affected area b.i.d.†
likelihood of recurrence.
Gentamicin cream or ointment (0.1%), applied to affected area t.i.d.
or q.i.d.
Furuncles and carbuncles Furuncles and carbuncles are
Penicillin V, 250–500 mg q.i.d. (pediatric: 25–50 mg/kg in divided deeper infections of the hair follicle that extend beyond the hair
doses q.i.d.)
follicle to involve the subcutaneous tissue. For both, S. aureus is
Amoxicillin, 250–500 mg t.i.d. (pediatric: 20–30 mg/kg/day p.o. in the usual causative organism.
divided doses t.i.d.)
A furuncle, or boil, is a small abscess, manifested as a firm, ten-
Dicloxacillin, 250–500 mg q.i.d. (pediatric: 12.5–25.0 mg/kg/day in der, erythematous nodule that tends to occur in skin areas ex-
divided doses q.i.d.)
posed to friction (e.g., the inner thighs and the axilla). Furuncles
Cephalexin, 250–500 mg q.i.d. (pediatric: 25–100 mg/kg/day in also may occur on the face, the neck, the upper back, and the but-
divided doses q.i.d.)
tocks. Possible predisposing factors include increased friction and
Cefadroxil, 500–1,000 mg b.i.d. (pediatric: 30 mg/kg/day in divided perspiration (as seen in obese individuals or athletes), corticos-
doses b.i.d.)
teroid use, diabetes mellitus, and inherited or acquired defects in
Erythromycin, 250–500 mg q. 6 hr (pediatric: erythromycin ethyl neutrophil function.20,22
succinate, 40 mg/kg in divided doses q.i.d.)
Initial treatment consists of applying warm compresses to help
Clindamycin, 150–450 mg q.i.d. (pediatric: 20 mg/kg/day in divided promote drainage and administering an oral antimicrobial agent
doses t.i.d. or q.i.d.)
that is effective against S. aureus (e.g., dicloxacillin, cephalexin,
Trimethoprim-sulfamethoxazole, 160/800 mg b.i.d. cefadroxil, erythromycin, or clindamycin) [see Table 5].With time,
Amoxicillin-clavulanate, 500 mg t.i.d. (pediatric: 40 mg/kg/day in the furuncle becomes fluctuant, and the pus coalesces at the skin
divided doses t.i.d.) surface. An incision-and-drainage procedure is necessary when
Ciprofloxacin, 500 mg p.o., b.i.d. these lesions do not drain spontaneously. This procedure should
be performed with local anesthesia, and care should be taken to
*All dosages are for patients with normal renal function. open the abscess cavity completely. Lesions that have drained
†Adult dosage and pediatric dosage are the same.
spontaneously should be examined to confirm that the cavity has
been opened sufficiently. Failure to drain these lesions adequate-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 2 SOFT TISSUE INFECTION — 8
Occlusional bites carry roughly the same risk of infection as ani- cefotetan, and piperacillin-tazobactam. Tenosynovitis, joint infec-
mal bites, except when they occur on the hand. Clenched-fist tions, and associated injuries to deep structures must also be treat-
injuries and all hand injuries are associated with a higher risk of ed if present.
infection. Clenched-fist injuries typically occur at the third meta-
carpophalangeal joint. Penetration of the metacarpophalangeal Cellulitis
joint capsule may occur, with subsequent development of septic Cellulitis is an acute bacterial infection of the dermis and the
arthritis and osteomyelitis.25 subcutaneous tissue that primarily affects the lower extremities,
Soft tissue infections resulting from human bites are polymi- though it can affect other areas as well (e.g., the periorbital, buc-
crobial, involving a mixture of aerobes and anaerobes. On average, cal, and perianal regions; the areas around incisions; and sites of
five different microorganisms are isolated from a human-bite body piercing).31 The most common causes of cellulitis are (1)
wound27—significantly more than are usually isolated from an ani- soft tissue trauma from injection of illicit drugs, puncture wounds
mal-bite wound. In addition, the concentration of bacteria in the from foreign bodies or bites (animal, human, or insect), or burns;
oral cavity is higher in humans than in animals.The anaerobic bac- (2) surgical site infection; and (3) secondary infection of preexist-
teria isolated from human-bite wounds are similar to those that ing skin lesions (e.g., eczema; tinea pedis; and decubitus, venous
cause infection after dog and cat bites, except that Bacteroides stasis, or ischemic ulcers). Less common causes include extension
species are more common [see Table 7]. Unlike the anaerobic of a subjacent infection (e.g., osteomyelitis) and bacteremia from
pathogens in dog and cat bites, however, those involved in human- a remote site of infection. Predisposing factors for the develop-
bite infections often produce β-lactamases.27 The predominant ment of cellulitis include lymphatic disruption or lymphedema,
aerobic organisms in human-bite infections are S. aureus, Staphy- interstitial edema, previous irradiation of soft tissue, diabetes mel-
lococcus epidermidis, α- and β-hemolytic streptococci, Corynebac- litus, immunocompromise, and peripheral vascular disease.
terium species, and E. corrodens. E. corrodens is a fastidious faculta-
tive aerobic gram-negative rod that is cultured from approximate- Nonnecrotizing The overwhelming majority of patients
ly 25% of clenched-fist injuries and frequently causes a chronic with cellulitis have a nonnecrotizing form of the disease. Patients
indolent infection.27 It typically is susceptible to amoxicillin-clavu- typically present for medical attention because of pain and soft tis-
lanate, trimethoprim-sulfamethoxazole, doxycycline, and cipro- sue erythema, and they often have constitutional symptoms (e.g.,
floxacin but resistant to dicloxacillin, nafcillin, first-generation fever, chills, or malaise). Physical examination reveals erythema
cephalosporins, clindamycin, and erythromycin. Other pathogens with advancing borders, increased skin warmth, tenderness, and
may also be transmitted as a result of contact with blood or saliva, edema. Lymphangitis may also be present, manifested as an ery-
including hepatitis B and C viruses, Mycobacterium tuberculosis, thematous linear streak that often extends to a draining lymph
and, possibly, HIV. node basin; associated lymphadenopathy, fever, and leukocytosis
Management of human-bite wounds is similar to that of ani- with a shift to immature forms may be apparent.
mal-bite wounds. The wound must be thoroughly irrigated, Cellulitis is usually caused by a single aerobic pathogen. The
preferably with 1% povidone-iodine, which is both bactericidal organisms most frequently responsible for cellulitis in otherwise
and viricidal. Puncture bite wounds should be irrigated with a healthy adults are S. pyogenes and S. aureus. Of the two, S. pyogenes
small catheter to achieve high-pressure irrigation. If the wound is the more common and is the usual pathogen in patients with
appears infected, aerobic and anaerobic cultures are obtained. associated lymphangitis. S. aureus is usually present in patients
Devitalized tissue should be debrided, and the wound should be with underlying chronic skin disease. Other microorganisms may
left open, whether infected or not. The injured extremity should cause cellulitis on rare occasions but usually only in specific clin-
be immobilized and elevated. ical circumstances. Haemophilus influenzae sometimes causes cel-
Because of the high degree of contamination and local tissue lulitis in children or adults infected with HIV.32 Streptococcus pneu-
damage associated with human-bite wounds to the hand, antimi- moniae may cause this condition in patients with diabetes mellitus,
crobial therapy is indicated for all such injuries. A prospective, alcoholism, nephrotic syndrome, systemic lupus erythematosus,
randomized study of 45 patients with human bites to the hand or hematologic malignancies.33 P. multocida may cause cellulitis as
seen within 24 hours after injury and without evidence of infec- a complication of dog or cat bites. S. epidermidis is a recognized
tion, tendon injury, or joint capsule penetration demonstrated cause of cellulitis among immunocompromised patients, includ-
that infection developed in 47% of the patients who did not ing those with HIV infection and those receiving organ trans-
receive antibiotics but in none of those who did.30 Patients with an plants.34 V. vulnificus occasionally causes cellulitis in patients who
uncomplicated human bite to the hand should receive a broad- have ingested raw seafood or who have experienced minor soft tis-
spectrum oral antimicrobial agent, such as amoxicillin-clavulanate sue trauma and are exposed to sea water.31 A. hydrophila may
(or doxycycline if they are allergic to penicillins). cause cellulitis in patients with soft tissue trauma who are exposed
Patients with human-bite wounds at sites other than the hand to fresh water.31 Cellulitis that complicates decubitus or other
who have risk factors for infection [see Table 6] should also receive nonhealing ulcers is usually a mixed infection that includes gram-
antimicrobial therapy. However, minor bite wounds in patients negative organisms.
who have no risk factors for infection do not call for antibiotic In most situations, cellulitis is treated with empirical antibiotic
therapy. As with animal-bite wounds, tetanus immunization status regimens that include agents effective against S. pyogenes and
should be determined, and tetanus toxoid, tetanus immunoglo- S. aureus. Attempts to isolate a causative pathogen are usually
bin, or both should be administered as indicated. unsuccessful; needle aspiration and skin biopsy at an advancing
Patients with systemic manifestations of infection (e.g., fever or margin of erythema are positive in only 15% and 40% of cases,
chills); severe cellulitis; compromised immune status; diabetes respectively.35 Bacteremia is uncommon, and as a result, blood
mellitus; significant bites to the hand; associated joint, nerve, cultures are positive in only 2% to 4% of patients with celluli-
bone, or tendon involvement; or infection refractory to oral antibi- tis.31,36 Blood cultures are obtained selectively when the patient
otic therapy should be admitted to the hospital for I.V. antibiotic has high fever and chills, preexisting lymphedema, or buccal or
therapy.27 Appropriate choices for I.V. treatment include cefoxitin, periorbital cellulitis or when a saltwater or freshwater source of
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 2 SOFT TISSUE INFECTION — 10
infection is suspected. In all of these clinical situations, the preva- Table 8 Suggested Parenteral Antibiotic Regimens
lence of bacteremia is higher.36 Radiologic examination should be for Treatment of Cellulitis in Adults
reserved for patients in whom it is difficult to exclude a deep
necrotizing infection.
Agent I.V. Dosage
In an otherwise healthy adult, uncomplicated cellulitis without
systemic manifestations can be treated with an oral antibiotic on Nafcillin 2 g q. 4 hr
an outpatient basis. Because the vast majority of cellulitides are
caused either by S. pyogenes or by a penicillinase-producing S. Cefazolin 1–2 g q. 8 hr
aureus, one of the following agents is usually given: dicloxacillin, Clindamycin 900 mg q. 8 hr
cephalexin, cefadroxil, erythromycin, or clindamycin [see Table 5].
Vancomycin 500–1,000 q. 12 hr
The margins of the erythema should be marked with ink to facil-
itate assessment of the response to treatment. For lower-extremi- Ampicillin-sulbactam 3 g q. 6 hr
ty cellulitis, reduced activity and elevation are important ancillary
measures. Appropriate analgesic agents should be given.
Patients who are diabetic or immunocompromised and those sic findings associated with these infections—skin discoloration,
who have high fever and chills, rapidly spreading cellulitis, or cel- the formation of bullae, and intense erythema—occur much later
lulitis that is refractory to oral antibiotic therapy should be admit- in the process. It is important to understand this point so that an
ted to the hospital for I.V. antibiotic therapy [see Table 8]. Nafcillin early diagnosis can be made and appropriate treatment promptly
is the preferred I.V. agent. Cefazolin or ampicillin-sulbactam is instituted.
recommended if gram-negative organisms are suspected
Necrotizing Fasciitis
pathogens, as when cellulitis complicates a decubitus or a dia-
betic foot ulcer. Clindamycin is recommended for patients with Necrotizing fasciitis is characterized by angiothrombotic micro-
infections caused by methicillin-resistant S. aureus (MRSA) and bial invasion and liquefactive necrosis.6 Progressive necrosis of the
those with serious penicillin allergies. Vancomycin is reserved for superficial fascia develops, and the deep dermis and fascia are
patients in these subgroups who are intolerant of or allergic to infiltrated by polymorphonuclear leukocytes, with thrombosis of
clindamycin. nutrient vessels and occasional suppuration of the veins and arter-
ies coursing through the fascia; bacteria then proliferate within the
Necrotizing Necrotizing cellulitis is similar to nonnecrotiz- destroyed fascia. Initially, tissue invasion proceeds horizontally,
ing cellulitis in etiology and pathogenesis but is more serious and but as the condition progresses, ischemic necrosis of the skin
progressive. Necrosis generally occurs when the infection is develops, along with gangrene of the subcutaneous fat and dermis
neglected or inadequately treated. The microbiology of necrotiz- (characterized by progressive skin necrosis, the formation of bul-
ing cellulitis is also similar to that of nonnecrotizing cellulitis, lae and vesicles, and occasional ulceration [see Figure 1]).
except that C. perfringens and other clostridial species may be
Myonecrosis
involved when necrosis is present. In addition to antimicrobial
therapy [see Table 8], urgent operative debridement is indicated. In Myonecrosis is a rapidly progressive life-threatening infection
other respects, necrotizing cellulitis is treated in much the same of skeletal muscle that is primarily caused by Clostridium species.
way as deep necrotizing infections are (see below). In some The classic example of myonecrosis is clostridial gas gangrene, a
patients with necrotizing fasciitis, the skin is involved secondarily. disease that was common in World War I soldiers who sustained
extremity injuries that were contaminated with soil. Delays in
DEEP NECROTIZING INFECTIONS definitive treatment and the use of primary closure for these con-
Infections that involve the soft tissues deep to the skin tend to taminated wounds contributed to the severity and mortality of
become apparent after necrosis has developed. It is possible that these infections.37 Clostridial myonecrosis may also occur as a
deep necrotizing infections begin without necrosis but progress deep surgical site infection after contaminated operations, partic-
rapidly as a result of intrinsic factors. Alternatively, such infections ularly those involving the GI tract or the biliary tract. Devitalized
may develop as a result of delayed recognition attributable to the tissue is a perfect environment for clostridial proliferation. A rare
tissue depth at which the process takes place and the lack of spe- form of this disease occurs in patients with colon cancer in whom
cific early signs and symptoms. The relatively poor blood supply myonecrosis caused by Clostridium septicum develops in the
to subcutaneous fat makes this tissue more susceptible to micro- absence of tissue damage. Myonecrosis may also result from the
bial invasion. Contamination of the deep soft tissues occurs either spread of contiguous fascial infections.
through neglect or inadequate treatment of cutaneous or subcu- Clostridial myonecrosis has a notably short incubation period:
taneous infections or through hematogenous seeding of microor- severe progressive disease can develop within 24 hours of con-
ganisms in an area of injury. tamination. This condition is characterized by acute catastrophic
Most deep necrotizing soft tissue infections are polymicrobial pain in the area of infection, with minimal associated physical
and occur on the extremities, the abdomen, and the perine- findings. Systemic signs of toxicity (e.g., confusion, incontinence,
um.12,13,15 Necrotizing infections that involve only muscle are un- and delirium) often precede the physical signs of localized infec-
common; therefore, necrotizing fasciitis can be considered the tion.The skin initially is pale, then gradually becomes yellowish or
paradigm for these infectious processes. bronze. Blebs, bullae, and skin necrosis do not appear until late in
The early signs and symptoms of deep necrotizing soft tissue the course of the disease. Edema and tenderness occur early, and
infection are localized pain, tenderness, mild edema, and erythe- the absence of erythema distinguishes clostridial infections from
ma of the overlying skin.These characteristics may be subtle, and streptococcal infection. A thin serosanguineous discharge is pres-
this diagnosis may not readily come to mind. Sometimes, there is ent in involved areas and may emanate from an involved incision.
a history of previous injury to the area of suspected infection, Gram stain reveals gram-positive coccobacilli with few leukocytes.
which can lead to confusion about the diagnosis. The more clas- When clostridial myonecrosis is suspected or confirmed, peni-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 2 SOFT TISSUE INFECTION — 11
cillin G, 2 to 4 million U every 4 hours, should be given immedi- soft tissue infection for which hyperbaric oxygen is recommended,
ately; clindamycin, 900 mg every 8 hours, should be added.When though as yet, there is little evidence that this modality im-
C. septicum is identified on culture, a search for an occult GI tract proves outcomes. If hyperbaric oxygen therapy is to be used, it
malignancy should be made. Clostridial myonecrosis is the one should not be given before operative debridement.
Discussion
Etiology and Classification of Soft Tissue Infection associated with decubitus or other nonhealing ulcers, and infec-
Soft tissue infection commonly results from inoculation of bac- tions in immunocompromised patients. These infections are typ-
teria through a defect in the epidermal layer of the skin, such as ically polymicrobial, often involving aerobic or facultative gram-
may occur with injury, preexisting skin disease, or vascular com- negative organisms and anaerobes in addition to aerobic gram-
promise. Less commonly, soft tissue infection may be a conse- positive bacteria.
quence of extension from a subjacent site of infection (e.g., osteo- Deep necrotizing soft tissue infections are polymicrobial 70%
myelitis) or of hematogenous spread from a distant site (e.g., to 75% of the time. They are caused by the synergistic activity of
diverticulitis or C. septicum infection in patients with colonic facultative aerobes and anaerobes [see Figure 7].40,41 S. aureus, S.
carcinoma). It may also occur de novo in healthy patients with pyogenes, and enterococci are the most common gram-positive
normal-appearing skin, often as a result of virulent pathogenic aerobes. Escherichia coli is the most common gram-negative
organisms.38 enteric organism. Bacteroides species and peptostreptococci are
Conditions that disrupt the skin and alter its normal barrier the most common anaerobes.13,18,41 The remaining 25% to 30%
function [see Table 2] predispose patients to bacterial contamina- of deep necrotizing infections are monomicrobial. Most primary
tion. Host factors may increase susceptibility to infection and necrotizing soft tissue infections are monomicrobial.38 These
limit the patient’s ability to contain the bacterial inoculum. infections are more fulminant and are notable for their acute
Clinically occult infection or inadequate treatment of other con- onset, rapid progression, and systemic toxicity. Their characteris-
ditions may also lead to secondary development of soft tissue tic clinical manifestations are related to exotoxin production by
infection (as is sometimes seen in patients with diverticulitis; the pathogen involved [see Table 9 and Pathogenesis of Soft Tissue
perirectal, pilonidal, or Bartholin’s cyst abscesses; strangulated Infections, below]. S. pyogenes is the pathogen in more than half of
hernias; or panniculitis). Delayed or inadequate treatment of monomicrobial infections; S. aureus, C. perfringens, V. vulnificus,
superficial infections (e.g., folliculitis, furuncles, carbuncles, cel- and P. aeruginosa are less common.
lulitis, and surgical site infections) may lead to more severe necro-
tizing infections. Pathogenesis of Soft Tissue Infections
Soft tissue infections may be classified as superficial or deep, as
nonnecrotizing or necrotizing, as primary (idiopathic) or second- Soft tissue infections generally induce localized inflammatory
ary, and as monomicrobial or polymicrobial. Superficial infec- changes in the involved tissues, regardless of the species of bacte-
tions involve the epidermis, dermis, superficial fascia, or subcuta- ria involved. As the infection progresses, tissue necrosis occurs as
neous tissue, whereas deep infections involve the deep fascia or a result of (1) direct cellular injury from bacterial toxins, (2) sig-
muscle [see Figure 6]. Necrotizing soft tissue infections are distin- nificant inflammatory edema within a closed tissue compart-
guished by the presence of extensive, rapidly progressing necrosis ment, (3) thrombosis of nutrient blood vessels, and (4) tissue
and high mortality. Such infections are termed necrotizing cel- ischemia.
lulitis, necrotizing fasciitis, or myonecrosis according to whether
the deepest tissue layer affected by necrosis is subcutaneous tis-
sue, deep fascia, or muscle, respectively.
Primary (idiopathic) soft tissue infections occur in the absence
of a known causative factor or portal of entry for bacteria. Such
infections are uncommon and are believed to result from hema-
togenous spread or bacterial invasion through small unrecognized
breaks in the epidermis.38,39 Soft tissue infection caused by V. vul-
nificus is an example of a primary soft tissue infection: it is attrib-
uted to bacteremia developing after the ingestion of contaminat-
ed raw seafood. Only 10% to 15% of all necrotizing soft tissue
infections are idiopathic; the remaining 85% to 90% are sec-
ondary infections, developing as a consequence of some insult to
the skin that predisposes to infection. Secondary soft tissue infec-
tions may be further categorized as posttraumatic, postoperative,
or complications of preexisting skin conditions.
Soft tissue infections are classified as monomicrobial when
they are caused by a single organism and as polymicrobial when
they are caused by multiple organisms. Most superficial soft tis-
sue infections are caused by a single aerobe, usually S. pyogenes or
S. aureus. Exceptions to this general rule include infections asso- Figure 7 Meleney’s ulcer is characterized by central necrosis,
ciated with skin damaged by animal or human bites, cellulitis erythema, and edema.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 2 SOFT TISSUE INFECTION — 12
Table 9 Major Exotoxins Associated with ci, spreading infections developed in 50% of animals, and when
Organisms Causing Monomicrobial Necrotizing the α-lysin of S. aureus was coinjected with streptococci, spread-
ing infections developed in 75%.
Soft Tissue Infection
Pyrogenic exotoxins A and B, hemolysin, Hemolytic streptococci were originally described by Meleney as
Streptococcus pyogenes the cause of a “synergistic gangrene.”2 The current resurgence of
fibrinolysin, hyaluronidase, streptokinase
necrotizing soft tissue infections attributed to so-called flesh-eat-
Hemolysins (intravascular hemolysis and
Staphylococcus aureus ing bacteria probably represents an adaptation of group A strep-
local tumor necrosis), coagulase
tococci to the contemporary environment.43 Streptococcal toxic-
Collagenase (local tissue damage and shock syndrome (STSS) is defined as the isolation of group A
Pseudomonas aeruginosa
necrosis)
streptococci from a normally sterile body site in conjunction with
α-Toxin (lecithinase causing tissue necrosis, hypotension and either renal impairment, acute respiratory dis-
Clostridium perfringens intravascular hemolysis, hemoglobinemia,
and acute renal failure) tress syndrome, abnormal hepatic function, coagulopathy, ex-
tensive tissue necrosis, or an erythematous rash.35 STSS is con-
sidered the probable diagnosis when these abnormalities occur
in conjunction with isolation of group A streptococci from non-
The exotoxins produced by gram-positive cocci and some sterile body sites. More than 60% of patients with STSS have
gram-negative bacteria are powerful proteolytic enzymes. S. pyo- bacteremia.
genes produces hemolysins, fibrinolysins, hyaluronidases, and Population-based studies in North America and Europe docu-
streptolysins. S. aureus and P. aeruginosa produce coagulases that mented a nearly fivefold increase in group A streptococcal infec-
result in local tissue damage and necrosis. C. perfringens produces tions between the late 1980s and 1995.44 The current incidence of
numerous exotoxins. The α-toxin, a lecithinase enzyme, is highly group A streptococcal infections in the population of Ontario,
lethal: it destroys cell membranes, causes hemolysis, and alters Canada, is estimated to be 1.5 per 100,000.44 STSS develops in
capillary permeability. Other clostridial toxins lyse red blood cells approximately 10% to 15% of these patients, necrotizing fasciitis
and have direct cardiotoxic effects.These toxins also cause platelet in about 6%.45 It is likely that the rise in serious group A strepto-
aggregation and fibrin deposition, with resultant vascular throm- coccal infections reflects an antigenic shift that has increased the
bosis and necrosis. Production of the θ-toxin leads to intravascu- virulence of these organisms.
lar leukostasis and inhibits diapedesis of white blood cells into Soft tissue infections associated with STSS typically involve an
infected tissue.This unique collection of bacterial toxins accounts extremity. Approximately 70% of patients will progress to necro-
for the rapid progression of C. perfringens infection in a setting of tizing fasciitis or myositis and will require operative treatment.
minimal inflammatory changes. Only about 50% of patients with streptococcal soft tissue infec-
That most necrotizing soft tissue infections involve multiple tions have a demonstrable portal of entry for bacteria.38,46
bacterial species strongly suggests that bacterial synergy plays an Severe pain is the most common initial symptom of STSS. It is
important role in their pathogenesis. Toxin-induced cellular ne- of sudden onset and generally precedes tenderness or other phys-
crosis establishes an anaerobic environment that facilitates the ical findings. Fever is another common early sign. About 80% of
growth of both facultative and anaerobic bacteria. These anaer- STSS patients show clinical signs of soft tissue infection (e.g.,
obes elaborate additional enzymes and other by-products that localized swelling, erythema, and tenderness) [see Figure 8]. In
facilitate tissue invasion and destruction. approximately 50%, blood pressure is initially normal, but hypo-
Preexisting local tissue damage frequently serves as a nidus for tension invariably develops within 4 to 8 hours after presentation.
soft tissue infection.The reduced oxygen tension of this abnormal Hemoglobinuria and an elevated serum creatinine concentra-
environment allows pathogens to proliferate. In addition, various
patient factors predispose susceptible individuals to these infec-
tions. Chronic illnesses can contribute to a diminished immuno-
logic response. Peripheral vascular disease impairs the local blood
and oxygen supply. Diabetes mellitus inhibits white blood cell
function. Chronic pulmonary disease can result in systemic hy-
poxemia. Patients with congestive heart failure or significant coro-
nary artery disease may be unable to increase their cardiac output
in response to infection. Malnutrition can result in a lack of nutri-
ents and critical enzymatic cofactors involved in the normal cellu-
lar response to infection. Each of these patient factors impairs the
host response and thereby increases the likelihood that infection
will develop.
In the 1920s, Meleney demonstrated that injection of animals
with pathogens isolated from patients with infectious gangrene
reproduced the characteristics of infection.2 Decades later, the
importance of bacterial synergy and exotoxins was demonstrated
in experiments performed by Seal and Kingston,42 who showed
that a spreading infection developed in 12% of animals that
received an intradermal injection of group A β-hemolytic strepto- Figure 8 Shown is the superficial appearance of streptococcal
cocci.When S. aureus was coinjected with β-hemolytic streptococ- gangrene of the posterior thigh.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 2 SOFT TISSUE INFECTION — 13
tion are hallmarks of renal involvement. Even when adequate re- gens bypass the normal antigen presentation pathway and do not
suscitation is provided and antibiotics and vasopressors are given, undergo phagocytosis. The superantigen processing pathway can
hypotension persists in the overwhelming majority of patients. stimulate more than a thousand times more T cells than the con-
Renal dysfunction can persist or progress for 48 to 72 hours ventional antigen pathway and thus can trigger a massive release
despite treatment. Hypoalbuminemia and hypocalcemia are of cytokines.The idea that T cell stimulation by superantigens can
common. Mild leukocytosis is present initially; however, the per- explain the severe degree of illness and exaggerated response seen
centage of immature neutrophils is generally 40% or higher. in these patients is attractive, but at present, there is no definitive
S. pyogenes can be classified into more than 80 different strains, proof that this process occurs in humans.
or M types, on the basis of the M proteins expressed. M proteins Although S. pyogenes is susceptible to penicillin and other β-lac-
impede phagocytosis of streptococci and induce vascular leakage tam antibiotics in vitro, clinical treatment failure sometimes
by forming complexes with fibrinogen.47 They also cleave nico- occurs when penicillin is used alone against S. pyogenes infec-
tinic acid dinucleotide (NAD), thereby interrupting elemental tions.43 Such failure is a particular problem with more aggressive
cellular processes. The M proteins M1 and M3 are associated group A streptococcal infections and may be attributable to the
with the majority of streptococcal necrotizing soft tissue infec- large inoculum size (the so-called Eagle effect).These large inoc-
tions.43 Streptococcal pyrogenic exotoxins (SPEs) are produced ula reach the stationary growth phase very quickly. Penicillin and
by most streptococci that cause severe soft tissue infection and other β-lactam antibiotics are ineffective in the stationary growth
can be transmitted by bacteriophages to different M types. They phase because of the reduced expression of penicillin-binding
are the cause of the fever, shock, and tissue injury associated with proteins in this phase. Moreover, toxin production is not inhibit-
these infections. SPE-A and SPE-B induce the synthesis of tumor ed by β-lactam antibiotics during the stationary growth phase. In
necrosis factor–α (TNF-α), interleukin-1β (IL-1β), and IL-6. contrast, antibiotics that inhibit protein synthesis have been asso-
Peptidoglycan, lipoteichoic acid, and killed organisms also are ciated with improved survival after serious group A streptococcal
capable of inducing TNF-α production. infections.
It has been proposed that M proteins or SPEs act as superanti- Clindamycin is more effective than β-lactam agents in manag-
gens. These exotoxins, along with certain staphylococcal toxins ing experimental and clinical infections caused by group A strep-
(e.g., toxic-shock syndrome toxin–1 [TSST-1] and staphylococcal tococci, particularly when necrosis is present.48 Clindamycin
enterotoxins), can stimulate T cell responses through convention- inhibits protein synthesis, and its efficacy is unaffected by inocu-
al antigen-presenting cells, as well as through direct binding to the lum size or the stage of bacterial growth. In particular, it sup-
Vβ region of the T cell receptor. Conventional T cell activation presses bacterial toxin synthesis and inhibits M-protein synthesis,
through antigen-presenting cells is a multistage process that stim- thus facilitating phagocytosis of S. pyogenes. Clindamycin also
ulates a relatively small percentage of T cells and limits the mag- suppresses synthesis of penicillin-binding proteins, and it can act
nitude of the resultant cytokine response. In contrast, superanti- synergistically with penicillin.
References
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30. Zubowicz VN, Gravier M: Management of early 37. Altemeier WA, Fullen WD: Prevention and treat- 44. Kaul R, McGeer A, Low DE, et al: Population-
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© 2003 WebMD Corp. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 3 OPEN WOUND REQUIRING RECONSTRUCTION — 1
Acute Reconstruction ment. However, accurate assessment of the chances for recovery
of specific structures within the wound is often difficult immedi-
EVALUATION AND INITIAL ately after injury.
TREATMENT OF OPEN
WOUND Evaluation
Problem wounds are The initial step in the management of problem wounds is to
characterized by one of the decide whether the wound is suitable for immediate soft tissue
following: large size that coverage. Wounds that are surgically created during the course of
precludes direct primary an elective procedure are almost always best treated with primary
closure, gross infection or uncertain bacteriologic status, or threat- definitive coverage. Traumatic wounds that present within 1 or 2
ened loss of critical structures exposed as a result of insufficient hours of injury and have a minimal crush component are also best
soft tissue coverage. Surgically created wounds, which generally treated with a primary definitive coverage procedure after thor-
pose less of a problem from a bacteriologic standpoint than trau- ough operative debridement.
matic wounds, are best managed by an immediate coverage pro- Injuries with a significant crush component and exposure of
cedure when direct closure is impossible. critical structures such as nerves, vessels, tendons, or bone are best
Traumatic wounds are more difficult to evaluate than surgical treated more aggressively. In these cases, thorough debridement
wounds for several reasons. First, in traumatic wounds, the poten- requires considerable surgical experience because the tendency is
tial for infection is high because of the environment in which the to debride inadequately. The degree of accuracy to which tissue
wound is created, the mechanism of injury, and the time that viability can be assessed varies among different types of tissue. For
elapses before operative intervention. Second, the mechanism of example, skin can be evaluated by its color, the nature of its capil-
injury (e.g., crush, avulsion, or gunshot) may extend the zone of lary refill, the quality of its dermal bleeding, or its bleeding
injury beyond what is immediately apparent [see Figure 1]. Serious response to pinprick. After I.V. fluorescein injection, skin viability
postoperative infection may develop in these cases if definitive can also be assessed qualitatively, with a Wood’s light, or quantita-
wound coverage is provided in the absence of adequate debride- tively, with a dermofluorometer. Muscle is the most difficult tissue
ment. Third, the long-term functional prospects for the injured to evaluate. Color, capillary bleeding, and contractile response to
part are a key determinant in selecting the method of acute treat- stimulation are not always reliable indicators of muscle viability. In
a b c
Figure 1 (a) A so-called bumper injury of the leg is shown after initial debridement and bony stabiliza-
tion (2 days after injury). (b) After the second debridement, the true extent of devitalization of bone and
soft tissue is apparent (4 days after injury). (c) A latissimus dorsi free flap has been used to reconstruct
the soft tissue defect (5 days after injury).
© 2003 WebMD Corp. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 3 OPEN WOUND REQUIRING RECONSTRUCTION — 2
Wound does not contain exposed bone, cartilage, nerve, or tendon but cannot be closed directly
Wound is a small defect but Wound has a large surface Wound is known to be
is in an area where graft area or is a small wound in significantly contaminated
contracture is not desirable a noncritical area
(e.g., face, hand, or flexion Apply meshed split-thickness
crease) Apply split-thickness skin graft. skin graft or consider delayed
skin graft replacement and
Apply full-thickness skin graft; open treatment of wound until
donor sites include the ear, bacteriologic status is clear.
upper eyelid, neck, and groin.
Defect is a small localized There is a shortage of skin One or more of the following
scar or a focal scar and subcutaneous tissue conditions is present:
contracture only, but skin graft coverage • Composite defect
is not desirable • Functional defect of muscle
Revise with Z-plasty or other or bone
local tissue rearrangement Use tissue expanders (except • Contour deformity
procedure. on hand or foot). • Unstable soft tissue
coverage of vital structure
• Inadequate soft tissue
coverage for bone or nerve
grafting
Bone, cartilage, nerve, or tendon is exposed and cannot be covered by direct wound closure
Local donor site meets needs and is not involved in Local flap is not possible or would not provide
the primary process appropriate tissue
severe injuries, they can be misleading. Inadequate debridement coccus is the dominant isolate, the wound should generally be
may lead to severe consequences resulting from infection. treated openly until cultures become negative.
Therefore, serial debridement at 24- to 48-hour intervals is essen-
tial for accurately establishing the limits of muscle injury. Efforts Systemic antibiotics The role of systemic antibiotics in
should be made during debridement to preserve tissues such as wound management is not clearly defined. Broad-spectrum
major nerves and blood vessels unless they are severely contused. antibiotics should be given in cases of severe trauma or estab-
These structures are vital for function and are of small mass com- lished, uncontrolled infection. They may also be useful for minor
pared with other tissues (e.g., skin, fat, and muscle) at risk for wounds that cannot be closed within 3 hours of injury.
necrosis and subsequent infection.
Wound debridement, therefore, should involve careful analysis Topical antibiotics Certain antibiotics provide broad-spec-
of the injury from an anatomic point of view; debridement should trum activity when applied topically. Neomycin, 10 mg/ml, or a
not consist of indiscriminate excision of blocks of tissue. Between combination of bacitracin, 50 U/ml, and polymyxin B, 0.05
debridement procedures, the wound should be treated with sterile mg/ml, kills most common wound pathogens.These solutions can
dressings but in an open manner (i.e., without closure by sutures be used when wet dressings are indicated.
and with wet-to-dry dressings changed three or four times a day).
A definitive soft tissue coverage procedure should then be per- Topical antiseptics A variety of topical antiseptics have been
formed as soon after the initial injury as wound conditions permit. used empirically in wound care. In the concentrations usually rec-
When thorough debridement and definitive coverage can be com- ommended, however, these solutions are detrimental to wound
pleted within less than a week, the wound will generally heal healing. Povidone-iodine (1%), hydrogen peroxide (3%), acetic
uneventfully. Inadequate debridement frequently results in the acid (0.25%), and sodium hypochlorite (0.5%) all have been
loss of any additional tissue invested to achieve acute soft tissue shown to be lethal to fibroblasts as well as to bacteria. More dilute
coverage. The wound becomes grossly infected, and important concentrations of povidone-iodine (0.001%) and sodium
functional structures within the wound are reexposed. hypochlorite (0.005%) are effective against bacteria while being
Infected surgical wounds, neglected wounds, or other complex safe for fibroblasts.6 A number of these agents also inhibit normal
wounds in which initial wound management fails should be white blood cell function in the wound.
debrided and then treated by open methods. Proper care of these
wounds is achieved by a multifaceted approach aimed at convert- Wet dressings Open wounds are treated with wet dressings,
ing established gross infection to a much lower level of bacterial generally consisting of gauze soaked in saline or an acceptable top-
contamination, which is then compatible with successful sec- ical antiseptic.Wet-to-wet dressings prevent desiccation of exposed
ondary wound closure. vital structures or freshly placed skin grafts. Wet-to-dry dressings
are useful for assisting in daily wound debridement. These dress-
Initial Treatment ings are allowed to dry on the wound; when they are removed,
Debridement Devitalized tissue provides an ideal culture adherent fibrinous debris is removed with the dressing.Wet dress-
medium for bacteria and isolates them from host defense mecha- ings of either type should be changed at least three times a day.
nisms. Surgical debridement must be performed as often as nec- Small wounds can be expected to close by contraction and sec-
essary to remove all necrotic tissue. ondary epithelialization after appropriate open management with
the techniques described. Large wounds will improve with aggres-
High-pressure irrigation A useful adjunct to debridement sive open care but will then stabilize into a chronic state of wound
is high-pressure irrigation, which has been shown experimentally to colonization of varying degrees. A soft tissue coverage procedure is
decrease wound infection rates significantly.1,2 The necessary pres- then necessary to complete closure in these cases.
sure of 8 psi can be achieved by forceful irrigation through a 35 ml
SELECTION OF COVERAGE
syringe fitted with a 19-gauge needle. Low-pressure irrigation with
PROCEDURE
a bulb-type syringe, for example, has not proved to be beneficial.
The goals of coverage
Quantitative bacteriology The degree of bacterial wound procedures [see 3:7 Surface
contamination can be accurately quantified. The standard tech- Reconstruction Procedures] in
nique of quantitative bacteriology requires several days to com- the management of acute
plete. In addition to a count, it provides identification and antibi- as well as chronic wounds
otic sensitivities of the organism. Quantitative bacteriology can are to achieve a healed
also be performed by using the rapid slide technique, which pro- wound and to avoid infec-
vides valuable information about the wound within 20 minutes.3,4 tion. The treatment of functional problems is generally deferred
The level of bacterial contamination has been shown to be a sig- for secondary reconstruction.
nificant predictor of outcome in wound closure by either skin-graft The method of coverage depends on whether vital structures,
or flap-coverage techniques. According to the golden-period prin- such as vessels, tendons, nerves, and bone, are exposed in the
ciple of wound closure, a minimum time interval is necessary for wound. If no vital structures are exposed, skin-graft coverage is
bacteria to proliferate to a certain threshold level. Contaminated indicated. Skin grafts can also be used over tendon if the paraten-
wounds take a mean time of about 5 hours to reach a bacterial on is intact, over nerve if the epineurium is intact, and over bone
count of 105/g of tissue. Attempts to close wounds that have counts if the periosteum is intact. Skin grafts are the most expendable
higher than 105/g of tissue will fail 75% to 100% of the time, type of soft tissue available for the coverage of open wounds.They
whereas wounds with lower counts are successfully closed more allow the wound to heal completely and set the stage for secondary
than 90% of the time.5 β-Hemolytic streptococci are an exception reconstruction, during which more valuable tissue can be used to
in that much lower concentrations of these organisms consistent- achieve other goals at minimal risk. When vital structures are
ly result in failure of wound closure. When a β-hemolytic strepto- exposed in the wound, a flap is preferred because it provides more
© 2003 WebMD Corp. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 3 OPEN WOUND REQUIRING RECONSTRUCTION — 5
Flaps
Flaps consist of tissues
that have a self-contained
vascular system [see 3:7
Surface Reconstruction Pro-
cedures]. They permit a
more substantial transfer of
tissue bulk than do skin
grafts and may consist of
either skin and subcutaneous tissue, fascia, muscle, bone, or a
combination of several of these tissue types. Local flaps consist of
tissue that is mostly detached from surrounding tissue but retains
enough connection to preserve an adequate blood supply to the
entire flap. Local flaps are either transposed, rotated, or advanced
into adjacent defects for purposes of reconstruction. Free flaps
are totally detached and have their blood supply reconnected at
the recipient site by surgically performed microvascular anasto-
moses between recipient-site blood vessels and the major vessels
that supply the flap.
LOCAL FLAPS MYOCUTANEOUS FLAPS FREE FLAPS
Local flaps versus free flaps The choice between a local
flap and a free flap is determined by the amount and the type of
Figure 3 Regional alternatives in flap selection are illustrated.
tissue needed, as well as by the availability of flaps in the immedi- Defects in the central portion of the body are treated with myocu-
ate area of the wound [see Figure 3]. Availability of local flaps, in taneous flaps primarily; defects of the peripheral areas are treat-
turn, is determined by the nature of the regional blood supply.The ed with either local flaps or free flaps. In some areas, several
vascular anatomy of a particular area determines the availability of options exist, and the choice is influenced by the size of the defect
arterialized skin flaps, fasciocutaneous flaps, myocutaneous flaps, and the specific tissue requirements.
© 2003 WebMD Corp. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 3 OPEN WOUND REQUIRING RECONSTRUCTION — 6
Arm Medial arm (Tagliacozzi) Latissimus dorsi; pectoralis major Lateral arm; forearm
Tensor fasciae latae; rectus femoris; vastus lateralis; vastus Anterior thigh; anteromedial thigh;
Thigh —
medialis; gracilis; biceps femoris; rectus abdominis posterior thigh
Midleg — Soleus; tibialis anterior Anterior leg; lateral leg; posterior leg
Distal leg — — —
Dorsalis pedis; plantar rotation; lateral Flexor digitorum brevis; abductor hallucis; abductor digiti
Foot —
calcaneal artery; plantar V-Y minimi; extensor digitorum brevis
healthy, well-vascularized tissue to be brought into the compro- Free flaps used in acute reconstruction can be grouped into
mised area. Moreover, if free tissue is transferred, the size of the three major types [see Table 2]. The soft tissue coverage require-
wound is not extended, because the donor site is not contiguous ments of most wounds can be met by so-called workhorse free
but instead is located at a distance from the wound. flaps. These flaps typically have the advantages of large size, ease
If expertise in microvascular surgery is available, free flaps are of dissection, and a vascular pedicle that is long and of large
frequently a first-line choice. Free flaps allow selection of the diameter.The disadvantages, such as awkward patient positioning
appropriate type of tissue in the most suitable size and configura- for flap harvest, are minor. Most workhorse flaps consist of mus-
tion for the specific reconstructive problem. Compared with free cle with an optional skin component; they are the flaps of choice
flaps, local flaps are inefficient ways of moving tissue because only for contaminated wounds [see Figure 4]. A second group of free
a small portion of a local flap actually reaches the defect itself.The flaps is useful for acute reconstruction of unusually large wounds.
choice of donor site is greater with free flaps because the limita- These flaps consist of combined vascular territories supplied by a
tions imposed by local availability are avoided. single vascular pedicle. A third category consists of smaller free
Reliable workhorse flaps Rectus abdominis Ideal pedicle; supine position; ease of dissection No major disadvantages
Lateral arm Thin, sensate; convenient for hand trauma Small vessels; donor-site scar
a b Small facial defects that do not directly involve the facial features
can often be closed with several types of flaps that rearrange the
existing tissue in the area—for example, Z-plasty or a Limberg
flap.Tissues that are difficult to match, such as those of the eyelids
or lips, can often be reconstructed with flaps that borrow tissue
from their opposite, intact counterparts; the Abbe lip flap is such
a flap.
For coverage of some large defects in the head and neck region,
the trapezius, the latissimus dorsi, and the pectoralis major can be
used. Each muscle can be raised with an optional skin island.
These flaps are generally too bulky to be used on the face, and
their reach is limited when used as pedicled flaps: none of them
can cover major portions of the scalp or comfortably reach the
upper face.
Latissimus dorsi, scapular, and rectus abdominis free flaps are
useful for very large defects of the scalp or upper face. Smaller
defects of the scalp are best treated with local scalp flaps.
Other free flaps of a specialized nature are superior for recon-
c d struction of the floor of the mouth and mandible, even though
local myocutaneous flaps will reach this area. For example, the
forearm free flap based on the radial artery is quite thin and pli-
able and therefore provides an ideal replacement for the floor of
the mouth. Composite free flaps that contain both bone and
skin, such as those taken from the scapula, ilium, radius, and
fibula, provide tissue of the appropriate type and proper config-
uration for defects of the lower face in which the mandible must
be reconstructed along with the intraoral lining, the external
skin, or both.
flaps that provide tissue that is superior in either amount or type Arm, forearm. Large
to the local flaps that are otherwise available. An additional wounds above the elbow
advantage of these flaps is that they tend not to be bulky.They are can be covered with a latis-
frequently used in areas such as the head, hands, distal third of simus dorsi myocutaneous
the leg, and feet [see Figure 5]. flap transposed as a pedi-
Flap coverage procedures are illustrated in greater detail else- cled flap, provided that the
where [see 3:7 Surface Reconstruction Procedures]. vascular pedicle of the mus-
cle has not been affected by
Regional alternatives the injury. Forearm wounds
in flap selection Head, that require flap closure are best treated with free flaps. A rectus ab-
neck. Facial defects of small dominis, scapular, or latissimus dorsi muscle flap can be used for
to moderate size are best large defects of the arm or forearm. Although soft tissue coverage
treated with local skin flaps. with simultaneous functional forearm muscle replacement can be
A variety of flaps are avail- achieved with a single flap such as the gracilis muscle, this proce-
able for reconstruction of dure is not generally recommended; rather, a skin flap such as a
limited defects of the eyelids, scapular free flap is preferred as a first stage of reconstruction to
cheeks, nose, and mouth.7-9 achieve wound healing.
© 2003 WebMD Corp. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 3 OPEN WOUND REQUIRING RECONSTRUCTION — 8
a b
c d
Figure 5 (a) A soft tissue sarcoma has recurred in the scar of a previous excision. (b) Reexcision of the
defect has exposed bone and tendons. No regional flaps are available for satisfactory coverage of this
defect. (c) The forearm is a source of small, thin free flaps. (d) Flap transfer is complete. The radial
artery and venae comitantes have been anastomosed to their dorsalis pedis counterparts.
Hand. Both free flaps flaps that can be raised from either the volar or lateral surfaces of
and pedicled skin flaps are the end of the finger.
useful for soft tissue cover-
age of hand wounds. The Abdomen. Defects of the
temporalis fascia free flap is abdominal wall that require
particularly thin and is ideal flap closure are best treated
for coverage of exposed with local muscle flaps such
tendons on the dorsum of as the tensor fasciae latae and
the hand. The lateral arm the rectus femoris from the
free flap is ideal for reconstruction of a large defect of the first web thigh. The rectus abdomin-
space; it has sensory potential because it contains a large sensory is also can occasionally be
nerve. Both of these free flaps are small. Pedicled distant skin flaps transposed to cover an abdo-
from the chest or abdomen are available as an alternative form of minal defect. Each of these flaps is harvested along with skin,
coverage of sizable hand defects. However, pedicled skin flaps have although a large tensor fasciae latae flap will probably require skin-
major disadvantages: wound care is difficult, edema persists graft closure of the donor site.The tensor fasciae latae flap has the
because elevation and movement of the hand are seldom possible advantage of including the thickened deep fascia (iliotibial band) of
while it is attached to the trunk, and a second procedure is need- the thigh, which can provide additional strength for abdominal wall
ed to divide these flaps. closure.
Digital injuries with exposed tendons can be closed with a vari-
ety of cross-finger flaps of skin and subcutaneous tissue raised Gluteal area, perineum.
from either the volar or extensor aspect of an adjacent digit. Local muscle flaps with or
Because these flaps do not contain a great deal of subcutaneous without skin are indicated
tissue, they are preferred for coverage of digits proximally, where a for defects in this area.They
thick subcutaneous pad is not essential. The thenar flap is useful are preferable to large, ran-
for fingertip injuries in which the soft tissue pad of the fingertip is dom-pattern advancement
lost and bone is exposed.This flap provides an ideal pulp replace- skin flaps from the posterior
ment as well as better sensory recovery than skin grafts. Fingertip thigh and thoracolumbar
injuries can also be closed with several types of V−Y advancement rotation skin flaps. The glu-
© 2003 WebMD Corp. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 3 OPEN WOUND REQUIRING RECONSTRUCTION — 9
teus maximus, for example, can be used as a rotation, V−Y advance- Superficial defects that lie completely within the non–weight-
ment, or turnover flap in the treatment of pressure sores. As a bearing portion of the midsole do not need flap coverage. Defects
turnover flap, it can be proximally or distally based, or it can be split of the weight-bearing heel and midsole area that are less than 6 cm
along its longitudinal axis so that only a portion of it is used. Also in diameter can be closed with a medially based skin rotation flap
useful for covering defects in the gluteal area and the perineum is that is raised superficial to the plantar fascia.12 This flap maintains
the myofasciocutaneous gluteal-thigh flap, a combination of a glu- plantar sensation. Limited defects of the distal plantar surface can
teus muscle flap and a fasciocutaneous flap from the posterior thigh be treated with local toe flaps that also maintain sensation. Very
that is supplied by an extension of the inferior gluteal artery. large plantar defects are best resurfaced with a muscle free flap
Because of its size and location, the gracilis is well suited for cover- (e.g., latissimus dorsi or rectus abdominis) covered with a skin
age of defects of the perineum. The gracilis and the biceps femoris graft. Although this type of flap lacks sensation, it appears to pro-
are generally secondary choices for the treatment of pressure sores vide the most durable form of coverage because it resists shear
over the ischium.The tensor fasciae latae is frequently used for treat- forces well.13
ing open wounds over the greater trochanter.The entire quadriceps Defects of the dorsum that require flap coverage are best cov-
can be used to close defects resulting from hemipelvectomy. ered either with a fascial free flap (e.g., temporalis fascia) and an
overlying skin graft or with a skin free flap that is thin (e.g., from
Thigh. Flaps are rarely the forearm). The extensor digitorum brevis can be raised from
required for soft tissue cov- the dorsum as a pedicled flap fed by the dorsalis pedis artery.This
erage in the thigh area, flap, which measures approximately 5 × 6 cm, has an arc of rota-
because critical vital struc- tion that makes it useful for the coverage of defects of the malleo-
tures are located deep with- lus or the Achilles tendon area. A narrow transposition skin flap
in the thigh and are rarely fed by the lateral calcaneal artery is useful for coverage of defects
exposed by injury or by surg- approximately 3 cm in diameter that lie over the Achilles tendon
ical procedures. A number or the non–weight-bearing posterior heel.
of regional muscle flaps are
available, however, including the tensor fasciae latae, the rectus
femoris, the vastus lateralis, and the vastus medialis. The gracilis Secondary Reconstruction
and posterior thigh muscles are rarely used in this area. An ante- Selection of the proper method for secondary reconstruction
rior defect with exposure of the femoral vessels can be covered requires analysis of the type and extent of tissue deficiency that is
with either an ipsilateral or a contralateral rectus abdominis present. Superficial defects may require replacement or supple-
myocutaneous flap. A number of smaller local skin flaps that are mentation of only skin and subcutaneous tissue, whereas more
supplied with blood from the deep fascia can be raised over por- complex defects may require replacement of several types of tis-
tions of the thigh; except for the posterior thigh flap, however, the sue. Specialized tissue such as vascularized nerve (i.e., a nerve free
clinical usefulness of these flaps remains to be demonstrated. flap) or intestine may be necessary to provide a functional recon-
struction in some cases (see below).
Knee, proximal leg, midleg. The two heads of the gastrocnemius
SMALL LOCALIZED SCAR
can be used either together or independently to cover defects of
the knee and proximal leg. The soleus is useful for coverage of When reconstruction is
defects of the proximal leg and midleg. Local flaps should not be indicated for a small local-
used for major leg wounds if the extent of the injury suggests ized scar, soft tissue cover-
involvement of the muscle donor site. Instead, a free flap should age is generally sufficient
be used to bring healthy tissue into the area. Therefore, free flaps and poses no threat of
are a first choice, for example, for coverage of major wounds of the breakdown leading to expo-
popliteal fossa, knee, and proximal leg that involve the sural artery sure of important struc-
blood supply to the gastrocnemius. tures. Instead, the recon-
structive problem is generally functional in nature. An example is a
Skin flaps fed by the fascial blood supply can also be raised over tight scar band across a flexion crease, commonly seen after a burn
the leg.11 A number of fasciocutaneous flaps have been described injury. A local procedure that rearranges the existing tissue can re-
in this area, but they tend to be smaller than muscle flaps and gen- lieve the tension by making more tissue available in one direction,
erally less reliable.These flaps are longitudinally oriented over the though the amount of tissue in the area is not actually increased.
course of the anterior tibial artery or the peroneal artery.The max- The Z-plasty is an example of such tissue rearrangement [see
imum length at which such fasciocutaneous flaps are safe and 3:7 Surface Reconstruction Procedures]. Multiple Z-plasties or
their specific applications have not been well established. other procedures, such as W-plasty, may be useful for some local-
ized scars.
Foot. The foot is as com-
SHORTAGE OF SKIN AND
plex as the hand and the
SUBCUTANEOUS TISSUE
face in that it is composed
of separate regions, each of A shortage of skin and
which has a unique set of subcutaneous tissue may re-
alternatives for reconstruc- sult from excision of a large
tion. These regions include scar or of a large congenital
the plantar surface; the defect (e.g., a nevus). Mas-
dorsum; and the posterior tectomy commonly leaves a
(non–weight-bearing) heel, Achilles tendon, and malleoli. shortage of skin that pre-
© 2003 WebMD Corp. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 3 OPEN WOUND REQUIRING RECONSTRUCTION — 10
vents creation of a breast mound. In these cases, extra tissue can be contour defects (see below), because the tissue they provide is two-
created locally with the use of tissue expanders. These devices are dimensional and lacking in bulk. Nor is expanded tissue adequate
inflatable plastic reservoirs of various shapes and volumes that are for coverage of chronically exposed structures (e.g., bone).Tissue ex-
implanted under the skin. The skin over the expander is stretched panders do not provide adequate replacement tissue to establish a
during a period of several weeks as the expander is gradually filled suitable bed for nerve or bone grafting.Therefore, they are not a sub-
by percutaneously injecting saline into an incorporated or remote stitute for flaps in general.
fill port.The expander is then removed as a second procedure, and The scalp is an ideal location for the use of tissue expanders
the expanded area of skin is advanced to cover the defect. because no equivalent substitute for this type of hair-bearing tis-
A number of important principles govern the use of tissue sue exists. Expanders work effectively when implanted over the
expanders.The expanders must be placed so as to allow expansion hard calvarium and are useful in cases of burn alopecia and large
only in normal skin adjacent to the defect, not in the defect itself. nevi involving the scalp. Expanders are also useful for breast re-
A sufficiently large expander or multiple expanders must be used construction, for carefully selected large lesions of the face, and for
to ensure adequate expansion. Complications associated with the certain scars of the limbs.They are generally not indicated for use
use of tissue expanders include infection, extrusion, deflation, in the hands or feet. Although some local flap donor sites, such as
flipped ports (remote type), and hematoma formation.14 the forehead, can be expanded before flap transfer, there is a loss
Tissue expanders are used in secondary reconstruction only; they of tissue pliability that appears to limit the usefulness of this par-
play no role in acute wound management.They are not indicated for ticular application.
a b
c d
COMPLEX DEFECTS either local or free flaps. A mastectomy defect, because of its
Certain reconstructive problems require substantial amounts of location on the chest, is suitable for reconstruction with one of
tissue of one or more types or of a very specialized type. Either several myocutaneous flaps from either the back or the abdomen
local or free flaps are used to meet these tissue requirements. [see 3:5 Breast Procedures]. A free flap from the abdomen or the
gluteal area is another alternative. The best reconstructive solu-
Composite Defect tion for a particular person is determined by variables such as
A composite defect may body habitus and the size and configuration of the contralateral
result from resection of an breast.
intraoral carcinoma with A contour defect of the lower extremity is best reconstructed
loss of the mandible and ei- with a large myocutaneous free flap that provides tissue of suffi-
ther the lining of the mouth cient quantity and flexibility to allow sculpting into the appropri-
or external skin. Another ex- ate shape.
ample is a crush injury of
Unstable Soft Tissue Coverage
the leg with loss of soft tis-
sue and a segment of weight-bearing bone. These defects require Marginal soft tissue coverage (e.g., skin grafts) may break down
that a composite flap be brought to the area to meet more than one after repeated minor trauma. Bones may become exposed and are
type of tissue deficiency. Local flaps generally do not provide the then at risk for osteomyelitis. This situation can be avoided by
necessary types of tissue or permit the freedom of design possible elective replacement of the tissue at risk with a more substantial
with free flaps.The wide variety of free flap donor sites that exists al- soft tissue covering. As in acute reconstruction, local flaps are the
lows tissue in the appropriate quantity and configuration to be se- first choice for lesions of the trunk or the proximal extremities,
lected for a particular defect [see Figure 6]. whereas free flaps are often more appropriate for lesions of the
distal extremities.
Functional Defect Soft tissue coverage is sometimes inadequate even in a healed
Functional defects require repair with specialized flaps. Free flaps wound. For example, certain procedures, such as nerve or bone
are frequently used because the specific tissue requirements usually grafting, require an ideal soft tissue bed to promote adequate graft
cannot be satisfied by a local flap. A functional defect may result, for revascularization. In some cases, it may be necessary first to
example, in the cervical esophagus from tumor resection or in the replace the existing soft tissue coverage as a first-stage procedure
forearm from Volkmann’s contracture. A segment of small intestine before grafting a bone or nerve gap. A skin or muscle flap is most
can repair the esophageal defect; transfer of a vascularized and commonly used in these cases. This problem is most common in
innervated muscle (e.g., the gracilis) can replace forearm muscle.15 areas such as the distal extremities, where native soft tissue cover-
age is not overly abundant and is easily lost from trauma or tumor
Contour Defect resection. Free flaps are usually chosen to provide a healthy, well-
Contour defects, such as those that result from mastectomy or vascularized soft tissue bed before further functional reconstruc-
from trauma to the lower extremity, can be reconstructed with tion is undertaken.
Discussion
normal skin, such as secretion from sweat glands and sebaceous thick grafts, which take longer to heal and can be associated with
glands, and of hair growth.These processes will be active only in significant scarring. The epidermis of a healed donor site is fully
full-thickness and thick split-thickness grafts. Secretion from differentiated within 3 to 4 weeks. The dermis shows little evi-
sweat glands depends on sympathetic reinnervation of the graft dence of regeneration, however. An occlusive dressing such as Op-
and follows the sweat pattern of the recipient site. Sebaceous Site promotes more rapid healing of the donor site than coverage
glands, on the other hand, secrete independently of graft rein- with fine mesh gauze.20
nervation by the recipient bed. Thin split-thickness skin grafts
FLAPS
tend to be quite dry because they contain inadequate numbers
of functioning sebaceous glands, which are more abundant in
thicker grafts. Resistance to Infection
Skin flaps, myocutaneous flaps, and fasciocutaneous flaps have
Revascularization been shown experimentally to vary in their resistance to bacterial
A phase of serum imbibition lasts for the first 2 days after infection.21 Random-pattern skin flaps are not as resistant as
placement of a skin graft. During this period, the graft is nour- myocutaneous flaps. The cutaneous portions of myocutaneous
ished by passive absorption of nutrients from serum in the recip- and of fasciocutaneous flaps have similar levels of resistance, but
ient bed and not by direct vascular perfusion. The graft gains as the muscle component of myocutaneous flaps is more resistant
much as 40% of extra weight because of fluid absorption.Vessels than the fascial component of fasciocutaneous flaps in situations
within the graft gradually dilate and fill with static columns of where the flap lies over a focus of infection within the wound.
blood. A fibrin network in the wound bed causes graft adherence Muscle therefore appears to be the type of flap most resistant to
during this early phase. infection. Such resistance is of clinical significance in cases of
The next phase in revascularization is a period of inosculation, exposed bone with chronic osteomyelitis, for example.This condi-
during which anastomoses are formed between vessels in the tion can be successfully treated by debridement and immediate
graft and those in the wound bed. It is not clear, however, coverage with a muscle flap.
whether connections are established between existing vessels in
the recipient bed and graft or whether new vessels grow into the Free Flaps and Concept of No-Reflow
graft from the recipient bed. Both processes may occur, and both Free tissue transfer is unique in that the flap is completely
may be important in graft revascularization. In any case, circula- ischemic for a given period. How long ischemia can be tolerated
tion is sluggish during postoperative days 3 and 4 but gradually without resultant flap failure (despite technically satisfactory
increases during postoperative days 5 and 6 to become essential- microvascular anastomoses) is an important clinical question.
ly normal by day 7.18 An increasing duration of ischemia has been associated experi-
Lymphatic drainage from the graft is established at approxi- mentally with obstruction to blood flow in the microcircula-
mately the same rate as the circulation of blood. Lymphatic flow tion.22,23 This obstruction results from cellular edema, increased
is present by postoperative day 5 or 6, and the graft starts losing interstitial fluid pressure, and sludging of blood and thrombus
the extra fluid weight it has gained.The graft begins to resume its formation. This phenomenon is initially reversible but becomes
normal weight by postoperative day 9. irreversible as the duration of ischemia increases. After 12 hours
of ischemia under experimental conditions, obstruction to blood
Factors Affecting Graft Survival flow has been demonstrated to be complete, preventing success-
Hematoma formation beneath a skin graft is the most com- ful reperfusion of the flap. How long uninterrupted ischemia can
mon cause of graft failure. Blood accumulation interferes with safely continue is not precisely known clinically, and evidence
graft adherence as well as with both imbibition and inosculation. suggests that the ischemic tolerance of specific types of tissue
Early evacuation of blood from beneath a skin graft can result in varies. For example, flaps that are primarily bone are more
graft survival. Shear forces that result from inadequate immobi- durable than muscle or bowel flaps. Evidence gained by clinical
lization cause graft failure by preventing or disrupting develop- experience has shown that up to 4 hours of ischemia is safely tol-
ing communications between vessels of the graft and the recipi- erated by most free flaps.
ent bed. Infection of the recipient bed makes the bed unsuitable
for grafting, and such infection is another major cause of graft Tissue Expansion
failure. Proteolytic enzymes produced by microorganisms Histologic changes of expanded skin include thinning of the
destroy the fibrin bond between the graft and recipient bed. dermis but not of the epidermis,24 suggesting a permanent net
Bacteria such as β-hemolytic streptococci and Pseudomonas are gain in epidermal tissue only.The mitotic rate in the epidermis has
particularly virulent because they produce high levels of plasmin been shown to increase with expansion, but the mechanism for
and other proteolytic enzymes. The type of organism present this increase is unclear.25
may actually be a more important factor in graft failure than the The circulation of expanded skin also changes. An increase in
number of organisms.19 vascularity of expanded tissue is partially explained by the fact that
tissue expansion is a form of delay procedure. However, experi-
Healing of Donor Sites mental studies suggest that an increased potential for flap surviv-
Donor sites for split-thickness grafts heal by reepithelialization. ability is directly attributable to the expansion process and not
Epithelial cells from remaining portions of skin appendages, such merely to its delay component.26-28 The fibrous capsule that forms
as hair follicles, sebaceous glands, and sweat glands, migrate across around the prosthesis during expansion appears to contribute to
the exposed dermis to establish a new epidermis. Donor sites for the increased vascularity of these flaps, and the increased pressure
thin grafts heal more rapidly and leave less of a scar than those for around the expander may stimulate angiogenesis.
© 2003 WebMD Corp. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 3 OPEN WOUND REQUIRING RECONSTRUCTION — 13
References
1. Edlich RF, Jones KC Jr, Buchanan L, et al: A dis- 11. Taylor GI, Giantoutsos MP, Morris SF: The 21. Gosain A, Chang N, Mathes S, et al: A study of
posable emergency wound treatment kit. J neurovascular territories of the skin and muscles: the relationship between blood flow and bacteri-
Emerg Med 10:463, 1992 anatomic study and clinical implications. Plast al inoculation in musculocutaneous and fascio-
2. Stevenson TR, Thacker JG, Rodeheaver GT, et Reconstr Surg 94:1, 1994 cutaneous flaps. Plast Reconstr Surg 86:1152,
al: Cleansing the traumatic wound by high pres- 1990
12. Hidalgo DA, Shaw WW: Reconstruction of foot
sure syringe irrigation. JACEP 5:17, 1976 injuries. Clin Plast Surg 13:663, 1986 22. Kerrigan CL, Stotland MA: Ischemia reperfu-
3. Hollander JE, Singer AJ, Valentine SM, et al: sion injury: a review. Microsurgery 14:165, 1993
13. May JW Jr, Halls MJ, Simon SR: Free microvas-
Risk factors for infection in patients with trau- cular muscle flaps with skin graft reconstruction 23. Kirschner RE, Fyfe BS, Hoffman LA, et al:
matic lacerations. Acad Emerg Med 8:716, 2001 of extensive defects of the foot: a clinical and gait Ischemia-reperfusion injury in myocutaneous
4. Edlich RF, Rodeheaver GT, Thacker JG: analysis study. Plast Reconstr Surg 75:627, 1985 flaps: role of leukocytes and leukotrienes. Plast
Technical factors in the prevention of wound Reconstr Surg 99: 1485, 1997
14. Bennett RG, Hirt M: A history of tissue expan-
infection. Surgical Infectious Diseases. Simmons sion: concepts, controversies, and complications. 24. Johnson TM, Lowe L, Brown MD, et al: Histo-
R, Howard R, Eds. Appleton-Century-Croft, J Dermatol Surg Oncol 19:1066, 1993 logy and physiology of tissue expansion. J Der-
East Norwalk, Connecticut, 1981 matol Surg Oncol 19:1074, 1993
15. Hidalgo DA, Disa JJ, Cordeiro PG: A review of
5. Robson MC, Heggers JP: Delayed wound clo- 25. Olenius M, Johansson O:Variations in epidermal
716 consecutive free flaps for oncologic surgical
sures based on bacterial counts. J Surg Oncol thickness in expanded human breast skin. Scand
defects: refinement in donor site selection and
2:379, 1970 J Plast Reconstr Hand Surg 29:15, 1995
technique. Plast Reconstr Surg 102:722, 1998
6. Teepe RG, Koebrugge EJ, Lowik CW, et al: 26. Babovic S, Angel MF, Im MJ, et al: Effects of tis-
Cytotoxic effects of topical antimicrobial and 16. McGrath MH, Hundahl SA: The spatial and sue expansion on secondary ischemic tolerance
antiseptic agents on human keratinocytes in temporal quantification of myofibroblasts. Plast in experimental free flaps. Ann Plast Surg
vitro. J Trauma 35:8, 1993 Reconstr Surg 69:975, 1982 34:593, 1995
7. Jackson IT: Local Flaps in Head and Neck 17. Rudolph R: Inhibition of myofibroblasts by skin 27. Matturri L, Azzolini A, Riberti C, et al: Long-
Reconstruction. CV Mosby, St Louis, 1985 grafts. Plast Reconstr Surg 63:473, 1979 term histopathologic evaluation of human ex-
8. Spinelli HM, Forman DL: Current treatment of 18. Angel MF, Giesswein P, Hawner P: Skin graft- panded skin. Plast Reconstr Surg 90:636, 1992
post-traumatic deformities: residual orbital, ing. Operative Plastic Surgery. Evans GRD, Ed. 28. Olenius M, Dalsgaard CJ, Wickman M: Mitotic
adnexal, and soft-tissue abnormalities. Clin Plast McGraw-Hill, New York, 2000, p 59 activity in expanded human skin. Plast Reconstr
Surg 24:519, 1997 19. Teh BT: Why do skin grafts fail? Plast Reconstr Surg 91: 213, 1993
9. Luce EA: Reconstruction of the lower lip. Clin Surg 63:323, 1979
Plast Surg 22:109, 1995 20. Smith DJ Jr, Thomson PD, Bolton LL:
10. Mathes SJ, Nahai F: Reconstructive Surgery: Microbiology and healing of the occluded skin- Acknowledgment
Principles, Anatomy, Technique, Vol 1. Churchill graft donor site. Plast Reconstr Surg 91:1094,
Livingstone, New York, 1997, p 37 1993 Figure 3 Carol Donner.
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 4 SKIN LESIONS — 1
4 SKIN LESIONS
Alan E. Seyfer, M.D.
Changes and irregularities in physical characteristics, history The lesion is stable and uniform in its physical characteristics
of chronic sun exposure, unfavorable location, and (e.g., size, shape, color, profile, texture). Monitor
presence of certain congenital lesions (e.g., dysplastic nevi) conservatively. Patient may choose elective excision
all raise suspicion of malignancy. for cosmesis.
No further treatment is necessary. Present biopsy to tumor board. If tumor is melanoma or other so-called
liquid tumor, consider ancillary treatment (e.g., perfusion therapy,
radiation therapy, chemotherapy) before reexcision.
Perform reexcision with appropriate margin and assess regional node
status.
Consider lymphatic mapping and SLN biopsy as staging option for
melanoma, squamous cell carcinoma, and Meckel cell carcinoma
[see 3:6 Lymphatic Mapping and Sentinel Lymph Node Biopsy].
Discussion
Nonmelanoma skin cancers are the most common cancers in with scaling of superficial skin cells at its center [see Figure 1a].
the United States, accounting for about 35% of all cancers diag- Perhaps the most dangerous type is the sclerosing, or mor-
nosed every year.1,2 Nonmelanoma skin cancers can be capri- pheaform, basal cell carcinoma—a light, plaquelike lesion that
cious, and it may be difficult to assess their biologic behavior can resemble a stellate scar [see Figure 1b]. Morpheaform basal
from their appearance alone. Certainly, it is possible for a cell carcinomas tend to be locally invasive, with multiple can-
benign-looking papule to exhibit aggressive biologic behavior. Mel- cer projections, resembling tentacles, that penetrate toward the
anomas, at the more malignant end of the spectrum, can metas- deep portions of the tissue. Therefore, it is possible—even like-
tasize early and even present initially with cerebral metastasis. ly—that tumor will be left behind after an excisional biopsy of
Sun exposure with actinic changes in the skin is a predis- the lesion.10 Such tumors can also ulcerate and resemble pig-
posing factor for skin cancers of all types.3-5 Fair-skinned per- mented melanomas [see Figure 1c].
sons lacking protective pigmentation are at much higher risk The distribution of basal cell cancers is strongly weighted
for the development of skin cancers.6 Failure of the immuno- toward the midface, cheek, and ear regions.11 Treatment is usu-
logic surveillance system, decreased cell-mediated immunity, ally surgical, with removal of a rim of normal skin around the
and use of immunosuppressive agents have all been implicated lesion. Morpheaform basal cell cancers should be treated with
as factors that may influence a patient’s predisposition to a wider margin of excision, and careful attention should be
malignant skin lesions.7,8 paid to the margins to confirm clearance of tumor cells. In
most cases, closure can be accomplished by wide undermining
Basal Cell Carcinoma of the skin and fat and direct closure. Otherwise, a skin graft is
a useful alternative.
Basal cell carcinomas originate in the pluripotential epithe- Radiation therapy for basal cell carcinomas claims an over-
lial cells of the epidermis and skin adnexa.1 These tumors tend all cure rate of over 90%.12 This therapy can be offered to each
to be characterized by slow growth and progressive morbidity patient, but the repeated treatments require multiple visits.
by local extension. Their viability seems to depend on attach- Radiation therapy is a safe, noninvasive form of treatment that
ment to the dermis, and systemic metastases are therefore rare. can be an attractive alternative for patients who are, for what-
However, certain types of basal cell carcinoma may be extremely ever reasons, considered bad candidates for surgical extirpa-
aggressive, resulting in morbidity, mutilation, and death by local tion. Radiation is a particularly attractive alternative for the
extension. This is particularly true of midface and sclerosing treatment of lesions in areas that are difficult to reconstruct,
basal cell cancers. such as the medial canthal margin of the eyelids, certain exter-
Clinically, there are several types of basal cell carcinomas [see nal ear lesions, and the nostril rim.
Figure 1]. The most common is the nodular type, which begins Another therapeutic option is Mohs’ micrographic surgical
as a flesh-colored, raised, telangiectatic lesion that may be diffi- operation. Frederic Mohs, a general surgeon, developed the
cult to distinguish from a common nevus.9 The nodular lesion is technique for lesions like basal cell carcinomas without meta-
rounded in appearance during its early phase and characteris- static potential that were of full thickness and involved the skin
tically assumes a raised rim with a craterlike central region, often and the mucous membranes of the nose.13 Perhaps the best indi-
a b c
Figure 1 (a) A pearly luster and telangiectasias are evident in this typical basal cell carcinoma on the cheek of
a 43-year-old man. (b) This sclerosing (morpheaform) basal cell carcinoma on the nose of a 55-year-old man was
found to be deeply invasive and exhibited multidirectional growth. (c) This basal cell carcinoma on the lower leg
of a 91-year-old woman showed ulceration and pigmentation similar to that of a melanoma.
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 4 SKIN LESIONS — 4
a b
c d
Figure 2 (a) This squamous cell carcinoma on the lip of a 70-year-old man was related to sun exposure;
the patient was a nonsmoker. (b) This squamous cell carcinoma involving the thumb and index finger of a
72-year-old man, a retired dentist, was related to exposure to occupational hazards; he had subjected these
digits to repeated radiation exposures by holding dental x-rays against his patients’ teeth. (c) The 61-year-old
man who had this indolent, slow-growing squamous cell carcinoma on the hand also had a synchronous penile
erythroplasia of Queyrat (localized)—a squamous cell carcinoma in situ; there was no evidence of metastasis
from either lesion. (d) This squamous cell carcinoma on the helix of the external ear in a 73-year-old man can
be seen extending to the scalp.
cation for the Mohs procedure is recurrent basal cell carcino- aggressive in comparison with that of basal cell cancers; fortu-
mas, especially those of the morpheaform type. The Mohs tech- nately, they are less common. Persons of fair complexion are at
nique usually incorporates wide enough margins to ensure a rea- increased risk; all skin cancers are more likely to develop in sun-
sonable cure rate. The Mohs technique may also be appropriate exposed regions16 [see Figure 2a]. Certain occupational hazards
for microcystic adnexal carcinoma and dermatofibrosarcoma have been associated with an increased risk for squamous cell can-
protuberans.14 The drawbacks to the Mohs procedure are that it cer, including those experienced by dental personnel who habit-
requires a considerable amount of time, exposure, and expense ually expose their hands to x-ray energy and technicians who
but has a cure rate similar to that of simple surgical excision. paint radium watch dials [see Figure 2b].
Histologically, squamous cell lesions are characterized by
Squamous Cell Carcinoma masses of squamous epithelium that invade downward through
the dermis in a palisade arrangement. The degree of epithelial
Like basal cell cancers, squamous cell cancers are associated differentiation determines the grade of the tumor. This grade is
with actinic solar damage but may also arise out of old scars, measured as a ratio of atypical cells to normal cells. In higher
radiation-damaged skin, or chronic, open wounds15 [see Figure 2]. grades of tumor (i.e., those with a high degree of biologic
Chronic inflammation and irritation appear to be the common aggressiveness), differentiation and keratinization are greatly
denominators. The biologic activity of squamous cell cancers is diminished.1 Anaplastic (i.e., undifferentiated) tumors may re-
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 4 SKIN LESIONS — 5
quire further characterization. The presence of cytokeratin anti- tissue invasion (Clark level)21 [see Melanoma Staging, below].
bodies (indicative of squamous cells) or antibody to S100 pro- Melanomas tend to grow both vertically and radially; those
tein (which may identify melanocytes, indicative of melanoma) that have a rapid onset in the vertical phase present as thicker
may also help in assessing the more anaplastic tumors. Immuno- lesions and have a worse prognosis.22
peroxidase staining may help distinguish between the desmoplas- Over the past 40 years, the incidence of melanoma has
tic variety of melanoma and certain squamous cell cancers.1,17 increased; it is now the most rapidly increasing cancer among
Differentiation of a squamous cell cancer, depth of invasion, and white males and the fourth most rapidly increasing cancer
the presence of perineural invasion correlate with biologic among white females.23 Despite the poor prognosis associated
aggressiveness.1 with melanoma, survival after therapy has improved over the
Clinically, the lesion may appear as a gradually enlarging, non- past 50 years. Some innovative and exciting immunotherapeu-
healing, nontender sore [see Figure 2c], or it may present as an tic strategies have been attempted, but the viable treatment
actinic patch—typically on the cheek or the external ear [see options remain exclusively surgical.
Figure 2d]. Tumors that arise in old scars or open wounds are As with other dermal neoplasms, a positive correlation is
characteristically aggressive. Squamous cell carcinomas that seen between sun exposure and the incidence of malignant
develop from Marjolin’s ulcer (which arises in burn scars and melanoma. Some 98% of melanomas occur in whites, and
open wounds such as osteomyelitis drainage sites) are character- within this population, the lighter-skinned persons are most at
ized by extreme aggressiveness after surgical resection; this risk. Painful, blistering sunburns, early childhood exposure,24
aggressive behavior may be attributable to the relatively and sun-induced freckling are associated with a two to three
immunologically privileged status of the tumors before extirpa- times higher risk of cutaneous melanoma.25
tion. Surgical excision seems to activate certain lesions. Although
DIFFERENTIAL CHARACTERISTICS OF BENIGN NEVI AND
the lesion may have remained indolent for many years, tumor
MALIGNANT MELANOMA
recurrence and metastasis are common after treatment.18,19
Certain areas of the body are especially prone to early Unfortunately, the clinical presentation of malignant and
metastases and have a higher risk of regional nodal metastases. benign pigmented lesions can be quite similar [see Figure 3].
For example, squamous cell cancers of the scalp, nose, and However, certain differences do exist that can be helpful in
extremities seem to metastasize early. Regional metastases are making the distinction. For example, benign lesions tend to be
associated with a poorer prognosis.1,20 less than 1 cm in diameter and have regular borders, a homo-
Bowen disease, a carcinoma in situ, presents as a red patch geneous color, and a smooth texture. Malignant lesions, on the
or plaque with small areas of crusting. The recommended other hand, are often larger, exhibit variable pigmentation and
treatment is wide-margin (0.5 to 1.0 cm) surgical excision.16 irregular borders, and are less orderly in their presentation.
Benign Nevi
Malignant Melanoma
Benign nevi, the most common pigmented lesions, are di-
Although the clinical course of malignant melanoma is vided into three major histologic groups: (1) junctional, (2)
characteristically unpredictable, treatment strategies for pri- compound, and (3) dermal.This classification, though arbitrary,
mary lesions and nodal drainage systems can be developed refers to characteristic features of acquired melanocytic nevi.
with the assistance of some important prognostic markers: the Junctional nevi are the earliest stage of intraepidermal pro-
thickness of the lesion (Breslow thickness) and the depth of liferation, the stage in which cells form nests along the dermal-
a b c
Figure 3 (a) Benign keratoacanthoma, such as this one on the hand of a 67-year-old man, is a rapidly growing
lesion that can be mistaken for a malignancy. (b) This dark lesion on the distal ulnar area of a 31-year-old man,
a posttraumatic arteriovenous fistula, is similar in appearance to a pigmented dermal lesion. (c) This rapidly
growing pyogenic granuloma on the index finger of a 24-year-old woman developed after a small skin wound;
microscopically, the lesion represents granulation tissue.
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 4 SKIN LESIONS — 6
a b
Figure 4 (a) This nevus on the thigh of an infant is problematic because of its congenital nature. (b) This
sebaceous nevus, or Jadassohn-Tièche nevus, involving the temporal scalp in a 19-year-old white man
may undergo malignant change.
epidermal junction.These lesions are relatively sessile and have a higher incidence in middle age, and typically presents over
a homogeneous, brownish pigmentation. Junctional nevi are the trunk, head, and neck.26 Lentigo malignant melanoma rep-
characteristically smooth and have round or oval borders.They resents only 7% to 8% of all melanomas.28,29 It presents in older
usually appear after 3 years of age and before adolescence, patients and tends to be indolent. Lentigo malignant melanoma
darken with the onset of puberty or pregnancy, and gradually was originally described by Hutchinson in 1894, and although
fade in color and decrease in height in the later years of life. it has been termed Hutchinson’s freckle—a name that implies
Compound nevi have junctional as well as dermal compo- benignity—the lesion does have clear malignant potential.
nents. Dermal nevi are slightly raised, homogeneous in pig-
MELANOMA STAGING
mentation, and well circumscribed, but they are confined to
the dermis histologically.26 Any lesion that tends to drift from The most common criteria for the staging of melanomas are
this natural history should be regarded with suspicion, espe- the classification systems formulated by Clark and Breslow.
cially in the years after adolescence [see Figure 4]. Clark categorized tumors according to their level of invasion
Certain lesions, including dysplastic nevi, have a higher risk into five separate regions [see Figure 6]. Clark level I, in which
for malignant transformation.27 The familial dysplastic nevus the tumor involves the epidermis, is essentially carcinoma in
syndrome is characterized by an autosomal dominant pattern situ. Level II indicates extension of the tumor into the papil-
and a unique histologic appearance. Dysplastic nevi are typi- lary dermis. Level III signifies a spreading of tumor cells along
cally larger than ordinary nevi, and significantly, their borders the papillary-reticular dermal interface. Level IV indicates
and color are irregular. Over time, dysplastic nevi progress to invasion into the reticular dermis. Level V indicates extension
melanoma. into the subcutaneous tissue. According to Clark’s criteria, sur-
vival decreases as the depth of invasion increases.30
Malignant Melanoma Clark’s dermal layers may be cumbersome, but the Breslow
Malignant melanoma is characterized by radial and vertical thickness provides comparable therapeutic and prognostic dis-
growth phases.21,22,26 During the radial growth phase, melano- crimination. Breslow classified the level of invasion by using an
cytes within the epidermis and papillary dermis grow in all direc- ocular micrometer to measure from the granular layer in the
tions. The result is slow radial enlargement of the lesion. Vertical epidermis to the deepest point of invasion in the dermis.
growth, which usually follows the radial growth phase, consists of Under Breslow’s criteria, thin melanomas invade 0.75 mm or
growth perpendicular to the direction of growth that occurred in less into the dermis (stage IA, T1). Intermediate-thickness
the radial phase. This pattern is characterized by deep invasion melanomas invade 0.76 to 3.99 mm; these are further subdi-
and subsequent development of metastases. vided into thin intermediate melanomas of 0.76 to 1.49 mm
Three types of melanoma are clinically distinguishable [see (stage IB, T2), intermediate intermediate melanomas of 1.5 to
Figure 5]. Superficial spreading melanoma is the most com- 2.49 mm (stage IIA, T3a), and thick intermediate melanomas
mon type of melanoma, and it may arise in a preexisting nevus. of 2.5 mm to 3.99 mm (stage IIA, T3b). Thick melanomas
The less common nodular melanoma usually exhibits more invade 4.0 mm and deeper (stage IIB, T4).31
rapid and aggressive growth. Nodular melanoma is not usually It is important to note that any suspicious lesion should ini-
associated with preexisting nevi, is more common in males, has tially be removed by means of a full-thickness excisional biop-
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 4 SKIN LESIONS — 7
a b c
d e f
Figure 5 (a) This melanoma, on the sole of the foot of a 47-year-old black woman, shows irregularities in shape,
contour, and pigmentation. (b) A so-called halo effect is visible along the left margin of this melanoma on the upper
back of a 33-year-old white woman; irregularities in shape, contour, and pigmentation are also evident. (c) This
melanoma of the postauricular scalp in a 56-year-old man exhibited ulceration and new growth (d) over the lower
portion of the lesion 2 weeks later. (e) This melanoma on the thigh of a 31-year-old woman shows a slightly
umbilicated center, irregular shape, and nonhomogeneous coloration. ( f ) This melanoma of the lower eyelid in
another patient is visible as the darkly pigmented area just below the eyelashes.
CLARK'S LEVELS
sy. This diagnostic excisional biopsy may be close, encompass- Although one might expect that patients with malignancies
ing as little as a 1 mm margin of normal skin. Sharp dissection that have a high incidence of systemic involvement might ben-
into and including a portion of subcutaneous fat will enable efit from adjuvant therapy, none has been proved to be uniform-
accurate histologic (depth and levels) staging. Shave biopsies ly effective. Allogeneic tumor vaccines (comprising a mixture of
must always be condemned because depth cannot be assessed. different tumor antigens) and other immunostimulation strate-
gies are being studied in clinical trials.21
Lymphatic Mapping and Sentinel Lymph Node Biopsy Trials of newer agents for the treatment of stage IV
Technological advances have made it possible for surgeons to melanoma (involving distant metastases) have been disap-
identify the general characteristics of lymphatic flow and inter- pointing. Studies of interleukin-2 (IL-2) immunotherapy for
cept early metastatic tissue by performing lymphatic mapping metastatic disease, both alone and with lymphokine-activated
and SLN biopsy. The rationale, techniques, and indications for killer cells (LAK cells, or lymphocytes grown in IL-2), show
this valuable procedure are discussed more fully elsewhere [see potential rewards. IL-2 appears to have a 10% to 25%
3:6 Lymphatic Mapping and Sentinel Lymph Node Biopsy], with response rate in metastatic melanoma. Unfortunately, fewer
particular reference to its use in patients with breast cancer or than 50% of the responses are complete, and most are of lim-
melanoma. In our unit, we now routinely employ lymphatic ited duration. IL-2 is currently approved only for the treatment
mapping and SLN biopsy for biopsy-proven melanomas, squa- of renal cell cancer. IL-2 and other cytokines in combination
mous cell carcinomas (especially large neurotropic ones), and with chemotherapeutic agents have generally shown little
Merkel cell carcinomas. Our usual practice is to use a combina- increase in benefit while carrying higher toxicity. IL-12, a
tion of isosulfan blue dye and unfiltered technetium-labeled sul- macrophage-derived cytokine, enhances cellular immunity and
fur colloid. may soon enter clinical trials.21,44,45
Certain melanoma surface antigens may be common to other
TREATMENT
tumors and may be recognized in an HLA class I
Effective treatment of melanoma remains exclusively surgi- molecule–restricted fashion. Melanoma patients who are HLA A1
cal. Initial complete excision is the therapeutic goal. Thin positive (26% of all whites) and whose tumors contain MAGE-1
melanomas can be safely excised with surgical margins of only (a tumor gene found in melanoma and other human tumors)
1 cm.32,33 However, the appropriate margins for excision of could be immunized against their tumors with cytotoxic T cells
intermediate-thickness lesions remain a matter of controversy. sensitized to the melanoma cell surface antigen or against MAGE-
The benefit of prophylactic regional node dissections in 1 alone. Vaccinia recognizance (viral) vectors incorporating this
patients with intermediate-thickness lesions and nonpalpable MAGE-1 gene are already being prepared for clinical trials.21
nodes is also controversial. Prospective, randomized trials and
a mathematical model indicate no survival benefit with elective Surgical Technique
lymph node dissection compared with subsequent so-called
therapeutic regional lymphadenectomy only when nodes
EXCISIONAL BIOPSY
become palpable.34,35 Intraoperative lymphatic mapping and
selective lymphadenectomy may be warranted in a case-specif- The biopsy can often be performed in the clinic operating
ic approach.36 room with the patient under local anesthesia. Care should be
Patients with intermediate-thickness tumors (between 0.76 taken to avoid injecting the lesion itself because the resulting
and 3.99 mm) may benefit if an elective regional lymph node bleeding may distort the histologic fixation of the specimen. A
dissection (of nonpalpable nodes) is included in their initial field block is usually sufficient.
surgical management. Benefit has also been shown with the Attention to proper surgical technique will prevent the
use of elective regional lymph node dissection for the treat- spread of cancer cells and allow the pathologist sufficient tis-
ment of thick melanomas (4 mm and greater) and thin inter- sue to make an accurate diagnosis. For the histologic diagno-
mediate melanomas (between 0.76 mm and 1.49 mm) in sis and staging of all skin lesions, the surgeon should submit at
men.37 However, a clear understanding of the influence of least a full-thickness portion of the lesion and preferably per-
other important factors, such as previous treatment, age, pres- form an excisional biopsy. With a larger tumor, it is important
ence of comorbid disease, and location of the primary lesion, to incorporate a representative portion of the lesion with 1 mm
awaits the results of ongoing trials. In addition to providing of normal skin at the margin so that the pathologist can exam-
local control, removal of lymph nodes may find its greatest ine the skin adjacent to the neoplasm. Diagnostic biopsies
utility in accurate pathologic staging.38-40 Many aspects of this should not be allowed to be damaged by electrocauterization.
therapeutic approach remain controversial.41 It is important to orient and mark the specimen properly so
Patients who have N1 or N2 regional node involvement tra- that the adequacy of the margins can be studied in relation to
ditionally have an unfavorable outcome but may benefit from the overall anatomy.
isolated limb perfusion or limb infusion. Several investigators Thus, the initial biopsy should include at least 1 mm of nor-
have reported increased survival rates in such patients with the mal skin, and the surgeon should take care to perform a full-
use of isolated limb perfusion.42 Perfusion with tumor necrosis thickness excision into the fat. The tissue is gently retracted as
factor–α appears to yield high local response rates, but the the incision is continued around the lesion. Before the lesion is
associated toxicity is high.43 Intralesional immunotherapy, removed from the field, an orientation suture is placed. My
local radiation therapy, and systemic chemotherapy are op- preference is to make a small drawing on the pathology sheet,
tions for the control of recurrent local lesions.21 Unfortunately, indicating where the suture is located in relation to the site on
regional disease develops within 3 years in all patients with the body from which the lesion came. For example, a suture is
thick melanomas (4 mm and greater) and stage IIIA disease, placed at 12 o’clock, a small drawing is made of the patient’s
and distant metastases develop within 5 years in more than hand or face, and the specimen is sketched on the drawing
60% of these patients.30,31,37 itself. This allows the pathologist to identify and localize any
© 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 4 SKIN LESIONS — 9
margin that exhibits microscopic involvement with tumor A wide ellipse (4 cm margin) incorporating the skin lesion
cells. Similarly, excision of a segment of subcutaneous fat al- is marked. The femoral artery is palpated and marked, and a
lows the pathologist to assess depth of invasion. diagonally oriented skin incision is planned. The incision will
course from the region of the anterosuperior iliac spine, cau-
SUPERFICIAL AND RADICAL GROIN DISSECTIONS dally over the central groin region, and through the femoral
The inguinal nodes drain the anterior and inferior abdomi- trigone, terminating at midthigh level on the anteromedial sur-
nal wall, the perineum, the genitalia, the hips, the buttocks, face of the thigh. This incision interferes least with the mus-
and the thighs. A superficial groin dissection removes the culocutaneous and cutaneous vascular territories of the skin,
inguinal nodes, whereas a radical dissection additionally incor- usually avoids ischemia to the skin, and promotes subsequent
porates the iliac and obturator nodes. Palpable nodes can be healing. The incision is made with a scalpel, and the electro-
marked on the patient before operation. Photography can be cautery is employed sparingly. The initial incision should
very helpful for both orientation and documentation. include the skin and subcutaneous fat and continue down
In cases of skin lesions overlying the anteromedial portion through the deep investing fascia overlying the muscle. The
of the thigh, the primary excision can often incorporate an in- dissection proceeds downward in a caudal direction, incorpo-
continuity groin dissection that is designed to eradicate the pri- rating the fascia and exposing the inguinal ligament, the deep
mary tumor along with the lymphatic drainage system.46 As a fascia, and the femoral vessels. Fat and nodal tissue are dis-
general principle, the skin lesion, the subcutaneous fat, the sected off the external oblique aponeurosis, the spermatic
lymphatic tissue, and the investing fascia are removed as a unit. cord, and the inguinal ligament [see Figure 7].The superficial fas-
cia over the vessels is removed, together with the fat and the con-
Technique
tents of the femoral trigone, proceeding from lateral to medial.
The patient is usually placed in a supine position on the The femoral vessels and the femoral nerve are left undisturbed,
operating table, with the hip slightly abducted and supported and the dissection proceeds to the fossa ovalis femoris. The great
by a pillow and with the hip and knee slightly flexed. A Foley saphenous vein is incorporated into the specimen, ligated by a
catheter is inserted, the patient is prepared and draped, and suture at its junction with the femoral vein [see Figure 7].The fas-
the drapes are stapled in position. cia is removed from the sartorius muscle, the adductor muscle
Pectineal Muscle
Femoral
Vein
Femoral
Artery
Inguinal Ligament
Pectineal Muscle
Femoral Sheath
Being Entered
Fascia
LATERAL DISSECTION
Iliopsoas Muscle
through Fascia
Fascia
Branch of
Femoral
Nerve
group, and the rectus femoris, with all lymphatic tissue included Retractors are inserted to widen the retroperitoneal space, and
in the surgical specimen [see Figures 8 and 9]. The dissection pro- the peritoneum and the abdominal viscera are retracted medially.
ceeds medially to the medial aspect of the femoral trigone. This The chain of lymph nodes, areolar tissue, and adventitial tissues
completes the superficial portion of the groin dissection. along the external iliac vessels is dissected; the dissection proceeds
If the surgeon decides to perform a radical (ilioinguinal) node proximally to the origins of the internal iliac vessels and incorpo-
dissection, the incision is extended through the inguinal ligament, rates the nodes overlying the obturator foramen by removing the
beginning medial to the anterosuperior iliac spine and continuing internal obturator fascia.The deep epigastric vessels are usually li-
to a point approximately 2 cm lateral to the femoral artery. The gated at their origins from the external iliac artery and vein. The
inguinal canal is further exposed by releasing the internal oblique lymph node–bearing specimen is then removed as a unit, oriented,
abdominal muscle, the transversus abdominis, and the fascia and labeled appropriately with sutures.The inguinal canal is recon-
transversalis and dissecting into the retroperitoneal space. The structed to prevent a hernia, and the sartorius muscle is mobilized
deep circumflex iliac vessels are ligated, and blunt finger dissec- to the midportion of the wound to cover the femoral vessels. The
tion separates the peritoneum from the preperitoneal fat and skin and the subcutaneous tissues are then closed in layers over a
nodes. soft suction drain.
References
1. Cottel WI: Skin tumors: basal cell and squamous cell noma (monograph). Department of Surgery, Ore- patients with localized (stage I) melanoma treated in
carcinoma. Selected Readings in Plastic Surgery gon Health Sciences University, Portland, Oregon, Alabama, USA, and New South Wales, Australia.
7(6):1, 1992 1994 Ann Surg 196:677, 1982
2. Silverberg E, Lubera J: Cancer statistics. CA Cancer 22. Morton DL, Dartyan DG,Wanek LA, et al: Multi- 38. Crowley NJ: The case against elective lymphade-
J Clin 39:3, 1989 variate analysis of the relationship between survival nectomy. Surg Oncol Clin North Am 1:223, 1992
3. Cancer of the Skin. Friedman RJ, Rigel DS, Kopf and the microstage of primary melanoma by Clark 39. Coates AS, Ingvar CI, Petersen-Schaefer K, et al:
AW, et al, Eds.WB Saunders Co, Philadelphia, 1991 level and Breslow thickness. Cancer 71:3737, 1993 Elective lymph node dissection in patients with pri-
4. Koh HK, Kligler BE, Lew RA: Sunlight and cutane- 23. Koh HK: Cutaneous melanoma. N Engl J Med 325: mary melanoma of the trunk and limbs treated at the
ous malignant melanoma: evidence for and against 171, 1991 Sydney melanoma unit from 1960 to 1991. J Am
causation. Photochem Photobiol 51:765, 1990 24. Armstrong BK: Epidemiology of malignant mela- Coll Surg 180:402, 1995
5. Green HA, Drake L: Aging, sun damage, and sun- noma: intermittent or total accumulated exposure to 40. Krag DN, Meijer SJ, Weaver DL, et al: Minimal-
screens. Clin Plast Surg 20:1, 1993 the sun. J Dermatol Surg Oncol 14:835, 1988 access surgery for staging of malignant melanoma.
Arch Surg 130:654, 1995
6. Urbach F: Geographic distribution of skin cancer. 25. Lew RA, Saber AJ, Cook N, et al: Sun exposure
J Surg Oncol 3:219, 1971 habits in patients with cutaneous melanoma: a case 41. Vetto J: Elective lymph node dissection for intermedi-
control study. J Dermatol Surg Oncol 9:981, 1983 ate thickness melanoma: does it have a future? Clin
7. Dellon AL: Host-tumor relationship in basal cell and Oncol Alert 11:6, 1996
squamous cell cancer of the skin. Plast Reconstr Surg 26. Evans GR, Manson PN: Review and current per-
spectives of cutaneous malignant melanoma. J Am 42. Hartley JW, Fletcher WS: Improved survival of pa-
62:37, 1978
Coll Surg 178:523, 1994 tients with stage II melanoma of the extremity us-
8. Marshall V: Premalignant and malignant skin tumors ing hyperthermic isolation perfusion with 1-pheny-
in immunosuppressed patients. Transplantation 17: 27. Anderson RG: Skin tumors II: melanoma. Selected lalanine mustard. J Surg Oncol 36:170, 1987
272, 1974 Readings in Plastic Surgery 7(7):1, 1992
43. Lienard D, Lejeune FJ, Ewalenko P: In transit
9. Wade TR, Ackerman AB: The many faces of basal 28. Mihm MC, Clark WH, From L:The clinical diagno- metastases of malignant melanoma treated by high
cell carcinoma. J Dermatol Surg Oncol 4:23, 1978 sis, classification, and histogenic concepts of the early dose rTNF-α in combination with interferon-gam-
10. Salasche SJ, Amonette RA: Morpheaform basal cell stages of cutaneous melanoma. N Engl J Med 284: ma and melphalan isolation perfusion.World J Surg
epitheliomas: a study of subclinical extension in a se- 1078, 1971 16:234, 1992
ries of 51 cases. J Dermatol Surg Oncol 7:387, 1981 29. Friedman RJ, Rigel DS, Silverman MK, et al: Malig- 44. Rosenberg SA, Lotze MT,Yang JC, et al: Prospec-
11. Shanoff LB, Spira M, Hardy SB: Basal cell carcino- nant melanoma in the 1990’s: the continued impor- tive trial of high-dose interleukin-2 alone or in con-
ma: a statistical approach to rational management. tance of early detection and the role of physician ex- junction with lymphokine-activated killer cells for
Plast Reconstr Surg 39:619, 1967 aminations and self-examination of the skin. CA the treatment of patients with advanced cancer. J
Cancer J Clin 41:201, 1991 Natl Cancer Inst 85:622, 1993
12. Bart RS, Kopf AW, Peratos MA: X-ray therapy of skin
cancer: evaluation of a “standardized” method for 30. Clark WH, From L, Bernardino EA, et al:The histo- 45. Nastala CL, Edington HD, Storkus WJ, et al: Re-
treating basal cell carcinoma. Fifth National Cancer genesis and biologic behavior of primary human ma- combinant interleukin-12 (r-mil-12) mediates re-
Conference. JB Lippincott, Philadelphia, 1970, p 559 lignant melanomas of the skin. Cancer Res 29:705, gression of both subcutaneous and metastatic mu-
1969 rine tumors. Surg Forum 44:518, 1993
13. Mohs FE: Chemosurgery: microscopically controlled
methods of cancer excision. Arch Surg 42:279, 1941 31. Breslow A:Thickness, cross-sectional areas and depth 46. Karakousis CP:Technique of lymphadenectomy for
of invasion in the prognosis of cutaneous melanoma. melanoma. Surg Oncol Clin North Am 1:157, 1992
14. Robinson JK: Mohs micrographic surgery. Clin Plast Ann Surg 172:902, 1970
Surg 20:149, 1993
32. Balch CM, Murad TM, Soong S, et al:Tumor thick-
15. Brownstein MH, Rabinowitz AD:The precursors of
ness as a guide to surgical management of clinical
cutaneous squamous cell carcinoma. Int J Dermatol Recommended Reading
stage I melanoma patients. Cancer 43:883, 1979
18:1, 1979
33. Veronisi U, Cascinelli N, Adamus J, et al:Thin stage I Cancer Facts and Figures—2001. American Cancer
16. Albricht SM:Treatment of malignant cutaneous tu-
primary cutaneous malignant melanoma: compari- Society, New York, 2001
mors. Clin Plast Surg 20:167, 1993
son of excision with margins of 1 or 3 cm. N Engl J
17. Kohn H, Baumal R, From L: Role of immunohisto- Hallock GG, Lutz DA: A prospective study of the accu-
Med 318:1159, 1988
chemistry in the diagnosis of undifferentiated tumors racy of the surgeon’s diagnosis and significance of pos-
34. Sim FH,Taylor WF, Prichard DC, et al: Lymphade- itive margins in nonmelanoma skin cancers. Plast
involving the skin. J Am Acad Dermatol 14:1063,
nectomy in the management of stage I malignant Reconstr Surg 107:942, 2001
1986
melanoma: a prospective randomized study. Mayo Mathes SJ, Eriksson E, McGrath MH, et al:
18. Bostwick J, Pendergrast J,Vasconez L: Marjolin’s ul- Clin Proc 61:697, 1986 Management of cutaneous malignancies. Contemp
cer: an immunologically privileged tumor? Plast Re- Surg 49:307, 1996
35. Veronesi U, Adamus J, Bandiera DC, et al: Delayed
constr Surg 57:66, 1976
regional lymph node dissection in stage I melanoma
19. Traves N, Pack GT: The development of cancer in of the skin and lower extremities. Cancer 49:2420,
burn scars: analysis and report of 34 cases. Surg Gy- 1982
necol Obstet 51:749, 1930 Acknowledgments
36. Morton DL,Wen DR,Wong JH, et al:Technical de-
20. Ames FC, Hickey RC: Metastasis from squamous tails of intraoperative lymphatic mapping for early Figures 7 through 9 Susan E. Brust, C.M.I.
cell skin cancer of the extremities. South Med J 75: stage melanoma. Arch Surg 127:392, 1992 The author is grateful to John Vetto, M.D., and Paul
920, 1982 Manson, M.D., for their suggestions in the preparation
37. Balch CM, Soong SJ, Milton GW, et al: A compari-
21. Vetto J: Advances in the Therapy of Malignant Mela- son of prognostic factors and surgical results in 1,786 of this chapter.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 5 BREAST PROCEDURES — 1
5 BREAST PROCEDURES
D. Scott Lind, M.D., F.A.C.S., Barbara L. Smith, M.D., Ph.D., F.A.C.S., and Wiley W. Souba, M.D., Sc.D., F.A.C.S.
The procedures used to diagnose, stage, and treat breast disease height-width ratio, margins, internal echo pattern, and presence
are rapidly becoming less radical, less invasive, and, possibly, more of shadowing versus posterior enhancement. Carcinomas are typ-
precise. Breast imaging procedures—such as mammography, ically hypoechoic masses that are taller than they are wide, with
ultrasonography, and magnetic resonance imaging—are playing irregular borders and broad acoustic shadowing. As with mam-
increasingly important roles in management, and any surgeon cur- mography, however, some malignancies cannot be visualized with
rently treating patients with breast disease should have a working ultrasonography, and thus, all clinically suspicious breast masses
knowledge of all of these modalities. In many surgical practices, should undergo biopsy.
breast ultrasonography and ultrasound-guided biopsy are now In the operating room, ultrasonography can help the surgeon
routinely performed. Ductoscopy and ductal lavage, though less locate and excise nonpalpable breast lesions and achieve clean
well established than ultrasonography, are nonetheless promising: lumpectomy margins. It is also being used to guide various inves-
their predictive value and clinical utility are not yet clearly defined, tigational tumor-ablating procedures [see Minimally Invasive
but it appears that they can provide important information regard- Ablative Techniques, below].
ing the status of the breast duct epithelium.1 Excisional breast
TECHNIQUE
biopsy has largely been supplanted by fine-needle aspiration
(FNA) biopsy for palpable breast lesions and by percutaneous Most real-time ultrasound imaging is performed with hand-
biopsy for nonpalpable breast lesions. Stereotactic and ultra- held probes generating frequencies of 7.5 to 10 MHz. The pro-
sound-guided core-needle biopsies are less invasive and less cost- cedure is conducted with the patient supine and a pillow behind
ly alternatives to open surgical biopsies for most patients with non- the shoulder. The outer breast quadrants are best visualized with
palpable breast lesions from which tissue must be acquired.2 the ipsilateral arm extended over the head. Application of sono-
Breast conservation has supplanted mastectomy for local graphic transmission gel between the transducer and the skin
breast treatment in most patients. Updates of multiple prospec- reduces air artifacts, and slight compression of the transducer
tive, randomized trials involving thousands of breast cancer improves image quality. The entire breast and axilla should be
patients continue to demonstrate that survival after lumpectomy imaged, usually in a radial pattern outward from the nipple.
and radiation therapy does not differ significantly from survival Lesions may also be viewed in several planes but should be char-
after mastectomy.3 Local recurrence rates after lumpectomy and acterized in at least two orthogonal planes.
radiation therapy range from 3% to 10%, depending on selection Many interventions done on the breast and the axilla can be
criteria. Even though most women with breast cancer are candi- performed under ultrasonographic guidance, including FNA,
dates for breast conservation, some either require or prefer mas- core-needle biopsy, and wire localization. Intraoperative ultra-
tectomy. Advances in reconstructive techniques have led to sig- sonography can also assist in the identification and removal of
nificantly improved outcomes after breast reconstruction.4 In nonpalpable masses and can reduce the miss rate with needle-
addition, management of the axilla has changed dramatically localized excisional breast biopsy. Ultrasonography can also be
since the early 1990s, and sentinel lymph node (SLN) biopsy has used to guide biopsy of clinically suspicious axillary lymph nodes
virtually replaced routine axillary dissection.5 Finally, various per- so as to better identify patients who are likely to benefit from neo-
cutaneous extirpative and ablative local therapies have been adjuvant therapy.
developed for managing breast cancer in certain carefully select-
ed patients.The roles of these therapies remain to be defined, and
investigations are currently under way.6 Breast Duct Visualization and Epithelial Cell Sampling
In what follows, we describe selected standard, novel, and inves-
DUCTOSCOPY
tigational procedures employed in the diagnosis and management
of breast disease.The application of these procedures is a dynam- Advances in endoscopic technology have made visualization
ic process that is shaped both by technological advances and by and biopsy of the mammary ducts possible. Mammary duc-
our evolving understanding of the biology of breast diseases. toscopy is a procedure in which a microendoscope is employed to
visualize the ductal lining of the breast directly and to provide
access for retrieval of epithelial cells by means of lavage. At pre-
Breast Ultrasonography sent, this technology is only available at a few centers, and as with
The increased use of breast ultrasonography has paralleled the all new technological developments, there is a learning curve
augmented use of screening mammography.7 Unlike mammog- associated with its application.
raphy, however, ultrasonography is not an effective screening tool; Ductoscopy is currently being evaluated for use in three main
it is mainly used in the office setting for further characterization areas: (1) evaluation of patients with pathologic nipple discharge,
and biopsy of breast masses and suspicious axillary nodes. (2) evaluation of high-risk patients, and (3) evaluation of breast
Ultrasonography is cancer patients to determine the extent of intraductal disease
particularly useful for differentiating cystic from solid breast and, perhaps, define the extent of resection more precisely.
lesions. Sonographically, simple cysts tend to be oval or lobulated Further study will be required to determine the precise role of
and anechoic, with well-defined borders. Solid masses are char- this investigational technique in the evaluation and management
acterized sonographically with respect to shape, compressibility, of breast disease.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 5 BREAST PROCEDURES — 2
Technique Patients may undergo mammary ductoscopy and T4 primary lesions, as well as chest wall and axillary recur-
either in the office setting or in the OR with minimal discomfort. rences for which systemic chemotherapy or irradiation is indicat-
The initial experience with ductoscopy involved the use of cum- ed as the first treatment modality. Because of sampling error, the
bersome rigid systems; however, newer systems are now com- procedure is less useful in evaluating small masses and areas of
mercially available that are small in diameter (0.9 mm) and have vague thickening or nodularity. In addition, it often cannot reli-
an outer air channel on the fiberscope, which permits instillation ably distinguish invasive from noninvasive cancer.
and collection of saline to retrieve cells from the ductal system.8 Discrete masses discovered on physical examination may be
Before the procedure, a nipple block is usually performed with either cystic or solid. Unless previous ultrasonographic examina-
topical lidocaine cream, supplemented (if necessary) by intrader- tion has shown the mass to be solid, the needle used should be
mal injection of 1% lidocaine around the nipple-areola complex, large enough to permit aspiration of potentially viscous fluid if
by intraductal instillation of lidocaine after cannulation of the the lesion proves to be cystic (i.e., 20 or 21 gauge). If the mass is
duct, or by both. The breast is massaged to promote expression known to be solid, a smaller needle (22 to 25 gauge) is sufficient
of nipple aspirate fluid and to facilitate visual identification of a for obtaining diagnostic tissue and will cause the patient less dis-
ductal orifice. The ductal opening is then gently dilated, and the comfort. For sufficient suction to be generated, a syringe with a
mammary ductoscope is advanced with the help of insufflation capacity no smaller than 10 ml should be used. A variety of
under direct visualization. Most ducts are readily identified and syringe holders are available that facilitate application of suction
can be dilated sufficiently to allow passage of the ductoscope. with a single hand.
The procedure is usually well tolerated.
Technique Once informed consent is obtained, the skin of
DUCTAL LAVAGE
the breast is prepared with alcohol or iodine, and the lesion that
The majority of breast cancers originate from the epithelium of is to undergo biopsy is held steady between the thumb and the
the mammary ducts. Ductal lavage is a method of recovering index finger of the nondominant hand. A local anesthetic is usu-
breast duct epithelial cells for cytologic analysis via a microcatheter ally not necessary; if it is used, it should be injected so as to cre-
that is inserted into the duct. It has several promising potential ate only a small skin wheal, so that there will be minimal distor-
applications, such as identifying high-risk women, predicting risk tion of the approach to the lesion.To facilitate visualization of the
with the help of molecular markers, monitoring the effectiveness collected sample, 1 to 2 ml of air is introduced into the biopsy
of chemopreventive agents as evidenced by regression of cellular syringe before the needle enters the skin. The tip of the needle is
atypia, and delivering drugs directly into the ducts. At present, advanced into the lesion before any suction is applied to mini-
however, ductal lavage remains investigational, and its predictive mize collection of tissue outside the lesion. Once the tip is in
value and clinical utility await further definition.9 place, strong suction is applied, and the needle is moved back
and forth within the lesion repeatedly along a 5 to 10 mm long
Technique The breast duct epithelium may be sampled by track to loosen and collect cells. (This oscillation of the needle
means of either nipple fluid aspiration or ductal lavage. In nipple along the same track is the most effective way of obtaining a cel-
fluid aspiration, the nipple is scrubbed with a dekeratinizing mild lular, diagnostic specimen.) The back-and-forth movement of
abrasive gel after the application of a topical anesthetic, a suction the needle within the lesion is continued until tissue becomes vis-
device is applied to the nipple, the nipple and breast are gently ible in the hub of the needle. Suction is released while the needle
massaged, and the fluid recovered is sent for analysis. In ductal is still within the lesion (again, to prevent collection of contami-
lavage, the nipple duct orifice is cannulated, the duct is irrigated nating tissue from outside the lesion).
with saline, and the effluent is collected for cytologic analysis. The needle is then withdrawn from the lesion, and its contents
Cannulation of the duct is possible in the majority of women. are expelled onto prepared glass slides, spread into a thin smear,
Both nipple fluid aspiration and ductal lavage are generally well and fixed according to the preferences of the cytology laborato-
tolerated.The former is simpler and less expensive, but the latter ry. Additional passes through the lesion may be made to ensure
retrieves more cells.10 that a sufficiently cellular sample has been obtained, and the
syringe may be rinsed so that a cell block can be prepared for fur-
ther analysis. An adhesive bandage is applied to the biopsy site. If
Breast Biopsy the lesion proves to be cystic, all fluid should be aspirated; this
should cause the mass to disappear. The fluid need not be sent
OPTIONS FOR PALPABLE MASSES
for analysis unless it is bloody or a palpable mass remains after as
Cytologic or tissue diagnosis of a palpable breast mass may be much fluid as possible has been aspirated. If the fluid is to be sent
obtained by means of FNA biopsy, core-needle biopsy, or open for analysis, it is injected directly into the pathologic preservative.
incisional or excisional biopsy. Needle biopsy techniques are less The patient is reexamined 4 to 8 weeks after successful aspi-
invasive, less costly, and more expeditious than open biopsy but ration. If the same cyst has recurred, it should be aspirated again
are significantly more likely to yield false negative results. The and the fluid sent for cytologic analysis.
choice of a biopsy technique should be individualized on the basis
of the clinical and radiographic features of the lesion, the experi- Interpretation of results Analysis by an experienced
ence of the clinician, and the patient’s condition and preference. cytologist is critical for accurate interpretation of FNA biopsy
results. Many cytology laboratories are able to perform immuno-
Fine-Needle Aspiration Biopsy histochemical analysis for hormone receptors on FNA specimens
FNA biopsy permits the sampling of cells from breast lesions if an appropriate fixative has been used. In most cytology labs,
for cytologic analysis. It is an appropriate first step in the evalua- the false positive rate for a diagnosis of malignancy in an FNA
tion of dominant breast masses, but it requires substantial expe- biopsy of a breast mass is only 1% to 2%.11 Thus, a diagnosis of
rience on the part of both the operator and the cytopathologist. malignancy that is based on cytologic analysis of an FNA speci-
FNA biopsy is usually the diagnostic procedure of choice for T3 men may generally be believed, and definitive surgery may be
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 5 BREAST PROCEDURES — 3
planned without further biopsy. Because FNA biopsy does not is reserved for situations in which multiple lesions must be
distinguish between invasive and in situ breast cancer, intraoper- excised and the amount of local anesthetic required would exceed
ative frozen section should be performed if necessary to deter- the maximum safe dose.
mine the need for axillary dissection.
The false negative rate for identifying breast malignancy, how- Technique Open biopsy incisions should generally be curvi-
ever, is high: FNA fails to diagnose as many as 40% of cancers.11 linear and should be placed directly over the lesion to minimize
Any cellular atypia on FNA biopsy is an indication for open biop- tunneling through breast tissue [see Figure 1]. Resection of a por-
sy. A diagnosis of normal or fibrocystic breast tissue should also tion of overlying skin is not necessary unless the lesion is extreme-
be viewed with suspicion; subsequent open biopsy is usually indi- ly superficial. In case the lesion proves to be malignant, all open
cated if the physical examination or a mammogram of the biop- biopsy incisions should also be oriented so that they can be
sied lesion gives rise to even a minor degree of concern about excised with any subsequent lumpectomy or mastectomy inci-
malignancy. If the cytologic analysis is diagnostic of a specific sion. Accordingly, if an open biopsy is to be done at an extreme-
benign lesion (e.g., a fibroadenoma or a lactating adenoma), it
may generally be relied on if it is in concordance with the clinical
features of the lesion, and no further workup is necessary. If the
evaluation is nondiagnostic, either aspiration should be reat-
tempted or core-needle or excisional biopsy should be performed.
If the FNA biopsy results are negative, core-needle or excisional a
biopsy should be done unless it is also the case that the physical
examination suggests a benign lesion and the mammogram is
normal (the so-called triple negative criteria). It has been sug-
gested that no further workup is required when the triple negative
criteria are present, particularly in younger women.
Core-Needle (Cutting-Needle) Biopsy
In contrast to FNA biopsy, core-needle biopsy removes a nar-
row cylinder of tissue that is submitted for standard pathologic
rather than cytologic analysis; consequently, this technique is
preferable if a skilled cytologist is not available for interpretation
of FNA biopsy specimens. Core-needle biopsy is highly accurate
when successful targeting of the lesion is confirmed by means of
breast imaging.12 The technical difficulty of accurately placing
and firing the core needle in small mobile lesions or in lesions sur-
rounded by dense fibrocystic tissue makes other biopsy tech-
niques preferable in these settings. Core-needle biopsy is, howev-
er, ideal for sampling large lesions or chest wall recurrences; the
larger samples permit more detailed pathologic analysis and easy
determination of hormone receptor levels.
ly lateral or medial site, it may be best approached via a radial site. Alternatively, if the surgeon has experience with breast ultra-
incision placed over the lesion rather than via a more vertical sonography, this imaging modality may be used intraoperatively
curvilinear incision. to identify the hematoma that results from stereotactic core-nee-
The incision should be long enough to provide adequate expo- dle biopsy.
sure and to ensure that the mass can be excised as a single spec-
imen with a small margin of grossly normal tissue. The surgeon Interpretation of results The introduction of large core-
should orient the specimen, and the pathologist should ink all biopsy needles (11 and 14 gauge), coupled with the use of vacu-
margins. Meticulous hemostasis should be achieved before clo- um assistance to draw additional tissue into the needle, has
sure to prevent the formation of hematomas that could compli- markedly improved the false negative rate for core-needle biopsy.
cate subsequent definitive oncologic resection. Deep breast tissue Currently, false negative rates for this procedure fall into the 1%
should be approximated only if such approximation does not to 2% range,13 results that compare favorably with those report-
result in significant deformity of breast contour. A cosmetic sub- ed for wire-localized open biopsy. It is now routine to perform
cuticular skin closure is preferred. radiography of core-needle biopsy specimens to confirm that tar-
geted calcifications have been removed.When the targeted lesion
OPTIONS FOR NONPALPABLE MASSES
comprises dense tissue rather than calcifications, care must be
The increasingly widespread use of screening mammography taken to confirm that the lesion was adequately sampled and thus
has led to the identification of more and more nonpalpable breast ensure that the findings can be interpreted reliably. Immediate
masses and microcalcifications for which tissue diagnosis is postbiopsy radiography may be performed to demonstrate that a
required. In most series, 15% to 30% of such lesions prove to be hole was made in the lesion. A finding of benign or fibrocystic tis-
malignant.12-14 Nonpalpable masses and microcalcifications may sue on such a biopsy should be viewed with some suspicion and
be approached via core-needle biopsy or open biopsy with wire interpreted in relation to the lesion sampled. One must decide
localization. whether the pathologic findings adequately account for the lesion
visualized. If any concern remains, open biopsy is indicated.
Image-Guided Core-Needle Biopsy Because false positive results are rare, a diagnosis of malignan-
Needle biopsy techniques are increasingly being used to diag- cy may be believed and acted on without further biopsy. In plan-
nose nonpalpable breast lesions. In general, FNA biopsy of non- ning treatment after core-needle biopsy that shows only carcino-
palpable lesions is inadvisable because of its high false negative ma in situ, one should remember that the lesion was only sam-
rate. Little is lost by attempting an FNA biopsy of a palpable pled and that invasive tumor may still be found when the lesion
lesion in the office setting, but performing a stereotactic or ultra- is completely excised.The likelihood of finding invasive tumor on
sound-guided FNA biopsy of a nonpalpable mass carries a sig- surgical excision after a core-needle biopsy indicative of ductal
nificant cost in terms of time, patient discomfort, and expense. carcinoma may be as high as 20%.14
The diagnostic accuracy currently achievable with FNA biopsy in A finding of atypical ductal hyperplasia on core-needle biopsy
this setting does not justify this cost. Consequently, image-guid- is an indication for wire-localized open biopsy. Open biopsy after
ed core-needle biopsy is the preferred approach for needle biop- a core-needle biopsy indicative of atypical ductal hyperplasia may
sy of nonpalpable lesions. reveal ductal carcinoma in situ (DCIS) in as many as 50% of
In choosing core-needle biopsy, both patient and physician patients; this may be a less frequent finding when a larger (e.g.,
must be comfortable with the fact that the lesion will only be 11 gauge) needle was used for the core-needle biopsy.
sampled rather than excised, must recognize that the possibility of
a sampling error that will cause the examiner to miss the lesion is Follow-up Whether short-interval mammographic follow-
higher with core-needle biopsy than with open biopsy, and must up is necessary after core-needle biopsy depends on the patho-
realize that equivocal findings will necessitate follow-up with logic findings and the mammographic appearance of the lesion.
open biopsy. The trade-off for these limitations is that core-nee- With a well-circumscribed lesion that pathologic evaluation shows
dle biopsy generally costs less than open biopsy, takes less time, to be a fibroadenoma or with calcifications that pathologic evalu-
and leaves only a tiny scar. After a core-needle diagnosis of malig- ation shows to be located in benign fibrocystic tissue, no special
nancy, the surgeon may proceed directly to wide local excision follow-up is required, and routine screening at normal intervals
and will often be able to obtain clean margins with a single open may be resumed. In general, if the pathologic findings are equiv-
procedure. ocal or discordant with the appearance of the lesion, immediate
open excision is preferable to a 6-month repeat mammogram.To
Stereotactic versus ultrasound-guided core-needle ensure appropriate follow-up, there should be close communica-
biopsy Whenever feasible, core-needle biopsy is performed tion between the physician ordering the core-needle biopsy, the
with ultrasonographic guidance, which permits real-time docu- physician performing the biopsy, and the pathologist analyzing
mentation of needle position within the lesion. Stereotactic mam- the specimen.
mography-guided core-needle biopsy is performed if the lesion is
not visualized ultrasonographically. Stereotactic biopsy is appro- Open Biopsy with Needle (Wire) Localization
priate for lesions that are favorably located within the breast (i.e., As is the case for open biopsy of palpable lesions, the vast
that can be stably positioned in the biopsy window of the majority of needle-localized breast biopsies are now performed
machine). Lesions very close to the chest wall or the areola may with local anesthesia or local anesthesia with intravenous seda-
not be accessible to stereotactic biopsy and are best approached tion.15 General anesthesia is reserved for excision of multiple
via open biopsy with needle localization (see below). lesions or other special circumstances.
Clustered microcalcifications may also be approached by
stereotactic core-needle biopsy. If the cluster is not large enough Technique The lesion to be excised is localized by inserting
for calcifications to remain to guide subsequent wide excision if a a thin needle and a fine wire under mammographic or ultrasono-
malignancy is found, a clip should be placed to mark the biopsy graphic guidance immediately before operation.To facilitate inci-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 5 BREAST PROCEDURES — 5
sion placement, images should be sent to the OR with the wire Radiography should immediately be performed on all wire-
entry site indicated on them. With superficial lesions, the wire localized biopsy specimens to confirm that the lesion has been
entry site is usually close to the lesion and thus may be included excised.The patient should remain on the operating table with the
in the incision.With some deeper lesions, the wire entry site is on sterile field preserved until such confirmation has been received. If
the shortest path to the lesion and so may still be included in the the mass was missed and the surgeon has some idea of the likely
incision. The incision is placed as directly as possible over the location of the missed lesion, another tissue sample may be excised
mass to minimize tunneling through breast tissue. Once the inci- immediately. If, however, the surgeon suspects that the wire was
sion is made, a core of tissue is excised around and along the wire dislodged before or during the procedure, the incision should be
in such a way as to include the lesion [see Figure 2]. This process closed. After the patient has healed sufficiently to be able to toler-
is easier and involves less excision of tissue if the localizing wire ate repeat mammography, another mammogram is obtained, and
has a thickened segment several centimeters in length that is repeat localization and biopsy are performed.
placed adjacent to or within the lesion. One then follows the wire
itself into breast tissue until the thick segment is reached and only Directional Vacuum-Assisted Breast Biopsy (Mammotomy)
then extends the excision away from the wire to include the lesion Directional vacuum-assisted biopsy (DVAB), or mammotomy,
in a fairly small tissue fragment. is a special procedure for obtaining specimens from single or mul-
With many lesions, the wire entry site is in a fairly peripheral tiple breast lesions (e.g., microcalcifications, circumscribed mass-
location relative to the position of the lesion, which means that es, and spiculated masses).16 DVAB is a diagnostic procedure and
including the wire entry site in the incision would result in exces- is not intended for therapeutic purposes. On the whole, it is safe,
sive tunneling within breast tissue. In such cases, the incision is and the complication rate is acceptably low.
placed over the expected position of the lesion [see Figure 3], the In comparison with core-needle biopsy, DVAB is more success-
dissection is extended into breast tissue to identify the wire a few ful at removing microcalcifications, can obtain more specimens in
centimeters away from the lesion itself, and the free end of the the course of a single procedure, and is more sensitive in detecting
wire is pulled up into the incision. A generous core of tissue is DCIS and atypical duct hyperplasia. DVAB also appears to diag-
then excised around the wire. Again, this process is easier if the nose nonpalpable breast lesions more effectively than stereotacti-
thick segment of the localizing wire is placed adjacent to or with- cally guided core-needle biopsy does. It may, in fact, be helpful to
in the lesion. perform DVAB after core-needle biopsy when the diagnosis of
b c
Figure 2 Needle-localized breast biopsy.15 (a) The mammographic abnormality is localized immediately
before operation. The relation between the wire, the skin entry site, and the lesion is noted by the surgeon. (b)
The skin incision is placed over the expected location of the mammographic abnormality. The dissection is
accomplished with the wire as a guide. (c) The tissue around the wire is removed en bloc with the wire and
sent for specimen mammography. Tunneling and piecemeal removal are to be avoided.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 5 BREAST PROCEDURES — 6
a b ing, and retrieving samples until the desired amount has been
removed. If the lesions being removed are calcifications, the suffi-
ciency of the sampling may be confirmed through x-rays of the
specimens.
Once the biopsy is complete, an inert metallic clip is deployed
into the biopsy site through the trocar so as to mark the lesion for
future reference in case it can no longer be visualized after biopsy;
deployment and positioning are confirmed by stereotactic imaging.
The biopsy device is then removed, the edges of the skin incision
are approximated with Steri-Strips, and a compressive bandage is
applied. Any bleeding occurring after removal of the biopsy device
should be controlled by manual pressure before the final bandage
is applied. Typically, 1 g of tissue (equivalent to approximately 10
to 12 samples with an 11-gauge probe) is sufficient for diagnosis of
benign disease, atypical ductal hyperplasia, or carcinoma.
Complications are uncommon. Brisk bleeding may occur dur-
ing and immediately after the procedure. Bruising and discol-
oration may result but generally resolve within days. Less fre-
quently still, hematomas may form, fat necrosis may occur, or the
Figure 3 Needle-localized breast biopsy.15 (a) It is sometimes patient may note a palpable lump. Caution is advisable in women
necessary to insert the localizing wire from a peripheral site to who are receiving anticoagulants. Surgical site infection has been
localize a deep or central lesion. The incision should be placed reported as well, but it is rare.
directly over the expected location of the lesion, not over the
wire entry site. (b) Once the skin incision is made, the dissection
is extended into breast tissue to identify the wire a short dis- Terminal Duct Excision
tance from the lesion. The free end of the wire is pulled into the Terminal duct excision is the procedure of choice in the surgi-
wound, and the biopsy is performed as in Figure 2.
cal treatment of nipple discharge.17 Local anesthesia with or with-
out sedation (as for breast biopsy) is generally sufficient for this
procedure. The goal is to excise the duct from which the dis-
atypical duct hyperplasia is being considered; this practice may charge arises along with as little additional tissue as possible. To
lead to a decrease in the number of open biopsies performed. this end, the surgeon should carefully note the precise position of
Suitable candidates for DVAB include patients with nonpalpa- the discharging duct at the time of the initial examination.
ble but mammographically visible clusters of suspicious calcifica-
tions, those with well-defined masses that are likely to be benign,
a
and those with suspicious masses. Target lesions must be clearly
visible on digital images and identifiable on stereotactic projec-
tions. DVAB is not recommended for patients with certain lesions
located very posteriorly or very anteriorly in the breast, those with
very small or very thin breasts, and those who, for one reason or
another, cannot be properly positioned for the procedure or can- b
not cooperate with the surgeon.The procedure is done on an out-
patient basis and usually can be completed in 1 hour or less.
Patients are restricted from engaging in strenuous activity for 24
hours after DVAB.
The probe employed for the procedure consists of an outer tro-
car cannula, a sliding inner hollow coaxial cutter, a so-called knock-
out shaft, a distal sampling notch, and a proximal tissue retrieval
chamber; in addition, it has a thumbwheel, which is used for man-
ual advancement, cutting, and retrieval of biopsy specimens. It
must be used under the guidance of an imaging modality (e.g.,
ultrasonography or roentgenography), and it may be either
mounted or handheld. The device is connected to a suction c
machine, which acts first to draw the target tissue into the sam-
pling notch and then to facilitate retrieval of tissue into the proxi-
mal collection chamber.
Stereotactic digital imaging is then performed to visualize the
target and calculate its location in three dimensions, and a suitable
trocar insertion site is identified.The skin is prepared, and a small
amount of buffered 1% lidocaine with epinephrine (usually 10 ml
or less) is administered.The skin at the insertion site is punctured Figure 4 Terminal duct excision (single duct).17 (a) A periareo-
with a No. 11 blade, the probe is manually advanced to the prefire lar incision is made. (b) The involved duct is identified by means
site, and the position of the probe is confirmed by means of stereo- of blunt dissection. (c) The duct is removed along with a core of
tactic imaging. The device is then fired, repeatedly cutting, rotat- breast tissue.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 5 BREAST PROCEDURES — 7
of tissue should be excised around the wire to obtain an adequate term results must be evaluated against those of standard breast
margin.The specimen should be oriented by the surgeon and the conservation techniques.18 The minimally invasive ablative tech-
margins inked by the pathologist; this orientation is useful if reex- niques clearly are technically feasible, and they appear to offer
cision is required to achieve clean margins. Reexcision of any some potential advantages, but it remains to be determined to
close margins may be performed during the same surgical proce- what extent they are oncologically appropriate.
dure if the specimen margins are assessed immediately by the
pathologist. Surgical clips may be left in the lumpectomy site
before closure to assist the radiation oncologist in planning the Lymphatic Mapping and SLN Biopsy
radiation boost to the tumor bed. The histologic status of the axillary nodes is the single most
In the closure of the incision, hemostasis should be meticulous: important predictor of outcome for breast cancer patients.
a hematoma may delay administration of radiation therapy or Traditionally, axillary dissection has been a routine part of the
chemotherapy. Deep breast tissue should be approximated only if management of breast cancer, but it has become clear that axil-
such closure does not result in significant deformity of breast con- lary dissection can be associated with sensory morbidities and
tour. A cosmetic subcuticular closure is preferred. lymphedema. The growing recognition of the morbidity of axil-
lary dissection, together with the increasing ability of mammog-
raphy to detect smaller and smaller node-negative tumors, gave
Minimally Invasive Ablative Techniques rise to the need for a less morbid axillary procedure. Lymphatic
The next step in the evolving application of less invasive tech- mapping and SLN biopsy [see 3:6 Lymphatic Mapping and
niques to breast cancer is to determine whether ablative local Sentinel Lymph Node Biopsy] is a minimally invasive method of
therapies can be effective substitutes for extirpative local thera- determining occult lymph node metastasis that is less morbid and
pies. Cryotherapy, laser ablation, radiofrequency ablation (RFA), more accurate than axillary dissection. SLN biopsy is based on
and focused ultrasound ablation have all been studied as means the principle that the SLN is the first node to which tumor
of eradicating small breast cancers.18 In most of these techniques, spreads; thus, if the SLN is tumor free, patients can be spared the
a probe is placed percutaneously into the breast lesion under the morbidity associated with axillary dissection.
guidance of an imaging modality, and tumor cell destruction is The technique of SLN biopsy continues to evolve, but at pres-
achieved by means of either heat or cold. ent, the most common method of identifying the SLN employs
Cryotherapy has been successfully used for some time in the both a vital dye and a radionuclide. Lymphatic mapping is a crit-
treatment of nonresectable liver tumors. It kills tumor cells by dis- ical part of the procedure. A radionuclide is injected before oper-
rupting the cellular membrane during the freeze/thaw cycle. ation, and dynamic gamma-camera imaging is subsequently
Unfortunately, early results of studies evaluating cryotherapy in employed to delineate sites of drainage. Several series examining
breast cancer patients indicate that it does not always achieve various sites of injection (peritumoral, intradermal, and subareo-
complete tumor destruction. In addition, ultrasonographic mon- lar) concluded that the breast and its overlying skin may drain to
itoring of cell death may not be precise enough to allow accurate the same few SLNs.19 In the OR, a vital blue dye is injected (usu-
determination of the adequacy of treatment. ally peritumorally), and the breast is massaged to stimulate lym-
Laser ablation causes hyperthermic cell death by delivering phatic flow.The surgeon then makes a small incision in the axilla
energy through a fiberoptic probe inserted into the tumor. and uses a handheld gamma probe to remove lymph nodes that
Because of the precise targeting required, ensuring complete are “hot” (i.e., radioactive), blue, or both. At the time of breast
tumor destruction has proved difficult with this technique as well. surgery, the SLN can be examined by means of frozen section
RFA is a minimally invasive thermal ablation technique in analysis or touch-print cytology. If metastases are present in the
which frictional heat is generated by intracellular ions moving in SLN, axillary dissection may then be performed.
response to alternating current. Currently, RFA appears to be the Because SLN biopsy involves analysis of only one or two
most promising ablative method for small breast cancers. Like nodes, the pathologist can carry out a more intensive pathologic
cryotherapy, RFA has also been extensively used to treat liver examination than would be possible with a standard axillary lym-
tumors. The RFA probe is percutaneously placed in the tumor phadenectomy specimen containing multiple nodes. Newer tech-
under imaging guidance, and a star-shaped set of electrodes is niques (e.g., immunohistochemical and molecular assays) can
extruded from the tip of the probe. Postprocedural MRI may help also be used to identify micrometastases that light microscopy
confirm complete tumor destruction, not only after RFA but after would fail to detect, but the therapeutic and prognostic signifi-
other ablative techniques as well. cance of tumor cells identified by such means remains unclear.20
Experience with ablative breast therapies is still relatively scant, Because there is a learning curve for SLN biopsy, the success
and these techniques remain investigational. To date, most of the rate varies with the surgeon’s experience. Accordingly, it is rec-
studies examining ablative breast cancer techniques have been ommended that surgeons first learning the technique use axillary
single-institution pilot studies involving highly selected patients dissection as a backup for the first 20 procedures to gain experi-
with small, well-defined lesions who do not have extensive intra- ence in identifying the SLN. Surgeons competent in SLN biopsy
ductal cancer or multifocal disease. In addition, these techniques should be able to identify the SLN with better than 85% accura-
have been restricted to lesions that are neither superficial nor cy and a false negative rate lower than 5%.21 Currently, axillary
deep, so as to avoid injury to the skin or the chest wall. Most of dissection is recommended for patients who have a positive SLN;
the initial ablative series involved subsequent surgical excision to however, prospective, randomized trials are required determining
obtain histologic evidence of cell death. Unfortunately, when to what extent this step is necessary in SLN-positive patients. A
ablative therapies are used alone, the benefits of pathologic number of studies have confirmed that the absence of metastases
assessment of the specimen, including evaluation of margin sta- in the SLN reliably predicts the absence of metastases in the
tus, are lost; positive surgical margins are associated with in- remaining axillary nodes.22-24
creased local recurrence rates. Preliminary data from the initial SLN biopsy has also been employed in DCIS patients.Women
studies demonstrate acceptable short-term results, but the long- with DCIS have high survival rates without undergoing any axil-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 5 BREAST PROCEDURES — 9
lary procedure, and there is concern that indiscriminate applica- or serratus muscle; and the inferior border is formed by the tail of
tion of SLN biopsy to these patients may result in unnecessary the breast. Level II nodes are easily removed by retracting the
axillary dissection and subsequent systemic chemotherapy. greater and smaller pectoral muscles medially; it is not necessary
Therefore, SLN biopsy should be limited to (1) patients with to divide or remove the smaller pectoral muscle. In general, level
extensive DCIS in whom percutaneous biopsy may have missed III nodes are not removed unless palpable disease is present.
areas of invasion and (2) patients with extensive DCIS who are Axillary dissection, either alone or in conjunction with lumpec-
undergoing mastectomy that would preclude SLN biopsy if tomy or mastectomy, usually calls for general anesthesia, but it
occult invasive disease were found on pathologic examination. may also be performed with thoracic epidural anesthesia supple-
The SLN identification rates and false negative rates reported mented by local anesthesia as needed. To facilitate identification
when SLN biopsy is performed after neoadjuvant chemotherapy and preservation of motor nerves that pass through the axilla, the
are similar to those seen when the procedure is performed after anesthesiologist should refrain from using neuromuscular block-
diagnosis but before systemic chemotherapy.25 ing agents. In the absence of neuromuscular blockade, any clamp-
Contraindications to SLN biopsy include the presence of pal- ing of a motor nerve or too-close approach to a motor nerve with
pable axillary nodes suggestive of metastatic disease, the presence the electrocautery will be signaled by a visible muscle twitch.
of large or locally advanced breast cancers, prior axillary surgery,
STRUCTURES TO BE PRESERVED
and pregnancy or lactation.
