Fischer’s

Mastery of
Surgery SIXTH EDITION

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd iii 16/11/11 1:54 AM

 Fischer’s
Mastery of
Surgery
SIXTH EDITION

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd i 16/11/11 1:54 AM

 Editor Assistant Editors
Josef E. Fischer, MD V. Suzanne Klimberg, MD
Professor of Surgery and Pathology
FRCS(E)HON, MD(HON) Department of Surgery
William V. McDermott Professor of Surgery University of Arkansas for Medical Sciences
Harvard Medical School Muriel Balsam Kahn Chair in Breast Surgical Oncology
Christian R. Holmes Professor of Surgery and Chair Director of Breast Cancer Program
Department of Surgery Winthrop P. Rockefeller Cancer Institute
University of Cincinnati College of Medicine, Emeritus Little Rock, Arkansas
Chair, Department of Surgery Steven D. Schwaitzberg, MD
Beth Israel Deaconess Medical Center, Emeritus
Associate Professor of Surgery
Boston, Massachusetts
Harvard Medical School
Chief of Surgery
Associate Editors Cambridge Health Alliance
Cambridge, Massachusetts
Daniel B. Jones, MD, MS, FACS
Professor in Surgery Kirby I. Bland, MD
Harvard Medical School Fay Fletcher Kerner Professor and Chairman
Vice Chair of Surgery Department of Surgery
Office of Technology and Innovation University of Alabama at Birmingham School
Chief, Minimally Invasive Surgical Services of Medicine
Beth Israel Deaconess Medical Center Surgeon-in-Chief
Boston, Massachusetts University Hospital
Senior Advisor to the Director UAB Comprehensive
Frank B. Pomposelli, MD Cancer Center
Professor of Surgery Birmingham, Alabama
Harvard Medical School
Chief, Vascular and Endovascular Surgery
Beth Israel Deaconess Medical Center
Boston, Massachusetts

Gilbert R. Upchurch Jr., MD

Chief of Vascular and Endovascular Surgery
William H. Muller, Jr. Professor of Surgery
University of Virginia
Charlottesville, Virginia

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd ii 16/11/11 1:54 AM

 Acquisitions Editor: Brian Brown
Product Manager: Brendan Huffman
Production Manager: Alicia Jackson
Senior Manufacturing Manager: Benjamin Rivera
Marketing Manager: Lisa Lawrence
Design Coordinator: Doug Smock
Production Service: Aptara, Inc.

© 2012 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business

Two Commerce Square
2001 Market Street
Philadelphia, PA 19103 USA
LWW.com

All rights reserved. This book is protected by copyright. No part of this book may be reproduced in
any form by any means, including photocopying, or utilized by any information storage and retrieval
system without written permission from the copyright owner, except for brief quotations embodied
in critical articles and reviews. Materials appearing in this book prepared by individuals as part
of their official duties as U.S. government employees are not covered by the above-mentioned
copyright.

Printed in the United States of America

Library of Congress Cataloging-in-Publication Data

Fischer’s mastery of surgery / editor, Josef E. Fischer ; associate

editors, Daniel B. Jones, Frank B. Pomposelli, Gilbert R. Upchurch, Jr. ;
assistant editors, V. Suzanne Klimberg, Steven D. Schwaitzberg,
Kirby I.
Bland.—6th ed.
p. ; cm.
Mastery of surgery
Rev. ed. of: Mastery of surgery / editor, Josef E. Fischer ; associate
editor, Kirby I. Bland ; section editors, Mark P. Callery . . . [et al.].
5th ed. c2007
Includes bibliographical references and index.
ISBN 978-1-60831-740-0 (hardback : alk. paper)
I. Fischer, Josef E., 1937- II. Mastery of surgery. III. Title: Mastery
of surgery.
[DNLM: 1. Surgical Procedures, Operative. WO 500]
617—dc23 2011041462

Care has been taken to confirm the accuracy of the information presented and to describe generally
accepted practices. However, the authors, editors, and publisher are not responsible for errors or
omissions or for any consequences from application of the information in this book and make no
warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the con-
tents of the publication. Application of the information in a particular situation remains the profes-
sional responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and
dosage set forth in this text are in accordance with current recommendations and practice at the
time of publication. However, in view of ongoing research, changes in government regulations, and
the constant flow of information relating to drug therapy and drug reactions, the reader is urged to
check the package insert for each drug for any change in indications and dosage and for added warn-
ings and precautions. This is particularly important when the recommended agent is a new or infre-
quently employed drug.
Some drugs and medical devices presented in the publication have Food and Drug Administration
(FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care
provider to ascertain the FDA status of each drug or device planned for use in their clinical practice.

To purchase additional copies of this book, call our customer service department at (800) 638-3030 or
fax orders to (301) 223-2320. International customers should call (301) 223-2300.

Visit Lippincott Williams & Wilkins on the Internet: at LWW.com. Lippincott Williams & Wilkins
customer service representatives are available from 8:30 am to 6 pm, EST.

10 9 8 7 6 5 4 3 2 1

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd iv 16/11/11 1:54 AM

 To Karen
Erich and Hallie
Alexandra and Peter

and

The late Dr. Howard I. Down

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd v 16/11/11 1:54 AM

 www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd vi 16/11/11 1:54 AM

 Contributors

Naji N. Abumrad MD, FACS J. Kyle Anderson, MD Chad G. Ball, MD, MSC, FRCSC
Professor and Chair Assistant Professor Assistant Professor
Department of Surgery Department of Urology Department of Surgery
Vanderbilt University School of Medicine University of Minnesota and Veterans Affairs University of Calgary
Nashville, Tennessee Medical Center Calgary, Alberta, Canada
Minneapolis, Minnesota
David B. Adams, MD Hans G. Beger, MD, FACS
Professor and Chief Victoria Ardiles, MD Emeritus Professor of Surgery
Division of Gastrointestinal and Laparoscopic Surgery Department of General Surgery Department of General Surgery
Co-Director, Digestive Disease Center Hospital Italiano de Buenos Aires University of Ulm
Medical University of South Carolina Buenos Aires, Argentina Ulm, Federal Republic of Germany
Charleston, South Carolina
Frank R. Arko, MD Michael Belkin, MD
Muneeb Ahmed, MD Chief Professor
Interventional Radiologist Department of Endovascular Surgery Department of Surgery
Beth Israel Deaconess Medical Center Associate Professor Harvard Medical School
Assistant Professor of Radiology Division of Vascular & Endovascular Surgery Chief of Vascular and Endovascular Surgery
Harvard Medical School Department of Surgery Brigham and Women’s Hospital
Boston, Massachusetts University of Texas Southwestern Medical Boston, Massachusetts
Center at Dallas
Gorav Ailawadi, MD Dallas, Texas Robert Bendavid, MD
Assistant Professor Advisory Council Member
TCV Surgery Shalini Arora, MD American Hernia Society
University of Virginia Surgeon Haifa, Israel
Charlottesville, Virginia Department of Medicine
John H. Stroger, Jr Hospital of Cook County Steve J. Beningfield, MD, MBChB, FFRad(D)SA
J. Wesley Alexander, MD, ScD Chicago, Illinois Chief Specialist and Head of Division
Professor Emeritus Radiology Department
Department of Surgery Stanley W. Ashley, MD Groote Schuur Hospital and University of Cape Town
University of Cincinnati Chief Medical Officer Western Cape, South Africa
Cincinnati, Ohio Brigham and Women’s Hospital
Mohamad E. Allaf, MD Frank Sawyer Professor of Surgery Parag Bhanot, MD
Associate Professor of Urology Harvard Medical School Assistant Professor of Surgery
Brady Urological Institute Boston, Massachusetts Department of Surgery
Johns Hopkins Hospital Georgetown University School of Medicine
Baltimore, Maryland Salman Ashruf, MD Attending Surgeon
Glen Burnie, Maryland Georgetown University Hospital
Robert J. Allen, Sr., MD, FACS Washington, DC
New York University Langone Medical Center Bernadette Aulivola, MD, RVT, MS
New York, New York Associate Professor James G. Bittner IV, MD
Department of Surgery Instructor in Surgery
Waddah B. Al-Refaie, MD Division of Vascular Surgery and Department of Surgery
Department of Surgery Endovascular Therapy Section of Minimally Invasive Surgery
The University of Minnesota and Minneapolis VAMC Loyola University Medicine Center Washington University in St. Louis School of Medicine
Minneapolis, Minnesota Stritch School of Medicine St. Louis, Missouri
Maywood, Illinois
Maraya Altuwaijri, MD, RPVI
OC Vein Care
Kirby I. Bland, MD
Sanjay P. Bagaria, MD Fay Fletcher Kerner Professor and
Newport Beach, California Departments of General Surgery and Chairman
Parvis K. Amid, MD Breast Clinic Department of Surgery
Clinical Professor of Surgery Mayo Clinic Hospital University of Alabama at Birmingham School of
Department of Surgery Jacksonville, Florida Medicine
University of California Surgeon-in-Chief
Attending Staff Robert W. Bailey, MD University Hospital
Department of Surgery Department of Surgery Senior Advisor to the Director UAB Comprehensive
Ronald Reagan Hospital/UCLA Medical Center Mount Sinai Medical Center Cancer Center
Los Angeles, California Miami, Florida Birmingham, Alabama
vii