There are a number of vascular structures and nerves passing
through the axilla that must be preserved during axillary dissec-
Axillary Dissection tion [see Figure 7]. These structures include the axillary vein and
Before the advent of SLN biopsy, axillary dissection was rou- artery; the brachial plexus; the long thoracic nerve, which inner-
tinely performed in breast cancer patients: it provided prognostic vates the anterior serratus muscle; the thoracodorsal nerve,
information that guided subsequent adjuvant therapy, it afforded artery, and vein, which supply the latissimus dorsi; and the medi-
excellent local control, and it may have contributed a small over- al pectoral nerve, which innervates the lateral portion of the
all survival benefit. greater pectoral muscle.
Axillary dissection for clinically node-negative breast cancer The axillary artery and the brachial plexus should not be
includes resection of level I and level II lymph nodes and the exposed during axillary dissection. If they are, the dissection has
fibrofatty tissue within which these nodes lie [see Figure 6].26 The been carried too far superiorly, and proper orientation at a more
superior border of the dissection is formed by the axillary vein lat- inferior position should be established. In some patients, there
erally and the upper extent of level II nodes medially; the lateral may be sensory branches of the brachial plexus superficial (and,
border of the dissection is formed by the latissimus dorsi from the rarely, inferior) to the axillary vein laterally near the latissimus
tail of the breast to the crossing point of the axillary vein; the dorsi; injury to these nerves results in numbness extending to the
medial border is formed by the pectoral muscles and the anteri- wrist. To prevent this complication, the axillary vein should ini-
tially be identified medially, under the greater pectoral muscle.
Medial to the thoracodorsal nerve and adherent to the chest wall
is the long thoracic nerve of Bell.The medial pectoral nerve runs
from superior to the axillary vein to the undersurface of the
III greater pectoral muscle, passing through the axillary fat pad and
II
across the level II nodes; it has an accompanying vein whose blue
color may be used to identify the nerve. If a submuscular implant
reconstruction [see Breast Reconstruction after Mastectomy, below]
is planned, preservation of the medial pectoral nerve is especially
important to prevent atrophy of the muscle.
The intercostobrachial nerve provides sensation to the posteri-
or portion of the upper arm. Sacrificing this nerve generally leads
to numbness over the triceps region. In many women, the inter-
costobrachial nerve measures 2 mm in diameter and takes a fair-
ly cephalad course near the axillary vein; when this is the case,
preservation of the nerve will not interfere with node dissection.
I Sometimes, however, the nerve is tiny, has multiple branches, and
is intermingled with nodal tissue that should be removed; when
this is the case, one should not expend a great deal of time on
attempting to preserve the nerve. If the intercostobrachial nerve
is sacrificed, it should be transected with a knife or scissors rather
than with the electrocautery, and the ends should be buried to
reduce the likelihood of postoperative causalgia.
OPERATIVE TECHNIQUE
Thoracodorsal
Nerve
Thoracodorsal
Artery
2nd Rib
Thoracodorsal
Vein
Latissimus
Dorsi Muscle
Long Thoracic
Nerve
below the lowest extension of hair-bearing skin, either as an ini- anterior-posterior position. It may be identified by spreading tis-
tial maneuver or after the initial identification of key structures. sue just medial to the thoracodorsal bundle and then running the
The key to axillary dissection is obtaining and maintaining index finger perpendicular to the course of the long thoracic
proper orientation with respect to the axillary vein, the thora- nerve on the chest wall to identify the cordlike nerve as it moves
codorsal bundle, and the long thoracic nerve. After the incision under the finger. Once the nerve is identified, axillary tissue may
has been made, the dissection is extended down into the true axil- be swept anteriorly away from the nerve by blunt dissection along
lary fat pad through the overlying fascial layer.The fat of the axil- the anterior serratus muscle; there are no significant vessels in this
lary fat pad may be distinguished from subcutaneous fat on the area.
basis of its smoother, lipomalike texture. There may be aberrant The junction of the thoracodorsal bundle with the axillary vein
muscle slips from the latissimus dorsi or the greater pectoral is 1.5 to 2.0 cm medial to the point at which the axillary vein
muscle; in addition, there may be an extremely dense fascial crosses the latissimus dorsi.The thoracodorsal vein enters the pos-
encasement around the axillary fat pad. It is important to divide terior surface of the axillary vein, and the nerve and the artery pass
these layers early in the dissection.The borders of the greater pec- posterior to the axillary vein.There are generally one or two scapu-
toral muscle and the latissimus dorsi are then exposed, which lar veins that branch off the axillary vein medial to the junction
clears the medial and lateral borders of the dissection. with the thoracodorsal vein. These are divided during the dissec-
The axillary vein and the thoracodorsal bundle are identified tion and should not be confused with the thoracodorsal bundle.
next. As discussed (see above), the initial identification of the axil- The axillary vein and the thoracodorsal bundle having been
lary vein should be made medially, under the greater pectoral identified, the greater pectoral muscle is retracted medially at the
muscle, to prevent injury to low-lying branches of the brachial level of the axillary vein, and the latissimus dorsi is retracted lat-
plexus. Sometimes, the axillary vein takes the form of several erally to place tension on the thoracodorsal bundle. Once this
small branches rather than a single large vessel. If this is the case, exposure is achieved, the axillary fat and the nodes are cleared
all of the small branches should be preserved. away superficial and medial to the thoracodorsal bundle to the
The thoracodorsal bundle may be identified either distally at level of the axillary vein. Superiorly, dissection proceeds medially
its junction with the latissimus dorsi or at its junction with the along the axillary vein to the point where the fat containing level
axillary vein. The junction with the latissimus dorsi is within the II nodes crosses the axillary vein.To improve exposure, the fascia
axillary fat pad at a point two thirds of the way down the hair- overlying the level II extension of the axillary fat pad should be
bearing skin of the axilla, or approximately 4 cm below the infe- incised to release tension and expose the lipomalike level II fat. As
rior border of the axillary vein. Occasionally, the thoracodorsal noted [see Structures to Be Preserved, above], the medial pectoral
bundle is bifurcated, with separate superior and inferior branch- nerve passes onto the underside of the greater pectoral muscle in
es entering the latissimus dorsi; this is particularly likely if the this area and should be preserved. One or more small venous
entry point appears very high. If the bundle is bifurcated, both branches may pass inferiorly from the medial pectoral bundle;
branches should be preserved. The thoracodorsal bundle may be particular attention should be paid to preserving the nerve when
identified at its junction with the latissimus dorsi by spreading ligating these venous branches.
within axillary fat parallel to the border of the muscle and look- The next step in the dissection is to reflect the axillary fat pad
ing for the blue of the thoracodorsal vein. The identification is inferiorly by dividing the medial attachments of the axillary fat
also facilitated by lateral retraction of the latissimus dorsi. The pad along the anterior serratus muscle. Care must be taken to
long thoracic nerve lies just medial to the thoracodorsal bundle preserve the long thoracic nerve. Because there are no significant
on the chest wall at this point and at approximately the same vessels or structures in the tissue anterior to the long thoracic
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 5 BREAST PROCEDURES — 11
nerve, this tissue may be divided sharply, with small perforating remove all skin that contributes to the forward projection of the
vessels either tied or cauterized. Finally, the axillary fat is freed breast skin envelope.
from the tail of the breast with the electrocautery or a knife. The incision may be either transverse across the chest wall or
There is no need to orient the axillary specimen for the pathol- angled upward toward the axilla as necessary to include the nip-
ogist, because treatment is not affected by the anatomic level of ple-areola complex and any incisions from previous biopsies.
node involvement. A surgical clip is placed at the apex of the dis- Care should be taken to make the upper and lower skin flaps of
section to assist the radiation oncologist in planning radiation similar length so that there is no redundant skin on either flap [see
fields. A closed suction drain is placed through a separate stab Figure 8]. The boundaries of the incision can be determined in
wound. (Some practitioners prefer not to place a drain and sim- the following five steps: (1) the lateral and medial end points of
ply aspirate postoperative seromas as necessary.) The use of fibrin the incision are marked, (2) the breast is pulled firmly downward,
sealants may reduce the incidence of seromas. A long-acting local (3) the upper incision is defined by drawing a straight line from
anesthetic may be instilled into the axilla—a particularly helpful one end point to the other across the upper surface of the breast,
practice if the dissection was done as an outpatient procedure. (4) the breast is pulled firmly upward, and (5) the lower incision
is defined by drawing a straight line from one end point to the
other across the lower surface of the breast.The outlined incision
Mastectomy is then checked to ensure that it can be closed without either
The goal of a mastectomy is to remove all breast tissue, includ- undue tension or redundant skin. The closure should be fairly
ing the nipple and the areola, while leaving well-perfused, viable snug intraoperatively, when the patient’s arm is positioned per-
skin flaps for primary closure or reconstruction. This is the case pendicular to the torso for exposure, because a significant
whether the mastectomy is performed for treatment of breast amount of slack is created when the arm is returned to a more
cancer or for prophylaxis in high-risk patients. Proper skin inci- normal position at the patient’s side. The medial and lateral end
sions and good exposure throughout the procedure are the key points of the incision may be adjusted upward or downward to
components of a well-performed mastectomy.The borders of dis- include any previous biopsy incisions in the specimen.
section extend superiorly to the clavicle, medially to the sternum,
inferiorly to where breast tissue ends (on the costal margin, below Flaps
the inframammary fold), and laterally to the border of the latis- In most patients, there is a fairly well defined avascular plane
simus dorsi. The fascia of the greater pectoral muscle forms the between subcutaneous fat and breast tissue. This plane is identi-
deep margin of the dissection and should be removed with the fied by pulling the edges of the incision upward with skin hooks
specimen. and beginning a flap that is 8 to 10 mm thick and extends
Mastectomy usually calls for general anesthesia, but it may be approximately 1 cm from the skin edge. After this initial release
performed with thoracic epidural anesthesia supplemented by of the skin edge, the desired plane is developed by applying firm
local anesthesia as needed. When a simple mastectomy is to be tension to pull breast tissue downward and away from the skin at
performed in a frail patient for whom general anesthesia poses a 45° angle. The fine fibrous attachments between breast tissue
unacceptable risks (particularly if the patient is elderly and has a and subcutaneous fat (Cooper’s ligaments) are then divided with
narrow-based, pendulous breast), local anesthesia with sedation the electrocautery or a blade, and crossing vessels are coagulated
is appropriate. or ligated as they appear. To protect both arterial supply to and
venous drainage from the skin flap, one must refrain from exces-
OPERATIVE TECHNIQUE
sive ligation or cauterization of vessels on the flap.
Skin-sparing mastectomy performed in conjunction with Completed mastectomy flaps are perfused through the net-
immediate reconstruction is discussed elsewhere [see Breast work of fine subdermal vessels that remains after dissection. The
Reconstruction after Mastectomy, below]. In a modified radical or viability of the flaps is determined by their length, the quality of
simple mastectomy without reconstruction, the goal is to leave a the vessels they contain, the damage sustained by the vessels dur-
smooth chest wall that permits comfortable wearing of a bra and ing the dissection, and the tension imposed by the final closure.
a prosthesis. It is important to remove a sufficient amount of skin For most women, flap viability is not an issue. It is, however, a
to ensure that no dog-ears or lateral skin folds are left on the ante- serious consideration for diabetics and other patients with diffuse
rior chest wall. This undesirable result can be prevented by small vessel disease. In such patients, flaps should be carefully
extending the incision far enough medially and laterally to planned so that they are no longer than necessary and there is no
Figure 8 Mastectomy. Shown are common incisions used for mastectomy.15 Any previous biopsy incisions should
have been done in such a way as to be included within the boundaries of the mastectomy incision.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 5 BREAST PROCEDURES — 12
excess tension, and extra care should be taken to preserve flap ves- is closed and a dressing applied according to the surgeon’s pref-
sels. Patients should be warned that even with these additional erence. Early arm mobilization is encouraged.
efforts, there may be some necrosis along the edges of the inci-
sion. Such necrosis is best treated with gradual debridement of Modified radical mastectomy The incision is placed and
the dark eschar that forms as epithelialization proceeds from flaps are raised as for simple mastectomy. At the lateral edge of the
viable tissue. dissection, the border of the latissimus dorsi is exposed, as is the
lateral border of the pectoral muscle. Some surgeons prefer to
Borders of Dissection proceed with axillary dissection first, leaving the breast attached
Flaps are raised superiorly to the clavicle, medially to the ster- to the chest wall, whereas others prefer to remove the breast from
num, inferiorly to where breast tissue ends on the costal margin the chest wall first and then use it to provide tension for the axil-
(generally below the inframammary fold), and laterally to the bor- lary dissection. In either case, mechanical or manual retraction of
der of the latissimus dorsi. The plane between breast tissue and the latissimus dorsi and the greater pectoral muscle generally pro-
subcutaneous fat is followed down to the greater pectoral muscle vides excellent exposure for axillary dissection. The landmarks of
and through the pectoral fascia both superiorly and medially. the axillary dissection are identified as described earlier [see
Inferiorly, the fascia of the abdominal muscles is not divided.The Axillary Dissection, above]. The thoracodorsal bundle can often
greater pectoral muscle, the abdominal muscles, and the anterior be seen running along the latissimus dorsi as the muscle is retract-
serratus muscle form the deep border of the dissection. The pec- ed laterally.
toral fascia is removed with the breast specimen and may be sep- Once the axillary dissection has been completed and the breast
arated from the muscle with either the electrocautery or a blade. has been removed from the chest wall, the incision is irrigated and
To maintain the skin tension needed for the development of two closed suction drains placed, one in the axilla and another
skin flaps, an assistant holds the flaps taut manually with skin under the lower flap to the midline.The skin is closed and a dress-
hooks, dull-toothed rakes padded with damp sponges, or Deaver ing applied according to the surgeon’s preference. Early arm
retractors. Care must be taken to obtain adequate tension and mobilization is encouraged.
exposure so that as much breast tissue as possible can be removed
without undue damage to the skin flaps. Skin-sparing mastectomy An increasingly popular ap-
proach for women requiring mastectomy is skin-sparing mastecto-
Simple versus Modified Radical Mastectomy my (SSM).27 This procedure consists of resection of the nipple-
Simple mastectomy is performed (1) to treat DCIS, (2) as a areola complex, any existing biopsy scar, and the breast parenchy-
prophylactic measure, (3) as a follow-up to lumpectomy and axil- ma, followed immediately by breast reconstruction. It is somewhat
lary dissection if lumpectomy margins are positive for malignan- demanding technically, in that the effort expended in preserving
cy, (4) to treat local recurrence of breast cancer after lumpectomy, the skin makes it difficult for the oncologic surgeon to ensure
node dissection, and irradiation, and (5) in elderly patients in removal of as much breast tissue as possible. Because the infra-
whom coexisting medical conditions or other factors constitute mammary fold is preserved and a generous skin envelope remains
contraindications to axillary dissection. Simple mastectomy is also after SSM, cosmetic results after reconstruction are optimized.
indicated for treatment of sarcomas of the breast: lymphatic SSM is oncologically safe and is not associated with an increased
spread to axillary nodes is not part of the natural history of this incidence of local recurrence. The recurrences that do occur typi-
disease. cally develop below the skin flaps and thus are easily detectable;
Modified radical mastectomy is performed to treat invasive deep recurrences beneath the reconstruction are comparatively
breast cancer when (1) there are contraindications to breast uncommon. Patients with locally advanced breast cancer are not
preservation or (2) the patient or the physician prefers mastecto- appropriate candidates for SSM with immediate reconstruction. In
my. Simple mastectomy in conjunction with SLN biopsy is an general, immediate reconstruction should be reserved for patients
increasingly common alternative to modified radical mastectomy at low risk for postoperative adjuvant therapies.
for patients with clinically negative axillary nodes. If the nodes are
positive for tumor on pathologic examination, the surgeon may
then elect to perform a completion axillary dissection. Breast Reconstruction after Mastectomy
Advances in reconstructive techniques have made breast recon-
Simple mastectomy As described earlier (see above), a skin struction increasingly popular. Reconstruction may be done either
incision is made, and thin flaps are raised to allow removal of all at the time of the mastectomy (immediate reconstruction) or later
breast tissue. Laterally, the dissection is extended to the border of (delayed reconstruction). It is well recognized that immediate breast
the latissimus dorsi, and breast tissue is removed anterior to the reconstruction after mastectomy is safe, does not significantly delay
long thoracic nerve. The dissection proceeds around the lateral subsequent administration of chemotherapy or radiation therapy,
edge of the greater pectoral muscle but stops before entering the and does not prevent detection of recurrent disease. Either implants
axillary fat pad. If one wishes to sample the low axillary nodes (as, or autologous tissue may be used in reconstruction.
for example, in a patient with extensive DCIS of comedo histol- In most cases, the option of breast reconstruction is presented
ogy), one may remove the lower portion of the axillary fat pad to the mastectomy patient by her breast surgeon during preoper-
between clamps. In so doing, one must avoid the long thoracic ative discussion of mastectomy or, in the case of delayed recon-
nerve and the thoracodorsal nerve and keep the dissection low struction, during follow-up after an earlier mastectomy. The
enough to ensure that the intercostobrachial sensory nerve is not patient, the plastic surgeon, and the oncologic or general surgeon
damaged.The breast is then taken off the underlying muscles, and will decide among the several reconstruction options available—
the pectoral fascia is included with the specimen. implants with tissue expansion, the transverse rectus abdominis
A single closed suction drain is placed through a separate stab myocutaneous (TRAM) flap, the latissimus dorsi myocutaneous
wound laterally to extend under the lower flap and a short dis- flap, and various free flaps—on the basis of patient preference and
tance upward along the sternal border of the dissection. The skin lifestyle, the availability of suitable autologous tissue, and the
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 5 BREAST PROCEDURES — 13
Options for breast reconstruction after surgical therapy for breast cancer
No reconstruction
Reconstruction Management of
of the ipsilateral the contralateral
breast breast
Mastopexy
Tissue expander
Transverse rectus
Can be used when
abdominis myocutaneous
creation of a breast
tissue is adequate for
mound with implants
creation of a pedicled flap
alone is difficult.
Consider transverse rectus
abdominis myocutaneous
flap.
Breast implant
Patient needs additional
cover for a breast implant,
and tissue expansion is
contraindicated
demands imposed by any additional cancer therapies required [see breast and axillary tissue. The nipple and the areola must be
Figure 9]. Familiarity with the strengths and drawbacks of these included in the resected skin, as must the biopsy incision
reconstruction options facilitates this decision. through which the malignancy was diagnosed [see Figure 10].
(One option for removing biopsy incisions while leaving the
OPERATIVE TECHNIQUE
maximal amount of unaffected skin is to place T-shaped inci-
Placement of the incision for mastectomy with immediate sions that extend outward from the areola.) FNA and core-nee-
reconstruction is determined in discussion with the plastic sur- dle biopsy incisions are generally not included in the excised
geon. The goal is to preserve as much viable skin as possible for skin segment; however, one may, if one wishes, excise a small
the reconstruction without compromising complete resection of amount of skin around a core-needle biopsy site. A linear inci-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 5 BREAST PROCEDURES — 14
a b c
Flap Configured to Deepithelialized
Mastectomy Areas
Form Breast Mound
Defect
Fascial
Closure
Skin and Superior
Subcutaneous Epigastric
Tissue Resection Pedicle
Remaining
Anterior
Rectus
Fascial Sheath
Resection
Abdominal
Scar
Figure 11 Breast reconstruction after mastectomy. Shown is autologous tissue reconstruction with a transverse rectus
abdominis myocutaneous (TRAM) flap. The infraumbilical flap is designed (a). The TRAM flap is tunneled subcuta-
neously into the chest wall cavity. Blood supply to the flap is maintained from the superior epigastric vessels of the rec-
tus abdominis. Subcutaneous fat and deepithelialized skin are positioned under the mastectomy flaps as needed to
reconstruct the breast mound (b). The fascia of the anterior rectus sheath is approximated to achieve a tight closure of
the abdominal wall defect and to prevent hernia formation. The umbilicus is sutured into its new position (c).
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 5 BREAST PROCEDURES — 15
a b
Pectoral Muscle
Thoracodorsal Submuscular
Vessels Implant
Latissimus Dorsi
Muscle
Figure 12 Breast reconstruction after mastectomy. Shown is autologous tissue reconstruction with a
latissimus dorsi myocutaneous flap in conjunction with a submuscular implant. (An implant is often
required to provide the reconstructed breast with adequate volume and projection.) The myocutaneous
flap is elevated; it is important to maintain the blood supply to the flap from the thoracodorsal vessels (a).
The flap is tunneled subcutaneously to the mastectomy defect (b). The latissimus dorsi is sutured to the
greater pectoral muscle and the skin of the inframammary fold, so that the implant is completely covered
by muscle.
significantly firmer than the contralateral breast. The life expec- the donor site. Smokers and patients with significant vascular dis-
tancy of currently available saline implants has not been estab- ease may not be ideal candidates for autologous tissue recon-
lished, but it may be less than a decade, which means that many struction. Partial necrosis of the transferred flap may create firm
patients who have received or are receiving implants may need areas; on rare occasions, complete necrosis and consequent loss
replacements at some point. of the flap can occur.
Patients who have previously undergone irradiation of the A number of factors are considered in choosing between the
breast or the chest wall may have tissue that cannot be adequate- TRAM flap and the latissimus dorsi flap. In a TRAM flap recon-
ly expanded and thus is unsuitable for implant reconstruction. If struction, the contralateral rectus abdominis is transferred along
the final pathologic evaluation of the mastectomy specimen indi- with overlying skin and fat to create a breast mound.This proce-
cates that radiation therapy is needed for local control, one may dure yields a flatter abdominal contour but calls for a long trans-
consider irradiating the chest wall before expansion with an verse abdominal incision and necessitates repositioning of the
expander in place; however, this is not an ideal solution. umbilicus. A major advantage of the TRAM flap is that it can
provide enough tissue to match all but the largest contralateral
Autologous tissue A second approach to reconstruction is to breasts. Some patients, however, such as those who have under-
transfer vascularized muscle, skin, and fat from a donor site to the gone an abdominal procedure that compromises the TRAM
mastectomy defect.The most commonly used myocutaneous flaps flap’s vascular supply, are not ideal candidates for TRAM flap
are the TRAM flap [see Figure 11] and the latissimus dorsi flap [see reconstruction. Postoperative discomfort is greater with TRAM
Figure 12]. Use of the free TRAM flap is advocated by certain cen- flap reconstruction than with other flap reconstructions because
ters; other free-flap options, including the free gluteus flap, are used of the extent of the abdominal portion of the procedure. In
in special circumstances, when other donor sites are unsuitable. young, healthy, and motivated patients who require bilateral
The major advantage of autologous tissue reconstruction is reconstructions, it is often possible to perform two TRAM flap
that it generally yields a superior cosmetic result. Often, the size procedures in the same operation.
and shape of the opposite breast can be matched immediately, In a latissimus dorsi myocutaneous flap reconstruction, the
with no need for subsequent office or operative procedures. The ipsilateral latissimus dorsi is transferred along with overlying skin
reconstructed breast has a soft texture that is very similar to that and fat to create a breast mound. Either a horizontal or a vertical
of the contralateral breast. In addition, the cosmetic result is sta- donor site incision may be made on the back.The operative tech-
ble over time.The main drawbacks are the magnitude of the sur- nique for the latissimus dorsi flap reconstruction is complex,
gical procedure required for the reconstruction (involving both a requiring two intraoperative changes in patient position (from
prolonged operating time and longer inpatient hospitalization), supine to lateral decubitus and from lateral decubitus back to
the potential need for autologous blood donation or transfusion, supine for mastectomy, muscle harvest, and final inset of the
and the pain, scarring, and loss of muscle function that arise at flap). Patients who have undergone irradiation of the breast, chest
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 5 BREAST PROCEDURES — 16
wall, or axilla (including irradiation of the thoracodorsal vessels) anastomoses and carrying a higher risk of total flap loss. The two
may not be eligible for this procedure. most commonly employed free-flap options are the free TRAM
A major advantage of the latissimus dorsi flap is that its donor flap and the free gluteus flap.
site is associated with less postoperative discomfort than the Donor site morbidity—including postoperative pain, wound-
abdominal donor site of the TRAM flap. In addition, transfer of the healing complications, decreased abdominal muscle strength, and
latissimus dorsi results in substantially less functional impairment hernia formation—is a prime disadvantage of pedicled or free
than transfer of the rectus abdominis. A drawback of the latissimus TRAM flap reconstruction. As a result, muscle-sparing alterna-
dorsi flap is that in many women, the latissimus dorsi is not bulky tives to autogenous breast reconstruction have been developed,
enough to provide symmetry with the contralateral breast. In such such as the deep inferior epigastric perforator (DIEP) flap.28 In
cases, an implant must be added to the flap to match the size and this approach, free flaps are used that comprise skin and fat alone,
shape of the opposite breast, which means that the drawback of the without the rectus abdominis. Avoidance of muscle sacrifice in
implant’s limited life span is added to the drawbacks already asso- the abdomen ultimately translates into greater patient satisfac-
ciated with autologous tissue reconstruction. tion, but careful patient selection is essential to optimize out-
Free-flap reconstruction options are utilized primarily when comes.The disadvantages of the DIEP flap include the consider-
other autologous and implant reconstruction options are not able technical expertise and long operating time required, as well
available, do not provide sufficient tissue volume, or have failed. as the greater potential for flap loss (because this flap has a more
They are more complex procedures, requiring microvascular tenuous blood supply than the standard TRAM flap).
References
1. Khan SA, Baird C, Staradub VL, et al: Ductal 12. Meyer JE, Smith DN, Lester SC, et al: Large-core 271, 1997
lavage and ductoscopy: the opportunities and the needle biopsy of nonpalpable breast lesions. 23. Krag D, Weaver D, Ashikaga T, et al: The sentinel
limitations. Clin Breast Cancer 3:185, 2002 JAMA 281:1638, 1999 node in breast cancer: a multicenter validation
2. Liberman L: Percutaneous image-guided core 13. King TA, Fuhrman GM: Image-guided breast study. N Engl J Med 339:941,1998
breast biopsy. Radiol Clin North Am 40:483, 2002 biopsy. Semin Surg Oncol 20:197, 2001
24. Sabel MS, Schott AF, Kleer CG, et al: Sentinel
3. Fisher B, Anderson S, Redmond CK, et al: Reana- 14. Klimberg VS: Advances in the diagnosis and exci- node biopsy prior to neoadjuvant chemotherapy.
lysis and results after 12 years of follow-up in a sion of breast cancer. Am Surg 69:114, 2003 Am J Surg 186:102, 2003
randomized clinical trial comparing total mastec- 15. Urist MM, Bland KI: Indications and techniques 25. Kinne DW, DeCosse JJ: Modified radical mastec-
tomy with lumpectomy with or without irradiation for biopsy. The Breast: Comprehensive Manage- tomy for carcinoma of the breast. Am Surg
in the treatment of breast cancer. N Engl J Med ment of Benign and Malignant Diseases. Bland 48:543, 1982
333:1456, 1995 KI, Copeland EM III, Eds. WB Saunders Co,
Philadelphia, 2004, p 791 26. Kinne DW: Primary treatment of breast cancer.
4. Shons AR, Mosiello G: Postmastectomy breast Breast Diseases, 2nd ed. Harris JR, Hellman S,
reconstruction: current techniques. Cancer Con- 16. Hoorntje LE, Peeters PH, Mali WP, et al:Vacuum- Henderson IC, et al, Eds. JB Lippincott Co,
trol 8:419, 2001 assisted breast biopsy: a critical review. Eur J Philadelphia, 1987
5. Shoher A, Lucci A: Emerging patterns of practice Cancer 39:1676, 2003
27. Hultman CS, Daiza S: Skin-sparing mastectomy
in the implementation and application of sentinel 17. Morrow M: Management of common breast dis- flap complications after breast reconstruction: re-
lymph node biopsy in breast cancer patients in the orders. Breast Diseases, 2nd ed. Harris JR, view of incidence, management, and outcome. Ann
United States. J Surg Oncol 83:65, 2003 Hellman S, Henderson IC, et al, Eds. JB Lip- Plast Surg 50:249, 2003
pincott Co, Philadelphia, 1987
6. Dowlatshahi K, Francescatti DS, Bloom KJ, et al: 28. Craigie JE, Allen RJ, DellaCroce FJ, et al: Auto-
Image-guided surgery of small breast cancers. Am 18. Simmons RM: Ablative techniques in the treat-
genous breast reconstruction with the deep inferi-
J Surg 182:419, 2001 ment of benign and malignant breast disease. J
or epigastric perforator flap. Clin Plast Surg 30:
Am Coll Surg 197:334, 2003
7. Rubio IT, Henry-Tillman R, Klimberg VS: Sur- 359, 2003
gical use of breast ultrasound. Surg Clin North Am 19. Rubio IT, Klimberg VS: Techniques of sentinel
83:771, 2003 lymph node biopsy. Semin Surg Oncol 20:214,
2001
8. Mokbel K, Elkak AE: The evolving role of mam-
20. Schwartz GF, Giuliano AE, Veronesi U, et al:
mary ductoscopy. Curr Med Res Opin 8:30, 2002
Proceedings of the consensus conference on the
Acknowledgments
9. Newman LA, Blake C: Ductal lavage for breast role of sentinel lymph node biopsy in carcinoma of
cancer risk assessment. Cancer Control 9:473, the breast, April 19–22, 2001, Philadelphia, Penn- The authors wish to thank David Van Hook, M.D.,
2002 sylvania. Cancer 94:2542, 2002 Chief of Mammography, Department of Radiology,
10. Dooley WC, Ljung BM, Veronesi U, et al: Ductal 21. Classe JM, Curtet C, Campion L, et al: Learning Penn State Hershey Medical Center, Hershey,
lavage for detection of cellular atypia in women at curve for the detection of axillary sentinel lymph Pennsylvania, for his assistance in preparing the section
high risk for breast cancer. J Natl Cancer Inst node in breast cancer. Eur J Surg Oncol 29:426, on directional vacuum-assisted breast biopsy (mammo-
93:1624, 2001 2003 tomy).
11. Stanley MW, Sidawy MK, Sanchez MA, et al: 22. Turner RR, Ollila DW, Krasne DL, et al: Histo- Figures 1 through 8, 10 Kerry G. Nicholson.
Current issues in breast cytopathology. Am J Clin pathologic validation of the sentinel lymph node Figure 9 Marcia Kammerer.
Pathol 113(5 suppl 1):S49, 2000 hypothesis for breast carcinoma. Ann Surg 226: Figures 11 and 12 Tom Moore.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 6 Lymphatic Mapping and Sentinel Lymph Node Biopsy— 1
Breast cancer and melanoma are among the most common priate treatment. The presence of lymph node metastases is the
malignancies treated by U.S. surgeons. In 2003, it was estimat- single most powerful predictor of recurrence and survival in
ed that there were 54,200 new cases of melanoma and 212,600 melanoma patients: 5-year survival is approximately 40% lower
new cases of breast cancer in the United States.1 The incidence in patients who have lymph node metastases than in those who
of melanoma has been rising rapidly in the past few decades, and do not. This finding suggests that many melanoma patients are
the incidence of breast cancer is also likely to keep rising as the likely to benefit from accurate nodal staging.
baby-boomer generation ages.
Over the past 20 years, significant strides have been made in Elective lymph node dissection Until the latter part of
the management of these two diseases from the standpoint of the 1990s, elective lymph node dissection (ELND) was the
both surgical and adjuvant treatment. For both patients with mainstay of the surgeon’s armamentarium for nodal staging of
melanoma and those with breast cancer, adjuvant therapies for melanoma patients. ELND removes clinically negative nodes, as
high-risk lesions have been shown to have a positive impact on opposed to therapeutic node dissections, which are done for
recurrence rates and overall survival. In melanoma, the admin- nodes with gross tumor involvement. Opinions are divided as to
istration of adjuvant interferon alfa-2b to patients with T4 (> 4.0 whether ELND actually extends survival or whether it is solely
mm deep) primary tumors or nodal metastases has led to lower a staging procedure.Two prospective, randomized trials failed to
recurrence rates and longer overall survival.2 In breast cancer, demonstrate better survival in melanoma patients treated with
there is a much more extensive body of experience with adjuvant ELND than in patients undergoing wide local excision (WLE)
chemotherapy and hormone therapy for optimization of survival alone as primary surgical therapy.5,6 Retrospective studies from
in high-risk patients.3,4 In both diseases, the presence or absence large databases, however, suggested that there may be subpopu-
of lymph node metastases is highly predictive of patient outcome lations of patients who do benefit from ELND. The Intergroup
and is the most important prognostic factor for disease recur- Melanoma Trial was the first randomized study to show
rence and cancer-related mortality. Surgical management of the enhanced survival in patient subgroups after surgical treatment
regional lymph nodes will continue to be an important compo- of clinically occult metastatic melanoma.7 The benefit was found
nent of therapy for patients with these malignancies. in patients with melanomas 1.1 to 2.0 mm thick and patients
Progress in the management of regional lymph nodes in mela- younger than 60 years.8
noma and in breast cancer has taken different routes to what is
likely to be the same destination—namely, the use of lymphatic Adjuvant therapy for high-risk melanoma Three
mapping and sentinel lymph node (SLN) biopsy in clinically national prospective, randomized trials sponsored by the
node-negative patients. The development of intraoperative lym- Eastern Cooperative Oncology Group (ECOG) investigated the
phatic mapping and selective lymphadenectomy has made it use of adjuvant interferon alfa-2b in patients with high-risk
possible to map lymphatic flow from a primary tumor to the ini- melanoma.The first trial, ECOG 1684,2 was the impetus for the
tial draining node or nodes (i.e., the SLN or SLNs) in the Food and Drug Administration’s approval of interferon alfa-2b,
regional nodal basin.The pathologic status of the SLN is known in that it was the first study to demonstrate that this agent was
to be concordant with the pathologic status of the nodal basin as an effective adjuvant therapy for patients with high-risk melano-
a whole. Integration of these techniques, along with increasing- ma. Patients eligible for ECOG 1684 had either thick primary
ly detailed and sophisticated pathologic examination of the melanomas (> 4.0 mm thick) or nodal metastases. ECOG 1684
SLN, into the surgical treatment of melanoma and breast can- and a subsequent trial, ECOG 1694,9 reported significant over-
cer offers the potential for more conservative operations, lower all survival benefits for patients receiving adjuvant interferon
morbidity, and more accurate disease staging. alfa-2b; a third trial, ECOG 1690,10 did not, though it did show
an improvement in disease-free survival for the treated group.
Given the results from the Intergroup Melanoma Trial and
Lymphatic Mapping and SLN Biopsy for Melanoma the three ECOG trials, one can make a strong argument that
when the risk of nodal metastases reaches a certain defined level,
RATIONALE
a nodal staging procedure should be performed. Because of the
morbidity associated with a negative ELND, lymphatic mapping
Assessment of Nodal Status and SLN biopsy has become the de facto procedure of choice
There are several established factors for predicting the risk of for nodal staging in melanoma patients.
metastatic disease in melanoma patients. These factors must be
taken into account to ensure that patients are appropriately Lymphatic mapping and selective lymphadenectomy
stratified into different risk groups and hence can receive appro- SLN biopsy in melanoma was first described in 1992 by Morton
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 6 Lymphatic Mapping and Sentinel Lymph Node Biopsy— 2
and associates,11 who outlined a procedure of intraoperative lym- of nodal metastasis is with respect to the cost and morbidity of
phatic mapping and selective lymphadenectomy in which a vital the procedure.
blue dye was injected into the skin around the site of the primary Patients with intermediate-thickness melanomas (1.0 to 4.0 mm)
melanoma. These investigators showed that the SLN is the first are the ones likely to gain most from SLN biopsy: the risk of nodal
node in the lymphatic basin into which the primary melanoma metastases in the absence of systemic disease is believed to be high-
consistently drains (though not necessarily the closest to the pri- est in this group. In patients with melanomas between 0.76 and 1.0
mary lesion).They harvested the SLN separately from the remain- mm thick, the risk of nodal metastasis is less than 6%, but the pro-
der of the regional nodes, and they found that the pathologic status cedure can certainly be justified in this population on the basis of
of the SLN was highly accurate at predicting the pathologic status its low morbidity. In patients with thin melanomas (< 0.76 mm),
of the entire nodal basin, which was surgically removed in all of the several prognostic factors have been shown to identify higher risk,
patients studied.These findings suggested that melanoma patients including primary tumor depth of Clark level III or higher, ulcera-
could be accurately staged with procedures that were far less ex- tion, the presence of regression, male sex, and axial location.12 Pa-
tensive than complete nodal dissections. tients with thin melanomas and multiple risk factors may be at
high enough risk to warrant SLN biopsy.
PREOPERATIVE EVALUATION
In patients with thick melanomas (> 4.0 mm), the risk of
occult systemic metastases is as high as 70%, and that of occult
Selection of Patients nodal metastases ranges from 60% to 70%. The high risk of sys-
The risk of nodal metastases in melanoma patients depends temic disease was the main reason why ELND was not recom-
on a number of factors, including primary tumor thickness, pres- mended for such patients in the past. Now that these patients
ence of ulceration, primary tumor location, and patient sex. Any have access to effective adjuvant therapy, however, they should
patient with invasive melanoma (Clark level II or higher) is at be offered lymphatic mapping and SLN biopsy as a staging pro-
some risk for nodal metastasis; however, before recommending cedure. Among patients with thick melanomas, those with nega-
SLN biopsy, the surgeon should determine what the relative risk tive nodes survive longer than those with microscopic nodal dis-
then shifted medial or lateral to the previous line, and the process is allows pathologists to focus their efforts on one node or a small
repeated until the entire area is evaluated. The location of a ra- number of nodes, and this focus has led to a process of ultrastaging.
dioactive hot spot is confirmed by identifying a discrete location Currently employed methods include serial sectioning, immuno-
where the radioactive counts are higher than the counts found in histochemical (IHC) staining for melanoma-associated antigens
the tissue 1 to 2 cm more proximal to the injection site (the back- (e.g., S-100 and HMB-45), and reverse transcriptase polymerase
ground skin count). The counts from the hot spot and the back- chain reaction (RT-PCR) for identification of messenger RNA
ground are recorded.The hot-spot site is marked on the skin to al- (mRNA) transcripts of the enzyme tyrosinase. It is clear that these
low more direct dissection to the SLN. techniques can improve identification of node-positive patients,
Concomitant use of a vital blue dye [see Sidebar Choice of Ra- but it is not yet clear what their prognostic value may be with
diocolloid and Vital Blue Dye for Lymphatic Mapping] is favored respect to determining patient outcome and guiding further ther-
by many surgeons.The blue dye is complementary to the radiola- apy. Additional study in this area is required to resolve this issue.
beled tracer; the combination of the two marking agents improves
COMPLICATIONS
the chances of identifying the SLN and facilitates node retrieval.
The blue dye is injected into the dermis immediately adjacent to Complications of SLN biopsy are quite uncommon. Allergic
the melanoma. For lesions on an extremity, the dye may be inject- reactions to the blue dyes occur in fewer than 1% of patients but
ed along the proximal margin of the lesion or biopsy site; for le- can range in severity from mild urticaria to anaphylaxis; thus, the
sions on other areas, it should be injected circumferentially. The surgical team and the anesthesia team should always be prepared
general recommendation is to wait 5 to 10 minutes after injecting for this uncommon but potentially serious problem.19 Motor
the dye before initiating SLN retrieval. nerve injury is rare. In a series of 30 patients who had head and
To minimize the dissection required for node resection, the inci- neck melanomas with SLN drainage to the parotid region, there
sion for the SLN biopsy should be made through the hot spot were no injuries to the facial nerve when the SLN was removed
identified by the gamma probe.The incision should also be situat- without nerve dissection.20 Similar results have been reported for
ed so that it can be incorporated into a longer incision should the nodes in the posterior triangle of the neck and the spinal acces-
finding of a positive SLN necessitate performance of a completion sory nerve, as well as for axillary nodes and the long thoracic and
lymph node dissection (CLND).The gamma probe is placed in a thoracodorsal nerves. The incidence of wound complications is
sterile sheath and used again after the incision is made to guide fur- quite low (1.7% wound complication rate; 3.0% seroma rate), as
ther dissection. If blue dye was used, the surgeon can visually fol- is the incidence of postbiopsy lymphedema (0.7%). In the Sunbelt
low the blue lymphatic channels to the blue-stained SLN. Melanoma Trial, the complication rate in 2,120 patients under-
An SLN is defined as either (1) the most radioactive node in going SLN biopsy was 4.6%, compared with 23.2% in 444
the basin or (2) a node that either is stained blue or clearly has a patients undergoing CLND.21
blue-stained lymphatic vessel entering it. When an SLN is
OUTCOME EVALUATION
removed, the ex vivo radioactivity count in the node is recorded.
This count is then used as a reference for determining which, if Studies of SLN biopsy in melanoma patients have demonstrat-
any, of the remaining nodes in that basin (some of which may be ed consistently good technical success and high pathologic accu-
potential SLNs) should be removed. In our view, if the radioac- racy with a variety of different techniques. There have been three
tivity count in the hottest remaining node in the basin is less than studies in which SLN biopsy was done with confirmatory CLND
10% of the ex vivo count in the hottest SLN, none of the remain- of all lymph node basins in which SLNs were identified.11,22,23
ing nodes should be considered SLNs, and none should be When the results of these studies are considered together, the
removed.18 Any nodes whose radioactivity counts exceed this pathologic false negative rate for SLN biopsy in clinically node-
10% threshold, however, should be removed. negative melanoma patients is about 6%. The pathologic accura-
A final count of the SLN biopsy bed is then taken to docu- cy rate (i.e., the rate at which the pathologic status of the SLN is
ment that all significantly radiolabeled SLNs have been account- the same as that of the entire nodal basin) is 98%.
ed for and removed. In addition, the tissues are examined for Several trials have prospectively followed patients treated with
blue-stained lymphatic channels or lymph nodes regardless of SLN biopsy and subsequent observation if the SLN was negative.24-27
radioactivity; as noted, blue staining confers SLN status even if These trials reported similar rates of technical success (94%–98%)
the node is not radioactive. Finally, when it appears that all rel- and of node positivity (12% to 16%).The rates of first relapse in the
evant SLNs have been removed, as confirmed by the final bed regional nodes in these patients were similar as well (range, 3.8%–8%;
count, the tissues are palpated for grossly suspicious nodes. Firm mean, 4.4%), a finding that is consistent with the rates of false neg-
tumor-involved nodes with obstructed afferent lymphatics may ative SLNs in the series in which CLND was performed. These
divert lymph flow to non-SLNs, and such diversion is a signifi- studies also found that the pathologic status of the SLNs was the most
cant cause of false negative SLN biopsy results. important predictor of disease-free survival and overall survival, a
Once an SLN is identified, it should be dissected out with as lit- result that further underscores the accuracy of the procedure and
tle trauma to the surrounding tissues as possible. Lymphatic chan- the importance of nodal staging in predicting melanoma outcomes.
nels to the node should be identified and either tied or clipped to The available data suggest that lymphatic mapping is appli-
reduce the risk of postoperative seroma formation. Because the cable to all primary body sites, including the head and the neck
gamma probe can localize SLNs with great accuracy, routine dis- (the most technically demanding sites).17,28 The best results are
section of motor nerves is not required; however, knowledge of the achieved with a combination mapping approach that employs
likely location of the motor nerves is critical for preventing inadver- both a vital blue dye and a radiocolloid. The procedure is associ-
tent injury to these structures during dissection. ated with slightly higher false negative rates in patients with head
and neck melanoma than in those with melanoma of the trunk or
Step 3: Pathologic Evaluation of SLN extremities (10% versus 1% to 2%). Nevertheless, the false nega-
The optimal extent of pathologic evaluation of SLNs in patients tive rates with head and neck melanoma are still low enough to
with melanoma has been the subject of some debate. SLN biopsy justify offering lymphatic mapping to patients—especially given
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 6 Lymphatic Mapping and Sentinel Lymph Node Biopsy— 5
that the only alternative method of obtaining the nodal staging infor- phoscintigraphy may help the surgeon identify SLNs located in
mation is CLND, a procedure that carries a much higher morbidity. extra-axillary sites (e.g., the internal mammary chain). Although
SLN biopsy may be performed with the patient under local
anesthesia, we favor general anesthesia for this procedure, par-
Lymphatic Mapping and SLN Biopsy in Breast Cancer ticularly when it is done in conjunction with the breast excision.
RATIONALE OPERATIVE TECHNIQUE
a b false negative rate can be reduced to about 5%,41,43 but at the cost
of 45 to 60 minutes of operating time and loss of tissues for perma-
nent histopathologic evaluation. In comparison, touch-imprint cy-
tology consumes much less time and tissue, is far more accurate
(false negative rate, 0.8%),44 and does not contaminate the cryo-
stat. It has also been applied to the evaluation of lumpectomy mar-
gins [see Figure 5]. The chief limitation of the touch-imprint
method is that for optimal results, it requires a pathologist who is
highly skilled in the cytologic evaluation of lymph nodes. Some
centers use rapid immunohistochemical (IHC) analysis for cyto-
keratin staining to detect tumor cells in touch-imprint or frozen-
section specimens, anticipating that detection of such cells can
thereby be improved, particularly in patients with invasive lobular
or well-differentiated ductal carcinomas.
Techniques used to date for permanent pathologic evaluation
of SLNs in the setting of breast cancer include (1) serial sec-
tioning of the nodes with routine hematoxylin-eosin (H&E)
Figure 5 Lymphatic mapping and SLN biopsy for breast cancer. staining, (2) cytokeratin IHC staining [see Figure 6], and (3)RT-
In touch-imprint cytology, slides are touched to tissue from a PCR detection of mRNA transcripts specific for epithelial cells.
“hot” specimen, and cells on the section or the margin are exfoli-
Each of these techniques is more sensitive in detecting tumor
ated onto the slide for cytologic preparation. Shown are (a) per-
cells in the SLNs than routine H&E analysis of bivalved nodes.
manent histology of an infiltrating ductal carcinoma extending
down to an inked margin and (b) a touch preparation demonstrat- There is, however, some controversy surrounding their use, cen-
ing bizarre malignant cells from the sampling of the margin. The tering on the clinical relevance of a positive result. Some of these
advantages of this technique are that the entire margin can be techniques (i.e., IHC and RT-PCR) are sensitive enough to identify
sampled and that tissue is not lost in the cryostat. single tumor cells in SLNs, but it is not clear whether such indi-
vidual cells are actually capable of forming metastases. In the
current staging system for breast cancer, metastases large
determining the completeness of radioactive SLN removal. As in enough to be seen on H&E sections are the benchmark for nodal
melanoma, if the remaining radioactivity in the nodal basin is more staging. Metastases 2 mm in size or larger are known to have a
than 10% of that in the hottest node removed, there may be SLNs negative impact on survival45; however, it is not certain that the
still in place that should be sought out and, if found, removed. If same can be said of smaller metastatic lesions. In 1999, the
the residual radioactivity in the nodal basin is less than 10% of that College of American Pathologists issued a consensus statement
in the hottest node, the remaining nodes should not be removed. recommending that the staging of SLNs be based on routine his-
These guidelines apply equally to SLN biopsy in extra-axillary lo- tologic evaluation of the nodes cut at approximately 2 mm inter-
cations. The remaining nodes in the nodal basin should also be vals.46 Routine use of cytokeratin IHC staining should not be
evaluated for blue staining of the nodes themselves or of the lym- adopted as standard until its significance is demonstrated in clin-
phatic channels entering them; any nodes meeting these criteria ical trials.
should be removed and labeled as SLNs.
COMPLICATIONS
Finally, before the SLN procedure is completed, the remain-
ing nodes in the basin should be palpated. If a firm, hard tumor- The complications of SLN biopsy in breast cancer patients are
replaced node is identified, it should be removed and categorized similar to those seen in melanoma patients. There is a minor
as an SLN. As in melanoma, the presence of a tumor-replaced
node can increase the risk of a false negative SLN biopsy.
Step 3: Pathologic Evaluation of SLN
Pathologic SLN evaluation in breast cancer patients has two
main aspects. The first is intraoperative evaluation of the SLN
when the pathologic status of the node is being used to deter-
mine the need for axillary dissection; the second is permanent
evaluation of the nodes to determine whether micrometastatic
disease is present.
Two techniques are commonly employed for intraoperative
evaluation of SLNs: frozen-section analysis and touch-imprint
cytology. Frozen-section histopathology is available in most hos-
pitals, and all surgical pathologists have some experience with it.
This technique has a drawback, however, in that it sometimes
uses up a large portion of the SLN, leaving a remnant that is
insufficient for permanent paraffin-embedded sections. In addi-
tion, the sectioning of radioactive nodes on a cryostat raises radi-
ation-safety issues for the pathologists. Figure 6 Lymphatic mapping and SLN biopsy for breast cancer.
Studies of frozen-section techniques of evaluating SLNs for Cytokeratin immunohistochemical staining finds metastatic cells
metastatic breast cancer report false negative rates of 27% and in 9.4% of breast cancer patients whose SLNs are histologically
32%.41,42 When 60 frozen sections are made from each SLN, the negative on routine examination.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 6 Lymphatic Mapping and Sentinel Lymph Node Biopsy— 8
Injection Location
Nodal Basin
Peritumoral* Intradermal/Subdermal† Periareolar/Subareolar‡ Intratumoral§
Axilla 92.0% (range, 86%–100%) 96.4% (range, 93%–100%) 98.4% (range, 94.2%–100%) 92.0% (range, 88%–96%)
Internal mammary chain 4.9% (range, 0%–25.3%) 0.6% (range, 0%–4%) 0% 18.4% (range, 13%–43%)
(< 1%) risk of allergic reactions to the blue dye. There is a small of nodal metastases from the SLNs removed was 97%, and the
risk of sensory or motor nerve injury or lymphedema whenever pathologic false negative rate was 11.4%. A subsequent multicen-
an axillary node procedure is performed; this risk is substantial- ter trial, using a combination of blue-dye staining and the gamma-
ly reduced, though not entirely eliminated, with SLN biopsy.47 probe technique in most patients, reported an SLN retrieval rate of
With an internal mammary SLN biopsy, there is a risk of pneu- 88% and a pathologic false negative rate of 7.2%.52 A third trial,
mothorax from unintended opening of the parietal pleura. This using the gamma-probe technique, reported an SLN retrieval rate
risk is very small with careful technique, however, and the prob- of 87% and a pathologic false negative rate of 13%.53 A fourth, us-
lem can almost always be corrected by closing the wound around ing both blue-dye staining and the gamma-probe technique, re-
a rubber catheter inserted through a small stab incision and ported an SLN retrieval rate of 86% and a pathologic false nega-
removing it at the end of a positive pressure breath given by the tive rate of 4%.54
anesthesiologist. Surgical site infections occur in fewer than 1% The numerous single-institution reports on SLN biopsy have
of cases, and small seromas occur in about 10%. made use of a variety of techniques.The technical variable of great-
est interest has been the route by which the radiolabeled tracer is
OUTCOME EVALUATION
injected into the breast.The routes evaluated include peritumoral
The first report of SLN biopsy in breast cancer, published in injection (as in the early studies), superficial injection into the der-
1993, described the use of the gamma-probe localization tech- mis of the skin overlying the tumor site, periareolar or subareolar
nique for SLN identification.48 A second report, published the fol- injection, and, most recently, intratumoral injection.
lowing year, described the use of the vital blue dye technique for We have reviewed the literature on the use of different routes of
this purpose.49 Since these initial reports, many single-center and injection and the associated rates of SLN localization by nodal
multicenter studies have been published that achieved remarkably basin, node positivity rates, and false negative rates.This review in-
similar results using either or both of these techniques. cluded those studies in which a radiolabeled tracer was used for
The early studies of SLN biopsy tended to use either a radiola- SLN identification (either by lymphoscintigraphy or by intraoper-
beled tracer or a vital blue dye alone. The first trial in which the ative gamma probe localization) and in which the location of the
two agents were used together was published in 1996.50 This study SLN basins and the pathologic status of the SLNs could be ascer-
documented an improvement in SLN localization and a 0% false tained [see Tables 1, 2, and 3]. Data on 8,951 patients were re-
negative rate, albeit in a small series of patients. Subsequent multi- viewed.39,41,50-52,54-95 The results of our review indicated that all of
center trials incorporating larger study groups yielded more reli- the approaches have acceptable SLN retrieval rates but that the
able indications of the applicability of these techniques to the over- rates are slightly higher with the more superficial ones (i.e., the der-
all surgical community. In one such study, surgeons from 11 mal, subareolar, and periareolar techniques).There are, however,
centers performed SLN biopsies and confirmatory axillary dissec- significant differences in the locations of the SLN basins identified
tion in clinically node-negative patients with invasive breast can- with the different methods: with the superficial injection tech-
cer.51 The overall success rate for identifying and removing an SLN niques, drainage is essentially confined to the axillary basin, where-
was 93%, the pathologic accuracy rate for predicting the presence as with the deeper injection techniques, as many as 22% of patients
Table 2—SLN Pathologic Positive Rates by Nodal Basin at Different Injection Sites39,41,50-52,54-95
Injection Location
Nodal Basin
Peritumoral* Intradermal/Subdermal† Periareolar/Subareolar‡ Intratumoral§
Axilla 34.0% (range, 21%–50%) 35.2% (range, 18.2%–51.3%) 26.2% (range, 23.1%–42.1%) 37.8% (range, 12.7%–43.7%)
Other NA 0% 0% 3.4%
† ‡ §
*28 trials; 5,924 patients. 11 trials; 1,872 patients. 5 trials; 486 patients. 5 trials; 669 patients.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 6 Lymphatic Mapping and Sentinel Lymph Node Biopsy— 9
Table 3—False Negative SLN Identification proliferate, as other specialists begin to move into areas once gen-
Rates at Different Injection Sites39,41,50-52,54-95 erally considered to be the domain of surgeons (e.g., radiologists
performing breast biopsies), and as new technical developments
promise to revolutionize surgical care. In an effort to address this
Injection Location Evaluable Patients (No.) False Negative Rate problem as it bears on lymphatic mapping, the ACS, in association
with the Moffitt Cancer Center, initiated a program designed to
Peritumoral* 3,909 6.0%
investigate how best to train teams (comprising surgeons, nuclear
Intradermal/subdermal† 1,734 6.5% medicine physicians, radiologists, and pathologists) in the new
technology. This formal training course is a 2-day session com-
Periareolar/subareolar‡ 19 0%
posed of didactic lectures, live surgery (including extensive sur-
Intratumoral§ 126 5.2% geon-audience interaction during the procedure), and a hands-on
† ‡ § laboratory.The program offers mentoring of initial cases as regis-
*28 trials; 5,924 patients. 11 trials; 1,872 patients. 5 trials; 486 patients. 5 trials; 669
patients. trants go back to their institutions, maintains national registries on
the Internet so that different experiences can be compared, and, fi-
nally, facilitates the participation of other university and communi-
ty physicians in national protocols. Further information may be
are found to have nodal basins outside the axilla. Approximately
obtained from the Center for Minimally Invasive Surgical Tech-
16% to 21% of the extra-axillary SLNs will be found to have
niques (888-456-2840; www.slnmapping.org). Participation in
metastatic disease if removed. The clinical ramifications of these
programs such as this one provides a certain degree of protection
findings are that some patients may be understaged if the extra-ax-
against medicolegal risk as new technology and procedures are in-
illary sites are not evaluated, and such understaging may affect the
troduced.
recommendations for systemic adjuvant therapy.What impact this
Another avenue of training that has been available to surgeons
possibility might have on tumor recurrence rates and patient sur-
is participation in clinical trials such as the NSABP B32 trial.
vival is unknown at present; to resolve the uncertainty would re-
Previous experience with SLN biopsy is not a requirement for
quire a large prospective, randomized trial. participation in this trial, and all participating surgeons are
To date, the only prospective, randomized trial of SLN biopsy in required to undergo a training process to gain experience with
breast cancer is that of Veronesi and coworkers.96 In this trial, a to- the procedure and familiarity with the specifics of the protocol.
tal of 516 evaluable patients were randomly assigned to undergo The techniques used in this trial represented a combination of
either SLN biopsy with confirmatory axillary dissection (257 pa- common methods designed to maximize the efficacy of the pro-
tients) or SLN biopsy with axillary dissection done only if the cedure. The training phase included distribution of a detailed
biopsy yielded positive results (259 patients). At a median follow- training manual, the opportunity to view a video of the proce-
up point of 46 months, no significant survival differences were re- dure, and a site visit by a protocol-designated core trainer to
ported, and there were no regional nodal recurrences in either explain the specifics of the procedure.
arm. Admittedly, the study size was quite small. Other, larger trials
that will have greater statistical power to evaluate the safety of SLN
biopsy when completed are the National Surgical Adjuvant Breast Radiation Exposure Guidelines and Policies
and Bowel Project (NSABP) B32 trial and the American College The amount and type of radioactivity injected in the course of
of Surgeons Oncology Group (ACOSOG) Z0010 trial. Another lymphatic mapping and SLN biopsy are relatively limited.
ongoing study is the ACOSOG Z0011 trial, the aim of which is to Typically, from 0.4 to 1.2 mCi of 99mTc is injected. This agent is
evaluate the effectiveness of SLN biopsy as the sole surgical proce- a pure gamma emitter with a short half-life (6 hours); thus, the
dure in patients with pathologically positive SLNs. risks of potentially harmful beta radiation are avoided. The total
radiation dose used is quite small—only about 5% of that used
in common nuclear scanning techniques (e.g., bone scans). It
Training and Credentialing
has been estimated that a maximum of 0.45 Gy could be
Credentialing criteria for new operative procedures have tradi- absorbed at the injection site. Of hospital workers, the surgeon is
tionally been under the jurisdiction of local hospital credentialing exposed to the highest levels of radiation. A study from Walter
committees. When new technology becomes available, adequate Reed Army Medical Center found that the hands of surgeons
training is essential, both to ensure that surgeons can perform the performing lymphatic mapping and SLN biopsy were exposed
new procedures competently and to address medicolegal liability to an average of 9.4 + 3.6 mrem per operation.97 Therefore, on
concerns. The American College of Surgeons (ACS) has a com- the basis of skin dosage recommendations set by the Nuclear
mittee (the Committee on Emerging Surgical Technology and Ed- Regulatory Commission, a surgeon would have to perform more
ucation) that monitors this activity. With some new techniques than 5,000 SLN procedures a year to incur more than the min-
(e.g., laparoscopic cholecystectomy and image-guided breast biop- imal level of risk.
sy), hospitals have required surgeons to attend formal training The low risk notwithstanding, proper handling of radioactive
courses and to have their first cases proctored by surgeons with ex- specimens is recommended. All such specimens should be han-
perience in the new technique before they are allowed to perform dled as little as possible for at least 24 to 48 hours and should be
the procedure on their own. appropriately labeled. Each institution performing these proce-
National organizations continue to struggle with the problem of dures should develop guidelines for handling and processing
educating and credentialing surgeons to perform new procedures. specimens in accordance with their own institution’s radiation
This problem takes on increasing urgency as medicolegal issues safety policies.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 6 Lymphatic Mapping and Sentinel Lymph Node Biopsy— 10
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(abstr). Presented at the International Congress on cancer: results in a large series. J Natl Cancer Inst phoscintigraphy. Ann Surg Oncol 8:234, 2001
Melanoma, Sydney, Australia, 1997 91:368, 1999 62. Solorzano CC, Ross MI, Delpassand E, et al: Utility
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3 BREAST, SKIN, AND SOFT TISSUE 6 Lymphatic Mapping and Sentinel Lymph Node Biopsy— 11
of breast sentinel lymph node biopsy using day-be- lymph drainage scintigraphy in patients with breast 88. Valdes-Olmos RA, Jansen L, Hoefnagel CA, et al:
fore-surgery injection of high-dose 99mTc-labeled carcinoma]. Zentralbl Gynakol 122:514, 2000 Evaluation of mammary lymphoscintigraphy by a
sulfur colloid. Ann Surg Oncol 8:821, 2001 76. Sardi A, Spiegler E, Colandrea J, et al:The benefit of single intratumoral injection for sentinel node identi-
63. Jinno H, Ikeda T, Matsui A, et al: Sentinel lymph using two techniques for sentinel lymph node map- fication. J Nucl Med 41:1500, 2000
node biopsy in breast cancer using technetium-99m ping in breast cancer. Am Surg 68:24, 2002 89. Valdes Olmos RA,Tanis PJ, Hoefnagel CA, et al: Im-
tin colloids of different sizes. Biomed Pharmacother 77. Mateos JJ, Vidal-Sicart S, Zanon G, et al: Sentinel proved sentinel node visualization in breast cancer by
56(suppl 1):213S, 2002 lymph node biopsy in breast cancer patients: subder- optimizing the colloid particle concentration and
64. Crossin JA, Johnson AC, Stewart PB, et al: Gamma- mal versus peritumoural radiocolloid injection. Nucl tracer dosage. Nucl Med Commun 22:579, 2001
probe-guided resection of the sentinel lymph node in Med Commun 22:17, 2001 90. Ronka R, Krogerus L, Leppanen E, et al: Sentinel
breast cancer. Am Surg 64:666, 1998 78. Martin RC, Derossis AM, Fey J, et al: Intradermal nodes outside level I-II of the axilla and staging in
65. Roumen RM,Valkenburg JG, Geuskens LM: Lym- isotope injection is superior to intramammary in sen- breast cancer. Anticancer Res 22:3109, 2002
phoscintigraphy and feasibility of sentinel node biop- tinel node biopsy for breast cancer. Surgery 130:432, 91. Shimazu K, Tamaki Y, Taguchi T, et al: Comparison
sy in 83 patients with primary breast cancer. Eur J 2001 between periareolar and peritumoral injection of ra-
Surg Oncol 23:495, 1997 79. Veronesi U, Paganelli G, Galimberti V, et al: Sentinel- diotracer for sentinel lymph node biopsy in patients
66. Snider H, Dowlatshahi K, Fan M, et al: Sentinel node biopsy to avoid axillary dissection in breast can- with breast cancer. Surgery 131:277, 2002
node biopsy in the staging of breast cancer. Am J cer with clinically negative lymph-nodes. Lancet
92. Klimberg VS, Rubio IT, Henry R, et al: Subareolar
Surg 176:305, 1998 349:1864, 1997
versus peritumoral injection for location of the sen-
67. Pijpers R, Meijer S, Hoekstra OS, et al: Impact of 80. Boolbol SK, Fey JV, Borgen PI, et al: Intradermal tinel lymph node. Ann Surg 229:860, 1999
lymphoscintigraphy on sentinel node identification isotope injection: a highly accurate method of lym-
phatic mapping in breast carcinoma. Ann Surg On- 93. Smith LF, Cross MJ, Klimberg VS: Subareolar injec-
with technetium-99m-colloidal albumin in breast tion is a better technique for sentinel lymph node
cancer. J Nucl Med 38:366, 1997 col 8:20, 2001
biopsy. Am J Surg 180:434, 2000
68. Cox CE, Pendas S, Cox JM, et al: Guidelines for 81. Motomura K, Inaji H, Komoike Y, et al: Combina-
tion technique is superior to dye alone in identifica- 94. Kern KA: Concordance and validation study of sen-
sentinel node biopsy and lymphatic mapping of pa-
tion of the sentinel node in breast cancer patients. J tinel lymph node biopsy for breast cancer using sub-
tients with breast cancer. Ann Surg 227:645, 1998
Surg Oncol 76:95, 2001 areolar injection of blue dye and technetium 99m
69. Borgstein PJ, Meijer S, Pijpers R: Intradermal blue sulfur colloid. J Am Coll Surg 195:467, 2002
dye to identify sentinel lymph-node in breast cancer. 82. Rink T, Heuser T, Fitz H, et al: Results of a standard-
ized protocol for sentinel node imaging in breast can- 95. Tuttle TM, Colbert M, Christensen R, et al: Subare-
Lancet 349:1668, 1997
cer with Tc-99m labeled nanocolloidal albumin. olar injection of 99mTc facilitates sentinel lymph
70. De Cicco C, Chinol M, Paganelli G: Intraoperative Nuklearmedizin 40:80, 2001 node identification. Ann Surg Oncol 9:77, 2002
localization of the sentinel node in breast cancer:
technical aspects of lymphoscintigraphic methods. 83. Rink T, Heuser T, Fitz H, et al: Lymphoscintigraphic 96. Veronesi U, Paganelli G,Viale G, et al: A randomized
Semin Surg Oncol 15:268, 1998 sentinel node imaging and gamma probe detection comparison of sentinel-node biopsy with routine ax-
in breast cancer with Tc-99m nanocolloidal albumin: illary node dissection in breast cancer. N Engl J Med
71. Bass SS, Cox CE, Ku NN, et al:The role of sentinel results of an optimized protocol. Clin Nucl Med 349:546, 2003
lymph node biopsy in breast cancer. J Am Coll Surg 26:293, 2001
189:183, 1999 97. Miner TJ, Shriver CD, Flicek PR, et al: Guidelines
84. Xavier NL, Amaral BB, Cerski CT, et al: Sentinel for the safe use of radioactive materials during local-
72. Winchester DJ, Sener SF,Winchester DP, et al: Sen- lymph node identification and sampling in women ization and resection of the sentinel lymph node.
tinel lymphadenectomy for breast cancer: experience with early breast cancer using 99m Tc labelled dex- Ann Surg Oncol 6:75, 1999
with 180 consecutive patients: efficacy of filtered tran 500 and patent blue V dye. Nucl Med Commun
technetium 99m sulphur colloid with overnight mi- 22:1109, 2001 98. Tanabe K: Lymphatic mapping and epitrochlear
gration time. J Am Coll Surg 188:597, 1999 node dissection for melanoma. Surgery 121:102,
85. Tavares MG, Sapienza MT, Galeb NA Jr, et al:The 1997
73. Haigh PI, Hansen NM, Giuliano AE, et al: Factors use of 99mTc-phytate for sentinel node mapping in
affecting sentinel node localization during preopera- melanoma, breast cancer and vulvar cancer: a study 99. Hung JC,Wiseman GA,Wahner HW, et al: Filtered
tive breast lymphoscintigraphy. J Nucl Med 41:1682, of 100 cases. Eur J Nucl Med 28:1597, 2001 technetium-99m-sulfur colloid evaluated for lym-
2000 phoscintigraphy. J Nucl Med 36:1895, 1995
86. Vargas HI,Tolmos J, Agbunag RV, et al: A validation
74. Sato K, Uematsu M, Saito T, et al: Indications and trial of subdermal injection compared with intra- 100. Nathanson SD, Anaya P, Karvelis KC, et al: Sentinel
technique of sentinel lymph node biopsy in breast parenchymal injection for sentinel lymph node biop- lymph node uptake of two different technetium-la-
cancer using 99m-technetium labeled tin colloids. sy in breast cancer. Am Surg 68:87, 2002 beled radiocolloids. Ann Surg Oncol 4:104, 1997
Breast Cancer 7:95, 2000 87. Doting MH, Jansen L, Nieweg OE, et al: Lymphatic 101. Wong J, Cagle L, Morton DL, et al: Lymphatic
75. Krause A, Dunkelmann S, Makovitzky J, et al: [De- mapping with intralesional tracer administration in drainage of skin to a sentinel node in a feline model.
tection of atypical site of “sentinel lymph nodes” by breast carcinoma patients. Cancer 88:2546, 2000 Ann Surg 214:637, 1991
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 7 SURFACE RECONSTRUCTION PROCEDURES — 1
7 SURFACE RECONSTRUCTION
PROCEDURES
Joseph J. Disa, M.D., Himansu R. Shah, M.D., and Gordon Kaplan, M.D.
a b c
d e f
Figure 1 Shown are types of sutures used in plastic surgical wound repair. (a) Simple interrupted sutures.
An equal bite of tissue is taken on each side of the wound; to ensure eversion of skin edges, a significant
amount of deeper tissue is incorporated. (b) Vertical mattress sutures. Bites are taken either (1) first close
to the wound and then distant from it or (2) vice versa. Bites on either side of the wound must be equally
spaced from the skin edges. (c) Horizontal mattress sutures. As with vertical mattress sutures, all bites are
equally spaced from the skin edges. (d) Subcuticular continuous suture. All bites, except for entrance and
exit bites, are within the dermis at the same level; the suture should enter and exit the dermis at right
angles. (e) Half-buried horizontal mattress sutures. These are similar to standard horizontal mattress
sutures except that tissue opposite the side where the stitch enters the skin is grasped in the subcuticular
level; thus, the needle passes into and out of the epidermis at only two locations. (f) Continuous over-and-
over suture. This resembles a simple suture except that it is continuously passed through the wound until
the desired terminus is reached.
vantages vis-à-vis full-thickness grafts are the increased sec- or saline [see Figure 3d]. The donor site closure is then closed,
ondary contraction and hyperpigmentation. either in two layers (for thicker donor sites such as the groin) or
in a single layer (for thinner donor sites such as the eyelid).
OPERATIVE TECHNIQUE
Full-Thickness Grafts
Table 1—Optimal Timing of Suture
The recipient site is adequately debrided, and the defect is Removal after Wound Closure
measured. An outline of the defect is made on the graft site. If
the graft is circular, it may have to be converted to an ellipse for
Optimal Suture Removal Time
smooth closure [see Figure 3a]. An incision is made around the Closure Site
(days after closure)
outline with a No. 10 or 15 blade.The edges of the graft are ele-
vated with skin hooks. Meticulous dissection is performed in Eyelid 3–5
such a way that as little subcutaneous tissue as possible is
Face 5–7
included with the graft [see Figure 3b]. Once the graft is harvest-
ed, any subcutaneous tissue is sharply removed (a step known as Lip 5–7
defatting the graft).The graft is then wrapped in a saline-soaked
Hands/feet 10–14
sponge until ready for use.
The graft is properly positioned and secured with absorbable Trunk 7–10
sutures [see Figure 3c]. A tie-over bolster dressing is applied—typ- Breast 7–10
ically, Xeroform wrapped around cotton soaked with mineral oil
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3 BREAST, SKIN, AND SOFT TISSUE 7 SURFACE RECONSTRUCTION PROCEDURES — 3
a b
c d
Figure 3 Skin grafts: full thickness.
(a) A retroauricular full-thickness skin
graft is outlined; conversion to an
elliptical shape may facilitate closure.
(b) The graft is elevated with skin
hooks, with care taken to include as
little subcutaneous tissue as possible.
(c) The graft is sutured in place. (d) A
tie-over bolster dressing is applied to
maintain pressure on the graft and
ensure good contact between it and the
recipient bed.
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3 BREAST, SKIN, AND SOFT TISSUE 7 SURFACE RECONSTRUCTION PROCEDURES — 4
a b
c d
Figure 4 Skin grafts: split thickness. (a) Shown is a cheek defect after excision of a melanoma in situ. (b) A der-
matome is used to harvest the graft. It is set to obtain a specific thickness of skin; 0.014 in. (0.356 mm) is a common
setting. (c) The graft is harvested by applying steady pressure to the skin with the dermatome while advancing it for-
ward. The assistant retracts the skin to optimize contact between blade and skin. (d) The skin is gently removed from
the dermatome. If necessary, it can be meshed to increase its size.
contract and fill with scar tissue; in addition, meshed grafts the trunk or the face) [see Figure 5b] or by wrapping gauze or an
often heal with a cobblestone appearance. There are two basic elastic bandage (or both) around it (for curved areas such as the
types of graft meshers, those that contain grooved meshing extremities). For a graft on an extremity, splinting may be nec-
boards and those that do not. Expansion ratios range from essary for immobilization.The donor site is then dressed with an
1.5:1 to 3:1. The desired ratio is selected by choosing either the occlusive dressing such as Op-Site or a semiocclusive dressing
appropriate meshing board or the appropriate cutting blade, such as Xeroform until reepithelialization occurs [see Figure 5c].
depending on the type of mesher used. In most circumstances,
POSTOPERATIVE CARE
an expansion ratio of 1.5:1, which increases surface area by
50%, is sufficient. On rare occasions, an expansion ratio of 3:1 The postoperative fate of a skin graft is largely determined by
is needed, depending on the availability of donor sites in rela- the circumstances of the wound (especially the presence or
tion to the requirements of the recipient area. The graft to be absence of infection) and the technical execution of the grafting
meshed is placed with the dermis side up on the grooved side procedure.3 Successful healing of skin grafts requires immobi-
of the meshing board. The meshing board is rolled through the lization of the recipient site for 5 to 7 days. Immobilization can
mesher, and the meshed graft is ready for final placement over be accomplished with tie-over bolsters; on extremities, skin
the recipient site. grafts can be further immobilized with plaster casts. Proper
The skin graft is secured to the recipient bed either with immobilization is critical for graft survival because it prevents
absorbable suture material or with staples [see Figure 5a]. A bol- shearing in the plane between the graft and the wound bed. After
ster dressing, made of Xeroform and of cotton soaked in saline 5 to 7 days of immobilization, either a gauze dressing such as
or mineral oil, is applied over the graft. The bolster is fixed in Xeroform or a lubricating antibiotic ointment should be applied
place either by tying sutures over it (for broad, flat areas such as for another 5 to 7 days.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 7 SURFACE RECONSTRUCTION PROCEDURES — 5
a b
c
Figure 5 Skin grafts: split thickness. (a) The skin graft
is sutured in place. Care is taken to trim all excess skin
and to ensure that the graft is in complete contact with
the bed. (b) A tie-over bolster dressing is applied. (c) The
donor site is dressed. In this case, calcium sodium alginate
is applied to the bed, followed by a bio-occlusive dressing.
The dressing is left intact until reepithelialization occurs
(typically, 7 to 10 days).
Figure 6 Local flaps. A random-pattern skin flap (left) is supplied by a subdermal plexus of small vessels
that do not have an axial orientation. An axial-pattern skin flap (center) is designed parallel to the axis of a
known major subcutaneous artery. It can have a greater length:width ratio because its blood supply is more
reliable. A myocutaneous flap (right) derives the blood supply of its skin component from vertical perfora-
tors from the underlying muscle. The skin can be completely isolated over the muscle as an island.
a b
c d
Figure 7 Local flaps. (a) The blood supply of random-pattern skin flaps is limited; only small flaps (e.g., thenar flaps,
shown here), are consistently reliable. (b) Shown is an axial-pattern skin flap. (c) The skin and subcutaneous tissue of a
myocutaneous flap can exist as a complete island because the blood supply is derived from vertical muscular perfora-
tors. (d) Shown are a large free flap of scapular area skin and the entire latissimus dorsi. The subscapular vessels that
connect the two will supply both components of the flap after microvascular anastomoses.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 7 SURFACE RECONSTRUCTION PROCEDURES — 7
only by the vascular pedicle, it is termed an island flap.The same supply the overlying skin [see Figures 7c, d].These vessels are not
flap is termed a free flap if the vascular pedicle is severed, the flap necessarily the exclusive supply to the skin in a specific region,
is transferred to a distant recipient site, and its circulation is but they are able to support the skin entirely when other sources
restored by microvascular anastomoses. of blood supply are eliminated. Investigation of the body mus-
culature showed that there were at least five basic patterns of
Blood Supply blood supply to muscle, distinguished by the existence of and
The earliest flaps in common use were skin flaps that had balance between primary pedicles and secondary sources of sup-
what is known as a random-pattern type of circulation [see Figure ply [see Figure 8]. Some muscles can be rotated or transposed as
7a], in which blood is supplied by the subdermal capillary plexus myocutaneous flaps on the basis of either their dominant or sec-
rather than by a major, named vessel.5 The precarious nature of ondary blood supply (e.g., pectoralis major and latissimus
the blood supply of such flaps severely limited flap design and dorsi). Some muscles have two dominant supplies and can be
resulted in a preoccupation with suitable length:width ratios. transposed on either one (e.g., rectus abdominis). Other muscles
Greater length:width ratios became possible after the empirical do not reliably support skin territories supplied by minor pedi-
discovery that a more vigorous circulation develops in flaps cles (e.g., gracilis).
raised in stages (the delay phenomenon).6 Other patterns of cutaneous blood supply are now well rec-
The next flaps to come into common use had an axial-pattern ognized. Fasciocutaneous flaps with high length:width ratios can
type of circulation, in which a sizable artery coursed directly to be reliably raised on the trunk, arms, and legs.The blood supply
a specific cutaneous territory [see Figure 7b]. The groin was the of deep fascia appears to consist of both a deep and a superficial
first region where this arrangement was carefully described, and fascial plexus. These vessels connect both to perforating vessels
it remains a useful source of flaps for selected applications. from the underlying muscles and to the subcutaneous tissue ves-
Because longer flaps can be made in areas where the blood sup- sels above them.8 At least three types of fasciocutaneous flaps
ply has an axial pattern, the length:width ratio and the delay may be distinguished on the basis of the fascial blood supply to
phenomenon became less important issues.7 Identification of an the skin [see Figure 9].9
axial-pattern blood supply to a given graft allows so-called In some areas, fascia supplies overlying subcutaneous tissue
islanding of the graft from the donor site except for the vascular and skin more directly. Such a blood supply is most evident in
connection, which is preserved. Such island flaps have greater the extremities, where direct branches from major vessels course
mobility than flaps with a less attenuated attachment to the through intermuscular septa to reach the deep fascia and supply
donor site. the overlying skin and subcutaneous tissue. The forearm is a
A third type of flap was based on the myocutaneous blood clinically important donor site because thin septocutaneous
supply, a network of vessels that perforate muscles vertically and flaps fed by the radial artery can be raised as either pedicled or
Tensor Fasciae Latae Gracillis Rectus Abdominis External Oblique Latissimus Dorsi
Figure 8 Local flaps. Schematized are the five basic patterns of blood supply to muscle. Individual muscles are
classified on the basis of the dominance, number, and size of the vessels that supply them. Type I is supplied by a
single dominant pedicle. Type II is supplied by one dominant vessel and several much smaller vessels. Type III is
supplied by two dominant pedicles. Type IV is supplied by multiple vessels of similar size. Type V is supplied by one
dominant pedicle and several smaller segmental vascular pedicles.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 7 SURFACE RECONSTRUCTION PROCEDURES — 8
Figure 9 Local flaps. At least three types of fasciocutaneous flaps exist, categorized by blood sup-
ply configuration. Type A is supplied by multiple small, longitudinal vessels coursing with the deep
fascia. These flaps must retain a base of a certain width and cannot be raised as islands (e.g., longi-
tudinally oriented flaps of skin and fascia on the lower leg). Type B is supplied by a single major
vessel within the fascia (e.g., scapular flap). Type C is supplied by multiple perforating segments
from a major vessel coursing through intermuscular septa (e.g., forearm flaps).
free flaps. Other examples of fasciocutaneous flaps include the at the base of the flap, with a blunt scissors to keep from disrupt-
lateral arm septocutaneous flap, fed by the profunda brachii ing the blood supply. The electrocautery should be used judi-
artery; the scapular flap, fed by the circumflex scapular artery ciously in the elevation of skin flaps: although cauterization caus-
[see Figure 7d]; and the fibular osteofasciocutaneous flap, fed by es less bleeding, skin flaps often rely on the subdermal plexus for
the peroneal artery. perfusion, and this plexus can be damaged by electrocautery dis-
section. Close attention to atraumatic technique throughout the
Method of Movement to Recipient Site procedure will result in less edema in the flap and, therefore, less
Local flaps may be called either rotation, advancement, or circulatory compromise. Hemostasis is essential; in small flap
transposition flaps, depending on how they are moved to reach procedures, bipolar coagulation controls bleeding with minimal
their recipient sites. damage to the flap’s blood supply. Two-layer closure is recom-
A more complete characterization of flaps is achieved by com- mended, with absorbable suture material in the deeper layer to
bining all of the descriptive categories mentioned. For example, decrease the tension and fine nylon for skin closure.
a muscle and skin flap that is rotated to cover an adjacent soft The recommendations just mentioned apply to local flap pro-
tissue defect is termed a myocutaneous rotation flap, and a skin cedures in general. In what follows, we describe several different
and bone flap used to reconstruct a distant composite defect is types of local flaps that are useful for the purposes of the general
termed an osteocutaneous free flap. surgeon, and we summarize key technical points specific to each.
OPERATIVE TECHNIQUE Transposition Flaps
In all forms of plastic surgery, it is essential to cause as little tis- A flap that is moved laterally into the primary defect is called a
sue trauma as possible when raising a flap. Using skin hooks transposition flap.The essential concept in the design of such a flap
rather than forceps is helpful in this regard. The flap is marked is to ensure that the flap is long enough to cover the entire defect,
and incised, and elevation is begun, first with a scalpel and then, so that the transfer can be done without tension [see Figure 10].
Figure 10 Local flaps: transposition flap. After excision of the defect, a transposition flap
of adequate length is designed and elevated in the subcutaneous plane. The flap is moved
laterally into the defect and inset. It may be necessary to excise a dog-ear of excess skin at
the tip of the flap harvest site.
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3 BREAST, SKIN, AND SOFT TISSUE 7 SURFACE RECONSTRUCTION PROCEDURES — 9
Figure 11 Local flaps: bilobed flap. A flap with two lobes is created, with the first lobe the same
size as the defect and the second lobe substantially (~50%) smaller than the first. The flap is
elevated in the submuscular plane. Wide undermining at this level is necessary for tension-free
transposition. The first lobe covers the initial defect, and the second covers the defect from the
first. The second lobe is placed in an area of loose skin, and its area of origin is closed primarily.
The skin is marked and incised with a scalpel, and dissection lobe is transposed into the donor defect left by the primary lobe,
is carried through the subcutaneous fat.The flap is retracted with and the defect left by the secondary lobe is closed primarily.
a skin hook, and dissection is performed with a blunt scissors Closure is accomplished with 5-0 or 6-0 nylon.
until the flap is elevated sufficiently to allow it to be transposed
into the defect without tension. The secondary defect is closed Rhomboid flap (Limberg flap) A rhomboid flap is a
primarily; alternatively, depending on the location of the donor transposition flap that is designed in a specific geometric fash-
area and the degree of skin tension present there, a skin graft may ion [see Figure 12].The initial defect is converted to a rhomboid,
be indicated. As with any local flap, wide undermining of the sur- with care taken to plan the flap in an area with minimal skin
rounding tissues may be necessary for closure of the defect and tension. The rhomboid must be an equilateral parallelogram
the donor site. Closure is then performed in two layers. with angles of 60º and 120º; this design allows the surgeon to
excise less tissue than would be needed for an elliptical flap.
Bilobed flap A bilobed flap is a transposition flap consist- One face of the rhomboid constitutes the first side of the flap
ing of two lobes of skin and subcutaneous tissue based on a com- (YZ), which should be aligned along the line of maximum
mon pedicle [see Figure 11]. It is often used to correct nasal extensibility.The short diagonal of the rhomboid is then extend-
defects involving the lateral aspect, the ala, or the tip.The keys to ed outward for a distance equal to its own length. This exten-
a successful bilobed flap are (1) accurate design and (2) wide sion should be oriented along relaxed skin tension lines, per-
undermining of the surrounding tissue in the submuscular plane pendicular to the line of maximum extensibility; it constitutes
to allow a smooth transposition. The primary lobe is usually at the second side of the flap (XY). Next, a line parallel to YZ is
an angle of 45º or less to the defect; the secondary lobe is drawn from X to outline the third side of the flap. Correct ori-
designed to achieve closure of the donor defect and is substan- entation of the rhomboid is vital for providing flap repair with
tially smaller than the primary lobe. The angle between the two minimal tension, particularly with respect to the line of maxi-
is 90º to 100º. Both flaps are raised simultaneously in the sub- mum extensibility: it is along this base line that maximum ten-
muscular plane. Wide undermining of the area (also in the sub- sion results when the donor defect is closed. Once the flap has
muscular plane) minimizes tension. The primary lobe of the been correctly designed and elevated, it is transposed into the
bilobed flap is transposed into the initial defect, the secondary defect. Closure is done in two layers.
a b c
X RSTL
LME
Y Z Z
Z
X Y
60° 120°
X Y
Figure 12 Local flaps: rhomboid (Limberg) flap. (a) The defect is converted to a rhomboid, with
all four sides of equal length and angles of 60º and 120º. An extension XY is made that is the
same length as the short diagonal of the rhomboid, and a line of equal length is drawn from X
paralleling YZ. (b) The flap is oriented so that XY follows the relaxed skin tension lines (RSTL)
and YZ the line of maximum extensibility (LME). (c) The flap is inset.
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3 BREAST, SKIN, AND SOFT TISSUE 7 SURFACE RECONSTRUCTION PROCEDURES — 10
a Advancement Flaps
Rotation Flaps
A flap that is rotated into the defect is called a rotation
flap.10,11 It takes the form of a semicircle of which the defect
occupies a wedge-shaped segment [see Figure 13]. The original
defect is converted to a triangular shape (ABC). One side of the
triangular defect (AC) is extended to a point (D) that will serve
as the pivot point for the flap. The distance between A and D
should be at least 50% greater than that between A and C. A
semicircular line extending from C to D is then defined.
The flap is incised with a scalpel, elevated, and rotated. As
with all local skin flaps, wide undermining of the surrounding
tissue may be necessary to allow tension-free rotation and
wound closure. The flap is secured with a two-layer closure; the Figure 14 Local flaps: direct advancement flap. (a) A flap whose
secondary defect may be closed primarily. Sometimes, a so- shape corresponds to that of the defect is elevated in the subcuta-
called back cut is required to gain adequate rotation. The most neous plane and advanced into the defect. (b) Excision of Burow’s
common technical error with rotation flaps is improper design: a triangles (excess skin at the flap base) may be necessary to permit
flap that is too small will not cover the defect adequately. advancement.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 7 SURFACE RECONSTRUCTION PROCEDURES — 11
Theoretical Amount of
Incision Angle (degrees) Lengthening (%)
30 25
45 50
60 75
75 100
90 120
Figure 15 Local flaps: V-Y advancement flap. (a) A V-shaped flap tations of technique and appreciate the subtleties of proper
is created whose length is 1.5 to 2 times that of the defect. With design. Important considerations in the use of Z-plasty include
subcutaneous connections to the skin preserved (because these appropriate determination of the length of the central limb and
constitute the blood supply to the flap), the flap is advanced into correct orientation of the limbs so that the new central limb
the defect. (b) The V incision is converted to a Y as the base is
formed after transposition is parallel to skin tension lines.
closed primarily.
Multiple Z-plasties may be useful for some localized scars.
POSTOPERATIVE CARE
The Z-plasty [see Figure 16] is an example of such tissue
rearrangement.12 Two triangular flaps are designed so that they
Local Flaps
have in common a central limb aligned in the direction along
which additional length is desired. For example, the limb may be The postoperative care of local flaps is not complex. Flap
placed along the line of a contracture. Two lines, approximately healing is supported by adequate nutrition and maintenance of
equal in length to the central limb, are drawn from either end of a normal hemodynamic state, including normal blood volume.
the limb, diverging from it at equal angles varying from 30º to Tension must not be placed on the flap. Tension can develop in
90º. The degree of lengthening obtained is determined by the flaps on the trunk as a result of changes in patient position or in
size of this angle [see Table 2]. In theory, maximal length gain is flaps on the limbs as a result of loss of immobilization.
achieved by using the largest angle possible, but in practice, the Generally, the tip of any local flap is not only its most valuable
maximum usable angle is determined by the limits of skin elas- portion but also its most vulnerable area. At the tip, the blood
ticity. A 60º angle, which is commonly used, will result in a 75% supply is the most precarious, and the detrimental effects of ten-
gain in length along the central limb. Triangular flaps are elevat- sion are magnified. Unfortunately, no pharmacologic agents are
ed, and the fibrous tissue band responsible for the contracture is of proven benefit in preventing necrosis of a flap with failing cir-
divided. The triangular flaps are transposed and inset, yielding culation. Any flap necrosis that might develop should be mini-
increased length in the desired direction, with the original Z mized by preventing infection of the necrotic tissue. Necrotic tis-
rotated 90º and reversed. sue must therefore be debrided after the extent of tissue loss
Although Z-plasty is conceptually simple, it is not necessarily becomes clear. Portions of the flap that are undergoing demar-
easy: experience is necessary for the surgeon to realize the limi- cation but do not appear actively infected can be protected by
the application of a topical antibiotic such as silver sulfadiazine
cream (Silvadene).
Extremities that are recipient sites for flaps, like those that are
recipient sites for skin grafts, should be elevated after the opera-
tion until satisfactory wound healing has occurred.
Free Flaps
A Survival of free flaps, unlike that of local flaps, tends to be an
B A
B all-or-none phenomenon. Careful postoperative monitoring of
A flap circulation is essential because flap failure is likely to be the
result of a problem at the vascular anastomoses. Flaps are usual-
B ly monitored for 7 days. However, the most critical time for free-
flap monitoring is the first 6 to 8 hours because the majority of
vascular crises usually occur within this period. Early detection
and aggressive investigation of such crises generally allow a flap
to be salvaged. Maintenance of normal blood volume and treat-
Figure 16 Local flaps: Z-plasty. (a) The central limb of the Z is
ment of hypothermia is particularly important in the early post-
placed along the line of contracture. Incisions diverging from the
scar at a 60° angle will yield an increase of approximately 75% in operative period to avoid vascular spasm. Spasm causes flaps to
the direction of the central limb. (b) The flaps are transposed. (c) appear pale and to exhibit a significant temperature drop.
The length has been increased in the desired direction, and the Free flaps exhibit venous engorgement when placed in a depen-
original Z design has been rotated 90° and reversed. dent position up to several weeks postoperatively. Such engorge-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 7 SURFACE RECONSTRUCTION PROCEDURES — 12
ment is generally not dangerous, though patients with free flaps is healthy, a drop of bright-red blood should appear at the punc-
below the knee should be gradually mobilized in the same fashion ture site within a few seconds, and another drop should appear
as patients with skin grafts in this location. These patients should each time the previous drop is wiped away by an alcohol swab.
also keep the lower extremity elevated for at least 10 to 14 days. The failure of blood to appear or the delayed appearance of a
Free flaps in the head and neck area require that the patient’s clear, serous ooze instead of blood is an indication of arterial
head motion be restricted somewhat for the first few days. It is insufficiency. Vigorous, dark bleeding confirms a venous prob-
important that electrocardiographic leads and tracheostomy tube lem. Flaps that are pale as a result of vascular spasm are difficult
ties not compress the external jugular vein if it was used as a recip- to assess because their bleeding response to needle puncture is
ient vessel for anastomosis. If central lines are used after opera- poor despite intact anastomoses. Whenever uncertainty exists,
tion, they should be placed on the contralateral side of the neck. however, surgical exploration should be undertaken because the
Free flaps should be monitored on an hourly basis during the entire flap may be in jeopardy.
early postoperative period. Most free flaps include an exposed Free flaps without skin islands are more difficult to monitor
skin island, which facilitates evaluation of the flap circulation.The accurately. Muscle flaps can be followed in much the same way as
flap is observed for color and for capillary refill. A pale flap gen- skin free flaps by inserting needle temperature probes directly
erally indicates arterial insufficiency; however, the normal, lighter into the muscle belly. A healthy muscle free flap is red in color and
color of certain donor sites, such as the abdomen, can be mis- typically has a serous ooze between the interstices of the overly-
leading. Flaps with venous insufficiency are characteristically blue ing meshed skin graft. A flap with an arterial problem quickly
in color and exhibit rapid capillary refill. Bleeding from the edges becomes dry and dark in appearance. A muscle flap with a venous
of a flap is common in the presence of venous hypertension. problem becomes dark and engorged with blood and exhibits
Surface temperature probes can be used to monitor free flaps bleeding from its surface and perimeter. A muscle free flap can be
that have a skin island. The advantages of this method are sim- punctured with a needle to assess the quality of the bleeding if its
plicity and reliability. One probe is placed on the flap and anoth- circulatory status is unclear.
er on a nearby area to serve as a control. The flap surface tem- Fascial free flaps covered with skin grafts are more difficult to
perature is generally less than the control temperature by 1.0° to assess. They tend to transmit body core temperature readily
2.5° C. A progressive widening of the temperature difference is because they are quite thin; therefore, needle temperature probes
ominous and calls for critical assessment of the flap circulation. are generally unreliable. It is often possible in these cases either
The absolute temperature of the flap probe is also significant: a to observe the arterial pulsations in the flap directly or to moni-
flap temperature greater than 32° C indicates healthy circula- tor them with a conventional Doppler device.
tion, whereas a temperature between 30° and 32° C indicates Some free flaps are completely buried beneath the skin.
marginal circulation and a temperature less than 30° C often Others, such as intraoral skin free flaps, are equally difficult to
indicates a vascular problem. In a healthy flap, temperature fluc- monitor postoperatively. Specialized transplants, such as
tuations may be caused by a dislodged probe, an exogenous heat jejunum, are particularly vulnerable to short periods of anoxia
source (such as a lamp), cooling of one of the probes from an and are not likely to be salvageable by the time a problem is rec-
oxygen mist mask, or cleaning of the flap skin with alcohol ognized. Alternative methods of monitoring buried free flaps are
(which results in a precipitous drop in skin temperature). being developed, although they are not in wide clinical use. One
To confirm the presence of an anastomotic problem, flap cir- example is the implantable Doppler monitor. This device is
culation is assessed directly by a full-thickness puncture of the placed in direct contact with the artery distal to the anastomosis
flap skin with a 20-, 22-, or 25-gauge needle. If flap circulation to obtain a continuous Doppler signal.13
References
1. Weinzweig N, Weinzweig J: Basic principles and 6. Cederna PS, Chang P, Pittet-Cuenod BM, et al: Strauch B, Vasconez LO, Hall-Findlay EJ, Eds.
techniques in plastic surgery. Mastery of Plastic The effect of the delay phenomenon on the vas- Lippincott-Raven Publishers, Philadelphia, 1998
and Reconstructive Surgery, Vol 1. Choen M, Ed. cularity of rabbit abdominal cutaneous island 12. McGregor IA, McGregor AD: The z-plasty.
Little, Brown, and Co, Boston, 1994 flaps. Plast Reconstr Surg 99:183, 1997 Fundamental Techniques of Plastic Surgery.
2. Borges AF: Elective Incisions and Scar Revision. 7. Milton SH: Pedicled skin-flaps: the fallacy of the Churchill Livingstone, Edinburgh, 1995
Little, Brown, and Co, Boston, 1973 length:width ratio. Br J Surg 57:502, 1970 13. Kind GM, Buntic RF, Buncke GM, et al: The
3. Smahel J: The healing of skin grafts. Clin Plast 8. Lamberty BG, Cormack GC: Fasciocutaneous effect of an implantable Doppler probe on the sal-
Surg 4:409, 1977 flaps. Clin Plast Surg 17:713, 1990 vage of microvascular tissue transplants. Plast
9. Cormack GC, Lamberty BG: Arterial Anatomy of Reconstr Surg 101:1268, 1998
4. Disa JJ, Alizadeh K, Smith JW, et al: Evaluation of
a combined sodium alginate and bioocclusive Skin Flaps. Churchill Livingstone, Edinburgh,
membrane dressing in the management of split 1987
thickness skin graft donor sites. Ann Plast Surg 10. Jackson IT: Local rotational flaps. Operative
46:405, 2001 Plastic Surgery. Evans GRD, Ed. McGraw-Hill, Acknowledgments
5. Daniel RK, Kerrigan CL: Skin flaps: an anatomi- New York, 2000
cal and hemodynamic approach. Clin Plast Surg 11. Worthen EF: Scalp flaps and the rotation fore- Figures 1 through 3, 10, 12 through 15 Tom Moore.
6:181, 1979 head flap. Grabb’s Encyclopedia of Flaps, Vol 1. Figures 6, 8, 9, 11, 16 Carol Donner.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 1 DYSPHAGIA — 1
1 DYSPHAGIA
Ahmad S. Ashrafi, M.D., F.R.C.S.C., and R. Sudhir Sundaresan, M.D., F.A.C.S., F.R.C.S.C.
Dysphagia may be defined as difficulty in transferring a food bolus (PET), is particularly valuable in assessing patients with esophageal
from the mouth to the stomach. It may be associated with abnor- cancer.
malities in the oral, the pharyngeal, or the esophageal phase of swal-
OROPHARYNGEAL DYSPHAGIA
lowing. Unlike the term globus, which describes a painless sensa-
tion of fullness in the neck or throat, the term dysphagia implies Oropharyngeal dysphagia is usually associated with symptoms
actual interference with the swallowing mechanism [see Sidebar that originate in the oropharynx, including inability to chew
The Swallowing Mechanism]. Dysphagia may be classified as oro- food, drooling, coughing during a meal, and nasal regurgitation
pharyngeal or esophageal. Whereas oropharyngeal dysphagia (i.e., of solids or liquids. In general, if a patient experiences dysphagia
dysphagia resulting from abnormalities in the oral or the pharyn- within 1 second of swallowing, an oropharyngeal origin is likely.
geal phase of swallowing) usually implies a functional disturbance A variety of different conditions are capable of causing oropha-
in the swallowing mechanism, esophageal dysphagia may result ryngeal dysphagia. The common causes can be grouped into
from a discrete mechanical obstruction or from an esophageal three broad categories: (1) generalized (systemic) conditions, (2)
motility disorder. intrinsic functional disturbances, and (3) conditions that give
The exact prevalence of dysphagia is difficult to determine, but rise to fixed mechanical obstruction [see Table 1]. Overall, the
it is estimated that 35% of persons older than 50 years complain most common cause of oropharyngeal dysphagia is a cerebro-
of dysphagia at least once a week. It is important to keep in mind, vascular accident (CVA).
however, that the changes in swallowing physiology associated
ESOPHAGEAL DYSPHAGIA
with aging rarely lead to true dysphagia. Esophageal dysphagia
arises primarily from intrinsic diseases of the esophagus; oropha- Esophageal dysphagia causes symptoms that are referable to the
ryngeal dysphagia frequently occurs as part of a neurologic, meta- chest or the abdomen. In approximately 75% of cases, the pa-
bolic, myopathic, or infectious syndrome.1 tient’s perception of the location of the obstructive site corre-
In what follows, we review the diagnostic and therapeutic deci- sponds to the actual anatomic site of the lesion.2 In addition to
sion-making approaches employed in assessing patients with dys- dysphagia, patients may experience associated symptoms, such as
phagia. Although it is important that surgeons have a working know- chest pain (with a character and a radiation pattern resembling
ledge of all causes of dysphagia, our focus here is on evaluation of those of coronary artery disease [CAD]), retrosternal burning,
conditions that give rise to esophageal dysphagia.We mention sur- and regurgitation of undigested food.3
gical management options but do not address them in detail; the As a general rule, if the swallowing difficulty gradually progress-
operative procedures performed to treat the various clinical enti- es from solids to liquids, the dysphagia probably has a mechanical
ties that cause dysphagia are described more fully elsewhere [see cause. Patients who have mechanical obstruction usually complain
4:4 Open Esophageal Procedures, 4:5 Minimally Invasive Esophageal of dysphagia without pain and can relieve their symptoms only by
Procedures, and 4:7 Video-Assisted Thoracic Surgery]. regurgitating or by altering their diet. If significant weight loss and
Clinical Evaluation
Evaluation of a patient with The Swallowing Mechanism
dysphagia must be performed
in a systematic manner. As- Swallowing consists of both a voluntary phase (comprising the oral
sessment begins with obtain- phase and the first part of the pharyngeal phase) and an involuntary
ing a detailed history, followed phase (comprising the latter part of the pharyngeal phase and the
esophageal phase). The voluntary phase starts with mastication and
by physical examination. Ex-
ends with the positioning of an appropriately sized food bolus in the
cept in the case of acute caustic ingestion, for which direct flexible back of the oropharynx via tongue retraction. The involuntary phase
esophagoscopy is the first line of assessment, the barium swallow, a starts with the opening of the glossopalatal gate and the propulsion of
readily available and noninvasive test, should be the first investiga- the bolus into the pharynx, beyond the upper esophageal sphincter.
tive tool. The barium swallow is a cost-effective, rapid, and easily Once in the esophagus, the food bolus is propelled into the stomach by
available test that provides a “road map” of the esophagus and the primary and secondary esophageal peristaltic waves. The lower esoph-
lesion and yields a tremendous amount of information before ageal sphincter relaxes, allowing the food to be delivered into the stom-
ach. The brain-stem swallowing center, located in the medulla and the
endoscopic assessment. Additional diagnostic information can be pons, provides involuntary control of swallowing. Although swallowing
obtained by means of fiberoptic esophagoscopy, manometry, 24- begins in the oropharynx and is initially voluntary, the subsequent reflex
hour pH study, and, occasionally, bronchoscopy and endoscopic mechanisms are based on peripheral input from the oropharyngeal in-
ultrasonography (EUS). Further diagnostic imaging, in the form nervation and are involuntary.
of computed tomography and positron emission tomography
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 1 DYSPHAGIA — 2
Evaluation of Dysphagia
Focus on underlying cause (e.g., scleroderma, Assess patient with manometry and endoscopy.
diabetes mellitus, alcoholism, amyloidosis,
Parkinson disease, Crohn disease, or
myxedema).
Patient has esophageal web Patient has Barrett’s esophagus Patient has normal or
inflamed esophagus
Treat with endoscopic dilatation. Rule out dysplasia.
Perform surveillance endoscopy.
Treat GERD symptoms medically
or surgically as appropriate.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 1 DYSPHAGIA — 3
Patient has peptic stricture Patient has Schatzki’s ring Patient has esophageal cancer
Treat with endoscopic dilatation, If lesion is asymptomatic, no treatment Perform esophagoscopy for pathologic
and perform brush biopsy to rule is required. diagnosis.
out malignancy. If lesion is symptomatic, treat with Rule out distant metastatic disease with CT
endoscopic dilatation and medical or PET. EUS may aid in locoregional staging.
(or, if necessary, surgical) therapy for Treat surgically according to stage of disease.
GERD.
If cancer is localized and patient is medically
fit, perform esophagectomy.
Give PPIs.
Consider manometry and 24-hr pH
study.
Consider antireflux surgery.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 1 DYSPHAGIA — 4
Table 1 Common Causes of disposed to ulcerative esophagitis and peptic stricture [see Dis-
Oropharyngeal Dysphagia orders Producing Fixed Mechanical Obstruction, Peptic Stric-
ture, below].
CVA Other causes of secondary esophageal motility disturbance
Generalized conditions resulting in dysphagia are amyloidosis, Parkinson disease, Crohn
Myasthenia gravis
disease, and myxedema.
Cricopharyngeal achalasia
Intrinsic functional disturbances
Zenker’s diverticulum INTRINSIC FUNCTIONAL
DISTURBANCES
Neoplasm
Conditions producing fixed Webs
mechanical obstruction Previous surgical treatment
Primary Motor Disorders
Previous radiation therapy Achalasia The majority
of patients with achalasia pre-
sent with dysphagia for liquids
anorexia develop and symptoms are progressing rapidly, esoph- and solids. Most describe a long-standing history of swallowing dif-
ageal cancer is the likely cause of the dysphagia. ficulty, with or without associated weight loss. Other presenting
If, however, the patient has dysphagia for both liquids and solids, symptoms include regurgitation, chest pain, heartburn, and cough-
an underlying esophageal motor disorder is probably responsible. ing or choking spells. Typically, patients will have developed coping
Patients who have motor disorders that cause dysphagia often mechanisms to deal with the problem (e.g., changing position dur-
develop certain unusual maneuvers to relieve their difficulty, ing eating, drinking liquids to “wash down” the food, and practic-
including repeated swallowing, raising the arms over the head or ing repetitive swallowing and chewing).
assuming different positions during swallowing, and the Valsalva A barium x-ray with fluoroscopy will show absent peristalsis
maneuver. Such patients also frequently complain of other associ- and a dilated esophagus. Other findings include a tapered nar-
ated symptoms (e.g., chest pain). rowing in the distal esophagus (a so-called bird’s beak [see Figure
Physical examination is not as helpful as a detailed history. 1]) and, occasionally, an epiphrenic diverticulum [see Esophageal
Clues that may help identify malignant conditions include the devel- Diverticula, below]. Because the study is dynamic, failure of LES
opment of head and neck lymphadenopathy, the presence of an oro- relaxation must be watched for as it is performed. Over time, the
pharyngeal mass, the appearance of subcutaneous lumps (sugges- esophagus can dilate significantly, to the point where it takes on a
tive of cutaneous metastasis), and the occurrence of clinical fea- sigmoid shape.
tures associated with abdominal organ metastasis (jaundice, as- Although some radiologists will declare a diagnosis of achalasia
cites, hepatomegaly). Muscle weakness, fatigability, and other solely on the basis of barium x-rays and fluoroscopy, upper GI
neurologic deficits detected on physical examination may suggest endoscopy is essential to rule out fixed mechanical obstruction
a CVA or myasthenia gravis as the cause of dysphagia. Like oro- (long-standing achalasia is a risk factor for squamous cell cancer
pharyngeal dysphagia, esophageal dysphagia may be caused by a of the esophagus because of chronic stasis and retention esophagi-
number of different generalized conditions, intrinsic functional tis) or so-called pseudoachalasia (a motility disorder resulting
disturbances, or conditions that give rise to fixed mechanical from a carcinoma on the underside of the cardia that extends
obstruction [see Table 2].4 proximally within the wall of the esophagus). The key diagnostic
test in the setting of suspected achalasia is esophageal manome-
Workup and Management
try. Characteristic manometric features of achalasia include aperi-
of Specific Causes of
stalsis and incomplete relaxation of the LES; the LES pressure
Dysphagia
may be either high or normal.
A detailed discussion of the management of achalasia is beyond
SECONDARY MOTOR
the scope of this chapter. Briefly, medical management offers vir-
DISORDERS RESULTING
tually no benefit. Pneumatic dilatation offers subjective improve-
FROM SYSTEMIC
CONDITIONS Table 2 Common Causes of
In patients with secondary motility disorders, the esophageal Esophageal Dysphagia
motor disturbance is a manifestation of a systemic condition; thus,
organs other than the esophagus are also involved. The classic Scleroderma
examples of systemic conditions that give rise to esophageal motil- Generalized conditions Diabetes mellitus
ity disorders are scleroderma, diabetes mellitus, and alcoholism. Alcoholism
Patients who have one or more of these conditions may present GERD with decreased motility
with varying degrees of dysphagia, and their evaluation usually Intrinsic functional disturbances
Motor disorders
entails functional and structural evaluation of the esophagus.
Treatment is aimed at the underlying cause. Patients with scle- Webs
Peptic strictures
roderma exhibit atrophy and sclerosis of distal esophageal smooth
Schatzki’s ring
muscle with fragmentation of connective tissue. Consequently,
Conditions producing fixed Caustic injury
primary peristalsis is absent, and the lower esophageal sphincter mechanical obstruction Neoplasms
(LES) is hypotensive or virtually absent. Patients usually present
Extrinsic compression
with gastroesophageal reflux and heartburn. Because they also Previous surgical treatment
lack secondary peristalsis, there is no mechanism for clearing the Previous radiation therapy
refluxed acid back to the stomach, and as a result, patients are pre-
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 1 DYSPHAGIA — 5
Midesophageal diver-
ticula Midesophageal diver-
ticula are true (i.e., traction)
diverticula that are caused by
periesophageal inflammation.
The usual cause is granulo-
matous inflammation of the
subcarinal lymph nodes
resulting from tuberculosis or fungal infection (typically, histoplas-
mosis). These diverticula are frequently asymptomatic and are
often found incidentally during evaluation for some other disorder.
Dysphagia does occur but is a rare symptom; the clinical manifes-
tations are usually related to the underlying inflammatory disease
or to associated complications (e.g., infection, bleeding, or fis-
tulization to the airway). If the diverticula are not symptomatic,
they need not be treated, and the therapeutic focus is on the
underlying problem that prompted the evaluation.
Epiphrenic diverticula
Epiphrenic diverticula are ac-
quired pulsion diverticula that
arise in the distal 10 cm of the
esophagus [see Figure 4]. Al-
though these diverticula are
usually associated with other
Figure 3 Shown is a large pharyngoesophageal pouch (Zenker’s esophageal motor disorders
diverticulum) in an elderly patient with dysphagia, regurgitation (e.g., achalasia, DES, and hypertensive LES), they occasionally occur
of old retained food, and recurrent pneumonia. in the absence of any underlying esophageal dysfunction. If symp-
toms are absent or mild, conservative management is appropriate. If
significant symptoms (e.g., dysphagia) are present, however, surgical
diffuse intramural diverticulosis, a rare condition characterized by management—usually entailing myotomy, diverticulectomy, and
the development of multiple 1 to 5 mm outpouchings in associa- modified fundoplication—is indicated. Before operation, patients
tion with esophageal inflammation and fibrosis. These outpouch- should undergo a thorough functional assessment with manometry.
ings are believed to be dilated esophageal mucous glands resulting
from chronic inflammation. Dysphagia is the most common pre-
senting complaint for this condition, though one third of patients
complain of gastroesophageal reflux.
DISORDERS PRODUCING annular fibrosis. Proton pump inhibitors (PPIs) have proved high-
FIXED MECHANICAL ly effective in controlling GERD symptoms and enhancing the
OBSTRUCTION healing of esophageal ulcers; as a result of their widespread use,
peptic stricture is now an infrequent complication.
Esophageal Webs
Peptic strictures may occur at any age, and there is usually an
A web is a localized narrow- antecedent history of GERD. The symptoms are progressive but
ing of the esophagus caused unlike those of a malignant process, in that the dysphagia usually
by intraluminal extension of dates back several years and weight loss is usually absent.Typical-
the mucosa and part of the submucosa of the esophageal wall. ly, a patient with a peptic stricture describes gradually worsening
Webs may be either congenital or, more commonly, acquired, usu- dysphagia, initially for solids and eventually for liquids as well. If
ally secondary to conditions such as iron deficiency anemia, pem- the patient has dysphagia for liquids before solids or has dyspha-
phigoid, and ulcerative colitis (among others). The main present- gia for both liquids and solids, an associated motility disorder
ing symptom is dysphagia, the severity of which is proportional to must be suspected. Strictures induced by reflux are located in the
the degree of obstruction. Treatment usually consists of simple distal esophagus at the squamocolumnar junction [see Figure 5];
endoscopic dilatation [see 5:18 Gastrointestinal Endoscopy] after the presence of strictures in other parts of the esophagus raises the
careful verification of the nature of the lesion. possibility of causes other than acid-peptic injury. The best initial
diagnostic testing approach consists of a barium swallow [see
Peptic Stricture
Figure 5] followed by upper GI endoscopy, which shows ulcers
GERD is a very common and a concentric stenosis (which is usually short).
problem. The majority of Management of GERD patients with peptic strictures is con-
patients will present with troversial. One approach consists of dilatation of the stricture [see
heartburn and regurgitation. 5:18 Gastrointestinal Endoscopy] in conjunction with high-dose PPI
Although the associated hy- therapy. An important component of this approach is the perfor-
pomotility observed in some mance of a brush biopsy at the time of dilatation to rule out a
GERD patients can account malignancy. If the stricture recurs, then dilatation with an antire-
for some of the dysphagia, it is important to consider (and, if pos- flux procedure [see 4:4 Open Esophageal Procedures and 4:5
sible, rule out) more significant complications, such as peptic Minimally Invasive Esophageal Procedures] is indicated. In the rare
stricture, Barrett’s esophagus, and carcinoma. cases in which the stricture cannot be dilated, esophageal resec-
Peptic stricture represents the end stage of ulcerative esophagi- tion [see 4:4 Open Esophageal Procedures and 4:7 Video-Assisted Thor-
tis, in which the healing of circumferential ulceration results in acic Surgery] must be considered.
Schatzki’s Ring
Schatzki’s ring is a concen-
tric, symmetrical narrowing
at the squamocolumnar junc-
tion that arises from the
development of submucosal
annular fibrosis and is usual-
ly accompanied by a small
hiatal hernia.5 The exact cause is unknown, though there is a
strong correlation with GERD. Dysphagia is usually for solids and
is proportional to the diameter of the ring. Barium swallow estab-
lishes the diagnosis [see Figure 6], and esophagoscopy is recom-
mended to confirm it.
For asymptomatic patients, no specific treatment is needed. For
patients who present with food impaction, emergency treatment,
involving rigid esophagoscopy and removal of the food bolus, is
indicated. Definitive treatment entails dilatation of the ring in con-
junction with medical therapy for GERD. If the ring proves refrac-
tory to this approach, dilatation plus antireflux surgery (fundopli-
cation) [see 4:4 Open Esophageal Procedures and 4:5 Minimally
Invasive Esophageal Procedures] may be indicated.
Chemical Ingestion
Alkali are commonly found
in household cleaning agents,
mostly in the form of sodi-
um or potassium hydroxide
(NaOH, KOH).The majority
Figure 5 Barium swallow shows severe ulcerative esophagitis, of alkali-related injuries occur
annular fibrosis (stricture), and evidence of acquired esophageal accidentally in children; how-
shortening. Shortness of narrowed segment suggests benign ever, such injuries also occasionally occur in adults as part of a sui-
underlying cause. cide attempt.The magnitude and site of the injury are directly relat-
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 1 DYSPHAGIA — 8
neck, abdomen, or back. Fistulization of an esophageal tumor into Treatment is determined by the stage of the disease. In a
the airway will result in ongoing aspiration (the so-called swallow- medically fit patient with localized esophageal cancer, esoph-
cough sequence) and pulmonary sepsis. Weight loss occurring in agectomy is indicated [see 4:4 Open Esophageal Procedures and
association with dysphagia is strongly suggestive of esophageal 4:7 Video-Assisted Thoracic Surgery]. Traditionally, CT scan-
cancer and should prompt appropriate investigation. ning of the neck, the chest, the abdomen, and the pelvis has
A complete history and physical examination should be carried been performed to rule out distant metastatic disease. More
out, followed by a barium swallow. Characteristic features of esoph- recently, PET scanning has also been used for this purpose.
ageal cancer on barium x-ray include narrowing, mucosal irregular- EUS, if available, may also aid in locoregional staging. For
ity, the presence of a mass, and, occasionally, a so-called shouldered lesions in the upper third or the middle third of the esopha-
stricture [see Figure 8]. Esophagoscopy is essential for establishing a gus, bronchoscopy is necessary to rule out direct tumor inva-
pathologic diagnosis by means of biopsy, brushings, and washings. sion of the airway.
References
1. Cook IA, Kahrilas PJ: AGA technical review on and other esophageal symptoms. Gastrointes- 5. Schatzki R, Gary JE: Dysphagia due to a
management of oropharyngeal dysphagia. Gas- tinal Disease: Pathophysiology, Diagnosis and diaphragm-like localized narrowing in the lower
troenterology 116:455, 1999 Management, 5th ed. Sleisinger MH, Fordtran JS, esophagus (lower esophageal ring). Am J Roent-
genol Radium Ther Nucl Med 70:911, 1953
2. Wilcox SM, Alexander LN, Clark WS: Locali- Eds.WB Saunders Co, Philadelphia, 1993, p 331
zation of an obstructing esophageal lesion: is the 6. Anderson KD, Rouse TM, Randolph JG: A con-
4. Dysphagia: Diagnosis and Management, 3rd ed. trolled trial of corticosteroids in children with
patient accurate? Dig Dis Sci 40:2192, 1995 Groher ME, Ed. Butterworth-Heinemann, Boston, corrosive injury of the esophagus. N Engl J Med
3. Richter JE: Heartburn, dysphagia, odynophagia, 1997 323:637, 1990
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 2 CHEST WALL MASS — 1
Perform excisional biopsy for diagnosis Perform incisional biopsy for diagnosis.
and treatment.
Management
Infectious Masses
Sternal infection Primary sternal
osteomyelitis may be seen in intravenous
drug abusers but is otherwise rare. Much
more common is osteomyelitis occurring after median sternoto-
my. Approximately 1% to 3% of median sternotomies for cardiac
procedures are complicated by sternal wound infection.3 Risk fac-
tors include diabetes, the use of bilateral internal mammary arter-
ies, and reoperation.4 Patients with poststernotomy osteomyelitis
present with pain, drainage, and, often, a palpable mass overlying
the incision. In most cases, the infection is not confined to the
sternum but extends deeply into the mediastinum as well. The
diagnostic study of choice is CT scanning of the chest, which will
Figure 2 CT scan shows typical appearance of SCJ infection,
determine the extent of mediastinal soilage.
including fluid collection around the joint and tissue stranding.
After CT, the patient is taken to the operating room for wide
drainage and sternal debridement. A number of different tech-
niques have been employed to treat these infections; of these, aggres-
sive surgical debridement of the infected area with flap closure yields is made on the basis of the history, the physical examination, and
the best overall clinical outcomes [see 4:6 Chest Wall Procedures].5 CT scanning of the chest (with particular attention paid to the
The patient who presents with a pulsating sternal mass after SCJ). Typical CT findings include tissue stranding and a collec-
sternotomy represents a special case. Such patients have a pseu- tion around the joint [see Figure 2].
doaneursym of the underlying aorta and are at risk for exsan- Treatment consists of wide resection of the SCJ and the proxi-
guination.They should undergo an emergency CT angiogram or mal third of the clavicle, as well as debridement of the manubri-
aortogram to confirm the diagnosis and then be taken directly to um [see 4:6 Chest Wall Procedures].6 Often, the proximal portion of
the OR, where they are placed on cardiopulmonary bypass the first rib is involved and also must be resected. Immediate
through femoral cannulation and cooled to a hypothermic state reconstruction is performed by rotating a pectoralis muscle flap
before the sternum is opened. into the resection cavity. After operation, I.V. antibiotics are ad-
ministered for 6 weeks. Most patients require intensive postoper-
Sternoclavicular joint infection Sternoclavicular joint ative physical therapy to restore strength, function, and mobility
(SCJ) infections present as painful palpable masses overlying the in the upper extremity.
joint [see Figure 1]. These infections are often associated with I.V.
drug abuse, infected indwelling subclavian catheters, or trauma. Osteomyelitis of rib Osteomyelitis of a rib presents as a
Most patients also have an underlying risk factor (e.g., diabetes or painful, swollen mass overlying an infected segment of rib. Often,
hepatic or renal insufficiency) or a history of sepsis.The diagnosis a draining sinus tract is present.The diagnosis is made on clinical
grounds. A CT scan of the chest is obtained to rule out an under-
lying intrathoracic condition (e.g., empyema).
Treatment consists of resection of the infected bone and soft
tissue coverage of the defect [see 4:6 Chest Wall Procedures]. Care
must be taken to avoid contamination of the underlying pleural
cavity during rib resection.
In children, the diagnosis is made on clinical grounds and may
be facilitated by the use of ultrasonography, which demonstrates
obliteration of the intermuscular planes adjacent to the infected
rib and pericostal edema.7 Again, a CT scan is usually obtained to
rule out other underlying pleura-based abnormalities. As with
adults, the range of pathologic organisms that may be recovered is
quite wide.
Benign Neoplasms
Benign neoplasms of the chest wall may be divided into those
arising from soft tissue and those arising from bone and cartilage
[see Table 2].
References
1. Fortier M, Mayo JR, Swensen SJ, et al: MR imag- 10. Gordon MS, Hadju SI, Bains MS, et al: Soft tis- tumors defined by specific chimeric transcripts. N
ing of chest wall lesions. Radiographics 14:597, sue sarcomas of the chest wall. J Thorac Cardio- Engl J Med 331:294, 1994
1994 vasc Surg 101:843, 1991 20. Saenz NC, Hass DJ, Meyer P, et al: Pediatric chest
2. Gattuso P, Castelli MJ, Reyes CV, et al: Cutaneous 11. Gross JL,Younes RN, Haddad FJ, et al: Soft-tissue wall Ewing’s sarcoma. J Pediatr Surg 35:550, 2000
and subcutaneous masses of the chest wall: a fine- sarcomas of the chest wall: prognostic factors. 21. Shamberger RC, LaQuaglia MP, Gebhardt MC,
needle aspiration study. Diagn Cytopathol 15:374, Chest 127:902, 2005 et al: Ewing sarcoma/primitive neuroectodermal
1996 12. King RM, Pairolero PC, Trastek VF, et al: Primary tumor of the chest wall: impact of initial versus
3. Toumpoulis IK, Anagnostopoulos CE, DeRose JJ, chest wall tumors: factors affecting survival. Ann delayed resection on tumor margins, survival and
et al: The impact of deep sternal wound infection Thorac Surg 41:597, 1986 use of radiation therapy. Ann Surg 238:563, 2003
on long-term survival after coronary artery bypass 13. Walsh GL, Davis BM, Swisher SG, et al: A single- 22. Paulussen M, Ahrens S, Lehnert M, et al: Second
grafting. Chest 127:464, 2005 institutional, multidisciplinary approach to prima- malignancies after Ewing tumor treatment in 690
4. Ridderstolpe L, Gill H, Granfeldt H, et al: Super- ry sarcomas involving the chest wall requiring full- patients from a cooperative German/Austrian/
ficial and deep sternal wound complications: inci- thickness resections. J Thorac Cardiovasc Surg Dutch study. Ann Oncol 12:1619, 2001
dence, risk factors and mortality. Eur J Car- 121:48, 2001 23. Veronesi G, Spaggiari L, De Pas T, et al: Preoper-
diothorac Surg 20:1168, 2001 14. Jennings CD, Foon KA: Recent advances in flow ative chemotherapy is essential for conservative
5. DeFeo M, Gregorio R, Della Corte A, et al: Deep cytometry: application to the diagnosis of hemato- surgery of Askin tumors. J Thorac Cardiovasc
sternal wound infection: the role of early debride- logic malignancy. Blood 90:2863, 1997 Surg 125:429, 2003
ment surgery. Eur J Cardiothorac Surg 19:811, 15. Dimopoulos MA, Moulopoulos LA, Maniatis A, 24. Miettinen M, Virtanen I: Synovial sarcoma: a mis-
2001 et al: Solitary plasmacytoma of bone and asymp- nomer. Am J Pathol 117:18, 1984
6. Song HK, Guy TS, Kaiser LR, et al: Current pre- tomatic multiple myeloma. Blood 96:2037, 2000 25. Deshmukh R, Mankin H, Singer S: Synovial sar-
sentation and optimal surgical management of 16. Liebross RH, Ha CS, Cox JD, et al: Solitary bone coma: the importance of size and location for sur-
sternoclavicular joint infections. Ann Thorac Surg plasmacytoma: outcome and prognostic factors vival. Clin Orthop Relat Res 419:155, 2004
73:427, 2002 following radiotherapy. Int J Radiat Oncol Biol 26. Singer S, Baldini EH, Demetri GD, et al: Synovial
7. Bar-Ziv J, Barki Y, Maroko A, et al: Rib osteomye- Phys 41:1063, 1998 sarcoma: prognostic significance of tumor size,
litis in children: early radiologic and ultrasonic find- 17. Murphey MD, Flemming DJ, Boyea SR, et al: margin of resection and mitotic activity for sur-
ings. Pediatr Radiol 15:315, 1985 Enchondroma versus chondrosarcoma in the ap- vival. J Clin Oncol 14:1201, 1996
8. Hayry P, Reitamo JJ, Totterman S, et al: The pendicular skeleton: differentiating features. Radio- 27. Burkhart HM, Allen MS, Nichols FC, et al: Re-
desmoid tumor: II. Analysis of factors possibly graphics 5:1213, 1998 sults of en bloc resection for bronchogenic carci-
contributing to the etiology and growth behavior. 18. Fong YC, Pairolero PC, Sim FH, et al: Chondro- noma with chest wall invasions. J Thorac Cardio-
Am J Clin Pathol 77:674, 1982 sarcoma of the chest wall. Clin Orthop Relat Res vasc Surg 123:670, 2002
9. Abbas AE, Deschamps C, Cassivi SD, et al: Chest 427:184, 2004 28. Downey RJ, Rusch V, Hsu FI, et al: Chest wall resec-
wall desmoid tumors: results of surgical interven- 19. Delattre O, Zucman J, Melot T, et al: The Ewing tion for locally recurrent breast cancer: is it worth-
tion. Ann Thorac Surg 78:1219, 2004 family of tumors—a subgroup of small-round-cell while? J Thorac Cardiovasc Surg 119:420, 2000
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 3 PARALYZED DIAPHRAGM — 1
3 PARALYZED DIAPHRAGM
Bryan F. Meyers, M.D., F.A.C.S., and Benjamin D. Kozower, M.D.
Clinical Evaluation
HISTORY
Figure 1 Shown is a postoperative radiograph from a 55-year-
In adults, the clinical presentation of uni- old woman who underwent left upper lobectomy. Because the
lateral paralysis of the diaphragm is highly tumor was directly adherent to the phrenic nerve, a 2 cm portion
variable. Right and left hemidiaphragmatic of the left phrenic nerve was resected along with the tumor.
paralysis seem to occur with equal frequency Recovery was uneventful, and the only late symptom was mild
and usually cause little or no respiratory dyspnea with exertion.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 3 PARALYZED DIAPHRAGM — 2
a b
c
Figure 3 Shown are three chest radi-
ographs of a 25-year-old man with residual
anterior mediastinal mass after treatment
for germ cell tumor. (a) Preoperative view
shows normal diaphragmatic positioning
bilaterally. (b) Immediate postoperative view
demonstrates an elevated right hemidi-
aphragm, attributed to stretch injury and
electrothermal injury caused by dissection of
mass from the vicinity of the phrenic nerve
at the right hilum. (c) Late view, 3 months
after operation, reveals gradual restoration
of normal diaphragm positioning. Patient is
asymptomatic.
radiographs. However, fluoroscopic examination is the most prac- sniff test, a definitive diagnosis can be made by employing cervi-
tical method of assessing the movement of the diaphragm. The cal phrenic nerve stimulation in conjunction with electromyo-
excursion of the domes of the diaphragm averages 3 to 5 cm and graphic measurement of phrenic nerve latency.13 This final test is
may range from 2 to 10 cm.11 The examination is typically per- rarely necessary.
formed with the patient standing, but it is more sensitive when the
patient is supine because the effect of gravity is removed. In a
patient with unilateral paralysis, the paralyzed hemidiaphragm Management
moves upward with rapid inspiration and downward with expira-
CONSERVATIVE VERSUS SURGICAL
tion. This paradoxical motion passively follows changes in
TREATMENT
intrapleural and intra-abdominal pressure.
The so-called sniff test is then performed to confirm that the Treatment is individualized and depends
abnormal diaphragm excursion is the result of paralysis rather on the degree to which the patient is inca-
than of weakness. During this test, the patient inhales forcefully pacitated. Most healthy adults with isolated
and rapidly through the nose with the mouth closed. A sharp and diaphragmatic paralysis are asymptomatic or suffer only from mild
brief downward motion in both hemidiaphragms is the normal exertional dyspnea. The vast majority of these patients do not
response when paralysis is absent. If an entire hemidiaphragm require surgical treatment and are best treated conservatively (e.g.,
exhibits a paradoxical upward motion greater than 2 cm, howev- with physical therapy, pulmonary rehabilitation, and counseling on
er, diaphragmatic paralysis is likely.12 The diagnosis of diaphrag- weight loss, if necessary). Just as many patients with normal lung
matic paralysis may be difficult to make in patients with severe function can tolerate major pulmonary resections, most patients
chronic obstructive pulmonary disease, in whom normal hemidi- who are otherwise fit can tolerate unilateral diaphragmatic paraly-
aphragms move very little. The sniff test may also be inconclusive sis without the need for surgical intervention.
in weak, debilitated patients, who often are incapable of produc- Operative management may, however, be indicated for children
ing a forceful sniff. In patients who are undergoing mechanical and for adults who have significant symptoms (e.g., dyspnea,
ventilation and in whom the diagnosis remains in doubt after a recurrent pneumonia, chronic bronchitis, chest pain, poor exercise
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 3 PARALYZED DIAPHRAGM — 5
tolerance, cardiac arrhythmias, or functional disorders of the There was a small improvement in tidal volume after bilateral pli-
stomach).14 The classic treatment is diaphragmatic plication, cation, but this was probably attributable to improved rib cage
which may be performed either via a thoracotomy or thoraco- efficiency secondary to diaphragmatic fixation.
scopically. Plication of the diaphragm was first performed in 1947 These findings may explain why bilateral plication has been
to treat congenital eventration of the diaphragm, and the basic more beneficial for adults than it has been for children,20 who
principles of the procedure have changed little since then.15 depend more on the diaphragmatic contribution to respiration.
In infants, the small improvement in rib cage efficiency may not
PLICATION OF DIAPHRAGM
be large enough to allow them to be weaned from mechanical ven-
tilation. In children with hemidiaphragmatic paralysis, however,
Open plication is essential for improving diaphragmatic efficiency and
A standard diaphragmatic plication is performed through a preventing complications associated with long-term mechanical
posterolateral thoracotomy in the eighth intercostal space. The ventilation.20
lung and the mediastinum are examined to exclude any unsus-
pected pathologic conditions. The uncut diaphragm is plicated Thoracoscopic
with four to six parallel rows of heavy nonabsorbable sutures.The In 1996, a thoracoscopy-assisted approach to diaphragmatic
stitches are placed in an anterolateral-to-posterolateral direction, plication was first described. The goal was to achieve an equiva-
and each row takes several bites of the diaphragm to form pleats. lent degree of plication by less invasive means.21 Three patients
The sutures are tied only after all the rows have been placed. were treated in this fashion.The procedure made use of a double-
When all of the sutures are placed and tied, the diaphragm should lumen endotracheal tube, two thoracoscopic ports, and a 5 cm
be tight, and much of the plicated tissue should lie within the cen- minithoracotomy. The diaphragm was invaginated and stitched
tral tendon. with two rows of continuous sutures. The results were excellent,
Open diaphragmatic plication is an effective procedure for and the average hospital stay was 8 days. All three patients showed
treating diaphragmatic paralysis. In a study of 17 patients who significant improvements in FVC and FEV1: FVC improved by
underwent plication for exertional dyspnea,16 no major complica- 9% to 22%, and FEV1 improved by 11% to 14%.These improve-
tions were reported during a mean hospital stay of 11 days. At 6 ments were maintained for a minimum of 17 months.
months’ follow-up, patients exhibited significant improvements Since this first description, several reports of successful
with respect to dyspnea score, forced vital capacity (FVC), total diaphragmatic plication with a purely thoracoscopic approach
lung capacity (TLC), functional residual capacity (FRC), and (using three or four ports) have been published.14,22 These case
arterial oxygenation. Furthermore, the subjective and objective reports documented symptomatic improvement and reduced
improvements were maintained for at least 5 years. In a subse- length of stay (4 days); however, they did not document significant
quent series from the United Kingdom, similar results were improvements in FVC or FEV1.Thoracoscopic diaphragmatic pli-
observed at a mean follow-up of 10 years: 14 of 15 patients were cation appears to be the surgical method of the future, but larger
satisfied with their plication and had returned to work.17 In addi- series with longer follow-up periods are needed. The main con-
tion, FVC, forced expiratory volume in 1 second (FEV1), FRC, traindication to thoracoscopic plication is extensive pleural adhe-
and TLC improved by 12%, 15%, 26%, and 13%, respectively. sions from inflammatory reactions or previous operations.
Research has also been performed on changes in respiratory
SURGICAL PROPHYLAXIS AFTER PHRENIC NERVE INJURY
mechanics after diaphragmatic plication. In 1980, one group
noted that plication was more successful for hemiparalysis than
for bilateral diaphragmatic paralysis.18 These clinical results sub- Phrenic Nerve Repair versus Prophylactic Plication
sequently led another group to hypothesize that normal function- An area of investigation that, to date, has not been sufficiently
ing of the contralateral hemidiaphragm might be required to explored is the potential role of prophylactic procedures in cases
derive significant benefit from diaphragmatic plication.19 These where one is confident that a phrenic nerve has been injured dur-
investigators demonstrated that plication for unilateral paralysis ing an operation and wishes to reverse or at least mitigate the
improved the strength of the normal contralateral hemidi- effect of the injury.
aphragm, so that the contralateral hemidiaphragm functioned as a If the injury resulted from sharp dissection, so that the entire
better pressure generator and thus made a greater contribution to nerve is present but divided, one may elect to repair the nerve. On
breathing. However, they found that bilateral plication for bilater- occasion, we have invited colleagues from plastic surgery to per-
al paralysis did not yield significant improvements with respect to form microsurgical anastomoses between the cut ends of the sev-
diaphragmatic function, lung compliance, or work of breathing. ered nerves, but we have never attempted a formal analysis of this
practice. Such a repair would not, of course, be feasible in a case
where the phrenic nerve was resected in the course of excision of
an attached invasive tumor.
Table 2—Differential Diagnosis of Elevated If the nerve was resected or was injured beyond hope of recov-
Hemidiaphragm on Chest Radiograph ery, one may reasonably consider plicating the diaphragm during
the same operation so as to minimize the impact of the diaphrag-
Volume loss (atelectasis, lobar collapse, hypoplasia)
Splinting
matic paralysis without having to perform another operation later.
Pleural disease (subpulmonic effusion, mass) This strategy has not yet been studied in the surgical literature, but
Diaphragmatic hernia it should be kept in mind for the rare instances of phrenic nerve
Eventration resection or injury during pulmonary or mediastinal resection.