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd vii 16/11/11 1:54 AM

 viii Contributors

Isaac A. Bohannon, MD Ronald W. Busuttil, MD, PhD Paul F. Castellanos, MD, FCCP
Department of Surgery Distinguished Professor and Executive Associate Professor of Surgery
Division of Otolaryngology-Head and Chairman of Surgery Division of Otolaryngology Head and
Neck Surgery Chief Neck Surgery
University of Alabama at Birmingham Department of Surgery University of Alabama at Birmingham
Birmingham, Alabama Division of Liver and Pancreas Transplantation Birmingham, Alabama
Dumont-UCLA Transplant Center
Richard D. Branson, MS, RRT David Geffen School of Medicine at UCLA Robert J. Cerfolio, MD
Professor of Surgery Los Angeles, CA Department of Cardiothoracic Surgery
Department of Surgery University of Alabama at Birmingham
University of Cincinnati Jeffrey A. Cadeddu, MD Birmingham, Alabama
Cincinnati, Ohio Professor
Department of Urology Irshad H. Chaudry, MD
Igal Breitman, MD University of Texas Southwestern Department of Surgery
Instructor Medical Center University of Alabama School
Department of Surgery Dallas, Texas of Medicine
Vanderbilt University School of Medicine Birmingham, Alabama
Nashville, Tennessee Casey M. Calkins, MD
Associate Professor of Pediatric Surgery Clark Chen, MD, PhD
Murray F. Brennan, MD Department of Surgery Instructor
Professor The Medical College of Wisconsin Department of Surgery
Department of Surgery Attending Surgeon Director, Clinical Neuro-Oncology
Weill Cornell Medical College General Pediatric and Thoracic Surgery Beth Israel Deaconess Medical Center
Attending Surgeon The Children’s Hospital of Wisconsin Boston, Massachusetts
Memorial Sloan-Kettering Cancer Center Milwaukee, Wisconsin
New York, New York Constance M. Chen, MD, MPH
Richard P. Cambria, MD Assistant Clinical Professor
Stacy A. Brethauer, MD Professor of Surgery Plastic and Reconstructive Surgery
Assistant Professor of Surgery Department of Vascular and Endovascular Surgery Tulane University
Cleveland Clinic Lerner College of Medicine Harvard Medical School New Orleans, Louisiana
Staff Surgeon Chief of Vascular and Endovascular Surgery Attending Surgeon
Bariatric and Metabolic Institute Massachusetts General Hospital Plastic and Reconstructive Surgery
Cleveland Clinic Boston, Massachusetts Lenox Hill Hospital
Cleveland, Ohio New York Eye and Ear Infirmary
Kenneth L. Campbell, MD New York, New York
David C. Brewster, MD Consultant Colorectal Surgeon
Clinical Professor of Surgery Ninewells Hospital and Medical School David C. Chen, MD
Department of Surgery University of Dundee Assistant Clinical Professor
Harvard Medical School Scotland Department of Surgery
Senior Surgeon University of California at
Division of Vascular and Endovascular Jeremy W. Cannon, MD, SM Los Angeles
Surgery Lt. Col, USAF, MC Los Angeles, California
Massachusetts General Hospital Assistant Professor of Surgery
Boston, Massachusetts Uniformed Services University of the Herbert Chen, MD
Health Sciences Professor and Vice-Chairman
L. D. Britt, MD, MPH, FACS Bethesda, Maryland Department of Surgery
Brickhouse Professor and Chairman Staff Surgeon University of Wisconsin
Department of Surgery Division of Trauma and Acute Care Surgery Chairman, General Surgery
Eastern Virginia Medical School Brooke Army Medical Center University of Wisconsin Hospital
Norfolk, Virginia Ft. Sam Houston, Texas and Clinics
Madison, Wisconsin
L. Michael Brunt, MD Tobias Carling, MD, PhD
Professor Assistant Professor of Surgery Yijun Chen, MD, PhD
Department of Surgery Department of Surgery Department of Medical Oncology
Washington University School of Medicine Yale University School of Medicine Buffalo Medical Group, P.C.
Barnes-Jewish Hospital New Haven, Connecticut Williamsville, New York
St. Louis, Missouri
Denise M. Carneiro-Pla, MD David K.W. Chew, MD
Henry Buchwald, MD, PhD Associate Professor Division of Vascular and Endovascular
Professor Department of Surgery Surgery
Department of Surgery Medical University of South Carolina Brigham and Women’s Hospital
University of Minnesota Charleston, South Carolina Harvard Medical School
Minneapolis, Minnesota Boston, Massachusetts
William R. Carroll, MD
Rudolf Bumm, MD George W. Barber Jr. Professor of Surgery Silas M. Chikunguwo, MD, PhD
Professor of Surgery The University of Alabama at Birmingham Department of Surgery
Chief, Department of Surgery Division of Otolaryngology Virginia Commonwealth University and
Klinik Weilheim University of Alabama Hospitals School of Medicine
Germany Birmingham, Alabama Richmond, Virginia

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd viii 16/11/11 1:54 AM

 Contributors ix

Kathleen K. Christians, MD Jay Collins, MD, FACS John A. Curci, MD, FACS
Professor Associate Professor Assistant Professor of Surgery
Department of Surgery Department of Surgery Section of Vascular Surgery
Medical College of Wisconsin Eastern Virginia Medical School Washington University in Saint Louis
Milwaukee, Wisconsin Norfolk, Virginia Saint Louis, Missouri

Charles Choy, MD Anthony J. Comerota, MD, FACS, RVT Gregory Dakin, MD

Department of Surgery Director Associate Professor of Surgery
North Shore-Long Island Jewish Health Jobst Vascular Center Department of Surgery
System The Toledo Hospital Weill Cornell Medical College
New York, New York Toledo, Ohio; Associate Attending Surgeon
Department of Surgery New York Presbyterian Hospital
Kevin C. Chung, MD, MS Division of Vascular Surgery New York, New York
Charles B. G. deNancrede Professor University of Michigan Medical School
Section of Plastic Surgery Ann Arbor, Michigan Kimberly Moore Dalal, MD
Department of Surgery Lieutenant Colonel, United States
The University of Michigan Medical School Robert E. Condon, MD Air Force
Ann Arbor, Michigan Department of Surgery Chief, Surgical Oncology
Medical College of Wisconsin David Grant United States Air Force
G. Patrick Clagett, MD Milwaukee, Wisconsin Medical Center
Jan and Bob Pickens Distinguished Professorship Assistant Clinical Professor (Volunteer)
in Medical Science Kevin C. Conlon, MA, MCh, MBA, FRCSI, University of California at San Francisco
Department of Surgery FACS, FRCS, FTCD Travis Air Force Base, California
Division of Vascular Surgery Professor of Surgery
University of Texas Southwestern Medical Professorial Surgical Unit Siamak Daneshmand, MD
Center at Dallas University of Dublin Associate Professor of Clinical Urology
Dallas, Texas Trinity College USC Keck School of Medicine
Consultant General /Upper GI Surgeon Los Angeles, California
Daniel G. Clair, MD Adelaide & Meath Hospital Incorporating the
Professor of Surgery National Children’s Hospital Marcelo C. DaSilva, MD
Cleveland Clinic Lerner College of Medicine Dublin, Ireland Department of Surgery
Chairman Division of Thoracic Surgery
Department of Vascular Surgery Joel D. Cooper, MD Brigham and Women’s Hospital
The Cleveland Clinic Professor of Surgery Boston, Massachusetts
Cleveland, Ohio Department of Thoracic Surgery
University of Pennsylvania Andrew M. Davidoff, MD
Rodrigo Sanchez Claria, MD Hospital of the University of Pennsylvania Professor
Department of HPB Surgery and Liver Philadelphia, Pennsylvania Department of Surgery and Pediatrics
Transplant University of Tennessee Health Science Center
Hospital Italiano de Buenos Aires Willy Coosemans, MD, PhD Chairman, Department of Surgery
Argentina Head of Clinic St. Jude Children’s Research Hospital
Transplant Surgeon Memphis, Tennessee
Clancy J. Clark, MD Thoracic Surgeon
Department of General Surgery Department of Thoracic Surgery Tomer Davidov, MD
Virginia Mason Medical Center University Hospital Gasthuisberg Department of Surgery
Seattle, Washington Leuven, Belgium University of Medicine & Dentistry of New Jersey –
Robert Wood Johnson Medical School
Pierre-Alain Clavien, MD, PhD Gene F. Coppa, MD New Brunswick, New Jersey
Swiss HPB and Transplantation Senior Vice President of Surgical Services
Center North Shore-Long Island Jewish Health System; Brian R. Davis, MD
Department of Surgery Chairman of Surgery Assistant Professor of Surgery
University Hospital Zurich North Shore University Hospital and Long Island Department of Surgery
Switzerland Jewish Medical Center Texas Tech University Health Sciences
Staten Island, New York Center
Ronald H. Clements, MD El Paso, Texas
Professor Alain Corcos, MD
Department of Surgery Assistant Professor of Surgery Herbert Decaluwé, MD
Vanderbilt University University of Pittsburgh Department of Thoracic Surgery
Director Chief, Section of Trauma and Burns University Hospital Gasthuisberg
Center for Surgical Weight Loss UPMC-Mercy Leuven, Belgium
Nashville, Tennessee Pittsburgh, PA
Malcolm M. DeCamp, MD
Daniel G. Coit, MD Robert S. Crawford, MD Fowler McCormick Professor
Professor Assistant Professor Department of Surgery
Department of Surgery Division of Vascular Surgery Northwestern University Feinberg School of
Weill Cornell Medical College University of Maryland Medical Center Medicine
Attending Surgeon Attending Surgeon Chief, Division of Thoracic Surgery
Memorial Sloan-Kettering Cancer Center Baltimore VA Medical Center Northwestern Memorial Hospital
New York, New York Baltimore, Maryland Chicago, Illinois