Phrenic nerve paralysis
Abdominal disease (dilated viscera, abscess) PACING OF DIAPHRAGM
Single-lung transplantation for pulmonary fibrosis Although pacing of the diaphragm requires an intact phrenic
nerve and thus is not useful in cases of classic diaphragmatic
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 3 PARALYZED DIAPHRAGM — 6
paralysis, it is an established mode of ventilatory support with requires normal lungs with the ability to oxygenate and ventilate
which the thoracic surgeon should be familiar.The two main indi- in response to diaphragmatic movement; severe restrictive lung dis-
cations for diaphragmatic pacing are central alveolar hypoventila- ease and major chest wall deformities are contraindications
tion and high cervical spinal cord injury; less common indications to pacing. In addition, it is crucial that the patient be cooperative and
are intractable hiccups and end-stage chronic obstructive pul- motivated and have adequate support from nursing staff and family.
monary disease. Central alveolar hypoventilation is a form of sleep Phrenic nerve pacing involves the use of an extracorporeal gen-
apnea resulting from failure of the respiratory drive itself rather erator with an antenna that transmits radiofrequency signals to a
than from an anatomic obstruction. It is also known as Ondine’s subcutaneous radio receiver; the receiver then translates the
curse (from the German myth about the water nymph Ondine, radiofrequency signal into direct current, which is delivered
who, finding that her mortal husband had been unfaithful, placed through electrodes to the phrenic nerves. The electrodes are
a fatal curse on him so that he would only breathe while awake).23 placed on the phrenic nerves via bilateral anterior thoracotomies
The underlying cause is impaired sensitivity of the brain’s respira- or neck incisions. Several different commercial pacing systems are
tory control center to alterations in oxygenation.The clinical result available, but they all work according to the same basic concept.
is persistent hypoventilation with sleep apnea and the develop- Phrenic nerve pacing remains a relatively rare procedure. The
ment of pulmonary hypertension. largest series published to date included 165 patients, of whom
The use of electricity to induce diaphragmatic contraction was 27% were paced on a full-time basis and 63% on a part-time
first suggested by Hufeland in 1783.24 Besides an intact phrenic basis.25 Phrenic nerve pacing met the ventilatory requirements of
nerve and a functioning diaphragm, diaphragmatic pacing also 47% of the patients and was partially successful in 36%.
Discussion
Diaphragmatic Anatomy
The left and right phrenic nerves arise from the C3–C5 nerve
For the purposes of discussion, the diaphragm may usefully be roots and travel a distance of 30 to 40 cm between their cervical
divided into left and right hemidiaphragms. In anatomic terms, origin and their termination on the surface of the diaphragm. A
the diaphragm is a dome-shaped muscle that can be described as firm understanding of the anatomy of the phrenic nerves is cru-
having both muscular and tendinous components. The muscular cial for the thoracic surgeon because iatrogenic injury during
portion of the diaphragm is divided into three parts, each of which operation is a leading cause of diaphragmatic paralysis. Both
originates from one of the three structural elements forming the nerves originate on the middle scalene muscle and cross to the
lower thoracic aperture: the pars lumbalis diaphragmatis (origi- anterior scalene muscle, where they descend within an investment
nating from the lumbar spine), the pars costalis diaphragmatis of fascia. At the base of the neck, the left phrenic nerve crosses the
(from the ribs), and the pars sternalis diaphragmatis (from the thoracic duct, descending into the thorax on the anterior surface
sternum). The pars lumbalis is the most powerful region of the of the left subclavian artery. It then travels between the left com-
diaphragm.26 All three parts insert into a central aponeurosis mon carotid and subclavian arteries, crosses in front of the vagus
known as the central tendon. This tendon has a cloverleaf shape, nerve, and passes lateral to the aortic arch, where it descends
with one leaf directed anteriorly and two leaves directed laterally along the pericardium to a point just above the diaphragm. At the
(one into each hemithorax). thoracic inlet, the right phrenic nerve is located behind the
The diaphragm possesses three major apertures, which allow innominate vein and usually crosses in front of the internal mam-
passage of the inferior vena cava, the esophagus, and the aorta. mary artery. It descends to the right of the innominate vein and
The caval orifice is located in the right portion of the central ten- the superior vena cava before reaching the pericardium, anterior
don, typically at the level of T8. Diaphragmatic contraction to the lung. Finally, the right phrenic nerve descends along the
stretches this orifice and may facilitate the return of blood to the inferior vena cava toward the diaphragm. Both phrenic nerves
heart during inspiration. The right phrenic nerve and some lym- branch just proximal to the diaphragm, and small terminal
phatic vessels also pass through this orifice.The esophageal hiatus branches innervate the muscle.
is located behind the central tendon at the level of T10.This aper-
ture, unlike the other two, is ventrally framed by muscle.The aor-
tic opening is anterior to T12, between the crura and behind the Normal Diaphragmatic Function
median arcuate ligament. The aortic opening also allows passage The diaphragm is the most important respiratory muscle.
of the azygos vein, the thoracic duct, and lymphatic channels as During inspiration, the diaphragm contracts and moves caudally
they descend from the thorax into the abdomen. in a pistonlike fashion.This motion forces the abdominal contents
The arterial supply to the cranial surface of the diaphragm down and forward, increasing the vertical dimension of the chest
consists of the pericardiophrenic, musculophrenic, and superior cavity. In addition, the ribs lift the lateral aspect of the diaphragm
phrenic arteries. The posterior aspect of the diaphragm is sup- during inspiration, causing the transverse diameter of the thorax
plied by small direct branches from the aorta.The caudal surface to increase. As the diaphragm contracts, pleural pressure decreas-
of the diaphragm is supplied by the inferior phrenic arteries, es, facilitating lung inflation. Normal diaphragmatic function
which arise from the aorta or the celiac trunk; these arteries are accounts for 75% of air movement during normal respiration and
much larger than the superior phrenic arteries. Occasionally, the is responsible for 60% of minute volume in the supine position.
right inferior phrenic artery originates from the right renal Diaphragmatic excursion averages about 1 cm during normal
artery.27 The venous drainage from the diaphragm mirrors the tidal breathing, but it can increase to 10 cm during forced inspi-
arterial supply. ration and expiration.28
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 3 PARALYZED DIAPHRAGM — 7
References
1. Whitelaw WA: Shape and size of the human Unexplained diaphragmatic paralysis: a harbinger in dogs with unilateral and bilateral phrenic nerve
diaphragm in-vivo. J Appl Physiol 62:180, 1987 of malignant disease? J Thorac Cardiovasc Surg paralyses. Chest 107:798, 1995
2. Gibson GJ: Diaphragmatic paresis: pathophysiol- 84:861, 1982 20. Simansky DA, Paley M, Refaely Y, et al: Dia-
ogy, clinical features, and investigation. Thorax 11. Gierada DS, Slone RM, Fleishman MJ: Imaging phragm plication following phrenic nerve injury:
44:960, 1989 evaluation of the diaphragm. Chest Surg Clin N a comparison of paediatric and adult patients.
3. Clague HW, Hall DR: Effect of posture on lung Am 8:237, 1998 Thorax 57:613, 2002
volume airway closure and gas exchange in hemidi- 12. Alexander C: Diaphragm movements and the 21. Mouroux J, Padovani B, Poirier NC, et al: Tech-
aphragmatic paralysis. Thorax 34:523, 1979 diagnosis of diaphragmatic paralysis. Clin Radiol nique for the repair of diaphragmatic eventration.
4. Easton PA, Fleetham JA, de la Rocha A, et al: 17:79, 1966 Ann Thorac Surg 62:905, 1996
Respiratory function after paralysis of the right 13. Stochina M, Ferber I, Wolf E: Evaluation of the 22. Sloane GT, Montany PF: Thoracoscopic dia-
hemidiaphragm. Am Rev Respir Dis 127:125, 1983 phrenic nerve in patients with neuromuscular dis- phragmatic plication. Surg Laparosc Endosc 8:
5. Rochester DF: The diaphragm: contractile prop- orders. Int J Rehabil Res 6:455, 1983 319, 1998
erties and fatigue. J Clin Invest 75:1397, 1985 14. Suzumura Y, Terada Y, Sonobe M, et al: A case of 23. Goldblatt D: Historical note: Ondine’s curse.
6. Curtis JJ, Weerachai N, Walls J, et al: Elevated unilateral diaphragmatic eventration treated by Semin Neurol 15:218, 1995
hemidiaphragm after cardiac operations: inci- plication with thoracoscopic surgery. Chest 112: 24. Hufeland CW: Usum uis electriciae in asphyxia
dence, prognosis and relationship to the use of 530, 1997 experimentis illustratum. Dissertatio Inauguralis
topical ice slush. Ann Thorac Surg 48:764, 1989 15. Bisgard JD: Congenital eventration of the dia- Medica, Göttingen, Germany, 1783
7. Wheeler WE, Rubis LJ, Jones CW, et al: Etiology phragm. J Thorac Surg 16:489, 1947 25. Glenn WWL, Bouillette RT, Dentz B, et al:
and prevention of topical cardiac hypothermia- 16. Graham FT, Kaplan D, Evans CC, et al: Dia- Fundamental consideration in pacing of the dia-
induced phrenic nerve injury and left lower lobe phragmatic plication for unilateral diaphragmatic phragm for chronic ventilatory insufficiency: a
atelectasis during cardiac surgery. Chest 88:680, paralysis: a 10-year experience. Ann Thorac Surg multi-institutional study: part II. Pacing Clin
1985 49:248, 1990 Electrophysiol 11:2121, 1988
8. Markand ON, Moorthy SS, Mahomed Y, et al: 17. Higgs SM, Hussain A, Jackson M, et al: Long 26. Fell SC: Surgical anatomy of the diaphragm and
Postoperative phrenic nerve palsy in patients with term results of diaphragmatic plication for unilat- the phrenic nerve. Chest Surg Clin N Am 8:281,
open-heart surgery. Ann Thorac Surg 39:68, eral diaphragm paralysis. Eur J Cardiothorac Surg 1998
1985 21:294, 2002 27. Schumpelick V, Steinau G, Schluper I, et al:
9. De Leeuw M, Williams JM, Freedom RM, et al: 18. Schonfeld T, O’Neal MH, Platzker ACG, et al: Surgical embryology and anatomy of the
Impact of diaphragmatic paralysis after cardio- Function of the diaphragm before and after plica- diaphragm with surgical applications. Surg Clin
thoracic surgery in children. J Thorac Cardiovasc tion. Thorax 35:631, 1980 North Am 80:213, 2000
Surg 118:510, 1999 19. Takeda S, Nakahara K, Fujii Y, et al: Effects of 28. West JB: Respiratory Physiology: The Essentials,
10. Piehler JM, Pairolero PC, Gracey DR, et al: diaphragmatic plication on respiratory mechanics 6th ed. Williams and Wilkins, Baltimore, 2000
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 1
The remarkable developments in diagnosis, imaging, and surgical nuclear studies for assessment of esophageal and gastric transit
treatment of esophageal diseases over the past 15 years have result- provide functional data that can facilitate the diagnosis and treat-
ed in markedly better patient outcomes: the morbidity and mor- ment of GERD, achalasia, and other disorders of the esophagus.
tality associated with surgery of the esophagus have been substan- They are useful complements to standard investigations (e.g., ciné
tially reduced. In particular, the operative techniques employed to barium swallow and endoscopy).
treat esophageal disease have advanced considerably, as a result of Complete preoperative investigation of all patients, even those
an improved understanding of esophageal anatomy and physiolo- with classic histories and physical findings, is mandatory.The data
gy and the successful introduction of minimally invasive approach- from anatomic and functional testing allow the surgeon to plan the
es to the esophagus [see 4:5 Minimally Invasive Esophageal Procedures]. operation more appropriately and effectively (e.g., deciding on the
For a number of diseases (e.g., achalasia), minimally invasive pro- need for esophageal lengthening in patients with paraesophageal
cedures have proved to be as effective as their open counterparts hernias or choosing between a complete and a partial fundoplica-
while causing less postoperative morbidity.The growing stature of tion in patients with hernias associated with varying degrees of
minimally invasive approaches does not, however, diminish the im- esophageal dysmotility).
portance of the equivalent open approaches. In this chapter, we
OPTIMIZATION OF PATIENT HEALTH STATUS
describe common open operations performed to excise Zenker’s
diverticulum, to manage complex gastroesophageal reflux disease Patients with obstructing esophageal diseases are often elderly,
(GERD), and to resect esophageal and proximal gastric tumors. debilitated, and malnourished. Although months of insufficient
nutrition cannot be corrected in the space of a few hours, anemia,
dehydration, and electrolyte abnormalities can be mitigated by
General Preoperative Considerations means of intravenous support and appropriate laboratory monitor-
ing. If esophageal obstruction prevents oral intake, endoscopic dila-
METHODS OF PATIENT ASSESSMENT
tion of the stricture, accompanied by either nasogastric intubation
The functional results achieved with esophageal procedures or percutaneous endoscopic gastrostomy (PEG) [see 5:18 Gastro-
become more predictable when the approach to preoperative intestinal Endoscopy], is indicated; the patient should then be able to
patient evaluation is precise and reproducible. The ciné barium resume at least a liquid diet. If weight loss has exceeded 10%, enter-
swallow remains the most cost-effective method for initial evalua- al nutrition, comprising at least 2,000 kcal/day of a high-protein liq-
tion of esophageal anatomy and function. It should be employed uid diet, should be administered for at least 10 days before the oper-
before endoscopy because the results may direct the endoscopist’s ation. Cardiovascular, renal, hepatic, and respiratory function should
attention to particular areas of concern. For example, a finding of be documented and optimized. If the patient is aspirating, the esoph-
abnormal angulation or strictures indicates that the endoscopist agus should be evacuated and the patient should be given nothing
should either use a pediatric-caliber endoscope or exercise more by mouth until after the operation. Aspiration pneumonia should
caution in passing a standard adult endoscope. In addition, endo- always be corrected preoperatively.
scopic examination alone is often insufficient for assessing
esophageal motility disorders or defining the complex anatomy of
a paraesophageal hiatal hernia. Cricopharyngeal Myotomy and Excision of Zenker’s
Endoscopic ultrasonography (EUS) is an extension of the Diverticulum
visual mucosal examination. The information it can provide
PREOPERATIVE EVALUATION
about the extension of mass lesions beyond the confines of the
esophageal wall is helpful in planning surgical resection. In addi- Patients who are candidates for cricopharyngeal myotomy usu-
tion, EUS can differentiate benign stromal tumors from cystic or ally present with difficulty initiating swallowing, cervical dysphagia
malignant neoplasms on the basis of characteristic echogenicity or odynophagia [see 4:1 Dysphagia], and a history of pulmonary
patterns. The combination of EUS and computed tomography aspiration. These symptoms of cricopharyngeal dysfunction may
permits highly precise anatomic assessment of esophageal neo- or may not be associated with a Zenker’s diverticulum. Ciné con-
plasms, definition of the extent of local invasion, and identifica- trast studies may reveal poor pharyngeal contractility, pulmonary
tion of regional metastases. or nasal aspiration, abnormalities of the upper esophageal sphinc-
Functional imaging with photodynamic or vital staining allows ter, pharyngeal pouches, or other structural abnormalities in the
accurate diagnosis of dysplastic or malignant mucosal lesions in distal esophagus. Barium is the usual contrast agent, but if aspira-
their earliest stages. Positron emission tomography (PET) yields tion is suspected, a nonionic contrast agent can be used instead to
similar results by localizing metabolically active tissue regionally or prevent pneumonitis.
at distant sites. The combination of morphologic data from high- Zenker’s diverticulum is a pulsion diverticulum that arises
resolution CT and functional data from PET is particularly effec- adjacent to the inferior pharyngeal constrictor, between the
tive for identifying occult metastases that would preclude curative oblique fibers of the posterior pharyngeal constrictors and the
resection for esophageal cancer. cricopharyngeus muscle. This mucosal outpouching results from
Esophageal manometry, 24-hour esophageal pH testing, and a transient incomplete opening of the upper esophageal sphinc-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 2
a b
Left
Recurrent
Laryngeal
Nerve
Figure 3 Cricopharyngeal myotomy and excision of Zenker’s diverticulum. (a) The diverticulum is dis-
sected away from the esophagus, and an esophageal myotomy is started approximately 3 cm below the
cricopharyngeus. The myotomy is continued proximally through the cricopharyngeus, and the muscle
around the diverticulum is freed. (b) A linear stapler is placed at the base of the sac and pressed firmly
against the esophagoscope. The stapler is fired, and the diverticulum is excised.
dissection is carried down to the prevertebral fascia [see Figure 2]. to injure the recurrent laryngeal nerve.The stapler is fired, and the
The endoscope placed in the diverticulum is palpated, and the diverticulum is excised.The staple line is cleaned with an antisep-
pouch is dissected away from the cervical esophagus up as far as the tic solution, and the incision is filled with saline.The esophagus is
pharyngoesophageal junction. The flexible endoscope is then insufflated with air to determine whether mucosal leakage has
removed from the pouch and advanced into the thoracic esopha- occurred, and the esophagoscope is removed; any mucosal leaks
gus so that it can be used as a stent for the cricopharyngeal myoto- found are closed with fine absorbable sutures. In the absence of a
my. Dissection of the pharyngeal pouch is then completed. stapler, the best way of excising the sac is to make a series of short
incisions through the neck of the sac with scissors, suturing the
Step 2: Myotomy edges after each cut with absorbable monofilament sutures (the
The esophageal myotomy is started approximately 3 cm below so-called cut-and-sew technique). The esophagoscope ensures
the cricopharyngeus on the posterolateral esophageal wall [see that the esophageal lumen is not narrowed.
Figure 3a].The esophageal muscle is divided down to the mucosa,
which is recognizable from its bluish coloration with the submu- Step 4: Drainage and Closure
cosal plexus overlying it.The esophageal muscle is dissected away Once hemostasis has been achieved, a short vacuum drain is
from the mucosa with a right-angle dissector and divided with a placed through the skin into the retroesophageal space.The platys-
low-intensity diathermy unit. The myotomy is then continued ma is repaired with absorbable sutures, and the skin is closed with
proximally through the cricopharyngeus and up into the muscular a subcuticular absorbable suture. Nasogastric intubation is unnec-
wall of the hypopharynx for 2 cm if there is no diverticulum pres- essary. Prokinetic agents and PPIs are administered to prevent
ent. The hypopharynx is distinguished by a pronounced submu- gastroesophageal reflux. A water-soluble contrast study is done on
cosal venous plexus. The muscle is then swept off the mucosa for the day of the operation. If the results are normal, the patient is
120°. started on a liquid diet, and the drain is removed on postoperative
day 1, when the patient is discharged.
Step 3: Freeing or Excision of Diverticulum
COMPLICATIONS
If there is a diverticulum less than 2 cm in diameter, the
cricopharyngeus is transected and the muscularis around the The main complications associated with cricopharyngeal myo-
diverticulum is freed. The myotomy is extended onto the tomy are recurrent laryngeal nerve trauma (occurring in 0.5% of
hypopharynx for 2 cm.The diverticulum may be suspended to the cases), fistulas (1%), hematoma formation, infection (2%), aspiration,
back wall of the pharynx. It should not be sutured to the prever- and recurrence (4%). Hematomas and infections must be drained
tebral fascia, because the passage of sutures through the divertic- promptly. Fistulas usually close once the prevertebral space is drained
ulum can contaminate the fascia, leading to an increased risk of and the associated infection controlled. Aspiration is the most
fascial infection. serious complication after cricopharyngeal myotomy. Gastroesoph-
If the diverticulum is more than 2 cm in diameter, it is excised ageal reflux may contribute to oropharnygeal dysphagia. Division
with a linear stapler loaded with 2.5 mm staples, which is placed of the upper esophageal sphincter in a patient with an incompetent
at the base of the sac and pressed firmly against the esophagoscope esophagogastric junction may lead to massive tracheobronchial
[see Figure 3b]. Particular care must be taken at this point so as not aspiration. Therefore, documented gastroesophageal reflux, gas-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 4
troesophageal regurgitation, and severe distal esophagitis may be the most appropriate form of repair is. Specifically, a history of
relative contraindications to cricopharyngeal myotomy until the heartburn and effortless regurgitation should be sought. Dysphagia
lower esophageal sphincter defect has been remedied with an anti- and odynophagia are not typically associated with hiatal hernia
reflux operation. unless there is a significant paraesophageal component. Persistent
dysphagia may reflect the presence of a stricture or a neoplasm [see
OUTCOME EVALUATION
4:1 Dysphagia]. Reflux-induced esophageal spasm may present
Of patients with a Zenker’s diverticulum, at least 90% experi- with occasional episodes of cervical dysphagia, but the transient
ence excellent results from surgical treatment. Of patients with- nature of the symptoms easily differentiates this condition from
out a Zenker’s diverticulum, one third experience excellent dysphagia caused by a fixed obstruction. Chest pain that radiates
results, another third show moderate improvement, and the remain- toward the back after meals and is relieved by nonbilious vomiting
ing third show no improvement.1 Patients with poor pharyngeal may indicate the presence of an incarcerated intrathoracic stomach
contractility in conjunction with normal upper esophageal that is hindering the emptying of the paraesophageal component.
sphincter function show little improvement with cricopharyngeal Atypical chest pain from cholelithiasis, peptic ulcer, or coronary
myotomy. Patients with oropharyngeal dysphagia secondary to artery disease may confound the diagnosis.
neurologic involvement who have intact voluntary deglutination,
adequate pulsion of the tongue, and normal phonation may Imaging
show improvement with cricopharyngeal myotomy. Appropriate Radiographic investigation should begin with a ciné barium
selection of patients for cricopharyngeal myotomy leads to bet- swallow, which will yield valuable information regarding the length
ter surgical outcomes. of the esophagus, its peristaltic function, and the integrity of the
mucosal surface. The gastric views can be used for qualitative
assessment of distal emptying. Any paraesophageal component
Transthoracic Hiatal Hernia Repair will be clearly demonstrated, along with any associated organoax-
Unlike most operations on the esophagus, which are extirpative ial volvulus. A simple barium swallow often yields the most useful
procedures, hiatal hernia repair with fundoplication is a recon- information for managing the complex problem of recurrent hiatal
structive procedure, the aim of which is to restore a high-pressure hernia and a slipped Nissen fundoplication.
zone at the esophagogastric junction that prevents reflux but also Next, esophagogastroscopy should be performed to examine
permits comfortable swallowing. Currently, this repair is often the mucosa for the presence of esophagitis, Barrett’s mucosa, stric-
accomplished via minimally invasive approaches; however, such ture, or malignancy. The locations of any lesions observed, along
approaches may be hampered by significant perceptual and motor with the position of the squamocolumnar junction, should be care-
limitations, such as loss of stereopsis, reduced tactile feedback, and fully documented in terms of their distance from the incisors. All
decreased range of motion for the instruments.The degree of ten- strictures must undergo cup or brush biopsy to rule out an occult
sion on the hiatal repair sutures, the quality of the crural tissue malignancy.The presence of severe esophagitis raises the possibil-
itself, and the caliber of the esophageal hiatus after repair all must ity of acquired shortening of the esophagus secondary to trans-
be assessed. In certain patients, laparoscopic reconstruction of a mural inflammation and contraction scarring. Every effort should
competent gastroesophageal high-pressure zone may be very diffi- be made to measure the length of the esophagus accurately.
cult and may demand a degree of tactile sensitivity that is not yet
achievable via video laparoscopy. Dilation
The long-term success of antireflux surgery, whether done via If a stricture is found during esophagoscopy, a decision must be
the transthoracic approach or by means of laparoscopy, depends made about whether to attempt esophageal dilation. This proce-
on three factors: (1) a tension-free repair that maintains a 4 cm dure carries the risk of perforation and should be performed only
long segment of esophagus in the intra-abdominal position, (2) after careful consideration. If the stricture is diagnosed at the time
durable approximation of the diaphragmatic crura, and (3) correct of the initial endoscopic examination, it is advisable to perform
matching of the fundoplication technique chosen to the peristaltic only the brush biopsy at this point, deferring dilation to a subse-
function of the esophagus. The transthoracic approach should be quent visit. Delaying dilation gives the surgeon time to reassess the
considered whenever the standard abdominal approaches to hiatal anatomy depicted on the barium swallow, to decide whether wire-
hernia repair carry an increased risk of failure or complication— guided dilation is necessitated by angulation of the esophagus, to
for example, in patients who have a foreshortened esophagus asso- obtain informed consent, to assemble the requisite equipment,
ciated with a massive hernia and an incarcerated intrathoracic and to plan sedation for what is often an uncomfortable proce-
stomach, patients with severe peptic strictures of the esophagus, dure. If a malignancy is suspected at the time of the initial endo-
patients in whom the hiatal hernia coexists with an esophageal scopic examination, dilation should be avoided. In this situation,
motility disorder or morbid obesity, and patients who have under- repair is impossible; thus, if iatrogenic perforation of a malignant
gone multiple previous abdominal operations. The transthoracic stricture occurs, the surgeon will have to attempt emergency resec-
repair is particularly useful when a previous open abdominal pro- tion in an inadequately prepared patient in whom proper staging
cedure has failed. In this situation, the reasons for such failure, is unlikely to have been completed.
whether technical or tissue-related, should be assessed so that a The standard flexible adult esophagoscope is approximately 32
compensatory strategy can be devised. French in caliber. In advancing the scope into the stricture, only
very gentle pressure should be necessary. As a rule, a mild stricture
PREOPERATIVE EVALUATION
that is not associated with steep angulation of the esophagus will
readily accept passage of the endoscope and will be amenable to
Symptomatic Evaluation subsequent blind dilation with Hurst-Maloney bougies.
All patients being considered for fundoplication to treat GERD After successful passage, the scope is removed, and sequential
must undergo a comprehensive evaluation to determine whether insertion of progressively larger dilators (starting at 32 French) into
there is indeed an anatomic substrate for their symptoms and what the stricture is attempted.The weight of the dilator alone should be
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 5
sufficient to effect its passage, with little or no forward force performed by the operating team. Insufflation should be done
applied. Although the patient will be able to swallow comfortably with as little air as is practical, particularly in the case of large
only after satisfactory passage of a dilator at least 48 French in cal- paraesophageal hernias. The extent of the pathologic condition is
iber, it is essential never to try to force passage.To this end, the sur- documented and the absence of malignancy verified.The stomach
geon must take careful note of the subtle signs of increasing resis- is decompressed with suction, and the endoscope is removed. An
tance transmitted through the dilator. Sequential dilation should orogastric tube is placed while the patient is supine.
be stopped whenever significant resistance is encountered or blood Tracheal intubation is performed with either a standard single-
streaks appear on the dilator. Sudden pain during dilation is an lumen endotracheal tube or a double-lumen tube. The former
ominous sign and calls for immediate investigation with a swallow requires that the ventilated left lung be retracted cephalad with
study using a water-soluble contrast agent (e.g., Gastrografin; moist packs during the procedure; the latter allows lung isolation
Schering AG, Berlin, Germany). Subcutaneous emphysema in the and is preferred by some surgeons. A Foley catheter is placed; cen-
neck or mediastinal air on a plain chest radiograph may also indi- tral venous access generally is not required. Subcutaneous heparin
cate an injury to the esophagus. Perforation must be definitively is administered for DVT prophylaxis, and pneumatic calf com-
ruled out before the patient can be discharged. pression devices are applied. Antibiotic prophylaxis is provided
Highly stenotic strictures that do not allow the passage of a [see 1:2 Prevention of Postoperative Infection].
standard adult endoscope may be associated with a distorted and The patient is positioned for a left thoracotomy. The table is
a steeply angulated esophagus. In such cases, the use of a pediatric flexed to distract the ribs. An axillary roll is placed to protect the
endoscope may permit directed placement of a guide wire right brachial plexus. The right leg is bent at hip and knee while
through the stricture; fluoroscopy is a useful adjunct for this pur- the left leg is kept straight. Pillows are placed between the legs, and
pose. A series of progressively larger Savary-Gillard dilators may all pressure points are padded.The arms are positioned so that the
then be passed over the guide wire to enlarge the lumen and allow humeri are at right angles to the chest and the elbows are bent 90º.
subsequent endoscopic biopsy. As a rule, much less tactile feed-
OPERATIVE TECHNIQUE
back is available during wire-guided dilation than during passage
of standard Maloney-Hurst bougies. Increased pressure is
required to pass the Savary-Gillard dilators because of the resis- Step 1: Incision and Entry into Chest
tance caused by the wire passing through the dilator itself. It is A standard left posterolateral thoracotomy is performed. The
essential that the wire be well lubricated and not be allowed to dis- latissimus dorsi is divided. The serratus fascia is incised, but the
lodge proximally between the sequential insertions of progressive- muscle itself can generally be preserved. For most patients, the
ly larger dilators.The caveats that apply to blind dilation also apply sixth interspace is the most appropriate incision site for exposing
to wire-guided dilation. the hiatus.The seventh interspace can also be used, particularly if
Patients whose esophagus can be dilated to 48 French and who the patient is tall or has a hyperextended chest as a result of chron-
are candidates for antireflux surgery may undergo subsequent ic pulmonary disease. The paraspinal muscles are elevated away
intraoperative dilation to 54 to 60 French. Patients who cannot be from the posterior aspect of the adjacent ribs, and a 1 cm segment
dilated to 48 French and fail to achieve comfortable swallowing of the rib below the selected interspace is resected to facilitate
should be classified as having a non-dilatable stricture and should exposure. The chest is then entered, and the lung and the pleural
be considered for transhiatal esophagectomy [see Resection of space are thoroughly inspected. The leaves of the retractor are
Esophagus and Proximal Stomach, below]. spread slowly over the course of the next several minutes so as not
to cause iatrogenic rib fractures.
Functional Evaluation
Esophageal manometry permits quantitative assessment of Step 2: Mobilization of Esophagus and Excision of Hernia Sac
peristalsis, a capability that is critically important for determining The inferior pulmonary ligament is divided with the electro-
which type of fundoplication is most suitable for reconstructing a cautery to the level of the inferior pulmonary vein [see Figure 4].
nonoccluding high-pressure zone at the esophagogastric junction. The mediastinal pleura overlying the esophagus is longitudinally
Stationary pH tests measure the capacity of the esophagus to clear incised to expose the esophagus from the level of the carina to the
acid, its sensitivity to instilled acid, the relationship of reflux diaphragm. Particular care is taken to avoid injury to the vagi.
episodes to body position, and the correlation between changes in Vessels supplying the esophagus and arising from the adjacent
esophageal pH and the subjective symptoms of heartburn. aorta are cauterized and divided. A few larger vessels may have to
Ambulatory 24-hour pH testing allows further quantification of be ligated with 2-0 silk.The esophagus is encircled just below the
reflux episodes with respect to duration, frequency, and associa- inferior pulmonary vein with a wide Penrose drain [see Figure 4].
tion with patient symptoms. The two vagi are mobilized and carried with the esophagus. (The
right vagus is located along the right anterior border of the des-
OPERATIVE PLANNING
cending aorta and can easily be missed.)
The transthoracic hiatus hernia repair may be completed with The esophagus is then elevated, and mobilization is circumfer-
either a partial fundoplication (as in the 240º Belsey Mark IV pro- entially completed in the direction of the diaphragm, starting from
cedure) or a complete fundoplication (as in the 360º Nissen pro- the level of the carina. In cases of giant paraesophageal hernia or
cedure). Acquired shortening of the esophagus may necessitate reoperation for a failed repair, the stomach will have a large intra-
lengthening of the esophagus by means of a Collis gastroplasty, in thoracic component. Dissection continues inferiorly to separate
which the portion of the gastric cardia along the lesser curvature the sac from the pericardium anteriorly and the aorta posteriorly.
and directly contiguous to the distal esophagus is fashioned into a The right pleura is closely approximated to the esophagus for 2 to
tube [see Operative Technique, Step 6a, below]. 5 cm above the diaphragm; in the presence of a substantial hiatal
A thoracic epidural catheter is placed for regional analgesia. hernia and its sac, it may be difficult to identify. The right pleura
General anesthesia is administered, and flexible esophagoscopy is should be gently dissected away from the sac without entry into
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 6
a b
Figure 7 Transthoracic hiatal hernia repair. (a) If esophageal foreshortening is present, a Collis gastro-
plasty is performed. A 54 French Maloney bougie is inserted through the esophagogastric junction. A 4 to
5 cm neoesophagus is formed with a 60 mm GIA stapler loaded with 3.5 mm staples. (b) Both the fundal
staple line and the lesser curvature staple line are oversewn with nonabsorbable monofilament suture.
diet as tolerated. Early ambulation is encouraged to prevent respi- Recurrent heartburn and regurgitation call for evaluation with
ratory complications. Judicious use of analgesics and antiemetics contrast studies and esophagoscopy. The barium swallow is the
minimizes nausea and vomiting. The thoracostomy tube is most useful test for assessing whether the repair has failed. If there
removed as drainage subsides.The epidural and Foley catheters are is an anatomic condition that is responsible for recurrent symptoms
generally removed later the same day. A barium swallow is per- (e.g., slipping of the fundoplication or disruption of the crural
formed on postoperative day 5 to verify the position of the wrap, to repair), reoperation is usually necessary; continued medical treat-
ensure that there is no significant esophageal obstruction, and to ment of symptoms related to a structural failure invariably proves to
provide a qualitative impression of gastric emptying. Gastroparesis be of little use. A barium swallow may also identify gastroparesis
secondary to vagal nerve dysfunction may be apparent. secondary to vagal nerve injury. Nuclear transit studies for gastric
Once patients can tolerate a soft solid diet, they are discharged emptying will help confirm this diagnosis. Dysphagia that is not
home with instructions about the gradual resumption of a normal
diet at home. Large meals and carbonated beverages should be
avoided in the early postoperative period.
COMPLICATIONS
related to recurrent reflux, ulceration, or stricture usually responds become apparent only at the time of operation. Thoracic epidural
to dilation; reoperation is not required if the barium swallow shows analgesia should be administered for pain control. If an Ivor-Lewis
contrast flowing through the esophagus and an intact wrap beneath or thoracoabdominal approach is taken, a double-lumen endotra-
the diaphragm. Given that patients with longstanding reflux are at cheal tube should be placed for separate lung ventilation.
higher risk for dysplasia and esophageal adenocarcinoma, it is
important to perform endoscopy to rule out malignancy. Imaging
Contrast esophagography, esophagoscopy with biopsy, and
OUTCOME EVALUATION
contrast-enhanced CT of the chest and the upper abdomen are
Transthoracic hiatal hernia repair yields good to excellent required before esophagectomy. The esophagogram identifies the
results in more than 85% of patients undergoing a primary repair. location of the tumor and may indicate whether it extends into the
Approximately 75% of patients who have previously undergone proximal stomach. Esophagoscopy allows direct assessment of the
hiatal hernia repair experience symptomatic improvement.2 mucosa, precise localization of the tumor, and collection of tissue
for histologic study. Retroflexion views of the stomach, after dis-
tention with air, are particularly important if proximal gastric inva-
Resection of Esophagus and Proximal Stomach sion is suspected, in which case esophagogastrectomy with recon-
In the remainder of the chapter, we describe the standard open struction of alimentary continuity by means of intestinal interpo-
techniques for resection of the esophagus and the esophagogastric sition may be required. In cases of midesophageal cancer, a bron-
junction. Transhiatal esophagectomy is commonly performed to choscopy is mandatory to rule out airway involvement. The cari-
treat end-stage benign esophageal disease and carcinomas of the na and the proximal left mainstem bronchus are the sites that are
cardia and the lower esophagus. Esophageal resection through a most at risk for local invasion.
combined laparotomy–right thoracotomy approach is ideal for Contrast-enhanced CT scans of the chest and abdomen are
cancers of the middle and upper esophagus. The gastric conduit standard.Thoracic and abdominal CT scans yield information on
may be anastomosed to the cervical esophagus either high in the the extent of any celiac or mediastinal adenopathy, the degree of
right chest (as in an Ivor-Lewis esophagectomy) or in the neck (as esophageal thickening, and the possibility of invasion of the adja-
in a transhiatal esophagectomy).The left thoracoabdominal approach cent aorta or tracheobronchial tree. The lung parenchyma is
is rarely used but may be indicated for resection of the distal esoph- assessed for metastatic nodules, as are the liver and the adrenal
agus and the proximal stomach in the case of a bulky tumor that glands. When the distal extent of tumor cannot be defined as a
is locally aggressive. result of near-complete obstruction on endoscopy, a prone
abdominal CT can help differentiate a tumor at the gastric cardia
PREOPERATIVE EVALUATION
from a collapsed but normal stomach. If the obstruction is not
Thorough preoperative preparation is essential for good post- complete, the stomach can be distended with air (through either
operative outcome. Smoking cessation and a graded regimen of the ingestion of effervescent granules or the passage of a small-
home exercise will help minimize postoperative complications and bore nasogastric tube) to improve visualization. A prone CT also
encourage early mobilization. Schematic diagrams have proved yields improved imaging of the gastrohepatic and celiac lymph
useful for educating patients and shaping their expectations about nodes by allowing the stomach to fall away from these adjacent
quality of life and ability to swallow after esophagectomy. structures. Metastatic cancer in the celiac lymph nodes portends
Illustrations, by emphasizing the anatomic relations, greatly facili- a very poor prognosis and is a contraindication to resection.
tate discussion of potential complications (e.g., hoarseness from PET scanning is useful for the detection of occult distant
recurrent laryngeal nerve injury, pneumothorax, anastomotic metastases that preclude curative resection. Suspicious areas
leakage, mediastinal bleeding, and splenic injury). should undergo needle biopsy or laparoscopic or thoracoscopic
Potential postoperative problems (e.g., reflux, regurgitation, assessment. Similarly, pleural effusions [see 4:8 Pleural Effusion]
early satiety, dumping, and dysphagia) must be discussed before must be tapped for cytologic evaluation. Invasion of mediastinal
operation. Such discussion is particularly relevant for patients structures and the presence of distant metastases are contraindi-
undergoing esophagectomy for early-stage malignant tumors or cations to transhiatal esophagectomy.
for high-grade dysplasia in Barrett’s mucosa. These patients gen- At present, EUS, though quite sensitive for detection of parae-
erally have no esophageal obstruction and may be completely sophageal adenopathy, is incapable of differentiating reactive
asymptomatic; accordingly, their expectations about postoperative lymph nodes from nodes invaded by malignancy. CT and PET
function may be quite different from those of patients with pro- have limitations, and thus, locoregional involvement may not be
found dysphagia secondary to near-complete esophageal occlu- recognized before resection is attempted. In patients who are mar-
sion. Support groups in which patients with upcoming operations ginal candidates for surgical treatment and in whom metastatic
can contact patients that have already undergone treatment have disease is suspected, thoracoscopy and laparoscopy have been
proved to be highly beneficial to all parties. Realistic expectations advocated for histologic evaluation of mediastinal lymph nodes,
improve the chances of a satisfactory outcome. pleural or peritoneal abnormalities, and celiac nodes. Although
this approach adds to the cost of investigation, it can save the
Evaluation of Operative Risk patient from having to undergo a major operation for what would
Preoperative assessment should include a thorough review of the later prove to be an incurable condition.
patient’s cardiopulmonary reserve and an estimate of the level of
operative risk [see ECP:4 Risk Stratification, Preoperative Testing, and Neoadjuvant Therapy
Operative Planning]. Spirometry, arterial blood gas analysis, and Patients with esophageal cancer who are candidates for resec-
exercise stress testing should be considered. Even when a transhiatal tion may benefit from neoadjuvant chemotherapy and concurrent
esophagectomy without thoracotomy is planned, patients should be radiation therapy. In particular, patients with good performance
assessed with an eye to whether they can tolerate a laparotomy and status and bulky disease should be considered for such therapy.To
a thoracotomy, in case the latter is made necessary by findings that date, no randomized trials have conclusively demonstrated a sur-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 10
vival benefit with this approach, but several series have document- Flexible esophagoscopy is performed (if it was not previously per-
ed a 20% to 30% rate of complete response with no viable tumor formed by the surgical team). A nasogastric tube is placed before
found at the time of resection. After chemoradiation, patients are final positioning and draping.
restaged with a barium swallow and CT. PET scanning after treat- The patient is placed in the supine position with a small rolled
ment may yield spurious results, in that inflammatory conditions sheet between the shoulders. The arms are secured to the sides,
can mimic the increased tracer uptake seen in malignant tissue. and the head is rotated to the right with the neck extended. The
Microscopic disease cannot be assessed, and scarring from radia- neck, the chest, and the abdomen are prepared as a single sterile
tion may further confound the situation by preventing tracer field. The drapes are placed so as to expose the patient from the
uptake in areas that actually harbor malignancy. left ear to the pubis.The operative field is extended laterally to the
If there are no contraindications to surgical treatment, resection anterior axillary lines to permit placement of thoracostomy tubes
is scheduled 2 to 3 weeks after the completion of neoadjuvant as needed. A self-retaining table-mounted retractor is used to facil-
therapy. This interval allows time for patients to return to their itate upward and lateral traction along the costal margin.
baseline activity level and for any induced hematologic abnormal-
ities to be corrected. Previous chemoradiation therapy does not Ivor-Lewis Esophagectomy
make transhiatal esophagectomy significantly more difficult or At many institutions, Ivor-Lewis esophagectomy is preferred
complicated. Many tumors are downstaged and less bulky at the because it provides excellent direct exposure for dissection of the
time of resection. In centers with experience in this approach, the intrathoracic esophagus, in that it combines a right thoracotomy
rates of bleeding and anastomotic leakage remain low. with a laparotomy. This procedure should be considered when
there is concern regarding the extent of esophageal fixation with-
OPERATIVE PLANNING
in the mediastinum. One advantage of Ivor-Lewis esophagectomy
is that an extensive local lymphadenectomy can easily be per-
Transhiatal Esophagectomy formed through the right thoracotomy. Any attachments to medi-
In transhiatal esophagectomy, the stomach is mobilized through astinal structures can be freed under direct vision. Whether any
a short upper midline laparotomy, the esophagus is mobilized regional lymph node dissection is necessary is highly controversial;
from adjacent mediastinal structures via dissection through the no significant survival advantage has yet been demonstrated.
hiatus without the use of a thoracotomy, and the stomach is trans- Long-term survival after Ivor-Lewis resection is equivalent to that
posed through the posterior mediastinum and anastomosed to the after transhiatal esophagectomy.3
cervical esophagus at the level of the clavicles. The main advan- The main disadvantages of the Ivor-Lewis procedure are (1) the
tages of this approach are (1) a proximal surgical margin that is physiologic impact of the two major access incisions employed (a
well away from the tumor site, (2) an extrathoracic esophagogas- right thoracotomy and a midline laparotomy) and (2) the location
tric anastomosis that is easily accessible in the event of complica- of the anastomosis (in the chest, at the level of the azygos vein).
tions, and (3) reduced overall operative trauma. Single-center stud- Incision-related pain may hinder deep breathing and the clearing
ies throughout the world have shown transhiatal esophagectomy to of bronchial secretions, resulting in atelectasis and pneumonia.
be safe and well tolerated, even in patients who may have signifi- Complications of the intrathoracic anastomosis may be hard to
cantly reduced cardiopulmonary reserve. Long-term survival is manage. Although the anastomotic leakage rate associated with
equivalent to that reported after transthoracic esophagectomy. Ivor-Lewis esophagectomy has typically been 5% or lower—and
Although transhiatal esophagectomy has been used for resec- thus substantially lower than the rate cited for the cervical anasto-
tion of tumors at any location in the esophagus, it is best suited for mosis after transhiatal esophagectomy—intrathoracic leaks are
resection of tumors in the lower esophagus and at the esopha- much more dangerous and difficult to handle than intracervial
gogastric junction. It should also be considered the operation of leaks. In many cases, drainage of the leak will be incomplete and
choice for certain advanced nonmalignant conditions of the empyema will result. Reoperation may prove necessary to manage
esophagus. Nondilatable strictures of the esophagus may occur as mediastinitis.
an end-stage complication of gastroesophageal reflux. Intractable
reflux after failed hiatal hernia repair may not be amenable to fur- Left Thoracoabdominal Esophagogastrectomy
ther attempts at reconstruction of the esophagogastric junction The left thoracoabdominal approach is indicated for resection
and thus may call for esophagectomy. Because of the high cervical of the distal esophagus and the proximal stomach when removal
anastomosis, a transhiatal esophagectomy is less likely to predis- of the stomach necessitates the use of an intestinal substitute to
pose to postoperative reflux and recurrent stricture formation than restore swallowing. If the proximal stomach must be resected for
a transthoracic esophagectomy would be. Achalasia may result in adequate resection margins to be obtained, then the distal stom-
a sigmoid megaesophagus and dysphagia that cannot be managed ach may be anastomosed to the esophagus in the chest.This oper-
without removal of the esophagus. Transhiatal esophagectomy ation is frequently associated with significant esophagitis from bile
permits complete removal of the thoracic esophagus and, in the reflux, and dysphagia is common. Consequently, many surgeons
majority of patients, restoration of comfortable swallowing with- prefer to resect the entire stomach and the distal esophagus and
out the need for a thoracotomy. then to restore swallowing with a Roux-en-Y jejunal interposition
Generally, patients are admitted to the hospital on the day of the anastomosed to the residual thoracic esophagus.
operation.Thoracic epidural analgesia is administered, both intra-
OPERATIVE TECHNIQUE
operatively and postoperatively, and appropriate antibiotic pro-
phylaxis is provided [see 1:2 Prevention of Postoperative Infection].
Heparin, 5,000 U subcutaneously, is given before induction, and Transhiatal Esophagectomy
pneumatic calf compression devices are applied. A radial artery Transhiatal esophagectomy is best understood as consisting of
catheter is placed to permit continuous monitoring of blood pres- three components: abdominal, mediastinal, and cervical. The ab-
sure. Central venous access is rarely required. General anesthesia dominal portion involves mobilization of the stomach, pyloromy-
is administered via an uncut single-lumen endotracheal tube. otomy, and placement of a temporary feeding jejunostomy.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 11
Step 1: incision and entry into peritoneum A midline Dissection then proceeds along the greater curvature toward
laparotomy is performed from the tip of the xiphoid to the umbili- the pylorus. The omentum is mobilized from the right gastroepi-
cus.The peritoneum is opened to the left of the midline so that the ploic artery.Vessels are ligated between 2-0 silk ties, and great care
falciform and the preperitoneal fat may be retracted en bloc to the is exercised to avoid placing excessive traction on the arterial
right. Body wall retractors are placed at 45º angles from the mid- arcade. A 1 cm margin is always maintained between the line of
line to elevate and distract both costal margins.The retractors are dissection and the right gastroepiploic artery. Venous injuries, in
placed so as to lift up the costal margin gently and open the particular, can occur with injudicious handling of tissue. The
wound. The abdomen is then inspected for metastases. ultrasonic scalpel is particularly efficient and effective for mobi-
lization of the stomach; again, this instrument must be applied
Step 2: division of gastrohepatic ligament and mobiliza- well away from the gastroepiploic arcade. Dissection is continued
tion of distal esophagus The left lobe of the liver is mobilized rightward to the level of the pylorus. It should be noted that the
by dividing the triangular ligament, then folded to the right and location of the gastroepiploic artery in this area may vary; often, it
held in this position with a moist laparotomy pad and a deep-blad- is at some unexpected distance from the stomach wall. Posterior
ed self-retaining retractor. Next, the gastrohepatic ligament is divided. adhesions between the stomach and the pancreas are lysed so that
Occasionally, there is an aberrant left hepatic artery arising from the lesser sac can be completely opened.
the left gastric artery [see Figure 9].The peritoneum over the right The assistant’s left hand is then placed into the lesser sac to
crus is incised, and the hiatus is palpated; the extent and mobility retract the stomach gently to the right and place the short gastric
of any tumor may then be assessed. The peritoneum over the left vessels on tension. The Penrose drain previously placed around
crus is similarly divided, and the esophagus is encircled with a 2.5 cm the esophagus facilitates exposure by retracting the cardia to the
Penrose drain. Traction is applied to draw the esophagogastric right. Dissection along the greater curvature proceeds cephalad.
junction upward and to the right; this measure facilitates exposure The vessels are divided well away from the wall of the stomach to
of the short gastric arteries coursing to the fundus and the cardia. prevent injury to the fundus. Clamps should never be placed on
the stomach. A high short gastric artery is typically encountered
Step 3: mobilization of stomach The greater curvature of just adjacent to the left crus. Precise technique is required to pre-
the stomach is inspected and the right gastroepiploic artery pal- vent injury to the spleen. The Penrose drain [see Step 2, above] is
pated.The lesser sac is generally entered near the midpoint of the exposed as the peritoneum is opened over the left crus.
greater curvature. The transition zone between the right gas- Mobilization of the proximal stomach and liberation of the distal
troepiploic arcade and the short gastric arteries is usually devoid esophagus are thereby completed.
of blood vessels. A moist sponge is placed behind the spleen to ele- Once the stomach has been completely mobilized along the
vate it and facilitate subsequent control of the short gastric vessels. greater curvature, it is elevated and rotated to the right [see Figure
Divided Left
Gastric Vessels
Lesser Omentum
Divided
Hepatic Splenic
Artery Artery
E
Intact Right
Gastroepiploic
Artery
Figure 10 Transhiatal esophagectomy. After the stomach has been completely mobilized A
along the greater curvature, it is elevated and rotated to the right. The left gastric vessels
are suture-ligated and divided. A 1 cm margin of the diaphragmatic crura is taken in con-
tinuity with the esophagogastric junction, providing ample clearance of the tumor and
improved exposure of the lower mediastinum.
10]; the left gastric artery and associated nodal tissues can then be Dissection is extended toward the duodenum with the aid of a
visualized via the lesser sac. The superior edge of the pancreas is fine-tipped right-angle clamp. The duodenal submucosa, recog-
visible, and the remaining posterior attachments of the stomach nizable by its fatty deposits and yellow coloration, is exposed for
are divided along the hiatus and the left crus.These may be quite approximately 0.5 cm. The duodenal submucosa is usually much
extensive if there has been a history of pancreatitis or preoperative more superficial than expected, and accidental entry into the duo-
radiation therapy. denum often occurs just past the left edge of the circular muscle
If the operation is being done for malignant disease, a final of the pylorus. Releasing the tension on the traction sutures helps
determination of resectability can be made at this point. Tumor the surgeon visualize the proper depth of dissection. Should entry
fixation to the aorta or the retroperitoneum can be assessed. Celiac into the lumen occur, a simple repair using interrupted fine
and paraortic lymph nodes can be palpated and, if necessary, sent monofilament (4-0 or 5-0 polypropylene) sutures to close the
for biopsy. The left gastric artery and vein are then ligated proxi- mucosa is performed. Small metal clips are applied to the knots of
mally, either through the lesser sac or directly through the divided the traction sutures before removal of the ends; these clips serve
gastrohepatic ligament. All nodal tissue is dissected free in antici- to indicate the level of the pyloromyotomy on subsequent radi-
pation of subsequent removal en bloc with the specimen. ographic studies.
Step 4: mobilization of duodenum and pyloromyotomy Step 5: feeding jejunostomy Placement of a standard
The duodenum is mobilized with a Kocher maneuver. Careful Weitzel jejunal feeding tube approximately 30 cm from the liga-
attention to the superior extent of this dissection is critical. ment of Treitz completes the abdominal portion of the transhiatal
Adhesions to either the porta hepatis or the gallbladder must be esophagectomy.
divided to ensure that the pylorus is sufficiently freed for later
migration to the diaphragmatic hiatus. Step 6: exposure and encirclement of cervical esophagus
Gastric drainage is provided by a pyloromyotomy. Two figure- The cervical esophagus is exposed through a 6 cm incision along
eight traction sutures of 2-0 cardiovascular silk are placed deeply the anterior edge of the left sternocleidomastoid muscle [see Figure
through both the superior and the inferior border of the pylorus; 1] that is centered over the level of the cricoid cartilage. The
traction is then placed on these sutures to provide both exposure platysma is divided to expose the omohyoid, which is divided at its
and some degree of hemostasis.The pyloromyotomy is begun 2 to tendon.The strap muscles are divided low in the neck.The esoph-
3 cm on the gastric side of the pylorus. The serosa and the mus- agus and its indwelling nasogastric tube can be palpated.
cle are divided with a needle-tipped electrocautery to expose the The carotid sheath is retracted laterally, and blunt dissection is
submucosa; generally, these layers of the stomach are robust, mak- employed to reach the prevertebral fascia. The inferior thyroid
ing the proper plane easy to find. artery is ligated laterally; the recurrent laryngeal nerve is visible just
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 13
deep and medial to this vessel. No retractor other than the surgeon’s
finger should be applied medially: traction injury to the recurrent
laryngeal nerve will result in both vocal cord palsy and uncoordi-
nated swallowing with aspiration. In particular, metal retractors
must not be used in this area. The tracheoesophageal groove is
incised close to the esophageal wall while gentle finger traction is
applied cephalad to elevate the thyroid cartilage toward the right.
This measure usually suffices to define the location of the nerve.
The esophagus is then encircled by passing a right-angle clamp
posteriorly from left to right while the surgeon’s finger remains in
the tracheoesophageal groove.The tip of the clamp is brought into
the pulp of the fingertip.The medially located recurrent laryngeal
nerve and the membranous trachea are thereby protected from
injury.The clamp is brought around, and a narrow Penrose drain
is passed around the esophagus [see Figure 11]. Blunt finger dis-
section is employed to develop the anterior and posterior planes
around the esophagus at the level of the thoracic inlet.
fingertips enter the space between the esophagus and the left main- Pericardium Vagus Nerves
stem bronchus.The hand is gently advanced, and the airway is dis- Carina Clipped
placed anteriorly. A blunt curved suction handle is employed from
above as a substitute finger. It is advanced along the anterior aspect
of the esophagus through the cervical incision. The right hand
guides the tip of the suction handle beneath the bronchus. Lateral
displacement of the handle allows further mobilization of the
bronchus away from the esophagus. Completion of the anterior
and posterior planes usually results in a highly mobile esophagus.
Third, the lateral attachments of the upper and middle esopha-
gus are divided. Upward traction is applied with the Penrose drain
previously placed around the cervical esophagus, allowing further
dissection at the level of the thoracic inlet. Lateral attachments are
pushed caudally into the mediastinum, and traction applied to the
esophagus from below allows these attachments to be visualized
inferiorly through the hiatus, then isolated with long right-angle
clamps and divided with the electrocautery. Caution must be exer-
cised so as not to injure the azygos vein. Dissection on the right
side must therefore be kept close to the esophagus. Once the last
lateral attachment is divided, the esophagus is completely free and
can be advanced into the cervical wound.
Close monitoring of arterial blood pressure is maintained
throughout.Transient hypotension may occur as a result of medi-
astinal compression and temporary impairment of cardiac venous
return as the surgeon’s hand or retractors are passed through the
hiatus. Vasopressors are never required for management: simple
Figure 14 Transhiatal esophagectomy. The esophagus is divided
in the neck and delivered into the abdomen. Retractors are
placed in the hiatus, and any vessels entering into the esophagus
are clipped and divided. The vagi are also clipped and divided.
mm GIA stapler loaded with 3.5 mm staples is then used to tran- ensure that injury to the gastroepiploic arcade does not occur at
sect the proximal stomach, proceeding from the lesser curvature this late point in the procedure.The hiatus is narrowed, but not so
toward the fundus [see Figure 15]. Resection of the cardia along much that three fingers cannot be easily passed alongside the gas-
with the adjacent portion of the lesser curvature effectively con- tric conduit. This reconstitution will help prevent herniation of
verts a J-shaped stomach into a straight tube. other abdominal contents alongside the gastric conduit. The liver
For maximizing the length of the gastric tube, there are several is returned to its anatomic position, thus also preventing any sub-
technical points that are critical. Tension must be maintained on sequent herniation of bowel into the chest.The pyloromyotomy is
the stomach as the stapler is serially applied cephalad.The stapler generally found at the level of the diaphragm. The laparotomy is
should be simply placed on the stomach and fired: no attempt then closed in the usual fashion.The viability of the fundus in the
should be made to telescope tissue into the jaws, because to do so neck incision is checked periodically as the abdominal portion of
would effectively reconstitute the curve of the stomach and dimin- the procedure is completed.
ish its upward reach. Typically, three staple loads are required.
The specimen is removed, and frozen section examination is Step 11: cervical esophagogastric anastomosis The con-
done on the distal margin.The completed staple line is then over- struction of the esophagogastric anastomosis is the most impor-
sewn with a continuous Lembert suture of 4-0 polypropylene. Once tant part of the entire operation: any anastomotic complication
again, tension is maintained along the stomach to prevent any fore- will greatly compromise the patient’s ability to swallow comfort-
shortening of the lesser curvature.The use of two separate sutures, ably. Accordingly, meticulous technique is essential.
each reinforcing half of the staple line, is helpful in this regard. A seromuscular traction suture of 4-0 polyglactin is placed
through the anterior stomach at the level of the clavicle and drawn
Step 10: advancement of stomach into chest or neck upward, thus elevating the fundus into the neck wound and great-
The mediastinal packs are removed, and hemostasis is verified in ly facilitating the anastomosis.The pack behind the fundus is then
the chest.The stomach is inspected as well.The ends of any short removed.
gastric vessels that were divided with the ultrasonic scalpel are The site of the anterior gastrotomy is then carefully selected: it
now tied so that subsequent manipulation does not precipitate should be midway between the oversewn lesser curvature staple
bleeding. The stomach is oriented so that the greater curvature is line and the greater curvature of the fundus (marked by the ligat-
to the patient’s left.There must be no torsion.The anterior surface ed ends of the short gastric vessels). The staple line on the cervi-
of the fundal tip should be marked with ink so that proper orien- cal esophagus is removed, and the anterior aspect of the esopha-
tation of the stomach can be confirmed after its passage into the gus is grasped with a fine-toothed forceps at the level of the
neck. The stomach can usually be advanced through the posteri- planned gastrotomy. A straight DeBakey forceps is then applied
or mediastinum without any traction sutures or clamps. The sur- across the full width of the esophagus to act as a guide for division.
geon’s hand is placed palm down on the anterior surface of the The esophagus is cut with a new scalpel blade at a 45º angle so
stomach, with the fingertips about 5 cm proximal to the tip of the that the anterior wall is slightly longer than the posterior wall; the
fundus. The hand is then gently advanced through the chest,
pushing the stomach ahead of itself. The tip of the fundus is gen-
tly grasped with a Babcock clamp as it appears in the neck.To pre-
vent trauma at this most distant aspect of the gastric tube, the
clamp should not be ratcheted closed.
No attempt should be made to pull the stomach up into the
neck: the position of the fundus is simply maintained as the sur-
geon’s hand is removed from the mediastinum. Further length in
the neck can usually be gained by gently readvancing the hand
along the anterior aspect of the stomach.This measure uniformly
distributes tension along the tube and ensures proper torsion-free
orientation in the chest. The stomach is pushed up into the neck
rather than drawn up by the clamp.
A useful alternative approach for positioning the gastric tube
involves passing a large-bore Foley catheter through the medi-
astinum from the neck incision. The balloon is inflated, and a 50
cm section of a narrow plastic laparoscopic camera bag is tied
onto the catheter just above the balloon. The gastric tube is posi-
tioned within the bag, and suction is applied through the catheter,
creating an atraumatic seal between the stomach and the sur-
rounding plastic bag. As the bag is drawn upward through the
neck with gentle traction on the Foley catheter, the stomach
advances through the mediastinum. A small dry pack is placed in
the neck behind the fundus to prevent retraction into the chest.
The stomach is not secured to the prevertebral fascia in any way.
The feeding jejunal tube is brought out the left midabdomen
Figure 15 Transhiatal esophagectomy. A gastric tube is formed
through a separate stab incision.The hiatus is inspected for hemo- by stapling along the lesser curvature of the stomach from the
stasis, as is the splenic hilum. It may be necessary to reconstitute junction of the right and left gastric vessels to the top of the fun-
the hiatus with one or two simple sutures of 1-0 silk placed dus. This staple line is oversewn with a continuous 3-0 suture,
through the crura. These sutures must be placed with care to with care taken not to foreshorten the gastric tube.
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4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 16
anterior wall then forms the hood of the anastomosis. The fine- a
toothed forceps is used to maintain orientation of the esophagus
throughout. Two full-thickness stay sutures of 4-0 Vicryl are
placed, one at the midpoint of the anterior cut edge of the esoph-
agus and one at the corresponding location posteriorly.The poste-
rior stitch is placed from inside the lumen, and the needle is left
on the suture for later use.
A 2 cm gastrotomy is then performed with a needle-tipped elec-
trocautery using cutting current.The incision is obliquely oriented,
with the cephalad extent proceeding slightly medially. The needle
from the stay suture previously placed on the posterior wall of the
esophagus is then passed the full thickness of the cephalad aspect
of the gastrotomy [see Figure 16a]. Traction on this untied suture
brings the esophagus toward the stomach. A 45 mm endoscopic
stapler loaded with 3.5 mm staples is used to form the back wall of
the anastomosis.The thicker portion of the device (the cartridge) is
advanced cephalad into the esophagus, with the narrower portion
(the anvil) in the gastric lumen [see Figure 16b]. The tip of the sta-
pler should be aimed toward the patient’s right ear. Tension is
applied to the stay suture holding the esophagus and stomach
together so as to bring tissue into the jaws of the device. The por-
tion of the fundus extending beyond the stapler is then rotated
medially to ensure that the new staple line is well away from the one
previously placed along the lesser curvature.This is a crucial point: b
crossing of the two staple lines may create an ischemic area that can
give rise to a large leak in the postoperative period.
The stapler is then closed, holding the esophagus and stomach
together, but not yet fired. The position of the nasogastric tube
should be maintained just at the level of the cricopharyngeus dur-
ing the construction of the anastomosis.This positioning keeps the
tube out of the operative field and protects it from being entrapped
by the jaws of the stapler; it also facilitates subsequent passage of
the tube into the gastric conduit once the posterior wall of the
anastomosis is complete. Two suspension sutures are placed on
either side of the closed stapler, one toward the tip and the other
near the heel of the jaws.These four sutures alleviate any potential
tension on the staple line by approximating the muscular layer of
the esophagus to the seromuscular layer of the stomach. The sus-
pension sutures are tied, and the stapler is fired, thereby complet- c
ing the posterior portion of the anastomosis [see Figure 16c].
The anterior portion of the anastomosis is closed in two layers.
The inner layer consists of a continuous 4-0 polydioxanone suture
placed as full-thickness inverting stitches, and the second layer
consists of interrupted seromuscular Lembert sutures [see Figure
17]. The lateral and medial corners of the anastomosis, where the
staple line meets the handsewn portion, merit extra attention.
These corners are quite fragile, and excessive traction may result
in dehiscence progressing cephalad along the staple line in a zip-
perlike fashion.The inner layer should therefore be started at each Figure 16 Transhiatal esophagectomy. (a) After the proximal
corner, incorporating the last 5 mm of the staple line. Once sever- end of the stomach tube is delivered into the neck, the esophagus
al stitches have been placed from the two corners, the nasogastric is cut at a 45° angle so that the anterior wall is longer than the
tube can be passed through the anastomosis.The nasogastric tube posterior wall. A gastrotomy is placed between the oversewn less-
is properly positioned when the most distal black marker is at the er curvature staple line and the greater curvature of the fundus.
nares.The inner layer is then completed as the two sutures are tied A full-thickness suture is placed through all layers of the esopha-
at the midpoint. gus and all layers of the gastrotomy. (b) An endoscopic GIA sta-
pler is used to form the back wall of the anastomosis. The thicker
Step 12: drainage, closure, and completion x-ray A portion of the device (the cartridge) is advanced cephalad into
the esophagus, with the narrower portion (the anvil) in the gas-
small Penrose drain is placed in the thoracic inlet below the
tric lumen. The tip of the stapler should be aimed toward the
anastomosis and brought out through the inferior end of the patient’s right ear. The staple line must be well away from the
neck incision. The drain is secured, and the incision is irrigated. lesser curvature staple line. Two suspension sutures are placed on
The strap muscles are not reapproximated but are merely either side of the closed stapler, one toward the tip and the other
attached loosely to the underside of the sternocleidomastoid near the heel of the jaws. (c) The stapler is fired to complete the
muscle with two interrupted 4-0 polyglactin sutures. The platys- posterior portion of the anastomosis.
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4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 17
a Ivor-Lewis Esophagectomy
Steps 1 through 5 Esophagoscopy is performed to confirm
the location of the tumor. Steps 1, 2, 3, 4, and 5 of an Ivor-Lewis
esophagectomy are virtually identical to the first five steps (i.e., the
abdominal portion) of a transhiatal esophagectomy. Once com-
plete mobilization of the stomach is verified, the pylorus is manu-
ally advanced to the level of the diaphragm to ensure that it is not
being tethered by the duodenum or the greater omentum. The
stomach is then placed back into the anatomic position, and the
laparotomy is closed.
ma is reconstituted with interrupted 4-0 polyglactin sutures.The Step 7: excision and removal of specimen The hiatus is
nasogastric tube is secured. incised and the abdomen entered. The stomach is drawn up into
A chest x-ray is obtained in the OR to verify the position of the the chest, with care taken not to place excessive traction on the
drains and the absence of any abnormal collections in the chest. gastroepiploic pedicle. The esophagus is divided with a stapler
Patients are extubated in the OR and transported to the anesthet- proximally at least 5 cm away from any grossly evident tumor. A
ic recovery area. Extubation should be carried out only when the margin is sent for frozen section examination.The distal resection
health care team is confident that subsequent reintubation is margin is completed in a similar manner, and the esophageal
unlikely to be necessary. Emergency reintubation after a cervical specimen is removed from the operative field [see Figure 19]. The
anastomosis is hazardous, in that vigorous neck extension may gastric staple line is oversewn, and the stomach is positioned in the
threaten the suture line. Once patients are awake and alert, which posterior mediastinum.
is usually 3 to 4 hours after the operation, they are taken to the
general ward. As a rule, admission to an intensive care unit is not Step 8: intrathoracic esophagogastric anastomosis The
required unless there are substantial comorbidities or intraopera- site of the esophagogastric anastomosis should be about 2 cm
tive concerns. To prevent excessive traction on the anastomosis, above the divided azygos vein. Several interrupted sutures are
the neck should be maintained in a flexed position with two pil- used to secure the transposed stomach to the adjacent pleura.The
lows placed behind the head. staple line on the esophagus is removed, and a gastrotomy is per-
In certain patients, a stapled anastomosis may be impractical. formed in preparation for a side-to-side functional end-to-end
In patients with a bull-neck habitus, for example, a partial sternal anastomosis [see Figure 20].With the aid of full-thickness traction
split may be required for adequate exposure of the cervical esoph- sutures, the esophagus is positioned along the surface of the stom-
agus, and a handsewn true end-to-end anastomosis may be nec- ach and well away from the oversewn staple line defining the gas-
essary. In addition, patients who have previously undergone tric resection margin. The posterior aspect of the anastomosis is
antireflux surgery may have a relatively short gastric tube that will completed with an endoscopic GIA stapler as described earlier
necessitate an end-to-end reconstruction. [seeTranshiatal Esophagectomy, Step 11, above, and Figures 16 and
Patients should, if possible, begin walking the morning after the 17]. A nasogastric tube is passed, and the anterior wall is com-
operation. An incentive spirometer should be constantly within pleted in two layers.The first layer consists of a full-thickness con-
arm’s length of the patient, and hourly use of this device should tinuous 3-0 polydioxanone suture; the second consists of inter-
be encouraged.The nasogastric tube is removed on postoperative rupted absorbable sutures approximating the seromuscular layer
day 3, and the patient is allowed ice chips in the mouth.The tho- of the stomach to the muscular layer of the esophagus.
racic epidural catheter is removed the afternoon after the chest Two alternative methods of anastomosis are sometimes used:
tube is removed.The diet is gradually advanced so that a soft diet (1) a totally handsewn end-to-side anastomosis and (2) a totally
is begun on postoperative day 5 or 6. A barium swallow is per- stapled end-to-end anastomosis. The latter technique involves
formed on postoperative day 6 in preparation for hospital dis- opening the previously placed gastric staple line and advancing
charge on day 7 or 8. the handle of an end-to-end anastomosis (EEA) stapler through
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 18
a b
Azygos Vein Diaphragm Left Recurrent
Ligated and Laryngeal
Divided Nerve and Nodes
Retracted
Right Lung
Right Recurrent Laryngeal
Nerve and Nodes
Thoracic Duct
Aorta
Left Vagus
Nerve
Azygos Vein
(Ligated)
Subcarinal
and Hilar
Figure 18 Ivor-Lewis esophagectomy. (a) The lung is retracted, Nodes
and the azygos vein is stapled and divided. The esophagus and Pericardium
the vagi are mobilized from the level of the diaphragm to the Periesophageal
thoracic inlet. (b) Dissection en bloc via right thoracotomy Left Nodes
of the thoracic duct, azygos vein, ipsilateral pleura, and all Lung
periesophageal tissue in the mediastinum. The specimen includes Thoracic Duct
the lower and middle mediastinal, subcarinal, and right-side (Ligated)
paratracheal lymph nodes.
the stomach. The proximal esophagus is dilated sufficiently to gastric tube is generally removed on postoperative day 3. Oral
accommodate at least a 25 mm head. The anvil is placed into the intake is not begun at this point; feeding is accomplished via the
distal esophagus and secured with a purse-string suture.The tip of temporary jejunostomy. A barium contrast study is performed
the stapler is brought out through the apical wall of the stomach approximately 5 to 7 days after the operation. If there is no anas-
and attached to the anvil. The stapler is then fired to create the tomotic leakage, oral intake is initiated and advanced as tolerated.
end-to-end anastomosis, and the gastrotomy is closed.The advan- The chest tubes are removed only after the reinstitution of oral
tages of this technique are its relative simplicity and the theoretical intake. Patients are generally discharged from the hospital by post-
security of a completely stapled anastomosis; the main potential operative day 8 to 10.
disadvantage is the risk of postoperative dysphagia resulting from
an overly narrow anastomotic ring. Left Thoracoabdominal Esophagogastrectomy
After completion of the anastomosis, the stomach is inspected for Step 1: incision and entry into peritoneum The patient is
any potential redundancy or torsion in the chest.To prevent torsion, placed in the right lateral position, with the hips rotated backward
the stomach is anchored to the pericardium with nonabsorbable about 30°. An exploratory laparotomy is performed through an
sutures.The diaphragmatic hiatus is then inspected: it should allow oblique incision extending from the tip of the sixth costal cartilage
easy passage of two fingers into the abdomen alongside the trans- to a point about halfway between the sternum and the umbilicus.
posed stomach. Interrupted sutures may be used to approximate the The peritoneal cavity is carefully examined to rule out peritoneal
edge of the crura to the adjacent stomach wall, thereby preventing and hepatic metastases. The region of the cardia is palpated and
any later herniation of abdominal contents into the pleural space. the mobility of the tumor assessed. If there is minor involvement
of the crura or the tail of the pancreas, resection may still be pos-
Step 9: drainage and closure Two chest tubes are placed sible; however, if the tumor is firmly fixed or there are peritoneal
through separate stab incisions. The tip of the posterior drain is or hepatic metastases, resection should be abandoned. A feeding
positioned alongside the stomach at the level of the anastomosis. jejunostomy, an esophageal stent, or both may be inserted to
Fine gut sutures secured to the adjacent parietal pleura will help improve swallowing and allow nutrition.
maintain the position of the tube. The thoracotomy is then
closed in the standard fashion. Step 2: assessment of gastric involvement and incision of
Patients should begin walking on postoperative day 1.The naso- diaphragm The extent to which the tumor involves the stom-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 19
Stomach and
Esophagus
Approximated
with Single Stitch
Gastrostomy Made
Figure 19 Ivor-Lewis esophagectomy. The esophagus and the
with Electrocautery
proximal stomach are divided and stapled at least 5 cm away for Technique with
from the gross tumor. Stapled Anastomosis
the esophagus and the hilum of the liver, then divided down to the
area of the pylorus, with the right gastric artery and vein preserved.
There is often a hepatic branch from the left gastric artery running
through the gastrohepatic omentum. If this hepatic branch is of sig-
nificant size, a soft vascular clamp should be placed on the artery
for 20 minutes so that the viability of the liver can be assessed. If
the liver is viable, the artery is suture-ligated and divided.
optimized through incentive spirometry, use of bronchodilators, and be temporary and require no specific treatment. Permanent injury
physical rehabilitation. Chronic nocturnal aspiration from esoph- will lead to hoarseness and impaired protection of the airway dur-
ageal obstruction should be watched for in the preoperative patient; ing deglutition. Pneumonia from chronic aspiration is a major
the head of the bed should be elevated 30° to 45° as a preventive problem. Meticulous protection of the nerve during the cervical
measure. Effective pain control is essential to prevent postopera- stage should minimize the incidence of this complication. If laryn-
tive atelectasis. Routine use of patient-controlled thoracic epidur- geal nerve injury becomes apparent in the postoperative period,
al analgesia should be considered. Deep breathing, early ambula- early medialization of the affected cord should be performed by an
tion, and chest physiotherapy encourage the clearing of bronchial otolaryngologist.
secretions. Certain patients will require nasotracheal aspiration or Of particular concern is the risk of bilateral nerve injury after a
bronchoscopy for pulmonary toilet. transthoracic esophagectomy with a cervical esophagogastric
anastomosis (i.e., a so-called three-hole esophagectomy). Any dis-
Tracheobronchial Injury section of the upper esophagus performed through the right chest
On rare occasions, lacerations of the membranous trachea or should be done as close to the esophagus as possible to avoid plac-
the left mainstem bronchus occur during esophagectomy. When ing traction on the right recurrent laryngeal nerve; the subsequent
such injuries occur during transthoracic resection, management is left cervical dissection may put the left recurrent laryngeal nerve at
relatively simple, thanks to the already excellent operative expo- risk for damage. Bilateral paralysis of the vocal cords is very poor-
sure. Direct suture repair and tissue reinforcement with adjacent ly tolerated and has a devastating impact on quality of life.
pleura or a pedicle of intercostal muscle provide safe closure in
almost all cases. When tracheobronchial injuries occur during Chylothorax
transhiatal esophagectomy, they are less obvious but no less Thoracic duct injuries typically present by postoperative day 3
urgent. This rare complication arises during mediastinal dissec- or 4. Dyspnea and pleural effusion may be noted if thoracostomy
tion. Typically, the anesthetic team notes a loss of ventilatory vol- tubes are not in place.Thoracentesis yields an opaque, milky fluid.
ume, and the surgeon may detect the smell of inhalational agents In patients who already have a chest drain in place, there is typi-
in the operative field. Bronchoscopy should be promptly per- cally a high volume of serous drainage in the first 2 postoperative
formed to identify the site of the injury. The uncut endotracheal days. As enteral nutrition is established and dietary fat reintro-
tube is then advanced over the bronchoscope and past the site of duced, the fluid assumes a characteristic milky appearance. In
the laceration to restore proper ventilation. High tracheal injuries most cases, the gross appearance is diagnostic, and there is rarely
can usually be repaired by extending the cervical incision and a need to confirm the diagnosis by measuring the triglyceride
adding a partial sternotomy. Injury to the carina or the left main- level. A thoracostomy drain is placed to monitor the volume of the
stem bronchus must be repaired via a right thoracotomy. chyle leak. Chest x-rays should be obtained to verify complete
drainage of the pleural space and full expansion of the lung.
Bleeding Patients with chylothorax should be converted to fat-free enteral
Hemorrhage should be rare during esophagectomy. In routine nutrition. Persistent drainage exceeding 500 ml/8 hr is an indication
situations, blood loss should amount to less than 500 ml. The for early operation and ligation of the thoracic duct; high-volume
blood supply to the esophagus consists of small branches coming chyle leaks are unlikely to close spontaneously. Prolonged loss of chyle
from the aorta, which are easily controlled and generally constrict causes significant electrolyte, nutritional, and immunologic derange-
even if left untied. Splenic injuries sometimes occur during mobi- ments that may prove fatal if allowed to progress. Accordingly, pa-
lization of the stomach. The resultant hemorrhage can be imme- tients with persistent chyle leakage should undergo operation with-
diate or delayed; blood loss may be significant, and splenectomy is in 1 week of diagnosis. A feeding tube is placed in the duodenum
usually required. Precise dissection around the left gastric artery is before operation if a jejunostomy tube is not already in place.
vital: the bleeding vessels may retract, and attempts at control may Jejunal feeding with 35% cream at a rate of 60 to 80 ml/hr is main-
result in injury to the celiac artery or its hepatic branches. tained for at least 4 hours before operation. Feeding is continued
Similarly, peripancreatic vessels may be difficult to control if inad- even during the procedure: the enteral fat stimulates a brisk flow of
vertently injured during the Kocher maneuver. chyle and greatly facilitates visualization of any thoracic duct injury.
Bleeding that arises during the mediastinal stage of the transhi- Right-side chyle leaks are approached via either a thoracotomy
atal esophagectomy generally subsides with packing if it derives or video-assisted thoracoscopy. The magnification and excellent
from periesophageal arterial branches. Brisk loss of dark blood usu- illumination associated with thoracoscopy are partially counter-
ally signifies injury to the azygos vein. The first step in addressing balanced by the constraints imposed by port placement and limit-
such injuries is to pack the mediastinum quickly so as to allow the ed tissue retraction. The inferior pulmonary ligament is divided,
anesthetic team to stabilize the patient and restore volume. Chest and the posterior mediastinum is inspected for extravasation of
tubes are immediately placed to allow detection of any free hemor- milky fluid. Any visible sources of chyle leakage can be controlled
rhage into the pleural space. Precise localization of the bleeding site with clips or suture ligatures. In some cases, mass ligation of the
may then follow. Injury to the azygos vein may be addressed via an thoracic duct at the level of the diaphragm, incorporating all the
upper sternal split; however, when the exposure is poor, the sur- soft tissue between the aorta and the azygos vein, may be required.
geon should not hesitate to proceed to a full sternotomy. Bleeding Left-side leaks can be difficult to manage. The subcarinal area
from the subcarinal area is usually bright red and may involve is typically involved; this is the level at which the thoracic duct
bronchial arteries or small periesophageal vessels arising from the crosses over from the right. Exploration should begin on the left
aorta, both of which can usually be controlled through the hiatus side. If the leak cannot be visualized, a right-side approach may be
with a long-handled pistol-grip clip applier or electrocautery. necessary to control the thoracic duct as it first enters the chest.
Laryngeal Nerve Injury Anastomotic Leakage
Injury to the recurrent laryngeal nerve is a major potential com- The consequences of anastomotic complications after esoph-
plication of transhiatal esophagectomy. Traction neuropraxia may agectomy vary considerably in severity, depending on their loca-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 23
tion and cause. The cervical anastomotic leaks that may develop problems and are difficult to manage; those presenting later are
after transhiatal esophagectomy are generally simple to treat. generally related to some degree of ischemic tissue loss. Patients
Leaks in the early postoperative period are usually related to tech- who have received radiation therapy or are nutritionally depleted
nical factors (e.g., excessive tension across the anastomosis). A may be especially vulnerable to problems with anastomotic heal-
nonviable stomach may not give rise to obvious signs, and thus, ing. A contrast swallow with dilute barium is the best method of
any possibility of ischemia in the transposed stomach must be evaluating the anastomosis. Leaks may be manifested either as a
addressed promptly.Tachycardia, confusion, leukocytosis, cervical free flow of contrast into the pleural space or as a contained fluid
wound drainage, and neck tenderness may or may not be present. collection.
The morbidity of an open cervical wound is not high—cer- Small leaks that drain immediately into properly placed thora-
tainly lower than that of an untreated leak. Accordingly, any clin- costomy tubes can usually be managed by giving antibiotics and
ical suspicion of a leak should prompt a diagnostic contrast swal- withholding oral intake. Local control of infection generally results
low study using dilute barium. Large leaks are manifested as in spontaneous healing. Anastomotic disruptions that are large or
persistent collections of contrast material outside the esophagus. are associated with a major pleural collection typically necessitate
Although such leaks rarely extend into the pleural space, any open drainage with decortication; percutaneous drainage may be
fluid in the chest must be drained so that its nature can be deter- considered as a preliminary approach in selected patients.
mined. The neck wound is opened by removing the sutures and Persistent soiling of the mediastinum and the pleural space is fatal
performing gentle digital exploration of the prevertebral space if untreated.
behind the esophagus as the finger is advanced into the medi- Early esophagoscopy is strongly advised to evaluate the viabili-
astinum; this is usually done at the bedside and requires little, if ty of the gastric remnant. Ischemic necrosis of the stomach neces-
any, patient sedation. sitates reexploration, decortication, takedown of the anastomosis,
Saline-moistened gauze packing is changed three or four times gastric debridement, return of any viable stomach into the abdo-
a day. Prolonged or copious cervical drainage may call for supple- men, closure of the hiatus, and proximal diversion with a cervical
mental deep wound aspiration with a Yankauer suction handle. esophagostomy. Repair or revision of the anastomosis in an infect-
Administering water orally during aspiration facilitates removal of ed field is certain to fail and should never be considered. In cer-
any necrotic debris. A fetid, malodorous breath associated with tain cases, diversion via a cervical esophagostomy and a comple-
sanguineous discharge from the nasogastric tube and purulent tion gastrectomy may be required.
fluid in the opened neck incision are ominous signs that should
prompt early esophagoscopy. Diffuse mucosal ischemia may indi- Late Complications
cate the presence of a nonviable stomach; reoperation with com- At every postoperative visit, symptoms of reflux, regurgitation,
pletion gastrectomy and proximal esophagostomy is required to dumping, poor gastric emptying, and dysphagia must be specifi-
treat this rare catastrophic complication. cally sought: these are the major quality-of-life issues for post-
Generally, leaks that occur more than 7 days after operation are esophagectomy patients.4 Reflux and regurgitation may complicate
small and are related to some degree of late ischemic disruption any form of alimentary reconstruction after esophagectomy, though
along the anastomosis. They can usually be managed by opening cervical anastomoses are less likely to be associated with sympto-
the cervical wound at the bedside and packing the site with gauze. matic reflux than intrathoracic anastomoses are. Reflux symptoms
Oral diet is advanced as tolerated. It may be noted that the volume generally respond to dietary modifications, such as smaller and
of the leak is markedly greater or less depending on the position of more frequent meals. Regurgitation is usually related to the supine
the head during swallowing. Accordingly, before discharge, patients position and thus tends to be worse at night; elevating the bed and
are taught how to temporarily adjust their swallowing as well as avoiding late meals may suffice for symptom control. Dumping is
how to manage their dressing changes. Applying gentle pressure to exacerbated by foods with high fat or sugar content. Dysphagia
the neck wound and turning the head to the left may help the may be related to narrowing at the anastomosis or, in rare instances,
patient ingest liquids with minimal soiling of the open neck inci- to poor emptying of the transposed stomach.Anastomotic strictures
sion. Dysphagia, even with an opened neck incision, should be are most commonly encountered as a sequel to a postoperative
treated by passing tapered esophageal dilators orally between 2 and leak.There may be excessive scarring at the anastomosis, associat-
4 weeks after surgery.When a bougie at least 48 French in caliber ed with local distortion or angulation. Specific tests for gastric atony
can be passed through the anastomosis, the patient can usually include nuclear medicine gastric emptying studies using radiola-
swallow comfortably.The size of the leak often decreases after dila- beled food. A simple barium swallow may indicate an incomplete
tion as food is allowed to proceed preferentially into the stomach. pyloromyotomy as a cause of poor gastric emptying; balloon dila-
To maximize the diameter of the anastomosis and reduce the like- tion often corrects this problem.
lihood of a symptomatic stricture, subsequent dilations should be Any form of anastomotic leak will increase the incidence of late
scheduled at 2-week intervals for the next few months. stricture. Dysphagia may be treated by means of progressive dila-
When a routine predischarge barium swallow after transhiatal tion with Maloney bougies. This procedure is performed in the
esophagectomy raises the possibility of an anastomotic leak in an outpatient clinic and often does not require sedation or any other
asymptomatic patient, the question arises of whether the wound special patient preparation. Complications are rare if due care is
should be opened at all. For small, contained leaks associated with exercised during the procedure. As noted [seeTransthoracic Hiatal
preferential flow of contrast material into the stomach, observa- Hernia Repair, Preoperative Evaluation, Dilation, above], it is
tion alone may suffice in selected cases. Patients must be closely essential that the caliber of the dilators be increased gradually and
watched for fever or other signs of major infection. Given the quite that little or no force be applied in advancing them. The appear-
low morbidity of cervical wound exploration, the surgeon should ance of blood on a withdrawn dilator signals a breach of the
not hesitate to drain the neck if the patient’s condition changes. mucosa; further dilation should be done cautiously lest a trans-
The incidence of anastomotic leakage is low after Ivor-Lewis mural injury result. Comfortable swallowing, of liquids at least, is
resection, but the consequences are significant. Leaks presenting usually achieved after the successful passage of a 48 French
early in the postoperative period are usually related to technical bougie. It is preferable, however, to advance dilation until at least
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 4 OPEN ESOPHAGEAL PROCEDURES — 24
a 54 French bougie can be passed with ease. For late strictures that with a totally handsewn anastomosis. As regards postoperative
are particularly difficult to dilate, endoscopic examination and his- function, stomach interposition through the posterior medi-
tologic evaluation may be required to rule out a recurrent tumor. astinum after transhiatal esophagectomy is associated with low
CT of the chest should also be performed whenever there is unex- rates of aspiration and regurgitation. Esophageal reflux and
plained weight loss or fatigue late after esophagectomy. esophagitis—commonly seen with intrathoracic esophagogastric
The Savary system of wire-guided dilators has been particular- anastomoses—are usually not clinically significant problems with
ly helpful in the management of tight or eccentric strictures. this approach. Patients are advised to elevate the head of their bed
Patients are generally treated in the endoscopy suite. Temporary and to continue taking PPIs for about 3 months after the opera-
sedation with I.V. fentanyl and midazolam is required. Fluoroscopy tion. Approximately one third will require esophageal dilation for
is used to confirm proper placement of a flexible-tip wire across dysphagia after the operation. Some 7% to 10% experience post-
the stricture. Serial wire-guided dilation can then be performed vagotomy dumping symptoms, which in most cases can be con-
with confidence and increased patient safety. trolled by simply avoiding high-carbohydrate foods and dairy
products.
OUTCOME EVALUATION
Ivor-Lewis Esophagectomy
Transhiatal Esophagectomy Ivor-Lewis esophagectomy is associated with anastomotic leak-
A 1999 study from the University of Michigan presented data age rates and operative mortalities of less than 3%.3,6 Approxi-
on 1,085 patients who underwent transhiatal esophagectomy mately 5% of patients will require anastomotic dilation. Again,
without thoracotomy, of whom 74% had carcinoma and 26% had patients are advised to elevate the head of the bed and to contin-
nonmalignant disease.5 Transhiatal esophagectomy was completed ue taking PPIs. In some patients, the gastric interposition rotates
in 98.6% of the patients; the remaining 1.4% were converted to a into the right posterolateral thoracic gutter, resulting in postpran-
transthoracic esophagectomy as a result of either thoracic esoph- dial gastric tension and rendering them more susceptible to aspi-
ageal fixation or bleeding. Previous chemotherapy or radiation ration. Compared with transhiatal esophagectomy, extended
therapy did not preclude performance of a transhiatal esophagec- transthoracic esophagectomy is associated with higher pulmonary
tomy. Nine patients experienced inordinate intraoperative blood morbidity and operative mortality but also with a superior 3-year
loss; three died as a result. The overall hospital mortality was 4%. survival rate.7
The overall 5-year survival rate for patients undergoing transhiatal
esophagectomy is approximately 20% for adenocarcinoma of the Left Thoracoabdominal Esophagogastrectomy
cardia and the esophagus and 30% for squamous cell carcinoma Left thoracoabdominal esophagogastrectomy is also associated
of the esophagus. with anastomotic leakage rates and operative mortalities of less
The stapled anastomosis described earlier [see Operative than 3%.8 Approximately 5% of patients will require esophageal
Technique, Transhiatal Esophagectomy, Step 8, above] reflects dilation. Reconstructions involving anastomosis of the distal stom-
numerous refinements introduced at the University of Michigan. ach to the esophagus are associated with a high incidence of
The endoscopic GIA stapler has a low-profile head that is ideally delayed gastric emptying and bile gastritis and esophagitis. Of all
suited to the tight confines of the neck, enabling the surgeon to the operations we have described, this one results in the lowest
fashion a widely patent side-to-side functional end-to-end anasto- postoperative quality of life. Accordingly, most surgeons prefer to
mosis with three rows of staples along the back wall. The rate of carry out a total gastrectomy. Swallowing is restored with a Roux-
anastomotic stricture is markedly lower with this anastomosis than en-Y jejunal interposition.
References
1. Lahey FH, Warren K: Esophageal diverticula. Surg nal function following esophagectomy for malig- transthoracic resection compared with limited tran-
Gynecol Obstet 98:1, 1954 nancy. Am J Surg 169:471, 1995 shiatal resection for adenocarcinoma of the esoph-
agus. N Engl J Med 347:1662,2002
2. Stirling MC, Orringer MB: Continued assessment 5. Orringer MB, Marshall B, Iannettoni MD:
of the combined Collis-Nissen operation. Ann Transhiatal esophagectomy: clinical experience and 8. Akiyama H, Miyazono H, Tsurumaru M, et al:
Thorac Surg 47:224, 1989 refinements. Ann Surg 230:392, 1999 Thoracoabdominal approach for carcinoma of the
cardia of the stomach. Am J Surg 137:345, 1979
3. Mathiesen DJ, Grillo HC, Wilkens EW Jr: 6. King RM, Pairolero PC, Trastek VF, et al: Ivor
Transthoracic esophagectomy: a safe approach to Lewis esophagogastrectomy for carcinoma of the
carcinoma of the esophagus. Ann Thorac Surg esophagus: early and long-term results. Ann Thorac Acknowledgment
45:137, 1988 Surg 44:119, 1987
4. Finley RJ, Lamy A, Clifton J, et al: Gastro-intesti- 7. Hulscher JBF, van Sandick JW et al: Extended Figures 1 through 24 Tom Moore.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 5 MINIMALLY INVASIVE ESOPHAGEAL PROCEDURES — 1
5 MINIMALLY INVASIVE
ESOPHAGEAL PROCEDURES
Marco G. Patti, M.D., F.A.C.S.
During the 1970s and the 1980s, operations for benign esophageal symptoms should be graded with respect to their intensity both
disorders were often withheld or delayed in favor of less effective before and after operation. Nonetheless, a diagnosis of GERD
forms of treatment in an effort to prevent the postoperative dis- should never be based solely on symptomatic evaluation. Many
comfort, the long hospital stay, and the recovery time associated authorities assert that the diagnosis can be made reliably from the
with open surgical procedures. For instance, pneumatic dilatation clinical history,10 so that a complaint of heartburn should lead to
became first-line therapy for achalasia, even though surgical man- the presumption that acid reflux is present; however, testing of this
agement had been shown to be clearly superior.1 diagnostic strategy demonstrates that symptoms are far less sensi-
In the first part of the 1990s, it became clear that treatment of tive and specific than is usually believed.11 For instance, a study
benign esophageal disorders with minimally invasive procedures from the University of California, San Francisco (UCSF), found
yielded results comparable to those of treatment with traditional that of 822 consecutive patients referred for esophageal function
operations while causing minimal postoperative discomfort, tests with a clinical diagnosis of GERD (based on symptoms and
reducing the duration of hospitalization, shortening recovery time, endoscopic findings), only 70% had abnormal reflux on pH mon-
and permitting earlier return to work.2,3 Consequently, minimally itoring.12 Heartburn and regurgitation were no more frequent in
invasive surgery was increasingly considered as first-line treatment patients who had genuine reflux than in those who did not; thus,
for achalasia, and laparoscopic fundoplication was considered symptomatic evaluation, by itself, could not distinguish between
more readily and at an earlier stage in the management of gas- the two groups.
troesophageal reflux disease (GERD). The response to proton pump inhibitors (PPIs) is a better pre-
Since then, minimally invasive esophageal procedures have con- dictor of abnormal reflux. For example, in the UCSF study just
tinued to evolve, thanks to better instrumentation and improved cited, 75% of patients with GERD reported a good or excellent
surgical expertise. In addition, with greater experience and longer response to PPIs, compared with only 26% of patients without
follow-up periods, it has become possible to analyze techniques GERD.12 Similarly, a study involving multivariate analysis of fac-
and their results more rigorously. For instance, whereas a few tors predicting outcome after laparoscopic fundoplication con-
years ago a left thoracoscopic Heller myotomy was considered the cluded that a clinical response to acid suppression therapy was one
procedure of choice for achalasia, the current procedure of choice of three factors predictive of a successful outcome, the other two
is a laparoscopic Heller myotomy with partial fundoplication, being an abnormal 24-hour pH score and the presence of a typi-
which has proved to be better at relieving dysphagia and control- cal primary symptom (e.g., heartburn).13
ling postoperative reflux.4-7 Similarly, whereas total fundoplication
and partial fundoplication were initially considered equally effec- Upper Gastrointestinal Series
tive in treating GERD,8 total fundoplication is now viewed as An upper GI series is useful for diagnosing and characterizing
clearly superior for this purpose and should be used whenever an existing hiatal hernia.The size of the hiatal hernia helps predict
feasible.9 how difficult it will be to reduce the esophagogastric junction
In this chapter, I focus on minimally invasive approaches to the below the diaphragm. In addition, large hiatal hernias are associ-
treatment of abnormal gastroesophageal reflux and esophageal ated with more severe disturbances of esophageal peristalsis and
motility disorders.The standard open counterparts of these opera- esophageal acid clearance.14 Esophagograms are also useful for
tions are described elsewhere [see 4:4 Open Esophageal Procedures]. determining the location, shape, and size of a stricture and detect-
ing a short esophagus.
Laparoscopic Nissen Fundoplication Endoscopy
Endoscopy is typically the first test performed to confirm a
PREOPERATIVE EVALUATION
symptom-based diagnosis of GERD. This approach has two pit-
All patients who are candidates for a laparoscopic fundoplica- falls, however. First, even though the goal of endoscopy is to assess
tion should undergo a preoperative evaluation that includes the the mucosal damage caused by reflux, mucosal changes are absent
following: (1) symptomatic evaluation, (2) an upper GI series, (3) in about 50% of GERD patients.12 Second, major interobserver
endoscopy, (4) esophageal manometry, and (5) ambulatory pH variations have been reported with esophageal endoscopy, partic-
monitoring. ularly for low-grade esophagitis.15 In one study, for instance, 60
(24%) of 247 patients with negative results on pH monitoring had
Symptomatic Evaluation been diagnosed as having grade I or II esophagitis.12 Accordingly,
The presence of both typical symptoms (heartburn, regurgita- I believe that endoscopy is most valuable for excluding gastric and
tion, and dysphagia) and atypical symptoms of GERD (cough, duodenal pathologic conditions and detecting the presence of
wheezing, chest pain, and hoarseness) should be investigated, and Barrett’s esophagus.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 5 MINIMALLY INVASIVE ESOPHAGEAL PROCEDURES — 2
shears or the clip applier is placed through the same port, it will need not be sutured; the disadvantage is that the surgeon must
not reach the upper short gastric vessels. If ports D and E are too then choose another insertion site. At the end of the case, the bal-
low, the dissection at the beginning of the case and the suturing at loon is deflated. If some bleeding is still present, it must be con-
the end are problematic. trolled with sutures placed from outside under direct vision. The
Other mistakes of positioning must be avoided as well. Port C second option is to use a long needle with a suture, with which one
must not be placed too medially, because the fan retractor may can rapidly place two U-shaped stitches, one above the clamp and
clash with the left-hand instrument; the gallbladder fossa is a good one below. The suture is tied outside over a sponge and left in
landmark for positioning this port. Port A must be placed with place for 2 or 3 days.
extreme caution in the supraumbilical area: its insertion site is just
above the aorta, before its bifurcation. Accordingly, I recommend Step 2: Division of Gastrohepatic Ligament; Identification of
initially inflating the abdomen to a pressure of 18 mm Hg just for Right Crus of Diaphragm and Posterior Vagus Nerve
placement of port A; increasing the distance between the abdom- Once the ports are in place, the gastrohepatic ligament is divid-
inal wall and the aorta reduces the risk of aortic injury. I also rec- ed. Dissection begins above the caudate lobe of the liver, where
ommend directing the port toward the coccyx. Once port A is in this ligament usually is very thin, and continues toward the dia-
place, the intraperitoneal pressure is reduced to 15 mm Hg. A phragm until the right crus is identified. The crus is then separat-
Hasson cannula can be used in this location, particularly if the ed from the right side of the esophagus by blunt dissection, and
patient has already had one or more midline incisions. Main- the posterior vagus nerve is identified. The right crus is dissected
taining the proper angle (60° to 120°) between the axes of the two inferiorly toward the junction with the left crus.
suturing instruments inserted through ports D and E is also
important: if the angle is smaller, the instruments will cover part Troubleshooting An accessory left hepatic artery originating
of the operating field, whereas if it is larger, depth perception may from the left gastric artery is frequently encountered in the gas-
be impaired. Finally, if a trocar is not in the ideal position, it is bet- trohepatic ligament. If this vessel creates problems of exposure, it
ter to insert another one than to operate through an inconve- may be divided; in my experience, doing so has not caused prob-
niently placed port. lems.When dissecting the right crus from the esophagus, the elec-
If the surgeon spears the epigastric vessels with a trocar, bleed- trocautery should be used with particular caution. Because the
ing will occur, in which case there are two options.The first option monopolar current tends to spread laterally, the posterior vagus
is to pull the port out, insert a 24 French Foley catheter with a 30 nerve may sustain damage simply from being in proximity to the
ml balloon through the site, inflate the balloon, and apply traction device, even when there is no direct contact. The risk of neuro-
with a clamp. The advantage of this maneuver is that the vessel praxia can be reduced by using the cut mode rather than the coag-
ulation mode when the electrocautery is close to the nerve. The
cut mode has problems of its own, however, and is not recom-
mended in most laparoscopic procedures. A better alternative is to
use the ultrasonic coagulating shears.
Step 3: Division of Peritoneum and Phrenoesophageal
Membrane above Esophagus; Identification of Left Crus of
Diaphragm and Anterior Vagus Nerve
The peritoneum and the phrenoesophageal membrane above
the esophagus are divided with the electrocautery, and the anteri-
or vagus nerve is identified. The left crus of the diaphragm is dis-
sected downward toward the junction with the right crus.
A left pneumothorax is usually caused by dissection done above gus but not too tight: a closed grasper should slide easily between
the left crus in the mediastinum rather than between the crus and the esophagus and the crura.
the gastric fundus. This problem can be avoided by properly dis-
secting and identifying the left crus. Troubleshooting The most worrisome complication during
Perforation of the gastric fundus is usually caused by pushing a this step is perforation of the esophagus.This can be prevented by
blunt instrument under the esophagus and below the left crus lubricating the bougie and instructing the anesthesiologist to
without having done enough dissection. Care must be exercised in advance the bougie slowly and to stop if any resistance is encoun-
taking down small vessels from the fundus when the area behind tered. In addition, it is essential to remove any instruments from
the esophagus is approached from the right: the anatomy is not as the esophagogastric junction and to open the Penrose drain; these
clear from this viewpoint, and perforation can easily occur. measures prevent the creation of an angle between the stomach
Sometimes, perforation is caused by the use of a monopolar elec- and the esophagus, which can increase the likelihood of perfora-
trocautery for dissection. An electrocautery burn can go unrecog- tion.The position of the bougie can be confirmed by pressing with
nized during dissection and manifest itself in the form of a leak a grasper over the esophagus, which will feel full when the bougie
during the first 48 hours after operation. is in place.
Step 5: Division of Short Gastric Vessels Step 8:Wrapping of Gastric Fundus around Lower Esophagus
The ultrasonic coagulating shears or the clip applier is intro- The gastric fundus is gently pulled under the esophagus with
duced through port B. A grasper is introduced by the surgeon the graspers. The left and right sides of the fundus are wrapped
through port D, and an assistant applies traction on the greater above the fat pad (which lies above the esophagogastric junction)
curvature of the stomach through port E. Dissection begins at the and held together in place with a Babcock clamp introduced
level of the middle portion of the gastric body and continues through port B. (The Penrose drain should be removed at this
upward until the most proximal short gastric vessel is divided and point because it is in the way.) Usually, three 2-0 silk sutures are
the Penrose drain is reached. used to secure the two ends of the wrap to each other. The first
stitch does not include the esophagus and is used for traction; the
Troubleshooting Again, there are two main problems to second and the third include a bite of the esophageal muscle.The
watch for during this part of the procedure: (1) bleeding, either bougie is passed into the stomach after the first stitch to assess the
from the gastric vessels or from the spleen, and (2) damage to the size of the wrap. If the wrap seems at all tight, the stitch is removed
gastric wall. and repositioned more laterally. Two coronal stitches are then
Bleeding from the gastric vessels is usually caused by excessive placed between the top of the wrap and the esophagus, one on the
traction or by division of a vessel that is not completely occluding right and one on the left. Finally, one additional suture is placed
with clips on both sides. Vessels up to 5 mm in diameter can be between the right side of the wrap and the closed crura.
taken down with the ultrasonic coagulating shears; this process To avoid the risk of injuring the inferior vena cava at the begin-
requires about half of the amount of time needed when only clips ning of the dissection, some surgeons use a different method—the
are used.The lower blade has a sharp, oscillating inferior edge that so-called left crus approach.19 In this approach, the operation
must always be kept in view to prevent damage to other structures begins with identification of the left crus of the diaphragm and
(e.g., the pancreas, the splenic artery and vein, and the spleen). division of the peritoneum and the phrenoesophageal membrane
Damage to the gastric wall can be caused by a burn from the elec- overlying it. The next step is division of the short gastric vessels,
trocautery used to dissect between vessels or by traction applied starting midway along the greater curvature of the stomach and
via the graspers or the Babcock clamp. continuing upward to join the area of the previous dissection.
When the fundus has been thoroughly mobilized, the peritoneum
Step 6: Closure of Crura is divided from the left to the right crus, and the right crus is dis-
The diaphragmatic crura are closed with interrupted 2-0 silk sected downward to expose the junction of the right and left crura.
sutures on a curved needle; the sutures are tied intracorporeally. With this technique, the vena cava is never at risk. In addition, the
Exposure is provided by retracting the esophagus upward and branches of the anterior vagus nerve and the left gastric artery are
toward the patient’s left with the Penrose drain.The lens of the 30° less exposed to danger. This technique can be very useful, partic-
laparoscope is angled slightly to the left by moving the light cable ularly for management of very large paraesophageal hernias and
of the scope to the patient’s right.The first stitch should be placed for second antireflux operations [see Reoperation for GERD,
just above the junction of the two crura. Additional stitches are below].
placed 1 cm apart, and a space of about 1 cm is left between the
uppermost stitch and the esophagus. Troubleshooting To determine whether the wrap is going to
be floppy, the surgeon must deliver the fundus under the esopha-
Troubleshooting Care must be taken not to spear the poste- gus, making sure that the origins of the short gastric vessels that
rior wall of the esophagus with either the tip or the back of the have been transected are visible. Essentially, the posterior wall of
needle. So as not to limit the space available for suturing, the the fundus is being used for the wrap. If the wrap remains to the
bougie is not placed inside the esophagus during this part of the right of the esophagus without retracting back to the left, then it is
procedure. floppy, and suturing can proceed. If not, the surgeon must make
sure that the upper short gastric vessels have been transected. If
Step 7: Insertion of Bougie into Esophagus and through tension is still present after these maneuvers, it is probably best to
Esophagogastric Junction perform a partial wrap [see Laparoscopic Partial (Guarner) Fun-
The esophageal stethoscope and the orogastric tube are doplication, below].
removed, and a 56 French bougie is inserted by the anesthesiolo- Damage to the gastric wall may occur during the delivery of the
gist and passed through the esophagogastric junction under fundus. Atraumatic graspers must be used, and the gastric fundus
laparoscopic vision. The crura must be snug around the esopha- must be pulled gently and passed from one grasper to the other.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 5 MINIMALLY INVASIVE ESOPHAGEAL PROCEDURES — 5
Sometimes, it is helpful to push the gastric fundus under the with swallowing. If part of the body of the stomach rather than
esophagus from the left. The wrap should measure no more than the fundus is used for the wrap, it will not relax as the LES does
2 to 2.5 cm in length and, as noted, should be done with no more on arrival of the food bolus.
than three sutures.The first stitch is usually the lowest one; it must 4. Choice of the wrong procedure. In patients who have severely
be placed just above the fat pad where the esophagogastric junc- abnormal esophageal peristalsis (as in end-stage connective tis-
tion is thought to be. sue disorders), a partial wrap is preferable. A 360° wrap may
If the anesthesiologist observes that peak airway pressure has cause postoperative dysphagia and gas bloat syndrome.
increased (because of a pneumothorax) or that neck emphysema
If the wrap slips into the chest, the patient becomes unable to
is present (because of pneumomediastinum), the pneumoperi-
eat and prone to vomiting. A chest radiograph shows a gastric bub-
toneum should be reduced from 15 mm Hg to 8 or 10 mm Hg
ble above the diaphragm, and the diagnosis is confirmed by means
until the end of the procedure. Pneumomediastinum tends to
of a barium swallow.This problem can be prevented by using coro-
resolve without intervention within a few hours of the end of the
nal sutures and by ensuring that the crura are closed securely.
procedure. Small pneumothoraces (usually on the left side) tend
Paraesophageal hernia may occur if the crura have not been
to resolve spontaneously, rendering insertion of a chest tube
closed or if the closure is too loose. In my opinion, closure of the
unnecessary. Larger pneumothoraces (> 20%), however, call for
crura not only is essential for preventing paraesophageal hernia
the insertion of a small (18 to 20 French) chest tube.
but also is important from a physiologic point of view, in that it
Step 9: Final Inspection and Removal of Instruments and Ports acts synergistically with the LES against stress reflux. Sometimes,
from Abdomen it is possible to reduce the stomach and close the crura laparo-
scopically. More often, however, because the crural opening is very
After hemostasis is obtained, the instruments and the ports are
tight and the gastric wall is edematous, laparoscopic repair is
removed from the abdomen under direct vision.
impossible and laparotomy is preferable.
Troubleshooting If any areas of oozing were observed, they POSTOPERATIVE CARE AND OUTCOME EVALUATION
should be irrigated and dried with sponges rolled into a cigarette-
Postoperative care and outcome evaluation of laparoscopic
like shape before the ports are removed. In addition, if some
Nissen fundoplication are considered elsewhere in conjunction
grounds for concern remain, the oozing areas should be examined
with the discussion of partial fundoplication [see Laparoscopic
after the pneumoperitoneum is decreased to 7 to 8 mm Hg to
Partial (Guarner) Fundoplication, Postoperative Care and Out-
abolish the tamponading effect exerted by the high intra-abdomi-
come Evaluation, below].
nal pressure.
All the ports should be removed from the abdomen under
direct vision so that any bleeding from the abdominal wall can be Laparoscopic Partial (Guarner) Fundoplication
readily detected. Such bleeding is easily controlled, either from
inside or from outside. PREOPERATIVE EVALUATION AND OPERATIVE PLANNING
OUTCOME EVALUATION
who underwent myotomy and Dor fundoplication.27
The initial results of laparoscopic fundoplication obtained in 2. The extension of the myotomy onto the gastric wall (clearly the
the early 1990s indicated that the operation was effective in con- most critical and challenging part of the operation) proved dif-
trolling reflux but that postoperative dysphagia occurred more ficult because of poor exposure, with the consequent risk of a
often than had been anticipated.8 Many experts thought that this short myotomy and persistent dysphagia. With the laparoscop-
problem could be avoided by tailoring the fundoplication to the ic approach, in contrast, excellent exposure of the esophagogas-
strength of esophageal peristalsis as measured by esophageal tric junction is easily achieved, and the myotomy can be extend-
manometry.8 Accordingly, partial fundoplication (240°) was rec- ed onto the gastric wall for about 2 to 2.5 cm.4
ommended for patients with impaired peristalsis, and total fundo- 3. Double-lumen endotracheal intubation and single-lung ventila-
plication (360°) was recommended for those with normal peri- tion were required, with the patient in the right lateral decubi-
stalsis. The short-term results of this tailored approach were tus position. In contrast, the setting for a laparoscopic myotomy
promising.8 Gradually, however, it became evident that partial (the same as that for a laparoscopic fundoplication) is much
fundoplication was not as durable as total fundoplication9 and that easier for the patient, the anesthesiologist, and the OR person-
total fundoplication did not pose a special problem for patients nel. In addition, most surgeons have by now acquired substan-
with weak peristalsis.25 tial experience with laparoscopic antireflux procedures and thus
Long-term follow-up of patients operated on in accordance are more familiar and comfortable with laparoscopic exposure
with the tailored approach at UCSF between October 1992 and of the distal esophagus and the esophagogastric junction.
December 1999 indicated that the promising short-term results 4. The average postoperative hospital stay was about 3 days
reported earlier8 were not maintained over time.20 After a mean because of the chest tube left in place at the time of the opera-
follow-up period of 70 months, 56% of the patients who under- tion and the discomfort arising from the thoracic incisions.
went partial fundoplication had recurrent reflux as documented After a laparoscopic Heller myotomy, the hospital stay is only 1
by pH monitoring, compared with only 28% of those who under- or 2 days; there is no need for a chest tube, and patients are
went total fundoplication. (These figures probably overestimate more comfortable.
the real incidence of postoperative reflux, in that most of the
Because of these drawbacks, left thoracoscopic myotomy is now
patients studied had heartburn and very few were asymptomatic.)
largely reserved for patients with achalasia who have undergone
In addition, more of the patients in the partial fundoplication
multiple abdominal operations (which may rule out a laparoscop-
group needed acid-suppressing medication (25% versus 8%) or a
ic approach). A laparoscopic Heller myotomy and Dor fundopli-
second operation (9% versus 3%).The incidence of postoperative
cation is considered the procedure of choice for achalasia.
dysphagia, however, was the same in the two groups, which indi-
cated that the completeness of the wrap played no role in causing PREOPERATIVE EVALUATION
this largely transient complication.These findings suggest that the
initial problems with postoperative dysphagia were primarily All candidates for a laparoscopic Heller myotomy should
attributable to unknown technical factors that were largely elimi- undergo a thorough and careful evaluation to establish the diag-
nated from the procedure as surgeons garnered more experience nosis and characterize the disease.28
with it. As a result, total fundoplication is currently considered the An upper GI series is useful. A characteristic so-called bird’s
procedure of choice for patients with GERD, regardless of the beak is usually seen in patients with achalasia. A dilated, sigmoid
strength of their esophageal peristalsis. esophagus may be present in patients with long-standing achala-
sia. A corkscrew esophagus is often seen in patients with diffuse
esophageal spasm. Endoscopy is performed to rule out a tumor
Laparoscopic Heller Myotomy with Partial Fundoplication of the esophagogastric junction and gastroduodenal pathologic
conditions.
Minimally invasive surgical procedures for primary esophageal
Esophageal manometry is the key test for establishing the diag-
motility disorders (achalasia, diffuse esophageal spasm, and nut-
nosis of esophageal achalasia.The classic manometric findings are
cracker esophagus) yield results that are comparable to those of
(1) absence of esophageal peristalsis and (2) a hypertensive LES
open procedures but are associated with less postoperative pain
that fails to relax appropriately in response to swallowing.
and with a shorter recovery time.26 Today, laparoscopic Heller
Ambulatory pH monitoring should always be done in patients
myotomy with partial fundoplication has supplanted left thoraco-
who have undergone pneumatic dilatation to rule out abnormal
scopic myotomy as the procedure of choice for esophageal achala-
gastroesophageal reflux. In addition, pH monitoring should be
sia.4-7 Long-term studies demonstrated that even though left tho-
performed postoperatively to detect abnormal reflux, which, if
racoscopic myotomy led to resolution of dysphagia in about 85%
present, should be treated with acid-reducing medications.28
to 90% of patients, it had the following four drawbacks.
In patients older than 60 years who have experienced the recent
1. Gastroesophageal reflux developed postoperatively in about onset of dysphagia and excessive weight loss, secondary achalasia
60% of patients because no fundoplication was performed in or pseudoachalasia from cancer of the esophagogastric junction
conjunction with the myotomy.4 With the laparoscopic should be ruled out. Endoscopic ultrasonography or computed
approach, in contrast, a partial fundoplication can easily be per- tomography can help establish the diagnosis.29
formed, which prevents reflux in the majority of patients4,5 and
corrects many instances of preexisting reflux arising from pneu- OPERATIVE PLANNING
matic dilatation.4 A prospective, randomized, double-blind clin- Patient preparation (i.e., anesthesia, positioning, and instru-
ical trial that compared Heller myotomy alone with Heller mentation) is identical to that for laparoscopic fundoplication.
myotomy and Dor fundoplication clearly demonstrated that the
addition of a fundoplication is essential: the incidence of post- OPERATIVE TECHNIQUE
operative reflux (as measured by pH monitoring) was 47.6% in Many of the steps in a laparoscopic Heller myotomy are the same
patients who underwent myotomy alone but only 9.1% in those as the corresponding steps in a laparoscopic fundoplication. The
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 5 MINIMALLY INVASIVE ESOPHAGEAL PROCEDURES — 7
Line of Myotomy perforation is a concern, the esophagus can be covered with water
from outside while air is insufflated from inside; bubbling will be
observed over the site of any perforation present.
Anterior Vagus Nerve At the beginning of a surgeon’s experience with laparoscopic
Heller myotomy, intraoperative endoscopy is a very important
and helpful step; however, once the surgeon has gained adequate
experience with this procedure and has become familiar with the
relevant anatomy from a laparoscopic perspective, it may be
omitted.
Esophagogastric
Junction
2 to 2.5 cm
Delayed esophageal leakage, usually resulting from an electro- Figure 8 Laparoscopic Heller myotomy with anterior partial
cautery burn to the esophageal mucosa, may occur during the first fundoplication (Dor procedure). The second and third stitches in
24 to 36 hours after operation.The characteristic signals are chest the second row incorporate only the fundus and the right side of
pain, fever, and a pleural effusion on the chest x-ray. The diagno- the esophageal wall.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 5 MINIMALLY INVASIVE ESOPHAGEAL PROCEDURES — 10
point where most referring physicians currently regard surgery as Troubleshooting Before the inferior pulmonary ligament is
the preferred treatment.32 divided, the inferior pulmonary vein must be identified to prevent
a life-threatening injury to this vessel. If oxygen saturation decreas-
es, particularly in patients with lung disease, the retractor should
Left Thoracoscopic Myotomy be removed and the lung inflated intermittently.
risk is particularly high in patients who have undergone pneumat- Table 2—Results of Thoracoscopic Myotomy
ic dilatation or injection of botulinum toxin, both of which may in 30 Patients with Achalasia4
lead to the replacement of muscle layers by scar tissue and the con-
sequent loss of the regular planes. Perforations recognized in the
Results Patients (% of Total)
OR can be repaired by thoracoscopic intracorporeal suturing or, if
this fails, by thoracotomy and open repair. The gastric fundus can Excellent (no dysphagia) 21 (70)
be used to buttress the repair. If it is unclear whether a perforation
has occurred, the esophagus should be covered with water and air Good (dysphagia < once/wk) 5 (17)
insufflated through the endoscope as described earlier [see Lapa-
roscopic Heller Myotomy with Partial Fundoplication, Operative Fair (dysphagia > once/wk) 3 (10)
Technique, Step 7, above]. Poor (persistent dysphagia) 1 (3)
Step 6: Insertion of Chest Tube and Removal of Thoracoports
A 24 French angled chest tube is inserted under direct vision mal. On the whole, this procedure is technically simpler than a left
through port D or port E. The ports are removed under direct thoracoscopic myotomy: because there is no need to go through
vision, and the thoracic wall is inspected for bleeding. the esophagogastric junction, perforation, postoperative dysphagia,
and abnormal gastroesophageal reflux are largely prevented.
COMPLICATIONS
proximally to the thoracic inlet.The endoscope plays a less critical to manometry and pH monitoring, a barium swallow is essential
role than in a left thoracoscopic myotomy because the esophagus to define the anatomy of the esophagogastric junction. A study
is easily identified and because the myotomy is not extended from the University of Washington35 found that the anatomic con-
through the esophagogastric junction. Instead, a 52 to 56 French figurations observed could be divided into three main types: (1)
bougie is placed inside the esophagus; this facilitates division of the type I hernia, in which the esophagogastric junction was above the
circular fibers and separates the edges of the myotomy nicely. diaphragm (subdivided into type IA, with both the esophagogas-
tric junction and the wrap above the diaphragm, and type IB, with
COMPLICATIONS
only the esophagogastric junction above the diaphragm); (2) type
A delayed esophageal leak is the most common postoperative II hernia, a paraesophageal configuration; and (3) type III hernia,
complication. It should be handled as described earlier [see in which the esophagogastric junction was below the diaphragm
Laparoscopic Heller Myotomy with Partial Fundoplication, and there was no evidence of hernia but in which the body of the
Complications, above]. stomach rather than the fundus was used for the wrap. In 10% of
patients, however, the cause of the failure could not be identified
POSTOPERATIVE CARE
preoperatively.33
The postoperative course of patients who have undergone this Some patients present with a mix of postprandial bloating, nau-
procedure is usually identical to that of patients operated on for sea, and diarrhea.These symptoms may be the result of damage to
achalasia. the vagus nerves. Radionuclide evaluation of gastric emptying
often helps quantify the problem.
OUTCOME EVALUATION
Long-term follow-up has confirmed the excellent results initial- OPERATIVE PLANNING
ly obtained for diffuse esophageal spasm with either a thoraco- Patient preparation (i.e., anesthesia, positioning, and instru-
scopic or a laparoscopic approach.26,33 The results for nutcracker mentation) for a reoperation for reflux is identical to that for the
esophagus, however, have been disappointing: a number of initial laparoscopic fundoplication.
patients have experienced postoperative dysphagia and recurrent
chest pain. In my view, the optimal treatment of nutcracker esoph- OPERATIVE TECHNIQUE
agus remains uncertain. The results of operative management are I routinely attempt a second antireflux operation laparoscopi-
less predictable with nutcracker esophagus than with other cally, but if the dissection does not proceed smoothly, I convert to
esophageal disorders, and chest pain often is not alleviated.33 a laparotomy. To provide a stepwise technical description that
would be suitable for all reoperations for reflux is impossible
Reoperation for GERD because the optimal procedure depends on the original approach
(open versus laparoscopic), the severity of the adhesions, and the
At the UCSF Swallowing Center, an increasing number of specific technique used for the first operation (total or partial fun-
patients are being seen for evaluation and treatment of foregut doplication).The key goals of reoperation for reflux are as follows.
symptoms after laparoscopic antireflux surgery.These patients are
treated as follows. 1. To dissect the wrap and the esophagus away from the crura.
This is the most difficult part of the operation.The major com-
PREOPERATIVE EVALUATION plications seen during this part of the procedure are damage to
Some degree of dysphagia, bloating, and abdominal discomfort the vagus nerves and perforation of the esophagus and the gas-
is common during the first 6 to 8 weeks after a fundoplication. If tric fundus.
these symptoms persist or heartburn and regurgitation occur, a 2. To take down the previous repair. The earlier repair must be
thorough evaluation (with barium swallow, endoscopy, esophageal completely undone and the gastric fundus returned to its natur-
manometry, and pH monitoring) is carried out with the aim of al position. If the short gastric vessels were not taken down dur-
answering the following three questions: ing the first procedure, they must be taken down during the
second.
1. Are the symptoms attributable to persistent gastroesophageal 3. To dissect the esophagus in the posterior mediastinum so as to
reflux? have enough esophageal length below the diaphragm and avoid
2. Are the symptoms attributable to the fundoplication itself? placing tension on the repair.
3. Can the cause of the failure of the first operation be identified 4. To reconstruct the cardia. The same steps are followed as for a
and corrected by a second operation? first-time repair. If, after extensive esophageal mobilization, the
Many patients report heartburn after a fundoplication. It is often esophagogastric junction remains above the diaphragm (short
assumed that this symptom must be the result of a failed operation esophagus), esophageal lengthening can be accomplished by
and that acid-reducing medications should be restarted. In most adding a thoracoscopic Collis gastroplasty to the fundoplication.
cases, however, this assumption is mistaken: postoperative pH To date, however, I have never found this step to be necessary.
monitoring yields abnormal results in only about 20% of patients.34
COMPLICATIONS
The value of manometry lies in its ability to document the changes
caused by the operation at the level of the LES and the esophageal Because the risk of gastric or esophageal perforation or damage
body. The pH monitoring assesses the reflux status and determines to the vagus nerves is much higher during a second antireflux oper-
whether there is a correlation between symptoms and actual ation, the surgeon must be ready to convert to a laparotomy if the
episodes of reflux. If abnormal reflux is in fact present, the thera- dissection is too cumbersome or the structures are not properly
peutic choice is between medical therapy and a second operation. identified. Most perforations are recognized and repaired intraop-
Other patients complain of dysphagia arising de novo after the eratively. Leaks manifest themselves during the first 48 hours.
operation. This symptom is usually attributable to the operation Peritoneal signs are noted if the spillage is limited to the abdomen;
itself and may occur in the absence of abnormal reflux. In addition shortness of breath and a pleural effusion are noted if spillage also
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 5 MINIMALLY INVASIVE ESOPHAGEAL PROCEDURES — 14
occurs in the chest.The site of the leak should always be confirmed stomach, thereby constricting the myotomy. In one patient, the
by means of a contrast study with barium or a water-soluble agent. short gastric vessels had not been taken down, and the body
Perforation is best handled with laparotomy and direct repair of the of the stomach rather than the fundus had been used for the
leak. fundoplication.
3. Transmural scarring caused by previous treatment. In patients
OUTCOME EVALUATION
treated with intrasphincteric injection of botulinum toxin, trans-
Whereas the success rate is around 80% to 90% for a first mural fibrosis can sometimes be found at the level of the esoph-
antireflux operation, it falls to 70% to 80% for a second such agogastric junction. This unwelcome finding makes the myoto-
operation. In my view, a second operation should be attempted by my more difficult and the results less reliable.
an expert team only if medical management fails to control heart-
There are two treatment options for persistent or recurrent dys-
burn or pneumatic dilatation has not relieved dysphagia.
phagia after Heller myotomy: (1) pneumatic dilatation and (2) a
second operation tailored to the results of preoperative evaluation.
Reoperation for Esophageal Achalasia In a 2002 study,36 pneumatic dilatation was successfully used to
treat seven of 10 patients who experienced dysphagia postopera-
Laparoscopic Heller myotomy improves swallowing in more
tively; of the remaining three patients, two required a second oper-
than 90% of patients. What causes the relatively few failures
ation and one refused any treatment.
reported is still incompletely understood.Typically, a failed Heller
In the UCSF study just cited,31 however, pneumatic dilatation
myotomy is signaled either by persistent dysphagia or by recurrent
was effective in only one of the eight patients in whom it was tried.
dysphagia that develops after a variable symptom-free interval fol-
That patient was the one with a short distal myotomy; none of the
lowing the original operation.
four patients with dysphagia resulting from a poorly constructed
A complete workup (routinely including barium swallow,
Dor fundoplication derived any benefit. In two patients who had
endoscopy, manometry, and pH monitoring) is required before
a short proximal myotomy, the myotomy was successfully extend-
treatment is planned. In addition, it is my practice to review the
ed to the inferior pulmonary vein through a left thoracoscopic
video of the first operation to search for technical errors that might
approach. Of the four patients with a constricting Dor fundopli-
have been responsible for the poor outcome. Such errors typically
cation, two underwent a second operation during which the Dor
fall into one of the following three categories.
was taken down, and one of these two had a second myotomy.
1. A myotomy that is too short either distally or proximally. If the Currently, both patients are free of dysphagia; however, they expe-
myotomy is too short distally, a barium swallow shows persis- rience abnormal reflux and are being treated with acid-reducing
tent distal esophageal narrowing and manometry shows a resid- medications.
ual high-pressure zone. If the myotomy is too short proximally, Reoperation for achalasia is a technically challenging proce-
it will be apparent from the barium swallow. dure. It is of paramount importance to avoid perforating the
2. A constricting Dor fundoplication. Often, manometry and pH exposed esophageal mucosa during the dissection. A small hole
monitoring yield normal results, but a barium swallow shows can be repaired, but a larger laceration might necessitate an
slow passage of contrast media from the esophagus into the esophagectomy. This option should always be discussed with the
stomach. In one study from UCSF,31 problems with Dor fun- patient before the operation.
doplications occurred in four (4%) of 102 patients. Analysis of Overall, about 10% of patients have some degree of dysphagia
the video records of the first operations showed that in three of after a Heller myotomy. Pneumatic dilatation, a second operation,
the four patients, all the stitches in the right suture row had or both should always be tried before a radical procedure such as
incorporated the esophagus, the right pillar of the crus, and the esophagectomy is decided on.
References
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Minimally invasive surgery for achalasia: an 8 year 1993
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therapy versus diagnostic tests in gastroesophageal 16. Fuchs KH, DeMeester TR, Albertucci M:
1999
reflux disease: a medical decision analysis. Dig Dis Specificity and sensitivity of objective diagnosis of
5. Zaninotto G, Costantini M, Molena D, et al: Sci 43:1001, 1998 gastroesophageal reflux disease. Surgery 102:575,
Treatment of esophageal achalasia with laparo- 11. Johnsson F, Joelsson B, Gudmundsson K, et al: 1987
scopic Heller myotomy and Dor partial anterior Symptoms and endoscopic findings in the diagno- 17. Patti MG, Arcerito M,Tamburini A, et al: Effect of
fundoplication: prospective evaluation of 100 con- sis of gastroesophageal reflux disease. Scand J laparoscopic fundoplication on gastroesophageal
secutive patients. J Gastrointest Surg 4:282, 2000 Gastroenterol 22:714, 1987 reflux disease–induced respiratory symptoms. J
6. Ackroyd R, Watson DI, Devitt PG, et al: Laparo- 12. Patti MG, Diener U, Tamburini A, et al: Role of Gastrointest Surg 4:143, 2000
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 5 MINIMALLY INVASIVE ESOPHAGEAL PROCEDURES — 15
18. Diener U, Patti MG, Molena D, et al: Esophageal 25. Oleynikov D, Eubanks TR, Oelschlager BK, et al: ures. Arch Surg 136:870, 2001
dysmotility and gastroesophageal reflux disease. J Total fundoplication is the operation of choice for 32. Patti MG, Fisichella PM, Perretta S, et al: Impact
Gastrointest Surg 5:260, 2001 patients with gastroesophageal reflux and defective of minimally invasive surgery on the treatment of
19. Horgan S, Pellegrini CA: Surgical treatment of peristalsis. Surg Endosc 16:909, 2002 esophageal achalasia: a decade of change. J Am
gastroesophageal reflux disease. Surg Clin North 26. Patti MG, Pellegrini CA, Arcerito M, et al: Coll Surg 196:698, 2003
Am 77:1063, 1997 Comparison of medical and minimally invasive 33. Patti MG, Gorodner MV, Galvani C, et al: The
20. Patti MG, Robinson T, Galvani C, et al:Total fun- surgical therapy for primary esophageal motility spectrum of esophageal motility disorders: impli-
doplication is superior to partial fundoplication disorders. Arch Surg 130:609, 1995 cations for diagnosis and treatment. Arch Surg (in
even when esophageal peristalsis is weak. J Am 27. Richards WO, Torquati A, Holzman MD, et al: press)
Coll Surg 198:863, 2004 Heller myotomy versus Heller myotomy and Dor 34. Lord RVN, Kaminski A, Oberg S, et al: Absence of
21. Patterson EJ, Herron DM, Hansen PD, et al: fundoplication for achalasia: a prospective ran- gastroesophageal reflux disease in a majority of
Effect of an esophageal bougie on the incidence of domized, double-blind clinical trial. Ann Surg patients taking acid suppression medications after
dysphagia following Nissen fundoplication: a 240:405, 2004 Nissen fundoplication. J Gastrointest Surg 6:3,
prospective, blinded, randomized clinical trial. 28. Patti MG, Diener U, Molena D: Esophageal acha- 2002
Arch Surg 135:1055, 2000 lasia: preoperative assessment and postoperative 35. Horgan S, Pohl D, Bogetti D, et al: Failed antire-
22. Guelrud M, Rossiter A, Souney PF, et al: The follow-up. J Gastrointest Surg 5:11, 2001 flux surgery: what have we learned from reopera-
effect of vasoactive intestinal polypeptide on the 29. Moonka R, Patti MG, Feo CV, et al: Clinical pre- tions? Arch Surg 134:809, 1999
lower esophageal sphincter in achalasia. Gas- sentation and evaluation of malignant pseudo- 36. Zaninotto G, Costantini M, Portale G, et al:
troenterology 103:377, 1992 achalasia. J Gastrointest Surg 3:456, 1999 Etiology, diagnosis and treatment of failures after
23. Tottrup A, Svane D, Forman A: Nitric oxide medi- 30. Watson DI, Liu JF, Devitt PG, et al: Outcome of laparoscopic Heller myotomy for achalasia. Ann
ating NANC inhibition in opossum lower esoph- laparoscopic anterior 180-degree partial fundopli- Surg 235:186, 2002
ageal sphincter. Am J Physiol 260:G385, 1991 cation for gastroesophageal reflux disease. J
24. Champion JK, Delisle N, Hunt T: Laparoscopic Gastrointest Surg 4:486, 2000
esophagomyotomy with posterior partial fundopli- 31. Patti MG, Molena D, Fisichella PM, et al: Acknowledgment
cation for primary esophageal motility disorders. Laparoscopic Heller myotomy and Dor fundopli-
Surg Endosc 14:746, 2000 cation for achalasia: analysis of successes and fail- Figures 1 through 13 Tom Moore.
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4 THORAX 6 CHEST WALL PROCEDURES — 1
Chest wall procedures are an important component of any tho- maximum voluntary ventilation.3 In a study that compared 37
racic surgeon’s practice. The approach to these procedures is patients who had undergone surgical repair of pectus excavatum
somewhat different from the approach to esophageal or pul- both with normal persons and with persons who had uncorrected
monary resections and requires specific knowledge of thoracic deformities, no differences in physical working capacity among the
musculoskeletal anatomy, as well as of the different types of autol- three groups were noted.4 Other studies have reported improve-
ogous and artificial grafts available for chest wall reconstruction. ments in exercise tolerance and regional ventilation and perfusion
Broadly, chest wall procedures may be divided into those per- after surgical repair of pectus excavatum.5,6 On the other hand,
formed to treat congenital chest wall disease and those done to some investigators have reported decreases in pulmonary function
treat acquired disease. In what follows, I describe the major surgi- in symptomatic patients after corrective surgery. One group attrib-
cal techniques in both categories and review the pitfalls that may uted this result to overly aggressive resection in very young pa-
accompany them. tients that led to growth restriction of the chest wall; accordingly,
they recommended delaying surgical repair until 6 to 8 years of
age.7
Procedures for Congenital Chest Wall Disease Severe pectus excavatum has also been reported to cause car-
Congenital chest wall defects arise from abnormal development diac dysfunction secondary to sternal compression of the right
of the sternum, the costal cartilages, and the ribs. Such defects ventricle. Several early studies found stroke volume and cardiac
include pectus excavatum (funnel chest), pectus carinatum (pigeon output to be lower in exercising upright patients than in supine
chest), cleft sternum, and Poland syndrome (absence of the breast patients.8,9 However, improvement in cardiac function after pectus
and the underlying pectoralis muscle and ribs). Of these, pectus excavatum repair has not been universally documented. In one
excavatum is by far the most common, accounting for more than study, first-pass radionuclide angiocardiography failed to show
90% of all congenital chest wall procedures; accordingly, the ensu- any improvements in left ventricular function after repair of pec-
ing discussion focuses on the surgical aspects of pectus excavatum tus excavatum.10 At present, there is no consensus on the car-
repair. diopulmonary benefits of pectus excavatum repair, and the major
reasons for surgical treatment are still patient discomfort and dis-
REPAIR OF PECTUS EXCAVATUM
satisfaction with appearance.
Preoperative Evaluation Operative Technique
Because pectus excavatum occurs in varying degrees of severi- A number of different procedures have been employed to treat
ty, patients may seek surgical treatment for any of a number of dif- pectus excavatum, but for present purposes, I focus on (1) the
ferent reasons, such as shortness of breath, early fatigue with exer- Ravitch procedure (and variations thereof) and (2) the Nuss pro-
cise, or simple dissatisfaction with their appearance. Thus, one of cedure. For historical reasons, the turnover technique, originally
the most important tasks for surgeons treating pectus excavatum described by Judet and Judet11 and later employed by Wada,12
is determining which patients are candidates for operative man- warrants a brief mention. Wada’s series included 199 patients
agement. In an attempt to facilitate this determination, the Con- whose deformities were corrected with a version of this technique;
genital Heart Surgery Nomenclature and Database Project has good results were achieved in 63% of patients, and there were only
developed a classification system for pectus excavatum, in which a three instances of partial sternal necrosis. Today, however, the
deformity less than 2 cm in depth is classified as mild, a deformi- turnover technique is rarely used because of the good results that
ty 2 to 3 cm in depth is classified as moderate, and a deformity can be achieved with techniques that do not carry a risk of sternal
greater than 3 cm in depth is classified as severe.1 A computed necrosis. It is usually reserved for extreme cases of pectus excava-
tomography–based index has also been devised, in which the tum, which often include deformities of the sternum in addition
transverse chest diameter is divided by the anteroposterior diam- to abnormalities of the costal cartilages.
eter; an index greater than 3.2 is considered indicative of severe
disease.2 Ravitch procedure Repair of pectus excavatum is based on
These classification attempts notwithstanding, the precise indi- the principle that the deformity is secondary to abnormal growth
cations for surgery remain unclear. Many studies have attempted of the costal cartilages. Accordingly, correction involves (1) resec-
to show that the depressed sternum leads to pulmonary compro- tion of the abnormal cartilages, (2) a transverse anterior sternal
mise, but for the most part, these studies have had small sample osteotomy to allow anterior displacement of the sternum, and (3)
sizes and have employed differing measures of lung function, both sternal fixation to prevent posterior displacement after the repair.
of which have made accurate comparisons difficult. In one study Most of the variations in the Ravitch procedure have to do with
that included 25 United States Air Force personnel with symp- the use of different sternal fixation techniques.
tomatic pectus excavatum, lung volumes were comparable to
those in normal persons, but there was a significant difference in Step 1: initial incision and exposure. Either a midline incision or a
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4 THORAX 6 CHEST WALL PROCEDURES — 2
a
Costal
c Cartilages
Edge of Reflected
Pectoralis Major
b Sternum
bilateral inframammary incision is made [see Figure 1a, b]; the latter The posterior plane between the cartilage and the perichondrium is
incision yields superior cosmetic results, especially in female pa- then developed in one area, and the cartilage is divided with a scalpel
tients, but necessitates the elevation of large subcutaneous skin flaps between the jaws of a right-angle clamp [see Figure 2b]. The cut end
to the level of the angle of Louis or the sternal notch superiorly and of the cartilage is grasped with a clamp, and the rest of the cartilage
to the xiphoid process inferiorly. The pectoralis muscles are then is dissected from the perichondrium. Once the correct plane is
mobilized from the chest wall, beginning medially and proceeding established, the dissection can be facilitated by gently pushing the
laterally until the costal cartilages are exposed [see Figure 1c]. perichondrium off the cartilage with a finger. The entire cartilage
should be removed from the sternum to the rib, with every attempt
Step 2: resection of abnormal cartilages. For each abnormal costal made to maintain the integrity of the perichondrium. During this
cartilage, the anterior perichondrium is scored with the electro- part of the procedure, the xiphoid process is also detached from the
cautery along the length of the cartilage, and the cartilage is dissect- sternum.The extent of cartilage removal depends on the individual
ed from the perichondrium with a periosteal elevator [see Figure 2a]. defect present but usually includes the third rib.
a b
Figure 2 Repair of pectus excavatum: Ravitch procedure. (a) The anterior perichondrium is opened,
and the abnormal cartilage is dissected free with a periosteal elevator. (b) The cartilage is divided.