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd ix 16/11/11 1:54 AM

 x Contributors

Georges Decker, MD Daniel T. Dempsey, MD Jonathan L. Eliason, MD

Visceral & Thoracic Surgery Chief, Department of Gastrointestinal Assistant Professor of Surgery
Zitha Klinik Surgery Section of Vascular Surgery
Department of Thoracic Surgery Assistant Director Department of Surgery
University Hospital Gasthuisberg Department of Peri-Operative Services University of Michigan School of
Leuven, Belgium Hospital of the University of Pennsylvania Medicine
Philadelphia, Pennsylvania Ann Arbor, Michigan
G. Michael Deeb, MD
Section of Cardiac Surgery Eduardo De Santibañes, DR, MD, PhD Sean P. Elliott, MD, MS
University of Michigan Medical School Full Professor in Surgery Associate Professor
Ann Arbor, Michigan Department of Surgery Department of Urology
Universid ad de Buenos Aires University of Minnesota
Alberto De Hoyos, MD Chairman General Surgical Service & Liver Minneapolis, Minnesota
Director Transplant Unit
Center for Robotic and Minimally Invasive Hospital Italiano E. Christopher Ellison, MD
Thoracic Surgery Buenos Aires, Argentina Professor and Chair
Co-Director Department of Surgery
Center for Complex Airway Surgery J. Michael Dixon, MBChB, MD The Ohio State University
Department of Thoracic Surgery Professor of Surgery Columbus, Ohio
Northwestern Memorial Hospital Consultant Surgeon
Chicago, Illinois University of Edinburgh Scott A. Engum, MD
Clinical Director of the Edinburgh Professor
John P. Delany, MD Breast Unit Department of Surgery
Chair in Clinical Surgical Oncology Western General Hospital Indiana University School of
Masonic Cancer Center Edinburgh, Scotland Medicine
University of Minnesota James Whitcomb Riley Hospital for
Minneapolis, Minnesota Eric J. Dozois, MD Children
Program Director Indianapolis, Indiana
Jorge I. de la Torre, MD Department of Colon and Rectal Surgery
Professor and Chief Mayo Medical School Mark K. Eskandari, MD
Division of Plastic Surgery Rochester, Minnesota Professor and Chief
University of Alabama at Birmingham Division of Vascular Surgery
School of Medicine Roger R. Dozois, MD Northwestern University Feinberg School of
Director Department of Colon and Rectal Surgery Medicine
Center for Advanced Surgical Mayo Clinic Northwestern Memorial Hospital
Aesthetics Rochester, Minnesota Chicago, Illinois
Birmingham, Alabama
Richard L. Drake, PhD, FAAA N. Joseph Espat, MD, MS, FACS
Paul De Leyn, MD, PhD Director of Anatomy Harold Wanebo Professor of Surgery
Professor of Surgery Professor of Surgery Acting-Chair, Department of Surgery
Dean of Clinical Clerkship Cleveland Clinic Lerner College of Medicine Director, Adele R. Decof Cancer
Faculty of Medicine Cleveland, Ohio Center
Department of Thoracic Surgery Chief, Surgical Oncology
University Hospital Gasthuisberg Kelli Bullard Dunn, MD Roger Williams Medical Center
Leuven, Belgium Associate Professor Boston University School of
Department of Surgical Oncology Medicine
Eric J. DeMaria, MD Roswell Park Cancer Institute Providence, Rhode Island
Attending Surgeon Department of Surgery
Department of Surgery University at Buffalo/State University of New York Steve Eubanks, MD, FACS
Durham Regional Hospital Buffalo, New York Director of Academic Surgery
Duke Health System Medical Director of the Institute for Surgical
Durham, North Carolina Philipp Dutkowski, MD Advancement
Swiss HPB and Transplantation Center Florida Hospital
Tom R. DeMeester, MD Department of Surgery Orlando, Florida
Emeritus Professor University Hospital Zurich
Department of Surgery Switzerland Douglas B. Evans, MD
University of Southern California Donald C. Ausman Family Foundation Professor
Los Angeles, California Brian D. Duty, MD of Surgery and Chairman
Clinical Instructor Department of Surgery
Demetrios Demetriades, MD, PhD, FACS Department of Urology Medical College of Wisconsin
Professor of Surgery The Arthur Smith Institute for Urology Milwaukee, Wisconsin
University of Southern California New Hyde Park, New York
School of Medicine Stephen R. T. Evans, MD
Director of Trauma, Emergency Surgery, Surgical John F. Eidt, MD Professor
Intensive Care Unit Professor of Radiology and Surgery Department of Surgery
Department of Surgery Department of Vascular and Endovascular Georgetown University
Los Angeles County and University of Southern Surgery Chief Medical Officer
California Medical Center University of Arkansas for Medical Sciences Georgetown University Hospital
Los Angeles, California Little Rock, Arkansas Washington, DC

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd x 16/11/11 1:54 AM

 Contributors xi

Amy R. Evenson, MD Josef E. Fischer, MD Herbert R. Freund, MD

Instructor William V. McDermott Professor of Surgery Emeritus Professor
Department of Surgery Harvard Medical School Department of Surgery
Beth Israel Deaconess Medical Christian R. Holmes Professor of Surgery and Chair Hebrew University Hadassah Medical
Center Department of Surgery School
Harvard Medical School University of Cincinnati College of Medicine, Emeritus Senior Surgeon
Boston, Massachusetts Chair, Department of Surgery Hadassah University Medical Center
Beth Israel Deaconess Medical Center, Emeritus Jerusalem, Israel
Salomao Faintuch, MD, MSc Boston, Massachusetts
Interventional Radiologist Flavio Frigo, MD
Beth Israel Deaconess Medical Center James W. Fleshman, MD Department of General Surgery
Instructor in Radiology Chief of the Section of Colon and Rectal Surgery Alta Padovana
Harvard Medical School Department of Surgery Padova, Italy
Boston, Massachusetts Washington University School of Medicine
Chief of Surgery Arlan F. Fuller, Jr., MD
Sheung Tat Fan, MS, MD, PhD, DSc Barnes Jewish West County Clinical Vice President for Oncology
Chair, Professor of Surgery St. Louis, Missouri Chief of Gynecologic Oncology
Department of Surgery Winchester Hospital Center for Cancer Care
The University of Hong Kong Jobe Fix, MD Winchester, Massachusetts
Honorary Consultant Professor
Queen Mary Hospital Department of Surgery Susan Galandiuk, MD
Hong Kong, China University of Alabama at Birmingham Professor of Surgery
School of Medicine Department of Surgery
Victor W. Fazio, MD Birmingham, Alabama University of Louisville
Chairman, Colorectal Surgery Louisville, Kentucky
Vice-Chairman, Division of Surgery W. Dennis Foley, MD
Cleveland Clinic; Professor of Radiology Steven S. Gale, MD, FACS
Professor of Surgery Director of Digital Imaging Clinical Assistant Professor of Surgery
Medical College of Ohio at Toledo
Health Science Center Medical College of Wisconsin
Associate Director
The Ohio State University; Milwaukee, Wisconsin
Jobst Vascular Center for Vascular Laboratories
Professor of Surgery Vein Solutions
Lerner College of Medicine Yuman Fong, MD Toledo, Ohio
Case Western Reserve University Professor of Surgery
Cleveland, Ohio Department of Surgery Sidhu P. Gangadharan, MD
Weill-Cornell Medical College Division of Thoracic Surgery and Interventional
Robert J. Feezor, MD Murray F. Brennan Chair in Surgery Pulmonology
Assistant Professor Memorial Sloan-Kettering Cancer Center Beth Israel Deaconess Medical Center
Department of Vascular Surgery and New York, New York Harvard Medical School
Endovascular Therapy Boston, Massachusetts
University of Florida Dennis L. Fowler, MD, MPH
Gainesville, Florida Professor of Clinical Surgery Ian Ganly, MD, PhD, FRCS
Department of Surgery Assistant Professor
David V. Feliciano, MD Columbia University College of Physicians Department of Otolaryngology
Professor and Surgeons Weill Cornell Presbyterian Medical Center
Department of Surgery Medical Director Assistant Attending
Mercer University School of Medicine Simulation Center Department of Head and Neck Surgery
Medical Center of Central Georgia New York Presbyterian Hospital/Columbia Memorial Sloan Kettering Cancer Center
Macon, Georgia New York, New York New York, New York
Attending Surgeon
Antonio Garcia-Ruiz, MD
Atlanta Medical Center Charles J. Fox, MD
Section Head
Atlanta, Georgia Associate Professor Minimally Invasive Surgery
Department of Surgery Hospital Central Militer
Alessandro Fichera, MD Uniformed Services University of the Mexico City, Mexico
Associate Professor of Surgery Health Sciences
Department of Surgery Attending Surgeon O. James Garden, MD, FRCSEd, FRCPEd,
The University of Chicago Medical Walter Reed National Military Medical Center FRACS(hon), FRCSCan(hon)
Center Bethesda, Maryland Regius Professor of Clinical Surgery
Chicago, Illinois Clinical Surgery
Spiros G. Frangos, MD, MPH, FACS University of Edinburgh
George Fielding, MD Associate Professor of Surgery Royal Infirmary
Fellow Trauma & Surgical Critical Care Edinburgh, United Kingdom
Royal Australasian College of NYU School of Medicine
Surgeons New York, New York Arthur I. Gilbert, MD, FACS
Royal College of Surgeons Voluntary Associate Professor of Surgery
England Morris E. Franklin, MD, FACS The Daughtry Family Department of
Associate Professor of Surgery Director Surgery
New York University School of Department of Minimally Invasive Surgery University of Miami Miller School of
Medicine Texas Endosurgery Institute Medicine
New York, New York San Antonio, Texas Miami, Florida