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4 THORAX 6 CHEST WALL PROCEDURES — 3
c
b 1 1
2 2
3 3
4
4
5
6 5
7
30°–35° 6
Figure 3 Repair of pectus 7
excavatum: Ravitch procedure. After
Before
re
(a) An osteotomy is made in
the upper sternum. (b) The
sternum is angled anteriorly;
when the desired angle is
reached, the osteotomy is
closed. (c) Shown is a lateral
view of the sternal angle before
and after correction. Osteotomy Closure
with Thumb Pressure
Step 3: sternal osteotomy. An osteotomy is made in the upper the defect. The bar that will be used for the repair is shortened to
anterior table of the sternum with either a periosteal elevator or a a length equivalent to the measured distance between the two
small reticulating bone saw [see Figure 3a], and the posterior table midaxillary lines minus 1 cm. A complex series of bends are then
of the sternum is fractured.The sternum can then be angled ante- placed in the bar to match its contours to those of the patient’s
riorly. When the desired angle is reached, the osteotomy is closed deformity.
with three interrupted nonabsorbable sutures or with microplates
and screws [see Figure 3b, c]. At this point, rotational sternal de- Step 2: initial incisions and creation of intrathoracic tunnel. In-
fects can be corrected by making anterior and posterior lateral cisions are made in the right and left midaxillary lines at the level
osteotomies on either side of the sternum and then closing the of the marks, and a subcutaneous flap is raised from each inci-
osteotomies with sutures or microplates. sion and extended to the defect. A Crawford vascular clamp or a
Step 1: configuration of bar. The patient is placed in the supine Figure 4 Repair of pectus excavatum: Ravitch pro-
position with the arms abducted, and marks are made on either cedure. Sternal fixation is accomplished through
side of the chest at spots that correspond to the deepest point of placement of a retrosternal bar.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 6 CHEST WALL PROCEDURES — 4
Outcome Evaluation
In general, the results of pectus excavatum repair are good, and
the overall complication rate is low. In one study, 90% of 76 pa-
tients operated on over a 30-year period experienced excellent
outcomes, and only one patient required reoperation for a recur-
rent defect.14 The incidence of complications (pleural effusions,
pneumonia, and wound seromas) was 14%.14 In another study, no
operative deaths occurred in more than 800 repairs, and only a few
cases of serious infections and bleeding were reported.16 Other
investigators have reported rare complications arising from the
migration of sternal support bars and wires.17
a b
Figure 6 Repair of pectus excavatum: Nuss procedure. (a) The pectus bar is pulled into the tunnel
opened by the vascular retractor, then flipped to provide the desired chest contour. (b)The ends of the
bar are then sutured to the chest wall musculature.
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4 THORAX 6 CHEST WALL PROCEDURES — 5
a b
Figure 8 Transaxillary first rib resection. (a) The anterior portion of the first rib is cut. (b) The anterior
scalene muscle is then divided.
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4 THORAX 6 CHEST WALL PROCEDURES — 6
Osteotome the rib. Alternatively, the intercostal bundle can be doubly ligated
and divided at the anterior resection margin. Once the intercostal
vessels are cleared from the lowest rib, the electrocautery is used to
divide the pleura below the rib toward the anterior boundary of the
resection.The rib is then divided with a rib cutter, with care taken
to ensure a margin of at least 5 cm from the tumor [see Figure
10]. Next, the intercostal bundle of the next higher rib is li-
gated and divided, the intercostal muscle is divided with the elec-
trocautery, and the rib is cut with a rib cutter in the same manner
as the previous rib. This process is repeated until the anterior
boundary of resection is completed. A subperiosteal plane is then
developed over the highest rib to be resected, the adjacent inter-
costal bundle is separated from the rib, and the parietal pleura is
divided with the electrocautery.
a Polypropylene Methylmethacrylate
Mesh Layers Layer between
Polypropylene Layers b
struction is warranted (as in anterior reconstruction); it not only tion resulting from the use of synthetic material. In particular, radi-
provides added protection of pleural and mediastinal structures ation injury may involve all layers of the chest wall, necessitating
but also creates a better cosmetic effect by recreating the shape of very large resections [see Figure 13a]. Muscle or omental flaps with
the chest wall. split-thickness skin grafts may be required for coverage; thus, pre-
To create the polypropylene-methylmethacrylate sandwich, two operative consultation with an experienced plastic surgeon is
pieces of polypropylene mesh are cut to the size of the defect. A advisable. A particular concern is what to use to reconstruct the
thin layer of methylmethacrylate cement is spread on one of the chest wall. Various tissues (e.g., fascia lata and ribs) have been
mesh pieces, and the other piece is then applied over the methyl- employed, but an easier substitute that works quite well is an
methacrylate layer. As this sandwich begins to harden, it is mold- absorbable synthetic mesh (e.g., Vicryl). The mesh is sewn to the
ed to the contours of the chest wall, with care taken to protect the ribs as previously described [see Step 6, above], and the tissue flap
patient’s skin against injury from the heat given off by the harden- is placed on top of the mesh, followed by a skin graft [see Figure
ing cement.When the sandwich is sufficiently hardened, it is sewn 13b, c]. Alternatively, some authors recommend the use of muscle
to the ribs with 0 polypropylene sutures [see Figure 12a]. The or myocutaneous flaps without rigid chest wall reconstruction
sutures may be passed around the uppermost and lowermost ribs after resection, particularly in infected fields.19
and may be placed directly through the anterior and posterior
margins [see Figure 12b]. If rib disarticulation was required to com- Outcome evaluation The results achieved after major chest
plete the posterior margin, holes may be drilled in the transverse wall resection have generally been excellent. One study reviewed
processes and the sutures passed through these holes; alternative- 200 patients who underwent resection and reconstruction over a
ly, the sandwich may be sutured to the paraspinal ligament. 25-year period.20 The reconstructions ranged from relatively
If polypropylene or Gore-Tex mesh is used without cement, it straightforward two-rib resections to more complex forequarter
should be cut to a size smaller than that of the defect. Thus, the amputations. The indications for resection were lung cancer
mesh will effectively be stretched when it is sutured to the chest (38%), osteoradionecrosis (29%), chest wall tumor (27%), and
wall, and any laxity in the reconstruction will thereby be alleviated. osteomyelitis (16%). Immediate reconstruction was performed in
98% of patients. The major muscle flaps utilized were latissimus
Step 7: closure and drainage. The serratus anterior and the latis- dorsi (20%), rectus abdominis (17%), pectoralis major (16%), and
simus dorsi are closed in the standard fashion, as are the subcuta- serratus anterior (9%). Free flaps were utilized in only 9% of cases,
neous and skin layers. With the exception of pleural tubes, drains and split-thickness skin grafts were required in 12% of patients.
are not routinely used. Special attention should be paid to postop- Reconstruction was performed with Prolene mesh (25%), Marlex
erative analgesia: patients who have undergone extensive resec- mesh (11%),Vicryl mesh (6%), or a polypropylene-methylmetha-
tions often experience considerable pain and are therefore prone crylate sandwich (6%). Operative mortality was 7%, and major
to atelectasis and pneumonia. Epidural analgesia should be em- morbidity occurred in 24% of patients. Most of the morbidity was
ployed routinely in such cases. accounted for by pneumonia (14%) and acute respiratory distress
syndrome (6%).
Troubleshooting If chest wall infection is a possibility (as
with osteoradionecrosis or osteomyelitis), alternative reconstruc- Manubrial and Clavicular Resection
tive techniques are required to obviate concerns about superinfec- Resection of the manubrium or the clavicle may be necessary if
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 6 CHEST WALL PROCEDURES — 9
a b
c
Figure 13 Chest wall resection. The presence of
osteoradionecrosis may necessitate very large
resections and resulting defects (a). Such defects
may be covered with absorbable mesh (b), followed
by an omental flap (c) or a muscle flap.
a b
advancement flap or, if skin was excised, a pedicled pectoralis space is opened with the electrocautery, any pus present is
myocutaneous flap. A pleural drain may be placed if either pleural drained, and the chest cavity is manually and visually explored.
space was entered, but this measure is not routinely employed. Next, 6 to 8 cm segments of two or three adjacent ribs are resect-
ed according to the same principles employed for other chest wall
Open Chest Drainage (Eloesser Flap) resections. The resulting thoracostomy is large enough to permit
Open drainage procedures are usually included in discussions drainage and packing.The skin overlying this thoracostomy is then
of treatment of empyema, but they really represent a type of chest marsupialized to the thickened parietal pleura with absorbable
wall resection. Open drainage techniques for empyema were first sutures [see Figure 15]. If the pleura does not possess sufficient
described in the late 1800s by Poulet and subsequently by Schede. integrity to hold the sutures, they can be placed through the
Graham, who headed the Army Empyema Commission during periosteum of the ribs.
World War I, is credited with the observation that ensuring pleu-
ral-pleural symphysis was the key to preventing the often fatal Step 3: packing and drainage. The wound is irrigated with nor-
complication of pneumothorax.22 Indications for open chest drain- mal saline and packed with saline-moistened gauze. Postopera-
age include postpneumonectomy empyema or bronchopleural tively, a chest x-ray should be obtained to rule out pneumothorax,
fistula, long-standing empyema in a patient who cannot undergo and twice- to thrice-daily packing is initiated. Packing is continued
decortication, and chronic bronchopleural fistula in a high-risk on an outpatient basis, and the wound is monitored. The wound
patient. will begin to close over the next several weeks. If the empyema or
bronchopleural fistula has not healed by the time the wound starts
Operative technique The technique currently employed by closing, the thoracostomy will have to be revised. In some cases,
most thoracic surgeons follows Symbas’s modification of Eloesser’s this can be accomplished merely by manually dilating the opening
open drainage technique.23 This procedure has come to be known in the operating room; in others, the entire thoracostomy must be
as the Eloesser flap. Preoperative chest CT is essential for identi- revised. In either case, the goal is to maintain a large enough open-
fying the exact location of the empyema, which determines the ing to allow adequate packing.
placement of the incision.
Step 4: closure of thoracostomy. Once the lung and the pleural
Step 1: initial incision and exposure. The patient is placed in the space have healed, the thoracostomy is closed. The procedure for
decubitus position, and a 6 to 8 cm incision is made over the area closing the thoracostomy depends on the size and nature of the
corresponding to the most dependent area of the infected cavity. remaining defect [see Figure 16a]. For small defects, simple closure
Symbas employed a U-shaped incision; however, a simple linear of the skin will suffice. For larger defects or residual spaces in the
incision can also be used with good results.The subcutaneous tis- pleura, however, muscle flap closure will be required [see Figure
sue and muscle are then divided down to the chest wall with the 16b]. Improvements in radiographic techniques and greater
electrocautery. emphasis on early intervention for empyemas have significantly
reduced the need for open chest drainage; however, this technique
Step 2: resection of ribs and creation of thoracostomy. The pleural can still be valuable in the appropriate clinical situation.
References
1. Backer CL, Mavroudis C: Congenital heart 8. Bevegard S: Postural circulatory changes at rest tum. Chest Surg Clin N Am 10:277, 2000
surgery nomenclature and database project: vascu- and during exercise in patients with funnel chest, 17. Stefani A, Morandi U, Lodi R: Migration of pec-
lar rings, tracheal stenosis, pectus excavatum. Ann with special reference to the influence on the tus excavatum correction metal support into the
Thorac Surg 69(4 suppl):S308, 2000 stroke volume. Acta Physiol Scand 49:279, 1960 abdomen. Eur J Cardiothorac Surg 14:434, 1998
2. Haller JA, Kramer Ss, Lietman SA: Use of CT 9. Gattiker H, Buhlmann A: Cardiopulmonary func- 18. Urschel HC: The transaxillary approach for
scans in selection of patients for pectus excava- tion and exercise tolerance in supine and sitting treatment of thoracic outlet syndrome. Chest
tum surgery: a preliminary report. J Pediatr Surg position in patients with pectus excavatum. Helv Surg Clin N Am 9:771, 1999
22:904, 1987 Med Acta 33:122, 1967
19. Arnold PG, Pairolero PC: Use of pectoralis
3. Weg JG, Krumholz RA, Harkleroad LE: Pul- 10. Peterson RJ, Young WG Jr, Godwin JD, et al: major muscle flaps to repair defects of anterior
monary dysfunction in pectus excavatum. Am Rev Noninvasive assessment of exercise cardiac func- chest wall. Plast Reconstruct Surg 63:105, 1979
Respir Dis 96:936, 1967 tion before and after pectus excavatum repair. J
20. Mansour KA, Thourani VH, Losken A, et al:
Thorac Cardiovasc Surg 90:251, 1985
4. Gyllensward A, Irnell L, Michaelsson M, et al: Chest wall resections and reconstruction: a 25-
Pectus excavatum: a clinical study with long 11. Judet J, Judet R: Sternum en entonnoir par resec- year experience. Ann Thorac Surg 73:1720, 2002
term postoperative follow-up. Acta Paediatr tion et retournement. Mem Acad Chir 82:250,
21. Song HK, Guy TS, Kaiser LR, et al: Current
255(suppl): 2, 1975 1956
presentation and optimal surgical management
5. Cahill JL, Lees GM, Robertson HT: A summary 12. Wada J, Ikeda K, Ishida T, et al: Results of 271 of sternoclavicular joint infections. Ann Thorac
funnel chest operations. Ann Thorac Surg 10: Surg 73:427, 2002
of preoperative and postoperative cardiorespira-
526, 1970 22. Somers J, Faber LP: Historical developments in
tory performance in patients undergoing pectus
excavatum and carinatum repair. J Pediatr Surg 13. Robicsek F, Cook JW, Daugherty HK, et al: the management of empyema. Chest Surg Clin
19:430, 1984. Pectus carinatum. J Thorac Cardiovasc Surg 78: N Am 6:404, 1996
52, 1979 23. Symbas PN, Nugent JT, Abbott OA, et al: Nontu-
6. Blickman JG, Rosen PR, Welch KJ, et al: Pectus
excavatum in children: pulmonary scintigraphy 14. Mansour KA, Thourani VH, Odessey EA, et al: berculous pleural empyema in adults. Ann Thorac
before and after corrective surgery. Radiology Thirty-year experience with repair of pectus Surg 12:69, 1971
156:781, 1985 deformities in adults. Ann Thorac Surg 76:391,
2003
7. Haller JA, Colombani PM, Humphries CT, et al: Acknowledgment
Chest wall constriction after too extensive and 15. Hebra A: Minimally invasive pectus surgery.
too early operations for pectus excavatum. Ann Chest Surg Clin N Am 10:329, 2000 Figures 1 through 8, 10 through 12, 14, and 15 Alice
Thorac Surg 61:1618, 1996 16. Robicsek F: Surgical treatment of pectus excava- Y. Chen.
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4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 1
7 VIDEO-ASSISTED THORACIC
SURGERY
Raja M.Flores, M.D., Bernard Park, M.D., andValerieW.Rusch, M.D., F.A.C.S.
The technique of thoracoscopy was first described in 1910 by Ja- has not been fully established, within the context of well-designed
cobeus, a Swedish physician who used a cystoscope to examine the clinical trials.
pleural space.1 Although thoracoscopy was initially performed for In particular, questions remain about the oncologic soundness of
diagnostic purposes, it later evolved into a therapeutic procedure. some VATS procedures. It appears that levels of cytokines and other
During the 1930s and 1940s, it was used to lyse intrapleural adhe- acute-phase reactants are lower with minimally invasive procedures
sions after collapse therapy for tuberculosis. During the 1950s, when than with the corresponding open procedures.13,14 However, it re-
effective antituberculous chemotherapy became available, thora- mains to be determined whether this decrease will ultimately result
coscopy fell into disuse in the United States2; however, it remained in decreased tumor growth or reduced recurrence rates. Rigorous
popular in Europe, where it was employed in diagnosing and treat- evaluation is needed to determine how VATS may be most appro-
ing problems such as pleural effusion, empyema, traumatic hemo- priately and safely employed in cancer patients.
thorax, persistent air leak after pulmonary resection, and sponta-
neous pneumothorax.3-5 During the 1970s and 1980s, a few North
American surgeons revived the practice of thoracoscopy, both to Operative Planning
manage pleural disease and to perform small peripheral lung biop-
POSITIONING AND PORT PLACEMENT
sies in patients with diffuse pneumonitis.
In the first stages of its revival, thoracoscopy was often per- Patient preparation and positioning are much the same for
formed with open endoscopes that were originally designed for most VATS procedures. As a rule, the lateral decubitus position
other procedures (e.g., mediastinoscopes).6,7 As optics and light- offers the best exposure, and it permits easy conversion to a tho-
ing systems improved, smaller-caliber endoscopes were created racotomy if necessary.There are occasional exceptions to this rule,
specifically for thoracoscopic applications8; however, these instru- however, and in such cases the choice of position is dictated by the
ments were limited, in that only one person could visualize the procedure planned. For instance, if a cervical mediastinoscopy or
operative field at a given time. In 1991, the application of video a Chamberlain procedure is being performed for lung cancer stag-
technology to thoracoscopy revolutionized the procedure because ing and the pleura must be examined to rule out the presence of
it allowed several persons to see the operative field simultaneous- metastases, the patient can be left in the supine position and the
ly and to operate together as they would during an open proce- videothoracoscope introduced through the parasternal incision or
dure. In addition, the development of endoscopic instruments, a separate inferior incision.15
particularly endoscopic staplers, enabled surgeons to perform Port placement, the use of so-called access incisions (utility tho-
major operations using minimally invasive techniques.The impact racotomies), and instrumentation may vary from one procedure
of this new technology was so profound that within a 2-year peri- to the next. In approximately 20% of patients undergoing VATS,
od, traditional thoracoscopic techniques were abandoned in favor intraoperative conversion to a standard thoracotomy will be nec-
of video-assisted thoracic surgery (VATS).9,10 essary for any of several reasons, including extensive pleural adhe-
In what follows, therefore, we focus on current VATS proce- sions and pulmonary lesions that cannot be located thoracoscop-
dures rather than on traditional thoracoscopic techniques. There ically or that necessitate a more extensive resection than can be
are numerous accepted diagnostic and therapeutic indications for accomplished endosurgically. With experience, one can learn to
VATS [see Table 1]. Accordingly, there are numerous operations predict the likelihood of such conversion in a given case. It is
that can be performed by VATS; we describe the most important important to discuss this possibility with the patient before oper-
of these, with the exception of esophageal myotomy and fundo- ation and to obtain informed consent to conversion. Any patient
plication, which are covered elsewhere [see 4:5 Minimally Invasive who is likely to require conversion to a thoracotomy or who may
Esophageal Procedures]. In addition, we describe the application of be undergoing lobectomy or pneumonectomy should receive the
telerobotics to VATS lobectomy. cardiopulmonary evaluation that is usual for such procedures
A major force that drives surgeons to perform VATS proce- before VATS is performed.
dures has been patient demand. Unfortunately, the application of
ANESTHESIA AND MONITORING
VATS has not always been accompanied by careful evaluation of
outcomes. Feasibility has sometimes been confused with success. VATS procedures are performed with the patient under general
Although VATS appears to have beneficial effects in terms of anesthesia. Very limited operations (e.g., pleural biopsies) can be
cosmesis and postoperative pain in the short term, it has not yet done with a single-lumen endotracheal tube in place, but most pro-
been proved to have beneficial effects on pulmonary function and cedures should be performed with single-lung ventilation using a
a return to normal activity in the long term.11,12 It is therefore the double-lumen endotracheal tube or a bronchial blocker.The degree
responsibility of thoracic surgeons to perform these procedures of intraoperative monitoring needed depends on the extent of the
selectively rather than indiscriminately, either in settings where the planned procedure and on the patient’s general medical condition.
effectiveness of VATS is clearly proved or, where the role of VATS Standard monitoring techniques (including pulse oximetry) are al-
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 2
ways used, but arterial lines are placed selectively. A central venous
catheter or a Swan-Ganz catheter is inserted only when the patient’s Table 1—Indications and Contraindications
baseline cardiac status demands precise hemodynamic monitoring.
A Foley catheter is inserted at the beginning of all VATS procedures
for VATS Procedures
to monitor urine output because it is not always possible to predict Diagnostic indications
how long the operation will take or whether conversion to thoracoto- Undiagnosed pleural effusion
my will prove necessary. Indeterminate pulmonary nodule
Undiagnosed interstitial lung disease
INSTRUMENTATION Pulmonary infection in the immunosuppressed patient
Instrumentation for VATS comprises (1) video equipment, (2) To define cell type in known thoracic malignancy
To define extent of a primary thoracic tumor
endoscopes and thoracoports, (3) staplers, (4) thoracic instru-
Nodal staging of a primary thoracic tumor
ments (e.g., lung clamps and retractors) modified for endoscopic Diagnosis of intrathoracic pathology to stage a primary extrathoracic
use, and (5) various devices for tissue cauterization, including tumor
lasers. Because immediate conversion to thoracotomy is occasion- Evaluation of intrapleural infection
ally necessary, a basic set of thoracotomy instruments should be Therapeutic indications
an integral part of a VATS instrument tray.16 Lung
Spontaneous pneumothorax
Video Equipment Bullous disease
Minor variations in lighting and optics aside, the basic compo- Lung volume reduction
nents of all video systems used for thoracoscopy are similar: a Persistent parenchymal air leak
Benign pulmonary nodule
large-screen (21 in.) video monitor, a xenon light source, a video
Resection of pulmonary metastases (in highly selected cases)
recorder, and a printer for still photography, mounted together on Resection of primary lung tumor (in highly selected cases)
a cart. A second video monitor, also mounted on a cart, is con- Mediastinum
nected by cable to the main monitor and is placed across from it Drainage of pericardial effusion
at the head of the operating table.Thus, both the surgeon and the Excision of bronchogenic or pericardial cyst
first assistant are able to look directly at a video display without Resection of selected primary mediastinal tumors
having to turn away from the surgical field. Alternatively, a single Esophageal myotomy
monitor can be placed at the head of the operating table.The only Facilitation of transhiatal esophagectomy
? Resection of primary esophageal tumors
additional item of equipment necessary for laparoscopy is an
? Thymic resection
insufflator. Therefore, to maximize cost-efficiency, hospitals
Ligation of thoracic duct
acquiring video monitors and endoscopes should coordinate the Pleura
choice of this expensive equipment among the specialties using it, Drainage of a multiloculated effusion
including thoracic surgery, general surgery, gynecology, and urol- Drainage of an early empyema
ogy. Hospitals performing many endoscopic procedures may find Pleurodesis
it advisable to dedicate one or more rooms to video endoscopic Contraindications
surgery and to mount video equipment on the ceilings or walls. Extensive intrapleural adhesions
Inability to sustain single-lung ventilation
Endoscopes and Thoracoports Extensive involvement of hilar structures
Some procedures are performed with a forward-viewing (0º) rigid Preoperative induction chemotherapy or chemoradiotherapy
scope; however, 30º angled scopes are useful for visualizing the sulci Severe coagulopathy
and the superior and posterior mediastinum and provide better over-
all visualization of the pleural space. In addition to the standard 10
mm thoracoscopes, there are 5 mm thoracoscopes whose resolution patients undergoing thoracoscopy are under general anesthesia
is nearly as good.The scope is attached to the light source by a light and have a double-lumen endotracheal tube in place, the cannu-
cable and is coupled to the video-monitor system by a camera cable las need not maintain an airtight seal, as they do in laparoscopy.
[see Figure 1]. Although camera cables can be sterilized, it is best to Accordingly, thoracoports, which are shorter than laparoscopy
cover the camera head and cable with a clear plastic bag so that the cannulas and have a corkscrew configuration on the outside that
cable can remain in the OR at all times.Videoscopes are now avail- stabilizes them within the chest wall, are routinely used. The tro-
able in which the camera chip is located at the tip of the scope rather car is simply a blunt-tip obturator that facilitates passage of the
than in the connecting camera cable; these are replacing the endo- cannula through the chest wall [see Figure 2a]. Thoracoports are
scopes previously used because they provide a sharper image. For available in several sizes (5, 10.5, 12, and 15 mm in diameter) to
complex procedures (e.g.,VATS lobectomy), we currently use a 30° accommodate various instruments.
rotating scope, which allows better orientation and visualization
around structures such as the pulmonary artery and bronchus. Flex- Staplers
ible thoracoscopes, which look like a short, heavy version of a flexible Endoscopic staplers that cut between two simultaneously
bronchoscope but have a more rigid distal end, are also available. applied triple rows of staples (gastrointestinal anastomosis [GIA]
Some surgeons feel that flexible thoracoscopes enhance their ability staplers) are available in lengths of 30 and 60 mm and in staple
to visualize the entire pleural space, but these devices are very expen- depths of 2.0, 2.5, 3.5, and 4.8 mm [see Figure 2b]. Like their
sive and continue to be premium purchases for most hospitals. counterparts designed for open procedures, they are disposable
Originally, thoracoscopy made use of trocar cannulas designed multicartridge instruments. The endoscopic GIA stapler with 2.0
for laparoscopy to access the pleural space. However, these devices and 2.5 mm staples is designed for division of pulmonary vessels.
are too long and have sharp ends that can injure the lung. Because Some surgeons are reluctant to use it on hilar vessels because if the
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 3
0° Rigid Scope
Detachable Camera
Cable
stapler fails mechanically (e.g., cuts without applying both staple the staple line with prosthetic materials (e.g., Gore-Tex; W. L.
lines properly), life-threatening hemorrhage can ensue. Endoscopic Gore, Boulder, Colorado) to reduce postoperative air leakage in
staplers that do not cut (transverse anastomosis [TA] staplers) are patients with emphysematous lung tissue.
also available. Although they have been largely supplanted by endoscopic GIA
Some advocate using two applications of the endovascular sta- staplers, standard stapling instruments can also be used during
pling device to minimize the risk of transecting the vessel as a con- some VATS procedures. They are unnecessary for most pul-
sequence of a stapling misfire. In this approach, the stapler is first monary wedge resections but may be helpful for more complex
fired proximally with the knife removed, leaving six rows of staples procedures (e.g., lobectomies). Standard GIA staplers and articu-
in place. Next, the stapler is fired again more distally with the cut- lated rotating TA staplers (Roticulator; AutoSuture, Norwalk,
ting mechanism intact to transect the vessel, leaving a total of nine Connecticut) are the most practical devices for VATS because they
rows of staples on the patient side and three rows of staples on the can be inserted and positioned through an access incision.
specimen side.
Endoscopic GIA staplers have revolutionized surgeons’ ability Instruments
to perform minimally invasive pulmonary resections. These Various types of Pennington and Duval clamps are available [see
devices are highly reliable and provide excellent hemostasis and Figure 2c]. Sponge sticks modified by the introduction of various
closure of air leaks. There are also stapler cartridges that buttress curves and a line of DeBakey-type teeth on the end can also be
a b
m
10 .5 m
Endoscopic Gastrointestinal
Anastomosis Stapler
Thoracoscopic Port
d
Curved Sponge Stick
Figure 2 Shown are instruments commonly used during VATS. Modified trocar cannulas, called thoracoports
(a), facilitate access to the pleural space. They are shorter than the cannulas used in laparoscopy and have a
corkscrew configuration on the outside that maintains their position on the chest wall. The trocar is a blunt-
tipped plastic obturator that facilitates passage of the cannula through the chest wall. A thin plastic diaphragm
stabilizes the position of the instruments or can be removed to facilitate access to the pleural space.
Endoscopic GIA staplers that make incisions between two triple rows of staples (b) can be inserted through
these ports. Like staplers designed for open procedures, endoscopic GIA staplers are disposable multifire
instruments that hold three replacements of the staple cartridge. Another instrument that can be inserted
through these ports is the nondisposable endoscopic lung clamp (c), which is available in various shapes with
serrations at the end or along the full length of the clamp. Finally, the port allows insertion of curved sponge
sticks (d), which have been modified for endoscopic use as lung clamps or lymph node holders.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 4
used as lung clamps or lymph node holders [see Figure 2d]. and pass a monofilament suture to the tip of the instrument. A
Several retractors have been developed for endoscopic sur- polyp forceps is an excellent instrument for holding and retract-
gery. One such device is a modified Finochietto retractor with ing lymph nodes during a mediastinal lymph node dissection
long, narrow blades, which is particularly helpful for retracting (MLND). Because polyp forceps have a slightly curved configu-
the chest wall soft tissues in an access incision. Others are the ration and a blunt tip, they can also be used to dissect around hilar
disposable vein retractor [see Figure 3a], the tip of which can be vessels.
withdrawn into the straight instrument shaft, and the fan retrac- Although biopsy forceps have been specifically created for
tor, which can be opened and closed like a fan by turning a knob laparoscopy and thoracoscopy, those used for mediastinoscopy
on the end of the retractor [see Figure 3b]. Of these, the fan are, in fact, well suited for thoracoscopy. Because laparoscopy
retractor is the most useful general retractor for thoracoscopic instruments were developed before thoracoscopy instruments,
procedures.Vein retractors are best suited for gentle retraction of many types of grasping forceps are available; however, most are
hilar or mediastinal structures (e.g., vessels, bronchi, esophagus, too traumatizing for thoracic surgery. DeBakey forceps, modi-
or lymph nodes). fied for endoscopic use, are the gentlest type available. Various
In major VATS procedures (e.g.,VATS lobectomy), the soft tis- curved and right-angle dissecting clamps, needle holders, and
sues of the access incision may be retracted by means of a cere- scissors have been developed [see Figure 4]. In addition, stan-
bellar (or Weitlaner) retractor.This measure allows the surgeon to dard thoracotomy instruments can be inserted through a
encircle the hilar vascular structures by using two instruments minithoracotomy incision and used just as they would be in an
simultaneously through the same incision. A Harken clamp is use- open procedure.
ful, in that it is long enough to reach behind a vascular structure
Devices for Tissue Cauterization
Most scissors have an electrocautery attachment that permits si-
a multaneous cutting and cauterizing.The neodymium:yttrium-alu-
minum-garnet (Nd:YAG) laser is sometimes applied to VATS resec-
Angled Dissecting Clamp
tion of pulmonary lesions. This is done by inserting the YAG
laser-fiber through angled or straight handpieces [see Figure 5].
Laser-assisted pulmonary resection is helpful in removing lesions on
the flat surface of the lung, where a stapler cannot be easily applied.17
The argon beam electrocoagulator (ABC) (ConMed Corpor-
ation, Utica, New York) is a noncontact form of electrocautery that
b provides superb hemostasis on raw surfaces (e.g., denuded pul-
monary parenchyma or the chest wall after pleurectomy) and helps
Curved Dissecting Clamp seal air leaks from the surface of the lung.18 The standard dispos-
able ABC handpiece used for open procedures is narrow enough
to pass through a thoracoport and thus may be used for VATS.The
optional Bend-a-Beam handpiece is extremely useful in VATS
c lobectomy because it allows the surgeon to shape the shaft of the
instrument for easier coagulation of hard-to-reach areas.
Scissors
YAG Laser
Fiber
Figure 4 Various right-angle (a) and curved (b) dissecting Angled Hand Piece
clamps are available. On the angled model shown (a), the knob
close to the handle rotates the shaft of the clamp 360º. Many Figure 5 Shown is an angled handpiece through which an yttri-
types of endoscopic scissors (c) are also available. Some scissors um-aluminum-garnet (YAG) laser can be placed during VATS. The
incorporate an attachment for an electrocautery so that the sur- handpiece is narrow enough to be used during thoracoscopy as
geon can cut and cauterize simultaneously. well as during open procedures.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 5
Instrumentation for videothoracoscopy continues to evolve, posterior axillary line at the seventh or eighth intercostal space.
especially as minimally invasive cardiac surgical procedures Instruments are introduced through two thoracoports: one is
become commonplace. Nevertheless, to put together the best set placed at approximately the fifth intercostal space in the anteri-
of instruments, it still is necessary to combine disposable and or axillary line, and the other is placed at the fifth space, parallel
nondisposable instruments from different manufacturers and to to and about 2 to 3 cm away from the posterior border of the
borrow instruments originally designed for other procedures. scapula [see Figure 6a]. If the procedure is converted to a thora-
Rather than create separate instrument trays for different VATS cotomy, the two upper incisions can be incorporated into the
procedures, it is best to maintain a single standard tray that thoracotomy incision and the lower incision can be used as a
includes the basic instruments required for most operations and to chest tube site. When a patient is being operated on for an api-
add instruments as needed. Again, this tray should also include the cal lesion (e.g., bullae causing a spontaneous pneumothorax)
instruments needed for conversion to thoracotomy. [see Figure 6b], the camera port can be placed at the fifth or sixth
intercostal space, and the two instrument ports may also be
moved higher, with one in the axilla and the other higher on the
Basic Operative Technique posterior chest wall at approximately the third intercostal space.
VATS procedures include both true videothoracoscopies and Depending on the location of the lesion being removed, a fourth
video-assisted procedures that are really a cross between videotho- port incision may be helpful to permit the introduction of addi-
racoscopies and standard thoracotomies. Because VATS proce- tional instruments.
dures are still evolving, there is no firm consensus among surgeons When the lung must be palpated so that a small or deep-seated
with respect to the number, size, and location of incisions. lesion can be located or when complex video-assisted procedures
The basic videothoracoscopy techniques have been well are being performed, a small (4 cm) intercostal incision is added
described.19 The primary strategy is to place the instruments and to the three port incisions.This utility thoracotomy, or access inci-
the thoracoscope so that all are oriented in the same direction, fac- sion, is usually placed in the midaxillary line or in the auscultatory
ing the target disease within a 180º arc [see Figure 6]; this posi- triangle. An infant Finochietto retractor or a Weitlaner retractor is
tioning prevents mirror imaging. The incisions should also be used to retract the soft tissues without actually spreading the ribs
placed widely distant from each other so that the instruments do [see Figure 7].
not crowd one another. These basic concepts regarding incision placement are modi-
For most procedures, the videothoracoscope is inserted fied as necessary to accommodate the procedure being performed
through a thoracoport placed between the midaxillary and the and the location of the lesion being removed (see below).
a b
Stapler
Retractor
Grasper
Camera Camera
Figure 6 Basic operative technique. Shown is the typical positioning of instruments and the
video camera for patients undergoing VATS for a lesion in the superior segment of the left lower
lobe of the lung. Instruments are introduced through two port incisions made anteriorly at
approximately the fifth intercostal space in the anterior axillary line and posteriorly parallel to
and 2 to 3 cm away from the border of the scapula (a). For patients undergoing thoracoscopy for
apical bullous disease in the left upper lobe of the lung, the camera port can be placed at the fifth
or sixth intercostal space; one instrument port can be inserted in the axilla and the other port
inserted higher on the posterior chest wall at approximately the third intercostal space (b).
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 6
by VATS may not affect survival significantly.30 This conclusion, VATS database at the Memorial Sloan-Kettering Cancer Center
however, is completely at odds with all of the previously published (MSKCC) found only one case of port-site recurrence.33 The
surgical literature on pulmonary metastasectomy performed via authors concluded that the incidence of such recurrences can be
thoracotomy. Improved survival in patients with pulmonary kept low if surgical oncologic principles are respected. At MSKCC,
metastases appears to be directly linked to the ability to remove all these principles include (1) reserving VATS for lesions that can be
gross tumor, and VATS does not allow the careful bimanual pal- widely excised; (2) conversion to an open thoracotomy for defini-
pation that is critical to detecting pulmonary metastases that are tive or extensive operations; and (3) meticulous technique for
too small or too deep to be visible endoscopically.30-32 Accordingly, extraction of specimens from the pleural space, with small speci-
most centers reserve VATS for diagnosis rather than treatment of mens removed directly through a thoracoport and larger speci-
pulmonary metastases. Until a well-designed prospective, ran- mens removed in specimen bags.
domized trial is conducted with survival as an end point, the stan-
OPERATIVE TECHNIQUE
dard of care remains thoracotomy and metastasectomy.
Anecdotal reports of port-site recurrence have also raised con- Once general anesthesia has been induced and a double-lumen
cerns about VATS as a treatment method in patients with malig- endotracheal tube inserted, the patient is placed in the full lateral de-
nancies. However, a 2001 study of 410 patients from a prospective cubitus position.Ventilation to the lung being operated on is stopped
as soon as the patient is rotated into the lateral decubitus position, so
that the lung will be thoroughly collapsed by the time the videotho-
racoscope is inserted into the pleural space. Small subpleural pul-
monary nodules are most easily identified in a fully atelectatic lung
because they protrude from the surrounding collapsed pulmonary
parenchyma, which is softer.19,20 Most pulmonary wedge resections
are performed as true videothoracoscopic procedures using just
three port incisions placed in the triangulated manner already de-
scribed [see Basic Operative Technique, above].
The pulmonary nodules to be removed are grasped with an
endoscopic lung clamp (Pennington or Duval) inserted through
one instrument port, and wedge resection is done with repeated
applications of an endoscopic stapler inserted through the oppo-
site port.24,34 As the resection is performed, it is often helpful to
introduce the stapler through each of two instrument ports to
obtain the correct angle for application to the lung [see Figure 8].
To prevent tumor implantation in the chest wall, small speci-
mens (usually those resected with three or fewer stapler applica-
tions) are removed via the thoracoport. Larger specimens are
placed in a disposable plastic specimen retrieval bag, which is
then brought out through a very slightly enlarged anterior tho-
racoport incision.
When the wedge resections have been completed, intercostal
blocks are performed under direct vision with a mediastinoscopy
aspiration needle, and a single chest tube is inserted through the
inferior port after the videothoracoscope is withdrawn.35 The
videothoracoscope can be placed through the anterior incision to
check the position of the chest tube and to confirm reinflation of
the lung after the double-lumen endotracheal tube is unclamped.
The remaining incisions are then closed with sutures.
TROUBLESHOOTING
localization techniques are effective, but they are also costly and VATS Procedures for Spontaneous Pneumothorax and
time-consuming and hence are not used by most surgeons. Bullous Disease
Finally, if careful endoscopic examination of the lung does not
reveal the location of a nodule, an access incision is added to the OPERATIVE TECHNIQUE
videothoracoscopy.24,39 Each lobe of the lung is sequentially rotat- VATS is now frequently performed for the management of
ed up to this non–rib-spreading utility thoracotomy for direct dig- recurrent spontaneous pneumothorax and for bullous disease.41,42
ital palpation. This technique almost always allows identification The approach is similar to that followed in a wedge resection, with
of a nodule when other techniques fail. As the endoscopist gains three or four port sites being utilized. The videothoracoscope is
experience with these techniques, conversion to thoracotomy inserted at the fifth intercostal space in the midaxillary line, and
solely for the purpose of locating a pulmonary nodule is rarely two other port sites are added at the fourth intercostal space in the
necessary.40 anterior and posterior axillary lines.
Pulmonary nodules located on the broad surface of the lung In patients with spontaneous pneumothorax, the responsible
may not be amenable to a wedge resection with an endoscopic bulla (which is usually apical in location) is identified, and wedge
stapler. Such nodules can be removed by means of electrocauter- resection is done with an endoscopic stapler.43,44 Bullae can be
ization, just as in an open thoracotomy. An extension is placed on excised by applying the stapler across the base of the area of bul-
the handle of the electrocautery, which is then introduced into lous disease. They can also be ablated with the ABC or the
the pleural space through either a port or an access incision. Nd:YAG laser, then suture-plicated if necessary; however, this
Another approach is to resect the pulmonary nodule with a laser approach may not be as successful over the long term.45,46
in either a contact or a noncontact mode. The potassium-titanyl- Taking note of the lower rate of recurrence, the shorter hospital
phosphate (KTP)/YAG laser is particularly suited to this task stay, and the relative cost-effectiveness, some surgeons advocate
because it is capable of both cutting and coagulation. To mini- performing VATS for the first episode of spontaneous pneumo-
mize bleeding and air leakage, raw pulmonary surfaces can be thorax.47,48 To justify this approach in patients with primary spon-
cauterized with either the Nd:YAG laser or the ABC.17 taneous pneumothorax, however, well-designed clinical trials
Numerous types of absorbable sealant patches or materials are rather than retrospective reviews will be required.
also available to control air leaks from areas of raw pulmonary
parenchyma. TROUBLESHOOTING
Occasionally, after a wedge resection, it is necessary to suture The placement of port incisions should be determined by the
together the pleural edges over an area of raw pulmonary paren- location of the bullae. Because bullous disease is generally apical,
chyma. The suturing can be done directly through a non–rib- port sites are correspondingly higher than for the average wedge
spreading access incision or through port sites. In the latter case, resection (i.e., at the fourth and sixth intercostal spaces rather than
the ports are removed and a 3-0 polypropylene suture is passed at the fifth or sixth and eighth spaces). The precise placement
through the anterior port site with a standard needle holder. A sec- should, however, be determined by pinpointing the disease site or
ond needle holder is introduced via the posterior port site and sites on the preoperative chest x-ray and CT scans.
used in place of a forceps to pick up and reposition the needle as The main problem after resection for bullous disease is pro-
it is passed through the lung. The surgeon and the first assistant longed leakage of air from the staple line. This problem can be
work together to oversew the lung, in contrast with the normal minimized by applying commercially available sleeves made of
practice for an open procedure, in which the surgeon uses a nee- bovine pericardium or Gore-Tex over the arms of the stapler to
dle holder and a forceps to place the sutures. reinforce the staple line and by performing some form of pleu-
a b c
Pleura
Resection Borderline
Figure 9 VATS procedures for spontaneous pneumothorax and bullous disease. Limited apical pleurectomy is a
useful alternative to chemical pleurodesis in young patients with spontaneous pneumothorax because these
patients may need to undergo thoracotomy later in life. Shown is an outline of the pleural resection (a) performed
in this procedure. The pleura is grasped at the inferior border with forceps and lifted in the avascular layer in a
cranial or ventral direction (b). A T-shaped incision is made in the pleura at the level of the subclavian artery or
the truncus brachiocephalicus. The dissection of the pleural flap thus created is extended in either the ventral or
the parasternal direction and in either the apical or the mediastinal direction (c).
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 9
a b
rodesis. Mechanical pleurodesis is done with a small gauze sponge carefully assessed. If the leak is small, the other side is operated on
passed through a port site. Some surgeons scarify the pleura by in the same setting; if the leak is large, the contralateral procedure
cauterizing it with the ABC or the Nd:YAG laser, but this is not as is put off to a later date. The use of fibrin glue or another com-
successful as mechanical pleurodesis. Chemical pleurodesis by talc mercially available pneumostatic sealant along the staple line should
poudrage is an appropriate option for older patients with emphy- be considered to minimize postoperative air leakage.
sema and bullous disease but is unwise in young patients with
spontaneous pneumothorax, who might require a thoracotomy
later in life.49 Another option in younger patients is a limited api- VATS Lobectomy and Pneumonectomy
cal pleurectomy [see Figure 9]. Special angulated instruments and Although VATS lobectomy is much less frequently performed
blunt dissectors have been designed for this procedure; however, a than VATS pulmonary wedge resection, standard techniques have
parietal pleurectomy is also easily performed with combinations of been developed for it.52 VATS pneumonectomy, on the other
standard blunt and sharp instruments.50 hand, is less well accepted. Both operations are done as video-
assisted procedures using a utility thoracotomy, which facilitates
insertion of standard thoracotomy instruments, extraction of the
VATS Lung Volume Reduction Surgery resected specimen from the pleural space, and performance of the
technically complex aspects of the procedure, including dissection
OPERATIVE TECHNIQUE
of the hilar vessels and the mediastinal lymph nodes.
VATS may also be applied to the performance of lung volume A 1998 retrospective study addressing the adequacy of VATS
reduction surgery (LVRS). If unilateral LVRS is planned, the lobectomy as an oncologic procedure reported on 298 patients
patient is placed in the lateral decubitus position and port place- who underwent VATS lobectomy with MLND for primary
ment is similar to that for a patient undergoing a wedge resection non–small cell lung cancer.53 On the basis of a 70% 4-year survival
of the upper lobe. Most patients undergoing LVRS, however, ben- rate for stage I tumors, the investigators concluded that outcome
efit from bilateral LVRS. For this procedure, the patient is placed after VATS lobectomy is comparable to that after open thoracoto-
in the standard supine bilateral lung transplant position, with my. At 5 years, however, survival rates after VATS are inferior,
shoulder rolls placed vertically in an I fashion behind the back and stage for stage, to the rates generally reported after thoracotomy.
with the arms positioned above the head. The camera port is Such differences could reflect either inaccurate staging or true
placed in the anterior axillary line at the sixth interspace. A lung oncologic differences between VATS and thoracotomy; additional
compression clamp is placed on the area that will be resected. A prospective studies are needed to clarify these issues.
Gore-Tex–reinforced stapler is then inserted into the chest and Although VATS lobectomy has not been proved to be oncolog-
fired sequentially until the desired area is excised [see Figure 10a]. ically sound in the long term, there is good evidence that it is safe
Another approach used to help buttress the tenuous staple line in acute settings.54 Therefore, it should certainly be performed to
in emphysematous lung tissue is lung plication [see Figure 10b].51 treat benign diseases (e.g., bronchiectasis).55 As with all minimal-
In this method, the defunctionalized, bullous lung tissue is stapled ly invasive procedures, conversion to open thoracotomy is indicat-
to itself to form a plicated autologous buttress [see Figure 11]. ed if technical issues require it. Some authors advocate VATS
Because the diseased bullous lung is not cut, the risk of postoper- lobectomy for low-grade malignancies (e.g., carcinoids) as well.56
ative air leakage is minimized. It must be recognized, however, that although carcinoids have a
lower malignant potential than non–small cell lung cancer, they
TROUBLESHOOTING
are still malignancies and must be treated appropriately for opti-
A major cause of morbidity and mortality with this procedure mal long-term outcome.
is the occurrence of air leaks, which sometimes are large enough Two approaches to lobectomy have been developed. One involves
to compromise ventilation significantly. Thus, once LVRS has sequential anatomic ligation of the hilar structures, much as in a
been done on one side, the lung is reexpanded and any air leaks standard lobectomy,57,58 and the other involves mass ligation of the
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 10
a b
Modified
d Lung Clamp
Stapler
c
1 3
2 4
Figure 11 VATS lung volume reduction surgery. Shown are the key steps in the plication method of LVRS.
(a) The apex of the lung area selected for plication is drawn to one side over a lung plication clamp, and the
retractable guidebar of the clamp is extended into position. (b) The clamp is rotated 180º to fold the lung over
itself. (c) The guidebar is retracted, a stapler is positioned with its jaws around the folded lung (but not yet
closed), and the plication clamp is removed. (d) Shown is a cross-section of the folded lung after the stapler has
been positioned but before the clamp has been removed. The stapler is then fired to complete the plication.
pulmonary vessels and the bronchus. Both approaches require at ation of single-lung ventilation, the camera port is placed at the
least two port incisions in addition to the utility thoracotomy inci- eighth interspace in the anterior axillary line (for right-side lesions)
sion. The sequential anatomic ligation approach has been well de- or in the posterior axillary line (for left-side lesions). The posterior
scribed and follows sound surgical oncologic principles.57 Accord- port is then placed where the lower lobe edge touches the diaphragm
ingly, it is our preferred method of performing VATS lobectomy. It (at the ninth or 10th interspace) along the anterior border of the
must be remembered, however, that VATS lobectomy is a procedure paraspinous muscle. A retractor is placed through the posterior port,
for which there is no accepted uniform definition. In a survey aimed and the upper lobe is retracted laterally to allow visualization of the
at defining the criteria used by minimally invasive thoracic surgeons superior pulmonary vein.The utility incision (no longer than 4 cm)
for VATS lobectomy,14 the length of the utility incision ranged from is placed directly over the superior pulmonary vein for upper lobec-
4 to 10 cm, the number of incisions ranged from three to five, and tomies (at approximately the third or fourth interspace) and one in-
the use of rib spreading was variable. In an effort to standardize the terspace lower for middle and lower lobectomies. A Weitlaner (or
approach at our own institution (MSKCC), we define a VATS cerebellar) retractor is used to retract the soft tissues, and there is no
lobectomy as an anatomic dissection that is performed entirely un- need for rib spreading. A rotating 30º videothoracoscope is always
der thoracoscopic visualization, proceeds in an anterior-to-posterior used for these procedures.
fashion, employs a 4 cm utility incision, involves absolutely no rib
spreading, and uses two thoracoscopy ports (one for the camera and Right-side resections Right upper lobe. The superior pul-
one for retraction). Our definition also includes nodal evaluation (ei- monary vein is dissected from the overlying pleura via the access
ther sampling or dissection) of levels 4, 7, and 9 on the right and lev- incision with long Metzenbaum scissors and DeBakey forceps,
els 5, 6, 7, and 9 on the left. much as in an open lobectomy. A Harken clamp is passed behind
the superior pulmonary vein after clear identification of the mid-
OPERATIVE TECHNIQUE
dle lobe vein. The superior pulmonary vein is encircled with a
monofilament tie and retracted upward via the utility incision. An
Lobectomy (Sequential Anatomic Ligation) empty sponge stick is then placed through the utility incision, and
Positioning and port placement Correct positioning and the upper lobe is retracted posteriorly. An endovascular stapler is
port placement are essential for a successful VATS lobectomy.The placed through the posterior port and, with the suture as a guide,
patient is placed in the maximally flexed lateral decubitus position to passed behind the superior pulmonary vein.
prevent the hip from impeding downward movement of the thoraco- Once the pulmonary vein has been divided, the anterior and
scope.Tilting the hip posteriorly, especially in obese patients, greatly apical segmental branches of the pulmonary artery are visualized.
increases the range of movement of the thoracoscope. After the initi- The level 10 lymph nodes are removed. A Harken clamp is passed
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 11
around the anterior and apical pulmonary arterial branches, and a endoscopic GIA stapler introduced via the access incision.The bi-
monofilament suture is passed around them and brought out furcation of the left upper and left lower lobe bronchi is identified,
through the utility incision. The endovascular stapler is passed and the left upper lobe bronchus is transected with an endoscopic
though the posterior port and used to transect the vessels. GIA stapler with 4.8 mm staples introduced via the posterior port.
Transection of the truncus artery branch exposes the right upper An empty sponge stick is then used to retract the stump of the
lobe bronchus. Dissection is performed to separate the ongoing bronchus laterally, which facilitates exposure of several branches of
pulmonary artery from the bronchus. A monofilament suture is the pulmonary artery, including the lingular artery.These branches
passed around the bronchus and brought out through the utility are transected individually via the posterior port.The fissure is then
incision. An endoscopic GIA stapler with 4.8 mm staples is placed completed by passing an endoscopic GIA stapler with 4.8 mm sta-
through the posterior port, and the right upper lobe bronchus is ples via the posterior port.
transected. This step exposes the branch of the pulmonary artery
to the posterior segment of the right upper lobe, which is tran- Left lower lobe. The lower lobe is retracted superiorly, the infe-
sected in the same manner through the posterior port. rior pulmonary ligament is transected, and level 9 lymph nodes
Once all the structures to the upper lobe have been divided, the are removed. Once the inferior pulmonary vein has been dissect-
fissure is assessed. A lung clamp placed through the posterior port is
ed free, an endoscopic GIA vascular stapler is placed via the utili-
used to retract the middle and lower lobes inferiorly, and a second
ty incision to transect the vessel. The lower lobe bronchus is
lung clamp placed through the utility incision is used to retract the
exposed from its inferior aspect to its bifurcation with the upper
upper lobe superiorly. Once the fissure is exposed, a long curved
lobe bronchus. The bronchus is left intact until the pulmonary
sponge stick is used to elevate the right upper lobe, and an endo-
scopic GIA stapler with 4.8 mm staples is passed through the utility artery to the lower lobe is exposed medially and superiorly from
incision to complete both minor and major fissures.The lobe is then the overlying fissure. After the pulmonary artery has been ade-
placed in a large surgical tissue pouch and removed via the utility quately exposed, the bronchus is transected with an endoscopic
incision. GIA stapler with 4.8 mm staples placed via the utility incision.The
Certain basic surgical concepts—dissection of hilar structures, pulmonary artery is then transected via the utility incision, and the
passage of a monofilament suture around the structure, and tran- fissure is completed via the posterior port. In cases with a very
section with a stapler—are similar for all lobectomies. However, thick incomplete fissure, the fissure between the lingula and lower
the order in which structures are transected and the ports through lobe should be opened before dissection of the pulmonary artery
which staplers are passed differ. to facilitate subsequent arterial exposure.
Lobectomy (Mass Ligation)
Right lower lobe. The lower lobe is retracted superiorly, the
inferior pulmonary ligament is transected, and the level 9 lymph The mass ligation method, or so-called SIS (simultaneous indi-
nodes are removed. Once the entire inferior pulmonary vein has vidual stapling) lobectomy, has also been used for VATS lobecto-
been dissected, a stapler is placed via the utility incision to transect my.59 Four incisions are made: an incision for the camera port at
the vessel. The lower lobe bronchus is exposed from its inferior the seventh intercostal space, a 2 cm incision in the midaxillary
aspect to its bifurcation with the middle lobe bronchus. The line at the sixth intercostal space for the insertion of staplers, and
bronchus is left intact until the pulmonary artery to the right lower two 3 cm incisions at the fourth intercostal space in the anterior
lobe is exposed medially and superiorly from the overlying fissure. and posterior axillary lines for the insertion of additional instru-
Once the pulmonary artery has been adequately exposed, the ments. In the initial report of this technique, the bronchus and the
bronchus is transected with a 4.8 mm universal stapler placed pulmonary vessels were ligated separately, but the vessels were sta-
through the utility incision. The pulmonary artery is then tran- pled en masse.60 Subsequently, the technique was refined so that
sected via the utility incision, followed by the fissure. the bronchus and the vessels were stapled simultaneously by
applying the stapler twice, the first time loosely to obtain closure
Right middle lobe. With the middle lobe retracted laterally, the of the bronchus and the second time more tightly to obtain hemo-
pleura overlying the middle lobe vein is incised. Once dissection of
static closure of the vessels.
the vein is complete, the vessel is transected with an endovascular
Although the early results of SIS lobectomy were satisfactory,61
stapler placed via the posterior port, and the middle lobe bronchus
concerns arose about the long-term risks of bronchovascular or
is exposed.The bronchus is encircled with a monofilament suture,
arteriovenous fistula formation resulting from mass ligation of the
and an endoscopic GIA stapler with 3.5 mm staples is placed via
hilar structures. Consequently, this approach has not gained wide
the posterior port to transect the bronchus. An empty sponge stick
is then used to place traction on the middle lobe bronchus, expos- acceptance and is rarely used at present.
ing the one or two branches of the middle lobe artery, which are Pneumonectomy
then transected via the posterior port. On occasion, the angle is
such that the middle lobe artery must be transected via the utility The approach to VATS pneumonectomy is similar to the sequen-
incision. The minor fissure is then completed by passing staplers tial anatomic ligation approach to VATS lobectomy. The thoraco-
via the utility incision. scope is inserted at the seventh intercostal space in the midaxillary
line, and a utility thoracotomy is performed at the fourth intercostal
Left-side resections Left upper lobe. The left upper lobe is space in the same line.Two port sites are then created at the sixth in-
retracted laterally, and the superior pulmonary vein is dissected free tercostal space in the anterior and posterior axillary lines.The hilar
and transected via the posterior port.The first apical branch of the vessels are sequentially isolated, ligated, and divided with endoscop-
pulmonary artery is dissected free and transected with an endoscop- ic or standard staplers.The inferior pulmonary vein is done first, fol-
ic GIA vascular stapler introduced via the posterior port.The anteri- lowed by the superior pulmonary vein and the pulmonary artery.
or aspect of the fissure is opened with one or two applications of an The bronchus is stapled and divided last.62,63
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 12
TROUBLESHOOTING tion that contains the computer, the three-dimensional imaging cen-
If ambiguous anatomy or excessive bleeding is encountered at ter, and the master controls that govern the robot’s function. The
any point during the procedure or if oncologic principles are vio- third part is the equipment tower, which holds the light source, the
lated, conversion to a thoracotomy is mandatory to ensure patient camera, and additional necessary components (e.g., the electro-
safety. A sponge on a stick, an open thoracotomy tray, and a cautery, the ultrasonic scalpel, and the insufflator).
polypropylene suture should always be readily available for emer- For our purposes, the da Vinci robot has three signal advantages.
gency control of hemorrhage. First, it offers a true three-dimensional imaging system with binocu-
To prevent too-distal or too-proximal dissection (which can lar vision. The scope is 12 mm in diameter, with a separate 5 mm
lead to bleeding and violation of oncologic principles), the surgeon scope for each eye.The left and right images remain separated from
should alternate frequently between panoramic and close-up the telescopes to the surgeon’s eyes, so that the right eye sees the
views. In addition, to ensure that the mainstem bronchus has not right image and the left eye sees the left image. Second, the instru-
been inadvertently dissected, the remaining lobes may be reinflat- ment and camera arms are all controlled by the surgeon through the
ed before bronchial transection. master controls and their interface with the computer; no voice or vi-
sual activation is necessary. Third, all of the surgical instruments,
with the exception of the SonoSurg (Olympus America, Melville,
Robot-Assisted VATS Lobectomy New York), have seven degrees of freedom and two degrees of axial
Current minimally invasive surgical technology has several rotation, which means that they can be articulated in a manner that
notable weaknesses. First, the camera platform is unstable, which replicates the action of a human wrist.
means that the operating surgeon must rely on an assistant with a
OPERATIVE TECHNIQUE
variable amount of experience and knowledge of the technical
aspects of the procedure to provide the needed visualization. To date, there have been only two published reports of the use of
Second, the straight instruments used are limited with respect to robotic technology during VATS lobectomy. One is a case report of a
range of movement and degrees of freedom when placed through VATS left lower lobectomy done with robotic assistance,70 and the
small incisions—a limitation that can be particularly significant other is a series of five patients, two of whom were converted to tho-
with thoracic procedures in which incision size is further limited racotomy for technical reasons.71 It is clear from the lack of a sub-
by the size of the intercostal space.Third, the cameras provide only stantial literature that a standardized approach has not yet been es-
two-dimensional imaging. Finally, as a result of all of the preced- tablished. At MSKCC, however, we have developed a technique of
ing factors, the ergonomics of these minimally invasive procedures robot-assisted VATS lobectomy that employs the da Vinci Surgical
for the operating surgeon and the assistants are often very poor.64 System as an adjunct to our standard VATS lobectomy technique.
These weaknesses provided the impetus for the application of This robot-assisted approach has proved to be safe and feasible in
robotic techniques to minimally invasive surgery. more than 30 consecutive patients.
The first generation of surgical robots focused primarily on the is-
Step 1: Initial Exploration of Chest and Positioning of Robot
sue of the unstable camera platform. In 1994, the Automated Endo-
scopic System for Optimal Positioning (AESOP) (Computer Mo- The patient is placed in a maximally flexed lateral decubitus
tion, Santa Barbara, California), a voice-activated robotic camera position after single-lung ventilation is established. Initial thoracic
holder, was approved by the Food and Drug Administration for clin- exploration is conducted by means of conventional thoracoscopy
ical use in abdominal surgery. Subsequently, the EndoAssist (Arm- to verify resectability and to establish the three standard VATS
strong Healthcare Limited, High Wycombe, United Kingdom), lobectomy access incisions. As noted [see VATS Lobectomy and
which allows the operating surgeon to control camera movement Pneumonectomy, Operative Technique, above], the location of the
through natural head movement, was also approved by the FDA. main utility incision varies slightly, depending on the lobe of inter-
The newest generation of surgical robots was designed to address est. Employing standard VATS lobectomy incisions has the bene-
issues beyond the camera platform by employing telerobotic tech- fit of allowing conversion to a conventional VATS procedure if the
nology to enable the operating surgeon to control the surgical robot need arises (e.g., as a result of minor bleeding, inadequate expo-
and its instruments by using a remote computer console. At present, sure, or mechanical or technical problems with the robot). Once
two FDA-approved systems are commercially available: the da Vinci the incisions have been made, the conventional VATS instruments
Surgical System (Intuitive Surgical, Sunnyvale, California) and the are removed, and the robot is brought into position from the pos-
ZEUS Surgical System (Computer Motion, Santa Barbara, Califor- terior aspect of the patient, with the center column at an angle of
nia). Both were originally designed for closed-chest cardiac sur- approximately 45° with respect to the patient’s longitudinal axis.
gery,65,66 and most of the published literature to date has been con- This positioning allows the field of dissection to include the hilar
cerned with this application. Nevertheless, the published experience structures and most of the chest.
with surgical telerobotics in minimally invasive surgery continues to A 12 mm trocar is placed through the anterior inferior access
expand, ranging from laparoscopic cholecystectomy to laparoscopic incision, and the camera arm is attached to the trocar. The three-
Nissen fundoplication to laparoscopic radical prostatectomy.67-69 dimensional 30° scope is introduced through the trocar and
At MSKCC, we employ the da Vinci Surgical System, which con- secured to the camera arm. The remainder of the positioning is
sists of three main parts.The first part is the basic robot.The robot accomplished under direct vision, both from outside the patient
has three arms—two instrument arms with a camera arm between and from within the thorax. The trocars attached to the two
them—all attached to a central column. Each instrument arm at- instrument arms are introduced into the two remaining access
taches to an 8 mm trocar, and the whole unit is placed into the pa- incisions. Care must be taken to ensure that the instrument arms
tient; surgical instruments are then introduced through the trocar for have full range of motion and do not collide with each other or
intracorporeal use.The camera arm attaches to a 12 mm trocar that with any portion of the patient.
is already positioned inside the patient.The second part of the sys- Once the camera and the instrument arms are in place, surgical
tem is the surgeon’s console, an ergonomically comfortable worksta- instruments are inserted through the attached trocars under direct
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 13
thoracoscopic vision. Our practice is to start the procedure with a the upper lobe bronchus is stapled and divided. The upper lobe is
Cadiere forceps in the left instrument arm (placed in the main then retracted laterally and inferiorly. Additional hilar nodal tissue is
utility incision) and a blunt permanent spatula hooked to an elec- resected, and the origins of the posterior ascending (or recurrent)
trocautery in the right instrument arm.When all instruments have artery, middle lobe artery, and superior segment pulmonary artery
been positioned optimally, the operating surgeon scrubs out and branches are defined.The recurrent artery branch is divided with an
moves to the control console. endoscopic GIA vascular stapler with 2.5 mm staples.
Once each of the hilar structures of the upper lobe has been
Step 2: Robot-Assisted VATS Dissection divided, only the fissure remains. At this point, the robotic portion
Two assistants are required: the first stands at the anterior of the procedure is terminated. The instruments and the instru-
aspect of the patient and assists through the main utility incision ment arms are removed under direct vision, followed by the cam-
by providing additional retraction of the lung and suction when era, the camera arm, and, finally, the robot. Conventional thora-
necessary, and the second is positioned at the posterior inferior coscopy is reestablished, and the fissure between the upper lobe
access incision. and the remaining middle and lower lobes is completed with mul-
At MSKCC, we typically begin the procedure with MLND. All tiple firings of the 4.8 mm endoscopic GIA stapler.The specimen
major nodal stations are explored with a combination of electro- is placed in a large laparotomy sac and brought out through the
cauterization and blunt dissection, and all nodal tissue is removed anterior superior access incision. Hemostasis is confirmed, inter-
and sent for frozen-section analysis to rule out occult stage III dis- costal nerve blocks are created with 0.5% bupivacaine, and a sin-
ease in patients with non–small cell lung cancer. Currently, we use gle chest tube is placed under direct vision.The remaining lung is
the SonoSurg in an effort to prevent postoperative chyle leakage, inflated, and the wounds are closed in the standard fashion.
though we have not yet encountered this complication.
If there are no contraindications to lobectomy, individual isola- Right middle lobe The main access incision is created in the
tion of the hilar structures proceeds with dissection around the midaxillary line one interspace below the level of the superior pul-
hilar vessels and bronchi performed with a combination of cauter- monary vein, and MLND of the right paratracheal and subcarinal
ization and sharp and blunt dissection, much as would be done spaces is performed. With the middle lobe retracted laterally, the
through a thoracotomy. The tissues overlying each structure, par- mediastinal pleura overlying the middle lobe pulmonary vein is
ticularly the regional lymph nodes, are precisely dissected away. incised with the Cadiere forceps in the left instrument arm and the
When either a vessel or the bronchus is sufficiently mobilized, two permanent spatula attached to the cautery in the right arm. The
blunt-tipped Cadiere forceps are used to reach around the struc- mediastinal pleura is further incised down to the level of the infe-
ture, place a tie, and create sufficient space for placement of an rior pulmonary vein. The spatula is replaced with a second
endovascular stapler. Cadiere forceps; the vein is encircled with a tie and divided with
the 2.5 mm endoscopic GIA vascular stapler inserted via the pos-
Step 3: Lobectomy terior access incision.
Right upper lobe The main utility incision is created in the Next, the anterior portion of the major fissure is completed with
midaxillary line at the level of the superior pulmonary vein. The the spatula and the cautery, and all regional lymph nodes encoun-
right upper lobe is retracted inferiorly and posteriorly for MLND tered are excised. The middle lobe bronchus is identified and
from the right paratracheal space, then anteriorly for the subcari- mobilized, with the peribronchial tissue swept distally. Division of
nal space. Next, the right upper lobe is retracted laterally, and the the bronchus with a 3.5 mm endoscopic GIA stapler placed via
mediastinal pleura overlying the superior pulmonary vein is in- the posterior incision facilitates subsequent dissection and ligation
cised with the Cadiere forceps in the left instrument arm and the of the middle lobe branches of the pulmonary artery. This is best
permanent spatula attached to the cautery in the right instrument accomplished by resecting the tissue overlying the ongoing pul-
arm. The full extent of the vein is defined by identifying the take- monary artery proximally up to the takeoff of the middle lobe arte-
off of the middle lobe vein inferiorly and the junction between the rial supply. The middle lobe pulmonary artery is encircled and
superior vein and the truncus arteriosus superiorly. Any regional divided with the 2.5 mm endoscopic GIA vascular stapler through
nodes present are resected. The spatula is replaced with a second the posterior incision. The minor fissure is completed with multi-
Cadiere forceps, and the vein is encircled with a tie to allow gen- ple firings of the 4.8 mm endoscopic GIA stapler through the
tle retraction.The left instrument arm is removed from the poste- anterior superior utility incision. The lobe is placed in a large tis-
rior inferior access incision just far enough to permit introduction sue pouch and brought out through the anterior utility incision.
of a 2.5 mm endoscopic GIA vascular stapler that is passed behind The robot is removed, and the procedure is completed in the same
the vessel. The tie is removed, the stapler is closed, and the vessel manner as a right upper lobectomy.
is stapled and divided. The left instrument arm is replaced, and
dissection continues by dividing the mediastinal pleura superiorly Right lower lobe As in a right middle lobectomy, the anteri-
and posteriorly over the truncus arteriosus toward the bronchus or utility incision is placed in the midaxillary line one interspace
with a combination of cauterization and blunt dissection. Any inferior to the level of the superior pulmonary vein, and MLND
additional regional nodes encountered are resected. of the subcarinal space is performed. The lower lobe is retracted
The truncus branches are isolated with the Cadiere forceps and toward the apex of the chest, the inferior pulmonary ligament is
divided in the same manner as the vein. Attention is turned to the divided with the electrocautery, and additional mediastinal lymph
right upper lobe bronchus, and the peribronchial tissue is bluntly nodes from levels 8 and 9 are resected. The pleura overlying the
swept distally.The bronchus is mobilized with the Cadiere forceps, inferior pulmonary vein is incised superiorly both anterior and
and an endoscopic GIA stapler with 4.8 mm staples is introduced posterior to the vessel.The Cadiere forceps are used to isolate this
again via the posterior access incision and closed around the vein, and a 2.5 mm endoscopic GIA vascular stapler placed
bronchus.The remaining lung is minimally ventilated to ensure that through the utility incision is used to divide the vessel. Retraction
the middle and the lower lobe are uncompromised; if this is the case, of the lung is maintained superiorly and posteriorly while the
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 14
major fissure is completed anteriorly with the spatula and the endoscopic GIA vascular stapler is placed through the utility inci-
attached cautery. sion to divide the vessel. Retraction of the lung is maintained supe-
The plane between the lower lobe bronchus and the basilar seg- riorly and posteriorly while the major fissure is completed anteri-
mental pulmonary artery is developed bluntly.This step facilitates orly with the spatula and the attached cautery.
dissection of the pulmonary artery branches, especially if the The plane between the lower lobe bronchus and the basilar seg-
major fissure is incomplete. In this instance, the bronchus may be mental pulmonary artery is developed bluntly.This step facilitates
divided before the artery with the 4.8 mm endoscopic GIA stapler dissection of the pulmonary artery branches, especially if the
inserted via the utility incision. The remainder of the pulmonary major fissure is incomplete. In this instance, the bronchus may be
artery may be approached either inferiorly or via the fissure and divided before the artery with the 4.8 mm endoscopic GIA stapler
may be similarly ligated with the 2.5 mm endoscopic GIA vascu- placed via the utility incision. The remainder of the pulmonary
lar stapler. The basilar and superior segmental branches may be artery may be approached either inferiorly or via the fissure and
divided separately if doing so is technically more feasible.The pos- may be similarly ligated with the 2.5 mm endoscopic GIA vascu-
terior aspect of the major fissure is completed with the stapler, and lar stapler. The basilar and superior segmental branches may be
the lobe is removed. The robot is extracted, and the procedure is divided separately if doing so is technically more feasible.The pos-
completed in the same manner as a right upper lobectomy. terior aspect of the major fissure is completed with the stapler, and
the lobe is removed. A subcarinal lymph node dissection is per-
Left upper lobe The main utility incision is created in the formed using blunt and cautery dissection with the Cadiere for-
midaxillary line at the level of the superior pulmonary vein. The ceps and the spatula. The robot is removed, and the procedure is
left upper lobe is retracted inferiorly and posteriorly to allow completed in the same manner as a right upper lobectomy.
MLND from the aortopulmonary window. The lung is then
TROUBLESHOOTING
retracted laterally, and the mediastinal pleura overlying the superi-
or pulmonary vein is incised. As on the right side, the Cadiere for- If concerns arise at any time during robot-assisted VATS lobec-
ceps is in the left instrument arm and the permanent spatula tomy about exposure, accurate identification of anatomic struc-
attached to the cautery in the right.The mediastinal pleura is fur- tures, the oncologic adequacy of the procedure, or safety, the sur-
ther incised down to the level of the inferior pulmonary vein. The geon must carefully consider whether it would be best to convert
full extent of the vein is defined by identifying the upper lobe to a standard VATS lobectomy or even to a thoracotomy. If such
bronchus inferiorly and the junction between the superior vein conversion is indicated at any point in the procedure, the robot can
and the anterior pulmonary artery branches superiorly. Any be quickly and easily moved away from the patient. The instru-
regional nodes present are resected.The spatula is replaced with a ments are removed under direct vision, followed by the camera.
second Cadiere forceps, and the vein is encircled with a tie. The The instrument arms and the camera arm are backed away from
left instrument arm is removed from the posterior inferior access the patient, and the robot can then be taken away.
incision to permit introduction of a 2.5 mm endoscopic GIA vas- There are several unique caveats that apply to robot-assisted
cular stapler, which is passed behind the vessel.The tie is removed, VATS procedures. First, before even attempting such a procedure,
the stapler is closed, and the vessel is stapled and divided. the operating surgeon, the assistants, and all other operating per-
The left instrument arm is replaced, and dissection is continued sonnel must be fully trained on the particular robotic surgical sys-
to mobilize the anterior pulmonary artery branches, which are encir- tem being used. In the early stages of a center’s experience with a
cled and divided with a 2.5 mm endoscopic GIA vascular stapler in- system, it is advisable to have a company representative present to
troduced through the posterior access incision. Ligating these arteri- help manage any complex technical issues that may arise. Second,
al branches greatly facilitates division of the upper lobe bronchus. care must be taken both during initial positioning and throughout
The upper lobe bronchus is then mobilized by means of blunt dis- the procedure to ensure that the arms of the robot do not collide
section and cauterization, with care taken not to include the entire with one another or, more important, with the patient.Third, there
left mainstem bronchus. A 4.8 mm endoscopic GIA stapler is used must be constant communication between all team members and
to staple and divide the bronchus. Once this is accomplished, the up- constant vigilance during the procedure. Untimely or unintended
per lobe is retracted laterally, which allows quick and easy identifica- manipulation of any component of the robotic system during dis-
tion, mobilization, and division of the apicoposterior and lingular section around delicate hilar structures can be potentially disas-
pulmonary artery branches with multiple firings of the 2.5 mm en- trous and should be completely avoidable.
doscopic GIA vascular stapler. Conventional thoracoscopy is then
reestablished, and the fissure between the upper and lower lobes is
completed with multiple firings of the 4.8 mm endoscopic GIA sta- VATS Mediastinal Lymph Node Dissection
pler. The lobe is placed in a large laparotomy sac and brought out
OPERATIVE TECHNIQUE
through the anterior utility incision, and the procedure is completed
in the same manner as a right upper lobectomy. For biopsy of the aortopulmonary window nodes or anterior me-
diastinal masses,VATS MLND is often performed as an alternative
Left lower lobe The anterior utility incision is placed in the to a Chamberlain procedure and is thought by some surgeons to
midaxillary line one interspace below the level of the superior pul- provide better exposure and a superior cosmetic result.72 The tho-
monary vein.The left upper lobe is retracted inferiorly and poste- racoscope is inserted at the fifth or sixth intercostal space in the pos-
riorly to allow MLND from the aortopulmonary window. Once terior axillary line. Instruments for retracting the lung inferiorly are
this is done, the lower lobe is retracted toward the apex of the introduced via a port at the seventh intercostal space in the midaxil-
chest, the inferior pulmonary ligament is divided with the electro- lary line. Instruments for dissecting nodes are introduced through
cautery, and additional mediastinal lymph nodes from levels 8 and ports placed at the fourth intercostal space in the anterior axillary
9 are resected.The pleura overlying the inferior pulmonary vein is line and in the auscultatory triangle.The lymph nodes are dissected
incised superiorly both anterior and posterior to the vessel. The free with graspers (e.g., curved sponge sticks or polyp forceps), scis-
Cadiere forceps are used to isolate the inferior vein, and a 2.5 mm sors, the electrocautery, and endoscopic hemostatic clips. A similar
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 15
approach can be used for biopsy of other mediastinal nodes, includ- agus. At the level of the primary tumor, periesophageal soft tissues
ing the paratracheal and periesophageal nodes. Dissection of level 4 are resected en bloc to ensure complete removal of the cancer.
and level 2 nodes on the right is facilitated by transection of the azy- When the esophagus has been fully mobilized down to the
gos vein.This method has become an accepted approach to the sur- diaphragmatic hiatus, a plastic tube is passed into the hiatus, where
gical staging of esophageal cancer.73,74 It is more difficult to do a it is grasped by the mediastinoscope. Both the mediastinoscope
complete en bloc subcarinal lymph node dissection on the left than and the plastic tube are then withdrawn to the cervical incision.
on the right with this method, though nodal sampling of this region The cervical esophagus is transected at the sternal notch with the
by means of VATS is certainly feasible, especially when an access in- GIA stapler, and the plastic tube is sutured to the distal end of the
cision is used. divided esophagus. The tube is then gently pulled back down to
the diaphragmatic hiatus; in the process, the thoracic esophagus is
TROUBLESHOOTING
folded onto itself. The mediastinoscope is reintroduced and used
Care should be taken not to injure the phrenic nerve as it cours- to follow the esophagus as it is removed from the mediastinum.
es along the superior vena cava on the right and across the anteri- Any undivided vessels or lymphatics are easily visualized and are
or aspect of the aortopulmonary window on the left. The vagus either ligated or cauterized. After the esophagus is extracted, the
nerve should be visualized, and the origin of the recurrent laryn- stomach is passed up to the neck via the posterior mediastinum,
geal nerve avoided during dissection. The recurrent laryngeal and the esophagogastric anastomosis is performed in the standard
nerve is easily injured on the left side, where it passes around the manner for a transhiatal esophagectomy [see Figure 12].
ligamentum arteriosum before traveling under the aortic arch;
however, it can also be injured on the right side if MLND is car- Transthoracic Approach
ried too high superiorly along the origin of the innominate artery. Transthoracic thoracoscopic techniques for esophagectomy
It is unwise to perform a VATS MLND after induction chemo- have been described by several authors.77-79 One group has refined
therapy or chemoradiotherapy because the lymph nodes will often a clinical VATS technique that is based on results from animal
be densely adherent to surrounding structures. This is especially studies.80 The most widely accepted method of performing a tho-
true on the right side, where the superior mediastinal lymph nodes racoscopic and laparoscopic esophagectomy, however, is the one
are usually densely adherent to the superior vena cava, the azygos developed by Luketich and associates, who have performed more
vein, and the right main pulmonary artery. A thoracotomy, with than 200 cases to date and have published a report of 77 patients
extensive exposure and sharp dissection, is usually required for a that demonstrated the feasibility of their approach.81
safe and complete MLND. A double-lumen endotracheal tube is inserted, the patient is
All lymphatic branches should be ligated during node biopsy or placed in the left lateral decubitus position, and four thoracoports
dissection to prevent leakage of chyle. There are often large lym- are placed. A 0 suture is placed in the central tendon of the
phatic branches in the distal right paratracheal area. In addition, diaphragm and brought out through an inferior anterior 1 mm skin
the thoracic duct can be injured if periesophageal or posterior nick to provide downward traction on the diaphragm and ade-
mediastinal lymph nodes are being removed. quate exposure of the esophagus. The mediastinal pleura is
opened widely, and the anterior edge is retracted with two stay
sutures.The azygos vein is divided with an endoscopic stapler, and
VATS Esophagectomy the inferior half of the thoracic esophagus is mobilized away from
the aorta and the pericardium. The subcarinal lymph nodes are
OPERATIVE TECHNIQUE
removed en bloc. The upper third of the thoracic esophagus is
To date, surgeons’ experience with thoracoscopic esophageal mobilized away from the trachea, and the right paratracheal lymph
resection has been limited.VATS esophagectomy can take either a nodes are removed, with care taken not to injure the recurrent
transhiatal or a transthoracic approach. laryngeal nerve. A Penrose drain is placed around the esophagus
and placed through the thoracic inlet for later retrieval via the neck
Transhiatal Approach incision. Once the esophagus has been fully mobilized, the pleu-
The technique originally described for VATS transhiatal ral traction sutures are removed, a chest tube is inserted through
esophagectomy75 is a modification of the open technique advocat- the camera port site, and the other port incisions are closed.
ed by Orringer76 [see 4:4 Open Esophageal Procedures] and allows The patient is then moved to the supine position.The stomach
the esophagectomy to be performed entirely under direct vision is mobilized laparoscopically. Port placement is similar to that for
with the help of a specially designed operating mediastinoscope. laparoscopic Nissen fundoplication. The patient is placed in a
This instrument has a partially concave olive tip that distracts the steep reverse Trendelenburg position. The gastrohepatic ligament
mediastinal tissues away from the mediastinoscope and cradles the is divided to expose the right crus of the diaphragm.The short gas-
esophagus in a stable position during the dissection. The medi- tric vessels are divided with ultrasonic shears; the right gastroepi-
astinoscope incorporates an optical system, an irrigation canal, ploic artery is preserved. The stomach is retracted superiorly to
and an operating channel for insertion of scissors, suction devices, facilitate nodal dissection of the celiac and gastric vessels.The left
and monopolar and bipolar cautery forceps. gastric artery and the left gastric (coronary) vein are then divided
The mediastinoscope is introduced through the neck incision with an endovascular stapler. A pyloroplasty is performed, with
used to expose the cervical esophagus, after the stomach and the ultrasonic shears used for the incision and an endoscopic suturing
distal esophagus have been mobilized via laparotomy.The thoracic device for the repair. The gastric tube is then created with a uni-
esophagus is circumferentially freed from the surrounding medi- versal 4.8 stapler, with care taken to preserve the right gastric ves-
astinal structures, beginning at the thoracic inlet and moving infe- sels. Once the gastric tube is complete, it is attached to the speci-
riorly to the hiatus, primarily by means of blunt dissection with the men with several applications of the suturing device in preparation
suction device.Vessels are cauterized or clipped. Dissection is per- for transport to the neck. A laparoscopic jejunostomy is then per-
formed first along the posterior wall of the esophagus, then along formed.The right and left crural areas are opened last to facilitate
both lateral walls, and finally on the anterior surface of the esoph- passage on the conduit without loss of pneumoperitoneum.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 16
a b
Mediastinoscope
Optic
Rinsing
Canal
Esophagus
Dissecting Scissors
c d
Figure 12 VATS esophagectomy. In the transhiatal approach, a specially designed operating mediastinoscope with
an olive-shaped tip (a) is used. This tip mechanically distracts the mediastinal tissues away from the medi-
astinoscope and keeps the esophagus in a stable position during dissection. The scope is shown cradling the esopha-
gus with the dissecting scissors inserted. During periesophageal dissection, the distal dilating olive of the medi-
astinoscope is placed behind the esophagus (b). The olive creates and maintains space by careful probing of the
periesophageal areolar tissue. When the esophagus has been fully mobilized down to the diaphragmatic hiatus, a
plastic tube is passed into the hiatus, where it is grasped by the mediastinoscope. Both the mediastinoscope and the
plastic tube are pulled up from the hiatus (c). After esophageal resection with an endoscopic GIA stapler, the
esophagus is folded over by using endoscopic control (d). Structures still attached to the esophagus are placed in
traction, coagulated, and divided.
A 5 cm collar incision is made to the left of the midline, and the sive dissection for safe mobilization away from adjacent mediasti-
cervical esophagus is exposed.The Penrose drain that was left in the nal structures.
thoracic inlet is then delivered into the wound to facilitate mobiliza- To date, comparison of the results of VATS esophagectomy
tion of the desired portion of the esophagus.The esophagus is divid- with those of open esophagectomy has not shown VATS to yield a
ed in the neck, and the specimen and the conduit are delivered significant decrease in major complications, especially postopera-
through the posterior mediastinum under laparoscopic visualization tive respiratory insufficiency and cardiac arrhythmias.83,84 As a
to ensure proper alignment of the conduit.The cervical anastomosis result, most centers still prefer the standard open transhiatal or
may be either handsewn or stapled.82 transthoracic approaches to esophagectomy.
VATS may also be used in the management of postoperative chy-
TROUBLESHOOTING
lothorax.85 The thoracic duct can be ligated thoracoscopically,
The technical problems associated with VATS esophagectomy though it is sometimes difficult to identify and ligate the primary site of
are similar to those associated with open thoracic esophagectomy, a postoperative lymphatic leak without reopening the thoracotomy.
including thoracic duct injury, recurrent nerve palsy, bleeding
from the intercostal vessels, and anastomotic leakage [see 4:4
Open Esophageal Procedures].These problems are best prevented by VATS Pericardial Window
obtaining good visualization of the superior and posterior medi-
OPERATIVE TECHNIQUE
astinum, which can be achieved by using a 30º angled thoraco-
scope.The most common reason for conversion to thoracotomy is Some surgeons create a pericardial window by means of VATS as
the presence of a locally advanced tumor that necessitates exten- an alternative to taking the subxiphoid approach or the left anterior
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 17
thoracotomy approach.86,87 A double-lumen endotracheal tube is in- been reported, and no studies examining long-term outcome have
serted with the patient under general anesthesia, and the patient is been published. Although a VATS approach to myasthenia gravis
rotated into the right lateral decubitus position.Three access sites are may appear attractive at first, it is not the least invasive approach
used, with the thoracoscope inserted at the seventh intercostal space to the thymus. Transcervical thymectomy is a minimally invasive
in the posterior axillary line and the instruments introduced through approach to the thymus that does not require a chest incision,
two ports, one at the tip of the scapula and the other at the sixth in- does not violate the pleural space, and allows most patients to be
tercostal space in the axillary line [see Figure 13a].The pericardium is discharged home the next day.90 There is still a degree of contro-
retracted with a grasper forceps, and scissors are used to resect 8 to versy as to whether complete thymic resection, including all ec-
10 cm2 areas of pericardium both anterior and posterior to the topic thymic tissue, is necessary to obtain clinical remission in pa-
phrenic nerve. If indicated, talc pleurodesis can be performed to con- tients with myasthenia gravis.91 For patients with a thymic mass,
trol an associated pleural effusion. One or two chest tubes are then we prefer a transsternal approach. It is imperative to maintain on-
inserted through the port-site incisions. cologic surgical principles; accordingly, en bloc resection is em-
phasized, so that pleural seeding is avoided and the risk of incom-
TROUBLESHOOTING
plete resection minimized. For patients with myasthenia gravis
When a pericardial effusion causes cardiac tamponade, a sub- who do not have a thymoma, however, we believe that there is a
xiphoid approach is preferable to VATS for creating a pericardial need for prospective studies comparing VATS with other surgical
window because it is safer to perform in a hemodynamically unstable approaches to thymectomy.
patient. A VATS pericardial window is also inadvisable in patients
OPERATIVE TECHNIQUE
with constrictive physiology or with intrapericardial adhesions dis-
covered at the time of operation. Conversion to an open procedure VATS has been used to resect masses in all of the mediastinal
with formal pericardiectomy is advisable under these circumstances. compartments. VATS resection is an ideal approach to posterior
neurogenic tumors that do not extend into the neural foramen or
the spinal canal.92,93 With the patient in the lateral decubitus posi-
VATS Procedures for Mediastinal Masses tion, the operating table is rotated anteriorly so that the lung falls
A 1998 multicenter trial aimed at defining the role of VATS in away from the paravertebral region.The port sites are placed ante-
the management of mediastinal tumors suggested that VATS can riorly: the thoracoscope is inserted at the fifth intercostal space in
be used safely to diagnose and resect most middle and posterior the midaxillary line, a lung retractor is inserted at the sixth inter-
mediastinal masses, especially in view of the typically benign costal space in the anterior axillary line, and dissecting instru-
nature of these tumors.88 ments are inserted at the second and fourth intercostal spaces in
VATS thymectomy has been employed to treat myasthenia the anterior axillary line [see Figure 13b].The mass is manipulated
gravis and thymoma.89 To date, only anecdotal experience has with a grasper to expose the posteriorly located pedicle, which is
a b c
Grasper
Scissors Grasper
Scissors
Camera
Camera
Retractor
Scissors
Camera
Grasper
Figure 13 (a) VATS pericardial window. Three access sites are used. The thoracoscope is inserted in the posterior
axillary line at the seventh intercostal space, the endoscopic scissors are inserted through one port at the tip of the
scapula, and the grasper forceps is inserted through another port in the anterior axillary line at the sixth intercostal
space. (b, c) VATS procedures for mediastinal masses. For posterior masses, the port sites are placed anteriorly (b),
and the thoracoscope is inserted at the fifth intercostal space in the midaxillary line. A lung retractor is inserted at
the sixth intercostal space in the anterior axillary line, and dissecting instruments are inserted at the second and
fourth intercostal spaces in the anterior axillary line. For anterior mediastinal masses and thymectomy, the port
sites are placed in more posterior locations (c). The thoracoscope is introduced at the fifth intercostal space in the
midaxillary or the posterior axillary line, and instruments are inserted through one port at the second intercostal
space in the midaxillary line and another at the fifth or sixth intercostal space in the anterior axillary line.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 18
then dissected, ligated, and divided with the scissors, clip appliers, etrating chest injuries had diaphragmatic injuries that necessitated
and the electrocautery.94,95 repair.102 For hemodynamically stable patients with suspected
For removal of anterior mediastinal masses, the port sites are diaphragmatic injuries, the VATS approach appears reasonable.
placed in more posterior locations. The thoracoscope is intro- When a patient has an ongoing intrathoracic problem (e.g., per-
duced at the fifth intercostal space in the midaxillary or posterior sistent bleeding or a large air leak 24 to 48 hours after a traumat-
axillary line, and instruments are inserted through two ports, one ic injury), VATS should be considered before a thoracotomy is
at the second intercostal space at the midaxillary line and the other done because most problems encountered at this time (e.g., chest
at the fifth or sixth intercostal space in the anterior axillary line [see wall bleeding and laceration of the lung parenchyma) can be man-
Figure 13c].The mass is retracted with a grasper and dissected free aged endoscopically, without the need for a thoracotomy.
with a combination of sharp and blunt dissection, clip appliers,
TROUBLESHOOTING
and the electrocautery.96,97
A similar technique is used to resect middle mediastinal mass- The main pitfall in thoracoscopic evaluation of the diaphragm
es, most of which are pericardial or bronchogenic cysts.98,99 The is failure to assess the abdomen appropriately and consequent fail-
access sites should be chosen according to the location of the mass ure to recognize an occult intra-abdominal injury. When lapa-
on the preoperative CT scan. Generally, however, the triangulated roscopy is performed in a patient with a diaphragmatic injury,
site placement used for pulmonary wedge resections provides insufflation of CO2 may cause a tension pneumothorax to develop
more suitable exposure than the site placement used for anterior on the side of the diaphragmatic injury. Accordingly, whenever
or posterior mediastinal masses. diaphragmatic injury is a possibility, the chest should be included
in the operative field to allow chest tube insertion if required.
TROUBLESHOOTING
Because thoracoscopy does not require CO2 insufflation, it is safer
The placement of the thoracoports and the positioning of the in such situations.
operating team for the resection of posterior mediastinal tumors or
for thoracic diskectomy differ significantly from the usual practice
in most other VATS procedures. In place of the standard arrange- VATS Sympathectomy and Splanchnicectomy
ment of trocars in an inverted triangle, the viewing port is placed Thoracic sympathectomy is known to be the most effective
in the posterior axillary line and the operating ports in the anteri- treatment for upper limb hyperhidrosis, and VATS is now an
or axillary line. The thoracic surgeon and the neurosurgeon both accepted approach to this operation.
stand on the anterior side of the patient, each viewing a monitor The main indication for splanchnicectomy is intractable abdomi-
on the opposite side. In addition, a 30º scope is essential for visu- nal pain from unresectable malignancies (e.g., pancreatic or gastric
alizing the intervertebral disk space.93,95 carcinoma) and chronic pancreatitis. The effects of celiac ganglion
Removal of dumbbell neurogenic tumors can be accomplished blocks are transient, and surgical manipulation of this area is usually
thoracoscopically if immediately preceded by posterior surgical very difficult because of the primary disease process, previous opera-
removal of the spinal component of the tumor via laminectomy tions, or both. In the past, thoracotomy was generally considered too
and intervertebral foraminotomy. Preoperative MRI scanning is invasive an approach to splanchnic denervation in these patients.
crucial for defining the extent of the tumor within the spinal Currently, however, because of the less invasive nature of thora-
canal.94 Resection of posterior mediastinal tumors is sometimes coscopy and the quicker recovery time associated with it, thoraco-
associated with significant bleeding from intercostal or spinal scopic splanchnicectomy is an attractive therapeutic option.103
arteries. If such bleeding occurs, there should be no hesitation in
OPERATIVE TECHNIQUE
converting to a thoracotomy.
Ideally, anterior mediastinal cysts should be resected in toto to
prevent recurrence. However, if the cysts are firmly adherent to Sympathectomy
vital mediastinal structures, partial excision with cauterization of VATS sympathectomy is performed with the patient under
the endothelial lining may be safer. general anesthesia and a double-lumen tube in place. Several
techniques have been described. Initially, the common practice
was to use three port sites: one for the thoracoscope at the third
VATS Management of Thoracic Trauma intercostal space in the midaxillary line, one at the third inter-
The major contraindication to thoracoscopy in thoracic trauma is costal space in the anterior axillary line, and one at the tip of the
hemodynamic instability. For major life-threatening injuries involv- scapula. Currently, the procedure is most often performed with
ing the great vessels and the mediastinum, thoracotomy is required two incisions: one at the fifth interspace at the border of the pec-
to obtain expeditious control of injured structures [see 7:5 Injuries to toralis and one at the fourth interspace in the anterior axillary
the Chest]. However, hemodynamically stable patients with certain line. The pleura is incised and divided from T2 to T5, and the
thoracic problems (e.g., diaphragmatic injury, slow continued in- sympathetic chain is dissected free with scissors and excised. For
trathoracic bleeding, persistent air leakage, and empyema) may be complete control of upper limb hyperhidrosis, VATS must be
diagnosed and often treated by means of VATS.100,101 done bilaterally.104,105
In the assessment of a trauma patient with a potential diaphrag- A 1998 study reviewed the long-term results in 630 patients who
matic injury, it is important not to ignore the high incidence of had undergone thoracoscopic sympathectomy for hyperhidrosis
associated intra-abdominal injury. If intra-abdominal injury has (median follow-up, 15 years).106 Of these patients, 68% were fully
been ruled out and there is concern about the presence of a dia- satisfied, and 26% were only partially satisfied but nevertheless
phragmatic tear, thoracoscopic assessment of the diaphragm is would agree again to the operation. Hyperhidrosis was cured perma-
justified. Such assessment allows a more thorough evaluation of nently in 93%. Compensatory sweating and gustatory sweating oc-
the entire diaphragm than the laparoscopic approach, which is curred in 67% and 47% of cases, respectively. Overall, patients were
limited by the liver on the right side. In the largest series published well satisfied with the results and considered the compensatory
to date, 60 of 171 patients who underwent thoracoscopy for pen- sweating less of a problem than the original hyperhidrosis.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 7 VIDEO-ASSISTED THORACIC SURGERY — 19
a b
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90. Cooper JD, Al-Jilaihawi AN, Pearson FG, et al: An
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92. Riquet M, Mouroux J, Pons F, et al:Videothoraco- 104. Dumont P, Denoyer A, Robin P: Long-term results Acknowledgment
scopic excision of thoracic neurogenic tumors. Ann of thoracoscopic sympathectomy for hyperhidrosis.
Thorac Surg 60:943, 1995 Ann Thorac Surg 78:1801, 2004 Figures 1 through 7 and 9 through 14 Tom Moore.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 8 PLEURAL EFFUSION — 1
8 PLEURAL EFFUSION
Rafael S. Andrade, M.D., and Michael Maddaus, M.D., F.A.C.S.
Pleural effusion is a common problem in surgical practice. It cer) can raise the index of suspicion for an effusion and provide
results from perturbations of normal pleural fluid transport, which guidance regarding possible causes. Careful physical examination
are produced by three main mechanisms—abnormalities in of the chest can detect an effusion, and many physical signs may
Starling’s equilibrium, increased capillary and mesothelial perme- provide clues to the cause. Physical signs that are particularly useful
ability, and interference with lymphatic drainage. These mecha- for diagnostic purposes include jugular venous distention and tachy-
nisms are associated with a variety of different causes [see Table cardia (suggestive of congestive heart failure); lymphadenopathy,
1].1,2 Often, more than one mechanism is involved. An inflamma- digital clubbing, and localized bone tenderness (suggestive of lung
tory effusion, for instance, is marked by increases in capillary and cancer); and ascites (suggestive of ovarian tumors or cirrhosis).
mesothelial permeability, which lead to elevated intrapleural on- Pleural effusion can occur in a wide variety of clinical situations,
cotic pressure. however, and it often evades clinical detection by history and phys-
Pleural effusion is classified as either transudative or exudative, ical examination. Consequently, imaging tests are indispensable in
depending on the chemical composition of the fluid. A transudate the workup of a patient with a possible pleural effusion. Pleural
is an ultrafiltrate of serum and has a low total protein content (≤ 3 fluid analysis, pleural biopsy, and thoracoscopy may also be re-
g/dl); an exudate is the result of increased permeability and has a quired for evaluation.
high total protein content. Increased pleural permeability results
from complex inflammatory mediator interactions between the
mesothelium (whose cells play an active role in inflammation, Investigative Studies
phagocytosis, leukocyte migration, tissue repair, antigen presenta-
IMAGING
tion, coagulation, and fibrinolysis3,4) and the capillary endotheli-
um. The distinction between transudative and exudative pleural
effusion is clinically significant in that the two types of effusion Chest Radiography
have different causes [see Table 2].1,4 To be detectable on a standard upright posteroanterior chest
radiograph, an effusion must have a volume greater than 150 ml.
If the volume is 150 to 500 ml, the lateral costophrenic angle will
Clinical Evaluation be blunted; if the volume is greater than 500 ml, a meniscus will
A complete history, phys- be created.5,6 A lateral decubitus chest radiograph can detect an
ical examination, and clini- effusion as small as 5 ml. As a general rule, a layering effusion that
cal acuity are the initial tools is at least 1 cm thick is accessible to thoracentesis.6,7 A loculated
used for diagnosing pleural effusion may appear as a so-called pseudotumor on a chest radi-
effusion. Important facts ograph and typically will not layer freely on a lateral decubitus
from a patient’s history (e.g., radiograph. Subtle changes on an upright chest radiograph (e.g.,
respiratory symptoms, pain, accentuation of a fissure, elevation of a hemidiaphragm [see 4:3
extrathoracic symptoms, duration of symptoms, previous medical Paralyzed Diaphragm], or increased separation between the lung
conditions, and risk factors for cardiopulmonary diseases or can- and subdiaphragmatic gas [see Figure 1]) may also signal an effu-
Increased capillary and lymphatic hydrostatic Increased venous pressure (e.g., biventricular
pressure heart failure, renal failure)
Suspected cause is PSI (PPE) Suspected cause is other Suspected cause is malignancy,
condition esophageal perforation,
hemothorax, or chylothorax
[See Table 3.]
Treat underlying cause.
Perform US or CT.
Perform VATS.
Suspected cause is PSI (PPE) Suspected cause is malignancy Suspected cause is nonmalignant
condition other than PSI (PPE)
[See Table 3.] Perform cytologic tests.
Perform cell count with differential.
Assess levels of triglycerides, cholesterol,
amylase, chylomicrons, rheumatoid factor,
and antinuclear antibodies.
Table 2 Causes of Transudative tween effusion and lung abscess, and for guiding and monitoring
and Exudative Pleural Effusion closed drainage of effusions.6,10,12,13
Magnetic Resonance Imaging
Type of Effusion Cause
Magnetic resonance imaging of the chest provides no useful
Congestive heart failure information beyond what can be obtained with CT scanning.
Cirrhosis MRI is neither efficient nor cost-effective in standard evaluation
Nephrotic syndrome of pleural effusion.12,14
Acute atelectasis
Transudative Renal failure THORACENTESIS
Peritoneal dialysis
If the cause of a pleural
Postoperative state
Myxedema
effusion cannot be explained
Postpartum state by the clinical circumstances
(e.g., congestive heart failure
Pneumonia or a recent surgical proce-
Malignancy
dure), diagnostic thoracen-
Infection
tesis [see Sidebar Techniques
Esophageal perforation
Hemothorax
of Bedside Thoracentesis and Tube Thoracostomy] is indicated.
Chylothorax Thoracentesis may also have therapeutic value, in that drainage of
Pseudochylothorax fluid may relieve dyspnea. Absolute contraindications to thoracen-
Connective tissue diseases tesis include lack of cooperation on the patient’s part, clinical insta-
Exudative Drug-induced pleuritis bility with hemodynamic or respiratory compromise, severe coag-
Pancreatitis ulopathy, and high-pressure ventilation. Relative contraindications
Uremia to thoracentesis include a nonlayering effusion, loculations, and
Postmyocardial infarction (Dressler syndrome) previous thoracic trauma, chest tube placement, or surgery.
Chronic atelectasis
A large effusion can be drained without any special imaging
Radiation therapy
guidance other than an upright lateral chest radiograph. Thora-
Asbestos exposure
Meigs syndrome
centesis for a small or loculated effusion is best done with ultra-
Ovarian hyperstimulation sound guidance; success rates are as high as 97%.15
Assessment of a pleural
fluid sample is guided, to
some extent, by the clinical
context in which the pleural
effusion occurs. When the
cause of the effusion is un-
known, evaluation of a pleu-
ral fluid sample typically in-
cludes measurement of total protein and lactic dehydrogenase
(LDH) concentrations, a cell count with differential, cause-specif-
ic testing, and microbiologic and cytologic analysis.
Biochemical Analysis of Pleural Fluid
A total protein concentration higher than 3 g/dl is generally
used as the main criterion for distinguishing a transudate from an
exudate; however, the use of this criterion may result in misclassi-
Figure 2 Supine chest radiograph of a patient with bilateral fication of as many as 15% of effusions. According to Light’s cri-
pleural effusion shows increased homogeneous density of the teria,19 which have a sensitivity of 99% and a specificity of 98% for
lower hemithoraces. identifying exudates, an effusion is an exudate if any of the follow-
ing three findings is present:
1. A pleural fluid–to–serum protein ratio higher than 0.5
2. A pleural fluid–to–serum LDH ratio higher than 0.6
3. A pleural fluid LDH concentration higher than two thirds of
the upper limit of the serum reference range
A 1997 meta-analysis of the diagnostic value of tests used to dis-
tinguish transudates from exudates did not find any test or com-
bination of tests to be clearly superior.20 The choice of a test for
this purpose is therefore a matter of individual preference. If only
one test is to be performed, measurement of the total protein con-
centration is the most practical choice, in view of its accuracy and
availability.
Assessment of pleural fluid pH and glucose levels may be used are idiopathic. As a rule, the presence of mesothelial cells is of lit-
adjunctively for risk stratification in patients with PSI, but the clin- tle diagnostic value; the exception to this rule is that if such cells
ical utility of these measurements is not well established (see account for more than 5% of WBCs, a tuberculous effusion is
below).21 unlikely.23,27
There are numerous pleural fluid components whose concen-
trations can be measured to help determine the specific cause of a Microbiologic Tests
pleural effusion, such as triglycerides, chylomicrons, and choles- If a PSI is suspected, Gram staining and standard bacterial cul-
terol (to help diagnose chylothorax); amylase (to help diagnose tures are indicated. If tuberculous pleurisy is a possibility, acid-fast
esophageal perforation or pancreatitis); rheumatoid factor (to help stains and mycobacterial cultures should be performed. Fungal,
diagnose rheumatoid effusion); antinuclear antibodies (to help viral, and parasitic PSIs are uncommon; accordingly, special stains
diagnose lupus pleuritis); carcinoembryonic antigen (to help diag- and cultures for these conditions are indicated only if dictated by
nose malignancy); and adenosine deaminase (to help diagnose a specific clinical setting.28
tuberculous pleurisy).3,22-25
Cytologic Tests
Cell Counts Cytologic testing of pleural fluid is routinely performed when-
Analysis of the number and type of white blood cells (WBCs) ever the cause of an effusion is unclear. The diagnostic yield for
present in pleural fluid is often diagnostically useful. Pleural effu- malignancy varies depending on the stage of the disease, but it
sions can be categorized according to the type of WBC that is pre- generally is in the range of 50% to 60% (higher in patients with
dominant. Generally, pleural fluid neutrophilia points to acute bulky pleural tumors). Repeat cytologic testing may increase the
inflammation (e.g., from PSI or pulmonary infarction) as the yield to more than 70%,10,29 and testing of three or more samples
underlying cause; however, the presence of a neutrophilic effusion may increase the yield to 90%.30
does not exclude malignancy. Pleural fluid lymphocytosis, in
PLEURAL BIOPSY
which lymphocytes account for more than 50% of WBCs, most
frequently is indicative of malignancy (occurring in 50% of malig- In approximately 25% of patients with exudative effusion, the
nant effusions), tuberculosis (occurring in 15% to 20% of tuber- cause remains unknown after clinical evaluation, imaging, and
culous effusions), or chylothorax.26 Pleural fluid eosinophilia, in pleural fluid analysis. The next step in the evaluation of such
which eosinophils account for more than 10% of WBCs, can be patients is pleural biopsy.
caused by a wide variety of benign and malignant conditions— Percutaneous pleural biopsy is an infrequently used tool that
even, in some cases, by the mere presence of air or blood in the has a diagnostic yield of 57% for carcinoma. Its low yield for
pleural space. Approximately one third of eosinophilic effusions malignant effusion can be explained by the uneven distribution of
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 8 PLEURAL EFFUSION — 7
Risk of Poor
Pleural Space Anatomy Pleural Fluid Bacteriology Category Drainage
Outcome
Minimal free-flowing effusion (< 10 mm Culture and Gram stain results unknown 1 Very low No
on lateral decubitus x-ray)
Small to moderate free-flowing effusion (> 10 mm Negative culture and Gram stain 2 Low No
but < 50% hemithorax)
Large free-flowing effusion (> 50% hemithorax), loc- Positive culture or Gram stain 3 Moderate Yes
ulated effusion, or effusion with thickened pari-
etal pleura (as seen on contrast-enhanced CT) Pus 4 High Yes
ondary to talc pleurodesis is not clear and is probably related to In most patients, PSI is caused by bacteria.The most common
multiple factors (e.g., talc dose, talc absorption, underlying lung pathogens are Staphylococcus aureus, Streptococcus pneumoniae,
disease, reexpansion pulmonary edema, systemic inflammatory enteric gram-negative bacilli, and anaerobes. Approximately 30%
response, tumor burden, and lymphatic obstruction). There is no to 40% of cultures are polymicrobial. In a subgroup of patients,
definitive evidence that the talc dose is correlated with the inci- there is sterile pus in the pleural space, as a consequence either of
dence of ALI; respiratory failure has been reported even with a 2 previous antimicrobial therapy or of bacterial autolysis. The
g talc dose.42,47-51 pathogens identified vary according to the cause of PSI. For
Treatment of malignant pleural effusion must be individual- instance, S. aureus and S. pneumoniae predominate in PPE; S.
ized. The key factors governing the choice of treatment approach aureus, in postthoracotomy PSI; mixed oropharyngeal organisms,
are (1) the patient’s performance status, (2) the prognosis, (3) the in PSI resulting from esophageal perforation28; and acid-fast bac-
pleural tumor bulk, and (4) the ability of the lung to reexpand. teria, in tuberculous empyema.55
Patients who have poor performance status (e.g., those with
advanced tumors or significant comorbid conditions) or a very Parapneumonic Effusion
poor short-term prognosis should undergo the least invasive treat- PPE occurs in as many as 57% of patients hospitalized with
ment—namely, drainage only. Patients who have better function- pneumonia, and pneumonia accounts for 42% to 73% of cases of
al status and are expected to survive longer should undergo tho- PSI. In most cases, early PPE is effectively treated by timely
racoscopically guided talc pleurodesis. Intrathoracic tumor bulk is antibiotic therapy aimed at the underlying pneumonia.21,28
important in that a bulky pleural lesion will interfere with pleu- In 2000, a panel convened by the Health and Science Policy
rodesis. The lung’s ability to reexpand after drainage of a malig- Committee of the American College of Chest Physicians (ACCP)
nant effusion is significant because if the lung is atelectatic as a reviewed the available literature with the aim of developing an evi-
result of airway obstruction or trapped as a result of pleural seed- dence-based clinical practice guideline for the treatment of PPE.21
ing, no agent will be able to induce pleurodesis, and the best treat- The panel formulated a clear and relatively simple classification
ment will be long-term drainage. system that used pleural anatomy and bacteriology to stratify
patients according to the risk of a poor outcome [see Table 3]. It
PLEURAL SPACE INFECTION
then made therapeutic recommendations on the basis of this clas-
PSI can be caused by a variety of factors, including pneumonia, sification. Some authors have used pleural fluid chemistry test
trauma, and intrathoracic procedures. It has a wide clinical spec- results (e.g., pH and glucose concentration) as additional criteria
trum, ranging from a small parapneumonic effusion (PPE) to a for categorizing PPE; for example, a pleural fluid pH lower than
pus-filled pleural space (empyema) with respiratory compromise 7.20 or a glucose level lower than 60 mg/dl has been considered
and sepsis. (The terms PSI and PPE are often used interchange- suggestive of moderate risk. To date, however, the clinical utility
ably.) PSI can be classified either according to its pathophysiolog- and decision thresholds of pH and glucose values have not been
ic stage (exudative, fibrinopurulent, or organizing) or according to well defined. Accordingly, we prefer to omit pleural fluid chem-
its anatomic appearance (nonloculated versus loculated or non- istry from these guidelines.
complicated versus complicated). The term empyema is com- The ACCP Health and Science Policy Committee evaluated
monly reserved for the most advanced stage of PSI.52 six primary management approaches: no drainage, therapeutic
The pathophysiology of PSI or PPE can be divided into three thoracentesis, tube thoracostomy, fibrinolytic therapy, VATS, and
stages.The exudative stage is characterized by the development of open surgery. Overall, pooled outcomes favored patients treated
an exudative effusion secondary to increased pleural permeability; with fibrinolytics, VATS, and open surgery. However, the success
the pleural space is often sterile initially, but if it is left untreated, of an approach is related to the patient’s risk category. The rec-
bacterial infection is likely to ensue. The fibrinopurulent stage is ommendations for drainage in relation to risk category are gener-
marked by the progressive deposition of fibrin and the increasing al guidelines, based on level C and D evidence (with level C refer-
presence of WBCs; gradual angioblastic and fibroblastic prolifera- ring to historically controlled series and case series and level D to
tion leads to extensive fibrin deposits, and the effusion becomes expert opinion). With these recommendations (and their limita-
loculated (complicated). The organizing stage starts as early as 1 tions) in mind, treatment should be tailored to the specific situa-
week after infection, with increasing collagen deposition and lung tion of each patient.
entrapment. After 3 or 4 weeks, the organized collagen has formed
a peel, and the pleural fluid is grossly purulent. Eventually, dense Category 1 and 2 PPE PPE in categories 1 (very low risk)
fibrosis, contraction, and lung entrapment develop.53,54 and 2 (low risk) can be treated with antibiotic therapy directed at
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 8 PLEURAL EFFUSION — 9
the underlying pneumonia. Some patients with category 2 PPE Tuberculous PSI
may require drainage for relief of dyspnea through either thora- Pleural effusion is common in patients with clinically evident
centesis or tube thoracostomy. pulmonary tuberculosis. Most cases of tuberculous effusion are
secondary to hypersensitivity and resolve spontaneously. Tuber-
Category 3 and 4 PPE Drainage options for categories 3 culous empyema is relatively rare; it is typically the result of active
(moderate risk) and 4 (high risk) PPE include tube thoracostomy pleural infection by acid-fast bacteria.55
alone, tube thoracostomy with intrapleural fibrinolytic therapy, Tuberculous PSI is also treated in accordance with the general
VATS drainage, and open surgical drainage. These various ap-
treatment guidelines for bacterial PSI. Chronic tuberculous PSI
proaches are not mutually exclusive: in some cases, patient out-
may present specific problems, such as drug resistance and im-
comes may be optimized by combining them.56
paired ability (or even inability) to reexpand the lung. Surgical pro-
Tube thoracostomy alone may be appropriate for category 3
cedures performed to manage chronic tuberculous empyema
patients with free-flowing effusion.With loculated effusion, howev-
include VATS, standard open decortication, thoracoplasty, parietal
er, the key to successful therapy is breaking down the fibrin septa-
wall collapse, open drainage, myoplasty, and omentopexy.55
tions. Evidence from three small randomized, controlled trials sug-
gested that intrapleural fibrinolytic therapy has an advantage over CHYLOTHORAX AND PSEUDOCHYLOTHORAX
tube thoracostomy alone for patients with category 3 or 4 PPE; a
Chylothorax is the presence of chyle in the pleural space as a
large trial is being conducted to address this specific issue.53 To
consequence of blockage of or damage to the thoracic duct or one
date, only one randomized study, including 20 patients with cate-
of its tributaries.The rate at which chyle flows through the thoracic
gory 3 or 4 PPE, has compared VATS with fibrinolytic therapy.
duct can be higher than 100 ml/hr, and thus, large amounts of
The primary treatment success rate was significantly higher in the
chyle can leak into the pleural space.61 The principal causes of chy-
VATS treatment group, the duration of chest tube drainage was
lothorax are surgical trauma and malignancy (70% to 80% are
less, and the total hospital stay was shorter.57 VATS allows not only
adequate drainage and visualization of the pleural space but also caused by non-Hodgkin lymphoma).46,61,62 Congenital chylotho-
decortication of the lung if required; however, if decortication can- rax is more often due to malformation of the thoracic duct than to
not be thoroughly accomplished by means of VATS and satisfac- birth trauma.24
tory lung expansion cannot be achieved, a thoracotomy should be The diagnosis of chylothorax is made by measuring triglyceride
performed.58 levels in pleural fluid. Levels higher than 110 mg/dl are highly sug-
The principles of PPE treatment can be applied to PSI from any gestive of chylothorax; levels between 50 and 100 mg/dl are equiv-
cause, but in view of the paucity of reliable data, caution should be ocal; and levels lower than 50 mg/dl rule out chylothorax.24
exercised. A pleura-to-serum triglyceride ratio higher than 1 can be a useful
indicator63; the presence of chylomicrons is synonymous with
Posttraumatic PSI chylothorax.25
PSI occurs in about 1% to 5% of patients who have sustained Treatment of chylothorax depends on its cause and severity.
blunt or penetrating thoracic injury. The incidence of PSI in the Postoperative chylothorax may be treated initially with conserva-
setting of trauma increases with the number of chest tubes placed tive measures (e.g., with a nihil per os [NPO] regimen, total par-
and with the duration of chest tube drainage. The effect of an enteral nutrition, and administration of octreotide). However,
undrained hemothorax on the risk of PSI has not been complete- drainage totaling more than 500 ml/day is considered to predict
ly defined, and prophylactic antibiotics have not been shown to failure of conservative management. Thoracic duct ligation is the
reduce the incidence of PSI.52 surgical treatment of choice and can often be performed thoraco-
As noted (see above), the general guidelines for the treatment of scopically. To help identify the leak intraoperatively, it may be
PPE apply to the treatment of posttraumatic PSI. helpful to administer 100 to 200 ml of heavy cream or olive oil
orally 2 to 3 hours before the operation.64,65 Early surgical inter-
Iatrogenic PSI vention is important because the ongoing loss of lymph has sig-
Iatrogenic PSI develops when a preexisting pleural effusion is nificant effects on fluid homeostasis, nutrition, and immunocom-
inoculated with bacteria during an invasive procedure (e.g., thora- petence (secondary to lymphocyte loss). In the early postligation
centesis or tube thoracostomy). The presence of fluid in the pleu- period, medical management should be continued to allow any
ral space appears to be a prerequisite for infection.52 small leaks to seal. An alternative to surgical ligation that has
A bronchopleural fistula (BPF) is by definition a PSI and there- evoked some interest is transabdominal percutaneous emboliza-
fore has a similarly broad spectrum of clinical presentation. The tion of the thoracic duct. This technique requires significant
overall incidence of BPF after lobar resection is approximately 1%; expertise.66
it is somewhat higher after resections for inflammatory diseases Lymphoma-related chylothorax is caused principally by obstruc-
than after resections for cancer. The incidence of BPF after pneu- tion and usually develops on the left side [see Figure 6]. In a stiff and
monectomy varies, depending on the side on which the pneu- infiltrated duct, minor triggers (e.g., a Valsalva maneuver) can lead
monectomy was done, the indications for surgery, the extent of to duct rupture. Although patients with chylothorax often have
preoperative irradiation, and the comorbid conditions present. In extensive disease, supradiaphragmatic disease is not always present.
a report encompassing 464 pneumonectomies for cancer, the inci- Lymphoma-related chylothorax is best managed with thoracentesis
dence of BPF was 8.6% after right pneumonectomy and 2.3% and with therapy directed at the underlying cause. If first-line ther-
after left pneumonectomy. The overall incidence of postpneu- apy fails, thoracoscopic talc pleurodesis is recommended; a small
monectomy empyema (generally but not always secondary to a series reported 100% resolution of lymphoma-related chylothorax
BPF) is 1% to 3%.59,60 with thoracoscopic talc pleurodesis. If the chylothorax does not
PSI that is not associated with a BPF is treated in accordance respond to any of these approaches, it may respond to thoracic duct
with the treatment guidelines for PPE, but if a BPF is present, ligation or pleuroperitoneal shunting. Chylothorax in the presence
operative management is required. of lymphoma-related chylous ascites is a difficult problem that is
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 8 PLEURAL EFFUSION — 10
Discussion
Pleural Anatomy
of the venules, which suggests that the pleural mesothelial cell
The pleura is a continuous membrane that covers the parietal layer may be as leaky as the venular endothelium.3,4,72
and visceral surfaces of the thorax. In adults, it has an estimated
surface area of 2,000 cm2.71 Light microscopy shows the pleura to
have five layers: (1) a mesothelial cell layer; (2) a mesothelial con- Pleural Fluid Physiology
nective tissue layer with basal lamina; (3) a superficial elastic layer; The amount of pleural fluid in an adult is 1 to 10 ml and forms
(4) a loose connective tissue layer with adipose tissue, blood ves- a 10 µm–thick layer.1,3,71,72 Fluid exchange across the pleural sur-
sels, nerves, and lymphatic vessels; and (5) a deep fibroelastic face depends on three mechanisms: (1) passive filtration following
layer.The parietal pleura establishes a pleurolymphatic communi- Starling’s equilibrium, (2) active solute transport, and (3) lym-
cation on the diaphragm to allow clearance of large (> 1,000 nm) phatic clearance. In the normal pleura, Starling’s equilibrium
particles and cells from the normal pleural space.The structure of favors the flow of fluid in a parietal-to-visceral direction.71 The rate
this pleurolymphatic communication consists of stomata 2 to 12 at which fluid traverses the pleura ranges from 20 to 160 ml/day
µm in diameter, which overlie bulblike lymphatic channels (lacu- in adults; maximal lymphatic clearance is believed to be approxi-
nae) separated by a layer of loose connective tissue (the mem- mately 700 ml/day.2,71,73-76
brana cribriformis). The chemical composition of normal pleural fluid is similar to
Electron microscopy reveals microvilli on the mesothelial cell that of interstitial fluid.The protein concentration is typically 1 to
surface of the pleura. The main function of these microvilli is to 2 g/dl.The concentration of high-molecular-weight proteins (e.g.,
enmesh glycoproteins rich in hyaluronic acid for purposes of LDH) is approximately half that seen in serum. Cell counts in
lubrication.The structure of the intercellular junction in the meso- normal pleural fluid range from 1,400 to 4,500 cells/mm3; macro-
thelial cells of the pleura is similar to that in the endothelial cells phages account for the majority of the cells.3,72
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© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 9 PERICARDIAL PROCEDURES — 1
9 PERICARDIAL PROCEDURES
Shari L Meyerson, M.D., and Thomas A. D’Amico, M.D., F.A.C.S.
Surgical procedures are performed on the pericardium either for The pericardium surrounds the heart and the great vessels [see
diagnostic purposes or for relief of the hemodynamic conse- Figure 1]. Its parietal and visceral surfaces meet superiorly at the
quences of pericardial disease.The pericardial processes for which ascending aorta and the superior vena cava. From that point, it
intervention is required can be divided into two broad categories: continues down the right border of the heart and over the anteri-
pericardial effusion and constrictive pericarditis. The decisions or surface of the pulmonary veins to the inferior vena cava. After
that must be made regarding the selection of patients, the timing crossing the inferior vena cava, the inferior pericardium is densely
of surgery, and the choice of technique or approach often pose adherent to the diaphragm. Just past the apex of the heart, it turns
substantial challenges to the surgeon. Accordingly, a thorough superiorly again and runs over the pulmonary veins back to the
knowledge of the anatomy, physiology, and pathophysiology of the aorta.
pericardium is essential for successful management of pericardial Anteriorly, there are normally no connections between the vis-
disease processes. ceral and parietal layers of the pericardium. Posteriorly, the pat-
tern of pericardial reflections around the pulmonary veins and the
venae cavae creates two sinuses. The oblique pericardial sinus is
Anatomic and Physiologic Considerations the space in the center of the pulmonary veins, directly behind the
left atrium. The transverse pericardial sinus is bordered anteriorly
ANATOMY
by the aorta and the main pulmonary artery and posteriorly by the
Like the pleura, the pericardium consists of two layers. The dome of the left atrium and the superior vena cava.
inner layer, the visceral pericardium (or epicardium), is a mono-
PHYSIOLOGY
layer of mesothelial cells that is adherent to the heart. The outer
layer, the parietal pericardium, is a tough fibrous structure com- The pericardium is normally filled with 15 to 50 ml of serous
posed of dense bundles of collagen fibers with occasional elastic fluid, which serves as lubrication to facilitate the motion of the
fibers.The fibrous structure of this layer renders the pericardial sac heart within this structure. By virtue of its relative noncompliance,
relatively noncompliant, and this noncompliance plays a signifi- the pericardium exerts an influence on cardiac hemodynamics.
cant role in pericardial function and pathophysiology. This influence can easily be seen in the normal inspiratory varia-
Aorta
Superior
Vena Cava Pulmonary Artery
Transverse
Sinus Pulmonary
Veins
Pulmonary
Veins
Oblique
Sinus
Inferior
Vena Cava
Table 1 Causes of Constrictive Pericarditis cause of constrictive pericarditis, and it is still the dominant infec-
tious cause in many developing countries today.1,2 In the United
Unknown States, tuberculosis is the cause of constrictive pericarditis in ap-
Infection proximately 6% of patients who undergo pericardiectomy.3 Con-
Tuberculosis strictive pericarditis also occurs after instrumentation of the peri-
Viral infection (coxsackievirus B) cardium and is seen occasionally (in 0.2% to 0.3% of cases) after
Bacterial infection cardiac surgery.4,5 It also may develop after iatrogenic cardiac per-
Fungal infection (histoplasmosis, coccidioidomycosis) foration in the course of catheterization or pacemaker placement
Parasitic infection (amebiasis, echinococcosis)
and after blunt or penetrating trauma—essentially, after any
Cardiac surgery or pacemaker insertion
Common causes Penetrating, nonpenetrating, or iatrogenic trauma
process resulting in an incompletely drained hemopericardium.6,7
Radiation therapy The pericardium may harbor metastatic disease or locally
Connective tissue disorders (rheumatoid arthritis, sys- advanced disease (e.g., mesothelioma), which may lead to peri-
temic lupus erythematosus, scleroderma) cardial constriction.8,9 Connective tissue disorders (e.g., rheuma-
Renal failure toid arthritis and lupus) can cause recurrent acute pericarditis and
Neoplasm pericardial effusions, eventually resulting in constrictive pericardi-
Metastatic disease (breast, lung, lymphatic system, skin) tis. A similar situation may arise in patients receiving radiation
Primary mesothelioma
therapy and patients with renal failure.
Drugs (procainamide, methysergide, hydralazine)
The stiffening and thickening of the pericardium have three
Myocardial infarction major physiologic effects. First, the thicker pericardium isolates
Asbestosis the heart from changes in intrathoracic pressure. Normally, the
Amyloidosis
Sarcoidosis
pulmonary veins (which are intrathoracic structures) and the car-
Uncommon diac chambers experience the same changes in intrathoracic pres-
causes Dermatomyositis
Actinomycosis sure. In the presence of pericardial constriction, however, the neg-
Lassa fever ative intrathoracic pressure generated during inspiration cannot
Whipple disease be transmitted to the heart. This isolation of the heart results in
Mulibrey nanism
decreased flow through the pulmonary veins during inspiration
and reduced left-side filling.
Second, the ventricles become interdependent. Because total
tion in systemic arterial pressure. Under normal circumstances, pericardial volume does not change, the inspiratory decrease in
intrapericardial pressure is slightly less than 0 mm Hg, becoming left ventricular filling seen with constriction must be accompanied
more negative during inspiration and less negative during expira- by an increase in right ventricular filling, with a resultant septal
tion. Negative intrathoracic pressure during inspiration augments shift toward the left ventricle. During expiration, the opposite
right ventricular filling. Because the pericardium does not allow occurs: left ventricular filling increases and right ventricular filling
significant acute right ventricular dilation, the ventricular cavity decreases, and there is a septal shift toward the right ventricle.
enlarges by shifting the septum toward the left ventricle. In addi- Third, the encasement of the heart impairs the diastolic filling
tion, the noncompliance of the pericardium prevents the free wall of all cardiac chambers. Elevated atrial pressure causes rapid ini-
of the left ventricle from distending to recapture its normal cavi- tial filling of the ventricle (with as much as 75% of the ventricle
tary volume. Thus, the volume ejected from the left ventricle is filled during the first 25% of diastole), but by the middle of dias-
slightly decreased, resulting in lower systemic arterial pressure. tole, filling abruptly decreases as a result of the rigid pericardium.
Normally, this effect is exceedingly small. However, it becomes Because of this limit to diastolic filling, increasing the heart rate
more pronounced when the pericardium is filled with fluid: ven- becomes the most effective method of increasing cardiac output.10
tricular distention is restricted even further, and paradoxical pulse
becomes clinically apparent.
Pericardial Drainage Procedures for Pericardial Effusion
Although the pericardium is resistant to rapid distention, it is
capable of distending over time. If filled slowly, it can expand to A number of different processes can result in the accumulation
contain significant amounts of fluid (sometimes more than 1 L) of fluid in the pericardial space [see Table 2]. Regardless of the ori-
before hemodynamic consequences develop. In the setting of an gin of the fluid accumulation, once the pericardium has reached
acute pericardial effusion (e.g., from trauma), however, devastat- the limits of its elasticity, the only way in which it can increase its
ing hemodynamic consequences may occur with only 100 to 200 volume is by reducing the volume occupied by the heart within it.
ml of blood in the pericardium. When the elastic capacity of the Increases in pericardial pressure result in progressive cardiac com-
pericardium is exceeded, even small increases in volume cause pression and reductions in intracardiac volumes and myocardial
large increases in intrapericardial pressure.
Constrictive pericarditis is defined as a chronic fibrous thicken-
ing of the pericardium that causes cardiac compression sufficient
Table 2 Common Causes of Pericardial Effusion
to prevent normal diastolic filling. It can best be thought of as the
chronic sequela of acute pericarditis or of any situation resulting in Malignancy Myocardial infarction
pericardial irritation and adhesion formation. Almost any cause of Trauma Iatrogenesis (intracardiac
acute pericarditis can result in pericardial constriction [see Table 1]. Uremia procedures)
Infection (viral, bacterial, fungal, Aortic dissection
In many patients, there is no clear antecedent event, and the cause
tubercular) Radiation
of the constrictive pericarditis cannot be determined with certain- Autoimmune processes Idiopathic origin
ty. Pathologic examination typically demonstrates end-stage fibro- Cardiac surgery (postoperative
sis, and these cases are presumed to be viral in origin. Historically, complication)
mycobacterial tuberculosis has been the most common infectious
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 9 PERICARDIAL PROCEDURES — 3
PERICARDIOCENTESIS
centesis, successful fluid removal with symptomatic relief was
achieved in 97.1% of cases.16 Of the 139 patients, 2.9% experi-
Operative Technique enced complications (e.g., pneumothorax and ventricular lacera-
Pericardiocentesis is performed either at the bedside in an tion), and one (0.7%) died. In all, 45 of the patients received no
urgent situation or, preferably, under echocardiographic guidance further therapy, and in 25 (55%) of the 45, recurrent effusions
in a catheterization laboratory. The basic technique is simple. developed that necessitated reintervention.
Several techniques for preventing recurrent pericardial effusion
Step 1: placement of needle A local anesthetic is infiltrated have been tried. Instillation of a sclerosing agent (e.g., tetracycline,
along the left side of the xiphoid. An 18-gauge spinal needle thiotepa, or bleomycin) into the pericardium to promote fusion
attached to a three-way stopcock and syringe is then advanced into of the two layers of the pericardium has been shown to increase
the pericardial space and directed cephalad toward the left shoul- the success rate of pericardiocentesis by as much as 85%.17-19
der at a 45° angle until fluid is aspirated [see Figure 3]; if air is aspi- Placement of an indwelling catheter (see above) also has been
rated, the needle is withdrawn and redirected more medially. Once shown to improve the success rate.16,20 Several authors have
fluid is aspirated freely, it is inspected. If the fluid is bloody, 5 ml described creating a pericardial window percutaneously by means
is withdrawn and placed on a sponge. If the fluid on the sponge of balloon dilation of the tract created by pericardiocentesis, which
clots, it is fresh blood, probably from a cardiac injury occurring theoretically allows fluid to drain into the pleural space or the sub-
during the procedure or from intracardiac positioning of the nee- cutaneous tissues, where it can be absorbed.21,22 However, it is
dle; blood that has been in the pericardium for even a short time unclear how long a window created in this fashion will remain
becomes defibrinated and will not clot.14 patent. Although pericardiocentesis provides initial symptomatic
relief in most patients, the observation that 15% to 45% of
Troubleshooting. The inherent danger of cardiac injury during patients require a further procedure for diagnosis and as many as
pericardiocentesis should be obvious.The risk is highest with small 55% require reintervention for recurrence has led some authori-
or loculated effusions and patients with coagulation abnormalities. ties to question its benefit.
The possibility of cardiac aspiration or injury can be minimized,
SUBXIPHOID PERICARDIOSTOMY (PERICARDIAL WINDOW)
though not eliminated, by means of various safety measures. The
simplest of these measures is to attach an ECG lead to the needle
and employ continuous ECG monitoring. If the needle contacts Operative Technique
the epicardium, ST segment elevation will be observed, in which Subxiphoid pericardiostomy may be performed either to diag-
case the needle is withdrawn until the ST elevation disappears. nose pericardial effusion or to manage tamponade. For diagnosis,
Another useful safety measure is to employ echocardiographic the procedure is usually done with general anesthesia. In an unsta-
guidance to help direct aspiration of a loculated area. Simulta- ble patient with significant tamponade, who would be at risk for
neous cardiac catheterization has also been used to locate the right hemodynamic collapse with general anesthesia, the procedure may
coronary artery and the atrioventricular groove. be performed with the patient under local anesthesia and mild
sedation and breathing spontaneously. If there is any question of
Step 2: placement of drainage catheter and aspiration of tamponade, the patient is prepared and draped while awake, and
fluid Once the needle is within the pericardial space, a guide anesthesia is induced only when the surgeon is ready to begin. In
wire is placed through it, and a small-bore drainage catheter is all patients, the entire chest should be prepared, in case a full ster-
advanced into the effusion by means of a modified Seldinger tech- notomy is required. Ideally, the patient is sedated and the airway
nique. Fluid is aspirated and sent for laboratory evaluation (in-
cluding cell count, chemistry, culture, and cytology). The cathe-
ter is then connected to a closed drainage system for 24 to 72
hours; this may help reduce recurrence.
Complications
The most common complications of pericardiocentesis are
pneumothorax, cardiac injury, misdiagnosis, and recurrence of
pericardial effusion. In every patient undergoing pericardiocente-
sis, pneumothorax must be ruled out by means of chest x-ray at
the completion of the procedure or, if respiratory or hemodynam-
ic changes develop intraoperatively, during the procedure. Cardiac
injuries range from minor needle lacerations to the epicardium,
which are self-limited in patients with normal coagulation param-
eters, to potentially fatal injuries that lead to acute cardiac tam-
ponade. Incorrect diagnoses based on pericardiocentesis are not
uncommon. Although a diagnosis can be confirmed by positive
results from fluid culture or cytology, negative results from cytol-
ogy do not rule out malignant effusion. Cytologic analysis of peri-
cardial fluid is diagnostic in only 55% to 85% of patients.15
Further diagnostic maneuvers often must be undertaken, usually
involving subxiphoid or thoracoscopic approaches with pericardial
biopsy. Recurrence of pericardial effusion after pericardiocentesis
is extremely common. In a review that included 139 patients with Figure 3 Pericardiocentesis. The needle is angled toward the left
malignant pericardial effusions who were treated with pericardio- shoulder at an angle of 45°.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 9 PERICARDIAL PROCEDURES — 5
controlled while spontaneous respiration is maintained to mini- to the pericardium. Upon entry into the pericardium, there is an
mize hemodynamic effects. If necessary, a local anesthetic may be initial outrush of fluid. A sanguineous effusion can be difficult to
infiltrated and the incision made before induction of anesthesia. differentiate from cardiac injury; therefore, the patient’s hemody-
namics should be carefully monitored during this time. When the
Step 1: initial incision and exposure of pericardium A pressure placed on the heart by an effusion is released, blood pres-
small vertical incision is made from the xiphisternal junction down- sure will usually rise and heart rate fall; however, if the heart has
ward to a point slightly below the tip of the xiphoid process [see been accidentally injured, the opposite will occur. Once hemody-
Figure 4a]. The upper extent of the linea alba is divided, with care namic stability is achieved, administration of a diuretic (e.g., furo-
taken not to enter the peritoneum. Peritoneal openings are easily semide) should be considered to reduce the risk of pulmonary
repaired but can make the procedure technically more difficult, in edema developing as a result of systemic fluid retention.
that abdominal contents tend to impede visualization, especially in
spontaneously breathing patients. The soft tissue attachments to Step 3: creation of pericardial window Pericardial fluid is
the xiphoid are divided, the veins running along either side of the collected for microbiologic and cytologic analysis and for any
xiphoid are controlled, and the xiphoid process is removed. additional testing suggested by the clinical scenario. The pericar-
The tissue plane behind the lower sternum is developed by dial space is gently explored with the fingers, and all remaining
means of blunt dissection.This maneuver exposes the retrosternal fluid is evacuated. The edge of the pericardial opening is grasped
space to allow visualization of the pericardium. To enhance expo- with a clamp and elevated [see Figure 4b]. A pericardial specimen
sure, the sternum is retracted upward by an assistant. The anteri- several square centimeters in size—or as large as can safely be
or pericardial surface is then exposed by sweeping away the re- managed—is resected and sent for pathologic and microbiologic
maining mediastinal fat. If necessary, the confluence of the peri- analysis.
cardium and the diaphragm may be retracted caudally to improve
exposure. Step 4: drainage and closure A separate stab incision for
drain placement is made below and to one side of the lowermost
Step 2: opening of pericardium The location of the peri- aspect of the skin incision. Bringing the drainage tube out through
cardial incision can be confirmed by palpating cardiac motion a separate incision helps prevent incisional complications (e.g.,
through the exposed pericardium.The pericardium is then opened infection and hernia). A 24 to 28 French chest tube (either straight
with a scalpel; shallow strokes should be employed to reduce the or right-angle) is tunneled through the fascia at the entry site so
chances of injuring underlying myocardium that may be adherent that it lies beneath the divided linea alba in the preperitoneal
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 9 PERICARDIAL PROCEDURES — 6
space. The tube is then directed through the pericardial window racoscopic pericardial drainage necessitates single-lung ventilation
and into the pericardial space and secured at skin level.The fascia and thus is unsuitable for unstable patients, especially those with
at the linea alba is closed with interrupted sutures to provide tamponade. Such ventilation can be accomplished by means of
secure closure and prevent late hernia; the skin and subcutaneous either a dual-lumen endotracheal tube or a bronchial blocker
tissue are closed in the standard fashion. The chest tube is con- placed through a standard endotracheal tube.
nected to a drainage system with a water seal. Pericardial drainage Once the tube is in place, the patient is turned to the appropri-
is maintained for several days postoperatively until the output falls ate lateral decubitus position. The side of approach is chosen on
below 100 ml/day. This period allows time for apposition and the basis of the location of a loculated effusion or the site of any
adhesion formation between the visceral pericardium and the pari- coexisting pathologic condition (e.g., a pleural effusion or pul-
etal pericardium. monary nodule). If the disease process or processes present do not
Although some fluid may initially drain into the subcutaneous dictate a particular side of approach, the right side is frequently
tissues and be absorbed, the name pericardial window is some- preferred. It is often easier to operate on the right side because
thing of a misnomer. The surgically created window in the peri- there is more working room within the pleural space; however,
cardium is unlikely to remain patent over the long term, and in operating on the left side usually allows the surgeon to create a
fact, obliteration of the pericardial space has been shown to be the larger pericardial window. If tamponade is present in a patient for
mechanism responsible for the success of this procedure.23,24 whom the thoracoscopic approach is desired, pericardiocentesis
may be performed before induction of general anesthesia.28
Complications
Complications from subxiphoid pericardiostomy are rare; Step 1: placement of ports and entry into pleural space
bleeding, infection, incisional hernia, anesthetic complications, An initial camera port is placed in the posterior axillary line at the
and cardiac injury have been reported. In a study that included eighth intercostal space [see Figure 5].The pleural space is entered
155 patients who underwent subxiphoid pericardiostomy over a 5- and explored, and any effusion present is drained. Pleural fluid is
year period, not a single death was attributable to the operative sent separately for culture and cytologic analysis.To prevent inad-
procedure itself.23 The 30-day mortality was high but was related vertent entry into the pericardium, which is often distended, a sec-
to the underlying disease process: 33% in patients with malignant ond incision is created anteriorly at the fifth intercostal space
effusions and 5% in those with benign effusions. Recurrent peri- under camera visualization.
cardial effusion necessitating additional procedures occurred in
four patients (2.5%). In a study that compared 94 patients who Step 2: opening of pericardium On the left side, the
underwent subxiphoid pericardiostomy with 23 patients who un- phrenic nerve, which runs midway between the hilum and the
derwent pericardiocentesis, the rate of recurrent effusion that anterior chest wall, is carefully identified, and an initial pericardial
necessitated reintervention was 1.1% after subxiphoid window but incision is made approximately 1 cm anterior to this nerve. Care
30.4% after pericardiocentesis.25 In this series, the rate of major must be taken to place this first incision in an area that is free
complications after the pericardial window procedure was 1.1% of cardiac adhesions. When grasped, the pericardium should tent
(one patient with bleeding that necessitated reexploration), com- outward slightly. Often, cardiac motion is visible through the
pared with a major complication rate of 17% after pericardiocen- pericardium.
tesis (including a mortality of 4%).