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xi 16/11/11 1:54 AM

 xii Contributors

Armando E. Giuliano, MD, FACS Angelita Habr-Gama, MD, PhD Frank Hinman, Jr. MD (Deceased)
Clinical Professor of Surgery Professor of Surgery Clinical Professor
University of California, Los Angeles University of Sao Paulo Medical School Department of Urology
Executive Vice Chair Sao Paulo, Brazil University of California
Department of Surgery San Francisco, California
Cedars-Sinai Medical Center Michael E. Halkos, MD
Los Angeles, California Assistant Professor of Surgery Mitchel S. Hoffman, MD
Division of Cardiothoracic Surgery Program Director
John M. Giurini, DPM Department of Surgery Division of Gynecologic Oncology Fellowship
Associate Professor Emory University Program
Department of Surgery Atlanta, Georgia Department of Obstetrics & Gynecology
Harvard Medical School
University of South Florida College of Medicine
Chief, Division of Podiatric Medicine and Surgery Allen D. Hamdan, MD Tampa, Florida
Beth Israel Deaconess Medical Center
Associate Professor of Surgery
Boston, Massachusetts
Harvard Medical School George W. Holcomb III, MD, MBA
Peter Gloviczki, MD Clinical Director, Vascular and Endovascular Professor
Professor of Surgery Surgery Department of Surgery
Chair Beth Israel Deaconess Medical Center University of Missouri-Kansas City
Department of Vascular Surgery Boston, Massachusetts Surgeon-in-Chief
Mayo Clinic Children’s Mercy Hospital
Rochester, Minnesota Kimberley J. Hansen, MD Kansas City, Missouri
Christopher J. Godshall, MD Professor of Surgery
Associate Professor Interim Chair Santiago Horgan, MD
Department of Surgery Department of Surgery Professor of Surgery
Division of Vascular and Endovascular Division of Vascular and Endovascular Surgery Director of Minimally Invasive Surgery
Surgery Wake Forest University School of Medicine Director of the Center for Treatment of Obesity
Wake Forest University School of Medicine Winston-Salem, North Carolina University of California San Diego
Winston-Salem, North Carolina San Diego, California
Per-Olof Hasselgren, MD, PhD
Matthew R. Goede, MD George H.A. Clowes, Jr. Professor of Surgery J. Jason Hoth, MD, PhD
Assistant Professor of Surgery Harvard Medical School Associate Professor of Surgery
University of Nebraska Medical Center Vice Chairman – Research Department of General Surgery
Omaha, Nebraska Director of Endocrine Surgery Wake Forest School of Medicine
Department of Surgery Winston Salem, North Carolina
S. Nahum Goldberg, MD Beth Israel Deaconess Medical Center
Radiologist Boston, Massachusetts Thomas J. Howard, MD, FACS
Hadassah Medical Center; Willis D. Gatch Professor of Surgery
Professor of Radiology Bruce H. Haughey, MBChB Indiana University School of Medicine
Hebrew University Professor Indianapolis, Indiania
Jerusalem, Israel Department of Otolaryngology Head and
Neck Surgery William J. Hubbard, MD
Washington University School of Medicine Assistant Professor
Philip H. Gordon, MD, FRCS(C), FACS,
St Louis, Missouri University of Alabama
FASCRS, FCSCRS, Hon FRSM, Hon FACGBI
Professor, Surgery and Oncology Thomas S. Huber, MD, PhD
McGill University Jeffrey W. Hazey, MD
Associate Professor of Surgery Professor and Chairman
Director of Colon and Rectal Surgery Department of Surgery
Sir Mortimer B Davis Jewish General Ohio State University Center for Minimally
Invasive Surgery Division of Vascular and Endovascular Surgery
Hospital University of Florida College of Medicine
McGill University The Ohio State University Medical Center
Columbus, Ohio Gainesville, Florida
Montreal, Quebec
Richard John Heald, MB, BChir Franziska Huettner, MD
Clive S. Grant, MD Peoria, Illinois
Professor of Surgery Professor
Department of Surgery Director of Surgery
Eric S. Hungness, MD
Mayo Clinic Pelican Cancer Foundation
Assistant Professor
Rochester, Minnesota Basingstoke, United Kingdom
Department of Surgery
Divisions of Gastrointestinal and Endocrine
Ana M. Grau, MD Peter Henke, MD
Surgery
Associate Professor Professor of Surgery
Northwestern University Comprehensive Center on
Department of Surgery Department of Surgery
Obesity
Division of Surgical Oncology & Endocrine Section of Vascular Surgery
Northwestern University Feinberg School
Surgery University of Michigan School of Medicine
of Medicine
Vanderbilt University Medical Center Ann Arbor, Michigan
Chicago, Illinois
Nashville, Tennessee
Jonathan M. Hernandez, MD John G. Hunter, MD
Arin K. Greene, MD, MMSc Department of Surgery Mackenzie Professor and Chair
Department of Plastic and Oral Surgery University of South Florida College of Department of Surgery
Children’s Hospital Boston Medicine Oregon Health and Science University
Boston, Massachusetts Tampa, Florida Portland, Oregon