Several studies have shown that the most important predictor of Step 3: creation of pericardial window A pericardial win-
long-term outcome is the underlying disease process. In one, the dow several square centimeters in area is removed. A similar win-
median survival time was 800 days for patients with benign dis- dow may be created posterior to the phrenic nerve—again, with
ease, 105 days for patients with known cancer but negative results care taken to stay at least 1 cm away from the nerve. The pericar-
from pericardial cytology and pathology, and only 56 days for dial space is inspected, and any loculations are opened. The pro-
patients with malignant effusions.23 It appears, however, that can- cedure is similar when performed on the right side, except that the
cer patients with hematologic malignancies and pericardial effu- phrenic nerve on the right runs much closer to the hilum; accord-
sion survive significantly longer than patients with other malig- ingly, instead of two pericardial windows (anterior and posterior to
nancies. In another study, the mean survival time after drainage of the nerve), only a single, larger pericardial window is created
pericardial effusion was 20 months for patients with hematologic (anterior to the nerve).
malignancies, compared with 5 months for patients with any other In patients who can tolerate general anesthesia, a pericardial
malignancies.26 The investigators suggested that this finding may window can be created thoracoscopically with excellent diagnostic
be related to the relative responsiveness of hematologic cancers to yield and relief of symptoms.29 The thoracoscopic approach allows
systemic chemotherapy. Patients with HIV disease have been directed access and can be useful in treating effusions that recur
shown to have universally dismal outcomes after they present after subxiphoid pericardiostomy.30
with pericardial effusion. In this population, surgical pericardial
drainage generally is not diagnostically revealing and is of little
therapeutic value. Several authors have questioned whether peri- Pericardiectomy for Constrictive Pericarditis
cardial drainage should even be offered to these patients.27
PREOPERATIVE EVALUATION
THORACOSCOPIC PERICARDIOSTOMY
Constrictive pericarditis appears to be about three times as
common in males as in females, and it may occur at any point in
Operative Technique life from childhood to the ninth decade.31 The symptoms of con-
Thoracoscopic pericardiostomy is a safe and effective approach strictive pericarditis usually develop progressively over a period of
to the diagnosis and management of pericardial effusion, especial- years but may develop within weeks to months after a defined
ly in patients with a unilateral pleural disease process that can be inciting event (e.g., mediastinal irradiation or cardiac surgery).
simultaneously addressed in the course of the procedure. Tho- Signs and symptoms are related to pulmonary venous congestion
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 9 PERICARDIAL PROCEDURES — 7
4–5 cm Incision in
1.5 cm Incision in Fifth Intercostal Space
Eighth Intercostal Space for Instruments
for Camera Port
Assistant
behind Patient
OPERATIVE PLANNING
(e.g., exertional dyspnea) and systemic venous congestion (e.g.,
elevated jugular venous pressure, hepatomegaly, ascites, and
peripheral edema). Choice of Approach
The physiologic effects of the thickened pericardium form the Pericardiectomy may be performed via either a median ster-
basis for the diagnosis of constrictive pericarditis and, more impor- notomy or a left anterolateral thoracotomy, with equivalent results.
tant, for the differentiation of constrictive pericarditis from restric- Median sternotomy provides better access to the right atrium and
tive cardiomyopathy, which often presents a similar picture. Echo- the great vessels, as well as easier access for cannulation if car-
cardiography can be employed to rule out other causes of right- diopulmonary bypass is required; left anterolateral thoracotomy
side failure. Specific findings that suggest pericardial constriction allows more complete release of the left ventricle. With either
include septal bounce (a respiratory phase–related septal shift) and approach, the patient should undergo full monitoring, including
decreased transmitral flow velocity during inspiration. Computed radial artery catheterization and central venous catheterization,
tomography and magnetic resonance imaging may demonstrate with consideration given to placement of a pulmonary arterial
thickened, often calcified, pericardium; however, the degree of catheter if there is significant hemodynamic compromise. Because
pericardial thickening does not necessarily correlate with the pres- significant blood loss can occur when densely adherent pericardi-
ence of hemodynamic effects. um is resected, large-bore intravenous access should be available as
Cardiac catheterization may demonstrate increases in and equal- well.
ization of end-diastolic pressure in all four cardiac chambers, a dip-
OPERATIVE TECHNIQUE
and-plateau pattern (the square-root sign) in the ventricular pres-
sure curves as a result of rapid early filling and limited late filling,
and rapid x and y descents in the atrial pressure curves. The most Median Sternotomy
useful information obtainable through cardiac catheterization has Step 1: initial incision and exposure The patient is placed
to do with the respiratory variation of ventricular pressure. In a in the supine position, and the skin incision is carried down to the
patient with a normal heart or a patient with restrictive cardiomy- level of the sternum. If there is no history of previous pericardial
opathy, inspiration causes a decrease in both right ventricular pres- procedures and it is possible to develop the plane behind the ster-
sure and left ventricular pressure as a consequence of decreased num bluntly at the superior and inferior aspects, a standard ster-
intrathoracic pressure. In a patient with constrictive pericarditis, notomy saw can be used for the median sternotomy. If, however,
because of the interdependence of the ventricles, inspiration caus- there are likely to be adhesions between the sternum and the peri-
es a decrease in left ventricular pressure but an increase in right cardium or the heart (as in the case of constrictive pericarditis after
ventricular pressure.32 coronary artery bypass grafting), a careful reoperative sternotomy
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 9 PERICARDIAL PROCEDURES — 8
should be performed with an oscillating saw. Access to the femoral pulmonary veins all the way over to the right pulmonary veins
vessels should be available within the sterile field; placement of a (including the origins of the venae cavae). The pericardium is
femoral arterial line will facilitate percutaneous cannulation in the resected from the left phrenic nerve to the right phrenic nerve [see
event that the heart is injured during sternal reentry. Figure 6].
After the sternum is opened, all adhesions are dissected away Cardiopulmonary bypass can make dissection easier, but in
from the sternum, with care taken to stay as close to the posterior view of the greater risk of bleeding and the increased transfusion
surface of the sternum as possible. Both pleural spaces are opened, requirements, it is best avoided if possible. Cardiopulmonary by-
and the left and right phrenic nerves are identified. pass does facilitate repair of cardiac injuries during sternal reentry
or dissection, and it should be used if cardiac procedures are to be
Step 2: dissection and resection of pericardium The performed concomitantly.
phrenic nerves define the limits of pericardial resection bilaterally.
Small loculated spaces are often present within the pericardium, Step 3: drainage and closure After completion of the peri-
especially near the great vessels and the diaphragm, and provide cardiectomy, mediastinal and pleural drains are placed, and the
good starting places for pericardiectomy. Once an initial flap is sternum is closed in the usual fashion.
raised, it is used to provide retraction to facilitate further dissec- Left Anterolateral Thoracotomy
tion. Careful attention must be paid to the coronary artery anato-
Step 1: initial incision and exposure The patient is placed
my: coronary arteries and bypass grafts are vulnerable to injury. If
in the supine position, with a roll under the left side of the torso to
the pericardium is densely adherent in the region of a coronary
elevate the left side 45°. It is often difficult to establish cardiopul-
artery, small islands of pericardium may be left on the heart. Areas
monary bypass through the chest via this approach; therefore, the
of calcification can be addressed with the use of bone-cutting femoral vessels should be available within the sterile field so that
instruments; however, if an island of calcification appears to extend femorofemoral bypass can be instituted if necessary. A curvilinear
into the myocardium, it should not be removed. submammary incision is created, and the chest is entered at the
Epicardium can also be involved in the disease process and fifth interspace. For improved exposure, the internal thoracic ves-
should be resected or scored until no further restriction to ventric- sels may be divided and the intercostal muscles divided posterior-
ular filling remains. The heart should be dissected free of the left ly. The left phrenic nerve is carefully identified.
a b
Aorta
Pulmonary
Left Anterior Descending Artery
Coronary Artery
Phrenic
Nerve
Aorta
Phrenic Nerve
Dissected Free
Lung
Figure 7 Pericardiectomy: left anterolateral thoracotomy approach. (a) The left phrenic nerve is
identified. (b) The entire pericardium is dissected free over the left ventricle, with an island of pericardium
left attached to the phrenic nerve along its length. Care must be taken to avoid injuring coronary vessels.
postoperative patients may reflect underlying cardiac dysfunction, Another study reported similar findings, with radiation-induced
as well as the vulnerability of previous bypass grafts to injury. The constriction leading to significantly decreased 10-year survival after
poor outcomes after pericardiectomy for radiation-induced con- pericardiectomy.31 The authors also noted that patients who under-
striction indicate that constriction is not the sole factor responsible went pericardiectomy for radiation-induced constriction had
for cardiac failure in this situation. Although cardiac failure has demonstrably worse late functional status. Fifteen of 17 long-term
been attributed to myocardial atrophy caused by prolonged con- survivors with a history of previous radiation therapy showed New
striction, the excellent outcomes reported after pericardiectomy York Heart Association class III or IV symptoms, whereas only 31
for idiopathic constrictive pericarditis suggest that constriction is of 112 patients without a history of radiation therapy had major
rarely the only cause of cardiac failure. symptoms of heart failure.
References
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2. Butany J, El Demellawy D, Collins MJ, et al: Con- 7. Isaacs D, Stark P, Nichols C, et al: Post traumatic Clin 9:665, 1991
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of the literature. Can J Cardiol 20:1137, 2004 2003 ade. Chest 113:1372, 1998
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pericardial diseases. Cardiol Clin 84:683, 1990 lioma. Curr Treat Options Oncol 3:369, 2002 Changes in pericardial morphology and fibrinolyt-
4. Cimino JJ, Kogan AD: Constrictive pericarditis 9. Quinn DW, Qureshi F, Mitchell IM: Pericardial ic activity during cardiopulmonary bypass. J
after cardiac surgery: report of three cases and mesothelioma: the diagnostic dilemma of mislead- Thorac Cardiovasc Surg 106:339, 1993
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1989 10. Myers RBH, Spodick DH: Constrictive pericardi- ease in patients with cancer. Am J Med 71:407,
5. Matsuyama K, Matsumoto M, Sugita T, et al: tis: clinical and pathophysiologic characteristics. 1981
Clinical characteristics of patients with constrictive Am Heart J 138:219, 1999 16. Vaitkus PT, Herrmann HC, LeWinter MM:
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J 65:480, 2001 cardiac tamponade: mainly the result of atrial, not JAMA 272:59, 1994
6. Swallow RA, Thomas RD: Pericardial constriction ventricular, compression. Circulation 71:154, 1985 17. Shepherd FA, Morgan C, Evans WK, et al:
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Medical management of malignant pericardial ponade. J Thorac Cardiovasc Surg 109:546, 1995 treatment of pericardial effusions. Am J Cardiol
effusion by tetracycline sclerosis. Am J Cardiol 24. Sugimoto JT, Little AG, Ferguson MF, et al: 82:124, 1998
60:1161, 1987 Pericardial window: mechanism of efficacy. Ann 30. Campione A, Cacchiarelli M, Ghiribelli, et al:
18. Davis S, Rambotti P, Grignani F: Intrapericardial Thorac Surg 50:442, 1990 Which treatment in pericardial effusion? J Cardio-
tetracycline sclerosis in the treatment of malignant 25. Allen KB, Faber LP,Warren WH, et al: Pericardial vasc Surg 43:735, 2002
pericardial effusion. J Clin Oncol 2:631, 1984 effusion: subxiphoid pericardiostomy versus per- 31. Ling LH, Oh JK, Schaff HV, et al: Constrictive
19. Girardi LN, Ginsberg RJ, Burt ME: Pericardio- cutaneous catheter drainage. Ann Thorac Surg pericarditis in the modern era: evolving clinical
centesis and intrapericardial sclerosis: effective 67:437, 1999 spectrum and impact on outcome after peri-
therapy for malignant pericardial effusions. Ann 26. Dosios T,Theaskos N, Angouras D, et al: Risk fac- cardiectomy. Circulation 100:1380, 1999
Thorac Surg 64:1422, 1997 tors affecting the survival of patients with pericar- 32. Nishimura RA: Constrictive pericarditis in the
20. Kopecky SL, Callahan JA, Tajik AJ, et al: Percuta- dial effusion submitted to subxiphoid pericardios- modern era: a diagnostic dilemma. Heart 86:619,
neous pericardial catheter drainage: report of 42 tomy. Chest 124:242, 2003 2001
consecutive cases. Am J Cardiol 58:633, 1986 27. Flum DR, McGinn JT, Tyras DH: The role of the 33. Bertog SC, Thambidorai SK, Parakh K, et al:
21. del Barrio LG, Morales JH, Delgado C, et al: ‘pericardial window’ in AIDS. Chest 107:1522, Constrictive pericarditis: etiology and cause-spe-
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22. DiSegni E, Lavee J, Kaplinsky E, et al: Percutan- and Laparoscopic Surgery, 2nd ed. Soper NL,
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© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 10 PULMONARY RESECTION — 1
10 PULMONARY RESECTION
Ara Vaporciyan, M.D., F.A.C.S.
Anatomic resections of the lung (including pneumonectomy and placed in the supine position, with a pillow placed in such a way as
lobectomy) are the standard operative techniques employed to to elevate the area of the thorax that will be operated on.
treat both neoplastic and nonneoplastic diseases of the lung. Any When the patient is in the lateral decubitus position, several
surgeon who intends to operate on the pulmonary system must be measures should be adopted to guard against injury. Adequate
keenly aware of the anatomy of the pulmonary vasculature, the padding should be employed to prevent the development of pres-
bronchi, and the relation between the two. There is no substitute sure points on the contralateral lower extremity. A low axillary roll
for this degree of familiarity. Detailed discussions are available in should be used to prevent injury to the contralateral brachial plexus
existing anatomy textbooks. In what follows, I describe several of and shoulder girdle. Finally, adequate padding should be placed
the more common techniques employed for anatomic resections of beneath the head to keep the cervical spine in a neutral position.
the lung.
GENERAL TECHNICAL CONSIDERATIONS
ed. In patients with malignant disease, biopsies of any suspicious often apply staples only to the proximal side of the bronchus and
nodules are performed. The presence or absence of pleural fluid divide the bronchus distal to the staple line. Once the stapler is
should be noted; if fluid is present, it should be aspirated and sent applied, every effort should be made to minimize its movement
for immediate cytologic analysis. during firing, so as to prevent injury to the remaining proximal
Frequently, the fissures are incomplete as a consequence of bronchial segment. With the stapler applied but not yet fired, the
congenital absence, inflammatory disease, or a neoplasm. If the remaining lung should be ventilated to determine whether there
adhesions within the fissure are filmy, they may be divided sharply is any impairment of ventilation secondary to placement of the
or with the electrocautery while the lung is being ventilated. If the stapler too close to a proximal lobar bronchus. Only when the
adhesions are more densely adherent, the fissures may have to be absence of ventilatory impairment has been confirmed should the
completed with staplers. During resection for malignancy, any evi- stapler be fired. When bronchial length is limited, one may per-
dence of tumor extension across a fissure or of hilar nodal involve- form suture closure of the bronchial stump rather than attempt to
ment should be noted. A decision is then made regarding the force a stapler around the bonchus. Whenever there is a high risk
extent of the required resection. If there is only minor extension, of bronchial stump dehiscence (e.g., after chemotherapy, radio-
wedge resection of a portion of the additional lobe is indicated. If, therapy, or chemoradiotherapy; in patients for whom adjuvant
however, the involvement is significant, segmentectomy, bilobec- therapy is planned; or after right pneumonectomy), a vascularized
tomy, or pneumonectomy may be indicated. Often, I develop the rotational tissue flap (e.g., from the pericardium, the pericardial fat
fissures during ventilation until a dense or incomplete region is pad, or intercostal muscle) should be used to reinforce the bron-
encountered, at which point I complete the remainder of the fis- chial closure.
sure with staples. For this approach to work, the vascular and
bronchial anatomy must already have been completely delineated. Closure and Drainage
If the vascular structures cannot be identified in the fissure Once the bronchial closure is complete, the next step is to test
because the fissure is fused, the pulmonary artery branches will its adequacy. The bronchial stump is submerged under normal
have to be approached from the anterior and posterior hilum. saline, and the lung is inflated to a tracheal pressure of 45 cm H2O.
Traditionally, during a lobectomy, the arterial branches are Any area of hilar dissection and divided fissures should be evalu-
divided first, followed by the venous branches. However, if condi- ated in a similar fashion. Significant parenchymal air leaks should
tions exist that limit exposure (e.g., a centrally placed tumor or be repaired with interrupted fine sutures (e.g., 4-0 polypropylene).
significant inflammation and scarring), the surgeon should start If the air leak is from a diffuse raw surface, especially after upper
with the structures that provide the most accessible targets. Veins lobectomy, construction of a pleural tent should be considered.
may be ligated first. Proponents of this approach believe that it Any air leak from the bronchial stump should be assessed very
may limit the escape of circulating tumor cells (an event that carefully. A simple repair with fine absorbable sutures may suffice,
rarely, if ever, occurs); opponents claim that initial vein ligation or the entire closure may have to be redone. Strong consideration
may lead to venous congestion and retention of blood that is sub- should be given to reinforcing the stump with vascularized tissue
sequently lost with the specimen, though peribronchial venous (see above).
channels will frequently prevent this result. The bronchus may The chest is usually drained with two chest tubes that are posi-
also be ligated first. However, there are two points that should be tioned anteriorly and posteriorly and exit through separate stab
kept in mind if this is done. First, the distal limb of the bronchus incisions in the chest wall. If an epidural or a paravertebral catheter
(the specimen side) should be oversewn to prevent drainage of is being employed for postoperative pain management, the chest
mucus into the chest. Second, after division of the bronchus, the tubes should exit through an intercostal space that is no more than
lobe is much more mobile; therefore, to prevent avulsion of the two spaces below the intercostal space used for entry into the
pulmonary artery branches, care should be taken not to employ chest. Failure to follow this recommendation is likely to result in
excessive torsion or traction. pain originating from the chest tube site that will not be ade-
The techniques used for dissection, ligation, and division of pul- quately addressed postoperatively and will lead to a significant
monary arteries and their branches differ from those used for increase in discomfort.
other vessels. Pulmonary vessels are low-pressure, high-flow, thin- After a pneumonectomy, the chest tubes can be omitted. If this
walled, fragile structures. Accordingly, for rapid and safe dissec- option is chosen, a needle should be used to aspirate 1,000 to
tion, a perivascular plane, known as the plane of Leriche, should 1,200 ml of air from the hemithorax operated on after closure of
be sought.This plane may be absent in the presence of long-stand- the skin. If a chest tube is used, a balanced drainage system is
ing granulomatous or tuberculous disease, after major chemother- employed without suction. At most institutions, suction is
apy, after thoracic radiotherapy, and in cases of reoperation. In employed postoperatively for all other resections (i.e., lobectomy,
these situations, proximal control of the main pulmonary artery segmentectomy, and wedge resection); however, careful use of
and the two pulmonary veins may be necessary before the more water seal in selected patients (i.e., those with small air leaks whose
peripheral arterial dissection can be started. Before any pulmo- lungs do not collapse while on water seal) may allow earlier with-
nary vessel is divided, it should be controlled either with two sep- drawal of the tube.
arate suture ligatures proximal to the line of division or with vascu-
lar staples; stapling devices are especially useful for larger vessels.
Exposure of the bronchus should not involve stripping the Operative Technique
bronchial surface of its adventitia. Aggressive dissection may com-
RIGHT LUNG
promise the vascular supply and lead to impaired healing and
bronchial dehiscence. Overlying nodal tissues should be cleared,
and major bronchial arteries should be clipped just proximal to the Right Upper Lobectomy
point of division. Bronchial closure has been greatly facilitated by Dissection begins within the interlobar fissure, and the pul-
the use of automatic staplers. Because the bronchus is frequently monary artery is exposed at the junction of the major and minor
the last structure to be divided before removal of the specimen, I fissures [see Figure 1]. In many cases, the artery is partially
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4 THORAX 10 PULMONARY RESECTION — 3
obscured by a level 11 interlobar lymph node, which should be fired, the right lung is ventilated to confirm that the bronchus
removed. Also present is the posterior segmental branch of the intermedius has not been compromised. The stapler is fired, the
superior pulmonary vein, which traverses the fissure in a posterior- bronchus is divided, and the specimen is removed.
to-anterior direction.The pulmonary artery lies medial and inferi- To prevent middle-lobe syndrome resulting from torsion of the
or to this venous branch. narrow hilum of the middle lobe after an upper lobectomy, the
Once the pulmonary artery is identified, the branches within middle lobe should be secured to the lower lobe. Once the lungs
the fissure are exposed, including the posterior ascending artery are reexpanded, a small portion of the lower lobe and a compara-
to the right upper lobe, the right middle-lobe artery, the superior ble portion of the middle lobe are grasped along the major fissure.
segmental artery to the right lower lobe, and the basilar branch- A single application (or, at most, two applications) of a TA stapler
es to the right lower lobe. If the exposure is adequate, the poste- should suffice to secure the lobes to each other at this site and thus
rior ascending branch can be ligated and divided. If additional prevent middle-lobe torsion.
length is required, the fissure between the superior segment of
the lower lobe and the posterior segment of the upper lobe can Right Middle Lobectomy
be completed. This is accomplished by opening the pleura in the The initial steps in a right middle lobectomy are similar to those
posterior hilum along the lateral edge of the bronchus inter- in a right upper lobectomy. The pulmonary artery and its branch-
medius. A level 11 lymph node will be encountered between the es are identified within the fissure.The middle-lobe artery is iden-
right upper-lobe bronchus and the bronchus intermedius. tified [see Figure 1]. Not infrequently, there are two middle-lobe
Removal of this interlobar node (sometimes referred to as the arteries. When this is the case, the most proximal branch is com-
sump node) will expose the posterior ascending branch. Either monly located across from the posterior ascending branch to the
the branch can be directly ligated and divided via this exposure, right upper lobe. Once the anatomy has been confirmed, the arte-
or the fissure can be completed with gastrointestinal anastomo- rial branches to the middle lobe can be individually ligated and
sis (GIA) staplers, with the vessel ligated and divided after com- divided. If additional exposure is needed before ligation, the fis-
pletion of the fissure.
The lung is then rotated posteriorly, and the pleura is incised
posterior to the course of the phrenic nerve, which usually passes Right
close to the base of the superior pulmonary vein. The phrenic Middle
Lobe
nerve is carefully and gently mobilized anteriorly.The superior pul- Interlobar
monary vein is dissected, and the apical, anterior, and posterior Pulmonary
Artery Right Middle-
branches are encircled [see Figure 2]. Care is taken to preserve the Lobe Artery
Posterior
middle-lobe branches. The branches draining the upper lobe are Segmental Basilar Segmental
then ligated and divided or controlled with a vascular stapler. Branch of Arteries to Right
Division of the veins before division of the arterial supply will not Right Superior Lower Lobe
cause the lobe to become engorged. Instead, through collateral Pulmonary Vein
Right
venous drainage to the middle lobe or via bronchial venous chan- Lower
nels, blood will be shunted away from the upper lobe. Lobe
The interlobar (or truncus posterior) branch of the right pul-
monary artery will be visible as it courses posterior to the superior
pulmonary vein branches. Dissection continues along the lateral
surface of the interlobar artery. Once the branches to the middle-
lobe artery are identified, the dissection should reach the region
previously dissected within the fissure. The fissure between the
middle lobe and the upper lobe can now be completed through
serial application of GIA staplers.
The right upper lobe is then rotated more inferiorly to provide
a better view of the superior aspect of the hilum. This step allows
complete exposure of the truncus anterior branch. Frequently, the
truncus anterior branch originates from the main right pulmonary
artery medial to the course of the superior vena cava; some ele- Right
ments of the pericardium may also encircle the artery at this loca- Upper
Lobe
tion. Once the vessel is exposed, it is either suture-ligated and
divided or transected with an endovascular stapler. Superior
The upper lobe is retracted superiorly and posteriorly, and the Posterior Ascending Segmental
Branch to Right Branch to Right
interlobar artery is gently retracted anteriorly.The bronchus to the Upper Lobe Lower Lobe
right upper lobe is circumferentially exposed, and all nodal tissue
surrounding the right upper-lobe bronchus is swept distally so that Figure 1 Right upper lobectomy. Shown is the surgeon’s view of
it can be included with the specimen. Every effort is made to avoid the right interlobar fissure. The fissures have been completed, and
the segmental arteries to the upper, middle, and lower lobes have
devascularizing the bronchus. Once an adequate length of the
been identified. The posterior ascending branch to the upper lobe
right upper-lobe bronchus is exposed, the lung is rotated anterior-
most commonly varies with respect to size and origin. This vessel
ly to allow visualization of the course of the bronchus intermedius may be absent or diminutive and may arise from the superior
[see Figure 3].The bronchus is ligated with a transverse anastomo- segmental branch to the lower lobe. The posterior segmental vein
sis (TA)–30 stapler loaded with 4.8 mm staples. Care is taken to draining into the superior pulmonary vein (not seen) is clearly
achieve close apposition of the anterior wall to the posterior mem- visualized in the right upper lobe, lateral to the pulmonary artery
branous wall of the bronchus. With the stapler applied but not branches.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 10 PULMONARY RESECTION — 4
Middle-Lobe
Vein
Vagus
Nerve
Pulmonary
Ligament
Posterior Segmental
Right Vein to Right Upper Lobe
Upper Lobe Truncus
Anterior Branch Interlobar Artery
Figure 2 Right upper lobectomy. Shown is the surgeon’s view of the anterior right hilum. The apical
venous branches of the superior pulmonary vein obscure the interlobar pulmonary artery and, to a
lesser degree, the truncus anterior branch. Division of these venous branches during upper lobectomy
improves exposure of the truncus anterior. The splitting of the main pulmonary artery into its two
main branches may occur more proximally, and care should be taken to identify both branches before
either one is divided. Another significant possible variation is a branch of the middle-lobe vein that
arises from the intrapericardial portion of the superior pulmonary vein.
Divided Inferior
Lower-Lobe Pulmonary Vein
Bronchus Esophagus
Figure 6 Right lower lobectomy. Shown is the surgeon’s view of the right fissure after
division of the lower-lobe vessels. The decision whether to divide the bronchi separately
or to transect them with a single oblique application of the stapler depends on the prox-
imity of the middle-lobe bronchus to the superior segmental and basilar bronchi.
Lingular
Segmental
Artery
Aorta
Left
Upper
Lobe
Left Lower
Lobe
Superior
Basilar Segmental Artery
Segmental Arteries
Figure 7 Left upper lobectomy. Shown is the surgeon’s view of the left interlobar
fissure. The recurrent laryngeal nerve can be seen coursing lateral to the ligamentum
arteriosum. The arterial branches supplying the left upper lobe between the apico-
posterior segmental branch and the lingular branch can vary substantially in number
and size. Another frequently encountered variation is a distal lingular branch that
arises from a basilar segmental branch.
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4 THORAX 10 PULMONARY RESECTION — 7
Phrenic Nerve
suture closure is selected instead, the bronchus is divided with the
Superior
clamp placed on the distal bronchus to prevent spillage.The open
Pulmonary Left Pulmonary end of the bronchus is then closed with nonabsorbable simple
Vein Artery sutures, with the cartilaginous wall approximated to the membra-
nous wall. To guard against necrosis of the bronchus, care should
Aorta
be taken not to tie the sutures too tightly. Coverage of the pneu-
Apical Left Upper monectomy stump with viable tissue is preferred, especially if the
Branch Lobe patient has received or will receive chemotherapy, radiation thera-
py, or both. The ideal choice for this purpose is either a rotated
intercostal muscle flap or a pericardial fat pad rotational flap. The
flap is secured with carefully placed 4-0 polypropylene sutures.
In the preceding description, the artery is divided first, followed
by the individual veins and finally by the bronchus; however, the
steps of this operation can be carried out in any order. The posi-
tion of the tumor may make the approach I describe difficult. For
example, an anteriorly placed tumor may hinder exposure of the
anterior hilum. In this situation, the bronchus can be divided first,
and the pulmonary artery can be approached from the posterior
hilum. As another example, if the tumor is very proximal, the peri-
cardium can be entered via a U-shaped incision along the anteri-
or, caudal, and posterior hilum.The pulmonary veins can then be
divided en masse as they originate from the left atrium, and the
pulmonary artery can be divided as it courses posterior to the
ascending aorta.
LEFT LUNG
Upper-Lobe Left Pulmonary the lingula and the lower lobe is completed with serial application
Bronchus Artery of GIA staplers [see Figure 9].The left upper lobe bronchus is encir-
cled and either clamped or controlled with a TA stapler.To prevent
inadvertent injury, the pulmonary artery branches to the lower lobe
should be gently retracted posteriorly during stapler placement.
With the stapler applied (or the clamp in place), the anesthesiolo-
gist ventilates the left lung to verify that air is flowing freely to the
entire left lower lobe. Once unobstructed airflow is confirmed, the
stapler is fired and the bronchus divided.
Left Lower Lobectomy
As in a left upper lobectomy, dissection begins within the inter-
lobar fissure. The pulmonary artery is identified, and the branches
to the upper and lower lobes are dissected [see Figure 7].The supe-
rior segmental artery is encircled first and is ligated and divided; not
uncommonly, there are actually two separate superior segmental
arteries. The basilar segmental arteries are then encircled distal to
the origin of the lingular artery. These vessels are also ligated and
divided, with care taken not to encroach on the blood flow to the
lingula.
The lung is rotated superiorly to expose the inferior pulmonary
vein. As in a right lower lobectomy, the vein is encircled by dissect-
ing first on its anterior surface with the lung rotated posteriorly,
Figure 9 Left upper lobectomy. Shown is the surgeon’s view of
then on its posterior surface with the lung rotated anteriorly [see
the left fissure after division of the upper-lobe arteries. Care Figure 10]. Once the vein is encircled, it is ligated and divided.
should be taken not to injure the pulmonary artery inadvertently Attention is then redirected toward the interlobar fissure, and
when applying a stapler. the left lower lobe bronchus is identified [see Figure 11].The origin
of the bronchus is cleared by sweeping nodal tissue distally with
blunt and sharp dissection. The upper-lobe branches of the pul-
nerve [see Figure 8].The superior pulmonary vein can then be iden- monary artery are gently retracted superiorly to allow placement of
tified easily. If the apical branch was not previously ligated, the sur- a TA stapler on the bronchus. With the stapler applied, the anes-
geon should make every effort not to damage the pulmonary artery thesiologist ventilates the left lung to confirm the adequacy of air-
branches that lie posterior to this portion of the vein.The majority flow to the upper lobe. The stapler is fired, and the bronchus is
of the superior pulmonary vein lies anterior to the left upper lobe divided distal to the staple line.
bronchus. Once this vein is encircled, it is ligated and divided.
Attention is then redirected toward the fissure, and the peri- Left Pneumonectomy
bronchial nodal tissue surrounding the left upper lobe bronchus is The initial steps of a left pneumonectomy are similar to those of
swept distally with blunt and sharp dissection.The fissure between a left upper lobectomy.The lung is retracted caudally, and the pleu-
Upper-Lobe
Bronchus
Left Pulmonary
Artery
Left Upper Left Mainstem divided first to facilitate arterial exposure (see below).
Lobe Bronchus Once the pulmonary artery is encircled, the vessel can be ligat-
ed and divided. My preferred method is to use an endovascular
GIA stapler, the advantages of which include its rapidity of use,
its consistently reproducible results, and its ability to control the
vessel along a broad surface. Mass ligation is not advisable,
because the risk of dislocation of the tie is too great. When the
length of exposed artery is too short or a stapler cannot be placed
safely, the surgeon may apply vascular clamps to the proximal and
distal portions of the vessel instead. Once the vessel is divided, the
proximal end may be oversewn with a continuous polypropylene
suture.
If additional vessel length is required because of the presence of
a proximal tumor, the ligamentum arteriosum may be divided.The
recurrent laryngeal nerve should be identified and preserved. In
dividing the left pulmonary artery proximal to the ligamentum
arteriosum, care should be taken not to narrow the main pul-
monary artery and thereby reduce right-side blood flow. For max-
imal safety, systemic blood pressures and oxygenation should be
evaluated for 1 to 2 minutes after application of the clamp or sta-
pler but before ligation.
Figure 11 Left lower lobectomy. Shown is the surgeon’s view of With the lung retracted posteriorly, the pleura is incised posteri-
the left fissure after division of the lower-lobe vessels. In this pro- or to the course of the phrenic nerve, and the superior pulmonary
cedure, a single oblique transection of the entire left lower-lobe
vein is identified [see Figure 8].The vein is encircled with blunt dis-
bronchus can be employed without any concern that a proximal
bronchus will be compromised; this step would not be feasible in
section, then ligated and divided. As noted (see above), the apical
a right lower lobectomy, in that the right middle-lobe bronchus branch usually travels across the apical branch of the pulmonary
arises from the bronchus intermedius. artery, and care should be taken not to injure this vessel during
dissection.
The lung is then retracted superiorly to expose the inferior pul-
ra is incised along the course of the aortic arch [see Figure 7]. The monary vein. Dissection is performed on the anterior and posteri-
superior and posterior surfaces of the pulmonary artery are dissect- or aspects of the inferior pulmonary vein, and blunt dissection is
ed as it enters the thorax under the aortic arch. Once the perivas- used to achieve complete encirclement of the vein [see Figure 10],
cular space is entered, the entire vessel can usually be encircled with which is ligated and divided.
blunt dissection. If the superior pulmonary vein’s apical branch lim- Next, the lung is retracted anteriorly and superiorly. Complete
its access to the anterior surface of the pulmonary artery, the branch dissection of the subcarinal lymph nodes is performed, facilitated
may be ligated and divided first to improve exposure of the artery; by division of one or two pulmonary branches of the left vagus
alternatively, the superior pulmonary vein itself may be ligated and nerve and both bronchial arteries. Gentle traction is applied in
Stumps of Left
Pulmonary Artery
conjunction with blunt dissection to allow encirclement of the the bronchus is divided distal to the staple line.
proximal left mainstem bronchus [see Figure 12]. An effort should Frequently, the position of the bronchial stump under the aor-
be made to encircle the bronchus within 1 cm of the carina. A TA tic arch and deep within the mediastinum renders coverage of the
stapler is then passed around the left mainstem bronchus and stump unnecessary. If the surgeon is concerned about possible
applied at this point. If excessive traction is required to achieve stump dehiscence (e.g., in a patient who has undergone high-dose
this placement, the bronchial stump can be left slightly longer: 1 preoperative radiotherapy), coverage with a flap from the pericar-
to 1.5 cm, as measured from the carina. The stapler is fired, and dial fat pad or intercostal muscle is appropriate.
Selected Reading
Fell SC, Kirby TJ: Technical aspects of lobectomy. tions. General Thoracic Surgery, 6th ed. Shields TW, Pearson FG, Cooper JD, Deslauriers J, et al, Eds.
General Thoracic Surgery, 6th ed. Shields TW, LoCicero J, Ponn RB, et al, Eds. Lippincott Williams & Churchill Livingstone, Philadelphia, 2002, p 974
LoCicero J, Ponn RB, et al, Eds. Lippincott Williams & Wilkins, Philadelphia, 2005, p 470
Wilkins, Philadelphia, 2005, p 433 Martini N, Ginsberg RJ: Lobectomy. Thoracic Surgery,
Hood RM: Techniques in General Thoracic Surgery, 2nd ed. Pearson FG, Cooper JD, Deslauriers J, et al,
2nd ed. Lea & Febiger, Philadelphia, 1993 Eds. Churchill Livingstone, Philadelphia, 2002, p 981 Acknowledgment
Kirby TJ, Fell SC: Pneumonectomy and its modifica- Waters PF: Pneumonectomy.Thoracic Surgery, 2nd ed. Figures 1, 2, and 4 through 12 Alice Y. Chen.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 11 COUGH AND HEMOPTYSIS — 1
CLINICAL EVALUATION
An acute or chronic cough is one of the most common chief pre-
senting complaints. In the United States, it accounts for approxi- An acute or self-limited cough is defined as one that resolves
mately 30 to 50 million physician visits each year, and more than within 3 weeks. Usually, an acute cough is the result of minor
$1 billion is spent annually on its workup and treatment.1 A cough infection or inhalation of irritant gases or particulate matter; some-
can result from a wide variety of conditions, ranging from fairly times, however, it is associated with a more serious condition.
non–life-threatening causes (e.g., bronchitis) to life-threatening Generally, a cough requires diagnostic attention when it persists
ones (e.g., lung cancer). Hemoptysis is also a common presenting for 3 weeks or longer, at which time it is deemed chronic. Numer-
complaint, with a similarly broad spectrum of possible causes. It ous conditions are capable of causing a chronic cough [see Table 1],
may range in severity from mild blood streaking in sputum to mas- and the differential diagnosis of this complaint is broad.
sive hemorrhage that, if left untreated, can lead to shock and rapid Careful diagnostic evaluation is required to identify potentially
death from blood loss and asphyxiation. Even mild hemoptysis is life-threatening causes of chronic coughing [see Figure 1]. Such
distressing to many patients and physicians and calls for prompt evaluation relies heavily on the history. Medications, tobacco use,
attention and diagnosis. In cases of massive hemoptysis, expedient and occupational exposure must all be considered in the effort to
evaluation and management are essential, often involving airway narrow the differential diagnosis. Associated symptoms offer
control with intubation and hemodynamic resuscitation. important clues; for example, in a patient with water brash and a
Because both cough and hemoptysis may be signs of urgent or chronic cough, reflux is more likely to be the cause of the cough
life-threatening disease, patients who present with either or both than it would be in a patient with copious nasal secretions.5,7,8 The
of these symptoms should undergo a thorough, methodical quality of the sputum is a particularly significant variable: purulent
workup consisting of a detailed history, a careful physical exami- sputum may lead one to suspect infection, whereas bloody sputum
nation, and appropriate diagnostic studies (usually computed may lead one to suspect malignancy, especially in a smoker.
tomography of the chest and bronchoscopy). Substantial experience and acute clinical judgment are required to
distinguish the relatively few patients with serious diseases from
the millions of patients who present with a benign cough each
Cough year.
A cough is a forceful expiration that is mediated through the
MANAGEMENT OF SPECIFIC CAUSES
activation of a complex reflex arc.The cough reflex is triggered by
the stimulation of various cough receptors, which are found not Common causes of a chronic cough include acute and chronic
only in the epithelium of the respiratory tract but also in the lower bronchitis, bronchiectasis, asthma, postnasal drip, and gastro-
esophagus, the stomach, and the diaphragm.2,3 These receptors esophageal reflux.4,5,9-15 Other, less common causes include drugs
can be activated by mechanical, chemical, or thermal stimuli; once (e.g., angiotensin-converting enzyme [ACE] inhibitors), intersti-
activated, they send signals to the medulla via the vagus nerve, the tial lung disease, congestive heart failure (CHF), bronchogenic
glossopharygneal nerve, the trigeminal nerve, or the phrenic carcinoma, tracheobronchial foreign bodies, and endobronchial
nerve. A center in the medulla then activates the muscles of expi- tumors (benign or malignant).7,16-18
ration by means of efferent signals transmitted via the vagus and
phrenic nerves.2,3
Mechanical stimuli that can trigger the cough reflex include Table 1 Differential Diagnosis of Cough
inhaled particulate matter and intrinsic and extrinsic tracheo-
bronchial compression. Intrinsic compression may be caused by Acute and chronic bronchitis
airway tumors, foreign bodies, granulomatous airway disease, or Bronchiectasis
bronchial smooth muscle that is constricted as a result of disease Most common causes Asthma
or exposure to noxious materials. Extrinsic compression may be Postnasal drip
caused by aortic aneurysmal disease, a pulmonary parenchymal Gastroesophageal reflux
neoplasm (e.g., lung cancer or a tumor that has metastasized to Drugs
the lung), edema from pulmonary parenchymal infection (e.g., Angiotensin-converting enzyme inhibitors
pneumonia or abscess), or pulmonary parenchymal fibrosis result- Interstitial lung disease
ing from any of a variety of interstitial lung diseases (e.g., idio- Eosinophilic bronchitis
Less common causes
pathic pulmonary fibrosis or sarcoidosis). Chemical stimuli that Congestive heart failure
can trigger coughing include inhaled irritant gases and aspirated Bronchogenic carcinoma
gastric acid or bile. A common thermal stimulus is hot or cold Tracheobronchial foreign body
Psychogenic
inhaled air (or other gas).4-7
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4 THORAX 11 COUGH AND HEMOPTYSIS — 2
Figure 1 Algorithm illustrates workup Perform diagnostic imaging with chest x-ray and,
of a patient with a chronic cough. if indicated, chest CT and bronchoscopy.
Tracheobronchial irritation can trigger the cough reflex. Acute chronically inflamed airways.5,6 In a smoker, a chronic cough is
irritation from inhaled substances (e.g., toxic fumes or cigarette not a particularly worrisome symptom; however, if the character
smoke) can lead to bronchospasm and thence to coughing. In of the cough or the quality of the sputum changes, further workup
addition, patients with asthma or reactive airway disease may pre- is indicated to look for a possible superimposed infection or neo-
sent with a cough. Asthma, in fact, is one of the most common plasm.21 With both acute and chronic bronchitis, the diagnosis
causes of cough. Although asthma is typically associated with can usually be made on the basis of the history and the physical
shortness of breath and expiratory wheezing, some variants of findings (especially the sputum quality).
asthma have cough as the sole presenting symptom (so-called Persistent airway inflammation from any cause (e.g., chronic
cough-variant or cough-type asthma).5,15,19 Most persons with bronchitis, asthma, granulomatous airway disease, or cystic fibro-
cough resulting from tracheobronchial irritation have a family his- sis) can lead to bronchiectasis, a state characterized by chronic air-
tory of atopy or asthma. Diagnosis rests on a history of symptom way dilatation with cystic changes in the lower bronchial tree.The
exacerbation with irritants or upper respiratory infections on the anatomic abnormalities in the dilated, cystic bronchi cause pool-
associated findings of end-expiratory wheeze; it is confirmed by ing of mucus and secretions and impair clearance of secre-
spirometry. tions.7,10,17 Cough, either dry or productive, is the major present-
Tracheobronchial infection can also lead to a chronic cough. ing symptom of bronchiectasis. This condition is often accompa-
Acute bronchitis from viral or bacterial infection (either primary nied by infection of the ectatic airway, which leads to purulent
infection or superinfection) is typically signaled by thick, purulent secretion and systemic signs of illness that necessitate prompt
secretions. It is usually self-limited, though in some cases, it may antibiotic therapy. In patients with cystic fibrosis, for example,
have to be treated with a short course of antibiotics.20 Chronic daily postural drainage of the bronchiectatic airways is required,
bronchitis is defined by the presence of a cough with sputum pro- and frequent hospitalization for intensive antibiotic therapy and
duction that persists for at least 3 months and sometimes for chest physiotherapy is necessary. The diagnosis of bronchiectasis
years. The sputum is clear or white, and there is no evidence of is made on the basis of the history and diagnostic imaging
systemic infection. Chronic bronchitis almost always occurs in (including chest x-ray and, currently, chest CT).
current smokers (or recent quitters), who almost invariably have Postnasal drip is one of the most common causes of cough. It
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 11 COUGH AND HEMOPTYSIS — 3
usually results from allergic rhinitis, sinusitis, or nasopharyngitis. cent structure (e.g., the esophagus, the mediastinum, or the pleu-
Nasal secretions irritate the larynx and trachea, leading to the acti- ra). Such a fistula can result from cancer, surgery, trauma, aspira-
vation of the cough reflex arc.7,12,14 Generally, the diagnosis is tion or swallowing of foreign objects (e.g., fish bones), radiation
made on the basis of the history and the symptom complex. Often, therapy, chemotherapy, or infection. In this setting, the cough is
however, the symptoms are vague, and the diagnosis is confirmed caused by secretions that enter the airway via the fistula.
only when the patient responds to empirical therapy directed at In the occasional patient, a chronic cough may be of psy-
the presumed underlying cause. Steroid nasal sprays and antihist- chogenic origin.
amines are useful for ameliorating symptoms. In recalcitrant cases, Finally, a chronic cough can be caused by an endobronchial
an otolaryngologic examination may be required to exclude sinus tumor (benign, malignant, or low-grade malignant).This is a quite
disorders. rare circumstance that occasionally develops in patients who have
Gastroesophageal reflux is increasingly being recognized as a no risk factors for lung cancer. Not uncommonly, a patient with a
cause of cough and asthma. Several mechanisms have been pos- carcinoid tumor of the airway will have been treated with inhalers
tulated for reflux-induced cough, including (1) mechanical aspira- and steroids for years because of the presumptive diagnosis of
tion of gastric contents that leads to stimulation of cough recep- asthma.
tors in the distal airways and (2) stimulation of cough receptors in
the distal esophagus and the proximal stomach from refluxed acid
or bile. The data currently available tend to support the second Hemoptysis
mechanism for reflux-induced cough and bronchospasm.9,11,13 As noted (see above), hemoptysis may be a harbinger of life-
Regardless of the mechanism responsible, the diagnosis is difficult threatening illness and should therefore be taken seriously in all
to make if the typical symptoms of reflux and heartburn are circumstances. As a rule, the blood seen in the sputum derives
absent. As awareness of reflux-induced asthma and cough grows, from either the pulmonary arteries or the bronchial arteries23,25,28;
more patients are being evaluated with barium studies and only rarely does it come from the pulmonary veins. Although the
esophageal pH monitoring, which often provide the correct diag- bronchial arteries provide less blood flow than the pulmonary
nosis when clinical evaluation cannot.9 arteries do, they supply the bulk of the blood received by the air-
Specific medications may also give rise to a cough. In particu- ways and, accordingly, are the source of the blood in most cases of
lar, cough is a well-recognized complication of ACE inhibitor ther- hemoptysis. Hemoptysis can be caused by either tracheobronchial
apy.3,4,7,8 Cough may also result from nonselective beta- disease or pulmonary parenchymal disease [see Table 2].23,25,28 One
blocker therapy or may develop as a consequence of idiosyncratic should also consider the possibility that hemoptysis may be the
reactions to a variety of drugs and herbal remedies. result of an aneurysm of the aorta (or one of its main branches)
The presence of bronchogenic cancer is always a concern in a that has ruptured into the lung.
smoker with a chronic cough.3,5,8,21,22 Any irritation of the airway,
CLINICAL EVALUATION
whether intrinsic (by airway tumors) or extrinsic (by parenchymal
tumors), with or without associated inflammation, can lead to The differential diagnosis of hemoptysis, like that of cough, is
coughing through mechanical or chemical stimulation of cough quite broad.The history and the physical examination play impor-
receptors. In the general population as a whole, a chronic cough is tant diagnostic roles.The presence of associated signs of other dis-
rarely the sole presenting symptom of developing lung cancer. In eases (e.g., interstitial lung diseases) often helps narrow the differ-
smokers, the presence of a chronic cough, in and of itself, is not ential diagnosis.23,25,28
particularly worrisome, but any change in the character of the
INVESTIGATIVE STUDIES
cough, especially a change in sputum quality, is grounds for con-
cern. Any degree of hemoptysis in a former smoker should be Any patient with significant hemoptysis should be admitted to
taken seriously, especially if it is not associated with an infection; a hospital and evaluated promptly. Routine chest x-rays are insen-
prompt evaluation with a chest x-ray and, if indicated, chest CT sitive. Chest CT with contrast can often identify the cause of he-
and bronchoscopy is indicated.23-25 moptysis for both tracheobronchial or parenchymal lesions29,30;
A chronic cough may also be a consequence of CHF (from any CT scanners capable of three-dimensional helical reconstruction
cause), though this is not a common occurrence. Mild CHF with are especially useful in this regard. MRI has also been employed
symptoms of orthopnea at night may be associated with coughing. to evaluate hemoptysis, but it has no clear advantages over chest
The diagnosis is made on the basis of a history of orthopnea and CT in this setting. Given that infection is commonly associated
associated cardiac risk factors or valvular disease, followed by car- with hemoptysis, one should probably consider administering
diac echocardiography. antibiotics to most patients. Antitussives may be helpful in patients
Occasionally, the presence of a small unrecognized tracheo- whose hemoptysis is exacerbated by excessive coughing. Coagu-
bronchial foreign body can lead to chronic irritation of the lopathy should be considered and, if present, corrected aggres-
bronchial epithelium and thence to a persistent cough; this pre- sively. Bronchoscopy is the key to the diagnosis, in that it is fre-
sentation is more common in children than in adults.16 The diag- quently able to define the pathology of the preceding hemoptysis
nosis is usually made by performing bronchoscopy in a patient (especially if the underlying condition is of tracheobronchial ori-
who is believed to be harboring a foreign body on the basis of chest gin). It is particularly effective if performed within 48 hours of pre-
imaging. sentation.23,25,28,31 Although either flexible bronchoscopy or rigid
Eosinophilic bronchitis is a rare cause of chronic cough that may bronchoscopy may be used, flexible bronchoscopy is preferred
be suspected in patients with no other clearly explainable diagno- because it is less traumatic to the airways and generally does not
sis.26,27 Patients typically have a history of atopy, and the diagnosis require general anesthesia.
is made on the basis of clinical suspicion and the results of Patients with massive hemoptysis should be promptly trans-
bronchial epithelial biopsy. Steroids are the mainstay of treatment. ported to the operating room (if there is time) and selectively intu-
In rare instances, a chronic cough may be the consequence of a bated with a rigid bronchoscope or special endotracheal tubes.
fistula that connects some part of the airway or the lung to an adja- Balloon catheters may be placed for selective occlusion of the air-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 11 COUGH AND HEMOPTYSIS — 4
Table 2 Differential Diagnosis of Hemoptysis (e.g., carcinoid and mucoepidermal carcinoma) that present in the
bronchial tree and may be associated with hemoptysis.
Acute or chronic bronchitis Tracheobronchial trauma, whether acquired or iatrogenic, is
Bronchiectasis another cause of bloody sputum. Penetrating trauma to the
Neoplasms bronchial tree or the pulmonary parenchyma, for example, can
Tracheobronchial disease
Foreign bodies lead to significant hemoptysis, especially if a major branch of the
Trauma bronchial artery is involved.23,25,28,42 Particularly massive hemop-
Tracheoinnominate fistula tysis may occur if a tracheoinnominate fistula develops after tra-
Infection cheostomy.43-45 There are two types of tracheoinnominate fistula:
Interstitial lung disease one develops at the tracheal stoma site as a consequence of erosion
Parenchymal disease of the artery by the tracheostomy tube, and the other develops as
Pulmonary embolism
Pulmonary arteriovenous malformations a consequence of a more distal tracheal injury by a high-pressure
cuff, which in turn injures the artery. Major bleeding can occur
Mitral valve disease
Miscellaneous conditions
Coagulopathy
with either type. Prompt diagnosis with bronchoscopy is required
in any patient with a tracheostomy who presents with hemoptysis;
an initial “sentinel” bleed can be followed by life-threatening hem-
way or airways from which the hemoptysis originates, permitting orrhage.24,25,46,47 Treatment usually involves stabilization with rigid
ventilation to continue through the unaffected airways. A rapid bronchoscopy and immediate sternotomy to control the artery and
evaluation must then be carried out to identify and manage the resect the fistula.
source of the bleeding.To this end, it may be necessary to perform Other forms of iatrogenic injury may occur in patients with tra-
urgent angiographic embolization of a bronchial artery, to place a cheobronchial stents, which often irritate the mucosa and cause
stent in a pulmonary artery, or to resect a portion of the lung. bleeding. In most cases, such bleeding is mild, but on occasion, the
Unfortunately, the majority of patients with massive hemoptysis do stents (particularly the metallic expandable ones) erode through
not survive, dying of hemorrhagic shock and suffocation.Thus, the the bronchial wall and penetrate into a major blood vessel (usual-
goal of the treating physician should be to identify and treat these ly the pulmonary artery or the aorta). Hemoptysis may also occur
patients before they experience their final hemoptysis. in patients who have undergone bronchial biopsies and those in
whom pulmonary arterial catheters have been placed.48,49 The
MANAGEMENT OF SPECIFIC CAUSES
same effect may be observed in patients who have harbored foreign
Tracheobronchial disease is the most common cause of hemop- bodies in the tracheobronchial tree for extended periods.24
tysis. Acute or chronic bronchitis leads to airway inflammation and Pulmonary parenchymal disease can lead to hemoptysis as well,
sputum production, often associated with hemoptysis from the though less often than tracheobronchial disease does. Parenchy-
bronchial artery branches found within the mucosa; the bleeding mal infection, especially from tuberculosis and aspergillosis, is a
is usually minor.23,25,28 Bronchiectasis leads to bronchial artery common cause of hemoptysis.23,25,28,50 Aspergillosis, in particular,
dilatation, along with cystic dilatation of the bronchial tree10,23,25,28; has a propensity for vascular invasion and thus can result in mas-
the bleeding is often massive in this setting. sive hemoptysis.50 The various interstitial lung diseases (e.g., colla-
Numerous types of tracheobronchial neoplasms, including var- gen vascular disorders, Goodpasture syndrome, and Wegener gran-
ious benign and malignant primary epithelial and soft tissue ulomatosis) often have hemoptysis as their primary presenting
tumors, have been associated with hemoptysis.32-39 The majority of symptom.51-53 Pulmonary embolism can lead to hemoptysis if it
primary airway tumors are malignant, with squamous cell carcino- involves a significant portion of pulmonary parenchyma.23,25,28,54
ma and adenoid cystic carcinoma being the primary malignancies Mitral valve disease with resulting left atrial hypertension can also
most frequently seen in the trachea.32-38 The majority of malignant result in hemoptysis. Any form of coagulopathy resulting from a
airway tumors, however, are metastases rather than primary malig- low platelet count or a deficiency in clotting factors, therapeutic or
nancies. Invasion of the tracheobronchial tree by adjacent lung, not, can lead to hemoptysis; such conditions must be corrected in
thyroid, esophageal, or laryngeal tumors is not common, but it has patients who experience massive or persistent episodes. Another
been described.33,34,39,40 Colon cancers, breast cancers, melano- rare cause of bloody sputum is congenital pulmonary arteriove-
mas, and renal cancers have been reported to metastasize to the nous malformation, which typically is diagnosed only after chest
trachea, albeit very rarely.39,41 There are also low-grade tumors imaging.55,56
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bronchitis: clinical manifestations and implications Endobronchial metastasis. J Thorac Cardiovasc Surg nary arteriovenous malformations: screening proce-
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© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 12 DIAPHRAGMATIC PROCEDURES — 1
12 DIAPHRAGMATIC PROCEDURES
Ayesha S. Bryant, M.S.P.H., and Robert James Cerfolio, M.D., F.A.C.S., F.C.C.P.
Although the diaphragm is sometimes thought of as little more drainage occurs via the inferior vena cava and the azygos vein on
than a partition between the thoracic organs and the abdominal the right and via the suprarenal and renal veins and the hemiazy-
organs, it is in fact a dynamic anatomic structure that plays a piv- gos vein on the left.
otal role in the physiology of respiratory mechanics. For example,
INNERVATION
paralysis of just one hemidiaphragm can lead to the loss of 50% of
a patient’s vital capacity.1 Like any other anatomic structure, the The diaphragm receives its muscular neurologic impulse from
diaphragm may be affected by either benign or malignant condi- the phrenic nerve, which arises primarily from the fourth cervical
tions. Overall, benign diseases of the diaphragm (e.g., paralysis) ramus but also has contributions from the third and fifth rami.
are far more common than malignant ones. With either type of The phrenic nerve originates around the level of the scalenus ante-
condition, however, the development of a safe surgical treatment rior and runs inferiorly through the neck and thorax before reach-
strategy depends on a solid knowledge of diaphragmatic anatomy ing its terminal point, the diaphragm. Because the phrenic nerve
and physiology. Accordingly, we begin with a brief review of the follows such a long course before reaching its final destination, a
embryology and anatomy of the diaphragm.We then describe the number of processes can disrupt the transmission of neurologic
main procedures performed to treat the more common congeni- impulses through the nerve at various points and thereby cause
tal diseases (e.g., congenital diaphragmatic hernia [CDH]) and diaphragmatic paralysis [see 4:3 Paralyzed Diaphragm].
acquired pathologic conditions (e.g., paralysis and tumor) that
affect this structure.
Procedures for Congenital Diaphragmatic Hernia
Preoperative Evaluation
abdomen. The primary pathologic condition is the presence of
posterolateral defects of the diaphragm, which result either in On chest radiography, a Morgagni hernia appears as a mass at
maldevelopment of the pleuroperitoneal folds or in improper or the right cardiophrenic angle [see Figure 2]. Computed tomogra-
absent migration of the diaphragmatic musculature. phy of the chest and abdomen, liver scintigraphy, and multiplanar
Bochdalek hernias occur in approximately one of every 2,500 magnetic resonance imaging are occasionally helpful in the diag-
live births and are twice as common in male neonates as in female nostic process.
neonates. Mortality ranges from 45% to 50%. The bulk of the
Operative Technique
morbidity and mortality of CDH is attributable to the resultant
hypoplasia of the lung on the affected side and to various associ- Morgagni hernias can be repaired via a subcostal, a paramedi-
ated abnormalities (e.g., malrotation of the gut, neural tube defects, an, or a midline incision. We prefer to use an upper midline
and cardiovascular anomalies). abdominal incision. Once the peritoneal cavity is entered, the her-
nia sac is identified just posterior to the xiphoid and the posterior
Preoperative Evaluation sternal border, then opened. The herniated abdominal viscera are
Prenatal ultrasound examination accurately diagnoses CDH in restored to their normal abdominal anatomic positions, and the
40% to 90% of cases.2 In most instances, the examination is per- sac is ligated.The entire hernia sac is defined, resected, and closed.
formed to rule out polyhydramnios. It is noteworthy that polyhy- The diaphragmatic defect may be repaired in several different
dramnios is present in as many as 80% of pregnant women whose ways, depending on its size and position. Because there is weak tis-
fetuses have CDH.3 In neonates with CDH, besides the upper sue in the area of the defect, we generally use a prosthetic patch for
gastrointestinal tract, parts of the colon, the spleen, the kidneys, the repair. Either polypropylene mesh (e.g., Marlex; C. R. Bard,
and the pancreas may herniate, and the abnormal position of Inc., Murray Hill, New Jersey) or polytetrafluoroethylene (PTFE)
these organs can be identified by means of ultrasonography. Mal- mesh (e.g., Gore-Tex; W. L. Gore and Associates, Newark, Del-
rotation and malfixation of the small bowel should be ruled out. aware) may be used for this purpose. We prefer PTFE because it
Once the diagnosis is confirmed, additional radiographic, echo- may cause fewer adhesions to the underlying abdominal structure,
cardiographic, and ultrasonographic studies should be performed which may be an important consideration if further abdominal
to rule out associated anomalies. surgery subsequently proves necessary. The prosthetic patch is
sewn to the midline abdominal fascia, with wide bites taken to pre-
Operative Technique vent an abdominal incisional hernia.The rest of the patch is sewn
to the thickened investing fascia that made up the edges of the her-
As a rule, neonates with Bochdalek hernias are taken to the oper-
nia sac. As noted, the frequently marginal quality of this tissue is
ating room immediately after birth. Some studies, however, have
the reason why a patch repair is almost always required.
shown that delayed surgical repair yields improved survival rates.4
Repair of a Morgagni hernia via a thoracic incision follows the
For left-side hernias, a transabdominal subcostal approach is
same basic principles.The hernia sac is entered, the visceral con-
generally preferred, whereas for right-side hernias, a transthoracic
tents are mobilized and reduced into the abdomen, the sac is
approach may be more useful.The herniated organs are returned
resected, and the diaphragm is repaired. Again, the closure should
to the peritoneal cavity. The lung is inspected, but no attempt to
be completed without tension. If the defect cannot be closed with
expand the hypoplastic lung should be made. If any extralobar
horizontal mattress sutures, a prosthetic patch should be used.
pulmonary sequestration is present (as is occasionally the case), it
should be excised. Most of the defects may be closed primarily Complications
with interrupted nonabsorbable sutures; particularly large defects The potential complications of surgical treatment of Morgagni
may be closed with a prosthetic patch. The left pleural space is hernia depend to an extent on the type of procedure undertaken
drained with a chest tube, which should be placed on water seal. to repair the defect. Laparoscopy may result in failure to reduce
the contents of the hernia sac, which necessitates conversion to an
Alternative technique Some surgeons have attempted sur- open procedure. Laparotomy has been associated with postoper-
gical correction of severe Bochdalek hernias in the prenatal period. ative pleural effusion,9 wound infection,10 deep vein thrombosis,11
The safety and feasibility of this therapeutic approach continue to and pulmonary embolism.12 Thoracotomy has been associated
be debated. Prenatal correction of these hernias poses a risk to both with pneumonia, sepsis, and bowel obstruction in the postopera-
the mother and the fetus, with possibly fatal results for both.5 tive period.13
REPAIR OF MORGAGNI HERNIA Outcome Evaluation
Morgagni hernias, named after the Italian anatomist and pathol- Most patients do not have any significant postoperative limita-
ogist Giovanni Battista Morgagni, are related to maldevelopment tions after repair of a Morgagni hernia, nor are such hernias like-
of the embryologic septum transversum and to failed fusion of ly to recur. In one study, 16 patients who underwent transthoracic
the sternal and costal fibrotendinous elements of the diaphragm.6 repair of a Morgagni hernia were followed for 5.7 years; no recur-
These hernias are generally asymptomatic7 and are usually detect- rences or symptoms related to the operation were reported.14
ed as incidental findings on radiographs. Accordingly, the average
age at diagnosis is typically greater for Morgagni hernia than for
Bochdalek hernia: in one report, the mean age at which the for- Procedures for Diaphragmatic Paralysis
mer was diagnosed was 45 years.8 Morgagni hernias are most The diaphragm is the most important of the respiratory mus-
commonly seen on the right side.The hernia sac usually contains cles: diaphragmatic contraction decreases intrapleural pressure dur-
omentum, but it may also contain part of the transverse colon ing inspiration, expands the rib cage, and thereby facilitates the move-
or, less commonly, parts of the stomach, the liver, or the small ment of gases into the lungs. Accordingly, paralysis of the dia-
bowel; almost any upper abdominal structure may herniate in this phragm can have a major adverse effect on respiratory function
setting. [see 4:3 Paralyzed Diaphragm]. Diaphragmatic paralysis may involve
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 12 DIAPHRAGMATIC PROCEDURES — 3
either the whole diaphragm (bilateral paralysis) or only one leaflet In most cases, the diagnosis of hemidiaphragmatic paralysis is
or hemidiaphragm (unilateral paralysis). The possible causes of suspected on the basis of incidental findings on a chest x-ray.
diaphragmatic paralysis are numerous [see Table 1]; the most com- Typically, the roentgenogram reveals an elevated hemidiaphragm,
mon causes are phrenic nerve trauma related to a surgical proce- diminished lung volume, and basilar atelectasis. Fluoroscopy may
dure (e.g., stretching, crushing, or transection) and invasion by a also be performed. The diagnosis is confirmed by performing a
malignant neoplasm. fluoroscopic sniff test, in which paradoxical elevation of the para-
lyzed diaphragm is observed with sniffing.15 The sniff test is the
DIAPHRAGMATIC PLICATION FOR UNILATERAL PARALYSIS
gold standard for the diagnosis of this condition. In certain pa-
tients, a chest CT scan may be indicated for evaluating the poten-
Preoperative Evaluation tial cause of the paralysis. If an obvious cause is not apparent from
With unilateral diaphragmatic paralysis, the paralyzed the history or a previous evaluation, CT scanning of the chest
hemidiaphragm paradoxically moves upward on inspiration and should be performed to ensure there is no pathologic process that
downward on expiration, passively following changes in is compressing or invading the phrenic nerve. Similarly, MRI of
intrapleural and intra-abdominal pressure. Patients with a par- the neck or the spine may be indicated in certain patients to look
alyzed hemidiaphragm who are otherwise healthy usually have for conditions that might be causing the diaphragmatic paralysis.
no symptoms at rest but experience dyspnea during exertion Two other tests that are also (albeit less commonly) used for the
and show a decrease in exercise performance. Physical exami- diagnosis of unilateral diaphragmatic paralysis are electromyogra-
nation may reveal dullness to percussion and an absence of phy and transdiaphragmatic pressure assessment. In the first, the
breath sounds over the lower chest on the involved side. phrenic nerve is electrically stimulated in the neck in an effort to
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 12 DIAPHRAGMATIC PROCEDURES — 4
Operative Technique
Table 1 Common Causes of
Diaphragmatic Paralysis Diaphragmatic plication may be performed with either sutures
or staples; we prefer sutures for this procedure. The chest is
Spinal cord transection entered through a thoracotomy in the seventh or eighth intercostal
Multiple sclerosis space. Horizontal mattress sutures buttressed with Teflon pledgets
Amyotrophic lateral sclerosis are then placed in a lateral-to-medial direction [see Figure 3]. We
Cervical spondylosis typically use monofilament nonabsorbable sutures that pass easily
Poliomyelitis through the muscle and can be tightened without dragging through
Guillain-Barré syndrome
tissue. To distribute the tension, multiple sutures must be placed;
Phrenic nerve dysfunction
this is especially important on the right side, where the diaphragm
Neurologic conditions Compression by tumor
Cardiac surgery cold injury
must be pulled down against the upward force exerted by the pres-
Blunt trauma ence of the right hemiliver.When the sutures are tied, the hemidi-
Idiopathic phrenic neuropathy aphragm should be almost back to its normal anatomic location.
Diabetes mellitus Care must be taken to ensure that the repair is not under undue
Postviral phrenic neuropathy (herpes zoster) tension: excessive tension is likely to result in early dehiscence.
Radiation therapy Occasionally, a prosthetic patch may be used to buttress the repair
Cervical chiropractic manipulation further, but in the majority of cases, this measure should be unnec-
Limb-girdle dystrophy essary. If the choice is made to use staples rather than sutures, care
Hyperthyroidism/hypothyroidism must be taken to ensure that the underlying abdominal contents
Malnutrition are not caught in the staple line.
Acid maltase deficiency
Connective tissue disease DIAPHRAGMATIC PACING FOR BILATERAL PARALYSIS
Myopathic conditions Systemic lupus erythematosus
Dermatomyositis Preoperative Evaluation
Mixed connective tissue disease
Amyloidosis
In patients with bilateral diaphragmatic paralysis, the respirato-
Idiopathic myopathy ry accessory muscles assume all the work of breathing by con-
Muscular dystrophy tracting more intensely. Both hemidiaphragms move upward on
Multiple sclerosis inspiration, concomitant with inward (rather than the normal out-
ward) movement of the abdominal wall.17 Patients typically pre-
sent with severe respiratory failure or with dyspnea (sometimes
misinterpreted as a sign of heart failure) that worsens in the supine
distinguish between neuropathic and myopathic causes of paraly-
position, and they generally exhibit tachypnea and rapid, shallow
sis. In the second, transdiaphragmatic pressures are measured by
placing a thin-walled balloon transnasally at the lower end of the
esophagus in such a way as to reflect changes in pleural pressure;
a second balloon manometer is then placed in the stomach in such
a way as to reflect changes in intra-abdominal pressure. The dif-
ference between the two pressures is the transdiaphragmatic pres-
sure. Measurement of transdiaphragmatic pressure can help dif-
ferentiate diaphragmatic paralysis from other causes of respiratory
failure.
Yet another test involves measurement of maximal inspiratory
pressures. Patients with diaphragmatic dysfunction and paralysis
show a decrease in their maximal inspiratory pressures. These
patients cannot generate high negative inspiratory pressures, and
thus, their maximal inspiratory pressures will be less negative than
–60 cm H2O.
Operative Planning
Surgical treatment of hemidiaphragmatic paralysis is reserved
for symptomatic patients who, after a follow-up period of at least
6 months, have persistent shortness of breath with exertion that is
sufficiently pronounced to interfere with lifestyle. For a patient to
be considered for operation, the sniff test should show significant
paradoxical motion.
The basic principle of the surgical procedure is to “reef” (i.e.,
reduce the surface area of) the redundant floppy diaphragm by
plicating it. This measure lowers the resting position of the
hemidiaphragm and thus affords the lung the opportunity to
expand fully. The effective result is an increase in the functional
vital capacity of the ipsilateral lung. A 2002 study found that pli- Figure 3 Diaphragmatic plication. Shown is suture plication of
cation of the diaphragm led to long-term improvements in pul- the right hemidiaphragm. Placement of sutures buttressed with
monary function test results, as well as reduced dyspnea.16 pledgets extends anteriorly to the level of the vena cava.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 12 DIAPHRAGMATIC PROCEDURES — 5
External Internal anterior horn cells in the nerve roots, diaphragmatic pacing is fea-
Receiver and sible only when the lesion is above the C2-C3 level. Accordingly,
Electrode
Antenna it is sometimes employed in patients with high spinal cord injuries.
Phrenic To date, only one pacing device has been approved by the Food
Nerve and Drug Administration: the Mark IV Breathing Pacemaker
System (Avery Biomedical Devices, Commack, New York). This
device possesses an internal component and an external compo-
nent [see Figure 4]. The internal component is surgically placed
adjacent to the skeletonized phrenic nerve and is connected to a
small, wafer-shaped receiving unit placed under the skin. A bat-
tery-powered external transmitting box connected to an antenna
is taped over the surface of the skin, just above the subcutaneous
receiver. This transmitting box permits adjustment of pulse dura-
tion, pulse train duration, respiratory rate, pulse frequency, and
current amplitude. In most patients, the only parameters that the
clinician adjusts are current amplitude and respiratory rate.
Implantation of a diaphragmatic pacer requires significant ex-
perience on the part of the surgeon—not so much because of any
particular technical demands imposed by the implantation itself
but because of the procedures for diaphragm training that must be
Diaphragm carried out in the postoperative period.
Mark IV
a b
Right Lower-Lobe
Tumor Invading Gore-Tex Patch
Diaphragm
Figure 5 Resection of diaphragmatic tumor. The patient has a right lower-lobe bronchogenic
malignancy with erosion into the right hemidiaphragm. (a) The tumor is resected en bloc with the
diaphragmatic fibers; the electrocautery is used to achieve clear surgical margins and hemostasis.
(b) The defect in the right hemidiaphragm is closed with a mesh patch.
it and secured with sutures. Care must be taken to ensure that the there are several specific complications associated with diaphragmat-
nerve is not injured during this step.The connecting wire from the ic pacing.The most common of these are dislodgment of the pacer
electrode is then tunneled subcutaneously to a subcutaneous pock- electrode, transmission of pacer impulses to the brachial plexus with
et that is created just below the ipsilateral clavicle.The connections resultant rhythmic jerking of the upper extremity (seen with cervical
are made and sealed, and the small incisions are closed. placement of the electrode), and hardware malfunction.
ported. Bilateral occurrence, calcification, sharp margins, and flat- the edges of the defect; this prevents the edges from retracting,
tened contours are indicative of a malignant process, such as pleur- helps keep the defect as small as possible, and keeps abdominal
al metastases, mesothelioma, or a primary diaphragmatic tumor. contents from interfering with the resection. In addition, we place
The most common indication for diaphragmatic resection is clips on the edges for guidance purposes, in case adjuvant radio-
mesothelioma. This remains true even though mesothelioma is therapy is delivered after the operation. If adequate margins are
relatively uncommon in comparison with bronchogenic malig- obtained, which is usually relatively easy in a diaphragmatic resec-
nancy and even though few patients with mesothelioma are actu- tion, postoperative radiotherapy should be unnecessary. If, how-
ally candidates for resection. Again, resection of a mesothelioma is ever, the tumor abuts vital structures (e.g., the suprahepatic vena
not addressed here. The ensuing operative description focuses on cava), postoperative radiotherapy may have a useful role to play.
diaphragmatic resection to treat either a lung cancer invading the Once the entire tumor has been resected and clear margins
diaphragm or a primary diaphragmatic tumor [see Figure 5]. have been confirmed by frozen-section examination, the diaphragm
is reconstructed. Primary repair is rarely indicated, because in most
OPERATIVE TECHNIQUE
cases, the defect is too large and the tension on the repair would
Once the decision is made to resect a tumor involving the be too great. Moreover, the tissue in the anterior aspect of the
diaphragm, the key considerations are (1) the surgical approach to diaphragm is thin and is likely to tear under tension. Accordingly,
be taken and (2) the placement of the incision in the diaphragm. repair with a prosthetic patch is the usual choice. Infection of such
We prefer a skin incision that is lower and slightly more anterior a patch is exceedingly rare, and with the exception of the cost,
than a normal posterolateral thoracotomy; such an incision allows there is little downside to the use of prosthetic material in this set-
easy entry over the top of the seventh rib. After entry into the chest, ting. As in the repair of a CDH, we prefer PTFE mesh [see Figure
the lung, the pericardium, and the pleural surface are carefully vis- 5b] to polypropylene mesh because it is less likely to adhere to
ualized and palpated to search for any signs of metastatic disease. underlying abdominal structures.
Next, the incision in the diaphragm is planned. Ideally, the inci- The mesh patch is sewn to the edges of the defect (preferably
sion should be made anterior or lateral to the tumor so that a hand with nonabsorbable suture material, such as 0 polypropylene),
can be placed easily into the peritoneal cavity [see Figure 5a]. Intra- starting at the most anterior and inferior portion of the opening
abdominal palpation confirms that the tumor has not extended and continuing toward the surgeon [see Figure 5].The inferior half
into underlying structures. This information is almost always of the repair is done with a continuous suture.The repair is com-
gleaned from the preoperative CT scan, but if any uncertainty pleted with two or three sutures, which are tied circumferentially.
remains after the scan, diagnostic laparoscopy may be performed To prevent paradoxical motion, the diaphragm must not be too
before the thoracotomy to look for possible tumor extension. redundant or floppy. It should remain in the normal anatomic
The tumor is then resected with 2 to 4 cm margins. The large position so that the remaining lung can expand completely. In
arteries that course through the diaphragmatic fibers are ligated. general, however, it is best to keep the repair taut so as to optimize
It is our practice also to place a few silk sutures (stay stitches) in pulmonary mechanics after the procedure.
References
1. Kirks DR, Caron KH: Gastrointestinal tract. 9. Jani PG: Morgagni hernia: case report. East Afr 18. Piehler JM, Pairolero PC, Gracey DR, et al:
Practical Pediatric Imaging, 2nd ed. Kirs DR, Ed. Med J 78:559, 2001 Unexplained diaphragmatic paralysis: a harbinger
Little, Brown & Co, Boston, 1991 10. Ngaage DL, Young RA, Cowen ME: An unusual of malignant disease? J Thorac Cardiovasc Surg
2. Lewin D, Bowerman R: Hirschel R: Prenatal combination of diaphragmatic hernias in a patient 84:861, 1982
ultrasonogram frequently fails to diagnose con- presenting with the clinical features of restrictive 19. Cerfolio RJ, Bryant AS, Patel B, et al: Intercostal
genital diaphragmatic hernia. J Pediatr Surg (in pulmonary disease: report of a case. Surgery Today muscle flap decreases the pain of thoracotomy: a
press) 31:1079, 2001 prospective randomized trial. J Thorac Cardiovasc
3. Adzick NS, Harrison MR, Glick PL, et al: 11. Missen AJB: Foramen of Morgagni hernia. Proc R Surg 130:987, 2005
Diaphragmatic hernia in the fetus: prenatal diag- Soc Med 66:654, 1973 20. Morgan JA, Morales DL, John R, et al: Endo-
nosis and outcome in 94 cases. J Pediatr Surg 12. Dawson RE, Jansing CW: Case report: foramen of scopic, robotically assisted implantation of phrenic
20:357, 1985 Morgagni hernias. J Kentucky Med Assoc 75:325, pacemakers. J Thorac Cardiovasc Surg 126:582,
4. Breaux CW Jr, Rouse TM, Cain WS, et al: 1997 2003
Improvement in survival of patients with congeni- 13. Lev-Chelouche D, Ravid A, Michowitz M, et al: 21. DiMarco AF, Onders RP, Kowalski KE, et al:
tal diaphragmatic hernia utilizing a strategy of Morgagni hernia: unique presentations in elderly Phrenic nerve pacing in a tetraplegic patient via
delayed repair after medical and/or extracorporeal patients. J Clin Gastroenterol 28:81, 1999 intramuscular diaphragm electrodes. Am J Respir
membrane oxygenation stabilization. J Pediatr Crit Care Med 166:1604, 2002
14. Kiliç D, Nadir A, Döner E, et al: Transthoracic
Surg 26:333, 1991
approach in surgical management of Morgagni 22. Cerfolio RJ, Price TN, Bryant AS, et al: Intracostal
5. Wenstrom KD,Weiner CP, Hanson JW: A five year hernia. Eur J Cardiothorac Surg 20:1016, 2001 sutures decrease the pain of thoracotomy. Ann
statewide experience with congenital diaphrag- Thorac Surg 76:407, 2003
15. Miller JM, Moxham J, Green M: The maximal
matic hernia. Am J Obstet Gynecol 165:838, 1991
sniff in the assessment of diaphragm function in 23. Elefteriades JA, Quin JA, Hogan JF, et al: Long-
6. Panicek DM, Benson CB, Gottlieb RH, et al: The man. Clin Sci (Colch) 69:91, 1985 term follow-up of pacing of the conditioned dia-
diaphragm: anatomic, pathologic, and radiologic phragm in quadriplegia. Pacing Clin Electro-
16. Higgs SM, Hussain A, Jackson M, et al: Long term
considerations. Radiographics 8:385, 1988 physiol 25:897, 2002
results of diaphragmatic plication for unilateral
7. Fraser RS, Pare JAP, Fraser RG, et al: Synopsis of diaphragm paralysis. Eur J Cardiothorac Surg
Diseases of the Chest, 2nd ed. WB Saunders Co, 21:294, 2002
Philadelphia, 1984 17. Higgenbottam T, Allen D, Loh L, et al: Abdominal
8. Minneci PC, Deans KJ, Kim P, et al: Foramen of wall movement in normals and patients with hemi-
Acknowledgment
Morgagni hernia: changes in diagnosis and treat- diaphragmatic and bilateral diaphragmatic palsy.
ment. Ann Thorac Surg 77:1956, 2004 Thorax 32:589, 1977 Figures 1 and 3 through 5 Tom Moore.
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4 THORAX 13 MEDIASTINAL PROCEDURES — 1
13 MEDIASTINAL PROCEDURES
Joseph B. Shrager, M.D., F.A.C.S., and Vivek Patel, M.B.B.S.
Chamberlain Approach
Anterior parasternal mediastinotomy (the Chamberlain proce-
dure) is favored by most surgeons for biopsy of lesions in the ante-
rior mediastinum and the aortopulmonary window. It is usually
Figure 1 (a) CT scan shows a well-encapsulated anterior medi-
done under general anesthesia, though local anesthesia may be
astinal mass—a thymoma. (b) CT scan shows a benign teratoma
of the anterior mediastinum; calcification and varying tissue used instead, and it does not require single-lung ventilation. This
densities may be seen. operation affords good exposure and allows generous biopsy spec-
imens to be taken, and it can be performed as an outpatient
procedure.
nign, are diagnosed in the second or third decade of life. Benign
teratomas are usually well encapsulated, with frequent recapitula- Operative technique Step 1: initial incision. A 5 cm trans-
tion of one or more tissue elements seen on radiography.4 The verse incision is made over the second costal cartilage on the side to
appearance of the lesions on CT is often diagnostic [see Figure 1b]. be operated on (the second cartilage is identified by its continuity
Surgical extirpation is the mainstay of treatment for these mature with the sternal angle).The pectoralis major is separated in a direc-
germ cell tumors, and biopsy is not indicated. Malignant germ tion parallel to the direction of its fibers, and the cartilage is resect-
cell tumors, on the other hand, are treated with primary che- ed in a subperichondrial plane [see Figure 2]. Leaving perichondri-
motherapy, radiotherapy, or both; when suspected, they should um behind facilitates postoperative regrowth of the cartilage.
undergo biopsy rather than proceed directly to resection.
Characteristic serum tumor markers, including β–human chori- Step 2: dissection and exposure. The posterior perichondrium is
onic gonadotropin (β-hCG) and alpha-fetoprotein (AFP), are incised, and the parietal pleura is bluntly dissected laterally with a
elaborated by most malignant germ cell neoplasms but are not peanut sponge; this affords entry into the mediastinal fat and
found in benign germ cell tumors.5 Elevation of the AFP level direct access to the tumor mass. Almost invariably, the internal
beyond 500 ng/ml is considered diagnostic of a nonseminomatous mammary vessels can be mobilized medially and preserved, but if
component in a malignant germ cell tumor and is usually associ- necessary, they may be ligated to improve exposure.
ated with a concomitant increase in serum β-hCG levels.6 In
the absence of any marked elevation in the AFP or β-hCG level, Step 3: biopsy. A generous wedge-shaped portion of the mass is
percutaneous needle biopsy usually suffices to establish the excised with a scalpel. Frozen-section examination is then per-
diagnosis. formed to confirm that diagnostic tissue has been obtained. It is
important to remember to request that flow cytometry be per-
OPERATIVE PLANNING
formed on the specimen.
Biopsy versus Resection Step 4: closure. The posterior perichondrium is reapproximated,
Clearly, the decision whether to perform a biopsy of an anteri- followed by the pectoralis major, the subcutaneous fat, and the skin.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 13 MEDIASTINAL PROCEDURES — 3
R2
Troubleshooting If the pleura was entered, a red rubber space for evidence of tumor dissemination. Robot-assisted thora-
catheter is used to evacuate the pleural space as the lung is inflat- coscopic procedures for anterior mediastinal masses have also
ed with a large positive pressure breath, and the catheter is with- been described,10 but their availability does not eliminate the
drawn through the layers of closure. A small postoperative pneu- major objection to transpleural approaches to mediastinal masses—
mothorax is almost always attributable to residual air rather than namely, the possibility of spreading a disease that had been con-
to an ongoing air leak. tained within the mediastinum into the pleural space.
Sometimes, the tumors are fairly vascular and bleed moderate-
RESECTION OF ANTERIOR MEDIASTINAL MASS
ly after biopsy is performed. This bleeding can always be con-
trolled with electrocauterization. We often leave an absorbable
hemostatic agent in place as well. Operative Planning
The most frequent indications for resection (as opposed to
Transcervical Approach biopsy) of an anterior mediastinal mass are (1) thymoma and (2)
As an alternative to the Chamberlain procedure, a mass of the thymectomy for MG. The principles underlying thymoma resec-
anterior mediastinum may be approached for biopsy through a tion can be applied to resection of other, rarer anterior mediasti-
cervical incision, exactly as in a transcervical thymectomy [see nal masses.The first successful resection of a thymic mass for MG
Resection of Anterior Mediastinal Mass, Transcervical Approach, was described in 1939.11 Since the introduction of transcervical
below]. The use of a Cooper thymectomy retractor (Pilling Com- thymectomy (TCT), there has been ongoing debate regarding the
pany, Fort Washington, Pennsylvania), which elevates the sternum, optimal method for thymectomy in patients with nonthymoma-
affords excellent exposure of the anterior mediastinum and some- tous MG. There is little debate, however, regarding the optimal
times allows direct examination to ascertain the invasiveness of an approach to resection of anterior mediastinal malignancies.
otherwise uncertain mass. In most cases, general anesthesia is For all primary invasive masses of the anterior mediastinum—
required, but transcervical biopsy can be performed as an outpa- including invasive thymomas, malignant germ cell tumors (after
tient procedure.We have used this technique at our institution and systemic treatment), thymic carcinomas, and other, less common
have achieved results comparable to those of anterior mediasti- malignancies—the most important prognostic factor is complete
notomy.9 Proper performance of this procedure does, however, resection. Accordingly, the operative approach must be selected
require a level of experience with the technique that is not widely with an eye to providing optimal exposure. There is little doubt
available. that a full median sternotomy is ideal in this regard. However, a
less than full sternotomy is a reasonable choice for small (< 3 cm)
Video-Assisted Thoracic Surgery noninvasive thymomas or other noninvasive mediastinal tumors
Video-assisted thoracic surgery (VATS) has been applied to (e.g., mature teratomas), particularly when the diagnosis of thy-
diagnostic biopsy [see 4:7 Video-Assisted Thoracic Surgery], but moma is in doubt before operation. In such situations, we usually
VATS biopsy procedures are not widely employed in the anterior begin with TCT,12 but we do not hesitate to convert to a ster-
mediastinum. The necessity of single-lung ventilation adds a level notomy if unexpected invasion is identified. Some surgeons have
of complexity to the procedure beyond what is required for the employed a partial upper sternotomy in these settings; however,
Chamberlain procedure or the transcervical approach. Further- this approach limits exposure, and we do not believe that it actu-
more, intercostal incisions are frequently more painful than trans- ally reduces morbidity in comparison with a full sternotomy.
cervical incisions or anterior mediastinotomies. VATS does have En bloc resection of malignancies is mandatory, and resection
certain advantages that may be of value in individual cases, such of adjacent serosal membranes (including pleura or pericardium)
as the capacity to provide simultaneous access to other compart- is required if there is any suggestion of attachment during the
ments of the mediastinum and the ability to evaluate the pleural operation. Resection of adjacent lung parenchyma is not uncom-
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 13 MEDIASTINAL PROCEDURES — 4
are not remarkably different from those after TCT, which is much
less invasive. Because we do not personally perform the maximal-
ly invasive procedure, we do not describe it in this chapter.
Median Sternotomy Approach
As noted (see above), the standard approach to masses of the
anterior mediastinum is via a median sternotomy. Resection of a
thymoma of the anterior mediastinum is performed as follows.
ies are required before TCT can be firmly recommended for treat-
ment of even small thymomas. On the other hand, it is likely that
surgeons who have extensive experience with TCT can safely
resect small (< 3 cm) thymomas via this approach without risking
tumor spillage or incomplete resection.
Step 2: mobilization of superior poles of thymus. The superior Step 6: dissection of posterior aspect of thymus. Once the thymus is
poles of the thymus are located (usually on the left side first) by freed from the innominate vein, dissection of the posterior aspect
means of gentle blunt dissection beneath the strap muscles. After of the gland must be continued directly on the surface of the peri-
one pole is identified, it is divided between ties at its superior cardium. This posterior dissection is carried as far down as possi-
extent. Its medial edge is then followed down to where it meets the ble, primarily in a blunt fashion. Most of the time, the surgeon
medial edge of the opposite superior pole, and this opposite pole holds one ring clamp containing a sponge dissector in each hand,
can then be similarly traced upward into the neck, ligated, and while an assistant holds the upper poles. Occasionally, the surgeon
divided. A very important part of the procedure is the placement holds the sutures attached to the upper poles in one hand while
of 0 silk ligatures around an area containing strong tissue within employing the sponge dissector in the other hand.
each superior pole.These ligatures are left long and clamped.The
surgeon or an assistant places traction on them during the remain- Step 7: removal of specimen. When the posterior dissection has
ing course of the dissection to manipulate and progressively mobi- been extended as far as possible toward the diaphragm, further
lize the gland [see Figure 8]. mobilization of the thymus is typically accomplished by working
the glandular tissue laterally, first off the pleura on one side, then
Step 3: continuation of dissection downward into superior mediasti- off the sternum anteriorly, and finally off pleura on the opposite
num. As traction is being placed on the upper poles, sharp and side. In this way, the entire gland is ultimately removed between
blunt dissection, staying outside the well-defined capsule of the the phrenic nerves and down to the diaphragm. During this final
gland, is extended downward into the superior mediastinum to mobilization, the surgeon periodically asks to have ventilation held
the level of the innominate vein. The procedure becomes much temporarily so that the pleura can fall back and thus permit
more difficult if the capsule is violated. improved visualization. Small feeding vessels from the mammary
are doubly clipped and divided as they are encountered.
Step 4: elevation of sternum. Finger dissection is performed in the Often, the final stages of blunt dissection may be facilitated by
substernal plane, and the arm of a Cooper thymectomy retractor is placing a ring clamp on the body of the gland to allow slightly
placed into the retromanubrial space to elevate the sternum. The more vigorous retraction than can be achieved by using the upper
retracting arm is placed under upward tension as the inflatable bag poles alone. If any suspicious residual tissue is seen in the medi-
beneath the shoulders is deflated. This step leaves most patients astinum at this point, it can be removed piecemeal; however, this
actually hanging from the retractor, thereby opening up a sizable is an unusual occurrence.
space that allows good visualization and ready passage of dissecting
instruments into the anterior mediastinum. Army-Navy retractors Step 8: closure. After inspection of the surgical field for hemo-
are placed in each of the two upper corners of the incision, and their stasis, the strap muscles and the platysma are closed over a red
distal ends are tied to the siderails of the table with Penrose drains rubber catheter, to which suction may be applied. The catheter is
to provide countertraction and to hold the skin incision open. subsequently removed, and the skin is closed.
Step 5: dissection of venous tributaries to innominate vein. With the Troubleshooting In the course of preoperative evaluation
superior poles gently pulled upward by an assistant (and at times before TCT, it is important to be sure that the patient is able to
looped over the Cooper retractor), the inferior surface of the gland extend the neck to a reasonable degree.TCT is simplest in young
is dissected until the innominate vein is encountered. The venous persons who are capable of good extension; it can be difficult or
tributaries draining the thymus into the innominate vein are iso- impossible in persons with cervical spine disease that hinders
lated sharply, ligated with fine silk sutures, and divided. extension.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 13 MEDIASTINAL PROCEDURES — 7
During the procedure itself, it is important that the branches of Occasionally, a seroma develops at the site of the incision, but it
the innominate vein be tied rather than clipped; the space anteri- almost always resolves either spontaneously or after a single per-
or to the vein becomes the avenue through which dissecting instru- cutaneous drainage procedure in the office.
ments are passed into and out of the mediastinum, and these
instruments often rub against the vein fairly vigorously.
When working laterally, one must take care not to injure the Procedures for Lesions of the Middle Mediastinum
phrenic nerves, and one certainly should not use the electro- The majority of masses found in the middle mediastinum in
cautery while working at the lateral extremes of the dissection. If adults are malignant, representing either lymphoma or lymph
the pleural space is entered while one is working laterally, a red node metastases from primary lung carcinoma. Accordingly, the
rubber catheter [see Operative Technique, Step 8, above] is advanc- procedures performed in this anatomic area primarily involve
ed well into that pleural space, and suction in the form of several biopsy for staging or diagnosis rather than curative or palliative
large positive pressure breaths is applied before the catheter is resection. On infrequent occasions, however, benign or primary
removed. malignant lesions of the middle mediastinum occur for which
If a thymoma is encountered during TCT, continuation via this resection is appropriate. In what follows, we briefly discuss resec-
approach may be considered. In our view, most noninvasive tion of such lesions; for the most part, the principles are the same
thymic lesions less than 3 cm in diameter can be safely and com- as those underlying resection of masses in the posterior medi-
pletely resected via the transcervical approach. In addition, it gen- astinum [see Procedures for Lesions of the Posterior Mediastinum,
erally is not difficult to resect a portion of the anterior pericardi- below].
um as well if a tumor or the thymus is adherent to it. However, Of particular surgical interest in the middle mediastinum are
because the evidence currently available does not conclusively benign cysts, which may arise from the pleura, the pericardium,
establish that TCT is equivalent to resection via sternotomy for the airways, or the esophagus. Bronchogenic cysts, which typical-
thymoma, some surgeons prefer to convert to a sternotomy if a ly develop in proximity to the carina, are probably the middle
suspicious mass is discovered during transcervical exploration. mediastinal cysts most commonly encountered in clinical practice,
Certainly, if any difficulty is encountered that might lead to an with pericardial cysts running a close second. On rare occasions,
incomplete thymectomy or incomplete removal of a thymoma, the ectopic remnants from cervical structures (e.g., the parathyroid
incision should be extended. and thyroid glands) are encountered in this compartment.16
Approximately 90% of patients are able to go home on the same
PREOPERATIVE EVALUATION
day as their procedure. The most common cause for hospital
admission is a pneumothorax that must be monitored or drained. CT generally provides an accurate preoperative diagnosis of a
benign middle mediastinal cyst, as well as information regarding
abutment of adjacent structures, the consistency of the mass, and
potential invasiveness. MRI may be helpful if there is concern that
a cyst might actually represent an aberrant vascular structure or an
aneurysm, if the simple nature of the cyst is in doubt, or if clearer
delineation of suspected invasion of surrounding structures is re-
quired. Radionuclide scans (e.g., with technetium-99m or radio-
active iodine) may be useful if the differential diagnosis includes a
parathyroid or thyroid mass. Cystic structures adjacent to the air-
ways and the esophagus are evaluated by means of bronchoscopy,
esophagoscopy, barium esophagography, or some combination
of these imaging modalities to rule out communication with the
lumina.
OPERATIVE PLANNING
cotomy for complete resection and (2) some other approach for
incomplete resection. Because this area is easily accessible by means Table 2 Indications for Planned Thoracotomy
of mediastinoscopy, and because we believe that mediastinoscopy Approach to Middle or Posterior Mediastinal Mass
both is simpler and causes less morbidity than VATS, we prefer par-
tial resection via mediastinoscopy as the initial approach to these Suggestion of malignancy on preoperative radiography
lesions.18 If cysts treated in this manner recur with associated symp- Presence of inflammation or infection, blurring tissue planes
toms, one can always perform thoracotomy for complete resection Large mass (> 5–6 cm)
at that time, and little will have been lost in the meantime. Esophageal duplication cyst believed to communicate with esophageal
lumen on the basis of preoperative CT, barium esophagography, or
esophagoscopy
MEDIASTINOSCOPIC PARTIAL RESECTION OF SUBCARINAL
Esophageal lesions without evidence of overlying normal esophageal
BRONCHOGENIC CYST mucosa on preoperative esophagoscopy or endoscopic
ultrasonography
Operative Technique Previous ipsilateral thoracotomy with adhesions
Tumor located at apex of the chest, which may necessitate
Step 1: mediastinoscopy and pretracheal dissection A thoracosternotomy
standard cervical mediastinoscopy is performed, with dissection in
the pretracheal plane down to the level of the carina.
generally,VATS results in less postoperative pain and quicker func-
Step 2: freeing of cyst from surrounding tissues With tional recovery.19,20 Some surgeons argue that a VATS approach
the cyst wall kept intact, as much of the wall as can safely be may be more likely to leave a patient with microscopic residual dis-
exposed is visualized by bluntly dissecting it away from the under- ease. In our experience and that of others, however, recurrences of
surface of the carina and the mainstem bronchi. Next, the mass is these lesions are very rare after VATS excision.21,22 Given the low
dissected away from the soft tissues anterior and posterior to it; recurrence rate and the fact that these masses are almost always
obviously, this must be done with caution, given that the right benign, we believe that the risk-benefit ratio is better with VATS in
main pulmonary artery and the esophagus are located nearby (an- most cases.
teriorly and posteriorly, respectively). There are, however, several circumstances in which thoracoto-
my is indicated from the outset [see Table 2]. A suggestion of malig-
Step 3: aspiration of cyst contents and excision of exposed nancy (in particular, invasion of surrounding structures) on pre-
cyst wall The contents of the cyst are aspirated for cytologic operative radiography mandates exploration and resection by tho-
and microbiologic examination, and the exposed portion of cyst racotomy; in this situation, the potential consequences of positive
wall is excised. Typically, approximately 50% of the cyst wall can margins justify the more aggressive approach. The presence of
be removed in this fashion. Some of the remaining cyst wall may active infection within a cyst is a relative indication for thoracoto-
be cauterized; this too must be done with caution, given the prox- my, in that it can cause disruption of normal tissue planes and
imity of the adjacent vital structures. thereby render VATS dissection more hazardous. Masses larger
than approximately 6 cm also call for an open approach: such
lesions are typically more difficult to mobilize safely from underly-
Procedures for Lesions of the Posterior Mediastinum
ing structures than smaller lesions are, they are more likely to be
The majority of posterior mediastinal masses occurring in adults malignant, and their removal between the ribs is likely to necessi-
are benign. These lesions may be usefully classified according to tate rib spreading, which may negate some of the benefit of true
their radiologic appearance—that is, as either cystic or solid. Cys- VATS.
tic masses in this region typically are bronchogenic cysts or esoph- When a cyst is arising from or abutting the esophagus, the pos-
ageal duplication cysts, whereas solid masses most frequently are sibility of a communication between the cyst and the esophageal
benign neurogenic tumors (e.g., schwannomas, neurofibromas, or
ganglioneuromas). Esophageal leiomyomas (benign intramuscular
tumors within the esophageal wall) are often grouped with these
posterior mediastinal lesions and are managed in a similar fashion.
In many cases, posterior mediastinal masses come to light as
asymptomatic radiographic abnormalities; however, they may also
be associated with signs of infection (in the case of infected cysts),
dysphagia, chest pain, or respiratory complaints. At pres-
ent, because of the growing availability of less morbid, minimally
invasive approaches to posterior mediastinal masses, most authors
recommend resection even when the lesion is asymptomatic. Al-
though this recommendation remains somewhat controversial, we
agree with it.
OPERATIVE PLANNING
sought before operation from all patients being treated for posteri-
or mediastinal lesions, even when VATS is the intended approach.
VATS RESECTION OF NEUROGENIC TUMOR OF POSTERIOR
MEDIASTINUM
Operative Technique
Alternative Upper Resection of a solid neurogenic tumor of the posterior medi-
Working Ports astinum that does not invade the neural foramen [see Figure 9] pro-
ceeds as follows.
brospinal fluid leak, which most often becomes evident only post-
operatively (in the form of persistent clear chest tube output).The
diagnosis of CSF leakage can be confirmed by measuring the β2-
transferrin level in the fluid. If CSF leakage is confirmed, reopera-
tion with a neurosurgeon is mandatory; the leak is repaired and
buttressed with vascularized tissue.
After resection of a tumor at the costoverterbral sulcus, regular
neurologic examinations of the lower extremities are indicated.
Tamponade with hemostatic agents should never be employed for
bleeding at the neural foramen: doing so can result in an intra-
spinal hematoma with subsequent cord compression. Careful use
of the electrocautery at the bony margins of the foramen or watch-
ful waiting is preferable. If hemostasis cannot be achieved with
these measures, a neurosurgical consultation should be obtained.
In the event of oozing from the vicinity of a foramen that is not eas-
ily controlled, there should be no hesitation in converting a VATS
procedure to an open procedure.
In a minority of patients, clipping and division of an intercostal
Figure 12 Resection of neurogenic tumor of posterior medi- nerve results in intercostal neuralgia after the procedure; the pos-
astinum. The final remaining intercostal stalk is divided. sibility that this may occur must be discussed with the patient pre-
operatively. Many patients who undergo division of a lower tho-
racic intercostal nerve that supplies an upper abdominal derma-
Step 3: incision of pleura The parietal pleura is incised tome notice postoperative bulging of the ipsilateral abdomen in the
around the mass, with a margin of approximately 2 cm circumfer- area supplied by that nerve.
entially. The pleura is tented up with the aid of the right-angle
clamp or the Maryland dissector to separate it from the underly- RESECTION OF BENIGN CYST OF POSTERIOR MEDIASTINUM
ing structures [see Figure 11]. This separation allows the use of the Resection of a benign cystic mass of the posterior mediastinum
electrocautery, which provides hemostasis while protecting the closely resembles resection of a neurogenic tumor [see Resection of
underlying esophagus, vagus and intercostal nerves, and azygos Neurogenic Tumor of Posterior Mediastinum, above]; the differ-
vein. This dissection and all subsequent work are facilitated by ences are relatively minor [see Troubleshooting, below].
placing gentle traction on the mass with a sponge stick or, for
smaller masses, by grasping the entire mass within a ring clamp. Troubleshooting
In the initial stages of dissection of a benign cyst of the posteri-
Step 4: dissection of soft tissue attachments Once the or mediastinum, care should be taken not to rupture the cyst; ini-
pleura has been incised circumferentially, the soft tissue attach- tial mobilization from surrounding structures is easier when the
ments are further dissected bluntly with the endoscopic peanut cyst wall is under tension [see Figure 13]. If the area of the cyst wall
dissector. Attachments that are relatively thick or vascular are best that directly abuts the mediastinum is found to be too adherent to
controlled by double-clipping and division. If the tumor originates underlying structures to be removed safely, we intentionally rup-
from an intercostal nerve, gentle dissection is done beneath the ture the cyst, then remove as much of the cyst wall as possible. As
tumor to identify the intercostal bundle that is the source of the much as 35% of the cyst wall may be left in place. In such cases,
lesion.
a b c
d e f
Figure 14 Resection of esophageal leiomyoma. (a) Shown is an esophageal leiomyoma beneath the azygos
vein. (b) The mediastinal pleura overlying the leiomyoma is incised. (c) The azygos vein is divided with an
endoscopic stapler. (d) The muscle fibers overlying the mass are divided. (e) Gentle traction is applied to
facilitate blunt dissection. (f) Shown is a completely resected horseshoe-shaped esophageal leiomyoma.
we ablate the residual intact cyst wall with the electrocautery to cedure [see Figure 14e]. Having an assistant place the endoscope
destroy any potential secretory tissue. If more than approximately within the esophageal lumen to distend and illuminate the
35% of the cyst must be left in place, conversion to thoracotomy mucosa also may be helpful at this stage. Once the mass has
should be considered. been completely resected, it is sent for pathologic examination
[see Figure 14f].
RESECTION OF ESOPHAGEAL LEIOMYOMA
5. The esophagus is distended by insufflating air from above while
Operative Technique the distal esophagus is occluded with a sponge stick. The air-
filled esophagus is then submerged in saline, and the area of the
In addition to the steps described for resection of a neurogenic resection is examined for air leakage.
mass, there are several special maneuvers that facilitate resection
of esophageal intramural masses, such as leiomyomata [see Figure Troubleshooting
14a] and duplication cysts.
Some surgeons routinely close the muscular defect in the esoph-
1. The pleura is incised longitudinally with the electrocautery agus after resection so as to reduce the risk that an esophageal
after it is tented up away from the esophagus, the vagus nerve, diverticulum will develop. Such closure may be accomplished by
and the azygos vein with a right-angle clamp or a Maryland dis- means of thoracoscopic suturing. Often, though, the muscle layer
sector [see Figure 14b]. is attenuated to the point where useful reapproximation is nearly
2. In some cases, exposure is facilitated by dividing the azygos vein impossible. For this reason, as well as because we believe that a
with an endoscopic stapler [see Figure 14c]. diverticulum is unlikely to develop in the absence of a distal func-
3. The longitudinal esophageal muscle fibers that overlie the mass tional obstruction, we do not routinely close the muscular defect.
are separated bluntly or with the electrocautery.These fibers are Frequently, duplication cysts are more adherent to the under-
often markedly attenuated as a result of the expansion of the lying esophageal mucosa than leiomyomata are, and transillumi-
mass [see Figure 14d]. nation of the esophageal wall helps define the plane at which blunt
4. Blunt dissection with an endoscopic peanut dissector allows dissection should be performed.Where the cyst wall becomes dif-
careful, progressive mobilization of the mass, first from the ficult to separate from the mucosa, a small amount of the wall may
muscle layer and then from the underlying mucosa. Gentle be left in place if, in the surgeon’s judgment, attempting to remove
traction on the mass facilitates exposure at this point in the pro- all of it might lead to a breach in the mucosa.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 13 MEDIASTINAL PROCEDURES — 12
References
1. Hoerbelt R, Keunecke L, Grimm H: The value of Ann Thorac Surg 79:450, 2005 20. Nagahiro I, Andou A, Aoe M, et al: Pulmonary
a noninvasive diagnostic approach to mediastinal 11. Blalock A, Masoj MF, Riven SS: Myasthenia gravis function, postoperative pain, and serum cytokine
masses. Ann Thorac Surg 75:1086, 2003 and tumors of the thymic region. Ann Surg 110: level after lobectomy: a comparison of VATS and
2. Koduri P: The diagnostic approach to mediastinal 544, 1939 conventional procedure. Ann Thorac Surg 72:362,
masses. Ann Thorac Surg 78:1888, 2004 2001
12. Shrager JB, Deeb ME, Mick R, et al: Transcervical
3. Vernino S, Lennon VA: Autoantibody profiles and 21. Martinod E, Pons F, Azorin J, et al: Thoracoscopic
thymectomy for myasthenia gravis achieves results
neurological correlations of thymoma. Clin Cancer excision of mediastinal bronchogenic cysts: results
comparable to thymectomy by sternotomy. Ann
Res 10:7270, 2004 in 20 cases. Ann Thorac Surg 69:1525, 2000
Thorac Surg 74:320, 2002
4. Drevelegas A, Palladas P, Scordalaki A: Mediastinal 22. Zambudio AR, Lanzas JT, Calvo MJ, et al: Non-
13. Cooper JD, Al-Jilaihawa AN, Pearson FG, et al: An
germ cell tumors: a radio-pathological review. Eur neoplastic mediastinal cysts. Eur J Cardiothorac
improved technique to facilitate transcervical
Radiol 11:1925, 2001 Surg 22:712, 2002
thymectomy for myasthenia gravis. Ann Thorac
5. Schneider DT, Calaminus G, Reinhard H, et al: Surg 45:242, 1988 23. Shadmehr MB, Gaissert HA, Wain JC, et al: The
Primary germ cell tumors in children and adoles- surgical approach to “dumbbell tumors” of the
14. Bril V, Kojic J, Ilse WK, et al: Long-term clinical
cents: results of the German cooperative protocols mediastinum. Ann Thorac Surg 76:1650, 2003
outcome after transcervical thymectomy for myas-
MEKEI 83/86, 89 and 96. J Clin Oncol 18:832, thenia gravis. Ann Thorac Surg 65:1520, 1998 24. Osada H, Aoki H,Yokote K, et al: Dumbbell neu-
2000 rogenic tumor of the mediastinum: a report of three
15. Calhoun RF, Ritter JH, Guthrie TJ, et al: Results of cases undergoing single-staged complete removal
6. Wood DE: Mediastinal germ cell tumors. Semin
transcervical thymectomy for myasthenia gravis in without thoracotomy. Jpn J Surg 21:224, 1991
Thorac Cardiovasc Surg 12:278, 2000
100 consecutive patients. Ann Surg 230:555, 1999
7. Watanabe M, Takagi K, Aoki T: A comparison of 25. Rzyman W, Skokowski J,Wilimski R, et al: One step
biopsy through a parasternal anterior mediastinot- 16. Nwariaku F, Snyder WH, Burkey SH, et al: Infra- removal of dumb-bell tumors by postero-lateral
omy under local anesthesia and percutaneous nee- manubrial parathyroid glands in patients with pri- thoracotomy and extended foraminectomy. Eur J
dle biopsy for malignant anterior mediastinal mary hyperparathyroidism: alternatives to ster- Cardiothorac Surg 25:509, 2004
tumors. Surg Today 28:1022, 1998 notomy. World J Surg, March 22, 2005 [Epub
ahead of print] 26. Vallieres E, Findlay JM, Fraser RE: Combined
8. Powers CN, Silverman JF, Geisinger KR, et al: microneurosurgical and thorascopic removal of
Fine-needle aspiration biopsy of the anterior medi- 17. Demmy TL, Krasna MJ, Detterbeck FC, et al: Mul- neurogenic dumbbell tumors. Ann Thorac Surg 59:
astinum: a multi-institutional analysis. Am J Clin ticenter VATS experience with mediastinal tumors. 469, 1995
Pathol 105:168, 1996 Ann Thorac Surg 66:187, 1998
9. Deeb ME, Brinster CJ, Kucharzuk J, et al: Expand- 18. Smythe WR, Bavaria JE, Kaiser LR: Mediastino-
ed indication for transcervical thymectomy in the scopic subtotal removal of mediastinal cysts. Chest Acknowledgments
management of anterior mediastinal masses. Ann 114:1794, 1998
Thorac Surg 72:208, 2001 Figure 1b Photo courtesy of Wallace T. Miller, Sr.,
19. Santambrogio L, Nosotti M, Bellaviti N, et al: M.D., University of Pennsylvania School of Medicine.
10. Savitt MA, Gao G, Furnary AP, et al: Application Videothoracoscopy versus thoracotomy for the
diagnosis of the intermediate solitary pulmonary Figures 2, 7, and 8 Alice Y. Chen.
of robotic-assisted techniques to the surgical evalu-
ation and treatment of the anterior mediastinum. nodule. Ann Thorac Surg 59:868, 1995 Figure 10 Tom Moore.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 14 SOLITARY PULMONARY NODULE — 1
The solitary pulmonary cative of severe obstructive ventilatory impairment are also associ-
nodule (SPN) is a common ated with an increased likelihood of malignancy.11 In addition, the
finding that is observed in SPNa is < 1.0 cm
IMAGING
the patient’s history and risk factors for malignancy in conjunction
with the results of radiographic studies [see Investigative Studies,
below] to develop an individualized care plan. Chest Radiography
Whereas the prevalence
FACTORS INFLUENCING PROBABILITY OF MALIGNANCY
of lung cancer is low in
Of the various factors that influence the probability that cancer comparison to that of
will be found in an SPN before radiographic evaluation, those breast or prostate cancer,
most strongly associated with lung cancer are age, smoking histo- the mortality for lung cancer exceeds that for breast, prostate, and
ry, and occupational history. Pulmonary function test results indi- colon cancer combined. As noted [see Clinical Evaluation, above],
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 14 SOLITARY PULMONARY NODULE — 2
Consider PET.
Pathology is indeterminate
Lesion is probably benign; treat appropriately. Consider PET scanning if nature of lesion is indeterminate. Otherwise,
assume malignancy and resect lesion via VATS or thoracotomy
after staging investigations.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 14 SOLITARY PULMONARY NODULE — 3
SPN has arisen or grown since previous images, SPN has remained unchanged for > 2 yr
or no previous images are available for review
Lesion is probably benign; treat appropriately.
Obtain CT scan.
Pathology is malignant
Table 1 Differential Diagnosis of Solitary Advocates of CT scanning for assessment of SPNs base their argu-
Pulmonary Nodule ment on two central points. First, as many as 83% of CT-detect-
ed stage I malignancies are not visible on chest x-ray.22 Second,
non–small cell lung cancer (NSCLC) is the malignancy most
Arteriovenous malformations
Vascular disease Pulmonary artery aneurysm
commonly identified, and the survival rate for stage I NSCLC is
relatively high. In patients whose SPN proves to be NSCLC, the
Tuberculosis 5-year survival rate is 67% for stage IA disease. This figure falls
Mycobacterium avium complex infection rapidly as the disease stage rises: the 5-year survival rate is 55% for
Aspergilloma stage IIA NSCLC and only 10% for stage IIIA NSCLC with
Histoplasmosis
mediastinal nodal metastasis.23
Echinococcosis
Infection Blastomycosis
Numerous studies have evaluated the use of screening CT both
Cryptococcosis in the general population and in at-risk groups consisting of older
Coccidioidomycosis patients with a smoking history.22,24,25 The greatest drawback to
Ascariasis screening CT is the high false positive rate: nodules are identified
Benign
Dirofilariasis on 23% to 66% of all CT scans, depending on the thickness of the
slices,22,26 and nearly 98% of these nodules are eventually deter-
Rheumatoid nodule
Inflammatory Sarcoidosis
mined to be benign. Sequential CT scanning is often required to
condition determine whether an SPN is benign or malignant. In 10% to
Wegener granulomatosis
15% of patients, however, this determination cannot be made even
Congenital when two CT scans are compared. Such patients may be assessed
Foregut duplication cyst
abnormality
with other imaging modalities (e.g., positron emission tomogra-
Rounded atelectasis phy [PET]) or may be referred for transthoracic needle biopsy
Other
Pulmonary amyloidosis (TTNB) or other invasive diagnostic tests.
Hamartoma There is currently some controversy regarding the optimal tim-
Benign tumor Lipoma ing of follow-up CT scanning after initial identification of an SPN.
Fibroma In the literature, the recommended interval between initial CT
scanning and repeat CT scanning has ranged from 1 month to 1
Non–small cell lung cancer
year.22,25,26 These varying recommendations are based on what is
Squamous cell carcinoma
Adenocarcinoma
considered the doubling time for an SPN. In a study from 2000
Large cell cancer that included 13 patients with a known diagnosis and lesions less
Primary lung cancer Bronchoalveolar carcinoma than 10 mm in diameter at initial evaluation, volumetric growth
Small cell lung cancer rates were measured to establish the doubling times of the nod-
Malignant Carcinoid ules.10 The doubling times ranged from 51 days to more than 1
Lymphoma year. For malignant lesions, the average doubling time was less
Colon cancer
than 177 days, whereas for benign lesions, it was more than 396
Testicular cancer days.
Metastatic cancer Melanoma In addition to delineating the size and contours of an SPN, CT
Sarcoma scans provide information on its internal characteristics. Certain
Breast cancer lesion characteristics noted on CT, though not absolutely defini-
tive, point more toward a benign condition, whereas others point
more toward malignancy. For example, although cavitation may
the overall 5-year survival rate for lung cancer patients is dismal, occur in either benign or malignant lesions, SPNs with walls thick-
in part because lung cancer is typically identified at a more er than 16 mm are much more likely to be malignant, whereas
advanced stage than other cancers are. Several trials performed those with walls thinner than 4 mm are much more likely to be
before the advent of CT scanning attempted to employ chest radi- benign.27 As another example, the presence of intranodular fat is
ography for early screening of lung cancer, but they were unable a reliable indicator of a hamartoma (a benign lesion) and is seen
to demonstrate that such screening yielded any better survival in as many as 50% of hamartomas.28 In addition, calcification is
than no screening at all.16-18 One explanation for these disappoint- most commonly associated with hamartomas and other benign
ing results may be that fewer than 10% of lung cancers are stage I nodules. Unfortunately, between one third and two thirds of be-
at presentation.16 nign lesions visualized are not calcified, and as many as 6% of
Although chest radiography is ineffective as a screening tool for malignant lesions are calcified.29-31 Finally, increased enhance-
early-stage lung cancer, it remains a valuable investigative tool in ment (measured in Hounsfield units [HU]) after injection with
the evaluation of SPNs. If an SPN’s appearance on chest x-rays intravenous contrast is strongly suggestive of malignancy. Lesions
has not changed for more than 2 years, the SPN will be benign in that enhance by less than 15 HU are most likely benign (positive
more than 90% of cases. In such cases, only yearly follow-up is predictive value, 99%), whereas lesions that enhance by more than
typically required; additional diagnostic tests are usually unneces- 20 HU are typically malignant (sensitivity, 98%; specificity,
sary.19,20 Therefore, an effort should always be made to obtain old 73%).32 Lesions that enhance by 15 to 20 HU should be consid-
chest radiographs if they are known to exist. ered indeterminate.
Because most SPNs are benign and because the risk of misdi-
Computed Tomography agnosing a malignant lesion is so great, it is important to make use
The advent of CT scanning has led to an increase in the num- of all of the data obtained from CT scanning in the effort to make
ber of SPNs detected21—but of course, it has also led to an cost-effective, logical decisions regarding further evaluation or
increase in the number of SPNs found that prove to be benign. treatment. Careful evaluation of the size, contours, and internal
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 14 SOLITARY PULMONARY NODULE — 5
characteristics of an SPN on successive CT scans—in conjunction 1.0 cm) may have an SUV lower than 2.5 and still be malignant.
with thoughtful consideration of the patient’s age, smoking histo- The reason is that their small volume causes their true activity
ry, and occupational exposure—provides the framework for ap- concentration to be underestimated, with the result that their SUV
propriate treatment. Because the doubling time is considerably drops below the threshold value for malignancy. In one prospec-
shorter for malignant lesions than for benign lesions, a repeat CT tive study of patients with SPNs, the overall sensitivity of FDG-
scan should be performed 3 months after the initial study. If the PET scanning was 79%, and the overall specificity was 65%.46
lesion is visibly larger on the repeat scan, it is probably malignant, When the SPN was smaller than 1.0 cm, however, all of the scans
and further diagnostic evaluation should be carried out with an were negative, even though 40% of the nodules were malignant.
eye toward resection. If, however, the lesion is still present and has In cases where the SPN is larger than 1.0 cm and no previous
not grown, a follow-up CT scan between 3 months and 12 radiographs or CT scans are available for comparison, PET scan-
months is warranted; the precise timing remains controversial and ning can provide information that may facilitate the decision
should be determined on the basis of individual patient and SPN whether to follow the lesion closely or to proceed with biopsy. PET
characteristics. New volumetric modeling methods have been scanning has a definite place in the evaluation of SPNs, but it is
developed that may be capable of detecting conformational not appropriate for every patient. A study that examined the cost-
changes over much shorter intervals, but at present, they are not effectiveness of PET in the evaluation of SPNs concluded that it
frequently used.33 was cost-effective for patients who had an intermediate pretest
probability of a malignant SPN and who were at high risk for sur-
Positron Emission Tomography gical complications.47 In all other groups, PET was not cost-effec-
PET is an imaging modality that employs radiolabeled isotopes tive, and CT led to similar outcomes (in terms of quality-adjusted
of fluorine, carbon, or oxygen; the most commonly used isotope is life years) and to lower costs.
18F-fluorodeoxyglucose (FDG). The rationale for FDG-PET
BIOPSY
scanning in the evaluation of SPNs is based on the higher meta-
bolic rate of most malignancies and the preferential trapping of If an SPN demonstrates characteristics suggestive of malignan-
FDG in malignant cells.34 However, increased FDG activity can cy, a tissue diagnosis should be obtained. There are several alter-
also occur in benign SPNs,35,36 especially those arising from active native biopsy techniques that may be performed in place of resec-
granulomatous diseases37,38 or inflammatory processes.39 These tion, including TTNB and bronchoscopy.Traditionally, open lung
benign diseases can produce false positive PET scans and thereby biopsy was performed for an SPN, but this approach has the draw-
reduce the sensitivity of the test. Conversely, some malignancies— back of the morbidity associated with a thoracotomy. For periph-
bronchoalveolar carcinoma and carcinoid tumors, in particular— eral lesions, video-assisted thoracoscopic surgery (VATS) has now
have low metabolic activity and commonly produce false negative supplanted thoracotomy as the procedure of choice. For central
PET scans.40-44 Thus, a negative PET scan is not a particularly lesions that cannot be diagnosed by means of less invasive tech-
helpful result, and it is necessary to follow the lesion with serial CT niques, more invasive approaches will still be required.
scans.
Efforts have been made to increase the sensitivity and specifici- Transthoracic Needle Biopsy
ty of PET scanning in the diagnosis of SPNs. One such effort Lesions that are between 1.0 and 3.0 cm in diameter should be
involves the use of the standardized uptake value (SUV), which is considered for TTNB. The diagnostic yield of this procedure for
a numerical indication of the activity concentration in a lesion, SPNs is excellent, reaching 95% in some studies. The reported
normalized for the injected dose.45 In many studies, an SPN is sensitivity ranges from 80% to 95%, and the specificity ranges
considered malignant when its SUV is higher than 2.5. Because of from 50% to 88%.48-50 A study of 222 patients who underwent
the method used to calculate the SUV, however, small tumors (< TTNB for an SPN reported a positive predictive value of 98.6%
and a negative predictive value of 96.6%51; however, several other
studies reported false negative rates ranging from 3% to 29%.48,52
Table 2 Factors Affecting Malignant Probability The complication rate associated with TTNB is relatively high—
of Solitary Pulmonary Nodule8 potentially as high as 30% and rarely lower than 10%, in even the
most experienced hands.49,53 Most commonly, a pneumothorax
Factor Likelihood Ratio for Malignancy results; however, chest tube placement is required only if the
patient becomes symptomatic, a situation that occurs in approxi-
Spiculated margins on CT scan 5.54 mately 50% of cases. In the absence of symptoms, observation
Age > 70 yr 4.16 with serial chest x-rays is generally appropriate. If no increase in
the size of the SPN is observed, the patient can be discharged with
Lesion size 2.1–3.0 cm 3.67
the expectation that the pneumothorax will resolve.
Doubling time < 465 days 3.40 For lesions smaller than 1.0 cm, the risk-to-benefit ratio of
TTNB rises to the point where other techniques are typically pre-
History of smoking 2.27
ferred.The utility of TTNB depends primarily on the characteris-
Age 50–69 yr 1.90 tics of the SPN—in particular, its location. Nodules that are cen-
tral or close to the diaphragm or the pericardium are less well suit-
Lesion size 1.1–2.0 cm 0.74
ed to this technique than those at other sites are.
Lesion size < 1 cm 0.52
Bronchoscopy
Smooth margins on CT scan 0.30
Bronchoscopy has a well-established role in the evaluation of
No history of smoking 0.19 central SPNs, which are amenable to direct visualization and biop-
Doubling time > 465 days 0.01 sy. Most SPNs, however, are not central. Various adjunctive mea-
sures, including transbronchial needle biopsy and cytology brush-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 14 SOLITARY PULMONARY NODULE — 6
Inflammatory Nodules
rupture could result in an anaphylactic reaction to the highly anti-
Sarcoidosis is known as the great mimicker, but it rarely presents genic contents. Patients may be treated with anthelmintic agents,
as an SPN.67 Most commonly, it presents as hilar and mediastinal but the incidence of persistent or recurrent disease is high. Accord-
lymphadenopathy and diffuse parenchymal involvement. When it ingly, surgical resection should be considered.
does present as an SPN, it is almost invariably a solid lesion, hard-
ly ever a cavitary one. The incidence of sarcoidosis is highest in OTHER CONSIDERATIONS
African-American women between 20 and 40 years of age. If sar- Pulmonary amyloidosis may present in either a diffuse or a
coidosis is suspected during the evaluation of an SPN, an elevated nodular form.The prognosis is most favorable when it presents as
angiotensin-converting enzyme level supports the diagnosis, but a an asymptomatic SPN. Typically, the nodule is well defined and
normal level does not exclude it. If a biopsy is performed, the pres- between 2 and 4 cm in diameter. Unless the patient exhibits sys-
ence of noncaseating granulomas on pathologic evaluation estab- temic manifestations of amyloidosis, the diagnosis can be con-
lishes the diagnosis. firmed only by biopsy of the nodule.35
Pulmonary rheumatoid nodules are present in fewer then 1% of Rounded atelectasis usually presents as a pleura-based nodular
patients with rheumatoid arthritis.68 They are usually associated density that occurs secondary to pleural scarring and thickening.
with rheumatoid nodules in other parts of the body but may pre- An effort should be made to look for associated pleural plaques
cede any systemic manifestations of the disease. Pulmonary resulting from asbestos exposure. The CT scan usually demon-
rheumatoid nodules, though generally asymptomatic in them- strates an SPN with a “comet tail.” Biopsy is not required unless
selves, arise from underlying rheumatoid activity.When the under- mesothelioma is strongly suspected or the SPN is seen to have
lying disease is active, the nodules may grow, simulating malignan- grown on successive CT scans.75
cy. An elevated serum rheumatoid factor level is typical and helps
confirm the diagnosis.
Wegener granulomatosis is a necrotizing vasculitis that affects Management
both the upper and the lower respiratory tract, as well as the kid- Currently, there are no evidence-based guidelines that fully
neys. It presents with an SPN in approximately 20% of patients.69 delineate a recommended approach to the workup and manage-
If vasculitis is suspected during evaluation of an SPN, laboratory ment of SPNs.76 The following is a summary of our preferred
studies should include testing for cytoplasmic antineutrophil cyto- approach.
plasmic antibodies (c-ANCA); a positive result on this test is high- The ultimate aim in the evaluation of an SPN is to classify the
ly suggestive of Wegener granulomatosis. Treatment includes the lesion as either benign or malignant.The first step toward that end
cytotoxic drug cyclophosphamide, either alone or in combination is to compare current chest x-rays or CT scans with any previous
with corticosteroids. images that are available. An SPN whose size has been stable for
Infectious Nodules 2 years on diagnostic images will be benign 90% to 95% of the
time. If no previous images are available for comparison, the
An SPN can also represent an infectious granuloma caused by
patient should undergo a complete evaluation as if the nodule
tuberculosis, atypical mycobacterial diseases, histoplasmosis, coc-
were an early-stage NSCLC. This evaluation must be individual-
cidioidomycosis, or aspergillosis. Such granulomas normally have
ized according to the characteristics of the patient and the lesion.
a cavitary appearance on CT scans. Occasionally, an upright chest
On the basis of the patient’s age and smoking history, the size of
x-ray taken with the patient in the lateral decubitus position shows
the SPN, and the characteristics of the lesion’s borders, an SPN
shifting of the position of the cavity’s contents or a crescent of air
for which no previous diagnostic images are available can be ini-
around the mass (the Monod sign).70 This radiographic finding is
tially classified as having a low, intermediate, or high probability
characteristic of a mycetoma, usually aspergilloma. Depending on
of cancer [see Table 3].7,77,78 This classification governs the subse-
the circumstances—in particular, on whether there has been sig-
nificant hemoptysis and whether pulmonary function is reasonably quent workup. Whereas a patient with a high-probability SPN
well preserved—many of these lesions are best treated by means of needs a complete workup, with the goal being resection, the same
resection. Others are best diagnosed by noninvasive techniques workup would not be cost-effective for a patient with a low-prob-
and treated with antibiotics. ability SPN. It is important not to subject a patient with a high-
Pulmonary dirofilariasis is a rare but well-attested cause of probability SPN to studies that will not change clinical manage-
SPNs that is the consequence of infestation of human lungs by the ment or outcome: doing so will delay diagnosis and treatment
canine heartworm Dirofilaria immitis.This organism is transmitted unnecessarily.
to humans in larval form by mosquitoes that have ingested blood At this point in the evaluation, if the nature of the SPN is still
from affected dogs.71 Because humans are not suitable hosts for
this organism, the larvae die and embolize to the lungs, where they
initiate a granulomatous response.Typically, these lesions are pleu- Table 3 Initial Assessment of Probability
ra based, and the diagnosis is made at the time of resection.72 Once of Cancer in Solitary Pulmonary Nodule
the diagnosis is made, no further therapy is required.
Echinococcosis is a hydatid disease caused by the tapeworm Characteristics of Probability of Cancer
Echinococcus granulosus. It is endemic to certain areas of the world Patient or Lesion Low Intermediate High
where sheep and cattle are raised. Normally, it is ingested inciden-
tally; the parasite penetrates the bowel wall and travels to the lungs Patient age < 40 yr 40–60 yr > 60 yr
in 10% to 30% of cases.73,74 A complete blood count usually de-
Patient smoking history Never smoked < 20 pack-years ≥ 20 pack-years
monstrates peripheral eosinophilia. If echinococcosis is suspected, a
hemagglutination test, which has a sensitivity of 66% to 100% and Lesion size < 1.0 cm 1.1–2.2 cm ≥ 2.3 cm
a specificity of 98% to 99% for Echinococcus, should be performed. Lesion margin Smooth Scalloped Spiculated
TTNB should not be performed, because there is a risk that cyst
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 14 SOLITARY PULMONARY NODULE — 8
indeterminate and the lesion is larger than 1.0 cm, there may be a vals for a minimum of 2 years. The rationale for this approach is
role for PET scanning. If PET scanning yields negative results, the based on the difficulty of identifying these lesions with VATS, the
SPN is probably benign, and follow-up with CT scanning is low likelihood of establishing a diagnosis with TTNB, and the pos-
appropriate. If PET scanning yields positive results and the patient sibility that the lesion may be benign. If the lesion has grown visi-
is a high surgical risk,TTNB may be performed to establish a diag- bly between scans, it is probably malignant, and proceeding with
nosis. If, however, the patient is a reasonable surgical risk, pro- resection for diagnosis and treatment is appropriate.The likelihood
ceeding directly to VATS resection (and, potentially, to lobectomy) that nodal metastases will develop in a closely followed SPN small-
offers the best chance of a cure. er than 1.0 cm is low.60 If the SPN proves to be malignant, scan-
For patients with SPNs smaller than 1.0 cm, the optimal ning at 3-month intervals is unlikely to alter the eventual
approach may be to perform serial CT scanning at 3-month inter- outcome.
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53. Geraghty PR, Kee ST, McFarlane G, et al: CT- 61. Pechet TT, Carr SR, Collins JE, et al: Arterial inva- 70. Suen HC, Mathisen DJ, Grillo HC, et al: Surgical
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54. Wallace JM, Deutsch AL: Flexible fiberoptic bron- ing conditions of 1539 population-based lung can- 71. Echeverri A, Long RF, Check W, et al: Pulmonary
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57. Davies AL: The current role of video-assisted tho- and atypical carcinoids within the pulmonary 75. Dial EM, Kane GC:Why the abnormal findings in
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82:229, 1997 66. Greelish JP, Friedberg JS: Secondary pulmonary 76. Ost D, Fein AM, Feinsilver SH: Clinical practice:
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4:9, 1999 Sarcoidosis presenting as an enlarging solitary pul- 77. Cummings SR, Lillington GA, Richard RJ: Esti-
59. Allen MS, Deschamps C, Jones DM, et al: Video- monary nodule. J Thorac Imaging 16:117, 2001 mating the probability of malignancy in solitary
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1998 bypass. J Extra Corpor Technol 24:107, 1993 ateness Criteria. Radiology 215(suppl):607, 2000
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 1 Acute Abdominal Pain — 1
The term acute abdominal pain generally refers to previously Clinical Evaluation
undiagnosed pain that arises suddenly and is of less than 7 days’
(usually less than 48 hours’) duration.1 It may be caused by a HISTORY
great variety of intraperitoneal disorders, many of which call for A careful and methodi-
surgical treatment, as well as by a range of extraperitoneal disor- cal clinical history should
ders,2 which typically do not call for surgical treatment [see be obtained that includes
Clinical Evaluation, Tentative Differential Diagnosis, below]. the mode of onset, dura-
Abdominal pain that persists for 6 hours or longer is usually tion, frequency, character,
caused by disorders of surgical significance.3 The primary goal in location, chronology, radiation, and intensity of the pain, as well
the management of patients with acute abdominal pain is to as the presence or absence of any aggravating or alleviating fac-
determine whether operative intervention is necessary and, if so, tors and associated symptoms. Often, such a history is more
when the operation should be performed. Often, this determina- valuable than any single laboratory or x-ray finding and deter-
tion is easy to make; on occasion, however, the evaluation of mines the course of subsequent evaluation and management.
patients with acute abdominal pain can be one of the most diffi- Unfortunately, when the ability of clinicians to take an orga-
cult challenges in clinical surgery. It is essential to keep in mind nized and accurate history has been studied, the results have
that most (at least two thirds) of the patients who present with been disappointing.7 For this reason, the use of standardized
acute abdominal pain have disorders for which surgical inter- history and physical forms, with or without the aid of diagnos-
vention is not required.2,4,5 tic computer programs, has been recommended.
Making the correct decision regarding whether to operate on a Computer-aided diagnosis has been extensively studied in
patient with acute abdominal pain requires sound surgical judg- England.8-11 In these studies, physicians collected clinical data
ment. The decision must be based on a detailed medical and sur- on structured data sheets and entered the information into a
gical clinical history as well as a meticulous physical examination. computer running a diagnostic program; the computer, which
These, in turn, must be based on experience, a thorough knowl- contained a large clinical database, then generated diagnostic
edge of the anatomy and physiology of the peritoneal cavity, and a probabilities. One such study demonstrated that integration of
clear understanding of the pathologic processes that occur within computer-aided diagnosis into the management of 16,737 patients
the abdomen. Much has been written about the diagnosis of acute with acute abdominal pain yielded a 20% improvement in diag-
abdominal pain since 1921, when Sir Zachary Cope first published nostic accuracy.8 This improvement resulted in statistically sig-
his now classic paper.3 Although the basic approach to assessment nificant reductions in inappropriate admissions, negative
of acute abdominal pain remains much the same today, the intro- laparotomies, serious management errors (e.g., failure to oper-
duction of new diagnostic technologies and better resuscitation ate on patients who require surgery), and length of hospital stay,
methods, coupled with an aging population (in the United States as well as statistically significant increases in the number of
and other developed countries) and new disease processes, neces- patients who were immediately discharged home without
sitates periodic revision of the traditional approach as well as con- adverse effects and the promptness with which those requiring
stant broadening of the differential diagnosis. For example, with the surgery underwent operation. Although these impressive
proliferation of less invasive surgery, the use of laparoscopy has results are undoubtedly attributable to more than one cause, it
expanded far beyond its initial application to cholecystectomy. is certain that the required use of a structured data sheet to
Emergency laparoscopy has become more widely accepted in the record the patient’s history for computer analysis played a cru-
treatment of acute surgical diseases (e.g., acute appendicitis and cial role. In fact, when the data sheets were used without the
perforated peptic ulcer) as general surgeons gain competence in its computer, diagnostic accuracy and overall decision making
use. Diagnostic laparoscopy has also proved valuable in the assess- were still significantly improved.
ment of acute abdominal pain (see below). There now appears to be more than sufficient evidence to
Historically, diagnosis of the causes of acute abdominal pain support the routine use of structured data sheets in the initial
has been based largely on pattern recognition, in which clini- stages of obtaining a history from a patient with acute abdomi-
cians attempt to match new cases to preexisting stereotypes (so- nal pain.9-11 An example of such a data sheet is the pain chart
called classic presentations) of various diseases. Certainly, developed by the World Organization of Gastroenterology (OMGE)
knowledge of these classic presentations is basic to successful [see Figure 1]. The components of this data sheet represent the
diagnosis, but it is crucial to remember that at least one third of consensus of the more than 2,000 surgeons worldwide who con-
patients with acute abdominal pain exhibit atypical features that tributed to its development and have used it to collect informa-
render pattern recognition unreliable.4,6,7 tion for the Research Committee of the OMGE and other groups
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 1 Acute Abdominal Pain — 2
Proceed with subsequent management on the basis Laboratory: complete blood count, hematocrit, electrolytes, creatinine,
of the working diagnosis. blood urea nitrogen, glucose, liver function tests, amylase, lipase,
Reevaluate patient repeatedly. If patient does not urinalysis, pregnancy test, ECG (if patient is elderly or has
respond to treatment as expected, reassess working atherosclerosis).
diagnosis and return to differential diagnosis. Imaging: Plain abdominal films (upright and supine) and chest
radiographs.
(Note: These studies are rarely diagnostic by themselves; their purpose
is primarily confirmatory.)
Consider early US or CT.
Patient requires early laparotomy Patient is candidate for elective Diagnosis is uncertain,
or laparoscopy laparotomy or laparoscopy or patient has suspected
nonsurgical abdomen
Early laparotomy or laparoscopy is Elective laparotomy or laparoscopy
reserved for patients whose conditions is reserved for patients who are Reevaluate patient as
are unlikely to become life threatening highly likely to respond to appropriate
if operation is delayed for 24–48 conservative medical management (see facing page).
hr (e.g., those with uncomplicated or whose conditions are highly
intestinal obstruction, uncomplicated unlikely to become life threatening
acute cholecystitis, uncomplicated during prolonged evaluation (e.g.,
acute diverticulitis, or nonstrangulated those with IBD, peptic ulcer disease,
incarcerated hernia). pancreatitis, or endometriosis).
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 1 Acute Abdominal Pain — 3
Remember that the majority of patients will turn out to have nonsurgical
diagnoses.
Take into account effects of age and gender on diagnostic possibilities.
Patient should be hospitalized Patient can be evaluated in Patient should be hospitalized and observed
and observed outpatient setting
Provide narcotic analgesia as appropriate.
Provide narcotic analgesia as Observe patient carefully, and reevaluate
appropriate. condition periodically.
Observe patient carefully, and Consider additional investigative studies.
reevaluate condition periodically.
Consider additional investigative
studies. CT and US may be
especially useful.
respiration worse
food
Duration
At Present other
none Type
intermittent
Relieving Factors
steady
lying still
colicky
vomiting
Radiation
antacids Severity
food moderate
other severe
none
jaundiced
cyanotic Murphy’s Sign Present
other
Intestinal Movement yes no
normal Bowel Sounds
poor/nil normal Diagnosis & Plan after Investigation
peristalsis absent
Scars increased
yes no Rectal-Vaginal Tenderness
Distention left
yes no right (time )
general
mass Discharge Diagnosis
none
Figure 1 Shown is a data sheet modified from the abdominal pain chart developed by the OMGE.13
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 1 Acute Abdominal Pain — 5
studying acute abdominal pain.12,13 Given that the data sheet is by Certain types of pain are generally held to be typical of certain
no means exhaustive, individual surgeons may want to add to it; pathologic states—for example, the general burning pain of a per-
however, they would be well advised not to omit any of the symp- forated gastric ulcer, the tearing pain of a dissecting aneurysm,
toms and signs on the data sheet from their routine examination and the gripping pain of intestinal obstruction. However, the
of patients with acute abdominal pain.14 character of the pain is not always a reliable clue to its cause.
When the surgeon obtains a complete clinical history with an For several reasons—atypical pain patterns, dual innervation by
open mind, the patient often provides important clues to the cor- visceral and somatic afferents, normal variations in organ position,
rect diagnosis. Patients should be allowed to relate the history in and widely diverse underlying pathologic states—the location of
their own words, and examiners should refrain from suggesting abdominal pain is only a rough guide to diagnosis. It is nevertheless
specific symptoms, except as a last resort. Any questions that must true that in most disorders, the pain tends to occur in characteris-
be asked should be open-ended—for example, “What happens tic locations, such as the right upper quadrant (cholecystitis), the
when you eat?” rather than “Does eating make the pain worse?” right lower quadrant (appendicitis), the epigastrium (pancreatitis),
Leading questions should be avoided. When a leading question or the left lower quadrant (sigmoid diverticulitis) [see Figure 2]. It is
must be asked, it should be posed first as a negative question (i.e., important to determine the location of the pain at onset because
one that calls for an answer in the negative), since a negative answer this may differ from the location at the time of presentation (so-
to a question is more likely to be honest and accurate. For exam- called shifting pain). In fact, the chronological sequence of events
ple, if peritoneal inflammation is suspected, the question asked in the patient’s history is often more important for diagnosis than
should be “Does coughing make the pain better?” rather than the location of the pain alone. For example, the classic pain of
“Does coughing make the pain worse?” appendicitis begins in the periumbilical region and settles in the
The mode of onset of abdominal pain may help the examiner right lower quadrant. A similar shift in location can occur when
determine the severity of the underlying disease. Pain that has a escaping gastroduodenal contents from a perforated ulcer pool in
sudden onset suggests an intra-abdominal catastrophe, such as a the right lower quadrant.
ruptured abdominal aortic aneurysm (AAA), a perforated viscus, It is also important to take into account radiation or referral
or a ruptured ectopic pregnancy. Rapidly progressive pain that of the pain, which tends to occur in characteristic patterns [see
becomes intensely centered in a well-defined area within a period Figure 3]. For example, biliary pain is referred to the right sub-
of a few minutes to an hour or two suggests a condition such as scapular area, and the boring pain of pancreatitis typically radi-
acute cholecystitis or pancreatitis. Pain that has a gradual onset over ates straight through to the back. The more severe the pain is,
several hours, usually beginning as slight or vague discomfort and the more likely it is to be referred.
slowly progressing to steady and more localized pain, suggests a The intensity or severity of the pain is related to the magnitude
subacute process and is characteristic of peritoneal inflammation. of the underlying insult. It is important to distinguish between the
Numerous disorders may be associated with this mode of onset, intensity of the pain and the patient’s reaction to it because there
including acute appendicitis, diverticulitis, pelvic inflammatory dis- appear to be significant individual differences with respect to toler-
ease (PID), and intestinal obstruction. ance of and reaction to pain. Pain that is intense enough to awak-
Pain can be either intermittent or continuous. Intermittent or en the patient from sleep usually indicates a significant underlying
cramping pain (colic) is pain that occurs for a short period organic cause. Past episodes of pain and factors that aggravate or
(a few minutes), followed by longer periods (a few minutes to relieve the pain often provide useful diagnostic clues. For example,
one-half hour) of complete remission during which there is pain caused by peritonitis tends to be exacerbated by motion, deep
no pain at all. Intermittent pain is characteristic of obstruction of breathing, coughing, or sneezing, and patients with peritonitis tend
a hollow viscus and results from vigorous peristalsis in the wall to lie quietly in bed and avoid any movement. The typical pain of
of the viscus proximal to the site of obstruction. This pain is acute pancreatitis is exacerbated by lying down and relieved by sit-
perceived as deep in the abdomen and is poorly localized. The ting up. Pain that is relieved by eating or taking antacids suggests
patient is restless, may writhe about incessantly in an effort to duodenal ulcer disease, whereas diffuse abdominal pain that ap-
find a comfortable position, and often presses on the abdominal pears 30 minutes to 1 hour after meals suggests intestinal angina.
wall in an attempt to alleviate the pain.Whereas the intermittent Associated gastrointestinal symptoms, such as nausea, vomiting,
pain associated with intestinal obstruction (typically described as anorexia, diarrhea, and constipation, often accompany abdominal
gripping and mounting) is usually severe but bearable, the pain pain; however, these symptoms are nonspecific and therefore may
associated with obstruction of small conduits (e.g., the biliary not be of great value in the differential diagnosis. Vomiting in par-
tract, the ureters, and the uterine tubes) often becomes unbear- ticular is common: when sufficiently stimulated by pain impulses
able. Obstruction of the gallbladder or bile ducts gives rise to a traveling via secondary visceral afferent fibers, the medullary vom-
type of pain often referred to as biliary colic; however, this term iting centers activate efferent fibers and cause reflex vomiting. Once
is a misnomer, in that biliary pain is usually constant because of again, the chronology of events is important, in that pain often pre-
the lack of a strong muscular coat in the biliary tree and the cedes vomiting in patients with conditions necessitating operation,
absence of regular peristalsis. whereas the opposite is usually the case in patients with medical
Continuous or constant pain is pain that is present for hours (i.e., nonsurgical) conditions.4,6 This is particularly true for patients
or days without any period of complete relief; it is more com- with acute appendicitis, in whom pain almost always precedes
mon than intermittent pain. Continuous pain is usually indica- vomiting by several hours. Similarly, constipation may result from
tive of peritoneal inflammation or ischemia. It may be of steady a reflex paralytic ileus when sufficiently stimulated visceral afferent
intensity throughout, or it may be associated with intermittent fibers activate efferent sympathetic fibers (splanchnic nerves) to
pain. For example, the typical colicky pain associated with sim- reduce intestinal peristalsis. Diarrhea is characteristic of gastroen-
ple intestinal obstruction changes when strangulation occurs, teritis but may also accompany incomplete intestinal obstruction.
becoming continuous pain that persists between episodes or More significant is a history of obstipation, because if it can be def-
waves of cramping pain. initely established that a patient with acute abdominal pain has not
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 1 Acute Abdominal Pain — 6
a b
EPIGASTRIC REGION
Peptic Ulcer
Gastritis
Pancreatitis
Duodenitis
Gastroenteritis
Early Appendicitis
Mesenteric Adenitis UMBILICAL REGION
Mesenteric Thrombosis Early Appendicitis
Intestinal Obstruction Gastroenteritis
Inflammatory Bowel Disease Pancreatitis
Aneurysm Hernia
Mesenteric Adenitis
Mesenteric Thrombosis
Intestinal Obstruction
DIFFUSE
Inflammatory Bowel Disease
Peritonitis
Aneurysm
Early Appendicitis
Pancreatitis
HYPOGASTRIC REGION
Leukemia
Cystitis
Sickle Cell Crisis
Diverticulitis
Gastroenteritis
Appendicitis
Mesenteric Adenitis
Prostatism
Mesenteric Thrombosis
Salpingitis
Intestinal Obstruction
Hernia
Inflammatory Bowel
Ovarian Cyst/Torsion
Disease
Endometriosis
Aneurysm
Ectopic Pregnancy
Metabolic Causes
Nephrolithiasis
Toxic Causes
Intestinal Obstruction
Inflammatory Bowel Disease
Abdominal Wall Hematoma
c
RIGHT UPPER QUADRANT
Cholecystitis
Choledocholithiasis
Hepatitis
Hepatic Abscess LEFT UPPER QUADRANT
Hepatomegaly from Gastritis
Congestive Heart Failure Pancreatitis
Peptic Ulcer Splenic Enlargement
Pancreatitis Splenic Rupture
Retrocecal Appendicitis Splenic Infarction
Pyelonephritis Splenic Aneurysm
Nephrolithiasis Pyelonephritis
Herpes Zoster Nephrolithiasis
Myocardial Ischemia Herpes Zoster
Pericarditis Myocardial Ischemia
Pneumonia Pneumonia
Empyema Empyema
Gastritis Diverticulitis
Duodenitis Intestinal Obstruction
Intestinal Obstruction Inflammatory Bowel Disease
Inflammatory Bowel Disease
LEFT LOWER QUADRANT
RIGHT LOWER QUADRANT Diverticulitis
Appendicitis Intestinal Obstruction
Intestinal Obstruction Inflammatory Bowel Disease
Inflammatory Bowel Disease Appendicitis
Mesenteric Adenitis Leaking Aneurysm
Diverticulitis Abdominal Wall Hematoma
Cholecystitis Ectopic Pregnancy
Perforated Ulcer Mittelschmerz
Leaking Aneurysm Ovarian Cyst/Torsion
Abdominal Wall Hematoma Salpingitis
Ectopic Pregnancy Endometriosis
Ovarian Cyst/Torsion Ureteral Calculi
Salpingitis Pyelonephritis
Mittelschmerz Nephrolithiasis
Endometriosis Seminal Vesiculitis
Ureteral Calculi Psoas Abscess
Pyelonephritis Hernia
Nephrolithiasis
Seminal Vesiculitis
Psoas Abscess Figure 2 In most disorders that give rise to acute abdominal pain,
Hernia the pain tends to occur in specific locations.
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 1 Acute Abdominal Pain — 7
Stomach
Pylorus
Figure 3 Pain of abdominal origin tends to be referred in characteristic patterns.54 The more severe the pain
is, the more likely it is to be referred. Shown are anterior (left) and posterior (right) areas of referred pain.
passed gas or stool for 24 to 48 hours, it is certain that some degree TENTATIVE DIFFERENTIAL
of intestinal obstruction is present. Other associated symptoms that DIAGNOSIS
should be noted include jaundice, melena, hematochezia, hema- Once the patient’s histo-
temesis, and hematuria.These symptoms are much more specific than ry has been obtained, the
the ones just discussed and can be extremely valuable in the differ- examiner should generate a
ential diagnosis. Most conditions that cause acute abdominal pain tentative differential diag-
of surgical significance are associated with some degree of fever. nosis and carry out the
Fever suggests an inflammatory process; however, it is usually low physical examination in
grade and often absent altogether, particularly in elderly and im- search of specific signs or findings that either rule out or confirm
munocompromised patients.The combination of a high fever with the diagnostic possibilities. Given that the list of conditions that can
chills and rigors indicates bacteremia, and concomitant changes in cause acute abdominal pain is almost endless [see Tables 1 and 2],
mental status (e.g., agitation, disorientation, and lethargy) suggest there is no substitute for some general knowledge of what the
impending septic shock. most common causes of acute abdominal pain are and how age,
A history of trauma (even if the patient considers the traumatic gender, and geography may affect the likelihood that any of these
event trivial) should be actively sought in all cases of unexplained potential causes is present.
acute abdominal pain; such a history may not be readily volun- Ambulatory patients with acute abdominal pain as a chief com-
teered (as is often the case with trauma resulting from domestic plaint constitute 2% to 3% of all patients in an office practice and
violence). With female patients, it is essential to obtain a detailed 5% to 10% of all patients seen in the emergency department.4,13,15
gynecologic history that includes the timing of symptoms within At least two thirds of these patients have disorders that do not call
the menstrual cycle, the date of the last menses, previous and cur- for surgical intervention.2,4,5 Although acute abdominal pain is the
rent use of contraception, any abnormal vaginal bleeding or dis- most common surgical emergency and most non–trauma-related
charge, an obstetric history, and any risk factors for ectopic pregnan- surgical admissions (and 1% of all hospital admissions) are ac-
cy (e.g., PID, use of an intrauterine device, or previous ectopic or counted for by patients complaining of abdominal pain, little infor-
tubal surgery). mation is available regarding the clinical spectrum of disease in
A complete history of previous medical conditions must be these patients.16 Nevertheless, detailed epidemiologic information
obtained because associated diseases of the cardiac, pulmonary, can be an invaluable asset in the diagnosis and treatment of acute
and renal systems may give rise to acute abdominal symptoms and abdominal pain.
may also significantly affect the morbidity and mortality associated The most extensive information available comes from the
with surgical intervention. Weight changes, past illnesses, recent ongoing survey begun in 1977 by the Research Committee of the
travel, environmental exposure to toxins or infectious agents, and OMGE. As of the last progress report on this survey, which was
medications used should also be investigated. A history of previous published in 1988,12 more than 200 physicians at 26 centers in 17
abdominal operations should be obtained but should not be relied countries had accumulated data on 10,320 patients with acute
on too heavily in the absence of operative reports. A careful family abdominal pain [see Table 3]. The most common diagnosis in
history is important for detection of hereditary disorders that may these patients was nonspecific abdominal pain (NSAP)—that is,
cause acute abdominal pain. A detailed social history should also the retrospective diagnosis of exclusion in which no cause for the
be obtained that includes tobacco, alcohol, or illicit drug use as well pain can be identified.17,18 Nonspecific abdominal pain account-
as a sexual history. ed for 34% of all patients seen; the four most common diagnoses
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 1 Acute Abdominal Pain — 8
accounted for more than 75%. The most common surgical diag- and pancreatitis were all approximately five times more common
nosis was acute appendicitis, followed by acute cholecystitis, than in patients younger than 50 years. Hernias were also a much
small bowel obstruction, and gynecologic disorders. Relatively more common problem in older patients. In the entire group of
few patients had perforated peptic ulcer, a finding that confirms patients, only one of every 10 instances of intestinal obstruction
the recent downward trend in the incidence of this condition. was attributable to a hernia, whereas in patients 50 years of age or
Cancer was found to be a significant cause of acute abdominal older, one of every three instances was caused by an undiagnosed
pain. There was little variation in the geographic distribution of hernia. Cancer was 40 times more likely to be the cause of acute
surgical causes of acute abdominal pain (i.e., conditions necessi- abdominal pain in patients 50 years of age or older; vascular dis-
tating operation) among developed countries. In patients who eases (including myocardial infarction, mesenteric ischemia, and
required operation, the most common causes were acute appen- ruptured AAA) were 25 times more common in patients 50 years
dicitis (42.6%), acute cholecystitis (14.7%), small bowel obstruc- of age or older and 100 times more common in patients older than
tion (6.2%), perforated peptic ulcer (3.7%), and acute pancreati- 70 years. What is more, outcome was clearly related to age: mor-
tis (4.5%).12 tality was significantly higher in patients older than 70 years (5%)
The finding that NSAP was the most common diagnosis in than in those younger than 50 years (less than 1%). Whereas the
patients with acute abdominal pain was confirmed by several other peak incidence of acute abdominal pain occurred in patients in
clinical studies4,5,16,19; the finding that acute appendicitis, cholecys- their teens and 20s, the great majority of deaths occurred in
titis, and intestinal obstruction were the three most common diag- patients older than 70 years.22
noses in patients with acute abdominal pain who require operation Further analysis of the data from the OMGE survey also makes
was also amply confirmed1,4,5,16,19 [see Table 3]. it clear that the disease spectrum in children is different from that
The data described so far provide a comprehensive picture of in adults: well over 90% of cases of acute abdominal pain in chil-
the most likely diagnoses for patients with acute abdominal pain dren are diagnosed as either acute appendicitis (32%) or nonspe-
in many centers around the world; however, this picture does not cific abdominal pain (62%).22 Similar age-related differences in
take into account the effect of age on the relative likelihood of the the spectrum of disease have been confirmed by other studies,16 as
various potential diagnoses. It is well known that the disease spec- have various gender-related differences.
trum of acute abdominal pain is different in different age groups, Knowledge of the most common causes of acute abdominal
especially in the very old and the very young.20 This variation is pain and familiarity with the special circumstances that make
apparent when the 10,320 patients from the OMGE study are particular causes more likely than others allow the surgeon to
segregated by age21 [see Table 4]. In patients 50 years of age or play the odds.14 As has often been said, common things are com-
older, cholecystitis was more common than either NSAP or acute mon—or, to put it another way, most patients get what most
appendicitis, and small bowel obstruction, diverticular disease, people get.
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 1 Acute Abdominal Pain — 9
PHYSICAL EXAMINATION
be sought before attention is directed to the patient’s abdomen.
In physical examination, Systemic signs of shock, such as diaphoresis, pallor, hypothermia,
as in history taking, there is tachypnea, tachycardia with orthostasis, and frank hypotension,
no substitute for organiza- usually accompany a rapidly progressive or advanced intra-abdom-
tion and patience; the inal condition and, in the absence of extra-abdominal causes, are
amount of information that an indication for immediate laparotomy. The absence of any alter-
can be obtained is directly ation in vital signs, however, does not necessarily exclude a serious
proportional to the gentle- intra-abdominal process.
ness and thoroughness of the examiner. The physical examina- The surgeon then begins the abdominal examination. This is
tion begins with a brief but thorough evaluation of the patient’s done with the patient resting in a comfortable supine position.
general appearance and ability to answer questions. The degree The examination should include inspection, auscultation, per-
of obvious pain should be estimated. The patient’s position in cussion, and palpation of all areas of the abdomen, the flanks,
bed should be noted: as an example, a patient who lies motion- and the groin (including all hernia orifices) in addition to rectal
less with flexed hips and knees is more likely to have generalized and genital examinations (and, in female patients, a full gyneco-
peritonitis, whereas a restless patient who writhes about in bed is logic examination). A systematic approach is crucial: an examin-
more likely to have colicky pain, which suggests different diag- er who methodically follows a set pattern of abdominal exami-
noses. The area of maximal pain should be identified before the nation every time will be rewarded more frequently than one
physical examination is begun. The examiner can easily do this who improvises haphazardly with each patient.
by simply asking the patient to cough and then to point with one The first step in the abdominal examination is careful inspection
finger to the area of maximal pain. This allows the examiner to of the anterior and posterior abdominal walls, the flanks, the per-
avoid the area in the early stages of the examination and to con- ineum, and the genitalia for previous surgical scars (possible adhe-
firm it at a later stage without causing the patient unnecessary sions), hernias (incarceration or strangulation), distention (intestinal
discomfort in the meantime. obstruction), obvious masses (distended gallbladder, abscesses, or
A complete physical examination should be performed and tumors), ecchymosis or abrasions (trauma), striae (pregnancy or as-
extra-abdominal causes of pain and signs of systemic illness should cites), everted umbilicus (increased intra-abdominal pressure), visi-
ble pulsations (aneurysm), visible peristalsis (obstruction), limita- the patient; in addition, it is much more accurate in demonstrat-
tion of movement of the abdominal wall with ventilatory move- ing rebound tenderness.
ments (peritonitis), or engorged veins (portal hypertension). The last step, palpation, is the most informative aspect of the
The next step in the abdominal examination is auscultation. Al- physical examination. Palpation of the abdomen must be done very
though it is important to note the presence (or absence) of bowel gently to avoid causing additional pain early in the examination. It
sounds and their quality, auscultation is probably the least rewarding should begin as far as possible from the area of maximal pain and
aspect of the physical examination. Severe intra-abdominal condi- then should gradually advance toward this area, which should be
tions, even intra-abdominal catastrophes, may occur in patients with the last to be palpated.The examiner should place the entire hand
normal bowel sounds, and patients with silent abdomens may have on the patient’s abdomen with the fingers together and extended,
no significant intra-abdominal pathology at all. In general, however, applying pressure with the pulps (not the tips) of the fingers by flex-
the absence of bowel sounds indicates a paralytic ileus; hyperactive or ing the wrists and the metacarpophalangeal joints. It is essential to
hypoactive bowel sounds often are variations of normal activity; and determine whether true involuntary muscle guarding (muscle spasm)
high-pitched bowel sounds with splashes, tinkles (echoing as in a is present.This determination is made by means of gentle palpation
large cavern), or rushes (prolonged, loud gurgles) indicate mechani- over the abdominal wall while the patient takes a long, deep breath.
cal bowel obstruction. If guarding is voluntary, the underlying muscle immediately relaxes
The third step is percussion to search for any areas of dullness, under the gentle pressure of the palpating hand. If, however, the
fluid collections, sections of gas-filled bowel, or pockets of free air patient has true involuntary guarding, the muscle remains in spasm
under the abdominal wall. Tympany may be present in patients (i.e., taut and rigid) throughout the respiratory cycle (so-called
with bowel obstruction or hollow viscus perforation. Percussion boardlike abdomen). True involuntary guarding is indicative of
can be useful as a way of estimating organ size and of determin- localized or generalized peritonitis. It must be remembered that
ing the presence of ascites (signaled by a fluid wave or shifting muscle rigidity is relative: for example, muscle guarding may be less
dullness). It is most useful, however, as a means of demonstrating pronounced or absent in debilitated and elderly patients who have
peritoneal irritation (rebound tenderness). The customary tech- poor abdominal musculature. In addition, the evaluation of muscle
nique is to dig the fingers deep into the patient’s abdomen and guarding is dependent on the patient’s cooperation.
then let go abruptly. This technique is a time-honored one, but it Palpation is also useful for determining the extent and severi-
is painful and often misleads the examiner into assuming that an ty of the patient’s tenderness. Diffuse tenderness indicates gen-
acute process is present when none exists. Gentle percussion over eralized peritoneal inflammation. Mild diffuse tenderness with-
the four quadrants of the abdomen is much better tolerated by out guarding usually indicates gastroenteritis or some other
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 1 Acute Abdominal Pain — 11
inflammatory intestinal process without peritoneal inflamma- Table 4 Frequency of Specific Diagnoses in
tion. Localized tenderness suggests an early stage of disease with Younger and Older Patients with Acute Abdominal
limited peritoneal inflammation.
Careful palpation can elicit several specific signs [see Table 5]— Pain in the OMGE Study12,21
such as the Rovsing sign (associated with acute appendicitis) and
the Murphy sign (acute cholecystitis)—that are indicative of local- Frequency (% of Patients)
ized peritoneal inflammation. Similarly, specific maneuvers can Diagnosis
Age < 50 Yr Age ≥ 50 Yr
elicit signs of localized peritoneal irritation, such as the psoas sign (N = 6,317) (N = 2,406)
(associated with retrocecal appendicitis), the obturator sign (pelvic
appendicitis), and the Kehr sign (diaphragmatic irritation). One Nonspecific abdominal pain 39.5 15.7
very important maneuver is the Carnett test, in which the patient Appendicitis 32.0 15.2
elevates his or her head off the bed, thus tensing the abdominal
muscles. Tenderness to palpation persists when the pain is caused Cholecystitis 6.3 20.9
by abdominal wall conditions (e.g., rectal sheath hematoma) but Obstruction 2.5 12.3
decreases or disappears when the pain is caused by intraperitoneal
conditions (the Carnett sign). Pancreatitis 1.6 7.3
Rectal, genital, and (in women) pelvic examinations are an Diverticular disease < 0.1 5.5
essential part of the evaluation in all patients with acute abdom-
inal pain. The rectal examination should include evaluation of Cancer < 0.1 4.1
sphincter tone, tenderness (localized versus diffuse), and pros- Hernia < 0.1 3.1
tate size and tenderness, as well as a search for the presence of
hemorrhoids, masses, fecal impaction, foreign bodies, and gross Vascular disease < 0.1 2.3
or occult blood. The genital examination should search for
adenopathy, masses, discoloration, edema, and crepitus. The
pelvic examination in women should check for vaginal discharge pected to be hepatobiliary in origin. Similarly, amylase and lipase
or bleeding, cervical discharge or bleeding, cervical mobility and determinations are mandatory when pancreatitis is suspected,
tenderness, uterine tenderness, uterine size, and adnexal tender- although it must be remembered that amylase levels may be low or
ness or masses. Although a carefully performed pelvic examina- normal in patients with pancreatitis and may be markedly elevated
tion can be invaluable in differentiating nonsurgical conditions in patients with other conditions (e.g., intestinal obstruction,
(e.g., PID) from conditions necessitating prompt operation (e.g., mesenteric thrombosis, and perforated ulcer).
acute appendicitis), the possibility that a surgical condition is Urinalysis may reveal red blood cells (suggestive of renal or
present should not be prematurely dismissed solely on the basis ureteral calculi), white blood cells (urinary tract infection or
of a finding of tenderness on pelvic or rectal examination. inflammatory processes adjacent to the ureters, such as retroce-
cal appendicitis), increased specific gravity (dehydration), glu-
cose, ketones (diabetes), or bilirubin (hepatitis). A pregnancy test
Basic Investigative should be considered in any woman of childbearing age with
Studies acute abdominal pain.
Although laboratory and IMAGING
radiologic studies rarely, if
ever, establish a definitive In most patients with acute abdominal pain, initial radiologic
diagnosis by themselves, they evaluation includes plain films of the abdomen in the supine and
are often useful for con- standing positions and chest radiographs.23 If the patient is un-
firming the diagnosis sug- able to stand, a left lateral decubitus radiograph should be ob-
gested by the history and the physical examination. tained. Like the basic laboratory studies (see above), these plain
radiographs may help confirm diagnoses suggested by the histo-
LABORATORY TESTS ry and the physical examination, such as pneumonia (signaled by
In all except extremely hemodynamically unstable patients, a pulmonary infiltrates); intestinal obstruction (air-fluid levels and
complete blood count, blood chemistries, and a urinalysis are rou- dilated loops of bowel); intestinal perforation (pneumoperi-
tinely obtained. The hematocrit is important in that it allows the toneum); biliary, renal, or ureteral calculi (abnormal calcifica-
surgeon to detect significant changes in plasma volume (e.g., tions); appendicitis (fecalith); incarcerated hernia (bowel pro-
dehydration caused by vomiting, diarrhea, or fluid loss into the truding beyond the confines of the peritoneal cavity); mesenteric
peritoneum or the intestinal lumen), preexisting anemia, or bleed- infarction (air in the portal vein); chronic pancreatitis (pancreat-
ing. An elevated white blood cell count is indicative of an inflam- ic calcifications); acute pancreatitis (the so-called colon cutoff sign);
matory process and is a particularly helpful finding if associated visceral aneurysms (calcified rim); retroperitoneal hematoma or
with a marked left shift; however, the presence or absence of leuko- abscess (obliteration of the psoas shadow); and ischemic colitis (so-
cytosis should never be the single deciding factor as to whether the called thumbprinting on the colonic wall).
patient should undergo an operation. A low white blood cell count A prospective study published in 1999 evaluated the utility of
may be a feature of viral infections, gastroenteritis, or NSAP. routine plain abdominal radiographs in the management of adult
Serum electrolyte, blood urea nitrogen, and creatinine concen- patients with acute right lower quadrant abdominal pain.24 The
trations are useful in determining the nature and extent of fluid results seem to demonstrate that indiscriminate use of such radio-
losses. Blood glucose and other blood chemistries may also be help- graphs in this patient subset is not helpful but that discriminating
ful. Liver function tests (serum bilirubin, alkaline phosphatase, and use in selected patients with clinically suspected small bowel obstruc-
transaminase levels) are mandatory when abdominal pain is sus- tion or urinary symptoms may be worthwhile. A subsequent study
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 1 Acute Abdominal Pain — 12
Aaron sign Referred pain or feeling of distress in epigastrium or precordial re- Acute appendicitis
gion on continued firm pressure over the McBurney point
Ballance sign Presence of dull percussion note in both flanks, constant on left side Ruptured spleen
but shifting with change of position on right side
Bassler sign Sharp pain elicited by pinching appendix between thumb of examin- Chronic appendicitis
er and iliacus muscle
Beevor sign Upward movement of umbilicus Paralysis of lower portions of rectus abdominis muscles
Carnett sign Disappearance of abdominal tenderness when anterior abdominal Abdominal pain of intra-abdominal origin
muscles are contracted
Chandelier sign Intense lower abdominal and pelvic pain on manipulation of cervix Pelvic inflammatory disease
Charcot sign Intermittent right upper quadrant abdominal pain, jaundice, and Choledocholithiasis
fever
Claybrook sign Transmission of breath and heart sounds through abdominal wall Ruptured abdominal viscus
Courvoisier sign Palpable, nontender gallbladder in presence of clinical jaundice Periampullary neoplasm
Cruveilhier sign Varicose veins radiating from umbilicus (caput medusae) Portal hypertension
Cullen sign Periumbilical darkening of skin from blood Hemoperitoneum (especially in ruptured ectopic pregnancy)
Cutaneous Increased abdominal wall sensation to light touch Parietal peritoneal inflammation secondary to inflammatory
hyperesthesia intra-abdominal pathology
Danforth sign Shoulder pain on inspiration Hemoperitoneum (especially in ruptured ectopic pregnancy)
Fothergill sign Abdominal wall mass that does not cross midline and remains palpa- Rectus muscle hematoma
ble when rectus muscle is tense
(continued)
suggested that plain abdominal radiographs are not sensitive in the Working Diagnosis
evaluation of adult patients presenting to the emergency depart-
Ideally, the tentative
ment with acute abdominal pain.25 Admittedly, plain abdominal
differential diagnosis list
radiographs cost relatively little; still, refraining from routinely
generated after the clinical
obtaining them in all patients with acute abdominal pain would history was obtained should
help reduce the cost of medical care appreciably. be narrowed down to a
The widespread availability of improved cross-sectional imag- working diagnosis by the
ing technology (e.g., portable ultrasonography and helical, or spi- physical examination and
ral, CT) has revolutionized the evaluation of patients presenting the information provided by the basic laboratory and radiologic
with acute abdominal pain.26 A 1999 prospective study suggested studies. Once this working diagnosis has been established, subse-
that ultrasonography should be part of the routine surgical inves- quent management depends on the accepted treatment for the par-
tigation of acute abdominal pain and that it should be mastered ticular condition believed to be present. In general, the course of
and used by surgeons themselves for this purpose.27 Two prospec- management follows four basic pathways (see below), depending
tive, randomized trials from 2002 demonstrated that routine early on whether the patient (1) is in need of immediate laparotomy, (2)
use of CT in the evaluation of acute abdominal pain can identify is believed to have an underlying surgical condition, (3) has an
unforeseen conditions and reduce length of hospital stay and over- uncertain diagnosis, or (4) is believed to have an underlying non-
all mortality in patients with acute abdominal pain of unknown surgical condition.
etiology.28,29 It must be emphasized that the patient must be constantly
An electrocardiogram is mandatory in elderly patients and in reevaluated (preferably by the same examiner) even after the
patients with a history of atherosclerotic heart disease. Abdominal working diagnosis has been established. If the patient does not
pain may be a manifestation of myocardial disease, and the phys- respond to treatment as expected, the working diagnosis must
iologic stress of acute abdominal pain can increase myocardial be reassessed and the possibility that another condition exists
oxygen demands and induce ischemia in patients with coronary must be immediately entertained and investigated by returning
artery disease. to the differential diagnosis list.
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 1 Acute Abdominal Pain — 13
Table 5—(continued)
Grey Turner sign Local areas of discoloration around umbilicus and flanks Acute hemorrhagic pancreatitis
Iliopsoas sign Elevation and extension of leg against pressure of examiner’s hand Appendicitis (retrocecal) or an inflammatory mass in contact
causes pain with psoas
Mannkopf sign Acceleration of pulse when a painful point is pressed on by examiner Absent in factitious abdominal pain
McClintock sign Heart rate > 100 beats/min 1 hr post partum Postpartum hemorrhage
Murphy sign Palpation of right upper abdominal quadrant during deep inspiration Acute cholecystitis
results in right upper quadrant abdominal pain
Obturator sign Flexion of right thigh at right angles to trunk and external rotation of Appendicitis (pelvic appendix); pelvic abscess; an inflammato-
same leg in supine position result in hypogastric pain ry mass in contact with muscle
Ransohoff sign Yellow pigmentation in umbilical region Ruptured common bile duct
Rovsing sign Pain referred to the McBurney point on application of pressure to de- Acute appendicitis
scending colon
Subcutaneous
crepitance Palpable crepitus in abdominal wall Subcutaneous emphysema or gas gangrene
Increased abdominal muscle tone on exceedingly gentle palpation Early appendicitis; nephrolithiasis; ureterolithiasis; ovarian
Summer sign of right or left iliac fossa torsion
Ten Horn sign Pain caused by gentle traction on right spermatic cord Acute appendicitis
HOSPITALIZATION AND
primary goal in the management of patients with acute abdominal pain
ACTIVE OBSERVATION
is not to arrive at an exact clinicopathologic diagnosis but rather to deter-
mine which patients require immediate or urgent surgical intervention. Numerous studies have
Indications for immediate laparotomy (see above) are essentially shown that of all patients
limited to severe hemodynamic instability. Indications for urgent admitted for acute abdom-
laparotomy are somewhat more numerous. inal pain, only a minority
Urgent laparotomy implies operation within 1 to 2 hours of the require immediate or urgent
patient’s arrival; thus, there is usually sufficient time for adequate operation.2,4,5 It is therefore
resuscitation, with proper rehydration and restoration of vital organ cost-effective as well as prudent to adopt a system of evaluation that
function, before the procedure. Indications for urgent laparotomy allows for thought and investigation before definitive treatment in all
may be encountered during the physical examination, may be patients with acute abdominal pain except those identified early on
revealed by the basic laboratory and radiologic studies, or may not as needing immediate or urgent laparotomy.The traditional wisdom
become apparent until other investigative studies are performed. is that spending time on observation opens the door for complica-
Involuntary guarding or rigidity during the physical examination, tions (e.g., perforating appendicitis, intestinal perforation associated
particularly if spreading, is a strong indication for urgent laparoto- with bowel obstruction, or strangulation of an incarcerated hernia);
my. Other indications include increasing severe localized tenderness, however, careful clinical trials evaluating active in-hospital observation
progressive tense distention, physical signs of sepsis (e.g., high fever, of patients with acute abdominal pain of uncertain origin have
tachycardia, hypotension, and mental-status changes), and physical demonstrated that such observation is safe, is not accompanied by
signs of ischemia (e.g., fever and tachycardia). Basic laboratory and an increased incidence of complications, and results in fewer nega-
radiologic indications for urgent laparotomy include pneumoperi- tive laparotomies.39
toneum, massive or progressive intestinal distention, signs of sepsis After the initial assessment has been completed, narcotic anal-
(e.g., marked or rising leukocytosis, increasing glucose intolerance, gesia for pain relief should not be withheld.40,41 In appropriately
and acidosis), and signs of continued hemorrhage (e.g., a falling titrated doses, analgesics neither obscure important physical find-
hematocrit). Additional findings that constitute indications for ur- ings nor mask their subsequent development.42 In fact, some
gent laparotomy include free extravasation of radiologic contrast physical signs may be more easily identified after adequate pain
material, mesenteric occlusion on angiography, endoscopically un- relief.43,44 Severe pain that persists in spite of adequate doses of
controllable bleeding, and positive results from peritoneal lavage narcotics suggests a serious condition that is likely to call for oper-
(i.e., the presence of blood, pus, bile, urine, or gastrointestinal con- ative intervention.41
tents). Acute appendicitis, perforated hollow viscera, and strangulat- Active observation allows the surgeon to identify most of the
ed hernias are examples of common conditions that necessitate patients whose acute abdominal pain is caused by NSAP or vari-
urgent laparotomy. ous specific nonsurgical conditions. It must be emphasized that
Several studies from the 1990s suggested that laparoscopy is active observation means something more than simply admitting
the procedure of choice when the primary clinical diagnosis is the patient to the hospital: it implies an active process of thought-
acute appendicitis or perforated peptic ulcer.30-35 In a prospec- ful, discriminating, and meticulous reevaluation of the patient (pref-
tive, randomized trial, Hansen and associates reported that erably by the same examiner) at intervals ranging from minutes to
laparoscopic appendectomy was as safe as open appendecto- a few hours, to be complemented by appropriately timed addition-
my.31 Although laparoscopic appendectomy requires a longer al investigative studies.
operating time (63 minutes versus 40 minutes), it has two Additional investigative studies beyond the basic ones already
advantages: the surgical site infection rate is lower, and patients mentioned should be obtained only if the results are likely to alter
return to normal activities earlier. A 2002 review of 45 ran- or improve patient management significantly. Furthermore, the
domized studies comparing laparoscopic surgery with open invasiveness, morbidity, and cost-effectiveness of each additional
surgery for suspected appendicitis concluded that in clinical set- test must be carefully weighed. More liberal use of supplemental
tings where the necessary surgical expertise and equipment are studies is justified in those patients in whom the history and phys-
available and affordable, the laparoscopic approach has diag- ical findings tend to be less reliable (e.g., the very young, the elder-
nostic and therapeutic advantages over the conventional open ly, the critically ill, or the immunocompromised).
approach (though some of those advantages are small and of Supplemental studies that may be considered include com-
limited clinical relevance).36 Accordingly, we recommend puted tomography, ultrasonography, diagnostic peritoneal la-
laparoscopic appendectomy as a worthwhile alternative for vage, radionuclide imaging, angiography, magnetic resonance
patients with a clinical diagnosis of acute appendicitis. In addi- imaging, gastrointestinal endoscopy [see 5:18 Gastrointestinal En-
tion, diagnostic laparoscopy through the right lower abdominal doscopy], and diagnostic laparoscopy. Diagnostic laparoscopy
incision can help establish the correct diagnosis in patients who has been recommended when surgical disease is suspected but
are operated on for suspected acute appendicitis but in whom its probability is not high enough to warrant open laparoto-
the appendix is grossly normal.32 my.45,46 It is particularly valuable in young women of childbear-
Laparoscopic treatment of perforated peptic ulcers—either with ing age, in whom gynecologic disorders frequently mimic acute
an omental patch or with sutures—is becoming more popular as appendicitis.47 A report by Chung and coworkers showed that
surgeons gain experience and competence with the technique.33-35 diagnostic laparoscopy had the same diagnostic yield as open
Two prospective, randomized, controlled trials comparing open laparotomy in 55 patients with acute abdomen; 34 (62%) of
repair of perforated peptic ulcers with laparoscopic repair found these patients were safely managed with laparoscopy alone, with
that the latter was safe and reliable and was associated with short- no increase in morbidity and with a shorter average hospital
er operating times, less postoperative pain, fewer chest complica- stay.48 Diagnostic laparoscopy has also been shown to be useful
tions, shorter postoperative hospital stays, and earlier return to in the assessment of acute abdominal pain in ICU patients49
normal daily activities than the former.37,38 and patients with AIDS.50
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 1 Acute Abdominal Pain — 15
less abdominal pain that is relieved in a few days without any complete clinical history and physical examination, coupled with
treatment), there have been no prospective studies detailing the careful in-hospital observation and a high index of suspicion,
symptomatology and physical findings associated with this dis- will in most cases prevent unnecessary laparotomy in patients
order. Furthermore, it remains unclear whether NSAP is in fact with nonsurgical causes of acute abdominal pain. On rare occa-
a single disease entity or is simply the presenting symptom com- sions, diagnostic laparoscopy may be employed to prevent
plex for many different minor and self-limited conditions.18 A unnecessary laparotomy.53
References
1. de Dombal FT: Diagnosis of Acute Abdominal 21. Telfer S, Fenyo G, Holt PR, et al: Acute abdominal 40. Zoltie N, Cust MP: Analgesia in the acute abdomen.
Pain, 2nd ed. Churchill Livingstone, London, 1991 pain in patients over 50 years of age. Scand J Gastro- Ann R Coll Surg Engl 68:209, 1986
2. Purcell TB: Nonsurgical and extraperitoneal causes of enterol. Suppl 144:47, 1988
41. Boey JH: The acute abdomen. Current Surgical
abdominal pain. Emerg Med Clin North Am 7:721, 22. Dickson JAS, Jones A,Telfer S, et al: Acute abdomi- Diagnosis and Treatment, 10th ed. Way LW, Ed.
1989 nal pain in children. Progress Report, 1986. Scand Appleton & Lange, Norwalk, Connecticut, 1994,
J Gastroenterol. Suppl 144:43, 1988 p 441
3. Silen W: Cope’s Early Diagnosis of the Acute Abdo-
men, 20th ed. Oxford University Press, New York, 23. Plewa MC: Emergency abdominal radiography. 42. McHale PM, LoVecchio F: Narcotic analgesia in the
2000 Emerg Med Clin North Am 9:827, 1991 acute abdomen—a review of prospective trials. Eur J
4. Brewer RJ, Golden GT, Hitch DC, et al: Abdominal 24. Boleslawski E, Panis Y, Benoist S, et al: Plain abdomi- Emerg Med 8:131, 2001
pain: an analysis of 1,000 consecutive cases in a uni- nal radiography as a routine procedure for acute ab- 43. Cuschieri A: The acute abdomen and disorders of
versity hospital emergency room. Am J Surg 131: dominal pain of the right lower quadrant: prospective the peritoneal cavity. Essential Surgical Practice.
219, 1976 evaluation.World J Surg 23:262, 1999 Cuschieri A, Giles GT, Moosa AR, Eds.Wright PSG,
5. Hawthorn IE: Abdominal pain as a cause of acute ad- 25. Ahn SH, Mayo-Smith WW, Murphy BL, et al: Acute Bristol, England, 1982, p 885
mission to hospital. J R Coll Surg Edinb 37:389, nontraumatic abdominal pain in adult patients: ab-
44. Attard AR, Corlett MJ, Kidner NJ, et al: Safety of ear-
1992 dominal radiography compared with CT evaluation.
ly pain relief for acute abdominal pain. BMJ 305:554,
Radiology 225:159, 2002
6. Staniland JR, Ditchburn J, de Dombal FT: Clinical 1992
presentation of acute abdomen: study of 600 pa- 26. Sucher JF, MacFadyen BV Jr: Imaging modalities for
acute abdominal pain. Semin Laparosc Surg 9:3, 45. Salky BA, Edye MB: The role of laparoscopy in the
tients. Br Med J 3:393, 1972 diagnosis and treatment of abdominal pain syn-
2002
7. Hickey MS, Kiernan GJ, Weaver KE: Evaluation of dromes. Surg Endosc 12: 911, 1998
27. Allemann F, Cassina P, Rothlin M, et al: Ultrasound
abdominal pain. Emerg Med Clin North Am 7:437, 46. Majewski W: Diagnostic laparoscopy for the acute
scans done by surgeons for patients with acute ab-
1989 abdomen and trauma. Surg Endosc 14:930, 2000
dominal pain: a prospective study. Eur J Surg
8. Adams ID, Chan M, Clifford PC, et al: Computer 165:966, 1999 47. Borgstein PJ, Gordijn RV, Eijsbouts QA, et al: Acute
aided diagnosis of acute abdominal pain: a multicen- 28. Tsushima Y,Yamada S, Aoki J, et al: Effect of contrast- appendicitis—a clear-cut case in men, a guessing
tre study. Br Med J 293:800, 1986 enhanced computed tomography on diagnosis and game in young women: a prospective study on the
9. Paterson-Brown S,Vipond MN: Modern aids to clin- management of acute abdomen in adults. Clin Radi- role of laparoscopy. Surg Endosc 11:923, 1997
ical decision-making in the acute abdomen. Br J Surg ol 57:507, 2002
48. Chung RS, Diaz JJ, Chari V: Efficacy of routine lapa-
77:13, 1990 29. Ng CS, Watson CJ, Palmer CR, et al: Evaluation of roscopy for the acute abdomen. Surg Endosc 12:219,
10. Wellwood J, Johannessen S, Spiegelhalter DJ: How early abdominopelvic computed tomography in pa- 1998
does computer-aided diagnosis improve the manage- tients with acute abdominal pain of unknown cause:
prospective randomised study. BMJ 325:1387, 2002 49. Orlando R, Crowell KL: Laparoscopy in the critically
ment of acute abdominal pain? Ann R Coll Surg
ill. Surg Endosc 11:1072, 1997
Engl 74:40, 1992 30. Fritts LL, Orlando R: Laparoscopic appendectomy: a
safety and cost analysis. Arch Surg 128:521, 1993 50. Box JC, Duncan T, Ramshaw B, et al: Laparoscopy in
11. de Dombal FT: Computers, diagnoses and patients
the evaluation and treatment of patients with AIDS
with acute abdominal pain. Arch Emerg Med 9:267, 31. Hansen JB, Smithers BM, Schache D, et al: Laparo-
and acute abdominal complaints. Surg Endosc 11:
1992 scopic versus open appendectomy: prospective ran-
1026, 1997
12. de Dombal FT: The OMGE acute abdominal pain domized trial.World J Surg 20:17, 1996
survey. Progress Report, 1986. Scand J Gastroenterol 32. Schrenk P, Rieger R, Shamiyeh A, et al: Diagnostic la- 51. Hobsley M: An approach to the acute abdomen.
144(suppl):35, 1988 paroscopy through the right lower abdominal inci- Pathways in Surgical Management, 2nd ed. Edward
sion following open appendectomy. Surg Endosc 13: Arnold Ltd, London, 1986
13. American College of Emergency Physicians: Clinical
policy for the initial approach to patients presenting 133, 1999 52. Larson FA, Haller CC, Delcore R, et al: Diagnostic
with a chief complaint of nontraumatic acute abdom- 33. Matsuda M, Nishiyama M, Hanai T, et al: Laparo- peritoneal lavage in acute peritonitis. Am J Surg 164:
inal pain. Ann Emerg Med 23:906, 1994 scopic omental patch repair for the perforated peptic 449, 1992
ulcer. Ann Surg 221:236, 1995 53. Jones PF, Krukowski ZH, Youngson GG: Random-
14. de Dombal FT: Surgical Decision Making in Prac-
tice: Acute Abdominal Pain. Butterworth-Heine- 34. Tate JJ, Dawson JW, Lau WY, et al: Sutureless laparo- ized clinical trial of early laparoscopy in the manage-
mann Ltd, Oxford, 1993, p 65 scopic treatment of perforated duodenal ulcer. Br J ment of acute non-specific abdominal pain. Br J Surg
Surg 80:235, 1993 87:523, 2000
15. Walters DT,Wendel HF: Abdominal pain. Prim Care
13:3, 1986 35. Darzi A, Cheshire NJ, Somers SS, et al: Laparoscopic 54. Cheung LY, Ballinger WF: Manifestations and diag-
omental patch repair of perforated duodenal ulcer nosis of gastrointestinal diseases. Hardy’s Textbook of
16. Irvin TT: Abdominal pain: a surgical audit of 1190 with an automated stapler. Br J Surg 80:1552, 1993 Surgery. Hardy JD, Ed. JB Lippincott Co, Philadel-
emergency admissions. Br J Surg 76:1121, 1989
36. Eypasch E, Sauerland S, Lefering R, et al: Laparo- phia, 1983, p 445
17. Jess P, Bjerregaard B, Brynitz S, et al: Prognosis of scopic versus open appendectomy: between evidence
acute nonspecific abdominal pain: a prospective 55. McFadden DW, Zinner MJ: Manifestations of gas-
and common sense. Dig Surg 19:518, 2002
study. Am J Surg 144:338, 1982 trointestinal disease. Principles of Surgery, 6th ed.
37. Lau WY, Leung KL, Kwong KH, et al: A randomized Schwartz SI, Shires GT, Spencer FC, Eds. McGraw-
18. Gray DW, Collin J: Non-specific abdominal pain as a study comparing laparoscopic versus open repair of Hill, New York, 1994, p 1015
cause of acute admission to hospital. Br J Surg 74: perforated peptic ulcer using suture or sutureless
239, 1987 technique. Ann Surg 224:131, 1996
19. Wilson DH,Wilson PD,Walmsley RG, et al: Diagno- 38. Siu WT, Leong HT, Law BK, et al: Laparoscopic re-
sis of acute abdominal pain in the accident and emer- pair for perforated peptic ulcer: a randomized con-
gency department. Br J Surg 64:249, 1977 trolled trial. Ann Surg 235:313, 2002 Acknowledgment
20. Bender JS: Approach to the acute abdomen. Med 39. Thomson HJ, Jones PF: Active observation in acute
Clin North Am 73:1413, 1989 abdominal pain. Am J Surg 152:522, 1986 Figures 2 and 3 Tom Moore.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 2 Abdominal Mass — 1
2 ABDOMINAL MASS
Romano Delcore, M.D., and Laurence Y. Cheung, M.D.
Abdominal masses are mentioned in some of the earliest known Clinical History
medical writings. The Papyrus Ebers (ca. 1500 B.C.) discusses A careful and methodical
the differential diagnosis of abdominal masses and describes clinical history should be
methods of abdominal examination by palpation.1 In his Book of obtained that includes the
Prognostics (ca. 400 B.C.), Hippocrates discussed the prognostic mode of onset, duration,
significance of abdominal masses: character, location, and
That state of the hypochondrium is best when it is free from pain, soft, chronology of the abdomi-
and of equal size on the right side and the left. But if inflamed, or painful, nal mass, as well as the pres-
or distended; or when the right and left sides are of disproportionate sizes; ence or absence of any asso-
all these appearances are to be dreaded. . . . Such swellings as are soft, free ciated symptoms. When the surgeon obtains an unhurried and
from pain, and yield to the finger, occasion more protracted crises, and complete clinical history, the patient often provides all the infor-
are less dangerous than the others .... Such, then, as are painful, hard, and
mation needed for making the correct diagnosis. In addition,
large, indicate danger of speedy death.2
such a history is often more valuable than any single laboratory
The term abdominal mass generally refers to a palpable mass or radiologic finding and determines the course of subsequent
that is anterior to the paraspinous muscles and is located any- evaluation and management. Patients should be allowed to relate
where between the costal margins, the iliac crests, and the pubic the history in their own words, and examiners should refrain
symphysis. An abdominal mass may be noticed initially by the from suggesting specific chronologies or symptoms except as a
patient or may be discovered by the surgeon as a new finding. In last resort. Any questions that must be asked should be open-
either case, the mass may have been present for days, months, or ended—for example, “When did you first notice a mass?” rather
even years and may be caused by any of a great variety of intra- than “Did you just notice the mass?” Leading questions should
abdominal, pelvic, or retroperitoneal disorders, as well as by any be avoided.When a leading question must be asked, it should be
of numerous different abdominal wall lesions. posed first as a negative question (i.e., one that calls for an
Occasionally, after examining a patient with an abdominal answer in the negative), since a negative answer to a question is
mass, the surgeon is so certain about the diagnosis that no fur- more likely to be honest and accurate.
ther investigation is necessary and appropriate management for Various GI symptoms (e.g., nausea, vomiting, anorexia, diar-
the condition can be instituted immediately. Conditions that rhea, constipation, and a decrease in stool caliber) often accom-
often can be readily diagnosed in this fashion include obesity, pany an abdominal mass. These symptoms are nonspecific but
ascites, pregnancy, abdominal wall hernias, sebaceous cysts, and may still be of some value in the differential diagnosis. Other
lipomas. It must be remembered, however, that even when an associated symptoms that should be noted are jaundice, melena,
experienced clinician is convinced of the presence of a mass, it is hematochezia, hematemesis, hematuria, and menorrhagia.These
still possible that no abnormality exists. In one study, 22% of symptoms are more specific and can be very valuable in the dif-
patients thought to have a palpable mass on the basis of physical ferential diagnosis. Urinary hesitancy or urgency in the presence
examination proved not to have any abnormalities on further of a lower abdominal mass may suggest bladder distention sec-
investigation.3 ondary to urethral obstruction or urinary retention caused by
Most often, the surgeon is confronted with a diagnostic chal- anticholinergic medications (e.g., phenothiazines). A female
lenge, in which assessing the origin and character of the abdom- patient with a pelvic mass should be asked for a detailed gyneco-
inal mass proves difficult, time consuming, and expensive. This logic history that includes the timing of symptoms within the
challenge involves not only establishing the correct diagnosis but menstrual cycle, the date of the last menses, previous and current
also determining whether this can be accomplished without use of contraception, any abnormal vaginal bleeding or dis-
operative intervention. Making the correct decision regarding charge, and a complete obstetric history. All patients with
whether to operate on a patient with an abdominal mass requires abdominal masses should also be asked about previous injuries,
sound surgical judgment. The decision must be based on a however minor: even a traumatic event the patient considers triv-
detailed medical and surgical history, as well as on a meticulous ial can be diagnostically significant.
physical examination. These, in turn, must be guided by experi- A complete history of previous medical conditions must be
ence; a thorough knowledge of the anatomy and physiology of obtained because associated diseases may give rise to abdominal
the abdominal wall, abdominal cavity, and retroperitoneum; and masses and may also significantly affect morbidity and mortality
a clear understanding of the physiologic and pathologic process- from subsequent surgical intervention. Weight changes suggest-
es within and around the abdomen. The arrival of new diseases, ing carcinoma, past illnesses, previous abdominal operations, and
coupled with the continuous development of new diagnostic recent travel (raising the possibility of amebic abscess or parasitic
technologies, calls for constant broadening of the differential cyst) should also be investigated. A careful family history is
diagnosis and periodic revision of established approaches to the important for detection of hereditary disorders that may cause
evaluation of abdominal masses. abdominal masses.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 2 Abdominal Mass — 2
The most common causes are the six Fs: fat, fluid, flatus,
fetus, feces, and fatal growths. Of these, the most
common is gaseous distention.
Diagnosis is obvious
Diagnosis is unknown
Biopsy is nondiagnostic
Diagnosis is established
Diagnosis is obvious
Patient appears to have distended bladder or stomach Patient does not have distended bladder or stomach
Decompress with Foley catheter or NG tube. Working diagnosis guides subsequent evaluation and management.
Tentative Differential
and splenic subcapsular hematomas, blood-filled pancreatic
Diagnosis
pseudocysts, and empyema of the gallbladder with associated
Once the history has been ascending cholangitis. The abdominal examination should
obtained, the examiner include inspection, auscultation, palpation, and percussion, gen-
should generate a tentative erally in that order; these maneuvers are described in more detail
differential diagnosis and elsewhere [see 5:1 Acute Abdominal Pain].
carry out the physical exami- Inspection of the abdomen may reveal either generalized
nation in search of specific enlargement or distention of the entire abdomen or the presence
signs or findings that either of one or more discrete masses of varying sizes. Conditions that
confirm or rule out the diagnostic possibilities. Failure to include may give rise to generalized abdominal distention include obesi-
a broad array of possibilities in the tentative differential diagnosis ty, tympanites or meteorism (swelling of the abdomen caused by
is a common and often costly mistake. For example, when uri- gas within the intestine or peritoneal cavity), ascites, pregnancy,
nary retention is not considered as part of the early differential fecal impaction, and neoplasm. An easy way of remembering
diagnosis of a large lower abdominal mass, the patient may these conditions is to use the so-called six Fs mnemonic device:
undergo needlessly extensive and expensive evaluations. Fat, Fluid, Flatus, Fetus, Feces, and Fatal growths.6-8
In the light of the large number of conditions that can give rise The most common cause of transient generalized enlargement
to an abdominal mass, the task of arriving at a specific diagnosis of the abdomen is intestinal gas or bloating. Gaseous distention
can appear overwhelming. To lessen the difficulty of this task, it may appear or disappear in minutes to hours and is usually
would be invaluable to have some general knowledge of what the accompanied by discomfort. Percussion of the abdomen elicits
most common causes of abdominal masses are, as well as how tympany. Because aerophagia and certain foods are common
age, gender, associated symptoms, and geography may affect the causes of gaseous distention, the differential diagnosis necessitates
likelihood that any of these potential causes is present. a detailed dietary history. Intestinal ileus and intestinal obstruc-
Unfortunately, abdominal masses as such usually are not coded tion (in particular, distal obstruction) can present with general-
in the medical record; rather, specific diseases or definitive diag- ized abdominal enlargement resulting from gaseous distention.
noses are coded. Consequently, the true incidence of abdominal The most common cause of chronic abdominal enlargement
mass remains unknown, nor is there much information in the lit- is obesity.This condition is usually readily apparent on inspection
erature regarding the relative frequency with which specific dis- and is confirmed on examination by the greatly increased skin-
eases present with an abdominal mass.4 Decades ago, two series fold thickness of the abdominal wall. When obesity results from
were published that provided a differential diagnosis of abdomi- adipose tissue in the mesentery, the omentum, and the extraperi-
nal masses based on statistical analysis and relative frequency.1,5 toneal layer, the diagnosis may not be so readily apparent. In gen-
These two series, however, have now been rendered hopelessly eral, obesity makes evaluation of discrete abdominal masses by
outdated by modern medical practice and the advent of newer means of physical examination much more difficult, to the point
diagnostic and therapeutic modalities. Nevertheless, knowledge where masses of remarkable size can be missed by even the most
of the most common disease processes associated with abdomi- careful examiner. Massive enlargement of a single organ (e.g., the
nal masses and familiarity with the characteristic signs and symp- liver, the spleen, or the kidneys) or a large fluid-filled cyst can
toms that accompany the most common causes of this present- also cause generalized abdominal enlargement, as can accumula-
ing symptom can greatly facilitate and shorten the evaluation of tion of ascitic fluid in the peritoneal cavity. A common and often
patients presenting with abdominal masses. overlooked cause of an abdominal mass, particularly in elderly or
institutionalized patients, is fecal impaction. Removal of the
impaction causes the mass to disappear.
Physical Examination A distended urinary bladder may extend up to the level of the
In physical examination, umbilicus; it is usually in the midline, and because of its extreme
as in history taking, there is size, it is commonly mistaken for an abdominal mass.The swelling
no substitute for organiza- is fluctuant and resolves with catheterization. In cases of acute
tion and patience; the gastric dilatation, the distended stomach may also occasionally be
amount of information that large enough to all but fill the abdomen. Decompres-
can be obtained is directly sion with a nasogastric tube leads to complete resolution.
proportional to the gentle- When the mass is discrete rather than generalized, the exam-
ness and thoroughness of the iner should note whether it moves with respiration; such move-
examiner. As in the evaluation of the acute abdomen [see 5:1 ment suggests that the mass is associated with a mobile organ in
Acute Abdominal Pain], the physical examination begins with a the abdominal cavity rather than located in the retroperitoneum
brief but thorough evaluation of the patient’s general appearance. or attached to the abdominal wall. Inspection should be followed
Any obvious pain or associated discomfort should be noted. A by auscultation, before percussion and palpation stimulate the
complete physical examination should be performed, and possi- abdominal viscera to abnormal activity that may obscure vascu-
ble extra-abdominal causes of the mass as well as signs of sys- lar bruits.
temic illness should be sought before attention is directed to the The examination begins with light palpation of the entire
mass. Systemic signs of shock, such as tachycardia, tachypnea, abdomen, which may reveal regions of tenderness and increased
diaphoresis, pallor, orthostasis, and frank hypotension, usually resistance that should be examined later in detail. Light palpation
accompany a rapidly progressive or advanced condition and are can determine only the presence of a mass and its location; fur-
an indication for immediate resuscitation and laparotomy. ther information must be sought through deep palpation, which
Abdominal masses that may occur in association with systemic is done to confirm the findings from inspection and light palpa-
signs of shock and that must be recognized as soon as possible tion and to search for previously unsuspected masses. Frequently,
include abdominal aortic and other visceral aneurysms, hepatic a mass that is not visible on inspection is easily felt on palpation.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 2 Abdominal Mass— 5
Normal structures felt during palpation must not be confused studies (e.g., laboratory testing, ultrasonography, or CT) are suf-
with abdominal masses. Prominent segments of the abdominal ficient to establish the diagnosis. Occasionally, they are not, and
wall musculature, the abdominal aorta, and the sacral promonto- further investigative studies are needed.
ry may be mistaken for abdominal masses on a cursory examina-
tion. Masses must also be distinguished from muscle spasms.
During palpation of the mass, every effort should be made to Investigative Studies
determine as many of the following characteristics as possible: Integrating the informa-
location, size, shape, consistency, surface (smooth or nodular), tion provided by one inves-
presence or absence of tenderness, temperature, the color of the tigative test with that pro-
overlying skin, degree of mobility, any fixation or attachments, vided by preceding and sub-
pulsatility, fluctuation, response to ballottement, and appearance sequent tests yields a higher
on transillumination. Clearly, it is not possible to determine all of degree of diagnostic accura-
these characteristics in every case. Knowing the location of the cy. Clearly, not every avail-
mass in the abdomen limits the number of possible organs to be able mode of investigation should be used in each patient. The
considered and may give an insight into the nature and extent of best evaluative approach in a given case depends somewhat on
the pathologic process. the preferences of the patient, the physician, and the institution
Whether the mass is located within the abdominal cavity or in as well as on consideration of relative costs. Most patients with
the wall of the abdomen is also an important diagnostic factor. A abdominal masses can be evaluated as outpatients, but in mak-
rectus sheath hematoma is an example of an abdominal wall ing this decision, the examiner must be sure that the patient is
lesion that is frequently mistaken for an intra-abdominal mass. both available and reliable. Investigative studies must be individ-
Masses situated in the abdominal wall itself can be recognized on ualized so that the examiner can reach an accurate diagnosis in
the basis of their superficial location; their adherence to skin, sub- the shortest possible time using the fewest, least invasive, and
cutaneous fascia, or muscles; or their failure to follow the move- (ideally) least expensive diagnostic tests possible.
ments of the viscera immediately underlying the abdominal wall.
LABORATORY STUDIES
It may, however, be impossible to differentiate an intra-abdomi-
nal mass that has become attached to the abdominal wall (as If the cause of the mass can be determined without question on
either an inflammatory or a neoplastic process) from an abdomi- the basis of the history and the physical examination, laboratory
nal wall lesion. A simple test that should be done with any patient evaluation may be unnecessary. If the cause of the abdominal mass
who has an abdominal mass is to direct the patient to raise the remains unknown, the patient should undergo testing for occult
head and shoulders or the legs from the examining table. This blood in the stool, a chemistry profile (which should include at
maneuver produces tightening of the abdominal muscles. If the least electrolytes, blood urea nitrogen [BUN], creatinine, and liver
mass is in the abdominal wall itself, it remains palpable, but if it function tests), a urinalysis, and a complete blood count with dif-
is within or behind the abdominal cavity, it is obscured. ferential. An unexpected abnormal laboratory value may be the
Some pathologic processes are suggested by the consistency of only finding that steers the surgeon toward the correct diagnosis.
the mass and its resistance to pressure: for instance, carcinoma may For example, an elevated alkaline phosphatase concentration may
be rock-hard, whereas an abscess may be soft and fluctuant. A suggest metastasis to the liver, and an elevated serum amylase con-
smooth surface implies diffuse involvement, and a nodular surface centration may lead to the diagnosis of a pancreatic pseudocyst.
suggests neoplastic metastases or granulomas. Tenderness may be
RADIOGRAPHIC STUDIES
caused by an acute inflammatory process or by distention of the
capsule of a viscus. As noted, mobility with respiration tends to dis- Advances in cross-sectional imaging modalities, such as ultra-
tinguish a peritoneal mass from an extraperitoneal one. Pulsatility sonography, CT, and magnetic resonance imaging, have made
should alert the examiner to the possibility that the mass is of vas- characterization of abdominal masses relatively simple and
cular origin [see 6:3 Pulsatile Abdominal Mass]. Pulsation in the epi- direct. The exquisite resolution of these imaging modalities per-
gastrium of a thin patient is apparent almost routinely on palpation mits accurate diagnosis, and when they are used to guide percu-
and usually results from the normal pulsation of the aorta lying taneous biopsy, they make exploratory laparotomy solely for the
over the vertebral bodies. In most cases, pulsation associated with purpose of diagnosis unnecessary in almost all instances.9
an epigastric mass represents a pulsation transmitted through a Each imaging modality has its unique strengths and weak-
pancreatic tumor or cyst or a gastric tumor. If, however, pulsation nesses, and the American College of Radiology has issued guide-
is associated with an expanding mass, it quite possibly represents lines for the appropriate use of different imaging modalities in the
an abdominal aortic aneurysm. Fluctuation may indicate a cyst, a evaluation of abdominal masses.10,11 The surgeon must correlate
pseudocyst, a hematoma, or an abscess. the clinical location of the mass with the history and the labora-
tory findings to determine which imaging modality is the most
expeditious and cost-effective in a given instance. Of the cur-
Working Diagnosis rently available imaging procedures, ultrasonography
The tentative differential diagnosis list that is generated after is the least expensive, the
the clinical history has been obtained can often be narrowed least invasive, and the most readily available. Proper interpreta-
down to a working diagnosis on the basis of the physical exami- tion of ultrasonograms is highly dependent on the skill and expe-
nation. Once a working diagnosis has been established, subse- rience of the ultrasonographer; however, even examiners who
quent management depends on the accepted methods of evalua- lack great expertise with this modality generally are still able to
tion and treatment for the particular condition believed to be obtain most of the information they need to evaluate an abdom-
present. In a number of cases, however, the diagnosis remains inal mass. The essential information available from the ultra-
unknown even after the physical examination. When this is the sonogram includes where the mass is anatomically located,
case, investigative studies are required. Often, basic investigative whether it is solid or cystic, and on what surrounding structures
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 2 Abdominal Mass — 6
a b
Figure 2 A 58-year-old male patient presented with a palpable, visible (a) abdominal mass. (b) A CT
scan showed a mass arising from the omentum. An omental leiomyosarcoma was surgically resected.
tion increases. For between masses and adjacent organs and structures.15-17 If, howev-
these reasons, ultrasonography is most effective in regions where er, the bowel is not opacified, the accuracy of CT in evaluating
an acoustic window exists, such as the right upper quadrant, the abdominal masses is significantly reduced because unopacified
pelvis, and the left upper quadrant. intestinal loops can simulate a mass or an abscess.
The principal disadvantage of ultrasonography is its depen- When the examiner suspects that an abdominal mass is neo-
dence on the technical proficiency of the operator. Because ultra- plastic, CT is the initial imaging procedure of choice because in
sonography is so operator dependent, it is quite possible that in addition to imaging the mass itself directly, CT provides invalu-
the hands of an inexperienced ultrasonographer, it can contribute able information for staging purposes (e.g., evidence of contigu-
to misdiagnosis. The experience level of the ultrasonographer ous spread or the presence of distant metastases).
must always be taken into account when ultrasonography is used
BIOPSY
in the evaluation of an abdominal mass.
Computed Tomography Image-Guided
Currently, CT is the most efficient imaging modality available for Percutaneous Biopsy
the evaluation of abdominal masses3,9,14: it has excellent spatial res- The value of image-guid-
olution and exquisite density discrimination, and it provides cross- ed percutaneous biopsy in
sectional images that are unaffected by bowel gas, bone, excessive the evaluation of abdominal
abdominal fat, or unusually large body size [see Figures 2 and 3]. CT masses is now firmly estab-
yields excellent visualization of vascular structures and can assess the lished.18,19 Recent improve-
vascularity of an abdominal mass after intravenous administration of ments in imaging techniques
contrast material. It routinely visualizes retroperitoneal and abdom- (in particular, developments
inal wall structures and perfectly displays the peritoneal compart- in high-resolution cross-sectional imaging), advances in cytolog-
ments, clearly defining tissue planes and illustrating relations ic methods (in terms of both performance technique and inter-
a b
Figure 3 A 49-year-old female patient presented with an abdominal mass. (a) A CT scan revealed a uterine fibroid
presenting as a pelvic mass. A normal CT of the same region (b) is provided for purposes of comparison.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 2 Abdominal Mass — 8
patients with uncorrectable coagulopathy, special expertise the mass.23,24,35 In a study of 200 consecutive CT-guided needle
and equipment are required. biopsies, the overall accuracy for all sites was 95%. Accuracy of
2. Absence of a safe biopsy route. When the location of the mass diagnosis was very high for hepatic (99%) and renal (100%) biop-
necessitates that the biopsy path extend through a large blood sies and for characterization of fluid collections (100%) but some-
vessel, the stomach, or an intestinal loop, the potential for what lower for retroperitoneal (87.5%) and pancreatic (82%)
hemorrhage or infection increases; however, neither potential biopsies.21 In a prospective study of 1,000 consecutive CT-guided
complication is a contraindication if a small-caliber needle is biopsies, the procedure was 91.8% sensitive and 98.9% specific.35
used. Biopsies done through collections of ascitic fluid have
also proved safe. Endoscopic Ultrasound-Guided Biopsy
3. Lack of cooperation on the part of the patient. An uncoopera- Endoscopic ultrasonography (EUS) is a relatively new cross-
tive patient’s uncontrolled motion during needle placement can sectional imaging modality that allows accurate visualization of
substantially increase the risk of tissue laceration and hemor- the gastrointestinal wall and surrounding structures with greater
rhage; in such cases, sedation or anesthesia may be necessary. spatial resolution and better anatomic detail than transcutaneous
ultrasonography or CT. In fact, EUS provides unique imaging
The safety of image-guided percutaneous biopsy is well attest- information currently unavailable with any other technology.40
ed.20,26 Several large multi-institutional reviews have reported Because depth of ultrasound penetration is inversely related to
mortalities ranging from 0.008% to 0.031% and major compli- frequency (whereas image resolution is directly related to fre-
cation rates ranging from 0.05% to 0.18%.27-29 A review of quency), endoscopic placement of an ultrasound transducer
11,700 patients who underwent percutaneous abdominal biopsy immediately adjacent to an area of interest allows the use of high-
with 20- to 23-gauge needles between 1969 and 1982 found a er ultrasound frequencies than is possible with transcutaneous
total complication rate of only 0.05% and a mortality of only ultrasonography. Thus, EUS can detect much smaller masses
0.008%.27 Another study, involving 63,180 patients, demonstrat- than is possible with conventional transcutaneous ultrasonogra-
ed a complication rate of 0.16%.30 A single-institution review of phy. For evaluation of some organs, such as the pancreas, EUS is
8,000 ultrasound-guided needle biopsies done with both large- the most sensitive diagnostic tool currently available, demon-
and small-caliber needles reported similar results: a mortality of strating greater sensitivity for small masses than CT.40,41 EUS also
0.038% and a major complication rate of 0.187%.31 A prospec- avoids the problem of intervening bowel gas that often limits the
tive study of 3,393 biopsies (1,825 ultrasound-guided and 1,568 use of transcutaneous ultrasonography as an adjunct to percuta-
CT-guided) showed a mortality of 0.06% and a complication rate neous biopsy. EUS-guided biopsy is therefore well suited for the
of 0.34% (0.3% for ultrasound-guided biopsies and 0.5% for CT- evaluation of abdominal masses that are too small for visualiza-
guided biopsies).26 tion by other cross-sectional imaging modalities or inaccessible
Of the major complications, hemorrhage is the most common- for percutaneous biopsy.40
ly reported. Other major complications reported are pneumotho- EUS-guided biopsy became widely available as a diagnostic
rax, pancreatitis, bile leakage, peritonitis, and needle-track seed- tool only recently because the original radial scanning systems
ing. Although needle-track seeding is an important theoretical utilized for EUS, although efficient for diagnostic imaging, did
consideration when a mass seems likely to be of malignant neo- not allow safe and direct guidance of needles for biopsy. With
plastic origin, it remains an exceedingly rare complication: fewer radial scanning echoendoscopes, a rotating transducer produces
than 100 cases have been reported in the literature, for an esti- a 360° view perpendicular to the axis of the endoscope and the
mated frequency of only 0.005%.30,32,33 Because seeding is so needle exiting the biopsy channel appears only as a dot on the
rare, it should affect the decision to perform percutaneous biop- ultrasound image. In the early 1990s, the linear scanning system
sy only when the surgeon is convinced the lesion is amenable to was introduced, with a plane of ultrasound imaging parallel to the
curative surgical resection. Most cases of needle-track seeding shaft of the endoscope that allows direct, real-time visualization
have occurred after biopsy of a pancreatic carcinoma; however, it of the biopsy needle throughout its entire course.The linear array
has also been reported after biopsy of hepatic and retroperitoneal instrument also has color flow Doppler capability that allows the
lesions. There is some evidence to suggest that with masses in endoscopist to avoid any vascular structures lying in the path of
solid organs, using large-caliber needles or cutting needles does the biopsy needle. EUS-guided biopsy with the linear scanning
not lead to a significantly higher complication rate than fine-nee- system offers clear and consistent visualization of the biopsy nee-
dle aspiration biopsy does, provided that there is a direct path to dle along its entire path in real time, excellent delineation of inter-
the mass.26,34,35 vening tissues, and no interference by intestinal gas.
The reported accuracy of ultrasound-guided biopsy ranges Compared with other cross-sectional imaging modalities, EUS
from 66% to 97%, depending on the location, size, and histolog- has proved superior for detection of pancreatic masses and nodal
ic origin of the mass.26 In one series of ultrasound-guided biopsies metastases, as well as for local tumor staging of other gastroin-
of 126 consecutive small (< 3 cm) solid masses in various anatom- testinal neoplasms.40-43 With EUS-guided biopsy, the risk of seed-
ic locations and of various histologic types, the overall accuracy of ing the needle track with malignant cells is minimized and
biopsy was 91%.36 Results improved as the size of the mass becomes irrelevant in many patients with potentially curable
increased, rising from 79% in masses 1 cm or less in diameter to lesions because the needle tract is later removed as part of the sur-
98% in masses 2 to 3 cm in diameter. The accuracy of biopsy for gical specimen (e.g., resection of a mass in the head of the pan-
hepatic masses of any size was 96%.36 Another report found ultra- creas by pancreatoduodenectomy). EUS-guided biopsy can now
sound-guided biopsy to be 91% accurate for small (< 2.5 cm) be considered a first-line modality for obtaining tissue diagnoses,
abdominal masses.37 Two organ-specific reviews demonstrated particularly in the evaluation of extraintestinal and pancreatic
94% accuracy for ultrasound-guided liver biopsy38 and 95% accu- masses.
racy for ultrasound-guided biopsy of pancreatic masses.39 In a large single-institution study, 327 abdominal masses were
The reported accuracy of CT-guided biopsy ranges from 80% sampled by EUS-guided biopsy, with an overall accuracy for the
to 100%, depending on the location, size, and histologic origin of diagnosis of malignancy of 86%, a sensitivity of 84%, and a speci-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 2 Abdominal Mass — 10
ficity of 96%. Only one patient (0.3%) suffered a complication.43 needle introduced at an independent site rather than with a biop-
Multiple other studies have confirmed the high sensitivity and sy forceps: forceps biopsy usually produces superficial, small,
specificity of EUS-guided biopsy, especially for the diagnosis of squeezed, and distorted specimens. Although percutaneous biop-
extraluminal abdominal masses, and confirmed the safety of the sies of this type can be especially useful when bleeding from the
procedure; reported complication rates are between 0.3% and biopsy site is a concern, image-guided percutaneous biopsy usu-
2%.40-44 This complication rate, while slightly higher than that of ally offers a more expedient, less invasive, cheaper, and often
diagnostic upper gastrointestinal endoscopy, appears to be lower safer means of obtaining the diagnosis. More important, in the
than the complication rate encountered with other advanced presence of adhesions, laparoscopic biopsy is much less effective
endoscopic procedures, such as therapeutic endoscopic retro- and typically fails to make a diagnosis altogether unless the mass
grade cholangiopancreatography. is clearly visible on the anterior surface of the viscera.
Currently, the most frequent application for EUS-guided
biopsy is in the diagnosis and staging of pancreatic masses. EUS-
guided biopsy should also be considered for the diagnosis of Exploratory Laparotomy
abdominal masses that are not readily accessible to percutaneous Despite recent advances
biopsy, because it may obviate more invasive procedures, such as in diagnostic imaging and
laparoscopy or laparotomy. In a 10-year study of the impact of laparoscopic procedures, it
EUS on patient management, 86% of patients avoided further still occasionally proves nec-
imaging and 25% avoided unnecessary laparotomy. Overall, essary to perform an ex-
EUS was found to significantly change clinical management in ploratory laparotomy for the
up to one third of the 537 patients studied.44 sole purpose of establishing
As is the case with transcutaneous ultrasonography, the prin- a diagnosis in the patient
cipal disadvantage of EUS-guided biopsy is its dependence on with an abdominal mass. It is essential to keep in mind, howev-
the proficiency of the ultrasonographer. Moreover, EUS-guided er, that many patients with abdominal masses have disorders for
biopsy is one of the most technically demanding of all GI endo- which operative intervention is not required. In addition,
scopic procedures, requiring an operator who is not only an although exploratory laparotomy can yield crucial information
experienced ultrasonographer but also an expert endoscopist. and may be, in a sense, the “ultimate diagnostic test” (as some
have referred to it), it is not infallible. Errors in the intra-abdom-
Laparoscopic Biopsy inal surgical diagnosis of abdominal masses can and do occur.
Even though laparoscopy provides excellent visualization of For example, in six instances observed during an 18-month peri-
the inside of the abdominal cavity and now plays an important od at a single institution, exploratory laparotomy failed to reveal
role in the staging of some abdominal neoplasms, its role in the abdominal masses that had already been demonstrated by pre-
evaluation of abdominal masses is limited.45 Laparoscopic biop- operative evaluation and were subsequently confirmed during
sy specimens are best obtained under direct vision with a biopsy the postoperative period.46
References
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Practice of Emergency Medicine, 2nd ed. Chir Scand 156:501, 1980 ration biopsy of abdomen and retroperitoneum.
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5. Cabot RC: Differential Diagnosis, Presented 14. Williams MP, Scott IHK, Dixon AK: Computed cedures. AJR Am J Radiol 139:1111, 1982
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Saunders Co, Philadelphia, 1915, vol 2, p 709 abdominal mass. Clin Radiol 35:293, 1984 neous fine-needle aspiration cytology in the
6. Schaffner F: Abdominal enlargement and mass- 15. Engel IA, Auh YH, Rubenstein WA, et al: Large diagnosis of intra-abdominal masses. Arch Surg
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Berk JE, Eds. WB Saunders Co, Philadelphia, graphic localization. Radiology 149:203, 1983 25. Jaeger HJ, MacFie J, Mitchell CJ, et al:
1998, p 138 Diagnosis of abdominal masses with percuta-
16. Pistolesi GF, Procacci C, Caudana R, et al: C.T.
7. Morales TG, Fennerty MB: Abdominal disten- neous biopsy guided by ultrasound. Br Med J
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Fincher RME, Johnson WP, et al, Eds. Mosby, 26. Rumack CM, Wilson SR, Charboneau JW:
St. Louis, 1996, p 290 17. Pandolfo I, Blandino A, Gaeta M, et al: CT find-
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8. DeGowin EL, DeGowin RL: Bedside Diagnostic abdomen and pelvis. Diagnostic Ultrasound.
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9. Gore RM: Palpable abdominal masses. Diagnostic biopsy of intraabdominal lesions. AJR Am J 27. Livraghi R, Damascelli B, Lombardi C, et al:
Imaging: An Algorithmic Approach. Eisenberg RL, Radiol 153:929, 1989 Risk in fine needle abdominal biopsy. J Clin
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28. Fornari F, Civardi G, Cavanna L, et al: guided liver biopsies: eight years’ experience. 41. Harewood GC, Wiersema MJ: Endosonography-
Complications of ultrasonically guided fine nee- Radiology 152:755, 1984 guided fine needle aspiration biopsy in the eval-
dle abdominal biopsy: results of a multi-centre uation of pancreatic masses. Am J Gastroenterol
35. Welch TJ, Sheedy PF, Johnson CD, et al: CT-
Italian study and a review of the literature (The 97:1386, 2002
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36. Reading CC, Charboneau JW, James EM, et al: fine needle aspiration of idiopathic abdominal
29. Smith EH: Complications of percutaneous masses. Gastrointest Endosc 55:854, 2002
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178:253, 1991 small (3 cm or less) masses. AJR Am J Radiol 43. Williams DB, Sahai AV, Aabakken L, et al:
151:189, 1988 Endoscopic ultrasound guided fine needle aspi-
30. Smith EH: The hazards of fine needle aspiration
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guided biopsy of small intra-abdominal masses. Gut 44:720, 1999
31. Nolsoe C, Nielsen L, Torp-Pedersen S, et al:
Can Assoc Radiol J 44:350, 1993 44. Kaffes AJ, Mishra A, Simpson SB, et al: Upper
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Clin Ultrasound 18:179, 1990 Ultrasound-guided fine-needle biopsy of focal impact on patient management: 1990–2000.
liver lesions: technique, diagnostic accuracy and Intern Med J 32:372, 2002
32. Engzell U, Esposti PL, Rubio C, et al: Investigation
on tumour spread in connection with aspiration complications: a retrospective study on 2091 45. Sackier JM, Berci G, Paz-Partlow M: Elective
biopsy. Acta Radiol Ther Phys Biol 10:385, 1971 biopsies. J Hepatol 11:344, 1990 diagnostic laparoscopy. Am J Surg 161:326,
33. Smith FP, Macdonald JS, Schein PS, et al: 39. Brandt KR, Charboneau JW, Stephens DH, et 1991
Cutaneous seeding of pancreatic cancer by skin- al: CT- and US-guided biopsy of the pancreas. 46. Harbin WP, Wittenberg J, Ferrucci JT, et al:
ny-needle aspiration biopsy. Arch Intern Med Radiology 187:99, 1993 Fallibility of exploratory laparotomy in detection
140:855, 1980 40. Pfau PR, Chak A: Endoscopic ultrasonography. of hepatic and retroperitoneal masses. AJR Am J
34. Martino CR, Haaga JR, Bryan PJ, et al: CT- Endoscopy 34:21, 2002 Roentgenol 135:115, 1980
© 2002 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 3 JAUNDICE — 1
3 JAUNDICE
Jeffrey S. Barkun, M.D., F.A.C.S., and Alan N. Barkun, M.D.
The term jaundice refers to the yellowish discoloration of skin, DIRECT VERSUS INDIRECT HYPERBILIRUBINEMIA
sclerae, and mucous membranes that results from excessive Once the presence of jaundice has been confirmed, further
deposition of bilirubin in tissues. It usually is unmistakable but clinical assessment determines whether the hyperbilirubinemia
on occasion may manifest itself subtly. It is generally held that is predominantly direct or indirect.This distinction is based on
jaundice develops when serum bilirubin levels rise above 34.2 the division of bilirubin into conjugated and unconjugated
µmol/L (2 mg/dl)1; however, the appearance of jaundice also fractions, which are also known, respectively, as direct and
depends on whether it is conjugated or unconjugated bilirubin indirect fractions on the basis of their behavior in the van den
that is elevated and on how long the episode of jaundice lasts. Bergh (diazo) reaction.3 If the patient has normal-colored
In what follows, we outline a problem-based approach to the urine and stools, unconjugated bilirubin [see Sidebar Uncon-
jaundiced patient that involves assessing the incremental infor- jugated (Indirect) Bilirubin] is predominant [see Table 1]. If the
mation provided by successive clinical and laboratory investi- patient has dark urine, pale stools, or any other signs or symp-
gations as well as the information obtained by means of mod- toms of a cholestatic syndrome (see below), the serum biliru-
ern imaging modalities. We also propose a classification of bin fractionation usually indicates that conjugated bilirubin is
jaundice that stresses the therapeutic options most pertinent to
surgeons. We have not attempted a detailed review of bilirubin
metabolism and the various pediatric disorders that cause
jaundice; such issues are beyond the scope of this chapter.
Unconjugated (Indirect) Bilirubin
Finally, we emphasize that modern decision making in the
approach to the jaundiced patient includes not only careful The breakdown of heme leads to the production of unconjugated
bilirubin, which is water insoluble, is tightly bound to albumin, and
evaluation of anatomic issues but also close attention to patient
does not pass into the urine. Excessive production of unconjugated
morbidity and quality-of-life concerns, as well as a focus on bilirubin typically follows an episode of hemolysis. In the absence of
working up the patient in a cost-effective fashion. For optimal concomitant liver disease or biliary obstruction, the liver can usually
treatment, in our view, an integrated approach that involves the handle the extra bilirubin, and only a modest rise in serum levels is
surgeon, the gastroenterologist, and the radiologist is essential. observed. There is a substantial increase in bile pigment excretion,
leading to large quantities of stercobilinogen in the stool. A patient
with hemolysis may therefore be slightly jaundiced with normal-col-
Clinical Assessment ored urine and stools. Blood tests reveal that 60% to 85% of bili-
rubin is indirect.105
When a patient presents with Possible causes of indirect hyperbilirubinemia include a variety of
a skin discoloration suggestive disorders that result in significant hemolysis or ineffective erythro-
of jaundice, the first step is to poiesis. The diagnosis of indirect hyperbilirubinemia attributable to
confirm that icterus is indeed hemolysis is confirmed by an elevated serum lactate dehydrogenase
present. To this end, the mu- (LDH) level, a decreased serum haptoglobin level, and evidence of
cous membranes of the mouth, hemolysis on microscopic examination of the blood smear.
Disorders associated with defects in hepatic bilirubin uptake or
the palms, the soles, and the sclerae should be examined in conjugation can also produce unconjugated hyperbilirubinemia. The
natural light. Because such areas are protected from the sun, most common of these, Gilbert syndrome, is a benign condition
photodegradation of bile is minimized; thus, the yellowish dis- affecting up to 7% of the general population.106,107 It is not a single
coloration of elastic tissues may be more easily detected. disease but a heterogeneous group of disorders, all of which are
Occasionally, deposition of a yellowish pigment on skin may characterized by a homozygosity for a defect in the promoter
mimic jaundice but may in fact be related to the consumption controlling the transcription of the UDP glucuronyl transferase I
of large quantities of food containing lycopene or carotene or gene.108 The consequent impairment of bilirubin glucuronidation
presents as a mild unconjugated hyperbilirubinemia. The elevated
drugs such as rifampin or quinacrine. In these cases, the skin bilirubin level is usually detected on routine blood testing, and affected
is usually the only site of coloration, and careful inspection of patients may report that their skin turns yellow when they are
sclerae and mucous membranes generally reveals no icteric fatigued or at stressful times (e.g., after missing meals, after vomiting,
pigmentation. In certain cultures, long-term application of tea or in the presence of an infection). Other causes of an unconjugated
bags to the eyes may lead to a brownish discoloration of the hyperbilirubinemia are beyond the scope of this chapter.
sclerae that can mimic jaundice.2
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5 GASTROINTESTINAL TRACT AND ABDOMEN 3 JAUNDICE — 2
Choledocholithiasis is the most likely diagnosis. Perform preoperative MRCP or ERCP and laparoscopic
Resuscitate, correct any coagulopathy, and give cholecystectomy.
appropriate antibiotics. Alternatively, perform laparoscopic cholecystectomy
Perform ERCP for definitive diagnosis and with intraoperative cholangiography.
treatment. If ERCP cannot be done, consider
transhepatic drainage or surgery.
© 2002 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 3 JAUNDICE — 3
The most common single cause is pancreatic cancer; Treat with ERCP or PTC and drainage. For
many of the other possible causes also involve malignancy. advanced malignant disease, supportive care
Perform spiral CT or MRI with MRCP to diagnose lesion alone may be indicated.
and assess resectability.
Consider EUS for distal-third obstruction.
Perform Doppler ultrasonography to stage lesion further;
Lesion appears resectable, or surgical
CT angiography or MRA may be considered if ultrasonogram
palliation is indicated
is abnormal.
Perform MRCP to assess intrahepatic biliary system in Treat with surgical bypass or resection as
patients with middle-third or upper-third obstruction. appropriate for level of obstruction.
Perform laparoscopy to confirm resectability
before laparotomy.
Palliation: bypass with left (segment III) Palliation: bypass with hepaticojejunostomy. Palliation: bypass with Roux-en-Y
hepaticojejunostomy. Resection for cure: resection of tumor and choledochojejunostomy.
Resection for cure: resection of tumor, reconstruction with hepaticojejunostomy. Resection for cure: resection of tumor
possibly with hepatectomy or with pancreaticoduodenectomy or
segmentectomy, and reconstruction local ampullary excision.
with hepaticojejunostomy or
cholangiojejunostomy.
© 2002 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 3 JAUNDICE — 4
Hepatic Jaundice Treatment, once again, is usually supportive, depending on the clinical
Hepatic jaundice may be either acute or chronic and may be caused presentation; whether more specific therapy is needed and what form
by a variety of conditions [see Table 2]. it takes depend on the cause of liver disease. Although physiologic
Acute hepatic jaundice may arise de novo or in the setting of ongo- tests have been developed to quantify hepatic reserve, the most wide-
ing liver disease. Historical clues may suggest a particular cause, ly used and best-validated prognostic index remains the Child-Pugh
such as medications or viral hepatitis. Physical examination usually classification (see below), which correlates with individual survival and
reveals little; however, an enlarged liver is sometimes palpated. In the has been shown to predict operative risk.112 Liver transplantation is the
presence of preexisting chronic liver disease, bedside stigmata (e.g., treatment of choice in most cases of end-stage liver disease.
ascites, spider nevi, caput medusae, palmar erythema, gynecomas-
tia, or Dupuytren contracture) may be present. Although specific
therapies exist for certain clinical problems (e.g., acetylcysteine for
The Child-Pugh Classification112
acetaminophen ingestion and penicillin plus silibinin for Amanita phal- Numerical Score (points)
loides poisoning), treatment in most cases remains supportive.
Patients in whom encephalopathy develops within 2 to 8 weeks of the
onset of jaundice are usually classified as having fulminant hepatic Variable 1 2 3
failure [see 8:9 Hepatic Failure]. Evidence of encephalopathy, renal
Encephalopathy Nil (0) Slight to mod- Moderate to
failure, or a severe coagulopathy is predictive of poor outcome in this
erate (1, 2) severe (3–5)
setting.109 The most common causes of fulminant hepatic failure are
viral hepatitis and drug toxicity. The mortality from fulminant hepatic Ascites Nil Slight Moderate to
failure remains high even though liver transplantation has favorably severe
affected the prognosis.110
In cases of chronic hepatic jaundice, the patient may have chronic Bilirubin, mg/dl < 2 (< 34) 2–3 (34–51) > 3 (> 51)
(µmol/L*)
hepatitis or cholestasis, with or without cirrhosis. The cause usually is
determined on the basis of the history in conjunction with the results of Albumin, g/dl > 3.5 (> 35) 2.8–3.5 < 2.8 (< 28)
serology, biochemistry, and, occasionally, histology. Causes include (g/L*) (28–35)
viral infection, drug-induced chronic hepatitis, autoimmune liver dis-
ease, genetic disorders (e.g., Wilson disease and α1-antitrypsin defi- Prothrombin > 70% 40%–70% < 40%
index
ciency), chronic cholestatic disorders, alcoholic liver disease, and
steatohepatitis.111 Physical examination reveals the stigmata of chron-
Modified Child’s risk grade (depending on total score): 5 or 6 points, grade A; 7 to 9
ic liver disease and occasionally suggests a specific cause (e.g., points, grade B; 10 to 15 points, grade C.
Kayser-Fleischer rings on slit-lamp examination in Wilson disease). *Système International d’Unités, or Sl units.
© 2002 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 3 JAUNDICE — 6
10%; its sensitivity is optimal for pancreatic lesions larger than The limited data currently available suggest that assays of
1.5 cm in diameter. The presence of ascites, liver metastases, tumor markers in serum and pancreatic fluid are useful, par-
lymph nodes larger than 2 cm in diameter, and invasion into ticularly for cystic lesions of the pancreas.76
adjacent organs are all signs of advanced disease.59 On the basis
of these criteria, spiral CT can predict that a lesion will not be Nonoperative Management:
resectable with an accuracy approaching 95%; however, as many Drainage and
as 33% of tumors that appear to be resectable on CT are found Cholangiography
to be unresectable at operation.57,58 Occasionally, spiral CT does In the majority of patients
not yield sufficient information, and as a result, supplementary with malignant obstructions,
imaging studies are required. treatment is palliative rather
MRI has also been shown to be helpful in determining the than curative. It is therefore
nature of the malignant obstruction, and MRI-based staging, especially important to recog-
along with MRCP, can further dictate the subsequent choice nize and minimize the iatrogenic risks related to the manipu-
of therapy.59-62 MRI may be particularly useful for following up lation of an obstructed biliary system; this is why staging and
patients in whom clip artifacts interfere with a CT image.59 It cholangiography are currently being performed with less inva-
also appears to be successful in detecting cholangiocarcinoma sive methods.
spreading along the proximal biliary tree.63
Only in a few very rare instances is traditional angiography used Cholangiography and decompression of obstructed
to assess resectability or stage a hepatobiliary or pancreatic neo- biliary system As a rule, we favor ERCP, although PTC
plasm. Increasingly, it is being replaced by CT angiography or may be preferable for obstructions near the hepatic duct bifur-
duplex Doppler ultrasonography, which can confirm the pres- cation. Whichever imaging modality is used, the following four
ence of flow in the hepatic arterial or portal venous systems and principles apply.
occasionally can demonstrate invasion of these vessels by tumor.64
1. In the absence of preexisting or concomitant hepatocellular
Magnetic resonance angiography (MRA) has also been used
dysfunction, drainage of one half of the liver is generally
with excellent results. As yet, none of these noninvasive modali- sufficient for resolution of jaundice.
ties has been shown to be clearly superior to any of the others.65
2. Because of its external diameter, a transhepatic drain, once
EUS appears to be a highly promising modality, particular- inserted, does not necessarily permit equal drainage of all
ly with respect to assessment of the resectability of pancreatic segments of the liver, particularly if there are a number of
tumors.43,66,67 In a large study comprising 232 patients, EUS intrahepatic ductal stenoses. Accordingly, some patients
was found to be superior to CT and to standard ultrasonogra- with conditions such as sclerosing cholangitis or a growing
phy in detecting venous and gastric invasion by cancers mea- tumor may experience persistent sepsis from an infected
suring 3 cm or less in diameter.68 In another large series, it was excluded liver segment even when the prosthesis is patent
reported to be more accurate than CT in the comparative stag- [see Figure 2]. An excluded segment may even be responsi-
ing of pancreatic and ampullary cancers.69 EUS is also useful ble for severe persistent pruritus.
for identifying small (< 2 cm) pancreatic tumors, which may 3. Any attempt at opacifying an obstructed biliary tree intro-
be suspected in a patient with an obstruction of the distal third duces a significant risk of subsequent cholangitis, even
of the bile duct and whose CT scan is normal.67 An addition- when appropriate antibiotic prophylaxis is provided.
al benefit is that one can perform guided FNA at the time of Accordingly, when one elects to perform direct cholangiog-
EUS. Furthermore, EUS is currently the dominant technique raphy, there should be a plan for biliary drainage either at
for staging ampullary tumors.70 the time of ERCP or PTC or soon thereafter.
At this point in the evaluation, patients can be referred for 4. Even though jaundice is believed to be associated with multi-
direct cholangiography (usually ERCP) to better delineate the ple adverse systemic effects (e.g., renal failure, sepsis, and im-
proximal biliary anatomy (for upper-third lesions) or to clarify paired wound healing),77,78 routine preoperative drainage of
a still-unclear diagnosis. There is, however, a growing body of an obstructed biliary system does not benefit patients who will
evidence suggesting that in patients with either pancreatic71,72 soon undergo operative correction.79,80 In fact, as noted (see
or hepatic73 malignancies, routine preoperative direct cholan- above), routine preoperative drainage of subsequently resect-
giography with decompression may be associated with a high- ed hepatic or pancreatic malignancies may be deleterious.
er incidence of postoperative complications when tumor resec-
tion is ultimately carried out. When direct cholangiography is ordered, it should be
If a biliary stricture is detected at cholangiography, brush cytol- thought of as more than just a diagnostic test: it is the ideal set-
ogy or biopsy is mandatory. Biliary cytology, however, has been ting for cytology, biopsy, or even drainage of the obstructed
disappointing, particularly at ERCP: diagnostic accuracy ranges bile duct via a sphincterotomy, a nasobiliary tube, or a catheter
from 40% to 85%,74,75 mostly because the negative predictive or stent. Accordingly, it is essential that the surgeon, the gas-
value is poor. Accuracy improves with multiple sampling and troenterologist, and the radiologist discuss the possible need
when a biliary rather than a pancreatic malignancy is detected. In for drainage well before it is required. Early, open communi-
addition, biopsy tends to be more accurate than brush cytology.74 cation among all the members of the treating team is a hall-
If a pancreatic tumor is suspected, percutaneous FNA cytol- mark of the modern management of biliary obstruction.
ogy may be helpful; the yield is best for larger tumors. Direct
FNA of the lesion at EUS is also an increasingly attractive Palliation in patients with advanced malignant disease
option. In the case of potentially resectable lesions, however, When a patient has advanced malignant disease, drainage of
this measure adds very little to the decision-making process. the biliary system for palliation is not routinely indicated,
© 2002 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 3 JAUNDICE — 9
a b c
Figure 2 ERCP (a) demonstrates missing liver segments. Transhepatic cholangiography (b) of
segment VI reveals excluded liver ductal system. MRCP (c) shows the excluded liver segments as
well as the biliary system, which still communicates with the common hepatic duct.
because the risk of complications related to the procedure may indicating that modern surgical approaches are resulting in lower
outweigh the potential benefit. Indeed, the best treatment for postoperative morbidity and, possibly, improved 5-year survival88;
a patient with asymptomatic obstructive jaundice and liver however, the prognosis is still uniformly poor, except for patients
metastases may be supportive care alone.81 Biliary decompres- with ampullary tumors. In fact, the surgical procedure rarely proves
sion is indicated if cholangitis or severe pruritus that interferes curative, even after meticulous preoperative patient selection.
with quality of life is present. The first step toward potential resection of a jaundice-caus-
We, like others,21 consider a stent placed with ERCP to be the ing cancer should be laparoscopy to determine resectability
palliative modality of choice for advanced disease, although and to prevent the hospital stay and prolonged convalescence
upper-third lesions may be managed most easily through the ini- associated with an unnecessary laparotomy. Laparoscopy is
tial placement of an internal/external catheter at the time of used mostly to detect peritoneal carcinomatosis, liver metas-
PTC. Metal expandable stents remain patent longer than large tases, malignant ascites, and gross hilar adenopathy.89,90 In a
conventional plastic stents,82,83 but the high price of the metal trial involving 115 patients with potentially resectable peripan-
stents has kept them from being widely used, and their overall creatic tumors, full laparoscopic staging could be performed in
cost-effectiveness has yet to be clearly demonstrated. Whether 94%, and the overall resectability rate was 76%.89 In several
plastic biliary stents should be replaced prophylactically or only studies, a combined approach including both laparoscopy and
after obstruction has occurred remains controversial; however, laparoscopic ultrasonography was associated with shorter hos-
results from a randomized trial favor the former approach.84 pital stays and lower costs.90-92 The main limitation of such an
Randomized controlled trials suggest that surgical biliary approach appears to be that it does not accurately detect the
bypass should be reserved for patients who are expected to sur- spread of tumors to lymph nodes or the vascular system.92
vive for prolonged periods because bypass is associated with more Once laparoscopy confirms that there is no obvious advanced
prolonged palliation at the cost of greater initial morbidity.85 disease, the patient should undergo a full laparotomy, usually in
The role of prophylactic gastric drainage at the time of oper- the same setting but occasionally in a different operative session.
ative biliary drainage remains controversial.86 However, jaun- In what follows, only the general principles of resection or bypass
diced patients with unresectable lesions who also present with at each level of obstruction are discussed; operative technical details
duodenal or jejunal obstruction should be referred for gastro- are addressed elsewhere [see 5:22 Procedures for Benign and Malignant
jejunostomy at the time of biliary bypass surgery. There is evi- Biliary Tract Disease]. Our preferred method of biliary anastomosis,
dence to suggest that when a pancreatic malignancy is present, for either reconstruction or bypass, involves the fashioning of a Roux-en-Y
intraoperative celiac ganglion injection should be performed loop, followed by a mucosa-to-mucosa anastomosis. In all cases, a cho-
for either prophylactic or therapeutic pain control.87 lecystectomy is performed to facilitate access to the biliary tree.
Operative Management at Upper-third obstruction
Specific Sites: Bypass and Palliation. In the absence of liver
Resection compromise, drainage of one
Surgical treatment of tumors half of the liver usually leads
causing biliary obstruction is to clearance of jaundice.93
determined primarily by the level Because the left hepatic duct
of the biliary obstruction. There has a long extrahepatic segment
is a growing body of evidence that makes it more accessible,
© 2002 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 3 JAUNDICE — 10
the preferred bypass technique for an obstructing upper-third preoperatively. In this situation, intraoperative choledochoscopy
lesion is a left (or segment 3) hepaticojejunostomy. This oper- before resection helps confirm the diagnosis and may even per-
ation has superseded the Longmire procedure because it does mit removal of the stone. Because of the growing use of EUS
not involve formal resection of liver parenchyma. Laparoscopic and MRCP, such a situation is increasingly uncommon.
bypass techniques that make use of segment 3 have been Resection of a lower-third lesion usually involves a pancreatico-
developed, but their performance has yet to be formally duodenectomy [see 5:24 Pancreatic Procedures], although local
assessed.94,95 ampullary resection may be an acceptable alternative for a small
Resection for cure. The hilar plate is taken down to lengthen adenoma of the ampulla; local duodenal resection with removal
the hepatic duct segment available for subsequent anastomo- of the head of the pancreas has also been described. For optimal
sis. Often, a formal hepatectomy or segmentectomy is required results, pancreaticoduodenectomy is best performed in special-
to ensure an adequate margin of resection. If the resection ized centers.100
must be carried out proximal to the hepatic duct bifurcation, It has been suggested that postoperative adjuvant therapy
several cholangiojejunostomies will have to be done to anasto- may improve the prognosis after resection of a pancreatic ade-
mose individual hepatic biliary branches. Frozen section nocarcinoma,88 but this debate falls outside the scope of our
examination of the proximal and distal resection margins is discussion.
important because of the propensity of tumors such as cholan-
giocarcinoma to spread in a submucosal or perineural plane.
The results of aggressive hilar tumor resections that includ- Postoperative Jaundice
ed as much liver tissue as was necessary to obtain a negative A clinical scenario of particular pertinence to surgeons that
margin appear to justify this approach.96 In cases of left hepat- we have not yet addressed is the development of jaundice in
ic involvement, resection of the caudate lobe (segment 1) is the postoperative setting.
indicated as well.97 Jaundice develops in approximately 1% of all surgical patients
after operation.101 When jaundice occurs after a hepatobiliary
Middle-third obstruction procedure, it may be attributable to specific biliary causes, such
Palliation. Surgical bypass of
middle-third lesions is techni-
cally simpler because a hepati-
cojejunostomy can often be per-
formed distal to the hepatic
duct bifurcation, which means
that exposure of the hilar plate
or the intrahepatic ducts is unnecessary.
Resection for cure. Discrete tumors in this part of the bile
duct, though uncommon, are usually quite amenable to resec-
tion along with the lymphatic chains in the porta hepatis.
Resection of an early gallbladder cancer may, on occasion,
necessitate the concomitant resection of segment 5, although
the value of resecting this segment prophylactically has not
been conclusively demonstrated. Sometimes, jaundice from a
suspected middle-third lesion is in fact caused by a case of
Mirizzi syndrome [see Figure 3]. In such cases, a gallstone is
responsible for extrinsic obstruction of the CBD, either by
causing inflammation of the gallbladder wall or via direct
impingement. Proper treatment of this syndrome may involve
hepaticojejunostomy in addition to cholecystectomy if a chole-
cystocholedochal fistula is present.98
Lower-third obstruction
Palliation. The preferred bypass
technique for lower-third lesions
is a Roux-en-Y choledochojeju-
nostomy. Cholecystojejunostomy
carries a higher risk of compli-
cations and subsequent develop-
ment of jaundice99; this remains
true even when it is performed laparoscopically.94 Occasionally,
it may be done as a temporizing measure before a more defin-
itive procedure in the context of an upcoming transfer to a spe-
cialized center. Figure 3 ERCP demonstrates extrinsic compression of the
Resection for cure. Occasionally, an impacted CBD stone at the common hepatic duct by a stone in Hartmann’s pouch. A biliary
duodenal ampulla mimics a tumor and is not clearly identified stent has been inserted for drainage.
© 2002 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 3 JAUNDICE — 11
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73. Jarnagin WR, Bodniewicz J, Dougherty E, et al: A 112. Pugh RN, Murray-Lyon IM, Dawson JL, et al:
prospective analysis of staging laparoscopy in
prospective analysis of staging laparoscopy in Transection of the esophagus for bleeding
patients with primary and secondary hepatobil-
patients with primary and secondary hepatobil- iary malignancies. J Gastrointest Surg 4:34, 2000 esophageal varices. Br J Surg 60:646, 1973
iary malignancies. J Gastrointest Surg 4:34, 2000 113. Fallon MB, Anderson JM, Boyer JL: Intrahepatic
93. Baer HU, Rhyner M, Stain SC, et al: The effect of
74. Davidson BR: Progress in determining the nature communication between the right and left liver on cholestasis. Diseases of the Liver, 7th ed. Schiff L,
of biliary strictures. Gut 34:725, 1993 the outcome of surgical drainage from jaundice Schiff ER, Eds. JB Lippincott Co, Philadelphia,
75. Hawes RH: Endoscopy and non-calculus biliary due to malignant obstruction at the hilus of the 1993, p 343
obstruction. Annuals of Gastrointestinal Endoscopy, liver. HPB Surg 8:27, 1994
8th ed. Cotton PB, Tytgat GNJ, Williams CB, Eds. 94. Gagner M: Personal communication
Current Science, England, 1995, p 101
95. Scott-Conner CE: Laparoscopic biliary bypass for
76. Fernandez Del Castillo C, Warshaw AL: Cystic
tumors of the pancreas. Surg Clin North Am
inoperable pancreatic cancer. Semin Laparosc Acknowledgment
Surg 5:185, 1998
75:1001, 1995
96. Chamberlain RS, Blumgart LH: Hilar cholangio- Figure 2c From MRI of the Abdomen and Pelvis: A Text-
77. Rege RV: Adverse effects of biliary obstruction:
carcinoma: a review and commentary. Ann Surg Atlas, by R. C. Semelka, S. M. Asher, and C. Reinhold.
implications for treatment of patients with ob-
Oncol 7:55, 2000 John Wiley and Sons, New York, 1997. Used with
structive jaundice. AJR Am J Roentgenol 164:287,
1995 97. Ogura Y, Kawarada Y: Surgical strategies for carci- permission.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 4 Intestinal Obstruction — 1
4 INTESTINAL OBSTRUCTION
W. Scott Helton, M.D., F.A.C.S., and Piero M. Fisichella, M.D.
Assessment of
Intestinal Obstruction Urgent operation
Indications include
• Lack of response to 24–48 hr of nonoperative therapy
(increasing abdominal pain, distention, or tenderness; NG
aspirate changing from nonfeculent to feculent; ↑ proximal
small bowel distention with ↓ distal gas).
• Early technical complications of operation (abscess, phlegmon,
hematoma, hernia, intussusception, anastomotic obstruction).
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 4 Intestinal Obstruction — 4
Investigative studies
Conditions that typically resolve with nonoperative Indications include nontoxic, nontender sigmoid volvulus with
therapy include adhesive obstruction (unless it sigmoidoscopically managed obstruction; recurrent adhesive
does not improve in 12 hr), early postoperative or stricture-related small bowel obstruction; partial colonic
obstruction (unless it does not improve in 2 wk), obstruction unresponsive to 24 hr of nonoperative therapy;
and various inflammatory conditions (IBD, radiation development and resolution of small bowel obstruction in patient
enteritis, diverticulitis, acute Crohn disease). who has never undergone abdominal operation.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 4 Intestinal Obstruction — 5
small bowel loops usually occupy the central abdomen [see Figure
1], whereas distended large bowel loops are typically seen around
the periphery [see Figure 2]. In patients with ileus, distention usual-
ly extends uniformly throughout the stomach, the small bowel, and D
the colon [see Figure 3], and air-fluid levels may be found in the
colon and the small intestine.
Patients with gastric outlet obstruction or gastric atony typical-
ly have a giant gastric bubble if no nasogastric tube has been
placed, with little or no air in the small bowel or the colon. B
Patients with mechanical small bowel obstruction usually have C
multiple air-fluid levels, with distended bowel loops of varying
sizes arranged in an inverted U configuration [see Figure 4]. A
dilated loop of small bowel appearing in the same location on
supine and upright films suggests obstruction of a fixed segment
of bowel by an adhesion or an internal hernia [see Figures 1 and
4]. Small bowel obstruction is often accompanied by a paucity of Figure 3 Radiograph from a patient with postoperative ileus
gas in the colon. The complete absence of colonic gas is strongly shows massive gastric distention (A), distended small bowel loops
suggestive of complete small bowel obstruction; however, the (B), air throughout the colon, mild dilatation of the sigmoid colon
presence of colonic gas does not exclude complete small bowel (C) with air mixed with stool, and a haustral fold in the apex of
obstruction, in that there may have been unevacuated gas distal the sigmoid colon (D).
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 4 Intestinal Obstruction — 7
Determination of Need
for Operation and
Classification of
Obstruction
The combination of a
thorough history, a carefully
performed physical exami-
nation, and correctly interpreted abdominal radiographs usually
allows one to identify the type of bowel obstruction present and
to decide whether a patient requires immediate, urgent, or
delayed operation [see Table 4] or can safely be treated initially
with nonoperative measures. To this end, it is particularly impor-
tant and useful to stratify patients into those with mechanical
obstruction and those with nonmechanical obstruction. In
patients with mechanical bowel obstruction, an effort should be
made to determine whether the obstruction is complete or par-
tial. Except for a few clinical situations, patients with complete
bowel obstruction require immediate operation; conversely,
patients with partial bowel obstruction rarely do. Finally, an effort
should be made to establish the level and cause of obstruction
because these factors often help guide therapy and affect the
probability of success in response to specific therapeutic inter-
vention. Patients with nonmechanical obstruction, which derives
from ileus or pseudo-obstruction [see Ileus and Pseudo-obstruc-
tion, below], do not require immediate operation.
Figure 4 Upright radiograph from the same patient as the ADJUNCTIVE TESTS FOR EQUIVOCAL SITUATIONS
supine radiograph in Figure 1 shows multiple air-fluid levels of
varying size arranged in inverted Us. In the right lower pelvis, a Sigmoidoscopy
loop of small bowel is seen in exactly the same location as on the
supine abdominal film (black arrow), a finding suggestive of adhe- When one is uncertain whether the obstruction is mechanical
sive obstruction. or not on the basis of the information in hand, additional diag-
nostic measures are immediately indicated. When large amounts
of colonic air extend down to the rectum, flexible or rigid sig-
moidoscopy will readily exclude a rectal or distal sigmoid
to a point of complete obstruction before the radiograph was obstruction. Care must be exercised to avoid insufflating large
taken. On the other hand, if repeat radiographs demonstrate amounts of air during endoscopy: excessive insufflation can cause
decreased or absent colonic or rectal gas in a patient with small overdistention of the colon above the level of the possible obstruc-
bowel obstruction who previously had more colonic or rectal gas, tion, which can be counterproductive and harmful. If sigmoid-
it is probable that partial obstruction has become complete, and oscopy yields normal findings but partial colonic obstruction
immediate operation is almost always indicated. High-grade seems to be the correct diagnosis, a water-soluble contrast enema
obstruction of the colon with an incompetent ileocecal valve may should be administered.7 Barium studies may be harmful in
manifest itself as distended small bowel loops with air-fluid levels, patients with acute obstruction when they are performed before
thereby mimicking small bowel obstruction. Hence, it is some- the nature of the obstruction (complete or partial) is determined.
times necessary to perform a barium enema to exclude colonic Abdominal ultrasonography, though not as definitive as a con-
obstruction. trast examination, is also able to diagnose suspected colonic
Massive gaseous distention of the colon is usually secondary to obstruction in 85% of patients.8
distal colonic or rectal obstruction, volvulus, or pseudo-obstruction
[see Figures 2, 5, 6, and 7]. There are well-defined radiographic cri- Ultrasonography, Computed Tomography, and Fast Magnetic
teria that are highly sensitive and specific for sigmoid volvulus.6 If Resonance Imaging
there is any uncertainty regarding the presence, type, or level of Abdominal radiographs can be entirely normal in patients with
colonic obstruction, immediate sigmoidoscopy followed by barium complete, closed-loop, or strangulation obstruction.9 Therefore, if
enema is diagnostic. the patient’s clinical profile and the results of physical examination
are consistent with intestinal obstruction despite normal abdomi-
LABORATORY TESTS
nal radiographs, abdominal ultrasonography, CT scanning, or fast
Serum electrolyte concentrations, the hematocrit, the serum MRI should be performed immediately.9-18 All three modalities are
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 4 Intestinal Obstruction — 8
Contrast Studies
Enteroclysis (direct injection of BaSO4 into the small bowel) is
generally considered the most sensitive method of distinguishing
between ileus and partial mechanical small bowel obstruction: it
has a diagnostic sensitivity of 87% for adhesive obstruction.26,27
Many surgeons are concerned that injection of barium might
cause partial obstruction to progress to complete obstruction;
however, there is no evidence that this ever occurs, and one there-
fore should not refrain from using barium to diagnose partial
small bowel obstruction.28-31 If complete obstruction is identified,
the patient should undergo immediate operation. If partial
obstruction is identified in either the small or the large bowel, the
patient is treated accordingly. If (1) mechanical obstruction is not
identified and (2) a point of obstruction, as evidenced by the find-
ing of both dilated and decompressed intestinal loops, cannot be
identified through abdominal ultrasonography, CT scanning, or
fast MRI, then the diagnosis is almost certainly ileus, in which
case one’s attention is directed toward identifying and correcting
the underlying precipitating cause [see Table 1 and Mechanical
Obstruction, No Operation, Adhesive Partial Small Bowel Ob-
struction, below].
Mechanical Obstruction
TERMINAL ILLNESS
Figure 6 (a) Radiograph from a patient with cecal volvulus
Patients with a terminal illness (e.g., AIDS or advanced carci-
shows a dilated cecum with no air distally in the colorectum.
Convergence of the medial walls of the loop (black arrow) points
nomatosis) to whom surgical treatment offers little hope of
to the right, a typical finding in cecal volvulus. (b) Barium exami- improved quality or duration of life may choose not to undergo
nation demonstrates a bird’s-beak deformity tapering at the point operative intervention for acute bowel obstruction. These patients
of volvulus (large white arrow). Note walls of dilated cecum (small should be offered comfort measures, including continuous mor-
white arrows). phine infusion, rehydration, and administration of antisecretory
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 4 Intestinal Obstruction — 10
Figure 8 CT scan from a patient with partial small bowel obstruction Figure 9 CT scan from a patient with adhesive partial small
shows distended, fluid-filled loops of small bowel with air-fluid levels, bowel obstruction shows massively dilated small intestine (black
hyperemia, and bowel wall thickening (large white arrow). Note the arrow) proximal to a thick adhesive band (large white arrow)
discrepancy in caliber between dilated small bowel and decompressed and decompressed small bowel distal to the adhesion (dashed
small bowel (dashed white arrow) and the stranding (small black white arrow). The patient was operated on because of the low
arrow) in the small bowel mesentery. Air in a decompressed descend- probability that this obstruction would resolve with conservative
ing colon (large black arrow) is indicative of partial obstruction. management.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 4 Intestinal Obstruction — 11
be the cause of the postoperative obstruction, it is reasonable for vation period, the patient must be constantly reevaluated, ideally
the surgeon to assume that the obstruction is secondary to post- by the same examiner. Analgesics can be safely administered, and
operative adhesions, which are best treated conservatively (see repeat abdominal examinations should be performed at 3-hour
below). intervals when the influence of narcotics has waned. Repeat
abdominal x-rays should be obtained no later than 6 hours after
NO OPERATION
nasogastric decompression, and the pattern of gas distribution
In selected patients, non- should be compared with that seen on the admission films. A
operative management of decrease in intestinal gas distal to a point of obstruction coupled
partial small bowel obstruc- with an increase in proximal dilatation suggests that the obstruc-
tion is highly successful and tion is worsening; conversely, a decrease in intestinal distention
carries an acceptably low coupled with the appearance of more gas distally in the colon sug-
mortality. Such patients in- gests that the obstruction is being reduced.The degree of abdom-
clude those whose partial inal distention, the passage of flatus, and the nature of the naso-
obstruction is secondary to gastric aspirate should be evaluated periodically. If abdominal
intra-abdominal adhesions, occurs in the immediate postoperative distention does not decrease or the gastric aspirate changes from
period, or derives from an inflammatory condition (e.g., inflam- bilious to feculent, the patient should be operated on.
matory bowel disease, radiation enteritis, or diverticulitis). Experimental and clinical studies suggest that patients under-
going nonoperative treatment of bowel obstruction may benefit
Adhesive Partial Small Bowel Obstruction from the administration of somatostatin analogues as a result of
Adhesions are the major cause of bowel obstruction. the potent effects these substances exert on intestinal sodium,
Obstruction resulting from adhesions can occur as early as 1 chloride, and water absorption.57 In one study, animals with either
month or as late as 20 years after operation.48 Adhesive partial complete or closed-loop partial small bowel obstruction were
small bowel obstruction is treated initially with nasogastric given either long-acting somatostatin or saline; the treatment
decompression, I.V. rehydration, and analgesia. Parenteral nutri- group had significantly less intestinal distention, less infarction,
tion should be begun if one believes that oral or enteral nutrition and longer survival than the control group.57,58 In a prospective,
will not be adequate within 5 days. Nonoperative therapy leads to randomized clinical trial evaluating the use of somatostatin in
resolution of adhesive partial obstruction in as many as 90% of patients who had complete small bowel obstruction without clin-
patients49,50; however, such resolution is followed by recurrence of ical or radiologic evidence of strangulation, the treatment group
obstruction in approximately 50% of cases.51,52 When operative was less likely to need operation, had less proximal intestinal dis-
adhesiolysis is performed, the mortality is less than 5% for tention, and exhibited decreased mucosal necrosis proximal to the
patients with simple obstruction but may be as high as 30% for point of obstruction.59 In other trials, long-acting somatostatin
patients with strangulation or necrotic bowel necessitating intesti- analogues and other nonsecretagogues significantly decreased the
nal resection.48 In view of this substantial difference in mortality, amount of gastric contents aspirated and alleviated the symptoms
it is extremely important to be able to confidently distinguish of intestinal obstruction in terminally ill patients with nonopera-
obstruction that is likely to resolve with nonoperative treatment ble malignant disease.32,33,37-40
from obstruction that is not. Patients with adhesive partial It should be possible to determine with a high degree of accu-
obstruction that can be accurately predicted to resolve with med- racy and safety which patients will require operation for adhesive
ical therapy can and should be treated nonoperatively. small bowel obstruction within 24 to 48 hours of admission to the
Some studies suggest that the nature of the previous abdomi- hospital. As a rule, patients with closed-loop or complete bowel
nal operation or the type of adhesions present may influence the obstruction, who require immediate or urgent operation, can be
probability that the obstruction will not respond to medical ther- readily identified by means of abdominal CT or MRI.12-14,17,18 For
apy.53-57 Operations associated with a lower likelihood of response the remaining patients, who have some degree of partial obstruc-
to medical therapy include those performed through a midline tion, the success or failure of conservative management can be
incision; those involving the aorta, the colon, the rectum, the predicted with high accuracy by recording the arrival of contrast
appendix, or the pelvic adnexa; and those done to relieve previous material (either a water-soluble agent or a mixed barium prepara-
carcinomatous obstruction. Matted adhesions, which are more tion) in the right colon within a defined time.14,30,60-63 One
common in patients who have undergone midline incisions or co- prospective study documented the arrival of diatrizoate meglu-
lorectal procedures, are less amenable to conservative manage- mine–diatrizoate sodium in the colon within 24 hours and found
ment than a simple obstructive band is.53 In the context of this this measure to have a sensitivity of 98%, a specificity of 100%, an
kind of operative history, strong consideration should be given to accuracy of 99%, a positive predictive value of 100%, and a neg-
surgical intervention if the obstruction does not resolve within 24 ative predictive value of 96% as a predictor of successful nonop-
hours—unless comorbid medical conditions tip the risk-benefit erative treatment.64 Other studies achieved comparable results
balance in the direction of nonoperative therapy. with shorter arrival times (e.g., 4 or 8 hours).14,61,65
There is an ongoing debate regarding how long patients with Several prospective, randomized clinical trials have addressed
partial adhesive obstruction should be treated conservatively. the issue of whether administration of contrast material can itself
After 48 hours of nonoperative management, the risk of compli- be therapeutic with respect to resolving adhesive small bowel
cations increases substantially, and the probability that the obstruction. Two such studies examined small bowel follow-
obstruction will resolve diminishes.43 Generally, if the obstruction through with barium, either alone or mixed with diatrizoate meg-
is going to resolve with nonoperative therapy, there will be a fair- lumine.30,31 Both found that the intervals between admission and
ly prompt response within the first 8 to 12 hours. Therefore, if a operation were shorter for patients randomized to the contrast
patient’s condition has deteriorated or has not significantly arm than for those in the control group but that contrast exami-
improved by 12 hours after nasogastric decompression and resus- nation did not lead to more expeditious resolution of obstruction.
citation, exploratory laparotomy is advisable. During this obser- Both studies also demonstrated that barium could be adminis-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 4 Intestinal Obstruction — 14
tered to patients with small bowel obstruction safely and without the best study published to date on this issue is a retrospective,
complications. matched-pair analysis that used an intention-to-treat analysis.71 In
Four prospective, randomized trials have investigated the effects this study, 52% of the patients in the laparoscopic group underwent
of administering water-soluble hyperosmolar contrast agents to conversion to open lysis of adhesions either for completion of adhe-
patients with small bowel obstruction.60,62,63,66 In one study, admin- siolysis or for management of complications. No perforations or
istration of 100 ml of diatrizoate meglumine (1,900 mOsm/L) recurrent obstructions were missed. Perforations were more com-
through the nasogastric tube promoted resolution of adhesive par- mon overall in the laparoscopic group than in the open group,
tial obstruction and shortened hospital stay but had no effect on though this difference was largely eliminated when patients from
whether laparotomy was required.60 No contrast-related complica- the laparoscopic group who underwent conversion to open lysis
tions were observed. In the second study, administration of a dif- were not considered. Patients with two or more previous laparo-
ferent water-soluble hyperosmolar contrast agent, ioxitalamate tomies had a higher incidence of intraoperative complications than
meglumine (1,500 mOsm/L), had no therapeutic effect on patients those with fewer laparotomies. Accordingly, the authors recom-
with partial small bowel obstruction.66 Again, no contrast-related mended against laparoscopic adhesiolysis in patients with two
complications were observed. In the third study, administration of or more previous laparotomies. The high conversion rate in this
100 ml of diatrizoate meglumine through the nasogastric tube sig- study notwithstanding, the laparoscopic group as a whole (includ-
nificantly accelerated the resolution of adhesive partial small bowel ing conversions) experienced an overall reduction in postoperative
obstruction and shortened hospital stay.62 Patients in whom con- complications.
trast reached the colon within 24 hours were able to tolerate imme- Another potential advantage of laparoscopic adhesiolysis is that
diate oral feeding. In addition, the time needed to decide on oper- it results in fewer intra-abdominal adhesions than open laparoto-
ative adhesiolysis was shorter in patients receiving the contrast my76,77 and thus may reduce the risk of recurrent bowel obstruction.
agent. In the fourth study, patients whose partial adhesive small However, one study found that despite a reduction in median
bowel obstruction did not resolve after 48 hours either received 100 length of stay, patients treated laparoscopically were at increased
ml of diatrizoate meglumine or underwent operative adhesiolysis.63 risk for early unplanned reoperation as a consequence of either
If administration of the contrast agent revealed complete bowel incomplete relief of obstruction or complications.70 In fact, bowel
obstruction, operative treatment was immediately initiated. If it perforation in the course of laparoscopic adhesiolysis often is not
revealed partial obstruction, conservative treatment was continued; detected during the procedure and presents in a delayed fashion.75
in 100% of these patients, the obstruction then resolved without Many such injuries are attributable either to insertion of the initial
operation. No contrast-mediated complications, no bowel strangu- trocar or to delayed perforation of a thermal injury. When laparo-
lation, and no deaths were reported.The significant treatment effect scopic adhesiolysis fails to identify and relieve an obvious point of
reported in three of the four randomized clinical trials, along with obstruction or when adhesiolysis is inadequate or unsafe, conver-
the absence of any deleterious contrast-related complications in all sion to an open approach is indicated.
four, constitutes sufficient evidence to support the administration of
100 ml of diatrizoate meglumine to patients with adhesive partial Early Postoperative Obstruction
small bowel obstruction. Early postoperative mechanical small bowel obstruction is not
By accelerating the resolution of partial small bowel obstruc- uncommon: it occurs in approximately 10% of patients undergo-
tion and ileus, administration of water-soluble contrast agents can ing abdominal procedures.78 Postoperative bowel obstruction is
shorten the expected hospital stay and thereby reduce the cost of often difficult to diagnose because it gives rise to many of the
care. Thus, it is reasonable that the first step in managing sus- same signs and symptoms as postoperative ileus: obstipation, dis-
pected partial small bowel obstruction from adhesions or postop- tention, nausea, vomiting, abdominal pain, and altered bowel
erative ileus should be to administer water-soluble contrast mate- sounds. In most cases, there are roentgenographic signs indicative
rial intragastrically. When bowel function does not return within of small bowel obstruction rather than ileus; however, in some
24 hours and the obstruction is demonstrated to be partial, con- cases, abdominal x-rays fail to diagnose the obstruction.79
tinued observation is safe and resolution without operation is still Traditionally, when plain radiographs are equivocal, an upper GI
highly probable. Eventually, however, there will be a point beyond barium study with follow-through views is the next test performed
which continued observation is no longer cost-effective in com- to distinguish ileus from partial or complete small bowel obstruc-
parison with operative adhesiolysis (especially laparoscopic adhe- tion80; however, such studies may yield the wrong diagnosis in as
siolysis). Additional prospective trials are necessary to determine many as 30% of cases.26,79,81 A number of authorities believe that
precisely how long the waiting period before operative treatment abdominal ultrasonography is excellent at distinguishing postop-
should be. erative ileus from mechanical obstruction and recommend that it
be done before any contrast study.22
Laparoscopic adhesiolysis Several clinical reports have Early postoperative obstruction is caused by adhesions in about
demonstrated that laparoscopic adhesiolysis for acute small bowel 90% of patients.79,82 When there are no signs of toxicity and no
obstruction is both feasible and safe.67-72 Laparoscopic or laparo- acute abdominal signs, such obstruction can usually be managed
scopic-assisted lysis of adhesions relieves bowel obstruction in more safely with nasogastric decompression.78,79,81,82 As many as 87% of
than 50% of patients and is associated with lower morbidity, earlier patients respond to nasogastric suction within 2 weeks. About 70%
return of bowel function, quicker resumption of normal diet, and a of the patients who respond to nonoperative treatment do so with-
shorter hospital stay than open operative lysis.67-71,73 To minimize in 1 week, and an additional 25% respond during the following 7
the risk for bowel injury at the beginning of the operation, the first days. If postoperative obstruction does not resolve in the first 2
trocar is inserted under direct vision by means of an open tech- weeks, it is unlikely to do so with continued nonoperative therapy,
nique, and the incision is placed well away from any previous and reoperation is probably indicated79,82; about 25% of patients
scars.74,75 whose postoperative obstruction was initially treated nonoperative-
At present, there are no prospective, randomized, controlled clin- ly eventually require reoperation. An exception to this guideline
ical trials comparing laparoscopic with open adhesiolysis. Perhaps arises in patients known to have severe dense adhesions (sometimes
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 4 Intestinal Obstruction — 15
ELECTIVE OPERATION
referred to as obliterative peritonitis) in response to multiple
sequential laparotomies.These patients may have a combination of
mechanical obstruction and diffuse small bowel and colonic ileus. Nontoxic, Nontender
The risk of closed-loop obstruction, volvulus, or strangulation in Sigmoid Volvulus
this group of patients is low. Repeat laparotomies and attempts to Patients with nontoxic,
lyse adhesions may lead to complications, the development of en- nontender sigmoid volvulus
terocutaneous fistulae, or exacerbation of the adhesions. Often, the whose bowel obstruction is
best approach to managing these patients is observation for pro- initially treated successfully
longed periods (i.e., months). Total parenteral nutrition (TPN) is with sigmoidoscopic decompression are at risk for recurrent
indicated. The addition of octreotide to the TPN solution may be colonic obstruction. Accordingly, these patients should undergo
helpful and may make patients more comfortable. elective sigmoid resection after complete bowel preparation.
Because the risk of intestinal strangulation in patients with
postoperative adhesive obstruction is extremely low (< 1%),79,83 Recurrent Adhesive or Stricture-Related Partial Small Bowel
one can generally treat these patients nonoperatively for longer Obstruction
periods. In fact, the conservative approach is often the wise one: Many patients whose adhesive bowel obstruction resolves
reoperation may do more harm than good (e.g., by causing experience no further obstructive episodes. If a patient does pre-
enterotomies and inducing denser adhesions). The traditional sent with recurrent obstruction from presumed adhesions, either
indications for operation in patients with early postoperative a contrast examination of the bowel or CT scanning is indicated
obstruction include (1) deteriorating clinical status, (2) worsen- to determine whether there is a surgically correctable point of
ing obstructive symptoms, and (3) failure to respond to nonop- stenosis. A strong argument can be made that non–high-risk
erative management within 2 weeks. With the rising cost of hos- patients should undergo elective operation after presenting with
pitalization, it might in fact be more cost-effective to reoperate on their second episode of mechanical obstruction. Similarly,
patients who have persistent obstruction after 7 days. This spec- patients with recurrent obstruction from strictures of any sort
ulation would have to be tested by a well-organized cost-benefit should undergo elective operation, given that these lesions are
study conducted in a prospective fashion. unlikely to resolve.
Some physicians have maintained that long intestinal tubes are
beneficial in the management of postoperative bowel obstruc- Partial Colonic Obstruction
tion.50 However, there is no convincing evidence that long intesti- The most common causes of partial colonic obstruction are
nal tubes are any better for resolving bowel obstruction than con- colon cancer, strictures, and diverticulitis. Cancer and strictures
ventional nasogastric tubes are. In fact, some authorities have usually must be managed surgically because they generally go on
reported that the use of such tubes increases morbidity.28,43,44 to cause obstruction later. Strictures from ischemia or endometrio-
One prospective, randomized clinical trial that addressed this sis usually call for elective colonic resection. Inflammatory stric-
issue found no differences between the two types of tube with tures from diverticulitis may resolve; however, if obstructive symp-
respect to the percentage of patients who were able to avoid oper- toms persist or if barium enema examination continues to yield
ation, the incidence of complications, the time between admis- evidence of colonic narrowing, elective resection is warranted.
sion and operation, or the duration of postoperative ileus.84 When abdominal x-rays suggest distal colonic obstruction,
digital examination and rigid sigmoidoscopy are performed to
Inflammatory Conditions exclude fecal impaction, tumors, strictures, and sigmoid volvulus.
Partial bowel obstruction secondary to inflammatory bowel If obstruction is proximal to the sigmoidoscope, barium contrast
disease, radiation enteritis, or diverticulitis usually resolves with examination is indicated. If barium examination does not
nonoperative therapy. Bowel obstruction accompanying an acute demonstrate mechanical obstruction, a presumptive diagnosis of
exacerbation of Crohn disease usually resolves with nasogastric colonic pseudo-obstruction is made.
suction, I.V. antibiotics, and anti-inflammatory agents. If, howev- The morbidity and mortality associated with elective colorec-
er, CT scanning detects intra-abdominal abscess, there is evi- tal procedures are significantly lower than those associated with
dence of a chronic stricture, or the patient exhibits persistent emergency colonic surgery. Furthermore, immediate operation
obstructive symptoms, operation may be necessary. Similarly, for left-side colonic obstruction almost always necessitates the
bowel obstruction arising from acute enteritis caused by radiation creation of a diverting colostomy. If a colostomy takedown sub-
exposure or chemotherapy usually resolves with supportive care. sequently proves necessary, the overall cost of caring for the
Chronic radiation-induced strictures are problematic; astute clin- patient will be significantly higher than it would have been had a
ical judgment must be exercised to determine when operative single-stage procedure been performed. For these reasons, one
treatment is the best option. should initially treat partial colonic obstruction with nasogastric
Patients with acute diverticulitis typically present with a history suction, enemas, and I.V. rehydration in the hope that the
of altered bowel movements, fever, leukocytosis, localized pain, obstruction will resolve and that the patient thus can undergo
tenderness, and guarding in the left lower quadrant of the mechanical and antibiotic bowel preparation and a single-stage
abdomen. Approximately 20% of patients with colonic diverticuli- procedure comprising resection and primary anastomosis.
tis also present with signs and symptoms of partial colonic obstruc- Patients who do not respond to nonoperative measures within 24
tion. A CT scan should be obtained early in all patients with diver- hours should undergo operation within 12 hours with the aim of
ticulitis to ascertain whether there is a pericolic abscess that could preventing perforation.
be drained percutaneously.85 Partial colonic obstruction in these In patients with partially obstructing rectal or distal sigmoid
patients usually resolves with antibiotic therapy, an NPO regimen, tumors or strictures that can be traversed with a radiologic guide
and nasogastric decompression. If obstructive symptoms persist for wire, balloon dilatation can be performed and a self-expanding
more than 7 days or if obstructive symptoms from a documented stent deployed.36,86-89 Clinical improvement and resolution of
stricture recur, operation is indicated. obstruction occur in more than 90% of patients within 96
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 4 Intestinal Obstruction — 16
hours.36,88 With restoration of the bowel lumen, patients can be a minimally invasive procedure. If no cause of obstruction is found
prepared for elective surgery, can be spared the creation of a at laparoscopy, open laparotomy is performed.
diverting colostomy, and can avoid the extra expense and mor-
bidity associated with the performance of two operations.88,89 Paraduodenal hernia Paraduodenal hernia, a congenital
This approach is also highly successful as primary therapy for defect resulting from intestinal malrotation, is probably more
bowel obstruction in patients who are not surgical candidates.36 common than was once thought. It accounts for approximately
In patients with large, fixed rectal masses, one should obtain CT 50% of internal hernias. Patients with paraduodenal hernia may
scans of the pelvis to assess the extent of the tumor. Transrectal present with a catastrophic closed-loop obstruction; more often,
laser fulguration and endoluminal stenting are palliative options however, they exhibit mild, nonspecific GI symptoms such as nau-
for restoring bowel lumen patency that may be considered for sea, vomiting, esophageal reflux, and abdominal pain. Duodeno-
patients with nonresectable recurrent rectal cancer or radiation gastric reflux and prominent bile gastritis in the absence of a pre-
strictures in whom operative risk is prohibitively high. vious operation or diabetic gastroparesis are indirect signs of a
paraduodenal hernia. The diagnosis is established by means of
Bowel Obstruction without Previous Abdominal Operation either an upper GI contrast study with small bowel follow-through
When partial small bowel obstruction develops and resolves in a or CT scanning. When a paraduodenal hernia is identified, oper-
patient who has not previously undergone an abdominal opera- ative treatment is indicated. Such treatment is usually successful in
tion, a diagnostic workup should be performed to identify the alleviating symptoms and preventing strangulation obstruction.91
cause of the obstruction; there may be an underlying condition
that is likely to cause recurrent obstruction (e.g., an internal her-
nia, a tumor, malrotation, or metastatic cancer).The first diagnos- Nonmechanical
tic test to be ordered should be a CT scan, followed by an upper Obstruction
GI barium study with follow-through views and a barium enema.90
ILEUS
If a pathologic lesion is identified, elective operation is indicated.
An argument can be made that no additional diagnostic tests Ileus, or intestinal paraly-
should be performed in these patients and that diagnostic laparos- sis, is most common after
copy should be performed instead to enable laparoscopic surgery abdominal operations but
in case a cause of obstruction is identified that can be treated with can also occur in response
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 4 Intestinal Obstruction — 17
Follow patient.
Operate.
to any acute medical condition or metabolic derangement [see and I.V. rehydration are indicated. In postoperative patients, it is
Table 1]. The pathophysiologic mechanisms that cause ileus are best not to use strong narcotics for analgesia and instead to rely
incompletely understood but appear to involve disruption of nor- on epidural anesthesia and nonsteroidal anti-inflammatory drugs.
mal neurohumoral responses.92 Ileus may be classified into two When ileus develops in patients who have not recently undergone
broad categories: postoperative ileus and ileus without antecedent an operation, a thorough history, a careful physical examination,
abdominal operation. Postoperative ileus is manifested by atony and well-chosen laboratory tests are necessary to identify the pos-
of the stomach, the small intestine, and the colon and usually sible causes.
resolves spontaneously within a few days as normal bowel motil- When ileus persists for what is, in one’s best clinical judgment,
ity returns.Typically, the small bowel regains its motility within 24 an inordinate length of time for the operation performed (typical-
hours of operation, followed 3 to 4 days later by the stomach and ly, longer than 3 to 4 days), the possibility of partial mechanical
the colon. Initial therapy of ileus is directed at identifying and cor- obstruction, possibly associated with an intra-abdominal abscess or
recting the presumed cause [see Figure 12]. If the patient experi- another source of infection, must be considered. If an abscess is
ences abdominal distention, abdominal pain, nausea, or vomiting, suspected, an abdominal CT scan should be obtained. Abdominal
then nasogastric decompression, placement of a Foley catheter, ultrasonography has been reported to distinguish postoperative
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 4 Intestinal Obstruction — 18
ileus from mechanical obstruction reliably.22 A small bowel contrast occasionally develops that can cause mechanical obstruction and
examination with barium identifies partial mechanical small bowel that may be surgically correctable.101,102
obstruction in about 75% of patients.26,28 CT scanning distin-
guishes ileus from obstruction in about 80% of patients.
Intragastric administration of a water-soluble contrast agent has Cost Considerations
shown great potential in the treatment of ileus.93,94 In one study, Cost considerations are exerting an ever-growing influence on
administration of 120 ml of diatrizoate meglumine or diatrizoate surgical care in general and on the decision whether to operate in
sodium via nasogastric tube to 40 adults with postoperative small particular. A large percentage of the high total cost of caring for
bowel ileus led to restored intestinal motility within 6 hours in all patients with ileus or mechanical intestinal obstruction is account-
40, allowing them to resume oral alimentation within 24 hours.93 ed for by the cost associated with hospitalization or the need for
Given these results, a prospective, randomized trial that addresses laparotomy.
cost-management end points is warranted. Strategies for reducing the overall cost of managing patients
with bowel obstruction may take several forms: the development
PSEUDO-OBSTRUCTION
of diagnostic and therapeutic methods that lead to more rapid
Pseudo-obstruction [see Figure 13] can exist in the small bowel diagnosis and resolution of ileus and partial small bowel obstruc-
or the colon and can be either acute or chronic. Acute colonic tion; the development of techniques for rapid identification of
pseudo-obstruction, also known as Ogilvie syndrome, is the most patients with complete or closed-loop obstruction and early
common form. Colonic pseudo-obstruction occurs most com- reversible strangulation, which would permit earlier operative
monly in hospitalized patients in the postoperative period or in intervention and thereby reduce the incidence of complications;
response to a nonsurgical acute illness (e.g., pneumonia, myocar- the development of therapeutic approaches that prevent postop-
dial infarction, hypoxia, shock, intestinal ischemia, or electrolyte erative ileus; and the development of methods for preventing
imbalance). The pathophysiologic mechanisms underlying idio- intra-abdominal adhesions, which would significantly reduce the
pathic pseudo-obstruction appear to be related to an imbalance overall incidence of bowel obstruction.Two prospective, random-
in the parasympathetic and sympathetic influences on colonic ized clinical trials demonstrated that placement of a bioresorbable
motility. membrane composed of sodium hyaluronate and carboxymethyl-
The presenting symptoms of acute colonic pseudo-obstruction cellulose underneath abdominal fascial closures significantly
are massive dilatation of the colon (with the cecum more dilated reduced the severity and density of postoperative adhesions.103,104
than the distal colon), crampy pain, nausea, and vomiting.95 If In theory, use of such a product should reduce the incidence of
peritoneal irritation or systemic toxicity is present, immediate adhesion-related bowel obstruction; however, longer-term studies
laparotomy is indicated; if not, treatment involves nasogastric are required to determine whether this will actually be the case.
decompression, placement of a rectal tube, tap-water enemas, From a management viewpoint, if a specific diagnostic test,
correction of any underlying metabolic disturbances, and avoid- medication, or approach (e.g., laparoscopy) costs less than a day of
ance of narcotic and anticholinergic medications. With conser- hospitalization does, it immediately becomes cost-effective if it
vative management, acute colonic pseudo-obstruction resolves reduces complications and shortens length of stay by 1 day. Intra-
within 4 days in more than 80% of cases.96 Colonoscopy was pre- gastric administration of a water-soluble contrast agent to relieve
viously the method of choice for decompression in this setting.97 small bowel ileus or partial adhesive obstruction is an example of
It has been shown, however, that I.V. administration of neostig- an innovative, cost-effective therapeutic strategy. Diagnostic lapa-
mine, 2.5 mg over 2 to 3 minutes, leads to prompt resolution of roscopy, abdominal ultrasonography, CT scanning, and fast MRI
acute colonic pseudo-obstruction within minutes in nearly all have all been successfully used to make earlier definitive manage-
cases.98,99 Now that this previously difficult and potentially lethal ment decisions and to prevent gangrenous obstruction. Laparo-
problem can readily be treated pharmacologically, colonoscopic scopic adhesiolysis also leads to earlier hospital discharge. On the
decompression and surgical intervention should be reserved for basis of the collective experience reported in a substantial number
cases in which pharmacologic measures fail. of studies (see above), a logical proposal for cost-effective manage-
Chronic intestinal pseudo-obstruction is a rare acquired disor- ment of patients with bowel obstruction would be to perform ultra-
der that is caused by various diseases involving GI smooth mus- sonography or abdominal CT scanning immediately after initial
cle, the enteric nervous system, or the extrinsic autonomic nerve resuscitation, then to perform laparoscopic surgery on those pa-
supply to the gut.100 These disorders are treated with an NPO tients in whom the contrast agent does not arrive in the right colon
regimen, home TPN, and octreotide. Patients with chronic within 24 hours. However, prospective, randomized clinical trials
intestinal pseudo-obstruction should be followed closely for long are needed to evaluate the cost-effectiveness of this and other newer
periods and should undergo repeat contrast studies: a condition management strategies.
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Acknowledgment
83. Spears H, Petrelli N, Herrera L, et al: Treatment value of Gastrografin in the differential diagnosis
of small bowel obstruction after colorectal carci- of paralytic ileus and mechanical obstruction. Figures 12 and 13 Marcia Kammerer.
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 5 Upper Gastrointestinal Bleeding — 1
Patient is stable
Stop NSAIDs.
Give H2 receptor blockers, omeprazole,
sucralfate, or antacids.
Give anti–Helicobacter pylori therapy
(e.g., 14-day course of metronidazole,
500 mg p.o., t.i.d.; omeprazole, 20 mg
p.o., b.i.d.; and clarithromycin, 500 mg
p.o., b.i.d.) as needed.
If bleeding stops: observe.
If bleeding continues: consider I.V.
somatostatin (250 µg bolus, then
250 µg/hr) or intra-arterial vasopressin
(10 U/hr). If this step is effective, observe;
if not, perform total or near-total
gastrectomy [see 5:20 Gastroduodenal
Procedures].
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 5 Upper Gastrointestinal Bleeding — 3
Work up patient
Attempt endoscopic Perform distal pancreatectomy Attempt endoscopic control Manage underlying
control of bleeding. [see 5:24 Pancreatic of bleeding. causes if known
If bleeding stops: Procedures], including excision Consider I.V. somatostatin (e.g., medications,
observe. of pseudocyst and ligation of (250 µg bolus, then 250 µg/hr). infections, or
bleeding vessel. gastrinomas).
If bleeding continues: If bleeding stops: observe.
ligate or excise vessel. If bleeding stops:
If bleeding continues: resect observe.
lesion.
If bleeding continues:
excise bleeding
segment of jejunum.
Repair surgically (either Give PPI and, if applicable, anti–H. pylori therapy
via open laparotomy or (e.g., 14-day course of metronidazole, 500 mg p.o., t.i.d.;
via minimally invasive omeprazole, 20 mg p.o., b.i.d.; and clarithromycin,
approach) [see 4:4 Open 500 mg p.o., b.i.d.).
Esophageal Procedures If bleeding stops: continue medical therapy.
and 4:5 Minimally Invasive
Esophageal Procedures]. If bleeding continues: perform Nissen fundoplication
[see 4:4 Open Esophageal Procedures and
4:5 Minimally Invasive Esophageal Procedures].
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 5 Upper Gastrointestinal Bleeding — 4
PHYSICAL EXAMINATION intervention. Video capsule endoscopy should be used with cau-
The physical examination is seldom of much help in determin- tion in patients exhibiting obstructive symptoms: if the capsule
ing the exact site of bleeding, but it may reveal jaundice, ascites, becomes trapped, complete obstruction may result.
or other signs of hepatic disease; a tumor mass; or a bruit from an Intraoperative endoscopic exploration may also prove useful in
abdominal vascular lesion. this situation. Before the small bowel is manipulated, a pediatric
colonoscope is introduced either orally or through a distal jejunal
NASOGASTRIC ASPIRATION enterotomy; the latter method allows easier viewing of the entire
The next step is nasogastric aspiration. A bloody aspirate is an small bowel.The mucosal detail is examined as the surgeon guides
indication for esophagogastroduodenoscopy (EGD), as is a clear, the scope through the small bowel.The bowel must be handled gen-
nonbilious aspirate if a bleeding site distal to the pylorus has not tly to avoid a mucosal injury, which could mimic a significant lesion.
been excluded. If the aspirate is clear and bile-stained, the source These tests, in conjunction with EGD, should allow the surgeon
of the bleeding is unlikely to be the stomach, the duodenum, the to establish the cause of upper GI bleeding at least 90% of the time.
liver, the biliary tree, or the pancreas. Nonetheless, if subsequent
evaluation of the lower GI tract for the source of the bleeding is Management of Specific
unrewarding, an upper GI site that had stopped bleeding when Sources of Upper GI
the nasogastric tube was passed or that was distal to the ligament Bleeding
of Treitz should still be considered.
CHRONIC DUODENAL
ULCER
Investigative Tests
The development of
UPPER GI ENDOSCOPY (ESOPHAGOGASTRODUODENOSCOPY) effective medical regimens
for controlling uncomplicated duodenal ulcers has led to a dras-
EGD [see 5:18 Gastrointestinal Endoscopy] almost always reveals
tic reduction in the number of elective surgical procedures per-
the source of upper GI bleeding; its utility and accuracy have been
formed for this purpose. Nevertheless, the incidence of bleeding
well documented in the literature.This procedure requires consid-
from duodenal ulcers that is severe enough to necessitate emer-
erable skill: identification of bleeding sites in a blood-filled stomach
gency endoscopic or operative intervention has not decreased
is far from easy. Hematemesis is an indication for emergency EGD,
over the past decade.
usually within 1 hour of presentation. If the rate of bleeding is high,
Once EGD has demonstrated that a duodenal ulcer is the
saline lavage may be performed to clear the stomach of blood and
source of the bleeding, the first question that must be addressed is
clots. If the rate of bleeding is moderate or low, as is often the case whether active bleeding is present. If it is, an attempt should be
in patients with melena, urgent EGD is indicated. made to control the hemorrhage endoscopically [see Figure 1].
EGD is not only an excellent diagnostic tool but also a valuable Because ongoing blood loss eventually leads to coagulopathies, the
therapeutic modality. Indeed, most upper GI hemorrhages may be surgeon must exercise good judgment in deciding how long to
controlled endoscopically, though the degree of success to be pursue endoscopic treatment before concluding that such treat-
expected in individual cases varies according to the expertise of ment has failed and that surgical treatment is necessary. In gener-
the endoscopist and the specific cause of the bleeding. Thera- al, substantial bleeding (four to six units or more) that is not
peutic endoscopic maneuvers include injection, thermal coagula- easily controlled endoscopically is an indication for immediate
tion, and mechanical occlusion of bleeding sites (by means of clip surgical intervention. Likewise, ongoing hemorrhage in a hemo-
application or variceal banding). The choice of therapy depends dynamically unstable patient (especially an elderly one) calls for
on the cause, the site, and the rate of bleeding. immediate surgical therapy.
OTHER TESTS
If bleeding is controlled endoscopically, then a proton pump
inhibitor (PPI)—such as pantoprazole, 40 mg/day—should be
If endoscopic examination reveals no lesions in the stomach or given intravenously. In addition, antibiotic therapy directed against
the duodenum and bleeding has ceased, enteroclysis (direct intro- Helicobacter pylori (e.g., a 14-day course of metronidazole, 500 mg
duction of BaSO4 into the small bowel) and roentgenography of p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500
the duodenum and the jejunum should be done next.This is prob- mg p.o., b.i.d.) should be considered if the organism is present;
ably a more sensitive radiologic test than a standard small bowel such therapy has been shown to decrease rebleeding rates after
roentgenogram. Nonetheless, the absence of a lesion on this test antacid medication has been stopped. Food need not be withheld
does not rule out the small bowel as the source of the hemorrhage; unless the likelihood of rebleeding is high, in which case operation
not uncommonly, the x-ray is negative when a bleeding small or repeat endoscopy would be necessary. Resumption of oral feed-
bowel lesion is present. ing does not appear to affect rebleeding rates.
Tagged red cell scans may confirm the presence of an active If bleeding continues despite medical and endoscopic therapy,
bleeding site; however, scans are fairly nonspecific with respect to it should be managed surgically. In addition, certain patients
determining the anatomic location of the bleeding. Arteriography whose bleeding was controlled endoscopically—such as those
may demonstrate that a lesion is present, but it cannot reliably with a visible gastroduodenal artery and a clot in the base of the
identify a bleeding site unless the bleeding is brisk (> 1 ml/min). ulcer, those who experience rebleeding despite medical and endo-
Occasionally, arteriography reveals the cause of the bleeding even scopic therapy, and those with giant ulcers—should be strongly
if the bleeding has stopped. Recurrent bleeding or bleeding that is considered for surgical therapy.
suspected to be secondary to small bowel pathology may be eval- Surgical management may be accomplished either laparoscopi-
uated by means of video capsule endoscopy, which is capable of cally or via an open approach. The latter [see 5:20 Gastroduodenal
localizing a variety of lesions (including arteriovenous malforma- Procedures] begins with an upper midline incision.The duodenum is
tions, ulcers, strictures, and malignancies) so as to direct surgical mobilized and an anterior longitudinal duodenotomy performed
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 5 Upper Gastrointestinal Bleeding — 5
Patient has bleeding from chronic duodenal addition, if a gastric ulcer does not resolve after 6 weeks of med-
or gastric ulcer ical therapy, surgical excision is often indicated.
In stable patients, surgical management of a nonhealing chronic
Attempt to control hemorrhage endoscopically.
gastric ulcer generally consists of a hemigastrectomy that includes
If bleeding stops: manage patient medically. the ulcer site; if the ulcer is located more proximally, it may be
If bleeding continues: perform suture ligation of removed by means of wedge excision [see 5:20 Gastroduodenal
bleeding vessel.
Procedures]. Excision of the ulcer should be immediately followed
by frozen section to rule out cancer.There is no need for a vagoto-
my in these instances. In unstable patients, hemigastrectomy
should probably be avoided because of the increased morbidity and
Duodenal ulcer Gastric ulcer mortality that can follow it. Wedge excision should be combined
Administer aggressive acid- Perform wedge excision.
with aggressive acid-suppressive therapy (PPIs or H2 receptor
suppressive therapy (proton antagonists), followed by anti–H. pylori treatment. Truncal vagot-
Administer aggressive acid-
pump inhibitor or H2 receptor suppressive therapy (proton omy with pyloroplasty is rarely indicated; however, it may be con-
antagonist) and, if indicated, pump inhibitor or H2 receptor sidered in a patient with previous complications from ulcer disease.
anti–H. pylori therapy (e.g., a antagonist) and, if indicated,
14-day course of metronidazole, anti–H. pylori therapy (e.g., a ESOPHAGEAL VARICES
500 mg p.o., t.i.d.; omeprazole, 14-day course of metronidazole,
20 mg p.o., b.i.d.; and 500 mg p.o., t.i.d.; omeprazole,
The value of endoscopy
clarithromycin, 500 mg p.o., b.i.d) 20 mg p.o., b.i.d.; and in the diagnosis and man-
postoperatively. clarithromycin, 500 mg p.o., b.i.d) agement of variceal bleed-
postoperatively. ing cannot be overempha-
sized. Even in patients with
Figure 1 Shown is an algorithm for management of bleeding known varices, the site of
from chronic duodenal or gastric ulcers. bleeding is frequently non-
variceal; endoscopy is therefore essential. If bleeding varices are
identified, rubber banding or intravariceal sclerotherapy with a
over the site of the ulcer.The bleeding vessel, which is usually on the sclerosing agent (1.5% sodium tetradecyl sulfate, ethanolamine,
posterior wall of the first portion of the duodenum, is ligated with sodium morrhuate, or absolute alcohol) is performed [see Figure 2].
nonabsorbable sutures at sites proximal and distal to the bleeding If these measures do not control the hemorrhage, balloon tampon-
point. A third stitch is placed posterior to the bleeding vessel. Pains ade is indicated. Patients who are to undergo this procedure should
must be taken to avoid injury to the common bile duct during the have an endotracheal tube in place. The tube we prefer to use for
placement of these sutures.The duodenotomy is then closed. balloon tamponade is the four-port Minnesota tube, although the
The role of vagotomy in the management of bleeding duodenal Sengstaken-Blakemore tube is also acceptable. The Minnesota
ulcers has been called into question. Previously, proximal gastric tube has a gastric balloon, an esophageal balloon, and aspiration
vagotomy was recommended for stable patients. It was considered ports for the esophagus and the stomach. The gastric balloon is
preferable to truncal vagotomy because it is less likely to result in inflated first and placed on traction. If the bleeding is not con-
gastric atony, alkaline reflux gastritis, dumping, and diarrhea. In trolled, the esophageal balloon is then inflated.The pressure in the
unstable patients, truncal vagotomy was typically performed in balloons should be released in 24 to 48 hours to prevent necrosis
conjunction with pyloroplasty [see 5:20 Gastroduodenal Procedures]. of the esophageal or the gastric wall. Successful balloon tamponade
Frozen section to confirm the presence of nerve tissue is helpful is followed by endoscopic variceal injection or variceal banding.
for ensuring that the vagotomy is complete. I.V. somatostatin (250 µg bolus, followed by infusion of 250
The recommendation for truncal vagotomy was based on data µg/hr) should be administered in conjunction with the above-men-
from studies done before PPI and anti–H. pylori therapy came tioned steps. Vasopressin (10 U/hr) may also be given; however, it
into use. Subsequent studies that evaluated rebleeding rates with causes diffuse vasoconstriction, and nitroglycerin is required to alle-
current medical regimens, however, demonstrated much lower viate cardiac side effects. Somatostatin has proved superior to
rebleeding rates. Furthermore, it seems probable that long-term placebo in controlling variceal hemorrhage when used in conjunc-
PPI therapy (e.g., omeprazole, 20 mg p.o., q.d.)—the medical tion with endoscopic sclerotherapy. It is as effective as vasopressin
equivalent of vagotomy—in conjunction with eradication of H. while giving rise to fewer side effects. Octreotide, a synthetic ana-
pylori and avoidance of NSAIDs, should decrease rebleeding logue of somatostatin, shares many of the properties of somato-
rates significantly. Therefore, one may consider an alternative statin but perhaps not all. Both agents decrease secretion of gastric
treatment approach in patients who had not been receiving ulcer acid and pepsin; to date, however, the decreased gastric blood flow
therapy before the bleeding began—namely, ligation of the bleed- observed with somatostatin administration has not been reported
ing vessel, postoperative administration of PPIs, and anti–H. with octreotide administration. Nevertheless, some clinicians in the
pylori therapy. This approach avoids the complications associat- United States elect to use octreotide (25 to 50 µg/hr) in place of I.V.
ed with truncal vagotomy. somatostatin because the former tends to be more widely available
in the United States. Multiple prospective, randomized trials showed
CHRONIC GASTRIC ULCER
that propranolol (40 mg b.i.d., p.o.) decreased the incidence of
Initially, bleeding from a chronic gastric ulcer is managed in first-time variceal bleeding as well as the incidence of recurrent
much the same way as that from a chronic duodenal ulcer (i.e., variceal bleeding. Propranolol should not be used during active
endoscopically) [see Figure 1].To prevent aggravation of the bleed- bleeding but should be started once bleeding stops.
ing, early biopsy generally is not recommended; repeat endoscopy After the acute variceal bleeding has been controlled, any
and biopsy are done at a later date. Emergency surgical indications remaining varices should be subjected to injection sclerotherapy or
for gastric ulcers are the same as those for duodenal ulcers. In banding at 2-week intervals until they too are obliterated.
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 5 Upper Gastrointestinal Bleeding — 6
If any varices remain, repeat injection Pass 4-port Minnesota tube, and perform
sclerotherapy or banding at 2-wk intervals balloon tamponade.
until varices are gone. Give propranolol p.o.
Bleeding does not recur Bleeding recurs Bleeding continues Bleeding stops
Patient is
Patient is aa transplant
transplant candidate
candidate Patient is not a transplant candidate
Decompress portal
Decompress portal venous
venous system
system with
with transjugular
transjugular intra-
intra- Procedure of choice depends on patient status.
hepatic portosystemic
hepatic portacaval shunt (TIPS).
shunt Proceed
(TIPS). Proceed withwith
transplantation
transplantation
when suitable
when suitable organ
organ is
is obtained.
obtained.
Obtain arteriograms with views of portal vein and Perform central portacaval shunting procedure
left renal vein. (usually side to side or with short PTFE interposition
If venous anatomy is suitable: perform distal graft).
splenorenal shunting procedure. Alternatively, consider esophageal transection
If venous anatomy is not suitable: consider (for esophageal varices only) or suture ligation
esophageal transection (for esophageal varices of bleeding gastric varices.
only) or mesocaval or portacaval shunt.
Figure 2 Shown is an algorithm for management of bleeding from esophageal or gastric varices.
The main indications for surgical intervention in patients with dimensional reconstruction may be performed. If the venous
bleeding esophageal varices are uncontrolled hemorrhage and per- anatomy is suitable—that is, if the diameter of the splenic vein is
sistent rebleeding despite endoscopic and medical therapy. When greater than 0.75 cm (preferably greater than 1.0 cm) and the vein
surgical intervention is planned, it is essential to determine whether is within one vertebral body of the renal vein on venography—a
the patient is a transplant candidate. If so, operation should be distal splenorenal shunting procedure should be feasible. If the
avoided and bleeding managed by decompressing the portal venous anatomy is not suitable, then esophageal transection, a
venous system with a transjugular intrahepatic portosystemic shunt mesocaval venous graft, or a portacaval shunt is required.
(TIPS). TIPS yields excellent short-term results with respect to In the emergency setting, we prefer a central portacaval shunt,
stopping bleeding and providing time to locate a liver suitable for usually in a side-to-side orientation or with a short polytetrafluo-
transplantation; however, it has not been shown to have the capac- roethylene (PTFE) interposition graft. Esophageal transection is
ity to control hemorrhage by itself over the long term.Thus, its use also a reasonable choice. This procedure is associated with a lower
in patients who are not transplant candidates is questionable. incidence of encephalopathy than a portacaval shunting procedure;
If the patient is not a transplant candidate and is not actively however, it is associated with higher rates of rebleeding (particularly
bleeding, a distal splenorenal shunt is preferable. Arteriograms late rebleeding), and it can be difficult to perform when active bleed-
with views of the portal vein and the left renal vein are obtained. ing is present. Suture ligation of the bleeding varices with devascu-
Alternatively, computed tomographic angiography with three- larization (the Segura procedure) should also be considered.
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 5 Upper Gastrointestinal Bleeding — 7
In general, prognosis is related to the underlying liver disease. mal tumors run the gamut from benign to highly aggressive.They
For example, patients with varices that are secondary to chronic typically present as a submucosal mass that may cause bleeding as
extrahepatic portal venous or splenic venous occlusion generally a result of mucosal ulceration. The bleeding may be treated with
have a much better prognosis than those whose portal hypertension wedge excision of the tumor. Such excision can often be accom-
is secondary to hepatic parenchymal causes.The severity of the cir- plished laparoscopically [see 5:20 Gastroduodenal Procedures].
rhosis also determines short-term and long-term survival and may Bleeding from malignant neoplasms, whether early stage or late
influence the decision whether to perform a shunting procedure. stage, generally can be controlled initially by endoscopic means;
Varices in children are generally secondary to portal vein throm- however, rebleeding rates are high. If the lesion is resectable, it
bosis. A conservative, nonoperative approach is preferred. If oper- should be excised promptly once the patient is stable and any
ation is required, either a portacaval shunt, a distal splenorenal coagulopathies have been corrected. If disease is advanced, how-
shunt, or a devascularization procedure is performed. In children ever, surgical options are limited, and a nonoperative approach,
or adults with varices that are secondary to splenic vein thrombo- though necessarily imperfect, is preferable.
sis (sinistral portal hypertension), a splenectomy is usually cura-
ESOPHAGEAL HIATAL HERNIA
tive; the procedure may be performed laparoscopically [see 5:25
Splenectomy]. Not infrequently, the source of chronic enteric blood loss is an
esophageal hiatal hernia. Major bleeding is rare in this condition
GASTRIC VARICES
but may occur as a result of linear erosions at the level of the
Gastric varices are managed in much the same way as esoph- diaphragm (Cameron lesions), gastritis within the hernia, or tor-
ageal varices [see Figure 2], though they are less amenable to scle- sion of a paraesophageal hernia. Endoscopy is generally diagnos-
rotherapy. If sclerotherapy fails to control bleeding from gastric tic, though the sources of chronic blood loss are not always obvi-
varices, surgical intervention—in the form of distal splenorenal ous. Recognition that the bleeding derives from a Cameron lesion
shunting, portosystemic shunting, or suture ligation with gastric should incline the surgeon toward operative intervention [see 4:4
devascularization—is indicated. If the patient is a suitable candidate, Open Esophageal Procedures and 4:5 Minimally Invasive Esophageal
liver transplantation may be performed as an alternative to shunting. Procedures]: this lesion is usually mechanically induced and there-
fore tends to be less responsive to antacid therapy.
MALLORY-WEISS TEARS
Chronic bleeding from a sliding esophageal hiatal hernia should
Mallory-Weiss tears are be treated initially with a PPI; anti–H. pylori therapy should be
linear tears at the esopha- added if biopsy shows this organism to be present. Operation (i.e.,
gogastric junction that are laparoscopic Nissen fundoplication [see 4:5 Minimally Invasive
usually caused by vomiting. Esophageal Procedures]) should be considered for fit patients who
Any patient who presents have complications associated with their hiatal hernia. A parae-
with vomiting that initially sophageal hernia should be repaired surgically; we prefer the
is not bloody but later turns laparoscopic approach when feasible.
so should be suspected of having a Mallory-Weiss tear. As a rule,
DIEULAFOY LESION
these lesions stop bleeding without therapy. If bleeding is substan-
tial or persistent, however, endoscopic coagulation may be neces- A Dieulafoy lesion (also
sary. In rare instances, the tear will have to be oversewn at opera- referred to as exulceratio
tion. This is accomplished via an anterior gastrotomy and direct simplex) is the rupturing of
suture ligation of the tear. a 1 to 3 mm bleeding vessel
through the gastric mucosa
ACUTE HEMORRHAGIC GASTRITIS
(usually in the proximal
Bleeding from gastritis is virtually always managed medically stomach) without surround-
with H2 receptor blockers, PPIs, sucralfate, or antacids (either ing ulceration.This lesion tends to be found high on the lesser cur-
alone or in combination), along with antibiotics if H. pylori is pres- vature, but it can also occur in other locations. Histologic studies
ent. Somatostatin may be beneficial. Sometimes, administration of have not revealed any intrinsic abnormalities either of the mucosa
vasopressin via the left gastric artery is needed to control bleeding. or of the vessel.
In rare cases, total or near-total gastrectomy [see 5:20 Gastro- Initial treatment consists of either coagulation of the bleeding
duodenal Procedures] is required; however, the mortality associated vessel with a heater probe or mechanical control with clips or rub-
with this operation in this setting is high. Stress ulcer prophylaxis ber bands; local injection of epinephrine may help control acute
in severely ill or traumatized patients is essential to prevent this hemorrhage while this is being done. In skilled hands, endoscopic
problem.The gastric pH should be kept as close to neutral as pos- therapy has a 95% success rate, and long-term control is excellent.
sible. If the gastritis is relatively mild, a biopsy specimen should be If endoscopic therapy fails, surgical options, including ligation or
obtained and tested for H. pylori.Treatment consists of acid reduc- excision of the vessel involved, come into play. Arteriographic
tion and anti–H. pylori therapy. embolization may be employed in patients who are too ill to toler-
ate surgical intervention.
NEOPLASMS
HEMOBILIA
Benign tumors of the up-
per GI tract (e.g., leiomyo- Hemobilia should be suspected in all patients who present with
mas, hamartomas, and he- the classic triad of epigastric and right upper quadrant pain, GI
mangiomas) bleed at times. bleeding, and jaundice; however, only about 40% of patients with
Wedge excision of the offend- hemobilia present with the entire triad. Endoscopy demonstrating
ing lesion is the procedure of blood coming from the ampulla of Vater points to a source in the
choice. Gastrointestinal stro- biliary tree or the pancreas (hemosuccus pancreaticus).
© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 5 Upper Gastrointestinal Bleeding — 8
Arteriography may provide the definitive diagnosis: a bleeding is an uncommon finding. CT scanning is the procedure of choice
tumor, a ruptured artery from trauma, or another cause. Arterio- for diagnosis.The finding of air around the aorta or the aortic graft
graphic embolization of the affected portion of the liver is the pre- is diagnostic and is an indication for emergency exploration. The
ferred treatment option; hepatic artery ligation (selective if possi- preferred surgical treatment is resection of the graft with extra-
ble) or hepatic resection [see 5:23 Hepatic Resection] may be abdominal bypass. Some authorities, however, advocate resection
required. of the graft with in situ graft replacement.
HEMOSUCCUS PANCREATICUS VASCULAR ECTASES
Bleeding into the pancreatic duct, generally from erosion of a Vascular ectases (also referred to as vascular dysplasia, angiodys-
pancreatic pseudocyst into the splenic artery, is signaled by plasia, angiomata, telangiectasia, and arteriovenous malformations)
upper abdominal pain followed by hematochezia. If endoscopy is may bleed briskly. As a rule, gastric lesions are readily identified and
performed when hematochezia is present, the bleeding site may the bleeding controlled by endoscopic means. Lesions that contin-
not be seen; however, if endoscopy is performed when pain is first ue to bleed, either acutely or chronically, despite endoscopic mea-
noted, blood may be seen coming from the ampulla of Vater.The sures should be excised. Some patients have multiple and extensive
combination of significant GI bleeding, abdominal pain, a histo- lesions that necessitate resection of large portions of the stomach or
ry of alcohol abuse or pancreatitis, and hyperamylasemia should the small intestine. Pharmacotherapy and hormone therapy have
suggest the diagnosis. Angiography can be diagnostic and, at been tried; the results have been mixed.
times, therapeutic. Distal pancreatectomy [see 5:24 Pancreatic
DUODENAL AND JEJUNAL DIVERTICULA
Procedures], including excision of the pseudocyst and ligation of
the splenic artery, is the preferred treatment and generally leads Duodenal and jejunal diverticula are rare causes of upper GI
to cure. bleeding. Accurate identification of a bleeding site within a given
diverticulum is difficult, but an attempt should be made to accom-
AORTOENTERIC FISTULA
plish this by means of peroral enteroscopy or video capsule
Aortoenteric fistulas may endoscopy. Excision is the preferred treatment and is accom-
occur spontaneously as a plished by means of segmental resection. Great care must be taken
result of rupture of an aor- in the treatment of duodenal diverticula in the region of the
tic aneurysm or perforation ampulla of Vater to ensure that the pancreatic duct and the bile
of a duodenal lesion; more ducts are not injured during excision.
often, they arise after aortic
JEJUNAL ULCER
surgery. A common initial
manifestation of an aortoenteric fistula is a small herald bleed that Ulcerations of the jejunum are also rare. They may be sec-
is followed a few days later by a massive hemorrhage. Patients ondary to medications (e.g., NSAIDs), infection, a gastrinoma, or
often present with the triad of GI hemorrhage, a pulsatile mass, idiopathic causes. Offending medications should be stopped,
and infection; however, not all of these symptoms are invariably infections should be treated, and gastrinomas should be excised. If
present. A high index of suspicion facilitates diagnosis. Endoscopy these measures do not control the hemorrhage, the bleeding seg-
may show an aortic graft eroding into the enteric lumen, but this ment of the jejunum should be excised.
Recommended Reading
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CONTROLLED TRIALS varices in men with alcoholic liver disease: a random- first upper gastrointestinal tract hemorrhage in
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randomised trial. Lancet 350:1495, 1997 variceal hemorrhage. Gastroenterology 99:1401, 1990 with a comparison of heat probe and ethanol injection.
Cello JP, Grendell JH, Crass RA, et al: Endoscopic Hartigan PM, Gebhard RL, Gregory PB: Sclero- Am J Gastroenterol 88:1842, 1993
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gency surgical treatment for nonvariceal bleeding of the
upper part of the gastrointestinal tract. Surg Gynecol Fox JG, Hunt PS: Management of acute bleeding gas- Wilairatana S, Sriussadaporn S, Tanphaiphat C: A
tric malignancy. Aust NZ J Surg 63:462, 1993 review of 1338 patients with acute upper gastrointesti-
Obstet 172:113, 1991
nal bleeding at Chulalongkorn University Hospital,
Cebollero-Santamaria F, Smith J, Gioe S, et al: Selec- Gaisford WD: Endoscopic electrohemostasis of active Bangkok. Gastroenterologia Japonica 26:58, 1991
tive outpatient management of upper gastrointestinal upper gastrointestinal bleeding. Am J Surg 137:47,
bleeding in the elderly. Am J Gastroenteral 94:1242, 1979
1999 Henriksson AE, Svensson J-O: Upper gastrointestinal Reviews
Costamagna G, Shah SK, Riccioni ME, et al: A bleeding (with special reference to blood transfusion). Cuschieri A: Laparoscopic gastric resection. Surg Clin
prospective trial comparing small bowel radiographs Eur J Surg 157:193, 1991 North Am 80:1269, 2000
and video capsule endoscopy for suspected small Himal HS, Perrault C, Mzabi R: Upper gastrointesti- De Franchis R: Emerging strategies in the manage-
bowel disease. Gastroenterology 4:123, 2002 nal hemorrhage: aggressive management decreases ment of upper gastrointestinal bleeding. Digestion
Gostout CJ, Wang KK, Ahlquist DA, et al: Acute gas- mortality. Surgery 84:448, 1978 60(suppl 3):17, 1999
trointestinal bleeding: experience of a specialized man- Jacobson AR, Cerqueira MD: Prognostic significance Groszmann RJ, Grace ND: Complications of portal
agement team. J Clin Gastroenterol 14:260, 1992 of late imaging results in technetium-99m-labeled red hypertension: esophagogastric varices and ascites.
blood cell gastrointestinal bleeding studies with early Gastroenterol Clin North Am 21:103, 1992
Hunt PS, Fracs MS, Korman MG, et al: An 8-year
negative images. J Nucl Med 33:202, 1992 Jenkins SA: Drug therapy for non-variceal upper gas-
prospective experience with balloon tamponade in
Jim G, Rikkers LF: Cause and management of upper trointestinal bleeding. Digestion 60(suppl 3):39, 1999
emergency control of bleeding esophageal varices. Dig
Dis Sci 27:413, 1982 gastrointestinal bleeding after distal splenorenal shunt. Kankaria AG, Fleischer DE: The critical care manage-
Surgery 112:719, 1992 ment of nonvariceal upper gastrointestinal bleeding.
Loftus EV, Alexander GL, Ahlquist DA, et al:
Kaye GL, McCormick A, Siringo S, et al: Bleeding Crit Care Clin 11:347, 1995
Endoscopic treatment of major bleeding from
from staple line erosion after esophageal transection: Katz PO, Salas L: Less frequent causes of upper gas-
advanced gastroduodenal malignant lesions. Mayo
effect of omeprazole. Hepatology 15:1031, 1992 trointestinal bleeding. Gastroenterol Clin North Am
Clin Proc 69:736, 1994
Kollef MH, O’Brien JD, Zuckerman GR, et al: Bleed: 22:875, 1993
Rockey DC, Cello JP: Evaluation of the gastrointesti- a classification tool to predict outcomes in patients Montgomery RS, Wilson SE: Surgical management of
nal tract in patients with iron-deficiency anemia. N with acute upper and lower gastrointestinal hemor- gastrointestinal fistulas. Surg Clin North Am 76:1148,
Engl J Med 329:1691, 1993 rhage. Crit Care Med 25:1125, 1997 1996
Terblanche J, Northoever JMA, Bornman P, et al: A Liebler JM, Benner K, Putnam T, et al: Respiratory Savides TJ, Jensen DM: Therapeutic endoscopy for
prospective evaluation of injection sclerotherapy in the complications in critically ill medical patients with nonvariceal upper gastrointestinal bleeding. Gastroen-
treatment of acute bleeding from esophageal varices. acute upper gastrointestinal bleeding. Crit Care Med terol Clin North Am 29:465, 2000
Surgery 85:239, 1979 19:1152, 1991 Stabile BE: Hemorrhagic complications of pancreatitis
Wilcox CM, Alexander LN, Straub RF, et al: A Lipper B, Simon D, Cerrone F: Pulmonary aspiration and pancreatic pseudocysts. The Pancreas: A Clinical
prospective endoscopic evaluation of the causes of during emergency endoscopy in patients with upper Textbook. Beger HG, Warshaw AL, Buchler MW, et al,
upper GI hemorrhage in alcoholics: a focus on alco- gastrointestinal hemorrhage. Crit Care Med 19:330, Eds. Blackwell Scientific Publications, Oxford, 1997
holic gastropathy. Am J Gastroenteral 91:1343, 1996 1991 Weiner FR, Simon DM: Gastric vascular ectases.
Zuckerman G, Benitez J: A prospective study of bidi- Miller AR, Farnell MB, Kelly KA, et al: The impact of Gastrointest Endosc Clin North Am 6:681, 1996
rectional endoscopy (colonoscopy and upper therapeutic endoscopy on the treatment of bleeding Zoller WG, Gross M: Beta-blockers for prophylaxis of
endoscopy) in the evaluation of patients with occult duodenal ulcers, 1980–90. World J Surg 19:89, 1995 bleeding from esophageal varices in cirrhotic portal
gastrointestinal bleeding. Am J Gastroenterol 87:62, Norton ID, Petersen BT, Sorbi D, et al: Management hypertension: review of the literature. Eur J Med Res
1992 and long-term prognosis of Dieulafoy lesion. 1:407, 1995/96
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 1
6 LOWER GASTROINTESTINAL
BLEEDING
Michael J. Rosen, M.D., and Jeffrey L. Ponsky, M.D., F.A.C.S.
Resuscitate as necessary.
Simultaneously, take history (nature and duration of bleeding,
associated symptoms, past medical history, complicating
comorbid conditions, medications) and perform physical
exam (postural vital signs, complete abdominal exam). Order
laboratory tests (CBC, serum electrolytes, coagulation profile,
and typing and crossmatching).
Place NG tube for gastric lavage.
Endoscopic Endoscopic
therapy succeeds therapy fails
Perform colonoscopy.
degree of hemodynamic stability. Severe hemodynamic instability ed. Depending on the indication and on the technique employed,
may necessitate monitoring in the intensive care unit. the diagnostic yield from push enteroscopy has ranged from 13%
to 78%.19 Typically, yields are highest (40% to 60%) in patients
with significant GI hemorrhage.
Investigative Studies
RADIOLABELED RED BLOOD CELL SCANNING
A number of diagnostic
techniques are available for de- Radionuclide scanning is highly sensitive for lower GI hemorrhage:
termining the source of lower it is capable of detecting bleeding at rates as slow as 0.1 to 0.4
GI hemorrhage, the most use- ml/min.20 Two imaging tracers, both labeled with technetium-99m
ful of which are colonoscopy (99mTc), are currently available for radionuclide scanning in this
[see 5:18 Gastrointestinal Endos- setting: 99mTc-labeled sulfur colloid (99mTc-SC) and 99mTc-labeled
copy], radionuclide scanning, red blood cells (RBCs). 99mTc-SC requires no preparation time
computed tomography, and and can be injected immediately into the patient; however, its rapid
angiography (in the form of absorption into the liver and the spleen can often hinder accurate
selective mesenteric arteriography). The goal of these tests is to localization of overlying bleeding sites.9 At our institution, we pre-
locate the site of bleeding accurately so that definitive therapy can fer to use 99mTc-labeled RBCs. This agent requires some prepara-
be properly directed. Which diagnostic test is chosen for a specific tion time, but it has a much longer half-life than 99mTc-SC does, it
patient depends on several factors, including the hemodynamic sta- is not taken up by the liver and spleen, and it can be detected on
bility of the patient, the bleeding rate, the comorbid conditions pres- images as long as 24 to 48 hours after injection [see Figure 1].21,22
ent, and the local expertise available at the physician’s hospital. One study directly compared these two techniques and found
99mTc-labeled RBC scanning to have an accuracy of 93%, com-
COLONOSCOPY
pared with an accuracy of only 12% for 99mTc-SC scanning.23
Several large series that evaluated the diagnostic utility of colo- The high sensitivity of 99mTc-labeled RBC scanning—80% to
noscopy in patients with lower GI bleeding found this modality to 98%—is well attested, but there is considerable disagreement in
be moderately to highly accurate, with overall diagnostic yields rang- the literature with regard to its specificity in identifying the
ing from 53% to 97% [see Table 1].3,13-17 Those studies that report- anatomic site of bleeding.24-27 For example, on one hand, a 1996
ed morbidity found colonoscopy to be safe as well, with an aver- study found radiolabeled RBC scanning to be 97% accurate for
age complication rate of 0.5%. Colonoscopy has both a higher localizing bleeding in 37 patients undergoing surgical resection27;
diagnostic yield and a lower complication rate than arteriography on the other hand, a 1990 study reported a 42% rate of incorrect
in this setting and thus would appear to be a more attractive initial resection when surgical therapy was based solely on this modali-
test in most circumstances.3,18 An argument has been made—one ty.26 In 2005, one group retrospectively reviewed 127 bleeding
with which we agree—that colonoscopy should be considered the scans in an effort to identify factors that might predict a positive
procedure of choice for structural evaluation of lower GI bleeding scan.28 The investigators found that tagged RBC scans were 48%
and that arteriography should be reserved for patients with mas- accurate in localizing bleeding sites later confirmed by
sive, ongoing bleeding in whom endoscopy is not feasible or endoscopy, surgery, or pathologic evaluation. Multivariate analy-
colonoscopy fails to reveal the source of the hemorrhage.12 sis demonstrated that both the number of units of blood trans-
The merits of colonic purging have been extensively debated in fused in the 24 hours preceding the scan and the lowest record-
the literature.3,11,14 Although no firm conclusion has been reached, ed hematocrit differed significantly between patients with positive
we feel that adequate colonic purging can improve both the diag- scans and those with negative scans. However, the clinical signif-
nostic yield and the safety of colonoscopy. Given the absence of icance of a positive scan was unclear in this study, in that the rate
any definitive data suggesting that colonic purging either reacti- of endoscopy was not significantly different between patients who
vates or increases bleeding,12 it is our practice to administer an oral had positive scans and those who did not.
purge after the patient has been adequately resuscitated. To date, no prospective, randomized trials have compared
If the entire colon has been adequately visualized and no source radionuclide scanning with colonoscopy as the initial diagnostic
for the bleeding has been identified, the ileum should be intu- procedure for patients with lower GI hemorrhage. In our view,
bated; fresh blood in this region suggests a possible small bowel
source. If no active bleeding is observed in the ileum, upper GI
endoscopy should be performed to rule out an upper GI bleed- Table 1 Diagnostic Accuracy of Colonoscopy in
ing site. Localizing Source of Lower GI Hemorrhage
When colonoscopy and routine upper GI endoscopy fail to
locate a bleeding source, push enteroscopy may be helpful. This
Study No. of Patients Diagnostic Yield (%)
procedure can be carried out in several ways. It can be performed
purely endoscopically with a pediatric colonoscope.This approach Richter13 78 70 (90%)
generally requires a high level of skill on the part of the endos-
copist, in that the lack of retroperitoneal attachments of the small Jensen3 80 68 (85%)
intestine makes endoscopic navigation extremely challenging. In Rossini14 409 311 (76%)
most cases, only the proximal 150 cm of the small intestine can be
evaluated in this way. Alternatively, push enteroscopy can be per- Goenka15 166 141 (85%)
formed in the operating room at the time of exploratory laparoto- Ohyama16 345 307 (89%)
my. The surgeon can manually “milk” the small bowel over the
scope to evaluate its distal portion. In addition, an enterotomy can Chaudhry17 85 82 (97%)
be made, and the scope can be passed in both a retrograde and an Total 1,163 979 (84%)
antegrade fashion so that the entire small intestine can be evaluat-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 5
Selective Mesenteric
however, given that radionuclide scanning (unlike colonoscopy Arteriography
and angiography) has no therapeutic intervention capabilities, its
Selective mesenteric arteri-
best use is in patients with non–life-threatening lower GI bleeding
ography is somewhat less sen-
as a prelude and a guide to mesenteric angiography after active
sitive than radionuclide scan-
hemorrhage has been confirmed.
ning for lower GI hemorrhage:
COMPUTED TOMOGRAPHY bleeding must be occurring
at a rate of at least 1.0 to 1.5
With the ongoing improvements in high-speed abdominal
ml/min to be detectable with
CT scanning, there has been growing interest in the evaluation
this test.31 The procedure in-
of GI bleeding with CT.29 Helical CT scanners can provide
volves percutaneous placement of a transfemoral arterial catheter
direct or indirect evidence of the source of GI bleeding. Typical
for evaluation of the superior mesenteric, inferior mesenteric, and
findings that can facilitate localization of bleeding sites include
celiac arteries. A positive test result is defined as extravasation of
spontaneous hyperdensity of the peribowel fat, contrast enhance-
contrast into the lumen of the bowel [see Figure 2]. Once the bleed-
ment of the bowel wall, vascular extravasation of the contrast
ing vessel has been localized angiographically, the area must be
medium, thickening of the bowel wall, polyps, tumors, and vas-
marked so that it can be successfully identified intraoperatively;
cular dilatation.
this is commonly accomplished by infusing methylene blue into
the bleeding artery [see Figure 3].32,33
In several large series [see Table 2], the overall diagnostic yield of
arteriography ranged from 27% to 67%.27,34-38 The complication
rate for arteriography performed for lower GI bleeding ranges
from 2% to 4%.2,38 Reported complications include contrast aller-
gy, renal failure, bleeding from arterial puncture, and embolism
from a dislodged thrombus.12
Unlike radionuclide scanning, arteriography provides several
therapeutic options, including vasopressin infusion and emboliza-
tion of bleeding vessels. Nonetheless, given that arteriography has
a lower diagnostic yield and a higher complication rate than
colonoscopy does, it is reasonable to attempt colonoscopy first in
patients with lower GI hemorrhage and to reserve angiography for
patients in whom the volume of bleeding is such that colonoscopy
would be neither safe nor accurate.
Provocative Angiography for Continued Obscure Bleeding
In a minority of patients, obscure bleeding persists despite neg-
ative findings from endoscopy, mesenteric arteriography, and radio-
labeled RBC scanning.This obscure bleeding presents a consider-
Figure 2 Angiographic study documents extravasation of contrast able diagnostic challenge, which some investigators have proposed
into small bowel. addressing by means of so-called provocative angiography.39,40
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 6
the main trunk of the vessel. Infusion of vasopressin is initiated at zation therapy should be the first choice for angiographic treat-
a rate of 0.2 U/min and can be increased to a rate of 0.4 U/min. ment of lower GI bleeding.65,66
Within 20 to 30 minutes, another angiogram is performed to
SURGICAL THERAPY
determine whether the bleeding has ceased. If the bleeding is
under control, the catheter is left in place and vasopressin is con- Although there are no ab-
tinuously infused for 6 to 12 hours. If the bleeding continues to be solute criteria for surgical
controlled, infusion is continued for an additional 6 to 12 hours at treatment of lower GI bleed-
50% of the previous rate. Finally, vasopressin infusion is replaced ing, there are several factors—
by continuous saline infusion, and if bleeding does not recur, the including hemodynamic sta-
catheter is removed.54,55 tus, associated comorbidities,
The vasoconstrictive action of vasopressin can have deleterious transfusion requirements, and
systemic side effects, including myocardial ischemia, peripheral persistent bleeding—that are
ischemia, hypertension, dysrhythmias, mesenteric thrombosis, instrumental in making an
intestinal infarction, and death.9,36 Occasionally, simultaneous I.V. appropriate and timely deci-
administration of nitroglycerin is necessary to counteract these sion whether to operate. In general, patients who require more than
systemic effects. The reported success rate of vasopressin in con- 4 units of blood in a 24-hour period to remain hemodynamically
trolling lower GI bleeding ranges from 60% to 100%, and the inci- stable, whose bleeding has not stopped after 72 hours, or who expe-
dence of major complications ranges from 10% to 20%.56-58 rience rebleeding within 1 week after an initial episode should
Rebleeding rates as high as 50% have been reported.57,58 undergo surgery.9
An alternative for patients with coronary vascular disease, If the patient’s hemodynamic status permits, surgical treatment
severe peripheral vascular disease, or other comorbidities that should be undertaken after accurate localization of the bleeding
prevent safe administration of vasopressin is transcatheter embo- site.When possible, directed segmental resection is the procedure
lization. In this technique, a catheter is superselectively placed of choice: it is associated with rebleeding rates ranging from 0% to
into the identified bleeding vessel and an embolizing agent (e.g., 14% and mortality rates ranging from 0% to 13%.10,36,67 Blind
a gelatin sponge, a microcoil, polyvinyl alcohol particles, or a bal- segmental colectomy should never be performed: it is associated
loon) is injected. Several small series found this technique to be with rebleeding rates as high as 75% and mortality rates as high as
90% to 100% successful at stopping bleeding.59-63 Equally im- 50%.68 If hemodynamic compromise and ongoing hemorrhage
pressive was the finding that the rebleeding rates in these series make it necessary to perform surgical exploration before the bleed-
were 0%. The complication rates of this procedure are generally ing site can be localized, every effort should be made to identify
reasonable as well; however, intestinal infarction has been the source of bleeding intraoperatively before embarking on resec-
reported.36,64 tion. Intraoperative options for bleeding-site localization include
The use of small microcatheters and the ability to superselec- colonoscopy (to allow for this option, patients should always be
tively embolize individual vessels have reduced the potential for placed in the lithotomy position), EGD, and transoral passage of
ischemic perforation. It is possible that as more experience is a pediatric colonoscope for enteroscopy with simultaneous
gained with these techniques, superselective embolization may intraperitoneal assistance for small bowel manipulation.9 If the
replace catheter-directed vasoconstrictive therapy, thus obviating bleeding site still cannot be accurately localized, subtotal colecto-
the potential deleterious systemic effects of vasopressin adminis- my is the procedure of choice. This procedure is associated with
tration. Some researchers have suggested that with the exception mortality rates ranging from 5% to 33%,69,70 which underscores
of cases of diffuse bleeding lesions or cases whose demands exceed the importance of accurate preoperative localization of bleeding
the technical limitations of superselective catheterization, emboli- before surgical intervention.
Discussion
Etiology of Lower GI Bleeding cularis to supply the mucosa9; as the diverticulum expands, these
As noted, lower GI bleeding has a wide array of possible causes vessels are displaced. A 1976 anatomic study of colonic specimens
[see Table 3].9,71 Of these, diverticular disease is the most common, from patients with diverticular bleeding used angiography to
accounting for 30% to 40% of all cases.72 Arteriovenous malfor- demonstrate that in all cases, the vasa recta overlying the divertic-
mations (AVMs), though extensively described in the literature, ulum ruptured into the lumen of the diverticulum, not into the
are considerably less common causes, accounting for 1% to 4% of peritoneum [see Figure 4].76
cases.73,74 Other significant causative conditions are IBD, benign It has been estimated that approximately 17% of patients with
and malignant neoplasms, ischemia, infectious colitis, anorectal colonic diverticulosis experience bleeding, which may range from
disease, coagulopathy, use of NSAIDs, radiation proctitis, AIDS, minor to severe and life-threatening.77 As many as 80% to 85% of
and small bowel disorders. diverticular hemorrhages stop spontaneously.78 In one series,
surgery was unlikely to be necessary if fewer than 4 units of packed
DIVERTICULAR DISEASE RBCs were transfused in a 24-hour period, whereas 60% of
The reported prevalence of colonic diverticulosis in Western patients receiving more than 4 units of packed RBCs in a 24-hour
societies is 37% to 45%.75 The vast majority of colonic diverticula period required surgical intervention.5 The risk of a second bleed-
are actually false diverticula (pseudodiverticula) that contain only ing episode is approximately 25%.3 Semielective surgical therapy
serosa and mucosa [see 5:12 Diverticulitis]. They occur at weak is usually offered after a second diverticular bleeding episode
points in the colonic wall where the vasa recta penetrate the mus- because once a second such episode has occurred, the risk that a
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 8
Table 3 Common Causes of Lower GI cytomegalovirus) can result in severe lower GI bleeding, but this
Hemorrhage is a relatively rare occurrence.
Increasing use of radiation therapy to treat pelvic malignancies
Cause of Bleeding Frequency
has led to a corresponding increase in the incidence of chronic
radiation proctitis.87 Radiation therapy damages bowel mucosa,
Diverticulosis 17%–40% resulting in the formation of vascular telangiectases that are prone
to bleeding.88 From 1% to 5% of cases of acute lower GI bleeding
Arteriovenous malformation 2%–30%
from radiation-induced proctocolitis are severe enough to necessi-
Colitis 9%–21% tate hospitalization.4,14 In a survey of patients with prostate cancer
who underwent pelvic irradiation, 5% of the patients reported
Neoplasia (including postpolypectomy bleeding) 7%–33%
hematochezia daily.89 Initial therapy for clinically significant hema-
Benign anorectal disease 4%–10% tochezia related to radiation proctitis should include some form of
endoscopic treatment (e.g., argon-beam coagulation). Surgery
Upper GI source 0%–11%
should be reserved for unstoppable hemorrhage or other major
Small bowel source 2%–9% complications, such as fistulas and strictures.87
NEOPLASIA
third will follow exceeds 50%.79 In a series of 83 conservatively
Significant GI bleeding from colorectal neoplasia [see 5:15
managed cases of diverticular disease, the predicted yearly recur-
Adenocarcinoma of the Colon and Rectum] accounts for 7% to 33%
rence rates were 9% at 1 year, 10% at 2 years, 19% at 3 years, and
of cases of severe lower GI hemorrhage.3,11,14,36,90 Such bleeding is
25% at 4 years.4
believed to result from erosions on the luminal surface.91 One
COLITIS report identified ulcerated cancers as the cause in 21% of cases of
hematochezia.14 Adenomatous polyps are implicated in 5% to
The broad term colitis includes IBD, infectious colitis, radiation
11% of cases of acute lower GI bleeding.7,8,14,92,93 Lower GI hem-
colitis, and idiopathic ulcers. IBD, in turn, includes Crohn disease
orrhage, either immediate or delayed, is the most common report-
[see 5:11 Crohn Disease] and ulcerative colitis [see 5:13 Fulminant
ed complication after endoscopic polypectomy, occurring in 0.2%
Ulcerative Colitis]. Patients with IBD usually present with bloody
diarrhea that is not life-threatening; however, 6% to 10% of to 6% of cases.3,4,94,95 Immediate postpolypectomy bleeding is
patients with ulcerative colitis have lower GI bleeding severe believed to result from incomplete coagulation of the stalk before
enough to necessitate emergency surgical resection,80,81 and 0.6% transection.52 Delayed bleeding has been reported as long as 15
to 1.3% of patients with Crohn disease have acute life-threatening days after polypectomy and is thought to be secondary to slough-
lower GI bleeding.80,82 In one review, 50% of patients with intesti- ing of the coagulum; it is less common than immediate bleeding,
nal hemorrhage from IBD experienced spontaneous cessation of occurring in only 0.3% of cases.14,52
bleeding.80 Approximately 35% of patients whose bleeding stops COAGULOPATHY
without intervention will have another bleeding episode. Because
of this high recurrence rate, semielective surgery is recommended Lower GI bleeding can be a presenting symptom both for pa-
after the first episode of severe GI bleeding secondary to IBD. tients with iatrogenic coagulopathy from heparin or warfarin ther-
Colitis caused by various infectious agents (e.g., Salmonella apy and for patients with a hematologic coagulopathy from throm-
typhi,83,84 Escherichia coli O157:H7,85 Clostridium difficile,86 and bocytopenia [see 1:4 Bleeding and Transfusion]. It is unclear, howev-
er, whether severe coagulopathy leads to spontaneous hemorrhage
or whether it predisposes to bleeding from an existing lesion.96,97 In
an early series of leukemic patients with thrombocytopenia and severe
GI hemorrhage, 50% of bleeding patients had platelet counts lower
than 20,000/mm3 without any identifiable mucosal lesions; fur-
thermore, when the platelet count rose above 20,000/mm3, the
incidence of bleeding decreased to 0.8%.96 The investigator con-
cluded that severe thrombocytopenia led to spontaneous GI hem-
orrhage. Other investigators subsequently challenged this conclu-
sion, arguing that spontaneous bleeding from coagulopathy is in
fact rare.98 In one report, the distribution of pathologic lesions in
patients with GI bleeding who were taking heparin or warfarin was
essentially equivalent to that in the general population.98 Regardless
of what the precise relation between coagulopathy and GI hemor-
rhage may be, a thorough investigation for an anatomic lesion is
imperative in the workup of patients with lower GI bleeding even
in the face of coagulopathy or thrombocytopenia.
BENIGN ANORECTAL DISEASE
Accurate localization of a bleeding site in the small intestine can be patients hospitalized for lower GI bleeding, benign anorectal dis-
highly challenging: the length and the free intraperitoneal position ease was the cause.123 Other significant causes of lower GI hem-
of the small bowel make endoscopic examination difficult, and the orrhage in this population are colonic histoplasmosis, Kaposi sar-
nature of the overlying loops makes angiographic localization coma of the colon, and bacterial colitis.123,124
imprecise. For these reasons, the small intestine is usually left for
NSAID USE
last in the attempt to localize the source of lower GI bleeding and
is examined only after sources in the colon, the upper GI tract, and The association between NSAID use and upper GI hemor-
the anorectum have been ruled out.9 rhage is well known.125 Current data suggest that NSAIDs have a
toxic effect on colonic mucosa as well.126 An epidemiologic study
AIDS
estimated the incidence of NSAID-associated large bowel bleed-
The etiology of lower GI bleeding in patients with AIDS differs ing to be 7/100,000.127 A retrospective review found that patients
from that in the general population.91 In AIDS patients, lower GI who had experienced lower GI bleeding were twice as likely to
bleeding is caused predominantly by conditions related to the have taken NSAIDs as those who had not.128 NSAIDs have also
underlying HIV infection. Cytomegalovirus colitis is the most been linked to diverticular hemorrhage: in one study, 92% of
common cause of such bleeding in this population, occurring in patients with diverticular bleeding were taking NSAIDs.107 The
39% of cases.122 AIDS patients with hemorrhoids or anal fissures exact mechanism of NSAID-induced colonic injury is unknown;
often experience significant bleeding as a result of HIV-induced nevertheless, heightened clinical awareness of this potential cause
thrombocytopenia.122 A 1998 study reported that in 23% of AIDS of lower GI bleeding is warranted.91
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angiography in obscure gastrointestinal bleeding. ment pathway. Curr Surg 60:344, 2003 85. Cohen MB, Giannella RA: Hemorrhagic colitis
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59. Matolo NM, Link DP: Selective embolization for 81. Binder SC, Miller HH, Deterling RA Jr: Emer- tients with rectal bleeding and anaemia. Int J
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62. Peck DJ, McLoughlin RF, Hughson MN, et al: an unexpected behavior of Salmonella typhi. Dis endoscopy) in the evaluation of patients with occult
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come for patients? Am J Gastroenterol 90:1779, athlete. Am J Gastroenterol 88:1157, 1993 orrhage in patients with AIDS. AIDS Patient
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5 GASTROINTESTINAL TRACT AND ABDOMEN 7 MORBID OBESITY — 1
7 MORBID OBESITY
Harvey J. Sugerman, M.D.
Many surgeons are afraid to operate on wedge pressure (PAWP) values will frequently be noted in patients
the morbidly obese patient (i.e., a patient with the respiratory insufficiency of obesity, especially those with
whose weight is 100 lb greater than ideal obesity hypoventilation syndrome (OHS) [see Respiratory Insuffi-
body weight or who has a body mass in- ciency, Obesity Hypoventilation Syndrome, below].1 Intubation and
dex [BMI] greater than 35 kg/mg2) be- ventilation in these patients will often be followed by a vigorous di-
cause they presuppose a marked increase uresis, and it is not unusual for a patient to lose 50 lb or more of re-
in perioperative morbidity and mortality. tained fluid. In a few obese patients, acute respiratory insufficiency
Although the morbidly obese patient is will be caused by a greatly expanded central blood volume and
certainly at greater risk, this risk can be heart failure. Abnormal blood gas values in these individuals will be
markedly reduced by paying careful at- corrected by vigorous diuresis alone. As with most other abnormal-
tention to detail in preoperative and post- ities related to morbid obesity, weight loss will also correct cardiac
operative care. The increased risks encountered in these patients dysfunction.
include wound infection, dehiscence, thrombophlebitis, pulmo-
nary embolism, anesthetic calamities, acute postoperative asphyxia
in patients with obstructive sleep apnea syndrome (SAS), acute Respiratory Insufficiency
respiratory failure, right ventricular or biventricular cardiac failure, Morbidly obese patients may suffer from obstructive SAS or
and missed acute catastrophes of the abdomen, such as an anasto- OHS.The simultaneous presence of SAS and OHS is known as the
motic leak. In a series of about 3,000 gastric procedures for morbid pickwickian syndrome [see Discussion, Respiratory Insufficiency of
obesity itself, we have observed the following incidence of compli- Obesity, below].2-4
cations: wound infection that delayed hospital discharge, 5%, as
SLEEP APNEA SYNDROME
well as minor infections or seromas in an additional 10%; clinically
apparent phlebitis, 0.4%; clinically diagnosed fatal pulmonary em- SAS is a potentially fatal complication
bolism, 0.2%; and pneumonia, 0.5%.We have observed a 1% op- of morbid obesity. A diagnosis of SAS
erative mortality. Although many of these patients had severe pre- should be suspected when there is a his-
operative morbidity (respiratory insufficiency, pseudotumor tory of loud snoring, frequent nocturnal
cerebri, or insulin-dependent diabetes), the risks of complications awakening with shortness of breath, and
approach the risks associated with major abdominal operation in daytime somnolence. It is estimated that
nonobese patients. In what follows, the focus is on issues that the 2% of middle-aged women and 4% of
surgeon should carefully consider when operating on an extreme- middle-aged men in the United States
ly overweight patient. workforce have SAS, and the incidence is
markedly higher in the severely obese.5
Patients will often admit to falling asleep while driving and wak-
Cardiac Dysfunction ing up with their car on the road’s median strip or bumping its
Morbidly obese patients are at signifi- guardrail. It is extremely important that trauma surgeons be
cant risk of coronary artery disease as a aware of the relation between obesity and somnolence should a
result of an increased incidence of sys- morbidly obese patient be seen in the emergency room after an
temic hypertension, hypercholesterole- automobile accident in which he or she fell asleep at the wheel.
mia, and diabetes. Because of this in- Elective patients with suspected sleep apnea syndrome should un-
creased risk for cardiac dysfunction, dergo preoperative polysomnography at a sleep center to confirm
preoperative electrocardiography proba- the diagnosis. Medications are usually ineffective. Stimulants, such
bly should be performed on all obese pa- as methylphenidate hydrochloride (Ritalin), should not be used. If
tients 30 years of age or older. a patient has a respiratory disturbance index (RDI) greater than
Most morbidly obese patients have minimal evidence of cardiac 25—indicating more than 25 apneic or hypopneic episodes per
dysfunction as detected by Swan-Ganz catheterization. Markedly hour of sleep—or has cardiac arrhythmias in association with ap-
elevated pulmonary arterial pressure (PAP) and pulmonary arterial nea, treatment by nocturnal nasal continuous positive airway pres-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 7 MORBID OBESITY — 2
Increased risks include • Missed abdominal catastrophe • Anesthetic calamities • Wound infection
• Respiratory failure • Pulmonary embolism • Postoperative asphyxia
• Cardiac failure • Internal hernia • Dehiscence
• Acute gastric distention • Thrombophlebitis
Patient reports loud snoring, frequent nocturnal awakening, Patient has heart failure or extreme shortness of breath
and daytime somnolence, or trauma victim has fallen asleep
at the wheel Suspect obesity hypoventilation syndrome (OHS).
OHS is confirmed by PaO2 ≤ 55 mm Hg or PaO2 ≥ 47 mm Hg
Suspect sleep apnea syndrome (SAS).
• If PAWP ≥ 18 mm Hg, try I.V. furosemide.
Confirm SAS by polysomnography in elective patients. Provide • If PAP ≥ 40 mm Hg, consider insertion of Greenfield vena
nocturnal nasal CPAP if apneic episodes are ≥ 25/hr of sleep or are caval filter.
associated with arrhythmias. If patient does not respond to — or • If Hb ≥ 16 g/dl, phlebotomize to Hb of 15 g/dl.
does not tolerate — CPAP, perform tracheostomy with extra-long tube.
Administer regular or low-molecular-weight heparin 30 min preoperatively and at appropriate intervals thereafter until
the patient is ambulatory.
Use intermittent sequential venous compression boots during anesthesia induction and throughout operation.
Two anesthesia personnel are required for induction and intubation of patients with SAS or OHS (one to hold the
mask and one to squeeze the ventilation bag).
Insert oral airway after administration of succinylcholine and sodium pentobarbital. Ventilate with 100% O2 for several
minutes before intubation. If intubation is unsuccessful, reinsert oral airway and ventilate with a mask. Patient should
be in reverse Trendelenburg position.
Patient does not have respiratory Patient has SAS Patient has OHS
insufficiency of obesity
In the absence of OHS, wean and extubate Continue mechanical ventilation after
Extubate in recovery room when patient the day after operation. If patient was on nasal operation until pain of breathing resolves.
is fully alert and ventilatory effort is CPAP before operation, reinstitute on second Wean to preoperative arterial blood gas
adequate; return patient to room. night after operation. Monitor for prolonged levels; several days may be required.
apnea or arrhythmia; if either occurs, awaken
patient.
Use intermittent sequential venous compression boots until patient is fully ambulatory.
Guarding, tenderness, and rigidity may be absent. Signs of infection (fever, tachypnea, tachycardia) may be absent. Acute respiratory
failure may be secondary to peritonitis. Radiographic contrast studies and laparotomy may be indicated even when clinical signs are few.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 7 MORBID OBESITY — 3
sure (nasal CPAP) should be provided. If the patient has severe morbidly obese patient is greatly enhanced with the reverse Trende-
SAS with an RDI greater than 40 and does not respond with elim- lenburg position, intermittent sequential venous compression boots
ination of the apneic episodes or cannot tolerate nasal CPAP, a tra- should be used to counteract the increased venous stasis and the
cheostomy should be considered. An extra-long tracheostomy tube propensity for clotting. It is important that the intermittent venous
is usually necessary because of the depth of the trachea in the mor- compression boots be used before induction of anesthesia and
bidly obese patient. throughout the operative procedure. Compression boots are usually
part of a standard preoperative protocol in gastric procedures for
OBESITY HYPOVENTILATION
weight control; their use should not be unintentionally neglected in
SYNDROME
preparation for other elective or emergency procedures on morbidly
OHS should be suspected in patients obese patients. Patients with severe venous stasis disease (e.g., pretib-
who present with heart failure or extreme ial stasis ulcers or bronze edema) are at significantly increased risk
shortness of breath. Patients who have a for fatal pulmonary embolism (PE).7 Prophylactic insertion of a
BMI of 50 kg/m2 or greater or who have Greenfield vena cava filter should be considered in both patients
a history of pulmonary problems (e.g., with severe venous stasis disease and patients with OHS and a high
smoking, chronic obstructive pulmonary PAP. Bariatric surgery–induced weight loss will correct the venous
disease, sarcoidosis, pulmonary fibrosis, stasis disease in most cases.7
or asthma) should undergo a baseline ar-
terial blood gas (ABG) determination
before operation. Diagnosis of OHS is confirmed when the patient’s Anesthesia in Patients with Respiratory Insufficiency
arterial oxygen tension (PaO2) is 55 mm Hg or less or the arterial Morbidly obese patients can be intimidating to the anesthesiolo-
carbon dioxide tension (PaCO2) is 47 mm Hg or greater.These pa- gist because they are at significant risk for complications from anes-
tients often have marked elevations in mean PAP, mean PAWP, or thesia, especially during induction.The risk is particularly great for
both, as well as severe polycythemia. In patients with obesity hy- obese patients with respiratory insufficiency. An obese patient often
poventilation syndrome, a Swan-Ganz catheter should be inserted has a short, fat neck and a heavy chest wall, which make intubation
as part of the preoperative evaluation. If PAWP is 18 mm Hg or and ventilation a challenge. If endotracheal intubation proves diffi-
greater, diuresis with intravenous furosemide is indicated. In many cult, however, these patients can usually be well ventilated with a
of these patients, however, an elevated PAWP reflects an increased mask. Awake intubation can be performed, with or without fiberop-
intrathoracic pressure and is necessary to maintain adequate cardiac tic aids, but is quite unpleasant and rarely necessary.
output; such patients do not have congestive heart failure, despite a It is extremely important that at least two anesthesia personnel be
markedly elevated filling pressure [see Discussion, below]. Little can present during induction and intubation for patients with respiratory
be done for the pulmonary hypertension that is seen in many of insufficiency of obesity.An oral airway is inserted after muscle paraly-
these patients; raising the PaO2 above 60 mm Hg usually will not sis with succinylcholine and sodium pentobarbital induction. One
lower PAP acutely. person elevates the jaw, hyperextends the neck, and ensures a tight fit
Polycythemia can significantly increase the incidence of phlebo- of the mask, using both hands.To ensure adequate oxygen delivery, a
thrombosis. If the hemoglobin (Hb) concentration is 16 g/dl or second person compresses the ventilation reservoir bag, using two
greater, phlebotomy to a concentration of 15 g/dl should be per- hands because of the resistance to air flow from the poorly compliant,
formed to reduce the postoperative risk of venous thrombosis. If heavy chest wall. After ventilation with 100% oxygen for several min-
PAP is 40 mm Hg or greater, consideration should be given to pro- utes, intubation is attempted. If difficulties are encountered within 30
phylactic insertion of a Greenfield vena caval filter because of the seconds, the steps above should be repeated until the patient has been
high risk of a fatal pulmonary embolism in these patients.6 Place- successfully intubated. A volume ventilator is required during opera-
ment of this filter can be a challenge because the appropriate land- tion. Placing the patient in the reverse Trendelenburg position ex-
marks cannot be identified in the operating room with fluoroscopy. pands total lung volume and facilitates ventilation8; however, the re-
It is necessary before operation to tape a quarter to the patient’s verse Trendelenburg position increases lower extremity venous
back over the second lumbar vertebra with the aid of fixed radio- pressure and therefore mandates the use of intermittent sequential ve-
graphs and then during operation to aim for the quarter with the in- nous compression boots [see Embolism, above]. It is helpful to moni-
sertion catheter, using fluoroscopy. Because these patients are usu- tor blood gases through a radial arterial line or digital pulse oximeter.
ally too heavy for angiography tables, the Greenfield filter usually
cannot be inserted percutaneously in the radiology department.
Postoperative Management
After operation, the obese patient
Embolism should be kept in the reverse Trendelen-
The risk of deep vein thrombosis [see burg position and should not be extu-
6:6 Venous Thromboembolism] increases bated until he or she is fully alert and
with a prolonged operation or a postoper- showing evidence of adequate ventilato-
ative period of immobilization, and it in- ry effort [see 8:5 Use of the Mechanical
creases even further in the morbidly Ventilator]. In the absence of respiratory
obese patient. Standard or low-molecu- insufficiency, most obese patients can
lar-weight heparin should be adminis- be extubated in the OR or the recovery
tered subcutaneously 30 minutes before room and returned to a standard hospital room.
operation and at appropriate intervals Patients with SAS, however, should be managed with overnight
thereafter (depending on the type of heparin used) for at least 2 days mechanical ventilation in the ICU. In the absence of concomitant
or until the patient is ambulatory. Because respiratory function in the OHS, they can usually be weaned and extubated the day after oper-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 7 MORBID OBESITY — 4
ation. Patients who were receiving ventilatory support with nasal tress syndrome (ARDS).Thus, peritonitis must be suspected in any
CPAP before operation should have this treatment reinstituted the morbidly obese patient with acute respiratory failure. Patients who
second night after operation; monitoring for prolonged apnea should have undergone a laparoscopic bariatric procedure may be reex-
be continued in the ICU or in a stepdown unit with digital oximetry. plored without much difficulty if there is concern about a possible
If apnea occurs, simply waking the patient should correct the prob- leak.
lem. Patients who required tracheostomy can also usually be weaned Because a high index of suspicion of peritonitis is required to detect
from the ventilator the morning after operation. the condition in morbidly obese patients, radiographic contrast stud-
Patients with OHS require prolonged mechanical volume venti- ies with water-soluble agents such as diatrizoate meglumine (Gas-
lation until the pain of breathing resolves. One cannot expect such trografin) may be indicated even when there are few clinical signs. If
patients to manifest normal ABG levels, and they should be weaned a perforated viscus is suspected, an exploratory laparotomy may be
to their preoperative values.This is why baseline ABG values are ob- necessary despite normal findings on radiographic contrast study.
tained preoperatively. The weaning process may require several
INTERNAL HERNIA
days. It is important that these patients remain in the reverse Tren-
delenburg position to maximize diaphragmatic excursion. Positive GBP places patients at risk for internal hernia with a closed-loop
end-expiratory pressure (PEEP) ventilation may be detrimental in obstruction, leading to bowel strangulation.There are three potential
patients with OHS because it can overdistend alveoli, thereby lead- locations for these internal hernias: the Roux-en-Y anastomosis; the
ing to capillary compression, decreased cardiac output, and in- opening in the transverse mesocolon through which the retrocolic
creased dead space, all of which can exacerbate retention of carbon Roux limb is brought; and the Petersen hernia, which is located be-
dioxide. hind the retrocolic Roux limb.The primary symptom of an internal
Swan-Ganz catheters, inserted preoperatively in patients with se- hernia is periumbilical pain, usually in the form of cramping consis-
vere OHS, are useful in monitoring postoperative intravascular vol- tent with visceral colic.These internal hernias may be very difficult to
ume and oxygen delivery status. Excessive diuresis or restriction of diagnose. Upper gastrointestinal radiographic series and abdominal
fluids should be avoided [see Discussion, below]. CT scans are often normal, providing a false sense of security.The
It is extremely important to encourage early postoperative ambu- resulting assumption that no problem exists may be devastating for
lation for the morbidly obese patient.These patients have surpris- the patient should bowel infarction occur as a consequence of
ingly little pain, and it is not unusual to see them walking in the af- closed-loop obstruction. One should always carefully inspect the
ternoon or early evening after a major abdominal procedure. If the plain abdominal radiograph for the abnormal placement or spread-
patients have been advised preoperatively of the merits of early post- ing of the Roux-en-Y anastomotic staples.The safest course of ac-
operative ambulation and know it is for their own welfare, they are tion in patients with recurrent attacks of cramping periumbilical
usually willing to cooperate. pain is abdominal surgical exploration.The frequency of this com-
plication seems to have increased with the advent of laparoscopic
GBP, presumably because of the difficulty of closing the potential
Complications of Gastric Surgery for Obesity hernia spaces completely. Some attribute the problem to the de-
Current gastric procedures for obesity include open and laparo- creased tendency toward adhesion formation after laparoscopic
scopic gastric bypass (GBP), gastroplasty, and laparoscopic ad- surgery.
justable gastric banding.The procedures themselves are described
ACUTE GASTRIC DISTENTION
in more detail elsewhere [see 5:19 Bariatric Procedures];
the following are some of the main complications associated After GBP, massive gaseous distention occasionally develops in
with any abdominal operation in a severely obese patient. the distal bypassed stomach; this can lead to a gastric perforation or
disruption of the gastrojejunostomy.The primary symptoms of this
ABDOMINAL CATASTROPHE
complication are hiccups and a bloated feeling. Massive gastric di-
It may be very difficult to recognize an latation can lead to severe left shoulder pain and shock.The prob-
abdominal catastrophe in patients who lem is usually secondary to edema at the Roux-en-Y anastomosis
are very young, very old, or morbidly but can also be secondary to a mechanical problem.The diagnosis
obese or who are receiving high doses of is made by means of an urgent upright abdominal radiograph,
steroids.The obese patient, for example, which reveals the markedly dilated and air-filled bypassed stomach.
may present in the emergency room with Occasionally, the stomach is filled with fluid, and the diagnosis may
a perforated duodenal ulcer or a rup- be more difficult. In those few cases in which the dilatation is pri-
tured diverticulum, complaining of ab- marily caused by air, the problem can be relieved by percutaneous
dominal pain, and yet on abdominal ex- transabdominal skinny-needle decompression with subsequent pas-
amination have no evidence of peritoneal sage of gas and gastric and biliopancreatic juices through the Roux-
irritation (no guarding, tenderness, or rigidity). This situation has en-Y anastomosis. Should the dilatation recur or the patient be in
been well documented in patients in whom an anastomotic or gas- serious difficulty, an emergency laparotomy with insertion of a gas-
tric leak has developed after operation for morbid obesity.9 Symp- trostomy tube should be performed and the jejunojejunostomy
toms include shoulder pain, pelvic or scrotal pain, back pain, tenes- evaluated. If a patient has extensive adhesions from previous ab-
mus, urinary frequency, and, of great importance, marked anxiety. dominal surgery, a gastrostomy tube should be inserted at the time
Signs of infection (e.g., fever, tachypnea, and tachycardia) may be of GBP to prevent gastric dilatation.
absent, though tachycardia is often the first sign of a significant
problem. Patients with peritonitis often have clinical symptoms and
signs suggesting a massive pulmonary embolus: severe tachypnea, Diabetes Mellitus
tachycardia, and sudden hypotension. Such acute pulmonary fail- Type 2 (non–insulin-dependent) diabetes mellitus, a nonketotic
ure is probably secondary to sepsis-induced acute respiratory dis- form of diabetes that is usually noted after age 40, is markedly ex-
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 7 MORBID OBESITY — 5
acerbated by obesity. Patients with this type of diabetes often re- obese patients is probably secondary to the increased intra-abdom-
quire large amounts of insulin for blood glucose control because of inal pressures (IAP) present in patients with central, or android,
a significant reduction in insulin receptors. It is not unusual, obesity.16
however, to note a complete absence of the requirement for insulin Obese diabetic patients are at risk for rapidly spreading pannic-
in the immediate postoperative period in morbidly obese patients. ulitis secondary to mixed aerobic and anaerobic organisms.17 Sub-
Therefore, insulin should be withheld on the morning of opera- cutaneous gas and extensive necrosis, which usually does not in-
tion.There is often a marked reduction in the requirement for in- volve the underlying muscle, are often present. It is uncommon to
sulin throughout the postoperative period and even at discharge in culture clostridia from these wounds. Even after extensive and
morbidly obese patients who have undergone GBP, probably be- repeated debridement, mortality remains high [see 3:2 Soft Tissue
cause of increased release of gastric inhibitory peptide (GIP) from Infection].
the proximal small bowel.Therefore, regular subcutaneous insulin
should be administered to GBP patients according to a sliding
Other Obesity-Related Diseases
scale after operation until insulin requirements can be determined.
Before discharge, the patient should be taking an appropriate dose GALLSTONES
of neutral protamine Hagedorn (NPH) or Lente insulin but must Approximately one third of morbidly obese patients either have
perform frequent finger-stick blood glucose determinations after- had a cholecystectomy or may have had gallstones noted at the time
ward, given that the need for insulin will decrease progressively of another intra-abdominal operative procedure, such as gastric op-
with weight loss. eration for morbid obesity. Preoperative evaluation of the gallbladder
In one study of 23 patients with diabetes mellitus who underwent may be technically quite difficult in morbidly obese patients because
gastric bariatric operation, the average requirement for insulin de- gallstones may be missed with either ultrasonography or oral chole-
creased from 74 units/day before operation to 8 units/day after op- cystography. Intraoperative sonography is probably much more ac-
eration.10 Fourteen of the 23 patients were able to discontinue in- curate. Should stones be present in a patient undergoing gastric op-
sulin completely, 11 by the time of discharge from the hospital 1 eration for obesity, the gallbladder should be removed. In the past,
week after operation.These benefits were maintained during long- obese patients with intermittent attacks of biliary colic were told to
term follow-up to 39 months and were a result of a major decrease lose weight before an elective cholecystectomy for fear of significant
in insulin resistance that was associated with decreased food intake morbidity and mortality from an elective operation.This attitude is
as well as weight loss. no longer valid, because among the large numbers of obese patients
who now undergo major elective abdominal procedures, morbidity
is similar to that seen in thin patients if appropriate precautions are
Wound Care taken. Furthermore, obese patients have great difficulty losing large
Morbidly obese patients have been reported to have an in- amounts of weight by diet alone and should be allowed to undergo
creased risk of wound infection and dehiscence. However, the inci- definitive corrective operative procedures before weight reduction.
dence of these complications in this group of patients can be very Rapid weight loss may lead to the development of gallstones in
low. In a randomized, prospective trial comparing a running, con- 25% to 40% of patients who undergo GBP.The risk of cholelithia-
tinuous absorbable No. 2 polyglycolic acid suture with a No. 28 sis in this setting can be reduced to 2% by administering ursodeoxy-
stainless-steel wire in morbidly obese patients who weighed an av- cholic acid, 300 mg orally twice daily.18
erage of 320 lb, there was no significant difference in complications,
PSEUDOTUMOR CEREBRI
including the incidence of incisional hernia, between the types of clo-
sure.11 However, the running absorbable suture closure required sig- Pseudotumor cerebri is an unusual complication of morbid obesi-
nificantly less time. Similar results comparing continuous with inter- ty that is associated with benign intracranial hypertension, papillede-
rupted sutures have been noted by others.12 Subcutaneous sutures ma, blurred vision, headache, and elevated cerebrospinal fluid pres-
should not be used, because the subcutaneous fat becomes reap- sures.19 It has been our experience that patients with pseudotumor
proximated during skin closure, and subcutaneous sutures have cerebri are not at any additional perioperative risk and that cere-
been found to increase the risk of wound infection.13 Obese pa- brospinal fluid does not have to be removed before anesthesia and
tients undergoing clean-contaminated intestinal procedures should major abdominal operation.Weight reduction will cure pseudotu-
be given a parenteral antibiotic immediately before the operation mor cerebri.20,21
and for only 24 hours after the operation14; it is important to note
DEGENERATIVE OSTEOARTHRITIS
that morbidly obese patients should receive a double dose of pro-
phylactic antibiotics because of the increased volume of distribu- Degenerative osteoarthritis of the knees, hips, and back is a com-
tion. If a gastric or gallbladder operation is planned, only aerobic mon complication of morbid obesity. Weight reduction alone may
bacterial coverage is necessary; a colon operation will necessitate greatly reduce the pain and immobility that afflict these patients, al-
anaerobic coverage as well. though the damage may be so extensive that a total joint replace-
It has been our experience that the incidence of incisional hernia ment may be desirable. However, joint replacement in patients who
is much higher in morbidly obese patients than in thin patients weigh more than 250 lb is associated with an unacceptable incidence
with ulcerative colitis who are taking large doses of corticosteroids of loosening.22 Weight reduction by means of a gastric bariatric oper-
and who undergo the same fascial wound closure with running ation may be the most sensible initial approach, to be followed by
No. 2 polyglycolic acid sutures.15 This increased risk in morbidly joint replacement after weight loss if pain and dysfunction persist.
© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 7 MORBID OBESITY — 6
Discussion
Morbidity Associated with Central Fat Deposition against a constant airway resistance enters the nasal pharynx and
Much has been written about the increased health risks inherent pushes the tongue forward to prevent recurrent obstruction.26 The
in central, or android, fat deposition as compared with peripheral, or pressure can be adjusted for each patient. Unfortunately, many pa-
gynoid, fat deposition. It is thought that in the former, the increased tients cannot tolerate the device, because it is cumbersome and noisy
metabolic activity of mesenteric fat is associated with increased me- and tends to dry out the upper airway, although dryness can be pre-
tabolism of amino acids to sugar, which leads to hyperglycemia and vented with an inexpensive room humidifier. If nasal CPAP cannot
hyperinsulinism. Hyperinsulinism gives rise to increased sodium ab- be tolerated by the patient, or if it is ineffective and the problem is se-
sorption and hypertension. Furthermore, central obesity has been vere (i.e., causing cardiac arrhythmias or severe hypoxia), tracheosto-
linked to hypercholesterolemia. Hence, these patients have a signifi- my is indicated.This procedure can be very difficult and dangerous
cantly higher incidence of diabetes, hypertension, hypercholesterol- and therefore should not be relegated to the youngest house officer
emia, and gallstones23—which explains the higher mortality of the in a surgical residency program. Because of the extremely deep neck
apple distribution of body fat as compared with the pear distribution. in obese patients, a standard tracheostomy tube is usually inade-
In the past, fat distribution was measured on the basis of the waist-to- quate, and a special tube with a deep bend should be used.
hip ratio; however, computed tomography scans have shown that ab- OHS is a condition associated with morbid obesity in which an
dominal circumference is a more accurate measurement of central individual suffers from hypoxemia and hypercapnia when breathing
fat distribution.24 We have found that morbidly obese women have room air while awake but resting.27 Spirometry reveals decreases in
significantly increased IAP and that this is associated with stress and forced vital capacity, residual lung volume, expiratory reserve vol-
urge overflow urinary incontinence.25 With weight loss comes a sig- ume, functional residual capacity, and maximum minute volume
nificant decrease in bladder pressure and correction of inconti- ventilation, usually without obstruction to airflow [see Figure 1].The
nence. We have found IAP, as reflected in bladder pressure, to be most profound decrease is that in expiratory reserve volume; it is
closely correlated with sagittal abdominal diameter and waist cir- probably secondary to increased intra-abdominal pressure and a
cumference but not with waist-to-hip ratio (many morbidly obese high-riding diaphragm.Thus, these patients have a restrictive rather
patients have both central and peripheral obesity). We have also than an obstructive pulmonary disease. The decreased expiratory
found that the increased IAP associated with central obesity may reserve volume implies that many alveolar units are collapsed at
cause additional comorbid factors, including venous stasis ulcers, end-expiration, which leads to perfusion of unventilated alveoli, or
OHS, gastroesophageal reflux, and inguinal and incisional hernias. shunting. Patients with OHS often are heavy smokers or have addi-
tional pulmonary problems, such as asthma, sarcoidosis, idiopathic
pulmonary fibrosis, or recurrent pulmonary emboli. One study of
Respiratory Insufficiency of Obesity patients who underwent operation for morbid obesity showed no
Obese patients are at risk for respiratory difficulties, which may statistically significant difference in weight between those who had
be present before operation or may be exacerbated by an operation. OHS and those who did not.3
The term pickwickian syndrome (which derives from The Posthu- As a result of chronic and severe hypoxemia, patients with OHS
mous Papers of the Pickwick Club, by Charles Dickens) was resurrect- are often markedly polycythemic.The polycythemia further increas-
ed from the late 1800s to describe a morbidly obese man 52 years es their already significant risk for venous thrombosis and pulmo-
of age who fell asleep in a poker game while holding a hand con- nary embolism. Because we have had several patients who later had
taining a full house.2 He was taken to the hospital by friends who a subclavian venous thrombosis and one patient who probably had
presumed he was ill. The pickwickian syndrome is now known to a transient sagittal sinus thrombosis, patients with OHS should
comprise two pulmonary syndromes associated with morbid obesi- probably undergo phlebotomy to a hemoglobin concentration of 15
ty: obstructive SAS and OHS.3 g/dl before elective operation.
Patients with SAS suffer from repeated attacks of upper airway Chronic hypoxemia also leads to pulmonary arterial vasocon-
obstruction during sleep.The cause is probably related to a large, striction and severe pulmonary hypertension1,28 and eventually to
fat tongue as well as to excessive fat deposition in the uvula, phar-
ynx, and hypopharynx. The normal genioglossus reflex is de-
100
pressed, but this depression may be secondary to the excessive
weight of the tongue.These patients are notorious snorers. As a re- * *
(% of predicted value)
* ** **
Pulmonary Function
right-sided heart failure or cor pulmonale with neck vein distention, 4.5 35
tricuspid valvular insufficiency, right upper quadrant tenderness
secondary to acute hepatic engorgement, and massive peripheral
70
sion and to increase residual lung volume.8 These patients will often
complain of air hunger and respiratory distress when they lie su- 60
pine. So-called breaking of the bed at the waist may exacerbate the
problem by pushing the abdominal contents into the chest, thereby 50
raising the diaphragm and further reducing lung volumes. Placing
these patients in the leg-down position may predispose them to ve- 40
demand for blood flow than the heart can provide.Vigorous diure-
sis will often correct such acute heart failure. Significant weight loss
will correct pulmonary hypertension [see Figure 3] as well as left
ventricular dysfunction associated with respiratory insufficiency.1,33
greater.With this approach (in which a vena caval filter was used in 15 *
15 patients), we have had one fatal pulmonary embolus in 156 pa- *
tients with respiratory insufficiency of obesity who have undergone †
gastric bariatric procedures.The fatality was a patient whose mean 10
PAP was initially 40 mm Hg but fell to 35 mm Hg with diuresis and
who was not considered to require a filter.
5
Venous stasis ulcers can be quite difficult to treat in a thin indi-
vidual; they are almost impossible to cure in a patient with morbid
obesity [see Figure 4].The most important goal in management of
these ulcers is weight loss, which almost invariably leads to healing 0 5 10 15 20 25 Release
of the ulcer, probably as a result of decreased IAP.7 Patients with ve- IAP (mm Hg above baseline)
nous stasis ulcers also are at high risk for fatal PE and should be
considered for prophylactic placement of a vena caval filter. No Sternotomy Sternotomy
should reduce this risk almost to that of the general population. A lose two thirds of the excess weight within 1 year after a standard
high index of suspicion for peritonitis must be maintained after an GBP or, if superobese, after a long-limb gastric bypass. Further-
intra-abdominal procedure or when the patient complains of ab- more, recent reports note that this weight loss is long-lasting and av-
dominal pain in the emergency room. Awareness of the problems erages 60% of excess weight at 5 years and more than 50% of excess
associated with respiratory insufficiency in obese patients should weight up to 10 years after operation.This weight loss is associated
enable the surgeon to avoid pitfalls when managing the patient with with the correction of insulin-dependent diabetes, obstructive SAS,
obstructive SAS or OHS.These patients may require preoperative OHS, pseudotumor cerebri, hypertension, chronic venous stasis ul-
pulmonary arterial catheterization for optimal fluid management cers, stress incontinence, gastroesophageal reflux, and female sex
before and after operation.The risks of venous thrombosis and PE hormone abnormalities, which may be related to dysmenorrhea,
are high, but the use of intermittent compression boots and early infertility, hirsutism, and an increased risk of endometrial carcino-
ambulation can minimize the dangers. The obese patient with ma.Weight loss can markedly improve the patient’s self-image and
non–insulin-dependent diabetes has been surprisingly easy to man- employability. Because techniques for operation for morbid obe-
age after major operation. sity continue to change as understanding of pathophysiology im-
Weight reduction by diet is associated with a 95% incidence of proves, it is important for surgeons to keep abreast of the latest
recidivism.The average morbidly obese patient can be expected to developments.
References
1. Sugerman HJ, Baron PL, Fairman RP, et al: Hemo- prophylaxis in gastric, biliary, and colonic surgery. 1:862, 1981
dynamic dysfunction in obesity hypoventilation syn- Ann Surg 184:443, 1976 27. Rochester DR, Enson Y: Current concepts in the
drome and the effects of treatment with surgically in- 15. Sugerman HJ, Kellum JM, Reines HD, et al: Incision- pathogenesis of the obesity hypoventilation syndrome:
duced weight loss. Ann Surg 207:604, 1988 al hernia: greater risk with morbidly obese than ster- mechanical and circulatory factors. Am J Med 57:
2. Burwell CS, Robin ED, Whaley RD, et al: Extreme oid dependent patients; low recurrence rate with pre- 402, 1974
obesity associated with alveolar hypoventilation—a fascial polypropylene mesh repair. Am J Surg 171:80, 28. Alexander JK, Amad KH, Cole VW: Observations on
pickwickian syndrome. Am J Med 21:811, 1956 1996 some clinical features of extreme obesity, with particu-
3. Sugerman HJ, Fairman RP, Baron PL, et al: Gastric 16. Sugerman H, Windsor A, Bessos M, et al: Intra- lar reference to cardiorespiratory effects. Am J Med
surgery for respiratory insufficiency of obesity. Chest abdominal pressure, sagittal abdominal diameter, and 32:512, 1962
89:81, 1986 obesity co-morbidity. J Intern Med 241:71, 1997 29. Ridings PC, Bloomfield GL, Blocher CR, et al: Car-
4. Sugerman HJ, Fairman RP, Sood RK, et al: Long- 17. Rouse TM, Malangoni MA, Schulte WJ: Necrotizing diopulmonary effects of raised intra-abdominal pres-
term effects of gastric surgery for treating respiratory fasciitis: a preventable disaster. Surgery 92:765, 1982 sure before and after volume expansion. J Trauma
insufficiency of obesity. Am J Clin Nutr 55(2 suppl): 18. Sugerman HJ, Brewer WH, Shiffman ML, et al: A 39:1168, 1995
597S, 1992 multicenter, placebo-controlled, randomized, double- 30. Coe NP, Collins RE, Klein LA, et al: Prevention of
5. Young T, Palta M, Dempsey J, et al:The occurrence of blind, prospective trial of prophylactic ursodiol for the deep vein thrombosis in urological patients: a con-
sleep-disordered breathing among middle-aged adults. prevention of gallstone formation following gastric- trolled, randomized trial of low-dose heparin and ex-
N Engl J Med 328:1230, 1993 bypass-induced rapid weight loss. Am J Surg 169:91, ternal pneumatic compression boots. Surgery 83:230,
6. Greenfield LJ, Scher LA, Elkins RC: KMA-Green- 1995 1978
field ® filter placement for chronic pulmonary hyper- 19. Corbett JJ, Mehta MP: Cerebrospinal fluid pressure 31. Kaltman AJ, Goldring RM: Role of circulatory con-
tension. Ann Surg 189:560, 1979 in normal obese subjects and patients with pseudotu- gestion in the cardiorespiratory failure of obesity. Am J
7. Sugerman HJ, Sugerman EL, Wolfe L, et al: Risks/ mor cerebri. Neurology 33:1386, 1983 Med 60:645, 1976
benefits of gastric bypass in morbidly obese patients 20. Sugerman HJ, Felton WL, Salvant JB, et al: Effects of 32. De Divitiis O, Fazio S, Petitto M, et al: Obesity and
with severe venous stasis disease. Ann Surg 234:41, surgically induced weight loss on pseudotumor cere- cardiac function. Circulation 64:477, 1981
2001 bri in morbid obesity. Neurology 45:1655, 1995 33. Alpert MA,Terry BE, Kelly DL: Effect of weight loss
8. Vaughan RW, Bauer S, Wise L: Effect of position 21. Sugerman HJ, Felton WL III, Sismanis A, et al: Gas- on cardiac chamber size, wall thickness and left ven-
(semirecumbent versus supine) on postoperative oxy- tric surgery for pseudotumor cerebri associated with tricular function in morbid obesity. Am J Cardiol 55:
genation in markedly obese subjects. Anesth Analg severe obesity. Ann Surg 229:634, 1999 783, 1985
55:37, 1976 34. Batist G, Bothe A, Bern M, et al: Low antithrombin
22. Goldin RH, McAdam L, Louie JS, et al: Clinical and
9. Mason EE, Printen KJ, Barron P, et al: Risk reduction radiologic survey of the incidence of osteoarthritis III in morbid obesity: return to normal with weight re-
in gastric operations for obesity. Ann Surg 190:158, among obese patients. Ann Rheum Dis 35:349, 1976 duction. JPEN 7:447, 1983
1979 35. Printen HJ, Miller EV, Mason EE, et al: Venous
23. Kissebah AH, Vydelingum N, Murray R, et al: Rela-
10. Herbst CA, Hughes TA, Gwynne JT, et al: Gastric tion of body fat distribution to metabolic complica- thromboembolism in the morbidly obese. Surg Gy-
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95:209, 1984 1982 36. Bloomfield GL, Ridings PC, Blocher CR, et al: Ef-
11. McNeill PM, Sugerman HJ: Continuous absorbable 24. Kvist H, Chowdhury B, Grangard U, et al:Total and fects of increased intra-abdominal pressure upon in-
vs interrupted nonabsorbable fascial closure: a pro- visceral adipose-tissue volumes derived from mea- tracranial and cerebral perfusion before and after vol-
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12. Richards PC, Balch CM, Aldrete JS: Abdominal 48:1351, 1988 posed relationship between increased intra-abdomi-
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25. Bump RC, Sugerman HJ, Fantl JA, et al: Obesity and
571 patients comparing continuous vs. interrupted Med 25:496, 1997
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Acknowledgments
26. Sullivan CE, Issa FG, Berthon-Jones M, et al: Rever-
Am J Surg 127:716, 1974 sal of obstructive sleep apnoea by continuous positive Figures 1 and 3 Albert Miller.
14. Stone HH, Hooper CA, Kolb LD, et al: Antibiotic airway pressure applied through the nares. Lancet Figures 2 and 5 Marcia Kammerer.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 8 Tumors of the Stomach, Duodenum, and Small Bowel — 1
Gastric Adenocarcinoma reported between cancer of the gastric cardia and infection with
The incidence of gastric carcinoma exhibits significant geo- Helicobacter pylori or Epstein-Barr virus.10,11
graphic variability. The disease is most common in Japan and CLASSIFICATION
China, and high rates of occurrence have also been reported in
Central and South America, Eastern Europe, and parts of the Adenocarcinoma of the stomach may be divided into two his-
Middle East.1 In most of the more developed nations, however, tologic subtypes, intestinal and diffuse.12 Each subtype has unique
gastric carcinoma is relatively uncommon.The overall incidence of pathologic, epidemiologic, etiologic, and prognostic features. The
this condition has decreased in the past few decades, but gastric intestinal (or glandular) subtype usually arises in the distal stom-
carcinoma remains the second leading cause of cancer death ach (often after a long precancerous phase), is more common in
worldwide. The reported reductions in gastric cancer mortality elderly patients, and has been closely associated with atrophic gas-
may be linked to better refrigeration and a concomitant decrease tritis and diets high in nitrates and nitrose compounds.13 The char-
in the intake of salted, pickled, smoked, and chemically preserved acteristic histologic finding is cohesive neoplastic cells that form
foods; however, this link remains controversial. An inverse associ- glandlike tubular structures.The diffuse subtype occurs more fre-
ation with the consumption of fresh fruits and vegetables has also quently in younger patients and has no identifiable precursor le-
been noted.2 sion. It may develop in any part of the stomach but shows a pre-
Gastric cancer occurs 1.5 to 2.5 times more frequently in males dilection for the cardia. Cell cohesion is absent; thus, individual
than in females. It is rarely diagnosed before the age of 40, and its cancer cells infiltrate and thicken the stomach wall without form-
incidence peaks in the seventh decade of life. African Americans, ing a discrete ulcer or mass.
Hispanic Americans, and Native Americans are two times more In general, the prognosis for the diffuse subtype is worse than
likely to have gastric cancer than white Americans are.3 that for the intestinal subtype. Whereas intestinal lesions are seen
In the United States in particular, the incidence of stomach more frequently in regions with a high incidence of gastric cancer,
cancer has fallen substantially over the past 70 years.4 Whereas this the incidence of diffuse lesions is constant among various popula-
disease was once a leading cause of cancer-related death in the tions throughout the world.14 Accordingly, the overall decline in gas-
United States, it now ranks 13th among major causes. Unfortun- tric cancer over the past century has been attributed to a decline in
ately, the decline in incidence has not translated into an improve- intestinal lesions and to a decline in the incidence of H. pylori
ment in the 5-year survival rate.5 Across all races, the 5-year rela- infection (see below).
tive survival was 23% for the period extending from 1992 to 1999.3
RISK FACTORS
This result is probably related to the advanced stage at which most
patients present. A 1995 study from the Commission on Cancer Historical studies of specimens obtained during operation or at
of the American College of Surgeons (ACS) found that 66% of autopsy suggest that gastric carcinoma, especially of the intestinal
patients with gastric cancer presented with locally advanced or subtype, frequently develops in the presence of chronic atrophic
metastatic disease.6 Resection rates ranged from 30% to 50%, and 5- gastritis and associated intestinal metaplasia. It has generally been
year survival rates after resection with curative intent were directly assumed that adenocarcinoma of the distal stomach progresses
related to stage at presentation. For stage I disease, the survival rate from chronic gastritis to metaplasia through the teratogenic influ-
was 43%; for stage II, 37%; for stage III, 18%; and for stage IV, 20%. ence of environmental factors. The most commonly studied envi-
Another relevant change in the epidemiology of gastric cancer is ronmental factors are the nitrates and nitrose compounds present
a shift in the distribution of primary lesion sites within the stom- in high levels in salted, smoked, or pickled foods consumed in
ach. In the first quarter of the 20th century, two thirds of gastric areas where gastric cancer is endemic.15 To date, however, no
cancers were located in the antrum and the prepyloric area, and prospective studies have conclusively demonstrated that modern
only 10% arose in the cardia or the esophagogastric junction. Since refrigeration practices and the subsequent decline in the salting,
the 1970s, however, adenocarcinoma of the proximal stomach has smoking, and pickling of food have been responsible for the rela-
become increasingly common. In one study, the incidence of ade- tive decline in intestinal gastric cancer. Furthermore, the intestinal
nocarcinoma of the gastric cardia rose from 29.1% to 52.2% in the subtype may arise in the absence of metaplasia. Finally, the emer-
period between 1984 and 1993.7 In another, which included 18,365 gence of chronic infection with H. pylori as the dominant risk fac-
gastric cancer patients from ACS-approved hospitals, a full 31% of tor for gastric adenocarcinoma has challenged the paradigm of the
tumors were found to be in the proximal stomach, compared with atrophic gastritis–intestinal metaplasia–gastric cancer sequence.
only 26% in the distal third.8 In the United States, carcinoma of the Epidemiologic studies across various populations worldwide
cardia occurs primarily in whites, with a male-to-female ratio of have consistently demonstrated a strong association between H.
approximately 2:1. Cancer of the cardia appears to be distinct from pylori infection and gastric cancer.16 Prospective serologic studies
adenocarcinoma of the distal esophagus, which frequently arises in have confirmed that persons with evidence of such infection are
the setting of Barrett’s esophagus.9 Associations have also been three to six times more likely to have gastric cancer than persons
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 8 Tumors of the Stomach, Duodenum, and Small Bowel — 2
a b
Figure 1 Shown are CT scans of a patient with a T3 carcinoma involving the posterior wall of the gastric
antrum, taken with the patient supine (a) and prone (b). By placing the patient in the prone position and dis-
tending the stomach with water, better definition of the extent of the tumor and clearer delineation of the inter-
face between the stomach and the pancreas is achieved.
the Internet (http://www.nccn.org/professionals/physician_gls/PDF/ CT with intravenous contrast plus appropriate gastric distention
gastric.pdf) and are updated annually. Multidisciplinary evalua- with 600 to 800 ml of water (a negative contrast agent), have
tion is recommended for all patients. A careful history is obtained allowed modest improvements in overall staging with CT [see
and a thorough physical examination performed, with special Figure 1]. Nevertheless, CT is still limited in its ability to evaluate
attention paid to comorbid conditions that might preclude opera- peritoneal disease and liver metastases smaller than 5 mm.31
tive intervention. Initial laboratory studies include a complete Given the limitations of CT, we believe that in the absence of
blood cell count with a platelet count; determination of serum elec- obvious metastatic disease, locoregional staging with endoscop-
trolyte, blood urea nitrogen, creatinine, and glucose concentrations; ic ultrasonography (EUS) is vital for accurately assessing tumor
and a liver function panel. Chest radiography is performed, along penetration through the gastric wall (T stage) and ascertaining
with computed tomography of the abdomen and pelvis. whether regional nodes (N stage) or even mediastinal or para-aor-
Whereas CT is invaluable for detecting ascites, bulky adenopa- tic lymph nodes may be involved (which would be considered M1
thy, and significant visceral metastases, its overall accuracy in stag- disease) [see Figure 2]. EUS is unique among imaging modalities
ing tumors is modest: only 70% for advanced lesions and 44% for in its ability to image the gastric wall as a five-layer structure, with
early lesions.30 CT assesses lymph node involvement primarily on each layer correlating with an actual histologic layer.32 The overall
the basis of node size. Thus, its sensitivity for N1 and N2 disease accuracy of EUS in determining the extent of infiltration ranges
is low, ranging from 24% to 43%; however, its specificity is high, from 67% to 92%.33 EUS features that suggest lymph node
approaching 100%. Technical advances, such as spiral (helical) metastasis include a rounded shape, hypoechoic patterns, and a
a b
Figure 2 (a) Shown is an EUS image of a T3 gastric neoplasm. (b) EUS reveals the presence of suspicious
perigastric (N1) nodes, later confirmed as malignant at operation.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 8 Tumors of the Stomach, Duodenum, and Small Bowel — 4
Perform helical CT of abdomen and pelvis with oral and I.V. contrast.
Perform EUS.
Assess severity of symptoms. Evidence of widely metastatic disease or the presence of locally
advanced unresectable disease is a contraindication to resection.
Provide supportive care.
Consider palliative chemotherapy, endoluminal stenting, or entry
into advanced disease clinical trials.
Tumor is in distal stomach Tumor is in fundus or proximal stomach Tumor is in distal esophagus,
esophagogastric junction, or cardia
Perform subtotal gastrectomy with Perform total gastrectomy with D2 dissection
D2 dissection and Billroth II reconstruction. and esophagojejunal reconstruction. Perform transthoracic or transhiatal
esophagogastrectomy with D2 dissection.
Figure 3 Algorithm illustrates workup and treatment of patient with gastric carcinoma.
size larger than 1 cm. In one study comparing preoperative find- ume ascites. If cytologic study of the ascitic fluid so obtained con-
ings from EUS with pathologic findings at operation, EUS was firms the presence of malignant cells, the patient is considered to
100% sensitive for N0 disease and 66.7% sensitive for N1 dis- have metastatic disease and therefore is not eligible for curative-
ease.34 EUS also allows identification and aspiration of small-vol- intent surgery. For all of these reasons, EUS is now widely accept-
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 8 Tumors of the Stomach, Duodenum, and Small Bowel — 5
ed as superior to conventional CT in the regional staging of gas- an R0 resection.41 Given the propensity of tumor for submucosal
tric cancer.9 spreading, many authors consider proximal margins of 5 to 6 cm,
with routine frozen-section analysis, to be optimal.42,43
Role of Laparoscopy In an effort to lower the positive margin rate, some surgeons
The ultimate goal of any staging evaluation is to ensure that have proposed that total gastrectomy be considered the operation
patients with metastatic disease are not treated with nontherapeu- of choice for all operable gastric cancers. This approach, original-
tic laparotomy or other local therapies (e.g., radiation therapy), ly based on historical data from single institutions, has been test-
which are generally ineffective against advanced disease. Even ed in three clinical trials. In the first trial, elective total gastrecto-
small-volume metastatic disease identified on the surface of the my was compared with subtotal gastrectomy as curative-intent
liver or the peritoneum at laparotomy is associated with poor sur- therapy for adenocarcinoma of the antrum.44 Elective total gas-
vival: in one study, patients with such disease had a life expectan- trectomy did not increase mortality, but it also did not improve 5-
cy of only 6 to 9 months.35 In these situations, there is little to be year survival (which was 48% in both treatment arms). In the sec-
gained from attempts at palliative resection. ond trial, patients with antral cancer were randomly assigned to
Staging laparoscopy [see 5:20 Gastroduodenal Procedures] has undergo either subtotal gastrectomy or total gastrectomy with
proved to be highly relevant to the evaluation of patients with gas- extended lymph node dissection (ELND) and en bloc distal pan-
tric cancer. In a study from the Memorial Sloan-Kettering Cancer createctomy and splenectomy.45 Total gastrectomy was associated
Center (MSKCC), the investigators performed laparoscopic explor- with increased operative time, greater transfusion requirements,
ation on 110 of 111 patients with newly diagnosed gastric cancer.36 and longer hospital stay; however, median survival was signifi-
Of these 110 patients, 94% were accurately staged, with a sensitiv- cantly better in the subtotal gastrectomy group (1,511 days versus
ity of 84% and a specificity of 100%, and 37% were found to have 922 days). In the third trial, the investigators concluded that sub-
subclinical metastatic disease. Hospital stay was substantially total gastrectomy should be the procedure of choice for cancer of
shorter in the 24 patients who underwent diagnostic laparoscopy the distal half of the stomach, provided that an adequate negative
with biopsy only (average, 1.4 days) than in comparable patients who proximal margin could be achieved.46 This conclusion was based
underwent exploratory laparotomy without resection (average, 6.5 on their finding that 5-year survival probabilities were essentially
days). Finally, at the time the data were reported, none of the equivalent in the two groups studied (65.3% in the subtotal gas-
patients who underwent laparoscopy had required palliative sur- trectomy group versus 62.4% in the total gastrectomy group).
gery. Subsequent single-institution series confirmed the utility of
staging laparoscopy, reporting accuracy rates ranging from 95% to Options for proximal gastric cancer As noted (see above),
97% and occult M1 disease rates approaching 30%.37,38 Taken as a adenocarcinoma of the gastric cardia and the esophagogastric
whole, the data, though derived from relatively small single-institu- junction appears to be clinically distinct from adenocarcinoma of
tion experiences, are compelling, and they have led the NCCN to the distal stomach,47 and its incidence is currently escalating across
encourage laparoscopic staging strongly, either before or at the all races and age groups. Accordingly, it is imperative that sur-
time of the planned resection.39 geons understand the surgical options for treatment of proximal
gastric cancer.48
MANAGEMENT
For tumors originating from the distal esophagus, esophagec-
tomy—either transhiatal esophagectomy with a cervical anasto-
Surgical Therapy mosis or transthoracic (Ivor-Lewis) esophagectomy with a tho-
Surgical resection [see 5:20 Gastroduodenal Procedures] remains racic anastomosis—is clearly the procedure of choice [see 4:4 Open
the only potentially curative therapy for localized gastric cancer Esophageal Procedures]. For tumors of the cardia, it has been sug-
[see Figure 3]. Cure requires removal of all gross and microscopic gested that esophagogastrectomy might offer a survival advantage
disease. More specifically, a margin-negative (R0) resection entails over total gastrectomy with an esophagojejunal anastomosis. This
wide local excision of the primary tumor with en bloc removal of suggestion was evaluated in a study of 1,002 patients with adeno-
all associated lymphatic vessels and any local or regional extension carcinoma of the esophagogastric junction.49 The investigators
of disease.The downside of surgical resection as a sole modality of divided tumors into three types on the basis of the location of the
therapy is that it is associated with a high rate of relapse. Conse- tumor center—cancers of the distal esophagus (type I), cancers of
quently, several areas of surgical treatment of stomach cancer the cardia (type II), and cancers of the subcardial fundus (type
remain subject to controversy. In particular, the extent of gastric re- III)—and analyzed the demographic and long-term survival data.
section, the extent of lymph node dissection, the optimal approach Operative mortality proved to be higher with esophagogastrecto-
to proximal stomach lesions, and the role of splenectomy and my than with extended total gastrectomy. Furthermore, R0 resec-
adjacent organ resection continue to generate significant debate. tion and lymph node status were found to be the dominant prog-
nostic factors influencing survival. Finally, in patients with type II
Extent of gastric resection R0 resection (i.e., resection of all lesions, the pattern of lymphatic spread was primarily to paracar-
gross disease with microscopically negative margins) has been dial, lesser curvature, and left gastric node groups. These data,
shown to have a clear impact on overall survival after potentially taken together, led the authors to conclude that total gastrectomy
curative surgery. In the German Gastric Cancer Study, a prospec- is preferable to esophagogastrectomy in this setting if a margin-
tive multicenter observational trial, the calculated 10-year survival negative resection can be achieved.
rate in the entire population was 26.3%, compared with 36.1% in An alternative approach to treating proximal gastric cancer is to
patients who underwent an R0 resection.40 In a large multi-institu- perform a proximal subtotal gastrectomy. To date, no prospective
tional adjuvant therapy trial, 19% of patients underwent an R1 studies have compared this method with total gastrectomy or
resection (i.e., had resection-line involvement); only 9% of patients transhiatal esophagogastrectomy for esophagogastric junction tu-
with stage I, II, or III disease and resection-line involvement sur- mors, but surgeons from MSKCC have published their retrospec-
vived beyond 5 years, compared with 27% of those who underwent tive experience with 98 patients who underwent either total gas-
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 8 Tumors of the Stomach, Duodenum, and Small Bowel — 6
trectomy or proximal subtotal gastrectomy for proximal gastric ed metastases underwent either total gastrectomy or, if 5 cm prox-
cancer over a 10-year period.50 There were no significant differ- imal margins could be obtained, distal gastrectomy. In this study,
ences between the groups with respect to morbidity, mortality, or a D2 lymph node dissection entailed distal pancreatectomy and
5-year survival. It remains to be seen whether such excellent splenectomy. Both morbidity and mortality were significantly high-
results can be achieved at other centers. er in the D2 group than in the D1 group, and D2 dissection con-
Thus, the evidence at present does not support routine perfor- ferred no demonstrable survival advantage at a median follow-up
mance of total gastrectomy for lesions of the distal fundus or of 72 months.
antrum, provided that histologically negative margins are achiev- In a trial from the Medical Research Council in the United
able without compromise of the gastric inlet. Our current practice Kingdom, 400 patients with stage I to IIB disease were randomly
is to perform a subtotal gastrectomy with Billroth II reconstruc- assigned to undergo either a D1 or a D2 lymph node dissection.58
tion for tumors of the distal stomach, a total gastrectomy with There was no significant difference in overall 5-year survival
Roux-en-Y esophagojejunostomy for most cancers of the fundus between the two arms, but multivariate analysis demonstrated that
and the proximal stomach [see 5:20 Gastroduodenal Procedures], clinical stages II and III, advanced age, male sex, and removal of
and either a transthoracic esophagogastrectomy or a transhiatal the pancreas and the spleen were independently associated with
esophagogastrectomy with gastric interposition for tumors of the poor outcome. The authors concluded that the classic Japanese
esophagogastric junction and the cardia [see 4:4 Open Esophageal D2 dissection offered no survival advantage over D1 dissection.
Procedures]. However, they hypothesized that D2 dissection with preservation
of the distal pancreas and the spleen might lead to decreased mor-
Extent of lymph node dissection Over the past decade, few bidity and mortality within the extended resection group and thus
topics in the surgical literature have generated more debate than potentially to superior outcomes.
the optimal extent of regional lymphadenectomy for gastric can- Further support for this hypothesis was provided by two non-
cer. In Japan, where radical surgery for gastric cancer is now uni- randomized trials from specialized centers. The Italian Gastric
versally accepted, the JRSGC has codified the extent of lymphat- Cancer Study Group (IGCSG) completed a phase II multicenter
ic dissection according to the level of nodes dissected.51 A D1 trial designed to evaluate the safety and efficacy of pancreas-pre-
lymph node dissection involves resection of the perigastric lymph serving D2 lymph node dissection.59 Quality control measures
nodes along the greater and lesser curvature of the stomach. A D0 included supervision by a surgeon who had studied the technique
dissection is anything less than a D1 dissection. A D2 dissection of D2 lymph node dissection at the National Cancer Center
entails resection of the D1 nodes along with nodes along the com- Hospital in Tokyo. At a median follow-up time of 4.38 years, the
mon hepatic artery, the left gastric artery, the celiac axis, and the overall morbidity rate for D2 dissection in the 191 patients enrolled
splenic artery. A D3 lymph node dissection adds resection of was 20.9%, and the in-hospital mortality was 3.1%. The 5-year
nodes in the hepatoduodenal ligament and the root of the mesen- survival rate for eligible patients was 55%. In a prospective series
tery. Finally, a D4 resection calls for a D3 dissection plus resection of 125 patients undergoing standardized D2 lymph node dissec-
of the retroperitoneal para-aortic and paracolic lymph nodes.52 tion at a single Western center, the investigators reported a mor-
The JRSGC defines a curative operation as a gastric resection that tality of 1.37% and an overall morbidity of 33.5%.60 As in the
includes lymph nodes one level beyond the level of pathologic IGCSG study, distal pancreatectomy was avoided in all cases,
nodal involvement.Thus, in Japan, a D2 lymph node dissection is except when direct extension was suspected on the basis of macro-
considered the standard resection for even relatively early cancers, scopic findings (5.5% of cases). Overall 5- and 10-year survival
and numerous studies have cited the benefits of D3 and even D4 rates for this highly selected cohort were 52.3% and 40%, respec-
lymphadenectomy for advanced carcinoma.53-55 tively. These studies suggest D2 lymph node dissection may be
Western surgeons have been reluctant to embrace radical lym- safely performed in Western centers, when accompanied by care-
phadenectomy, arguing that it has yet to demonstrate an unequiv- ful selection of patients, strict standardization of technique, and a
ocal survival advantage in any prospective, randomized trial from strategy of pancreatic preservation.
a Western institution or cooperative group. Detractors further Current AJCC guidelines state that pathologic examination of
argue that the survival advantage associated with more radical at least 15 lymph nodes is required for adequate staging.28 In an
procedures simply reflects stage migration, a higher incidence of effort to confirm the benefit of this staging system, investigators
early gastric cancers, and differences in tumor biology and body from MSKCC reviewed their experience with 1,038 patients who
habitus between Japanese and Western populations, and they point underwent R0 resection for gastric cancer.61 The location of posi-
to the increases in operating time and morbidity that often accom- tive lymph nodes (within 3 cm of the primary tumor versus more
pany extended gastric resections. One retrospective review of the than 3 cm away) did not significantly affect median survival; how-
tumor registries of over 2,000 hospitals in the United States found ever, the number of positive lymph nodes had a profound effect on
that D2 lymph node dissection had no survival advantage over D1 survival. Furthermore, in cases in which at least 15 nodes were
lymph node dissection in terms of either the median survival time examined (27% of the total), the median survival for patients with
or the 5-year survival rate.56 N1 (metastasis in one to six regional lymph nodes), N2 (metasta-
Two prospective trials from Western Europe examined this issue sis in seven to 15 regional lymph nodes), and N3 disease (metas-
further in an effort to evaluate the safety and efficacy of ELND. In tasis in more than 15 regional lymph nodes) was significantly
the Dutch Gastric Cancer Group trial, 711 patients were ran- longer than the median survival reported in cases in which 14 or
domly assigned to undergo either D1 or D2 lymphadenectomy as fewer nodes were resected with the specimens. These findings are
part of a potentially curative gastrectomy for biopsy-proven ade- consistent with published data from our own institution (North-
nocarcinoma.57 This trial was unique in its use of extensive quali- western University Feinberg School of Medicine), which indicate
ty control measures, which included instruction and operative that the number of positive lymph nodes is a highly significant pre-
supervision by an expert gastric cancer surgeon from Japan (who dictor of survival.62 In our series of 110 patients, those with N2 or
also assisted with the processing and pathologic examination of N3 disease (seven or more positive lymph nodes) had a median
the surgical specimens). Patients without evidence of disseminat- disease-free survival (DFS) of 17.6 months, whereas those with
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 8 Tumors of the Stomach, Duodenum, and Small Bowel — 7
N0 or N1 disease (six or fewer positive nodes) had a median DFS routine splenectomy does not increase survival, and it should be
of 44 months. Data from other centers support this view as well reserved for situations in which the gastric tumor directly invades
[see Table 3]. the splenic hilum or there is evidence of gross nodal metastases
It is our current practice to perform a D2 lymph node dissec- along the splenic artery.
tion, with resection of all perigastric lymph nodes along the
greater and lesser curvatures of the stomach, as well as those along Nonsurgical Therapy
the common hepatic artery, the left gastric artery, the celiac axis, Adjuvant therapy As noted (see above), the majority of
and the splenic artery [see 5:20 Gastroduodenal Procedures]. We patients who present with gastric carcinoma and undergo poten-
make every attempt to preserve the tail of the pancreas and spleen, tially curative surgical treatment will experience locoregional fail-
with multivisceral resection reserved for cases of overt direct ex- ure, distant metastasis, or both and will succumb to their disease.
tension of malignant disease in the absence of disseminated me- Accordingly, numerous adjuvant approaches—including chemo-
tastasis.This strategy should provide adequate staging in terms of therapy, radiotherapy, chemoradiation, immunochemotherapy, and
the AJCC guidelines, minimize morbidity, and possibly confer a intraperitoneal chemotherapy—have been tried in gastric cancer
survival advantage on certain patient subgroups, as suggested by patients with the aim of improving overall survival and DFS. The
the results of the trials mentioned. results, for the most part, have been disappointing.
Results from prospective, randomized, controlled trials of adju-
Role of splenectomy Routine splenectomy has been pro- vant radiation therapy in this setting have failed to establish a sur-
posed as a means of facilitating clearance of metastatic nodes vival benefit. In a multi-institutional trial from 1994, patients were
along the splenic artery and in the splenic hilum, but there is little randomly assigned to undergo surgery alone, surgery plus adju-
evidence to support this practice in the treatment of proximal gas- vant radiation, or surgery plus adjuvant multiagent chemothera-
tric cancers. Indeed, numerous studies have documented the dele- py.66 There was no significant benefit to either adjuvant regimen:
terious effect of splenectomy when it is performed as part of an overall 5-year survival was 20% for surgery alone, compared with
extended gastric resection. 12% for surgery plus radiation therapy and 19% for surgery plus
In a retrospective study of 392 patients who underwent curative chemotherapy.
gastrectomy at a high-volume cancer center, the impact of splen- Results from trials of chemotherapy alone have been equally un-
ectomy on survival and postoperative morbidity was evaluated.63 satisfactory. Because of the established inefficacy of single-agent
Splenectomy was not predictive of death on multivariate analysis, 5-fluorouracil (5-FU) therapy, combination chemotherapy regi-
but complications were far more frequent in patients who under- mens have been employed. Such regimens have included nitro-
went splenectomy as part of surgical treatment than in those who sourea compounds, mitomycin-C, anthracyclines, and members
did not (45% versus 21%). Specifically, the incidence of infectious of the cisplatin family.23 In a meta-analysis of 13 trials comparing
complications was far higher in the splenectomy group than in the adjuvant chemotherapy with observation in non-Asian countries,
nonsplenectomy group (75% versus 47%). the odds ratio for death in the treated group was 0.8, correspond-
In a review of data from an American College of Surgeons ing to a relative risk of 0.94.67 This result did not, however, reflect
Pattern of Care Study, the investigators reported that the opera- a statistically significant improvement. Most oncologists have now
tive mortality was 9.8% in patients who underwent splenectomy abandoned the use of chemotherapy by itself in the adjuvant setting.
during gastric resection, compared with 8.6% for those who did In an effort to derive greater therapeutic benefit than can be
not.64 More significantly, the 5-year observed survival rate was achieved with either radiation therapy or chemotherapy alone,
20.9% in the splenectomy group, compared with 31% in the non- combinations of the two have been used in the adjuvant setting. In
splenectomy group. Intergroup Trial 0116, 556 patients who had undergone R0 resec-
In a randomized, prospective trial, early and late results of total tion of adenocarcinoma of the stomach or the esophagogastric
gastrectomy alone were compared with those of total gastrectomy junction were randomly assigned to treatment with either surgery
plus splenectomy in patients being treated for cancers of the upper alone or surgery plus postoperative chemoradiotherapy.68 Patients
third of the stomach.65 All patients underwent a D2 lymph node with tumors ranging from stage IB to stage IVM0 were included;
dissection. The operative mortalities and the 5-year survival rates the majority had T3 tumors and node-positive disease.The thera-
were similar in the two groups, but the splenectomy group had peutic regimen consisted of 5-FU and leucovorin administered con-
more infectious complications. Specifically, the splenectomy group comitantly with 45 Gy of external-beam irradiation over a period
had higher incidences of pulmonary complications, postoperative of 5 weeks. Median overall survival in the surgery-only group was
fever higher than 38° C (100° F), and subphrenic abscess forma- 27 months, compared with 36 months in the surgery-chemoradi-
tion. We agree with the conclusions of the authors of this study: ation group. In addition, the 3-year survival rate was 41% in the
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 8 Tumors of the Stomach, Duodenum, and Small Bowel — 8
surgery-only group, compared with 50% in the surgery-chemora- gical resection with D2 lymphadenectomy; four patients (17%)
diation group.The hazard ratio for death in the surgery-only group had progressive disease and did not undergo resection. Morbidi-
as compared with the surgery-chemoradiation group was 1.35. ty and death rates were acceptable (32% and 5%, respectively),
In the United States, the results of Intergroup Trial 0116 have and 11% of patients exhibited complete pathologic responses.
led to the acceptance of chemoradiotherapy as standard adjuvant Overall, 63% of patients showed pathologic evidence of a signif-
therapy for patients who have undergone curative-intent resection icant treatment effect.
of gastric cancer. Nonetheless, numerous criticisms of this trial Newer neoadjuvant treatment strategies employ multiagent in-
have been expressed. Specifically, a review of the operative and duction chemotherapy followed by chemoradiotherapy and planned
pathology reports of 453 of the patients revealed a lack of surgical gastric resection in patients with locally advanced but potentially
standardization.69 When the extent of lymphadenectomy was cat- resectable gastric cancer.73
egorized, the majority (54.2%) of the patients were found to have
FOLLOW-UP AND MANAGEMENT OF RECURRENT DISEASE
undergone a D0 dissection; 38.1% underwent a D1 dissection,
and only 7.5% underwent a D2 or D3 dissection. These findings Even after gross resection of all disease with microscopically
suggest that the main effect of the chemoradiation therapy may negative margins (R0 resection), recurrence of gastric carcinoma
have been simply to compensate for inadequate surgery.This sug- is common. Adenocarcinoma of the stomach may spread through
gestion is supported by the observation that the number of patients direct extension, via lymphatic channels to regional and distant
with local and regional recurrences was higher in the surgery-only lymph nodes, or via the bloodstream to distant sites. Further-
group (178 versus 101), whereas the number of patients with dis- more, once tumors have penetrated the serosa (T3), peritoneal
tant failure was slightly higher in the adjuvant-therapy arm (40 metastasis becomes a possibility. Through autopsy series and
versus 32). Furthermore, when the Maruyama Index of Un- clinical studies, certain definite patterns of locoregional failure
resected Disease (a computer model developed for accurate pre- and distant metastasis have been established. Locoregional
diction of nodal station involvement in gastric cancer) was applied recurrences are common in the gastric bed and the adjacent
to the 556 patients eligible for the Intergroup Trial, the median lymph nodes. Clinical and reoperative evaluation have docu-
Maruyama Index was 70.70 This value was far above the level con- mented recurrent disease at the anastomosis, in the retroperi-
sidered to represent optimal surgical therapy (i.e., Maruyama toneum, or in the regional lymph nodes in 3% to 69% of
Index < 5) and led the authors to conclude that the vast majority patients; the incidence of recurrence may vary, depending on
of patients in the trial had been surgically undertreated. whether the patients had received adjuvant therapy.23 One autopsy
Currently, physicians, especially in Europe, generally eschew series documented a locoregional recurrence rate of 94% in pa-
adjuvant therapy after R0 resection of gastric cancer, except under tients treated with surgery alone. The peritoneum is ultimately
the auspices of a clinical trial.9 The Radiation Therapy Oncology involved in 17% to 50% of all patients. The most common sites
Group has initiated a phase II trial of adjuvant chemoradiothera- of visceral metastases are the liver and the lungs.
py using 45 Gy of external beam radiation with cisplatin and pax- In view of the high recurrence rates, all patients who have
itaxel, with or without 5-FU. If promising results are found, a undergone resection should be seen for routine surveillance exam-
phase III trial will follow. It is to be hoped that ongoing trials will inations. Currently, the NCCN recommends that a complete his-
shed further light on this complex management issue. tory and physical examination be conducted every 4 months for 1
year, then every 6 months for 1 year, and then yearly thereafter.39
Neoadjuvant therapy As a response to the disappointing A complete blood count, serum electrolyte concentrations, and
results of adjuvant therapy and the inability of many patients to liver function studies should also be considered. Imaging studies
regain adequate performance status after radical gastric surgery, (e.g., CT and endoscopy) are ordered as indicated, usually in
neoadjuvant therapy protocols have been proposed.71 The theo- response to new symptoms. In addition, long-term vitamin B12
retical benefits of a neoadjuvant treatment strategy include treat- supplementation should be initiated for patients who have under-
ment-induced tumor downstaging, which may enhance resectabil- gone a proximal or subtotal gastrectomy.
ity, and early administration of systemic therapy, which allows
almost all patients to receive and complete the prescribed treat-
ment. Furthermore, because treatment is administered when mea- Other Gastric Malignancies
surable disease is present, response to therapy may be assessed and
GASTRIC LYMPHOMA
continued only in patients who are likely to benefit. Finally, patients
who are found to have rapidly progressive disease during preoper- Gastric lymphoma is the second most common malignancy of
ative chemotherapy may be spared having to undergo a nonthera- the stomach, accounting for 2% to 9% of gastric tumors in the
peutic gastrectomy.72 United States. Lymphomas of the stomach are of the non-Hodgkin
In a report of three phase II trials from the M. D. Anderson type.The stomach is the most common site of extranodal involve-
Cancer Center, encompassing 83 patients who received neoadjuvant ment of non-Hodgkin lymphoma (NHL) and accounts for nearly
chemotherapy before planned surgical resection, clinical response 50% of all such cases.74
rates ranged from 24% to 38%, with three patients (4%) exhibit-
ing a complete pathologic response.72 Sixty-one patients (73%) Clinical Evaluation
were able to undergo a curative-intent resection, and the response The presenting symptoms of gastric lymphoma, like those of
to chemotherapy was the only significant predictor of survival on gastric adenocarcinoma, are nonspecific and include loss of ap-
multivariate analysis. petite, weight loss, vomiting, and bleeding. Overt clinical symp-
Preoperative chemoradiation therapy has also been shown to toms (e.g., fever and night sweats) are relatively rare: in one mul-
be feasible in phase II trials. In a 2001 trial that included 23 ticenter trial concerned with primary gastric lymphoma, they
patients, 96% of the study population received combined-modal- occurred in fewer than 12% of patients enrolled.75 Risk factors for
ity therapy.71 Nineteen patients (83%) were able to undergo sur- gastric lymphoma include H. pylori infection, immunosuppression
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 8 Tumors of the Stomach, Duodenum, and Small Bowel — 9
after solid-organ transplantation, celiac disease, inflammatory bowel bleeding or perforation. In the German Multicenter Study Group
disease, and HIV infection.76 trial, 185 patients with stage I or II gastric lymphoma were treat-
ed either with gastrectomy followed by radiation or (in the case of
Investigative Studies high-grade lesions) chemotherapy plus radiation or with chemo-
The diagnosis of gastric lymphoma is most frequently estab- therapy and radiotherapy alone.75 There was no significant differ-
lished by means of endoscopy with biopsy. Staging studies in- ence in survival between the group receiving surgical treatment
clude a comprehensive blood count, a lactate dehydrogenase and the group receiving nonoperative therapy: overall 5-year sur-
(LDH) level, and a comprehensive chemistry panel; CT of the vival rates were 82.5% and 84%, respectively. There were no per-
chest, the abdomen, and the pelvis; and, often, a bone marrow forations, and there was only one hemorrhage (in a patient treat-
biopsy. All pathology slides should be reviewed by an experienced ed with chemotherapy alone). Similarly, in a single-institution,
hematopathologist.77 prospective, randomized trial comparing chemotherapy alone
with chemotherapy plus surgery for stage I and II lymphoma,
Staging and Prognosis there were no instances of perforation and only three instances of
Numerous staging systems have been employed to stage NHL GI bleeding in the chemotherapy group, compared with two
of the GI tract. Of these, the one most commonly applied is a bleeding episodes in the surgery plus chemotherapy group.79
modification of the Ann Arbor staging system for lymphoma.76 Currently, patients with early-stage high-grade gastric lym-
For surgeons, the most important determination is often whether phomas are treated primarily with chemotherapy or radiation
the NHL (1) is confined to the stomach and the perigastric nodes therapy; only rarely do they require surgical intervention for com-
(stage I and II disease), (2) involves other intra-abdominal nodes plications encountered during therapy. Patients with locally ad-
and organs (stage III), or (3) extends outside the abdomen vanced (stage III) or disseminated (stage IV) gastric lymphoma are
(stage IV).78 clearly best treated with chemotherapy, with or without radiation.
Occasionally, surgery is indicated in such patients to treat residual
Management disease confined to the stomach or to palliate bleeding or obstruc-
Over the past decade, the management of patients with gastric tion that does not resolve with nonoperative therapy. Primary sur-
lymphoma has undergone significant changes. Generally, there has gical therapy is to be avoided in these patients because of the sig-
been a shift away from surgical management, even in relatively nificant risk of complications and the delay in initiating systemic
localized cases (stages I and II).79 This shift is the result not only of therapy.
the documented success of chemotherapy alone for more ad-
GASTROINTESTINAL STROMAL TUMOR
vanced cases (stages III and IV) but also of a better understanding
of the etiology of gastric lymphoma.80 Approximately 45% of all Gastrointestinal stromal tumor (GIST), though relatively rare
gastric lymphomas are low-grade mucosa-associated lymphoid tis- in absolute terms, is the most common sarcoma of the GI tract,85
sue (MALT) lymphomas.75 The gastric mucosa is normally devoid with approximately 6,000 cases reported each year in the United
of lymphoid tissue. It is hypothesized that MALT develops in the States alone. The stomach is the most common site of involve-
stomach in response to chronic H. pylori infection.81 ment, accounting for 60% to 70% of cases86; the small intestine
(25%), the rectum (5%), the esophagus (2%), and a variety of
Nonsurgical therapy Low-grade MALT lymphoma usually other locations account for the remainder. On the basis of their
presents as stage I or II disease and has an indolent course. Since appearance on light microscopy, GISTs were once thought to be
1993, when regression of low-grade MALT lymphoma after erad- of smooth muscle origin, and most were classified as leiomyosar-
ication of H. pylori was first reported, numerous trials have docu- comas.87 Thus, extended gastric resection, often including con-
mented the efficacy of anti–H. pylori therapy, with complete remis- tiguous organs, was advised. Recurrence developed after R0 resec-
sion rates ranging from 50% to 100%.79 In the German MALT tion in approximately 50% of cases.88 With the advent of immuno-
Lymphoma Study, the complete remission rate was 81%; 9% of histochemistry and electron microscopy, it became clear that
patients exhibited partial responses, and 10% showed no response.82 GIST has both smooth muscle and neural elements, and the cell
Low-grade lymphomas that are more advanced or do not regress of origin is now believed to be the interstitial cell of Cajal, an
with antibiotic therapy may be treated with H. pylori eradication intestinal pacemaker cell.89 The diagnosis of GIST is secured by
and radiation (with or without chemotherapy).83 For localized per- immunohistochemical staining for the tyrosine kinase receptor
sistent disease, modest doses of radiation, on the order of 30 Gy, KIT (CD117), which highlights the presence of interstitial cells of
may be employed.When chemotherapy is required, multiagent re- Cajal. More than 95% of GISTs exhibit unequivocal staining for
gimens, such as cyclophosphamide-vincristine-prednisolone (COP), KIT.86 Approximately two thirds of GISTs also express CD34.
are often used. Histologically, these tumors may exhibit a spindle cell pattern, an
Approximately 55% of gastric lymphomas are high-grade le- epithelioid pattern, or a mixed subtype.
sions, which can occur with or without a low-grade MALT com-
ponent.75 These lymphomas are treated with chemotherapy and Clinical Evaluation
radiation therapy according to the extent of the disease.The cyclo- The median age of incidence is 63 years, and tumors are gen-
phosphamide-doxorubicin-vincristine-prednisolone (CHOP) regi- erally between 0.5 and 44 cm in diameter at the time of diagnosis
men is the one most frequently employed. In some studies, the (median diameter, 6 cm).86 Mass-related symptoms (e.g., abdom-
anti-CD20 monoclonal antibody rituximab has been either added inal pain, bloating, and early satiety) may be present. Melena or
to standard therapy or used alone, with encouraging results.84 anemia from overlying mucosal ulceration may be present as well.
A small subset of patients have peritonitis as a consequence of
Surgical therapy Surgical resection, once thought to be tumor rupture and subsequent hemorrhage. Finally, many GISTs
essential for the diagnosis, staging, and treatment of early-stage are discovered incidentally during operation, abdominal imaging,
gastric lymphoma, now is used mainly in patients who experience or endoscopy.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 8 Tumors of the Stomach, Duodenum, and Small Bowel — 10
When a GIST is suspected, abdominal and pelvic imaging with Gastric carcinoid tumors are rare, accounting for fewer than
either CT or MRI is indicated. Chest imaging is performed as 11% to 30% of all GI carcinoids and fewer than 1% of all gastric
well. Endoscopy, with or without EUS, may occasionally help with tumors.92 The median age at diagnosis is 62, and tumors are
surgical planning, but because of the infrequency of mucosal in- equally distributed between men and women.
volvement, it is rarely diagnostic.90 Surgical consultation should be
Clinical Evaluation and Investigative Studies
obtained to determine whether the lesion can be resected. If the
tumor is resectable, biopsy should not be performed, because of Gastric carcinoid tumors are often discovered during endo-
the risk of tumor rupture and intra-abdominal dissemination. Biop- scopic examination of patients experiencing chronic abdominal
sy may be required, however, if the patient has widespread disease pain; patients may also complain of vomiting and diarrhea. These
or may be enrolling in a trial of neoadjuvant therapy. In such cases, tumors are rarely associated with symptoms of the carcinoid syn-
biopsy may be performed percutaneously or at the time of EUS. drome. Diagnosis is usually confirmed by endoscopic biopsy, and
EUS is helpful in determining the extent of gastric wall penetra-
Staging and Prognosis tion and the degree of regional lymph node involvement.
Although the majority of gastric GISTs have a benign course, a Gastric carcinoid tumors have been divided into three types,
wide spectrum of biologic behavior has been observed. Of the primarily on the basis of their association (or lack thereof) with
prognostic factors examined to date, tumor size and mitotic rate hypergastrinemia.Type I tumors are associated with chronic atro-
appear to be the most valuable. If the tumor is less than 2 cm in phic gastritis, are generally small (< 1 cm), and are often multiple
diameter and the mitotic count is lower than five per high-power and polypoid. They grow slowly and only rarely metastasize to
field (HPF), the risk of an aggressive disease course is considered regional nodes or distant sites. Type II tumors are associated with
to be very low. Conversely, if the tumor is larger than 10 cm, if the the Zollinger-Ellison syndrome and multiple endocrine neoplasia
mitotic count is higher than 10/HPF, or if the tumor is larger than type I (MEN I) and, like type I tumors, are usually small and mul-
5 cm with a mitotic count higher than 5/HPF, the risk of aggres- tiple. They also grow slowly, but they are more likely to metasta-
sive clinical behavior is considered to be high. For all other tumors, size than type I gastric carcinoids are. Type III (sporadic) gastric
the risk of aggressive disease is considered to be intermediate.86 carcinoid tumors are the most biologically aggressive type. They
are often large (> 1 cm) at the time of diagnosis and are not asso-
Management ciated with hypergastrinemia. Type III lesions frequently metasta-
Surgical therapy The role of surgery in the treatment of a size to regional nodes (54%) or the liver (24%).92
GIST is to resect the tumor with grossly negative margins and an Management
intact pseudocapsule. Lymph node involvement is rare with
For patients with small, solitary type I tumors, endoscopic
GISTs, and thus, no effort is made to perform ELND.The tumor
polypectomy [see 5:18 Gastrointestinal Endoscopy] or open resection
must be handled with care to prevent intra-abdominal rupture.
via gastrotomy (local excision) [see 5:20 Gastroduodenal Procedures]
Formal gastric resection is rarely required: as a rule, it is indicated
is the procedure of choice. For patients with multiple or recurrent
only for lesions in close proximity to the pylorus or the esopha-
tumors, antrectomy [see 5:20 Gastroduodenal Procedures] is indicat-
gogastric junction.
ed to remove the source of the hypergastrinemia. For patients with
type II lesions, treatment is similar to that for patients with type I
Nonsurgical therapy If the tumor has metastasized or has
lesions, with the extent of gastric resection determined by the size
advanced locally to the point where surgical therapy would result
and number of lesions. For patients with type III lesions, however,
in excessive morbidity, the patient is treated with the tyrosine kinase
either distal or total gastrectomy with ELND is required.93 All
inhibitor imatinib mesylate. Imatinib is a selective inhibitor of a
patients undergoing a less than total gastrectomy should be fol-
family of protein kinases that includes the KIT-receptor tyrosine
lowed with serial endoscopy at regular intervals.94
kinase, which is expressed in the majority of GISTs. Originally
indicated for the treatment of chronic myelocytic leukemia, ima-
tinib was approved for the treatment of KIT-positive GIST in Table 4 American Joint Committee of Cancer TNM
2002, when phase II clinical trials documented sustained objective
Clinical Classification of Small Bowel Carcinoma
responses in a majority of patients with advanced unresectable or
metastatic GIST.91 Patients with borderline resectable lesions should
TX Primary tumor cannot be assessed
be treated with imatinib until they exhibit a maximal response as T0 No evidence of primary tumor
documented by CT and positron emission tomography (PET); TisCarcinoma in situ
surgery may then be undertaken to resect any residual foci of dis- T1 Tumor invades lamina propria or submucosa
ease. Similarly, whereas patients with metastatic disease are unlike- T2 Tumor invades muscularis propria
ly to manifest a complete response to imatinib therapy, they should Primary tumor (T) T3 Tumor penetrates < 2 cm into subserosa or into
nonperitonealized perimuscular tissue (mesentery for
be periodically reevaluated and considered for resection should sur- jejunum or ileum, retroperitoneum for duodenum)
gical treatment become technically feasible.90 T4 Tumor penetrates visceral peritoneum or directly
After an R0 resection of a GIST, no adjuvant therapy is indi- invades > 2 cm into adjacent structures
cated unless the patient is participating in a clinical trial. The
NX Regional lymph node(s) cannot be assessed
American College of Surgeons Oncology Group is currently con- Regional lymph N0 No regional lymph node metastasis
ducting two trials of imatinib in the postoperative setting. A phase nodes (N)
N1 Regional lymph node metastasis
II trial (Z9000) of imatinib, 400 mg/day, for patients with high-risk
MX Distant metastasis cannot be assessed
GIST, has reached accrual, and a phase III trial (Z9001) compar-
Distant metastasis (M) M0 No distant metastasis
ing 1 year of imatinib, 400 mg/day, with placebo in patients with
M1 Distant metastasis
intermediate-risk GIST is currently under way.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 8 Tumors of the Stomach, Duodenum, and Small Bowel — 11
Table 5 American Joint Committee on Cancer nosis is often made by means of esophagogastroduodenoscopy
Staging System for Small Bowel Carcinoma (EGD). Lesions within the first 100 cm of the small bowel may be
evaluated with push enteroscopy.When the adenocarcinoma is sit-
uated elsewhere in the small bowel, it is localized with small bowel
Stage T N M radiographs. Some authors consider enteroclysis to be superior to
the more commonly used small bowel follow-through in this set-
Stage 0 Tis N0 M0
ting, in that enteroclysis is better able to demonstrate fine mucosal
Stage I T1, T2 N0 M0 detail.99 In experienced hands, enteroclysis may therefore be more
Stage II T3, T4 N0 M0
sensitive.100 Some lesions are identified when CT or MRI is per-
formed to evaluate complaints of abdominal pain. Furthermore,
Stage III Any T N1 M0 abdominal imaging may yield complementary staging information
Stage IV Any T Any N M1 (e.g., the presence of regional adenopathy or metastatic disease). One
promising new method for the identification of small bowel tumors
is wireless capsule endoscopy.101 This minimally invasive technique
Small Bowel Malignancies
may be particularly useful in identifying small lesions in the distal
Malignant tumors of the small intestine are rare, accounting for jejunum and ileum that cannot be identified radiographically.
fewer than 5% of all GI tract malignancies. In the United States,
MANAGEMENT
only a few thousand new cases of small bowel cancer are report-
ed each year.95 The majority of small bowel malignancies are ade- Aggressive surgical resection remains the cornerstone of thera-
nocarcinomas, lymphomas, or carcinoid tumors,96 though GISTs py for adenocarcinoma of the small intestine.102 For periampullary
are being noted with increasing frequency in the small intestine. lesions, pancreaticoduodenectomy is typically required to achieve a
Treatment of lymphomas, carcinoid tumors, and GISTs in the margin-negative resection. For lesions in the distal duodenum, a
small bowel is nearly identical to treatment of the same lesions in segmental sleeve resection with a duodenojejunostomy is appro-
the stomach [see Other Gastric Malignancies, above] and thus will priate. For lesions in the jejunum or the ileum, segmental resection
not be covered further in this chapter. Our focus here is on the may be performed with a wide mesenteric resection to encompass
presentation, diagnosis, and treatment of adenocarcinoma of the potentially involved regional lymph nodes. Contiguous organs are
small bowel. Like gastric adenocarcinoma, small bowel adenocar- resected en bloc as necessary.98
cinoma is usually staged according to the AJCC/UICC TNM Because the presenting signs and symptoms are often vague and
classification system [see Tables 4 and 5]. nonspecific, diagnosis is often delayed. In one series, only 6 (11%)
of the 53 patients were suspected of having a small bowel tumor at
CLINICAL EVALUATION
admission.102 In a retrospective review of patients with small bowel
Between 46% and 55% of small bowel adenocarcinomas occur tumors treated at our institution, the mean duration of symptoms
in the duodenum.96,97 Patients frequently present with nausea, before surgical management was 110 months, and more than 50%
vomiting, abdominal pain, weight loss, and GI bleeding98; occa- of the patients were found to have stage III or IV disease.98
sionally, they present with iron deficiency anemia or a positive fecal The 5-year survival rate continues to be low (24% to
occult blood test result. In rare cases, small bowel obstruction, 37%).98,103,104 Significant predictors of good overall survival in-
often with the tumor serving as a lead point for intussusception, is clude complete (R0) resection and low AJCC tumor stage.98,103,104
the first manifestation of the disease.97 The available evidence indicates that all patients with small bowel
neoplasms should be offered an oncologically sound surgical resec-
INVESTIGATIVE STUDIES
tion. In one series, curative (R0) resection was accomplished in
When an adenocarcinoma is located in the duodenum, the diag- 51% of cases.103
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lesser sac endoscopy in gastric carcinoma oper- D2 gastrectomy for gastric cancer. Br J Cancer 78. Talamonti MS: Gastric cancer. Cancer Surgery
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Center Network tomy in Western patients with gastric cancer based 79. Yoon SS, Coit DG, Portlock CS, et al: The
http://www.nccn.org on a new concept: a prospective long-term fol- diminishing role of surgery in the treatment of
40. Siewert JR, Bottcher K, Stein HJ, et al: Relevant low-up study. Surgery 123:573, 1998 gastric lymphoma. Ann Surg 240:28, 2004
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5 GASTROINTESTINAL TRACT AND ABDOMEN 8 Tumors of the Stomach, Duodenum, and Small Bowel — 13
cobacter pylori infection and gastric lymphoma. N cal management and staging. Ann Surg 215: 97. Torres M, Matta E, Chinea B, et al: Malignant
Engl J Med 330:1267, 1994 68, 1992 tumors of the small intestine. J Clin Gastroenterol
81. Isaacson PG: Recent developments in our un- 88. Conlon KC, Casper ES, Brennan MF: Primary 37:372, 2003
derstanding of gastric lymphomas. Am J Surg gastrointestinal sarcomas: analysis of prognostic 98. Talamonti MS, Goetz LH, Rao S, et al: Primary
Pathol 20:S1, 1996 variables. Ann Surg Oncol 2:26, 1995 cancers of the small bowel. Arch Surg 137:564,
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82. Stolte M, Bayerdorffer E, Morgner A, et al: Heli- 89. Corless CL, Fletcher JA, Heinrich MC: Biology
cobacter and gastric MALT lymphoma. Gut of gastrointestinal stromal tumors. J Clin Oncol 99. Zuckerman GR, Prakash C, Askin MP, et al: AGA
50:III19, 2002 22:3813, 2004 technical review on the evaluation and manage-
ment of occult and obscure gastrointestinal
83. Schechter NR, Yahalom J: Low-grade MALT 90. Soft Tissue Sarcoma, Practice Guidelines in On-
bleeding. Gastroenterology 118:201, 2000
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gible for anti–Helicobacter pylori therapy. J Clin Med 347:472, 2002
Oncol 23:1979, 2005 92. Gilligan CJ, Lawton GP, Tang LH, et al: Gastric 102. Lambert P, Minghini A, Pincus W, et al: Treat-
carcinoid tumors: the biology and therapy of an ment and prognosis of primary malignant small
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al: Gastrointestinal stromal tumors: the inci-
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93. Schindl M, Kaserer K, Niederle B: Treatment of ment of small bowel cancer: a 20-year single insti-
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86. Miettinen M, Sobin LH, Lasota J: Gastrointes- 94. Modlin IM, Cornelius E, Lawton GP: Use of an
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lar genetic study of 1765 cases with long-term 95. Jemal A, Murray T, Ward E, et al: Cancer Statis- node status assessment for gastric carcinoma: is
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testinal leiomyosarcomas: implications for surgi- 1994 J Surg Oncol 69:15, 1998
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 9 Tumors of the Pancreas, Biliary Tract, and Liver — 1
Numerous types of tumors affect the pancreas, the biliary tree, Significant weight loss (≥ 10% of body weight) is common even
and the liver. Each year, hundreds of papers are published on the when the pancreatic cancer is resectable.
topics of pancreatic, biliary, and hepatic cancer. Accordingly, in In some patients, steatorrhea or diarrhea from obstruction of
this chapter, we concentrate on essential principles rather than the pancreatic duct, weight loss, pain, or a combination of these is
details. In particular, we focus on common malignant tumors, the presenting symptom, rather than jaundice. A presentation
addressing benign tumors and uncommon tumors only insofar as with steatorrhea or diarrhea is usually the result of a tumor in the
they are important in differential diagnosis. uncinate process that obstructs the pancreatic duct but not the
When a patient presents with an apparent cancer of the pan- bile duct. Often, these symptoms are overlooked until the tumor
creas, the biliary tree, or the liver, the surgeon must attempt to extends and causes jaundice. About 5% of patients have a history
answer the following three important questions: of diabetes of recent onset. Migratory thrombophlebitis (the
1. What is the diagnosis? Trousseau sign) is uncommon and usually signifies metastatic dis-
2. What is the surgical stage of the disease—that is, is the ease. Pancreatobiliary malignancies cause biliary obstruction, but
tumor resectable? such obstruction is not commonly associated with biliary tract
3. What is the operative rationale that will encompass the infection before instruments have been employed in the biliary
tree. Therefore, in patients presenting with cholangitis who have
disease and produce a margin-free resection (and, for
not undergone biliary tract instrumentation, other diagnoses
pancreatobiliary cancers, an N1 resection)?
should be suspected. Patients with pancreatic cancer may also
These questions form the underpinning for the process of present with acute pancreatitis as the first manifestation.Vomiting
investigation and management. In what follows, we describe our and GI bleeding are uncommon presenting symptoms and sug-
approach to each of the cancers in these terms. gest the presence of advanced tumors that are obstructing or erod-
ing the duodenum.
Pancreatic Cancer Physical examination. Examination reveals scleral icterus. In
some cases, the distended gallbladder may be palpable. In
DUCTAL ADENOCARCINOMA
advanced cases, signs of metastatic disease (e.g., hepatomegaly
and ascites) may be detected.
Adenocarcinoma of Head of Pancreas
Adenocarcinoma of the pancreatic head is common (with 30,000 Investigative studies Laboratory tests. Liver function tests
new cases occurring annually in the United States) but remains (LFTs) are of limited value in diagnosis.The serum bilirubin level
one of the hardest GI cancers to cure. In the past 25 years, the effi- is elevated in jaundiced patients, with the direct fraction exceed-
cacy of surgical treatment has improved dramatically, but 5-year ing 50%. The serum alkaline phosphatase level is almost always
actual survival rates in patients who have undergone resection are elevated when the bile duct is obstructed, and levels three to five
still low (about 15%).1 Cancer of the head of the pancreas is the times normal are common. Aminotransferase levels usually are
prototypical tumor that causes painless jaundice; however, other moderately elevated as well.Very high aminotransferase levels sug-
cancers that obstruct bile ducts also cause jaundice, including gest a hepatocellular cause of jaundice, usually viral, though
extrahepatic bile duct cancers, gallbladder cancers, ampullary impaction of a stone in the bile duct can cause transient rises in
malignancies, and some duodenal cancers. Some of the following serum aspartate aminotransferase (AST) to levels higher than
discussion is generalized with an eye to determining the diagnosis 1,000 IU/ml. By themselves, LFTs cannot effectively distinguish
in patients presenting with obstructive jaundice [see 5:3 Jaundice]. among jaundice arising from a hepatocellular cause (e.g., viral
hepatitis or drug-induced cholestasis), jaundice resulting from a
Clinical evaluation History. The classic presentation of disease of microscopic bile ducts (e.g., primary biliary cirrhosis),
cancer of the head of the pancreas is unremitting jaundice, usual- and jaundice caused by any of the malignancies that obstruct the
ly accompanied by dark urine, light stool, and pruritus. Darkening major bile ducts.To make this distinction, radiologic imaging tests
of the urine or pruritus is often the first symptom, and scleral are required [see Imaging, below].
icterus frequently is first noted by family members or coworkers. Serum concentrations of the tumor marker CA 19-9 are often
The pruritus is often severe. The jaundice sometimes is painless elevated in patients with pancreatic or biliary adenocarcinomas.2
but more frequently is associated with epigastric pain. This pain The upper limit of the normal range is 37 U/ml. Concentrations
usually is not severe; severe, acute pain is more often associated higher than 100 U/ml are highly suggestive of malignancy, but ele-
with other conditions that may cause jaundice (e.g., choledo- vations between 37 and 100 U/ml are less specific. Serum levels
cholithiasis and pancreatitis). Back pain suggests that the tumor generally reflect the extent of the tumor: small tumors (< 1 cm in
has invaded tissues outside the pancreas and is unresectable. diameter) are rarely associated with levels higher than 100 U/ml,
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 9 Tumors of the Pancreas, Biliary Tract, and Liver — 2
Figure 1 Shown is a typical hypoattenuating cancer of the pancreat- Figure 2 In the same patient as in Figure 1, pancreatic duct
ic head.The tumor is invading the right side of the portosplenic con- dilation is apparent in the body of the pancreas, with atrophy of
fluence, as evidenced by the “beaking” of the vein at that point. the parenchyma.
whereas very high levels (> 1,000 U/ml) suggest metastatic dis- also obstructed. As a result, the pancreatic duct may be dilated in
ease. High levels may also accompany cholangitis. Measurement the tail, body, and neck of the pancreas, with dilatation terminat-
of CA 19-9 concentrations may be employed to detect recurrences ing sharply at the edge of the tumor. Pancreatic duct dilatation is
in patients who have elevated CA 19-9 levels that return to nor- often accompanied by atrophy of the body and the tail of the pan-
mal after tumor resection; a second rise in the CA 19-9 level in the creas [see Figure 2].
follow-up period is indicative of recurrence in most cases. When a jaundiced patient is discovered to have a typical-appear-
ing localized cancer of the pancreatic head on CT scanning, no fur-
Imaging. Several different imaging tests may be used for diag- ther diagnostic tests are needed, and operative management should
nostic purposes in jaundiced patients, including computed tomog- be the next step.Tissue diagnosis is unnecessary. Negative biopsy re-
raphy, magnetic resonance imaging, endoscopic retrograde cholan- sults rarely change the therapeutic approach, and in that they are
giopancreatography (ERCP), endoscopic ultrasonography (EUS), sometimes falsely negative, they are potentially misleading. Further-
and transabdominal ultrasonography. The technical advances in more, omitting biopsy eliminates the small risk of tumor implantation
imaging achieved over the past few years are remarkable. CT and in the needle tract. Selection of axial imaging as the first test often
MRI, which only a few years ago were limited to axial images, on renders diagnostic ERCP, which is a more invasive test, unnecessary
one hand, and fuzzy MRI cholangiopancreatography (MRCP), on as well. Cholangiography also is not required for staging pancreatic
the other, can now provide high-quality images of blood vessels head tumors [see Surgical Staging, below].The advantages of starting
and ducts and their anatomic relation to tumors.These images can with axial imaging in jaundiced patients with suspected cancer are
even be projected in three dimensions if desired. discussed in greater detail elsewhere [see Biliary Tract Cancer, Extra-
Selection of appropriate imaging tests in a jaundiced patient is hepatic Cholangiocarcinoma, Upper-Duct Cholangiocarcinoma,
influenced by patient characteristics and by the symptoms Investigative Studies, below].
observed. For instance, the type and order of investigations appro-
priate for an older patient presenting with obstructive jaundice, Additional diagnostic imaging for atypical CT or MRI findings. In
who is likely to have a malignancy, differ from those appropriate many patients with adenocarcinoma of the pancreatic head, the
for a young woman with severe pain, who is more likely to have typical CT findings are absent and additional diagnostic imaging
choledocholithiasis. The best initial imaging test in a patient in is required. Such patients may be categorized into two groups:
whom malignancy is suspected is either a fine-cut (3 mm between those with an atypical mass and those with no mass on axial imag-
slices) three-phase (no-contrast phase, arterial phase, and venous ing. In either case, before ordering additional tests, it is appropri-
phase) helical (spiral) CT scan or a high-quality MRI scan.Although ate to determine whether the CT scan is of adequate quality. For
MRI has the advantage of being able to provide a cholangiogram example, the scan may have been performed without contrast, the
(i.e., with MRCP), small and medium-sized radiologic facilities arterial and venous phases may not have been captured appropri-
currently tend to be more skilled at CT than at MRI; this differ- ately, or the slice thickness may have been too great for precise
ence should be taken into account when the first test is ordered. visualization of the head of the pancreas. Small adenocarcinomas
High-quality MRI scanners and the very latest generation of CT may be missed when the venous phase is timed poorly, especially
scanners are capable of providing cholangiograms and angiograms, if slice thickness is 5 mm or greater, and masses that appear atyp-
as well as axial images. ical initially may exhibit a typical appearance when the CT scan is
The typical pancreatic cancer appears as a lucent zone in the optimized. Neuroendocrine cancers commonly display arterial-
pancreatic head [see Figure 1], associated with upstream dilatation phase enhancement, which will be missed if the scan is mistimed.
of the bile ducts and the gallbladder. Often, the pancreatic duct is In our experience, about 40% of referred patients who underwent
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 9 Tumors of the Pancreas, Biliary Tract, and Liver — 3
CT scanning before arrival require a so-called pancreas protocol The ultimate diagnostic test is pancreaticoduodenectomy. If
CT scan (i.e., a fine-cut three-phase helical scan) when they are there is a strong suspicion of cancer before laparotomy or the find-
first seen; in many of these cases, the second CT scan yields ings at laparotomy are strongly suggestive, this procedure should
important diagnostic findings. be performed without preliminary biopsy. When this approach is
When no mass is present in a jaundiced patient with a peri- followed, a small number of patients with suspected malignant dis-
ampullary tumor or another focal obstructing process (e.g., pan- ease will ultimately turn out to have benign disease when operat-
creatitis), the CT scan usually shows bile duct dilatation extend- ed on; this possibility should be explained to patients who do not
ing down to the intrapancreatic portion of the duct.The dilatation undergo confirmatory tissue diagnosis before operation. Because
may terminate anywhere from the upper border of the pancreas to of the limited negative predictive value of currently available tests,
the duodenum, depending on the site of the tumor and the nature pancreaticoduodenectomy is sometimes still required to make a
of the process obstructing the bile duct. In these conditions, definitive diagnosis.
ERCP is a good choice as the second test. The finding of an atypical pancreatic head mass on a CT scan
ERCP provides an endoscopic view of the duodenum that allows poses an additional challenge. Atypical masses may take different
identification and biopsy of ampullary and duodenal tumors that forms. In some cases, they exhibit attenuation that differs only
may be blocking the bile duct and producing jaundice. It confirms slightly from that of the surrounding pancreas; in others, they have
the presence of a bile duct stricture and displays its form, which is a ground-glass appearance. They may extend into the body and
helpful in diagnosis. Focal strictures, especially those with shoulders, tail of the pancreas, or they may be localized to the head. With
suggest malignancy. Long, tapering strictures limited to the intra- atypical masses, the most common problem is how to differentiate
pancreatic portion of the bile duct suggest chronic pancreatitis. Con- focal pancreatitis from adenocarcinoma. This differentiation can
comitant narrowing of the pancreatic duct in the head of the pan- be very difficult to achieve. Pancreatitis may be present without
creas (the double-duct sign) suggests the presence of a small antecedent acute attacks; without a history of alcoholism, gall-
pancreatic cancer that is not visible on the CT scan. Longer or mul- stones, or hyperlipidemia; without diabetes or steatorrhea; and
tiple pancreatic strictures suggest chronic pancreatitis. A single focal without calcifications in the gland. Cancer appears to be more
bile duct stricture in the absence of pancreatic duct abnormalities is common in patients who have had chronic pancreatitis, and the
the hallmark of cancer of the lower bile duct. Infiltrating cancers of diseases may coexist. Therefore, one cannot feel confident that
the bile duct may cause more than one stricture along the bile duct, cancer is absent simply because chronic pancreatitis is present.
but when more than one stricture is present, other diagnoses (e.g., Cancer should be suspected in patients with an established diag-
primary sclerosing cholangitis) should be considered. Both pancre- nosis of chronic pancreatitis who undergo a rapid change in status
atic and bile ducts may be assessed with brush cytology.This test has (e.g., weight loss). Diabetes is common in patients with chronic
a 45% to 50% sensitivity for cancer3; therefore, only a positive test pancreatitis, but it may also be the first sign of pancreatic cancer
result is significant. in patients without chronic pancreatitis. Chronic pancreatitis can
ERCP findings in a patient with no mass must be evaluated in the cause painless jaundice. A rare immune form of chronic pancre-
light of findings from other investigations. Patients with the classic atitis, known as lymphoplasmacytic sclerosing pancreatitis, has been
double-duct sign or single focal shouldered bile duct strictures are recognized that is particularly hard to differentiate from cancer.4
likely to have small pancreatic or bile duct tumors. Further diagnos- EUS is becoming increasingly important in the management of
tic support is usually not needed before laparotomy, though such patients with atypical pancreatic head masses.5 When jaundice is
support may be reassuring when the CA 19-9 concentration is high- present, ERCP followed by EUS is our usual approach; when it is
er than 100 U/ml.When doubt persists, EUS often helps resolve it. absent, EUS without ERCP is preferred. EUS-guided biopsy is
EUS may identify a small mass that was not seen on the CT scan, superior to CT-guided transabdominal biopsy, in that access to the
and biopsies may then be done. Occasionally, EUS reveals enlarged head of the pancreas is easier and the chance of needle tracking is
lymph nodes, which may also undergo biopsy. However, negative reduced (because the biopsy is taken through the duodenal wall,
EUS-guided biopsy results in patients who present with painless which is resected if a Whipple procedure is done).
jaundice do not exclude malignancy. When such patients have an At the conclusion of all of the preceding investigations, it still
identifiable mass on EUS, pancreaticoduodenectomy is recom- may not be clear whether a malignancy is present. Clinical judg-
mended, even if EUS-guided biopsy yields negative results. If a non- ment must be exercised in deciding whether to operate or to
operative approach is taken, short-term follow-up at 4 to 6 weeks repeat investigative studies after an interval of 2 to 3 months.
with repeat imaging and biopsy is mandatory. If the findings persist, Operation is favored in patients who are jaundiced, who have
laparotomy is advisable. less pain, who have elevated CA 19-9 levels, and whose mass is
Occasionally, preoperative testing reveals no mass, but a mass is suspicious for cancer. Elevation of the CA 19-9 concentration
subsequently discovered by intraoperative palpation or intraoper- beyond 100 U/ml should be regarded as a very important find-
ative ultrasonography (IOUS). A mass palpated in the head of a ing. When EUS is inconclusive, ultrasound-guided diagnostic
pancreas that is otherwise normal or near normal in texture is laparoscopy may be performed to obtain core tissue biopsies
highly suggestive of malignancy and constitutes sufficient justifi- from several areas of the mass. This technique is especially use-
cation for resection.The same is true of a mass detected by IOUS ful when chronic pancreatitis is strongly suspected,6 in that the
if the mass has characteristics of malignancy (i.e., is hypoechoic). multiple long core biopsies obtainable with this procedure pro-
If the IOUS findings are inconclusive, biopsy with frozen-section vide a greater degree of assurance against false-negative findings
examination is a reasonable approach. In many such cases, the for cancer. Even this test, however, is not 100% accurate in this
whole pancreas is diffusely firm or hard, and IOUS demonstrates regard.The penultimate diagnostic test is laparotomy with mobi-
a diffuse change in the normal texture of the gland.When the pan- lization of the pancreatic head and IOUS-guided transduodenal
creas is diffusely firm and no localized process is seen on IOUS, core biopsies of the mass. The ideal outcome with this approach
biopsies should be directed toward the stent in the bile duct at the is to perform pancreaticoduodenectomy in all patients who actu-
point where the bile duct narrows (as seen on ultrasonography). ally have cancer while reducing to a reasonable minimum resec-
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 9 Tumors of the Pancreas, Biliary Tract, and Liver — 4
tion in patients with benign disease, who in most cases are bet-
Table 2 American Joint Committee on Cancer
ter served by biliary bypass.
Staging System for Pancreatic Cancer
Surgical staging The term staging is currently used to Stage T N M
denote the process by which the surgeon determines whether a
tumor is resectable. We prefer to use the term surgical staging for Stage 0 Tis N0 M0
this process so as to distinguish it from those staging classifications
Stage IA T1 B0 M0
that define the life history and prognosis of tumors and provide the
basis for comparison of results—namely, the TNM classifications Stage IB T2 N0 M0
developed by the American Joint Committee on Cancer (AJCC).
Stage IIA T3 N0 M0
These latter systems are also of great importance to the surgeon
dealing with pancreatic tumors. Stage IIB T1, T2, T3 N1 M0
Surgical staging is started preoperatively and completed intra- Stage III T4 Any N M0
operatively. Preoperative staging tests determine operability—that
is, whether the tumor appears resectable after preoperative testing. Stage IV Any T Any N M1
However, the final decision regarding resectability is made only
during the operation, on the basis of intraoperative staging. A
tumor of the head of the pancreas is deemed unresectable when it tified; ascitic fluid may be sent for cytologic analysis, and omental
is determined to have extended beyond the boundaries of a pan- nodules may undergo ultrasound-guided biopsy. Invasion of the
creaticoduodenectomy. Common reasons for unresectability include mesentery, the mesocolon, or retroperitoneal tissues may also be
(1) vascular invasion (i.e., invasion of the superior mesenteric vein, detected by CT scanning. In the view of some surgeons, such inva-
the portal vein, the superior mesenteric artery, or, less commonly, sion may render the tumor unresectable, but in our experience,
the hepatic artery); (2) lymph node metastases that fall outside the this is rarely the case in the absence of concomitant vascular inva-
scope of a pancreaticoduodenectomy (e.g., metastases to para-aor- sion: the resection may still be accomplished with clear margins by
tic and celiac lymph nodes); (3) hepatic metastases; (4) peritoneal resecting the portion of the mesocolon or the mesentery that was
metastases; and (5) extra-abdominal metastases (usually pul- locally invaded.
monary). Limited vascular invasion of the superior mesenteric EUS may be used to guide biopsy of suspicious lymph nodes
vein and the portal vein may be overcome by resection and recon- when these lie outside the planned resection zone. It has also been
struction and thus is only a relative contraindication to resection. employed to assess vascular invasion, but in our experience, it has
This is especially true when the tumor is small and has arisen in no advantage over CT scanning in this regard; what is more, it is
the vicinity of the veins. In a series from our institution (Washington highly operator dependent. Staging laparoscopy is particularly
University in St. Louis), about 20% of resections done for pan- effective at finding small hepatic and peritoneal nodules. About
20% of patients thought to have resectable pancreatic adenocarci-
creatic cancer involved resection of these veins.7
noma of the head of the pancreas before staging laparoscopy are
The tests used to establish the diagnosis and those used to
found to have liver or peritoneal metastases upon laparoscopy.8
accomplish surgical staging go hand in hand. Abdominal CT
Staging is completed intraoperatively by carefully inspecting the
scans, abdominal MRI, thoracic CT scans, and chest radiographs
intra-abdominal contents, opening the lesser sac, mobilizing the
are obtained to detect hepatic metastases, vascular invasion, and
head of the pancreas, performing biopsies of suspicious nodules or
pulmonary metastases. To assess vascular invasion, fine-cut three-
nodes outside the planned resection zone, and attempting dissec-
phase helical CT scans or MRI scans are required.These tests may
tion of the superior mesenteric vein or the portal vein. Formal clin-
detect enlarged lymph nodes, but it should be remembered that
icopathologic staging according to the AJCC’s TNM system is
nodes may be enlarged for reasons other than cancer. Sometimes, useful for establishing the prognosis and planning additional treat-
ascitic fluid collections or peritoneal or omental nodules are iden- ment [see Tables 1 and 2].
All authorities agree that axial imaging of the abdomen and
Table 1 American Joint Committee on Cancer TNM chest (or roentgenography of the chest) is standard practice for
Clinical Classification of Pancreatic Cancer staging pancreatic cancer; however, not all agree on the value of
other staging tests. Many authorities advocate omission of staging
laparoscopy or EUS-guided biopsy of nodes, on the grounds that
TX Primary tumor cannot be assessed patients are better served by palliative surgery than by endoscopic
T0 No evidence of primary tumor
stenting of the bile duct. There is no advantage in knowing
Tis Carcinoma in situ
whether small liver metastases or celiac node metastases are pres-
Primary T1 Tumor limited to pancreas, ≤ 2 cm in greatest dimension
tumor (T) T2 Tumor limited to pancreas, > 2 cm in greatest dimension
ent if laparotomy is to be undertaken anyway.The literature on this
T3 Tumor extends beyond pancreas but without involvement issue is unclear regarding what constitutes best practice. The two
of celiac axis or SMA randomized trials published to date reported differing outcomes,
T4 Tumor involves celiac axis or SMA with one favoring surgical bypass9 and the other endoscopic stent-
ing. We continue to recommend staging laparoscopy in patients
Regional NX Regional lymph nodes cannot be assessed
lymph N0 No regional lymph node metastasis
with adenocarcinoma of the pancreas. In those considered likely to
nodes (N) N1 Regional lymph node metastasis have a short life expectancy because of peritoneal or hepatic
metastases discovered upon laparoscopy, the procedure is discon-
MX Distant metastasis cannot be assessed tinued, and endoscopic stenting with metal stents is performed.
Distant metas- M0 No distant metastasis
tasis (M) We no longer advocate using staging laparoscopy with ultrasonog-
M1 Distant metastasis
raphy to determine if the tumor is unresectable solely because of
SMA—superior mesenteric artery local vascular invasion; these patients are likely to have a longer life
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 9 Tumors of the Pancreas, Biliary Tract, and Liver — 5
Gastrosplenic Nodes
Gastroduodenal
Nodes
Celiac Nodes
Splenic
Nodes
(RAMPS), which accomplishes the desired goals by performing with radiating arms ringed by multiple grape-sized cysts.When the
the resection in an antegrade manner from right to left and which cysts are tiny (honeycomb pattern), SCAs may also appear to be sol-
is based on the established lymph node drainage of the gland [see id tumors. Unlike pseudocysts and IPMNs, neither MCNs nor
Figure 4].16 RAMPS also allows early control of the vasculature. SCAs communicate with the pancreatic duct, though they may
compress it. Measurement of the CEA level in cyst fluid is a good
Mucinous Adenocarcinoma means of distinguishing MCN from SCA. SCAs have very low levels
Mucin-producing cancers are special variants of adenocarcino- of CEA, with the cutoff being 5 ng/ml.18 In MCNs, the cyst fluid is
ma of the pancreas that often arise in preexisting lesions.The two often mucinous, and cytologic assessment may show mucin-produc-
main types are mucinous cystic neoplasm (MCN) and intraduc- ing cells; typically, the fluid is high in CEA.The CA 19-9 concentra-
tal papillary mucinous neoplasm (IPMN) (also referred to as tion may also be used to distinguish MCNs from SCAs, but it is not
intraductal papillary mucinous tumor [IPMT]).17 A complete dis- as reliable as the CEA concentration for this purpose.18
cussion of pancreatic cyst disease is beyond the scope of this chap-
ter. Accordingly, we briefly address such disease as it relates to Surgical staging. Surgical staging is required when MCNs are
cancer of the pancreas, omitting discussion of less common cystic malignant, and essentially the same methods are used as for any
malignancies of the pancreas. pancreatic adenocarcinoma (see above). Malignancy is suggested
by a solid intracystic or extramural component. Sometimes, a mu-
MCN MCN occurs most often in middle-aged women, typical- cinous tumor is frankly malignant with a large or dominant solid
ly in the body and tail of the pancreas. MCNs are unilocular or sep- component. Such a tumor is better termed a mucinous adenocar-
tated cysts whose diameter ranges from subcentimeter size to 15 cm cinoma, and it should be evaluated and treated from the outset in
or larger. Occasionally, calcium is present in the wall. Excrescences the same manner as any other adenocarcinoma of the pancreas.
may be present on the inner wall; if so, malignancy is likely. Most
symptomatic MCNs are between 4 and 7 cm in diameter. Management. In symptomatic patients, preoperative differen-
tiation between MCNs and SCAs is unnecessary, because resec-
Clinical evaluation and investigative studies. Patients with MCNs tion is the treatment for both. In asymptomatic patients, MCNs
typically present with left-side pain, often in the flank and the more than 2 cm in diameter should be excised because of the pos-
back, though these lesions also are frequently discovered inciden- sibility of malignant degeneration. The standard procedure has
tally. Pancreatitis is rare and jaundice is uncommon, even when been open distal pancreatectomy with splenectomy, though lesser
the lesions are situated in the head of the pancreas. MCNs must procedures, such as spleen-sparing distal pancreatectomy,19
be differentiated from pseudocysts and from serous cystadenomas laparoscopic distal pancreatectomy,20 central pancreatectomy, and
(SCAs), which are benign cysts. Differentiation between MCNs enucleation,21 have all been used as well.These procedures appear
and pseudocysts is based on the history, imaging studies, and cyst to be reasonable choices, provided that there is no suggestion of
fluid analysis. The diagnosis of pseudocyst is supported by a his- invasive malignancy on imaging (i.e., that there are no excres-
tory of pancreatitits; a thick-walled, uncalcified cyst with associat- cences on the inner lining and that the surrounding pancreas
ed radiologic signs of pancreatitis; and cyst fluid with high levels of appears normal). Enucleation may be associated with a higher
amylase and lipase and a relatively low level of carcinoembryonic incidence of postoperative fistula. If invasive cancer is not detect-
antigen (CEA) (< 500 ng/ml). ed in the resected specimen, the chances that the malignancy will
SCAs have the same clinical presentation as MCNs. SCAs are recur are small; in fact, we have never seen such a recurrence.
more frequently polycystic than MCNs are, but this difference is not The 2 cm cutoff for treatment of MCNs in asymptomatic pa-
a certain means of discriminating between the two. In a minority tients is arbitrary. It is still possible that malignant degeneration
(25%) of cases, SCAs have a pathognomonic central calcification could occur in a cyst smaller than 2 cm, but many cysts of this size
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 9 Tumors of the Pancreas, Biliary Tract, and Liver — 7
are found in the course of axial imaging performed for other rea- The diagnosis is made on the basis of the presentation and the
sons. Such cysts are difficult to diagnose because of the small vol- findings from axial imaging and ERCP. ERCP sometimes shows
ume of cyst fluid present, and the benefit to be gained from per- mucus bulging from the mouth of the pancreatic duct when the
forming a large number of pancreatectomies for these small cysts duodenum is inspected. In main duct disease, the pancreatic duct is
is questionable, even when they are diagnosable as MCNs. Some dilated, but sometimes, the mucus prevents complete filling. In this
authorities feel that large SCAs should also be excised because of situation, CT scans or MRI with MRCP may be quite useful for de-
rare instances of malignant degeneration. Occasionally, MCNs or tecting ductal dilatation and atrophy of the pancreas. MRCP is best
symptomatic SCAs are located in the head of the pancreas and at detecting excrescences emanating from the surface of the duct,
must be treated with pancreaticoduodenectomy. which signal progression of the disease toward neoplasia. In side-
branch IPMN, ERCP typically demonstrates communication be-
IPMN IPMN begins as the cells lining the pancreatic ducts tween the cysts and the main duct, which is often normal in size; this
undergo a metaplastic alteration from a low cuboidal serous type finding is not present in MCN or SCA and is very useful for distin-
of cell to a mucin-producing type. These cells are prone to dys- guishing side-branch IPMN from these other types of cysts.
plasia and eventual malignant transformation. Overall, IPMNs
appear to undergo malignant transformation much more regular- Management. IPMN is treated by resecting the involved por-
ly than MCNs do. There are two recognized types of IPMN, tion of the gland. In about 50% of patients, the resection margin
which may occur either separately or together.The more common is involved with atypia or cancer, and the planned resection may
type affects the main pancreatic duct [see Figure 5], which becomes have to be extended.22 In some cases (about 20%), total pancrea-
dilated and filled with mucin. As the disease progresses toward tectomy is required; in others, partial pancreatectomy and close
malignancy, papillary processes may project into the lumen. The follow-up of the pancreatic remnant with MRCP and serum CA
less common type, so-called side-branch IPMN, affects the small- 19-9 measurement are indicated. Most patients who require total
er ducts and presents as multiple (usually small) pancreatic cysts. pancreatectomy tolerate the procedure well when they are enrolled
In either type of IPMN, the disease may be either diffuse or focal; in a program keyed to this operation.The mucinous cancers asso-
when it is focal, the head of the pancreas is the site of disease in ciated with IPMN have a better prognosis than ductal adenocar-
the majority (60%) of cases. About 20% of IPMN patients have a cinomas do.23 Frank mucinous cancers may appear in patients
malignancy at the time of diagnosis, though the cancer may not be with IPMN as well; they should be managed in much the same
evident until the specimen is examined pathologically. fashion as other adenocarcinomas, with the additional require-
ment that the resection should encompass the entire IPMN-bear-
Clinical evaluation and investigative studies. IPMN occurs pre- ing portion of the pancreas.
dominantly in males and usually affects patients in their 60s. Pain
NEUROENDOCRINE CANCERS
(usually attributable to pancreatitis arising from mucous obstruc-
tion of the pancreatic duct) is a common presenting symptom. In most large centers, neuroendocrine cancers account for fewer
Another common presentation is pancreatic insufficiency with di- than 5% of surgically treated pancreatic malignancies. Some of these
abetes or steatorrhea. Accordingly, it is not surprising that former- cancers are functional tumors, which produce hormones leading to
ly, many IPMN patients were diagnosed as having chronic pan- paraneoplastic syndromes. Examples include gastrinoma, insulino-
creatitis. IPMN may also be discovered incidentally or may ma, glucagonoma and vasoactive intestinal polypeptide–secreting tu-
present as a cancer with signs and symptoms similar to those of mor (VIPoma), all of which are associated with characteristic clinical
other pancreatic cancers, depending on the part of the gland in syndromes.These syndromes are often produced while the tumors
which they arise. On rare occasions, cholangitis from obstruction are still small. A detailed discussion of functional neuroendocrine tu-
of the common channel by mucus is the presenting problem. mors is beyond the scope of this chapter.
a b
Other neuroendocrine tumors are nonfunctional and, as a re- Table 4 American Joint Committee on Cancer
sult, reach a larger size before giving rise to symptoms. These le- Staging System for Extrahepatic Bile Duct Cancer
sions present with symptoms caused by the mass effect and must
be differentiated from ductal adenocarcinomas. Nonfunctional Stage T N M
neuroendocrine cancers are slow-growing tumors that tend to
push rather than invade structures but are capable of metastasiz- Stage 0 Tis N0 M0
ing to lymph nodes, as well as to the liver and other organs. Pain Stage IA M0
T1 N0
is the most common presenting symptom. Jaundice, pancreatitis,
and systemic symptoms (e.g., weight loss) are less common with Stage IB T2 N0 M0
these tumors than with adenocarcinoma of the pancreas. Because Stage IIA T3 N0 M0
of the propensity of neuroendocrine tumors to deflect rather than
invade the bile duct, jaundice may be absent even when tumors Stage IIB T1, T2, T3 N1 M0
are located in the head of the gland. Stage III T4 Any N M0
Diagnosis, surgical staging, and treatment rationale are essen-
tially the same for neuroendocrine cancers as for ductal adenocar- Stage IV Any T Any N M1
cinomas. On CT scans, these lesions characteristically show en-
hancement in the arterial phase and are seen to push on bile ducts
and vascular structures rather than encase them. Complete resec- for establishing the prognosis and planning further treatment [see
tion by means of pancreatoduodenectomy or distal pancreatecto- Tables 3 and 4].
my [see 5:24 Pancreatic Procedures] is indicated. Given the slow Lower-Duct Cholangiocarcinoma
growth rate of neuroendocrine cancers and their relatively favor-
able prognosis (50% to 60% 5-year survival rate), removal of the Clinical evaluation and investigative studies Much of what
primary lesion and any hepatic secondary lesions is justified if all the surgeon needs to know about lower-duct CCA has already been
tumor tissue can be removed with clear margins. addressed elsewhere [see Pancreatic Cancer, Adenocarcinoma of
Head of Pancreas, above]. By far the most common presentation is
painless jaundice with its constellation of associated symptoms (es-
Biliary Tract Cancer pecially pruritus). Laboratory tests reveal the characteristic pattern of
obstructive jaundice. A serum CA 19-9 concentration higher than
EXTRAHEPATIC CHOLANGIOCARCINOMA 100 U/ml facilitates the diagnosis. Axial imaging reveals dilation of
Extrahepatic cholangiocarcinoma (CCA) may be subdivided the intrahepatic bile ducts, the gallbladder (in most cases), and the
into lower-duct CCA and upper-duct CCA, with the former aris- extrahepatic bile ducts down to the level of the pancreatic head,
ing in the intrapancreatic or retroduodenal portion of the bile duct where the dilatation terminates abruptly. Usually, no mass is visible.
and the latter arising above it. In practice, most upper-duct CCAs ERCP or MRCP shows a focal stricture, and ERCP brushings are
(also referred to as hilar CCAs or Klatskin tumors) arise just positive in about 50% of cases. EUS may be helpful, in that it is more
below the union of the right and left hepatic ducts, at the union of sensitive for small tumors than CT scanning is. Needle biopsy is di-
the ducts, or in the main right or left hepatic ducts. Cancer of the rected toward the mass or, if no mass is visible, toward the narrowest
midportion of the bile duct at the cystic duct’s usual insertion segment of the bile duct. A negative biopsy result does not rule out a
point is more likely to be an extension of a gallbladder cancer than small bile duct cancer.
a primary CCA. AJCC staging criteria for these tumors are useful The differential diagnosis includes other potential causes of focal
strictures of the bile duct.24 The most common cause of a benign
stricture of the intrapancreatic bile duct is pancreatitis, which may
be diffuse or focal. Other causes of benign stricture include iatro-
Table 3 American Joint Committee on Cancer genic injury, choledocholithiasis, sclerosing cholangitis, and benign
TNM Clinical Classification of Extrahepatic Bile inflammatory pseudotumors [see Upper-Duct Cholangiocarcinoma,
Duct Cancer Investigative Studies, Imaging, below]. Iatrogenic injuries rarely
involve the intrapancreatic portion of the bile duct, though such
TX Primary tumor cannot be assessed injuries can occur in this area as a consequence of forceful instru-
T0 No evidence of primary tumor mentation. Sclerosing cholangitis may affect this section of the bile
Tis Carcinoma in situ duct but usually affects other areas of the biliary tree as well. The
T1 Tumor confined to bile duct histologically diagnostic steps for differentiating benign neoplasms from malig-
T2 Tumor invades beyond wall of bile duct nant tumors are essentially the same for lower-duct CCA as for
Primary tumor (T) T3 Tumor invades liver, gallbladder, pancreas, or pancreatic cancer. As noted, resection may be required to make the
unilateral branches of portal vein or hepatic artery
diagnosis. In any patient presenting with jaundice and a focal stric-
T4 Tumor invades any of the following: main portal vein
or branches bilaterally, coronary artery, or other ture of the bile duct, lower-duct CCA should be strongly suspected.
adjacent structures (e.g., colon, stomach, duodenum,
or abdominal wall)
Surgical staging Surgical staging of lower-duct CCAs is
NX Regional lymph nodes cannot be assessed usually straightforward. These tumors are usually remote from
Regional lymph N0 No regional lymph node metastasis major vascular structures and thus are not subject to the same
nodes (N)
N1 Regional lymph node metastasis local staging considerations as adenocarcinomas of the pancreatic
head are. The exception is a tumor that extends to the top of the
MX Distant metastasis cannot be assessed
Distant metas- retroduodenal portion of the bile duct. At this point, the bile duct
M0 No distant metastasis
tasis (M) is apposed to the portal vein and the hepatic artery, and these
M1 Distant metastasis
structures may be invaded by bile duct tumors in this location.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 9 Tumors of the Pancreas, Biliary Tract, and Liver — 9
Management The treatment for resectable lesions is pan- the left hemiliver develops, the hepatic artery may come to lie
creaticoduodenectomy. directly in front of the bile duct.
Upper-Duct Cholangiocarcinoma Clinical evaluation The usual presentation of hilar CCA
Upper-duct (or hilar) CCA is a sporadically occurring tumor consists of painless jaundice with its accompanying symptoms
that may also be seen in patients with primary sclerosing cholan- (especially pruritus), though some pain may be present. Cholan-
gitis, ulcerative colitis, or parasitic infestation. It is characteristi- gitis before instrumentation of the bile duct is uncommon. In pa-
cally slow growing and locally invasive, and it metastasizes more tients who present in the late stages of the disease, general manifes-
readily to lymph nodes than systemically, though intrahepatic tations of cancer (e.g., malaise, weight loss, or ascites) may be noted.
and peritoneal metastases are not uncommon. Most hilar CCAs
are cicatrizing diffusely infiltrating cancers, but some are nodular, Investigative studies Laboratory tests. Laboratory testing
and others present as papillary ingrowths. These tumors are follows the pattern previously described for obstructive jaundice
divided into four types according to the Bismuth classification, [see Pancreatic Cancer, above]. Again, the most helpful diagnostic
which is based on the upper extent of the tumor [see Figure 6].25 laboratory test is the serum CA 19-9 concentration: levels higher
When the CCA originates in one of the hepatic ducts, that than 100 U/ml are strongly suggestive of cancer. In patients with
duct may be obstructed for a considerable period before the primary sclerosing cholangitis, the presence of CCA is often sug-
tumor causes jaundice by growing into the other hepatic duct or gested by a rapid deterioration in condition. It is not unusual for
the common bile duct. Such prolonged unilateral obstruction patients with hilar CCA to have undergone a cholecystectomy in
before the onset of the presenting symptom of jaundice may the recent past; the symptoms of pain and jaundice may be mis-
result in atrophy of the obstructed side of the liver, which may taken for symptoms of gallbladder disease in patients who happen
affect subsequent management. For example, because the disease also to have gallstones.
is more advanced on the obstructed side, it is the atrophied half
of the liver that will be removed in almost all cases where resec- Imaging. Earlier [see Pancreatic Cancer, Ductal Adenocarcino-
tion is indicated. In addition, when one side of the liver under- ma, Adenocarcinoma of Head of Pancreas, above], the point was
goes atrophy, the other side undergoes hypertrophy. These made that it is preferable to employ axial imaging rather than ERCP
changes lead to rotation of the liver, which in turn may cause the as the first imaging test in the jaundiced patient because doing so
structures in the hepatoduodenal ligament to be rotated out of will often render ERCP, an invasive test, unnecessary.This point car-
their normal anatomic location. For instance, if hypertrophy of ries even more force in the setting of hilar CCA. Injection of dye
a b c
d e
Table 5 American Joint Committee on Cancer TNM lobe is resected because cholangiocarcinomas tend to invade
Clinical Classification of Gallbladder Cancer along the short caudate bile ducts, which enter the posterior sur-
faces of the main right and left bile ducts at the bifurcation of the
common hepatic duct.)
TX Primary tumor cannot be assessed Liver transplantation has been used successfully to manage
T0 No evidence of primary tumor
Bismuth type IV tumors and is usually performed after neoadju-
Tis Carcinoma in situ
vant chemoradiation therapy and staging laparotomy in highly
T1 Tumor invades lamina propria or muscle layer
T1a: Tumor invades lamina propria
selected patients.29
Primary tumor (T) T1b: Tumor invades muscle layer
GALLBLADDER CANCER
T2 Tumor invades perimuscular connective tissue
T3 Tumor perforates serosa (visceral peritoneum) or di- The incidence of gallbladder cancer in the United States is about
rectly invades one adjacent organ (≤ 2 cm into liver) 9,000 cases a year. This cancer almost always arises in patients
T4 Tumor extends > 2 cm into liver or invades two or with preexisting gallstones and is most often seen in elderly
more adjacent organs (e.g., duodenum, colon,
pancreas, omentum, or extrahepatic bile ducts) patients. Like ductal adenocarcinoma of the pancreas, it is highly
malignant, and it tends to spread at an early stage to lymph nodes,
NX Regional lymph nodes cannot be assessed to peritoneal surfaces, and through the bloodstream. AJCC stag-
N0 No regional lymph node metastasis
ing criteria are helpful for planning management of this cancer [see
Regional lymph N1 Metastasis in cystic duct, pericholedochal, or hilar
nodes (N) lymph nodes (i.e., in hepatoduodenal ligament) Tables 5 and 6].
N2 Metastasis in peripancreatic (head only), periduo-
denal, periportal, celiac, or mesenteric lymph nodes Clinical Evaluation
Imaging Because gallbladder cancer is most curable in its In more advanced stages of disease (T3 and T4), the aim is still
early stages and because the symptoms in those stages are those of excision with clear margins and resection of portal and celiac
cholelithiasis, it is helpful to be aware of subtle signs of gallbladder lymph nodes. To obtain clear local margins with these tumors, in
cancer that are occasionally present on sonograms. These signs addition to what is required for T2 tumors, more extensive hepat-
include thickening of the gallbladder wall, a mass projecting into ic resections—up to a trisectionectomy (resection of segments 4
the lumen, multiple masses or a fixed mass in the gallbladder, cal- through 8) [see Liver Cancer, Anatomic Considerations, below]31—
cification of the gallbladder wall (so-called porcelain gallbladder), may be necessary, as well as resection of adjacent organs.
and an extracholecystic mass. Displacement of a stone to one side
of the gallbladder should also be viewed with suspicion. Incidentally discovered gallbladder cancer Gallbladder
In later stages of disease, CT scans usually show a gallbladder cancer may be an incidental finding at laparoscopic cholecystecto-
mass with or without invasion of the liver or other adjacent organs. my, as it has been at open cholecystectomy. The incidence of this
Obstruction of the bile duct produces the usual features associated finding ranges from 0.3% to 1.0%. A concern that has arisen in
with obstructive jaundice. Percutaneous CT-guided biopsy is a use- the current era, in which the laparoscopic approach to cholecys-
ful technique for confirming the diagnosis in patients with unre- tectomy is dominant, is the risk of port-site implantation of tumor.
sectable tumors. Porcelain gallbladder is a premalignant condition, Port-site implantation may simply be the result of contact between
though there is some evidence that the incidence of cancer depends the malignancy and the tissues surrounding the port site at the
on the pattern of calcification: selective mucosal calcification appar- time of gallbladder extraction; however, positive pressure pneu-
ently carries a significant risk of cancer, whereas diffuse intramural moperitoneum may also play a causative role. When evidence of
calcification does not.30 It seems reasonable to resect only tumors gallbladder wall thickening is noted intraoperatively, the gallblad-
with the former pattern, but whenever there is a question about the der should be extracted in a sac. The gallbladder should be in-
pattern of calcification, one should err on the side of resection. spected at the time of extraction, and any questionable areas
should undergo biopsy.
Surgical Staging If a gallbladder cancer is discovered at the time of operation, it
Staging of gallbladder cancer requires knowledge of the extent should be treated without delay according to the principles stated
of direct invasion into the liver and other adjacent organs and tis- earlier (i.e., depending on whether the margins on the excised gall-
sues (especially the bile duct, the portal veins, and the hepatic bladder are clear and on the T stage of the tumor). From an onco-
arteries). As in hilar CCA, this information may be obtained by logic viewpoint, it would seem ideal to resect the tissue around all
means of MRCP and MRA or CT with the latest-generation scan- trocar port sites. From a technical viewpoint, however, it would be
ners. Staging laparoscopy is very helpful in managing gallbladder very difficult and impractical to excise the full thickness of the
cancer. As many as 50% of patients with this disease are found to abdominal wall circumferentially around four port sites, especial-
have peritoneal or liver metastases upon staging laparoscopy,8 and ly because the tract of the port site often is not at a 90° angle to
as with carcinoma of the body of the pancreas, there are no useful the abdominal wall. If the gallbladder was extracted through a port
palliative measures that can be undertaken at laparotomy. site without having been placed into a bag, it is reasonable to
attempt excision of that one port site.
Management Sometimes, cancer is suspected, but frozen-section examination
Rationale for surgery When early-stage gallbladder cancer is is inconclusive and the definitive diagnosis of cancer is not made
suspected on the basis of diagnostic imaging, open cholecystectomy, until the early postoperative period. More often, cancer is not sus-
rather than laparoscopic cholecystectomy, is probably the procedure pected intraoperatively, and the diagnosis is made only when per-
of choice [see 5:21 Cholecystectomy and Common Bile Duct Exploration manent sections of the gallbladder are examined. In these situa-
and 5:22 Procedures for Benign and Malignant Biliary Tract Disease]. In- tions, patients with completely excised T1 lesions require no fur-
traoperatively, if there is no evidence of spread outside the gallblad- ther therapy, and patients with higher-stage lesions should under-
der, we recommend performing an extraserosal cholecystectomy, in go reoperation in accordance with the principles outlined earlier
which the fibrous liver plate is excised along with the gallbladder so (see above). Other appropriate reasons for not performing the
that bare liver is exposed. It is possible to perform an extraserosal re- additional surgery at the time of the cholecystectomy are (1) the
section laparoscopically; however, in our opinion, this should not be desire to discuss the management scheme with the patient and (2)
attempted, because gallbladder perforation and bile spillage are more lack of experience with the procedure for T2 tumors. Not infre-
common with the laparoscopic version of the procedure.The nega- quently, patients are referred to hepatic-pancreatic-biliary (HPB)
tive consequences of tumor implantation or incomplete excision far centers 10 to 14 days after surgery, which is an inopportune time
outweigh any benefit that a minimally invasive approach might confer. for reoperation, especially if the first procedure was difficult.
The excised specimen should be inked and a frozen section Surgery may then be delayed for 3 to 4 weeks.We restage patients
obtained. If there is gallbladder cancer in the specimen but the with abdominal CT scans when they are referred with this diag-
resection margins are clear and the tumor is a T1 lesion (i.e., has nosis, and it is not unusual to find hepatic metastases when this is
not penetrated the muscularis), the procedure is considered com- done.The survival rate is much higher after radical resection than
plete, in that lymph node metastases are uncommon with T1 after cholecystectomy, even when cholecystectomy was the first
tumors (incidence < 10%). However, lymph node metastases are procedure.32
present in 50% of patients with T2 lesions (i.e., tumors that have
invaded the muscularis). Therefore, if margins are positive or the Gallbladder polyps Gallbladder polyps are discovered inci-
tumor is a T2 lesion, resection of segments 4b and 5 of the liver dentally on ultrasonograms or CT scans or are diagnosed when
and dissection of portal and celiac lymph nodes, along with resec- they cause biliary colic. They may be malignant but are rarely so
tion of the extrahepatic bile duct and hepaticojejunostomy, are when less than 1 cm in diameter, especially when they are multi-
recommended. If it is already clear at the commencement of the ple. Most gallbladder polyps are less than 0.5 cm in diameter;
operation that the tumor is T2, one should proceed directly to these are almost always benign cholesterol polyps and may be fol-
liver, lymph node, and bile duct resection. lowed if they are not giving rise to symptoms. Single polyps
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 9 Tumors of the Pancreas, Biliary Tract, and Liver — 13
between 0.5 and 1 cm in diameter should probably be removed by ramifications of the hepatic artery and the bile duct are regular and
means of cholecystectomy; multiple polyps in this size range virtually identical. Liver anatomy is best understood by first fol-
should be followed. About one quarter of all single gallbladder lowing these structures through a series of orderly divisions. The
polyps more than 1 cm in diameter are malignant, and such polyps branching of the portal vein on the right side is similar to that of
should be treated as malignant as a matter of policy. Almost all the bile duct and the hepatic artery, but its branching on the left
polyps more than 1.8 cm in diameter are malignant.33 side, because of the fetus’s need to use the umbilical portion of the
portal vein as a conduit, is unusual.
The first-order division of the proper hepatic artery and the
Liver Cancer common hepatic duct into the right and left hepatic arteries and
the right and left hepatic ducts, respectively, results in division of
ANATOMIC CONSIDERATIONS
the liver into two parts (or volumes), referred to as the right and
A long-standing problem in discussing any surgical liver disease, left hemilivers (or the right and left livers) [see Figure 8 and Table
especially liver cancer, has been the confusing terminology applied 7]. In this system of terminology, the term lobe is never used to
to liver anatomy and the various hepatic resections. Fortunately, a denote a hemiliver, because it bears no relation to the internal
lucid and cogent terminology has emerged that is sanctioned by vascular anatomy. The right hepatic artery supplies the right
both the International Hepato-Pancreato-Biliary Association hemiliver, and the left hepatic artery supplies the left hemiliver.
(IHPBA) and the American Hepato-Pancreato-Biliary Association The right and left hepatic ducts drain the corresponding
(AHPBA).31 This terminology has been widely adopted around the hemilivers. The plane between these two zones of vascular sup-
world and translated into many languages. It may be briefly sum- ply is called a watershed. The border or watershed of the first-
marized as follows. order division is a plane that intersects the gallbladder fossa and
The fundamental principle is that the anatomic divisions of the the fossa for the inferior vena cava and is called the midplane of
liver are based on vascular and biliary anatomy rather than on sur- the liver.
face markings [see Figure 8]. This is an important point because The second-order division divides each of the hemilivers into
surgical resection is a process of isolating specific liver volumes ser- two parts [see Figure 8 and Table 7], referred to as sections. The
viced by specific vascular and biliary structures. The anatomic right hemiliver comprises the right anterior section and the right
1, 9
7
Falciform
Ligament
5
Portal Vein
6
Common
Hepatic Artery
Common
Bile Duct
Figure 8 Illustrated are the anatomic divisions of the liver according to IHPBA/AHPBA-
sanctioned terminology, including first-order divisions (hemilivers), second-order divisions
(sections) and third-order divisions (segments).
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5 Gastrointestinal Tract and Abdomen 9 Tumors of the Pancreas, Biliary Tract, and Liver — 14
Table 7 Brisbane 2000 Terminology for Hepatic Anatomy and Resections from IHPBA
Corresponding
Preferred Anatomic Preferred Term for Surgical
Level of Division Couinaud Comments
Term Resection*
Segments (Sg)
Right hepatectomy
Right hemiliver
Sg 5–8 (± caudate or
or
lobe†) Right hemihepatectomy
Right liver The border or watershed separating the two hemilivers is a
(stipulate ± caudate lobe)
First order (hemiliver) plane that intersects the gallbladder fossa and the inferior
vena cava fossa; this plane is referred to as the midplane
Left hemiliver Left hepatectomy
of the liver
or Sg 2–4 (± caudate or
lobe) Left hemihepatectomy
Left liver
(stipulate ± caudate lobe)
*It is also permissible to refer to any resection in terms of its third-order components. Thus, a left hemihepatectomy may be referred to as a resection Sg 2–4 (or 1–4).
†
The caudate lobe comprises segments 1 and 9. IHPBA—International Hepato-Pancreato-Biliary Association
posterior section. These sections are supplied by a right anterior common cancer in the world. About 90% of cases arise in
sectional hepatic artery and a right posterior sectional hepatic patients with chronic liver disease, especially when the disease
artery and are drained by a right anterior sectional hepatic duct has progressed to cirrhosis. Although any condition that pro-
and a right posterior sectional hepatic duct. The left hemiliver duces cirrhosis may lead to HCC, the most common cause is
comprises the left medial section and the left lateral section.These viral hepatitis. In the United States, some 3 million people are
sections are supplied by a left medial sectional hepatic artery and infected with hepatitis C virus (HCV), and more than 1 million
a left lateral sectional hepatic artery and are drained by a left medi- people have liver disease associated with hepatitis B virus
al sectional hepatic duct and a left lateral sectional hepatic duct. (HBV). HCV infection is much more likely to lead to HCC than
The third-order division divides the liver into nine segments, HBV infection is. AJCC staging criteria are useful for planning
each of which has its own segmental artery and bile duct [see the management of liver cancer [see Tables 8 and 9].
Figure 8 and Table 7]. The caudate lobe, a unique portion of the
liver that is separate from the right and left hemilivers, comprises Clinical evaluation The usual presentation of sporadic
segments 1 and 9. The left lateral section comprises segments 2 HCC consists of pain, mass, and systemic symptoms of cancer,
and 3; the left medial section comprises segment 4 (which is some- though the disease may also be discovered incidentally. HCC
times further divided into segments 4a and 4b); the right anterior occurring as a complication of liver disease may present similar-
section comprises segments 5 and 8; and the right posterior sec- ly, but it is often manifested first as a deterioration of liver func-
tion comprises segments 6 and 7. tion with the onset of jaundice, ascites, or encephalopathy.
PRIMARY CANCERS
Investigative studies Screening programs are employed in
high-risk populations. These programs, which use α-fetoprotein
Hepatocellular Cancer (AFP) levels and ultrasonographic examination of the liver to
Hepatocellular cancer (HCC), or hepatoma, is the fifth most detect early HCC, may detect asymptomatic tumors.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 9 Tumors of the Pancreas, Biliary Tract, and Liver — 15
Table 8 American Joint Committee on Cancer TNM disease. For instance, resection of more than two segments is limited
to patients with normal liver function.Too-extensive resection puts
Clinical Classification of Adult Primary Liver Cancer
the patients at risk for liver failure in the postoperative period. In
Japan and China, indocyanine green (ICG) clearance is used in
TX Primary tumor cannot be assessed Child class A patients to determine the possible extent of resection.
T0 No evidence of primary tumor
T1 Solitary tumor without vascular invasion
Management Rationale for surgery. The rationale for sur-
T2 Solitary tumor with vascular invasion; multiple
Primary tumor (T) tumors, none > 5 cm in greatest dimension gery is clear in patients without liver disease or in Child class B or
T3 Multiple tumors > 5 cm in greatest dimension or C patients with chronic liver disease. The rationale for surgery in
tumor involving major branch of portal or hepatic vein Child class A patients, however, remains controversial.
T4 Tumor or tumors with direct invasion of adjacent Partial liver resection [see 5:23 Hepatic Resection] is the proce-
organs (other than gallbladder) or visceral peritoneum
dure of choice for sporadic HCC in patients with normal livers. In
NX Regional lymph nodes cannot be assessed Child class B or C patients with chronic liver disease, liver resec-
Regional lymph N0 No regional lymph node metastasis tion can be hazardous, and orthotopic liver transplantation (OLT)
nodes (N)
N1 Regional lymph node metastasis is the procedure of choice.To justify the use of donor organs, how-
MX Distant metastasis cannot be assessed
ever, it is necessary to select patients with HCC so that the long-
Distant metastasis (M) M0 No distant metastasis term outcome of OLT for HCC is similar to that of OLT for
M1 Distant metastasis benign conditions. To achieve this goal, OLT is restricted to
patients with a single tumor less than 5 cm in diameter or to pa-
tients with as many as three tumors, none of which are more than
The diagnosis of sporadic HCC is based on elevation of AFP lev- 3 cm in diameter (the Milan criteria). These criteria have been
els (an indicator with 50% to 60% sensitivity) and the presence of a shown to be associated with OLT outcomes comparable to those
hepatic mass on axial images. HCCs typically demonstrate hyper- for benign conditions.35
vascularity, which is best seen on arterial-phase images [see Figure 9]. In Child class A patients with liver disease, hepatic resection
A pseudocapsule is often visualized, which is best seen on portal ve- and OLT are options if the Milan criteria are met. The optimal
nous–phase images. Multifocality is also common in HCC, and this therapeutic approach in this situation has been the subject of con-
finding often serves to differentiate it from other hepatic neoplasms. siderable debate, with proponents arguing for one of two strate-
Routine biopsy is not indicated in patients with a characteristic mass, gies—namely, (1) primary OLT or (2) resection followed by OLT
those who have a mass and an elevated AFP level, or those who are if HCC recurs, provided that the patients still meet criteria for
symptomatic and require treatment for pain. HCC may be very well OLT (so-called salvage OLT). A complete discussion of this con-
differentiated and difficult to distinguish from hepatic adenoma and troversy is beyond the scope of this chapter. Currently, it would
focal nodular hyperplasia on biopsy. It may also be hard to distin- seem that the best strategy in patients who meet the criteria for
guish from cirrhotic nodules. Biopsy is associated with a small risk of OLT is to perform primary OLT for HCV-associated disease36
bleeding or tumor seeding. and to perform resection and salvage OLT for HBV-associated
disease37 and other HCCs of non-HCV origin. In patients who do
Surgical staging Staging of sporadic HCC requires axial not meet the OLT criteria, resection would be performed even if
imaging of the abdomen and imaging of the chest. FDG-PET the tumor is of HCV origin. At present, there is a trend toward lib-
scanning is only marginally useful: HCCs are typically well differ- eralizing the OLT criteria to include single tumors 6 or 7 cm in
entiated, and as a result, only 50% of the tumors are visualized. diameter, especially if the source of the organ is a living donor.
Staging laparoscopy is helpful: additional tumors are found in When OLT is to be performed, it is important that the waiting
about 15% of patients.34 time be short; these tumors progress over a timescale of a few
Staging also requires evaluation of the extent of liver disease.The months, and when viewed on an intention-to-treat basis, the
Child-Pugh classification is used to determine operability.With few results of OLT deteriorate significantly if the waiting time is
exceptions, resection is limited to Child class A patients with near- long.38 In the United States, this concern has been dealt with by
normal bilirubin levels (< 1.5 mg/dl), a normal or marginally raised
prothrombin time (PT), and no or minimal portal hypertension.
The extent of resection must be tailored to the severity of the liver
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage IIIA T3 N0 M0
Stage IIIB T4 N0 M0
the introduction of the Model for End-stage Liver Disease that is indistinguishable from a hepatic metastasis arising from a
(MELD) scoring system, which gives priority to recipients with primary adenocarcinoma in one of several intra-abdominal or
HCC. It is common in the United States—and usual in countries extra-abdominal sites. Special stains may be helpful in differenti-
with longer waiting times—to inhibit the growth of the HCC with ating this tumor from a true secondary malignancy, but the differ-
various bridging-to-transplantation strategies during the waiting entiation is rarely certain. An elevated CA 19-9 concentration is
period for OLT. Such strategies include systemic chemotherapy, strongly suggestive of this diagnosis if it is higher than 100 U/ml.
local treatments (e.g., radiofrequency [RF] ablation and alcohol To make the diagnosis of intrahepatic CCA, primary tumors in
injection), transarterial chemoembolization (TACE), and even other sites must be excluded by means of axial imaging of the
resection of the HCC (so-called bridge resection). chest, the abdomen, and the pelvis; upper and lower GI endos-
In patients with nondiseased livers, the extent of the resection copy; and mammography. FDG-PET scanning is another means
depends on the size and position of the tumor. As much as 70% by which an extrahepatic primary may be identified, but it has not
of the liver may be safely excised when normal liver function is been fully evaluated in this setting.
present.The size of the future hepatic remnant may be determined
by means of imaging. PVE of the side of the liver to be resected Surgical staging FDG-PET scanning appears to be a
may be performed preoperatively to increase the size of the future promising staging tool for identifying portal lymph node and dis-
remnant. It may also be used for this purpose in patients with liver tant metastases when the primary is actually an intrahepatic CCA.
disease. In these patients, PVE functions as a test of the liver’s abil- Portal lymph node metastases are a contraindication to resection
ity to regenerate. Failure to respond to PVE is itself a contraindi- in patients with MF tumors; the results of resection in this situa-
cation to surgery in patients with chronic liver disease. tion are very poor. Left-side tumors may metastasize to lymph
As a rule, liver resections for HCC should be anatomic [see 5:23 nodes at the cardia of the stomach and along the lesser curvature.
Hepatic Resection]. Recurrence rates are higher with nonanatomic
resections because HCCs grow along portal veins and metastasize Management The considerations related to resection for
locally within segments, sections, or hemilivers, depending on how intrahepatic CCA are similar to those for sporadic HCC (see
far they reach back along the portal veins.When HCC reaches the above). Liver transplantation generally is not performed for this
main portal vein, resection is generally contraindicated; the results tumor, because of the typically poor results.
are very poor in this situation.
SECONDARY CANCERS
Intrahepatic Cholangiocarcinoma
Clinical evaluation Intrahepatic CCAs arise from intrahe- Colorectal Metastases
patic bile ducts.There are three types: a mass-forming type (MF), Clinical evaluation and investigative studies About 50%
a periductal infiltrating type (PI), and a type that grows as an intra- of the 150,000 patients who are diagnosed with colorectal cancer
ductal papillary tumor (IG).The MF type is by far the most com- annually in the United States either have or will have liver metas-
mon. Intrahepatic CCA tumor usually occurs in normal livers. tases. About 10% of patients with these colorectal metastases
The presentation is similar to that of sporadic HCC. (CRMs) are eligible for liver resection. CRMs may be diagnosed
either at the time of treatment of the primary colorectal cancer
Investigative studies On diagnostic imaging, the appear- (synchronous tumors) or at a later stage (metachronous tumors).
ance of intrahepatic CCA is suggestive of a secondary tumor [see Synchronous tumors are diagnosed by means of either preop-
Figure 10]. Unlike diagnosis of HCC, diagnosis of intrahepatic erative CT scanning [see Figure 11] or intraoperative palpation.
CCA usually requires a biopsy, which reveals an adenocarcinoma LFTs may show elevations (especially of the serum alkaline phos-
phatase level), but these results are not specific. CEA levels are not
helpful as long as the primary tumor is in place. Metachronous
tumors are most often diagnosed in the course of a postcolectomy
surveillance program, either by imaging the liver with CT scans or
FDG-PET scans or by detecting a rise in the CEA level. When
synchronous metastases are discovered preoperatively, a FDG-
PET scan should be done to complete the staging.
a b
Figure 11 (a) CT scan shows a single large CRM. (b) Shown is the specimen after resection.
The main value of FDG-PET in this setting is its ability to discov- Synchronous resection of the primary tumor and the liver
er unsuspected extrahepatic disease. In so doing, it helps eliminate metastases has proved to be safe41 and is desired by many patients.
futile hepatic resections. If a patient with extrahepatic disease is treat- The decision to proceed with hepatic resection should not be
ed with hepatic resection, a “recurrence” is inevitable. Elimination of made until resection of the primary tumor has been completed
pointless resections has a positive effect on survival: a 2004 study and it has been determined that the margins are clear and the
from our institution found that the overall 5-year survival rate after patient is stable. Some patients with a small number of lung
FDG-PET was about 60%, compared with 40% after conventional lesions in addition to liver lesions have been cured by resection.
imaging.39 Furthermore, the study showed that after FDG-PET
scanning, the classic prognostic factors of the secondary tumor (e.g., Ablation of colorectal metastases. In situ destruction of tumors
tumor number and tumor size) were no longer significant; rather, the with cryotherapy or RF ablation may expand the surgeon’s ability
most important prognostic factor was the grade of the primary tu- to eradicate CRMs localized to the liver.42 RF ablation has largely
mor. FDG-PET–scanned patients with poorly differentiated prima- supplanted cryotherapy in this context as a result of its lower inci-
ry tumors did very poorly in terms of overall survival after hepatic re- dence of complications and greater ease of use. Ablation may be
section.39 Currently, standard PET scanners are rapidly being used either as an adjunct to operative management or as the sole
replaced with CT-PET scanners, which fuse the images and provide treatment when there are many metastases (but usually < 10).The
superior diagnosis and staging. For planning surgical extirpation, efficacy of RF ablation as an adjunct to surgery remains to be
however, the level of detail provided by high-quality contrast-en- determined. It is doubtful, however, that using this modality alone
hanced CT or MRI is also required. to eradicate multiple lesions will improve overall survival signifi-
cantly, because the tumor biology in such cases is likely to be that
Management Rationale for surgery. The criteria that deter- of an aggressive tumor. FDG-PET scans should be performed in
mine eligibility for resection are (1) that the primary tumor has been all such patients; the likelihood of discovering extrahepatic tumors
or can be completely resected, (2) that (with uncommon exceptions) increases as the number of hepatic tumors increases.39
there is no extrahepatic tumor (other than the primary), and (3) that RF ablation is not recommended for treatment of resectable
it is possible to resect all tumors in the liver while leaving enough of a metastases: it is not approved for this purpose, and using it in this
hepatic remnant to ensure that hepatic failure does not develop post- way would mean substituting an unproven therapy of unknown
operatively.The considerations governing the extent of the resection efficacy for a proven therapy of known value. If a consenting
and the use of PVE are similar to those for sporadic HCC. patient with resectable metastases nevertheless insists on this less
Treatment of multiple tumors is much more common with invasive therapy, the surgeon should document that the preceding
CRMs than with HCC. However, nonanatomic resections are as considerations have been explained to him or her. RF ablation
effective as anatomic resections as long as the resection margin is may be applied by means of open, laparoscopic, or percutaneous
microscopically clear.The traditional view has been that resection methods. There is good reason to believe that targeting ability is
margins of 1 cm are mandatory. Whereas 1 cm margins may still degraded as one moves to less invasive methods. This considera-
be a reasonable goal, margins as narrow as 1 mm are satisfactory tion should also be explained to patients, though undoubtedly
and are probably as effective as traditional margins, provided that there are some patients who, because of comorbid conditions, are
they are free of microscopic and gross cancer.When close margins candidates only for percutaneous or laparoscopic approaches.
are expected, transection of the liver with a saline-linked RF abla-
tion device may be useful, in that this device leaves a margin of Neuroendocrine Metastases
devitalized tissue in the patient, as well as in the specimen.40 When Neuroendocrine metastases are characteristically slow growing.
the margin is very close, it may be extended by painting the cut Some are functional, especially if they arise from the ileum; metastat-
surface of the hepatic remnant with the RF device. ic liver disease from this source may produce carcinoid syndrome.
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 9 Tumors of the Pancreas, Biliary Tract, and Liver — 18
111In-pentetreotide imaging (OctreoScan; Mallinckrodt Inc., Hazel- The differential diagnosis of the benign solid hepatic mass in-
wood, Missouri) provides staging information comparable to that cludes hepatic adenoma, focal nodular hyperplasia (FNH), focal
provided by FDG-PET in patients with CRMs. fatty infiltration, cavernous hemangioma, and other rare neo-
The aims of surgical treatment are (1) to eradicate the cancer and plasms (e.g., mesenchymal hamartoma and teratoma)—all of
(2) to reduce hormonal symptoms.The considerations regarding tu- which must be distinguished not only from one another but also
mor eradication for neuroendocrine metastases are similar to those from malignant tumors. In the past, several diagnostic tests (e.g.,
for CRMs—that is, resection should be performed if all cancer can ultrasonography, CT, sulfur colloid scanning, and angiography)
be removed and no extrahepatic cancer is detectable. In highly were used to differentiate these neoplasms. Currently, our usual
symptomatic patients in whom conservative therapy with octreotide practice is to perform MRI with gadolinium contrast enhance-
has failed, debulking the tumor by means of either chemoemboliza- ment, which generally allows accurate differentiation among be-
tion or surgery may provide relief.The former is more suitable for nign tumors with a single test. Cavernous hemangiomas are usu-
patients with multiple small, diffuse metastases, whereas the latter is ally easy to distinguish because they have a characteristic appearance
preferred for patients with large localized tumors. RF ablation may on MRI (hypointense on T1-weighted images, very intense on
also be employed, either combined with surgical treatment or alone; T2-weighted images, and filling in from the periphery with gado-
this is an excellent use of this procedure, in that the aim is cytore- linium injection); if they are asymptomatic, they need not be re-
duction rather than eradication. Debulking tumors in asymptomatic sected. It is important to distinguish asymptomatic FNHs from
patients with the intention of extending survival is controversial. hepatic adenomas: whereas resection is recommended for adeno-
mas, because of their potential for hemorrhage or malignant de-
Noncolorectal, Nonneuroendocrine Metastases generation, asymptomatic FNHs can safely be observed. An
Occasionally, liver metastases from other primary sites behave like FNH is nearly isointense on T1- and T2- weighted images; it shows
CRMs, in that they are localized to part of the liver in the absence of slightly more enhancement than normal liver parenchyma in the
extrahepatic disease. Such patients can be managed according to the early phase after contrast injection, then becomes isointense. A
same approach employed for CRMs, though the outcome is some- central scar is often, but not always, seen. Conversely, a hepatic
what less satisfactory.Tumors that have been treated in this way with adenoma exhibits strong early-phase enhancement with contrast
acceptable results include breast cancers, renal cell cancers, gastric administration, and it tends to be hyperintense on T1-weighted
cancers, acinar cell cancers of the pancreas, and ovarian cancers. images.
Liver resection for more aggressive malignancies (e.g., metastases Given that a symptomatic hepatic mass is usually treated with
from gallbladder cancer and pancreatic ductal adenocarcinomas) resection, preoperative biopsy for tissue diagnosis is rarely neces-
can be expected to yield very poor results. sary or desirable. Modern noninvasive radiologic tests, in con-
junction with a careful patient history, are often quite accurate in
INCIDENTALLY DISCOVERED ASYMPTOMATIC HEPATIC MASS
predicting histologic diagnosis. Biopsy of hepatic lesions should
Now that transaxial imaging of the abdomen is commonly per- not be performed indiscriminately, because there is a small risk of
formed for a variety of complaints, the problem of the incidental- complications or tumor tracking and because biopsy results often
ly discovered asymptomatic hepatic mass is being encountered do not change management. As a rule, biopsies should be per-
with increased frequency. Generally, cysts are easily distinguished formed when definitive surgical intervention is not planned and
from solid tumors; the main diagnostic issue is differentiation of when pathologic confirmation is necessary for institution of non-
the various solid lesions. surgical therapy.
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Acknowledgment
tumors and Klatskin mimicking lesions of the bil- 36. Adam R, Azoulay D, Castaing D, et al: Liver resec-
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© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 10 PORTAL HYPERTENSION — 1
10 PORTAL HYPERTENSION
Clifford S. Cho, M.D., and Layton F. Rikkers, M.D., F.A.C.S.
Clinical strategies for managing portal hypertension have under- cellular necrosis results in marked elevations in serum amino-
gone significant refinements over the past half-century. This evo- transferases that are readily observed in patients with chronic
lution has been driven by advances in our understanding of the active viral or alcoholic hepatitis. An alanine aminotransferase
physiology of both the disease and the therapies employed against (ALT)–aspartate aminotransferase (AST) ratio of 2 or higher is
it. Today, clinical management of the portal hypertensive patient often seen in patients with alcoholic liver disease.
is a truly multidisciplinary endeavor, requiring the coordinated The Child-Pugh scoring system is a useful tool for quantifying
efforts of skilled intensivists, gastroenterologists, hepatologists, hepatic functional reserve [see Table 2].1 Based on total bilirubin
interventional radiologists, and surgeons. Nevertheless, portal and albumin levels, PT (INR), and the clinical severity of ascites
hypertension and its manifold complications remain some of the and hepatic encephalopathy, the Child-Pugh score predicts both
most vexing problems encountered in modern medicine and the likelihood of variceal hemorrhage and its anticipated mortali-
surgery. ty. A newer assessment tool, the Model for End-Stage Liver
In this chapter, we briefly review portal venous anatomy and Disease (MELD) scoring system, which takes the degree of renal
the pathophysiology of portal hypertension [see Sidebar Portal impairment and the cause of hepatic dysfunction into account,
Hypertension: Anatomic and Physiologic Considerations]; how- has also been used to predict outcomes in cirrhotic patients.2
ever, our main focus is on current practical approaches to man-
aging portal hypertension and its associated sequelae (variceal
bleeding, ascites, and hepatic encephalopathy). Of particular rele- Management of Variceal Bleeding
vance to surgeons is that the role of surgical therapy has shifted The prognosis of variceal hemorrhage depends on the presence
significantly. Operative treatment now occupies only the final or absence of underlying cirrhosis. In noncirrhotic patients, the
steps in modern treatment protocols for portal hypertension— mortality associated with a first episode of variceal hemorrhage
that is, it serves as a form of salvage for intractable cases that are ranges from 5% to 10%; in cirrhotic patients, the range is from
refractory to other forms of therapy. 40% to 70%. Esophagogastric varices ultimately develop in
approximately one half of cirrhotic patients, and bleeding epi-
sodes occur in approximately one third of cirrhotic patients with
Clinical Evaluation varices. If the initial hemorrhagic episode resolves spontaneously,
The ultimate aims of diagnostic evaluation in a patient with 30% of patients experience rebleeding within 6 weeks, and 70%
portal hypertension are (1) to determine the cause of portal hy- experience rebleeding within 1 year. It is noteworthy that overall
pertension [see Table 1], (2) to estimate hepatic functional reserve, mortality in patients who survive 6 weeks after an episode of
(3) to define the portal venous anatomy and assess hemodynam- variceal bleeding is statistically indistinguishable from that in per-
ic status, and (4) to identify the site of GI hemorrhage (if present). sons who have never experienced such an episode.
Any history of chronic alcohol abuse, hepatitis, or exposure to
hepatotoxins raises the suspicion of cirrhotic liver disease. Confir-
matory evidence of chronic liver disease on physical examination Table 1 Causes of Portal Hypertension
may be found in the form of jaundice, chest wall spider angioma-
ta, palmar erythema, Dupuytren contractures, testicular atrophy,
Extrahepatic
or gynecomastia. Ascites, splenomegaly, caput medusae, encepha-
Portal vein thrombosis
lopathic alterations in mental status, and asterixis are all sugges- Splenic vein thrombosis
tive of portal hypertension. Intrahepatic
Presinusoidal obstruction
Congenital hepatic fibrosis
Primary biliary cirrhosis
Investigative Studies Sarcoidosis
Laboratory studies can also provide indicators of hepatic dys- Schistosomiasis
function.The hypersplenism that often accompanies cirrhosis can Steatohepatitis
produce mild to moderate pancytopenia. Anemia may also reflect Sinusoidal obstruction Wilson disease
variceal hemorrhage, hemolysis, or simply the chronic malnutri-
tion or bone-marrow suppression associated with chronic alco- Extrahepatic
Budd-Chiari syndrome
holism. Associated hyperaldosteronism, emesis, or diarrhea may
Right heart failure
give rise to electrolyte derangements, including hyponatremia,
Intrahepatic
hypokalemia, metabolic alkalosis, and prerenal azotemia. Coagu- Postsinusoidal obstruction Hemochromatosis
lopathy is usually attributable to chronic deficiencies in clotting Laennec (alcoholic) cirrhosis
factors that are normally synthesized by the liver; thus, elevation Secondary biliary cirrhosis
of the prothrombin time (PT) or the international normalized Posthepatitic cirrhosis
ratio (INR) often reflects the degree of chronic hepatic impair-
Arteriovenous fistula
ment. Similarly, the degree of hyperbilirubinemia can be a mea- High-flow states Massive splenomegaly
sure of both acute and chronic hepatic dysfunction. Hepato-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 10 PORTAL HYPERTENSION — 2
Anatomy of Portal Venous System and fibrosis causing hepatic venule compression; however, the
demonstration of collagen deposition within Disse’s space in cirrhotic
The 6 to 8 cm portal vein is formed by the confluence of the splenic
livers suggests the presence of a concurrent sinusoidal locus as well.
vein and the superior mesenteric vein behind the pancreatic neck and
is the most posterior component of the portal triad in the hepatoduo- Similarly, the extrahepatic postsinusoidal Budd-Chiari syndrome often
denal ligament. The inferior mesenteric vein, though prone to anatom- produces cirrhotic changes that create a secondary intrahepatic sinu-
ic variation, typically enters the splenic vein at or near its confluence soidal cause of portal hypertension.
with the superior mesenteric vein. The left gastric vein drains the less- Normal portal vein pressures range from 3 to 6 mm Hg, with daily
er curvature of the stomach and typically enters the portal vein near circadian variation. Transient pressure elevations are commonly de-
its origin. tected after eating, exercise, and Valsalva maneuvers. Sustained ele-
The unique dual blood supply of the liver, consisting of the portal vations in portal vein pressure to levels higher than 10 mm Hg can re-
vein and the hepatic artery, is coordinated by a compensatory regula- sult in gradual shunting of blood from the portal circulation into the
tory system. Total hepatic blood flow, which averages 1.5 L/min, ac- adjacent low-pressure systemic circulation via certain collateral ves-
counts for about one quarter of cardiac output. The portal circulation sels. Formation and expansion of these collaterals are thought to
typically accounts for two thirds of this hepatic blood flow but provides progress by means of active angiogenesis. The most clinically signifi-
only one third of hepatic oxygen content. Portal blood flow is an indi- cant of these vessels are the left gastric vein and the short gastric
rect function of splanchnic arterial vasoconstriction and vasodilatation;
veins, which decompress hypertensive portal flow into the azygous
in contrast, hepatic arterial flow is directly regulated by sympathetic in-
vein via esophageal and gastric submucosal veins, respectively. Col-
nervation and circulatory catecholamines. As a result, changes in por-
tal blood flow resulting from splanchnic circulatory changes can be lateral filling from the left portal vein to the epigastric veins through re-
compensated for by hepatic arteriolar dilatation or constriction. In this canalization of the obliterated umbilical vein can result in the caput
manner, hepatic arterial autoregulatory vasodilatation can preserve medusae pattern of dilated abdominal wall veins that is readily appre-
normal hepatic blood flow even in the setting of significant decreases ciated on physical examination. Portosystemic shunting also takes
in portal flow resulting from shock, hypovolemia, splanchnic vasocon- place via retroperitoneal and anorectal collateral vessels.
striction, or portosystemic shunting. Although hepatic oxygenation Long-term shunting of high-pressure portal venous blood through
may be preserved in this fashion, augmented hepatic arterial flow systemic venous vessels evolved for low-pressure capacitance can
does not replace the essential regulators of hepatic metabolism and eventually result in variceal dilatation of the latter. Sustained portal
growth (e.g., insulin) that are found in portal venous blood. As a con- pressures of 12 mm Hg or higher are necessary to produce sufficient
sequence, prolonged restriction of portal perfusion, as is seen with distention of these thin-walled vessels to induce rupture. Variceal rup-
portal hypertension–induced portosystemic collateralization or surgi- ture presents as GI hemorrhage. Although varices can form through-
cally created portosystemic shunts, results in deprivation of these he- out the entire length of the alimentary canal, the majority of portal hy-
patotrophic factors, which can ultimately contribute to hepatic atrophy
pertensive bleeding is from esophagogastric varices. Unfortunately,
and failure.
prediction of variceal hemorrhage can be difficult; only one third to
Pathophysiology of Portal Hypertension one half of patients with portal pressures exceeding 12 mm Hg will
Traditionally, the various causes of portal hypertension have been cat- experience bleeding episodes. On the basis of Laplace’s law, one
egorized according to the anatomic locus of increased resistance to can expect variceal size, intraluminal variceal pressure, and overlying
portal flow. In reality, this categorization is an oversimplification, in that epithelial wall thickness to be predictive of the likelihood of variceal
individual causes have been shown to exert their inciting effects at rupture. Clinically, variceal size and the presence and severity of red-
multiple levels. For example, portal hypertension arising from alcoholic wale markings on upper GI endoscopy (a marker of epithelial thick-
cirrhosis has classically been considered an intrahepatic postsinu- ness) can be used in conjunction with the Child-Pugh score to predict
soidal obstructive process resulting from regenerative hepatic nodules the likelihood of variceal hemorrhage.54
Further risk stratification is based on the extent of hepatic disease often necessitates vigorous replacement of circulatory vol-
decompensation. The mortality associated with variceal hemor- ume and coagulation factors, often involving infusion of colloids
rhage is 5% for patients with Child class A cirrhosis, 25% for and transfusion of fresh frozen plasma and packed red blood cells.
those with Child class B cirrhosis, and over 50% for those with Antibiotic prophylaxis therapy is recommended because of the
Child class C cirrhosis.The likelihood of recurrent hemorrhage is propensity of bacterial infections to develop in patients with
28% for patients with Child class A cirrhosis, 48% for those with chronic liver disease after bleeding episodes.
Child class B cirrhosis, and 68% for those with Child class C cir-
rhosis.3 Pharmacologic Therapy
First-line pharmacotherapy for acute variceal bleeding relies
TREATMENT OF ACUTE VARICEAL HEMORRHAGE
on the long-acting somatostatin analogue octreotide, which has
Management of acute variceal hemorrhage [see Figure 1] begins been shown to decrease splanchnic blood flow and portal venous
with the establishment of adequate airway protection. The risk of pressure. Octreotide is administered in a 250 µg I.V. bolus, fol-
aspiration and consequent respiratory deterioration is particular- lowed by infusion of 25 to 50 µg/hr for 2 to 4 days.4 In addition,
ly high among patients with hepatic encephalopathy and those vasopressin, a strong splanchnic vasoconstrictor, has been shown
undergoing endoscopic therapy. Accordingly, the threshold for to control approximately 50% of acute variceal bleeding
early endotracheal intubation should be low, particularly if episodes.4,5 Vasopressin is typically administered in a 20 U I.V.
endosopic therapy is considered. As with all cases of brisk hemor- bolus over 20 minutes, followed by infusion of 0.2 to 0.4 U/min.
rhage, adequate venous access is mandatory; placement of a cen- The therapeutic benefits of octreotide and vasopressin appear to
tral venous catheter for accurate volume assessment is particular- be similar, though the side-effect profile of octreotide appears to
ly useful in cases of major bleeding.The presence of chronic liver be much lower than that of vasopressin monotherapy.4 Adjunctive
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 10 PORTAL HYPERTENSION — 3
use of nitroglycerin at an initial rate of 50 µg/min (titrated accord- Patient has acute variceal hemorrhage
ing to blood pressure tolerance) effectively reduces the cardiac
complications of vasopressin and thereby facilitates its adminis- Protect airway.
tration.6 The long-acting vasopressin analogue terlipressin has Initiate resuscitation.
been shown to be approximately as effective as octreotide.7 Obtain I.V. access.
Administer prophylactic antibiotics.
Endoscopic Therapy
Endoscopic treatment, in the form of sclerosant injection or
band ligation, has become a standard form of therapy for acute Give octreotide (250 µg bolus, then 25–50 µg/hr
variceal hemorrhage. Experienced endoscopists achieve initial con- for 2–4 days).
trol of hemorrhage in 74% to 95% of cases; however, rebleeding Alternatively, give vasopressin (20 U bolus, then
rates ranging from 20% to 50% are typically observed. 0.2–0.4 µg/min) plus nitroglycerin (initially 50 µg/min,
titrated to BP).
In endoscopic sclerotherapy, a sclerosant—typically either 5%
sodium morrhuate (more common in the United States) or 5%
ethanolamine oleate (more common in Europe and Japan)—is
injected either intravariceally to obliterate the varix or para- Hemorrhage
Hemorrhage is not controlled
variceally to induce submucosal fibrosis and thereby prevent is controlled
variceal rupture. Three prospective, randomized, controlled trials Perform endoscopic variceal
demonstrated that endoscopic sclerotherapy, compared with tra- ligation or endoscopic sclerotherapy.
ditional balloon tamponade, achieved better initial hemorrhage
control, resulted in fewer episodes of rebleeding, and, in selected
cohorts of patients, led to improved long-term survival.8-10 Fur-
thermore, routine use of balloon tamponade after sclerotherapy Hemorrhage is not controlled Hemorrhage
is controlled
appeared not to confer any additional therapeutic benefit.8 There
are, however, significant risks associated with the use of endo- Consider TIPS.
scopic sclerotherapy, including pulmonary complications, tran-
sient chest pain, esophageal stricture formation with recurrent
sclerotherapy, iatrogenic portal vein thrombosis, hemorrhagic
esophageal ulceration, bacteremia, and esophageal perforation.11 TIPS is available TIPS is unavailable or
Partially in response to the potential complications of endo- and successful unsuccessful
scopic sclerotherapy, endoscopic variceal band ligation has been Perform balloon tamponade.
advocated as a sclerosant-free therapeutic alternative.The limited
data comparing the two approaches suggest a trend toward fewer
rebleeding episodes, fewer endoscopic interventions, and signifi-
cantly lower procedure-related morbidity and overall mortality Hemorrhage is not Hemorrhage
after variceal ligation.12 controlled is controlled
Parameter 1 2 3
Ascites is intractable Ascites is absent
Total bilirubin (mg/dl) 1–2 2.1–3 ≥ 3.1 or manageable
Construct side-to-side
Albumin (g/dl) ≥ 3.5 2.8–3.5 ≤ 2.7 portosystemic shunt. Construct end-to-side
INR < 1.7 ≥ 2.4
portacaval shunt.
1.8–2.3
or
PT (sec) 1–4 4.1–6 ≥ 6.1 Figure 1 Algorithm outlines treatment of acute variceal bleeding.
operations (mostly side-to-side) over a 28-year period. Unfortu- PREVENTION OF RECURRENT VARICEAL HEMORRHAGE
nately, these investigators’ experience stands in stark contrast to
that of most other groups, who uniformly reported operative mor- Pharmacotherapy
talities of about 40% and 5-year survival rates of about 30%. Without further treatment, the likelihood that hemorrhage will
Another potential drawback to urgent operative shunting is the recur within 1 year after control of an acute episode of variceal
manipulation and dissection that are often necessary in the region bleeding is approximately 70%.26 The pharmacologic maneuver
of the porta hepatis: these measures can result in adhesions and that has been used most extensively to prevent recurrent variceal
scarring, which can complicate future orthotopic liver transplan- bleeding [see Figure 4] is nonselective beta-adrenergic blockade,
tation. For this reason, some surgeons have advocated using the most commonly with propranolol. Although beta blockade has
mesocaval interposition shunt [see Prevention of Recurrent Vari- been shown to lower portal pressure and hepatic vein wedge pres-
ceal Hemorrhage, Surgical Therapy, Portosystemic Shunts, Non- sure, its ability to induce this effect is variable and unpre-
selective Shunts, below] in the emergency setting because of its dictable.27 Nevertheless, a meta-analysis of multiple trials study-
ability to lower portal pressure without complicating the hilar dis- ing the effectiveness of nonselective beta blockade demonstrated
section that will be necessary if transplantation is carried out a significant decline in recurrent bleeding and a trend toward
later.25 In addition, surgeons familiar with the distal splenorenal improved overall survival.4 Patients with decompensated hepatic
shunt (DSRS) can employ this selective shunt in some cases of function appear to derive less benefit from beta blockade, possi-
acute variceal hemorrhage unaccompanied by refractory ascites. bly because of the downregulation of beta-adrenergic receptors
a b
Hepatic Vein
Portal Vein
c d
Figure 3 Depicted is the procedure for performing TIPS. (a) A needle is passed under radio-
logic guidance from a hepatic vein into a major portal venous branch, and a guide wire is
advanced through this needle. (b) A balloon is passed over the guide wire, creating a tract in
the hepatic parenchyma. (c) An expandable stent is placed though this tract. (d) The effective
result is a nonselective portosystemic shunt.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 10 PORTAL HYPERTENSION — 6
Give propranolol, with or without ISMN. Give propranolol, with or without ISMN.
Patient has Child class A or Patient has more severe Child Tertiary care is readily Tertiary care is not
mild Child class B cirrhosis class B or Child class C cirrhosis accessible readily accessible
associated with cirrhosis.28 Adjunctive use of the long-acting Transjugular Intrahepatic Portosystemic Shunting
vasodilator isosorbide 5-mononitrate (ISMN) appears to potenti- TIPS [see Figure 3] has been employed to prevent recurrent
ate the efficacy of propranolol therapy.29 episodes of variceal hemorrhage, particularly as a form of bridge
Endoscopic Therapy therapy for patients awaiting orthotopic liver transplantation. The
potential advantage TIPS has over surgical portosystemic shunting
Repeated endoscopic therapy with sclerosant injection or is the ability to decompress the portal system without the risks asso-
band ligation has been advocated as a means of completely erad- ciated with general anesthesia and without postoperative complica-
icating esophageal varices. Once the varices are eliminated, rou- tions.The major limitation of TIPS is the shunt stenosis (caused by
tine endoscopy is performed at 6- to 12-month intervals to pre- neointimal hyperplasia or thrombosis) that occurs in as many as
vent recurrent hemorrhage. Compared with medical treatment, 50% of patients in the first year after the procedure. Fortunately,
long-term endoscopic therapy results in fewer rebleeding epi- most such episodes of stenosis are amenable to balloon dilatation
sodes.4 Nevertheless, approximately one half of endoscopically or secondary shunt insertion; however, 10% to 15% of TIPS recip-
treated patients eventually experience recurrent hemorrhage, ients experience total shunt occlusion that cannot be reversed.
usually within the first year. Approximately one third of patients Furthermore, TIPS functions as a nonselective shunt, leading to
treated with repeated endoscopy ultimately must be converted to hepatic encephalopathy in approximately one third of patients.32
another form of therapy because of unrelenting major bleed- Meta-analytic comparison of TIPS with endoscopic therapy
ing.30,31 For this reason, such extended endoscopic surveillance indicates that rebleeding episodes are markedly reduced in pa-
and treatment should be reserved for compliant patients who live tients treated with TIPS, but at the cost of a higher incidence of
in proximity to tertiary medical care and should be administered encephalopathy and a shunt malfunction rate of at least 50%.That
with the understanding that conversion to a more definitive form the efficacy of TIPS is relatively short-lived makes this modality an
of therapy may be necessary if endoscopy fails. ideal form of bridge therapy for patients who are awaiting ortho-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 10 PORTAL HYPERTENSION — 7
topic liver transplantation or those who have severe hepatic blood flow into the liver. Consequently, the encephalopathy rates
decompensation and thus are unlikely to live long enough to expe- are no different from those observed after end-to-side portacaval
rience failure of TIPS. TIPS can reduce the number of bleeding shunting. Side-to-side portacaval shunting does offer the benefit
episodes for patients on the transplant waiting list. In addition, the of decompressing the hepatic sinusoidal pressure via reversed
significant reduction in portal pressure produced by TIPS techni- (i.e., hepatofugal) flow of blood from the liver into the portal vein.
cally facilitates future liver transplantation. Finally, unlike surgical Because transudation of interstitial fluid from both the liver and
shunts,TIPS is completely removed at the time of recipient native the intestines is thought to contribute to ascites formation, better
hepatectomy. control of ascites is achieved with a side-to-side portacaval shunt,
which effectively decompresses both the splanchnic veins and the
Surgical Therapy intrahepatic sinusoids, than with an end-to-side portosystemic
Surgical therapy is the most effective method of controlling shunt, which decompresses only the splanchnic veins.The side-to-
portal hypertension and preventing recurrent variceal hemor- side portacaval shunt is therefore also recommended for patients
rhage. The operative procedures available to the surgeon have with Budd-Chiari syndrome, in whom an end-to-side portacaval
undergone numerous modifications and become more effective shunt would not relieve intrahepatic congestion resulting from
over the years. Review of the surgical experience reveals that with hepatic venous outflow occlusion. Otherwise, no significant out-
the onset of alternative modalities (e.g., TIPS and transplanta- come differences between end-to-side and side-to-side portacaval
tion), the risk status of patients undergoing surgical therapy (as shunts have been documented.The end-to-side variant is, howev-
predicted by Child’s classification) and the frequency of emer- er, technically easier to construct.
gency operations have steadily declined. As a result, the incidence Placement of an interposition mesocaval shunt [see Figure 5c]
of postoperative hepatic encephalopathy has gradually fallen and composed of prosthetic or autogenous vein grafts offers the tech-
overall survival has gradually improved.33 Surgical options for the nical advantages of avoiding hilar dissection (thereby making fu-
prevention of recurrent variceal hemorrhage in patients with por- ture liver transplantation less complicated) and permitting inten-
tal hypertension may be divided into three categories: (1) por- tional shunt ligation in the event of refractory postoperative en-
tosystemic shunt procedures, (2) esophagogastric devasculariza- cephalopathy. Like the side-to-side portacaval shunt, the interpo-
tion, and (3) orthotopic liver transplantation. sition shunt functions physiologically as a nonselective shunt
because of the hepatofugal portal venous blood flow. The major
Portosystemic shunts Surgical portosystemic shunting pro- drawback to the interposition shunt is shunt thrombosis, which
vides a means of decompressing the hypertensive portal venous may develop in as many as 35% of cases.
system into the low-pressure systemic venous circulation. The conventional (proximal) splenorenal shunt [see Figure 5d]
Diversion of portal blood flow from the liver also deprives the liver was initially advocated as a means of decompressing portal venous
of important hepatotrophic hormones that are present in portal flow while retaining hepatopedal hepatic portal perfusion. This
venous blood while routing cerebral toxins normally metabolized shunt is constructed by performing a splenectomy and anasto-
by the liver directly into the systemic circulation. As a result, the mosing the proximal splenic vein to the left renal vein. Physiologic
primary complications of surgical portosystemic shunting are ac- testing of patent conventional splenorenal shunts suggests that
celerated hepatic dysfunction and hepatic encephalopathy. they eventually divert all portal flow into the renal vein and there-
Primarily in an attempt to minimize these adverse sequelae, vari- fore effectively function as nonselective shunts. Indeed, long-term
ous forms of portosystemic shunting operations have evolved, rates of hepatic encephalopathy appear to be no lower after con-
which may be classified as nonselective shunts, selective shunts, or ventional splenorenal shunting than after portacaval shunting.38
partial shunts. Shunt occlusion develops in about 18% of cases.39
In short, nonselective portosystemic shunts are an effective
Nonselective shunts. The classic nonselective portosystemic means of controlling variceal hemorrhage in cases that are refrac-
shunt is the end-to-side portacaval shunt (the so-called Eck fistu- tory to other therapeutic approaches. Given the absence of any
la) [see Figure 5a].This is the only nonselective shunt that has been major differences in the rate of encephalopathic complications
rigorously compared with conventional nonoperative therapy. Sev- after the various nonselective shunts, the choice of a nonselective
eral randomized, controlled trials demonstrated superior control of shunting procedure should be based on the surgeon’s technical
bleeding after operative shunting: 9% to 25% of patients experi- familiarity with the operations and on the patient’s candidacy for
enced rebleeding after portacaval shunting (mostly related to non- future transplantation. The end-to-side portacaval shunt can be
variceal hemorrhage or shunt thrombosis), whereas 65% to 98% constructed relatively quickly but should be avoided in patients
of patients experienced rebleeding after medical therapy.34-37 who have intractable ascites or Budd-Chiari syndrome and those
Markedly higher rates of spontaneous posttreatment encephalopa- who may subsequently undergo liver transplantation.The side-to-
thy were reported in the operative shunt groups; however, the side portacaval shunt may provide better control of ascites but is
overall rates of encephalopathy did not differ between the opera- technically more challenging to construct and should also be
tive groups and the medical groups, because the encephalopathy avoided if future transplantation is an option. The interposition
seen in the medically treated patients (mainly attributable to hem- mesocaval shunt is relatively easy to construct and avoids hepatic
orrhage and infection) eventually became equivalent to that seen hilar dissection but is associated with a relatively high rate of shunt
in the surgically treated patients. There were trends toward im- occlusion when a nonautogenous conduit is used. The conven-
proved overall survival in the surgical groups, but these trends did tional splenorenal shunt also avoids hilar dissection but is associ-
not attain statistical significance. ated with a high shunt occlusion rate and is technically challeng-
The side-to-side portacaval shunt [see Figure 5b] maintains the ing to construct.
anatomic continuity of the portal vein as it passes into the liver.
However, the high sinusoidal resistance typically present in the Selective shunts. In response to the postoperative complications
setting of cirrhosis effectively renders this shunt a nonselective seen after nonselective portosystemic shunting (hepatic en-
one, with no measurable antegrade (i.e., hepatopedal) portal cephalopathy and hepatic failure), Warren and colleagues intro-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 10 PORTAL HYPERTENSION — 8
a b
c d
Splenectomy
3
2
Figure 5 Nonselective portosystemic shunts either immediately or eventually divert all portal
blood flow from the liver into the systemic venous circulation. Shown are the four main variants:
(a) end-to-side portacaval shunt, (b) side-to-side portacaval shunt, (c) interposition shunt (por-
tacaval [1], mesocaval [2], and mesorenal [3]), and (d) conventional (proximal) splenorenal shunt.
duced the distal splenorenal shunt in 1967.40 The DSRS has be- Unfortunately, perfusion studies indicate that approximately
come the prototypical selective shunt, in that it selectively decom- one half of patients lose hepatopedal flow within 1 year after a
presses the esophagogastric veins while maintaining hepatopedal DSRS procedure. This is a particular problem in patients with
flow from the mesenteric veins. It is performed by anastomosing alcoholic cirrhosis.The loss of shunt selectivity is believed to result
the distal splenic vein to the left renal vein and interrupting venous from progressive collateral diversion of portal flow into the splenic
collaterals (e.g., the left gastric and right gastroepiploic veins) [see vein via a network of pancreatic and peripancreatic veins (the so-
Figure 6]. As a result, the DSRS effectively separates the portal sys- called pancreatic siphon effect). Extensive skeletonization of the
tem into two components: (1) a decompressed esophagogastric ve- splenic vein off the pancreas (so-called splenopancreatic discon-
nous circuit and (2) a persistently hypertensive mesenteric venous nection) has been proposed as a means of minimizing this
circuit that continues to provide hepatopedal portal flow.Thus, the unwanted collateralization,41 but at present, the evidence is insuf-
DSRS does not address the mesenteric and sinusoidal hyperten- ficient to support routine employment of this measure.
sion that is responsible for ascites formation. Indeed, it is believed The complications of DSRS procedures are well described.
that the extensive retroperitoneal dissection required to construct Depending on patient selection, postoperative ascites formation is
this shunt may actually contribute to ascites formation through seen in 7% to 98% of cases; however, in only 0% to 14% of cases
inadvertent disruption of retroperitoneal lymphatic vessels. The is ascites clinically significant and refractory to dietary sodium
DSRS is contraindicated in patients who have refractory ascites or restriction and diuresis.23 Hepatic encephalopathy is reported in
splenic vein thrombosis, those who have previously undergone 0% to 32% of cases; several clinical trials comparing DSRS with
splenectomy, and those with an excessively small (< 7 mm) splenic nonselective shunting demonstrated significantly lower rates of
vein diameter. encephalopathy after DSRS, whereas other trials found no statis-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 10 PORTAL HYPERTENSION — 9
tically significant difference. With respect to overall survival and thy rate was lower, and shunt occlusion was reduced, but the inci-
hemorrhage control, DSRS and nonselective shunts appear to be dence of postoperative ascites was higher.43 A National Institutes
equivalent.42 of Health–sponsored randomized comparison between DSRS
Comparison of DSRS construction with endoscopic therapy and TIPS is currently under way at multiple centers.
has yielded interesting results. Two controlled trials comparing The other main form of selective portosystemic shunt is the
endoscopic therapy and salvage DSRS with early DSRS alone coronary-caval shunt, initially described in Japan in 1984.44 This
demonstrated superior hemorrhage control with early DSRS.30,31 shunt is constructed by anastomosing an interposition graft to the
Rates of hepatic encephalopathy did not differ between the two left gastric (coronary) vein on one end and the inferior vena cava
groups. One of the trials, conducted in an urban-suburban area on the other. To date, the applicability of this procedure has been
where 85% of sclerotherapy failures could be rescued with salvage limited, and most surgeons have relatively little experience with it.
DSRS, found survival to be improved in patients treated with
endoscopic therapy and salvage DSRS, compared with survival in Partial shunts. Various small-diameter interposition portosys-
patients treated with early DSRS alone.30 The other, performed in temic shunts have been proposed as partial shunts, designed to
a less densely populated region where only 31% of sclerotherapy achieve partial decompression of the entire portal venous system
failures could be rescued with salvage DSRS, found survival to be while maintaining a degree of hepatopedal portal flow to the liver.
improved in the early DSRS group.31 These data suggest that early The most successful of these partial shunts has been the small-
definitive surgical intervention may be preferable for patients who diameter portacaval interposition shunt. The use of a 10 mm or
are too far from a tertiary medical center to be able to reach one smaller interposition shunt, combined with extensive disruption
expeditiously in the event of uncontrollable hemorrhage. of portosystemic collateral venous circuits, serves to maintain
Attention is now being turned toward comparisons between some degree of hepatic portal perfusion. Early experience with the
the DSRS and TIPS. One uncontrolled comparative study found 8 mm ringed polytetrafluoroethylene graft suggests that hepatic
that with DSRS, hemorrhage control was better, the encephalopa- encephalopathy rates are lower with this shunt than with nonse-
Splenic Vein
Inferior
Mesenteric
Vein
Renal Vein
Inferior
Mesenteric
Vein
Superior
Right Mesenteric
Gastroepiploic Vein
Vein
Figure 6 The distal splenorenal shunt diverts portal flow from the spleen and short gastric
veins into the left renal vein. The DSRS provides selective shunting by preserving portal flow
from the mesenteric circulation. Potential sites of collateralization (e.g., the left gastric vein,
the gastroepiploic vein, and the umbilical vein) are routinely interrupted to preserve
hepatopedal portal flow.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 10 PORTAL HYPERTENSION — 10
lective 16 mm grafts and that use of the smaller shunt yields com- endoscopic examination have been shown to predict the likelihood
parable long-term survival.45 An early comparison of the small- of rupture: evidence of variceal wall thinning (cherry-red spots,
diameter portacaval shunt with TIPS demonstrated lower rates of red wales), variceal tortuosity, superimposition of varices on other
shunt occlusion and treatment failure in the operative therapy varices, and the presence of gastric varices all appear to be corre-
group.46 lated with a higher likelihood of hemorrhage.54
At present, pharmacologic therapy is the only measure that
Esophagogastric devascularization The most effective provides effective prophylaxis against variceal hemorrhage.
nonshunt operation for preventing recurrent variceal hemorrhage Nonselective beta-adrenergic blockade, either with propranolol or
is esophagogastric devascularization with esophageal transection the long-acting agent nadolol, reduces portal venous pressure by
and splenectomy, as advocated by Sugiura and associates.47 Unlike decreasing cardiac output and favoring splanchnic vasoconstric-
simple esophageal transection, which has been used with limited tion. Clinical trials examining the efficacy of propranolol therapy
success in the setting of acute hemorrhage, the Sugiura procedure demonstrated lowered rates of initial variceal bleeding, though the
and its subsequent modifications [see Figure 7] involve ligation of ultimate influence of beta blockade on patient survival was
venous branches entering the distal esophagus and the proximal mixed.55-57
stomach from the level of the inferior pulmonary vein, combined Endoscopic sclerotherapy has not been consistently effective in
with selective vagotomy and pyloroplasty [see 5:20 Gastroduodenal preventing initial variceal bleeding. In fact, several trials found sur-
Procedures]. A key point is that the left gastric (coronary) vein and vival to be poorer in patients treated with prophylactic sclerother-
the paraesophageal collateral veins are preserved to permit por- apy than in those managed with prophylactic pharmacotherapy.4,58
toazygous collateralization, which inhibits future varix formation. This difference is probably attributable to the well-documented
Initial reports from Japan cited a 5.2% operative mortality and a complications associated with endoscopic sclerotherapy.
6.3% rate of recurrent hemorrhage (most often from nonvariceal The flaws of prophylactic endoscopic sclerotherapy have led
causes).47,48 Unfortunately, these successes have not been easily some authorities to advocate endoscopic variceal band ligation as
replicated in the United States, where operative mortality with this a more effective form of prophylaxis. One trial demonstrated that
procedure has exceeded 20%, with bleeding recurring in 35% to variceal band ligation achieved better prophylaxis of initial variceal
55% of patients.49,50 Nevertheless, modifications of the Sugiura bleeding than propranolol therapy did.59 Clearly, this observation
procedure continue to be performed in patients who are unable to warrants further investigation.
undergo shunting procedures because of extensive splanchnic vein Early trials comparing prophylactic portosystemic shunting
thrombosis. with medical prophylaxis definitively showed that early operative
intervention conferred no significant benefit. In fact, the signifi-
Orthotopic liver transplantation Orthotopic liver trans- cant morbidity associated with surgical shunting and the substan-
plantation is the most definitive form of therapy for complications tial risk of accelerated hepatic dysfunction and encephalopathy
of portal hypertension.The cost of cadaveric and living-donor liver led to lower survival rates in patients treated with prophylactic
transplantation and its attendant immunosuppression, as well as surgical procedures.6,60 At present, the data are insufficient to rec-
the paucity of available allografts, make liver replacement an ommend the use of prophylactic TIPS to prevent acute variceal
option for only a select minority of patients presenting with portal hemorrhage.
hypertensive sequelae. Accordingly, careful analysis of the out-
comes of transplantation procedures in comparison with those of
nontransplantation procedures is necessary for optimal allocation Management of Ascites
of this limited resource. The presence of ascites in a patient with portal hypertension is
For patients whose portal hypertension has become refractory typically an ominous finding that is of significant prognostic
to nonoperative management strategies, the decision whether to importance: 1-year mortalities as high as 50% have been reported
employ transplantation or nontransplantation operative therapy in cirrhotic patients with new-onset ascites, whereas baseline 1-
can be based on the level of hepatic functional reserve. Patients year mortalities in cirrhotic patients without ascites are in the
with Child class A or mild class B cirrhosis appear to do well with range of 10%.61 The pathogenesis of ascites formation appears to
nontransplantation therapy as first-line operative treatment, with be related to the relative hypovolemia and the primary avidity of
the understanding that liver transplantation may remain an option renal sodium retention that develop in patients with cirrhosis.
for salvage therapy in the event of future hepatic functional dete- Hypovolemia induces renin-angiotensin activation and salt and
rioration. In contrast, patients with more advanced Child class B water reabsorption, which, in the setting of chronic liver dysfunc-
or Child class C cirrhosis appear to benefit from early transplan- tion, results in excessive transudation of fluid out of the liver and
tation, with nonoperative strategies employed strictly as bridge the intestines and into the peritoneal cavity. The major complica-
therapy for maintenance during the time spent on the allograft tions of this process are spontaneous bacterial peritonitis (SBP)
waiting list.51,52 and hepatorenal syndrome (HRS) [see Complications, below],
which account for the bulk of the morbidity and mortality associ-
PROPHYLAXIS OF INITIAL VARICEAL HEMORRHAGE
ated with ascites in patients with portal hypertension.
The significant mortality associated with variceal hemorrhage
NONSURGICAL THERAPY
has prompted efforts to devise effective means of preventing the
onset of initial variceal bleeding.The difficulty of identifying those By addressing the hyperavidity of sodium retention that drives
20% to 33% of cirrhotic patients who will experience bleeding much of ascites formation, restriction of dietary salt intake (to lev-
episodes remains the primary challenge in the application of pro- els as low as 2 g of sodium a day) can resolve ascites in approxi-
phylaxis for variceal hemorrhage. Patient characteristics that pre- mately 25% of cases. The hyperaldosteronemic state that exists
dict an increased likelihood of variceal bleeding include alcoholic can be countered by initiating diuresis with spironolactone, which,
cirrhosis, active alcohol consumption, and severe hepatic dysfunc- at dosages ranging from 100 to 400 mg/day, can relieve ascites in
tion.53 Certain anatomic features of varices seen at the time of an additional 60% to 70% of patients. Although automatic addi-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 10 PORTAL HYPERTENSION — 11
Interior
Pulmonary
Vein
Selective
Vagotomy
Pyloroplasty
Splenectomy
Paraesophagogastric
Devascularization
tion of loop diuretics has not been proved to enhance the clinical sions.64 Long-term follow-up, however, indicates that shunt occlu-
efficacy of spironolactone, augmentation of spironolactone thera- sion occurs in 47% of patients so treated and disseminated
py with furosemide can be helpful for patients whose ascites is intravascular coagulation in as many as 35%.
refractory to spironolactone monotherapy or who have hyper- The morbidity and mortality associated with operative therapy
kalemia as a result of spironolactone treatment. Gradual diuresis make routine use of side-to-side portacaval shunts a poor option
is necessary to prevent potential complications (e.g., prerenal for managing ascites.The exceptions to this general statement are
azotemia and HRS).62 cases in which ascites proves refractory to medical and TIPS ther-
In cases of ascites that is refractory to medical dietary restric- apy or in which concomitant refractory variceal hemorrhage is
tion and diuretic therapy, large-volume paracentesis has been present.
employed with some success. Albumin is typically infused at a
COMPLICATIONS
dose of 6 to 8 g per liter of ascitic fluid to prevent the hypotension
that results from acute volume shifts. Patients in whom ascites SBP is the most common form of ascitic infection. It typically
recurs after multiple rounds of large-volume paracentesis should is signaled by fever and abdominal tenderness and often is also
be considered for TIPS. TIPS is particularly useful in patients accompanied by acute hepatic and renal deterioration. The diag-
with ascites and a history of bleeding esophageal varices; it cor- nosis is generally made by analyzing ascitic fluid collected through
rects as many as 80% of medically refractory cases of ascites.63 paracentesis and is defined by the presence of a positive bacterial
However, the efficacy of TIPS is counterbalanced by its attendant culture and a neutrophil count higher than 250/mm3 in the
risks (i.e., hepatic encephalopathy, shunt occlusion, and acceler- absence of an obvious intra-abdominal source of infection. Unlike
ated hepatic failure), especially in patients with poor hepatic func- secondary peritonitis, SBP is typically monomicrobial, and the
tional reserve. frequency with which enteric gram-negative rods are found with
SBP suggests intestinal bacterial translocation as a potential cause.
SURGICAL THERAPY
SBP carries a mortality of 25% and should therefore be treated
Operative intervention plays only a limited role in the manage- aggressively with I.V. antibiotic therapy. Given the 70% recurrence
ment of ascites. Surgically inserted peritoneovenous shunts have rate after an initial episode of SBP, continuation of suppressive
been compared with large-volume paracentesis in patients with antimicrobial therapy until ascites resolves is warranted.65
ascites refractory to medical therapy. No significant differences in HRS, a poorly understood state characterized by progressive
early control of ascites have been detected, but patients treated and refractory renal impairment, typically occurs in the setting of
with peritoneovenous shunting appear to benefit from faster tense ascites and hepatic disease. Management of HRS is strictly
ascites resolution, longer palliation, and fewer hospital readmis- supportive, in that the syndrome often responds only to correc-
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 10 PORTAL HYPERTENSION — 12
tion of the underlying liver dysfunction. Accordingly, the only mercaptans, and γ-aminobutyric acid) away from hepatic metab-
proven therapy for HRS is liver transplantation. olism is what causes hepatic encephalopathy; however, the
absolute level of circulating ammonia correlates poorly with the
magnitude of encephalopathic symptoms.
Management of Hepatic Encephalopathy Correction of the triggers that cause hepatic encephalopathy
Hepatic encephalopathy is a complex of symptoms character- often reverses the psychoneurologic disturbances. In severe cases,
ized by mental status changes ranging from impaired mentation patients should also receive neomycin (1.5 g every 6 hours), which
to frank stupor.The classic neurologic finding associated with this covers enteric urease-positive bacteria, and lactulose (20 to 30 g
symptom complex is asterixis. Typically, hepatic encephalopathy two to four times daily), a disaccharide GI cathartic. Both agents
develops in the setting of significant portosystemic shunting or are believed to reduce intestinal levels of ammonia and inhibit its
significant hepatic functional impairment. It is most commonly enteric absorption. Whereas neomycin has long-term side effects
observed after the creation of a therapeutic nonselective portosys- (i.e., nephrotoxicity and ototoxicity), long-term lactulose therapy
temic shunt. Its onset is usually precipitated by dehydration, GI is generally well tolerated. Dietary protein restriction should also
hemorrhage, sepsis, or excessive protein intake; in fact, the spon- be employed for long-term suppression of hepatic encephalopa-
taneous development of hepatic encephalopathy mandates work- thy. On occasion, refractory cases of shunt-induced hepatic en-
up for these physiologic triggers. It has been speculated that the cephalopathy may be treated by means of intentional ligation or
shunting of intestinally absorbed cerebral toxins (e.g., ammonia, occlusion of the portosystemic shunt.
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esophagogastric devascularization in the treatment esophagogastric varices: a multicenter, random-
of esophageal varices. J Vasc Surg 1:254, 1984 ized clinical trial. Hepatology 13:902, 1991 Acknowledgments
48. Idezuki Y, Kokudo N, Sanjo K, et al: Sugiura 58. Prophylactic sclerotherapy for esophageal varices
procedure for management of variceal bleeding in alcoholic liver disease: a randomized, single- Figure 2 Carol Donner.
in Japan. World J Surg 18:216, 1994 blind, multicenter clinical trial. N Engl J Med Figures 3 and 5 through 7 Alice Y. Chen.
© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 11 CROHN DISEASE — 1
11 CROHN DISEASE
Susan Galandiuk, M.D., F.A.C.S., F.A.S.C.R.S.
The role of surgery in the management of Crohn disease has the known risk of disease recurrence after surgical treatment of
undergone a dramatic evolution over the past 50 years. Crohn disease and the significant associated operative morbidity. In
Currently, surgical treatment of Crohn disease is seldom per- one single-center study, the reoperation rate for Crohn disease was
formed in the emergency setting; it is nearly always performed 34% at 10 years.3 The agents used to treat Crohn disease can be di-
after failed medical therapy.The decision to proceed with opera- vided into several broad groups: probiotics, antibiotics, anti-inflam-
tive management is based on careful patient evaluation, with full matory drugs, immunosuppressive drugs, and biologic agents.These
awareness of the potential complications and ramifications of can be used alone or in combination to treat disease, as well as to
treatment. In particular, attention must be paid to the risk of maintain remission [see Table 1].
recurrent disease, the possible surgical sequelae, and the side Few good studies have been done on the cost-effectiveness of
effects of medical therapy.