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xii 11/16/11 10:39 AM

 Contributors xiii

Roger D. Hurst, MD Stephanie B. Jones, MD Michael C. Kearney, MD

Associate Professor of Surgery Associate Professor of Anesthesia Division of Urologic Surgery
The University of Chicago Medical Center Harvard Medical School; Department of Surgery
Chicago, Illinois Vice Chair for Education Beth Israel Deaconess Medical Center
Residency Program Director Boston, Massachusetts
John M. Hutson, MB, BS, MD, FRACS Department of Anesthesia, Critical Care and Pain
Professor of Pediatric Surgery Management Michael R.B. Keighley, MBBS, FRCS (Edin),
Department of Pediatrics Beth Israel Deaconess Medical Center FRCS (Eng), MS
University of Melbourne Boston, Massachusetts Consultant Surgeon
Director, Department of General Surgery Priory Hospital
Royal Children’s Hospital Ravi Kacker, MD Birmingham, West Midlands, United Kingdom
Victoria, Australia Division of Urologic Surgery
Beth Israel Deaconess Medical Center Mark Keldahl, MD
Elias S. Hyams, MD Boston, Massachusetts Department of Vascular Surgery
Instructor in Urology Northwestern Memorial Hospital
Brady Urological Institute Venkat R. Kalapatapu, MD Chicago, Illinois
Johns Hopkins Hospital Assistant Professor of Clinical Surgery
Baltimore, Maryland Clinical Practices of the University of Pennsylvania Mark C. Kelley, MD, FACS
University of Pennsylvania College of Medicine Associate Professor
Karl A. Illig, MD Philadelphia, Pennsylvania Chief
Department of Surgery Division of Surgical Oncology
University of South Florida College Jeffrey Kalish, MD Vanderbilt University Medical Center
of Medicine Laszlo N. Tauber Assistant Professor of Surgery Nashville, Tennessee
Tampa, Florida Department of Surgery
Boston University School of Medicine Edward Kelly, MD
Mihaiela Ilves, MD Director of Endovascular Surgery Assistant Professor
Division of Vascular and Endovascular Section of Vascular Surgery Department of Surgery
Surgery Boston Medical Center Harvard Medical School
University of Texas Southwestern Medical Boston, Massachusetts Associate Surgeon
Center at Dallas Brigham and Women’s Hospital
Dallas, Texas Vikram S. Kashyap, MD, FACS Boston, Massachusetts
Professor of Surgery
Carlos Eduardo Jacob, MD, PhD Chief, Division of Vascular Surgery and Keith A. Kelly, MD
Department of Gastroenterology Endovascular Therapy Scottsdale, Arizona
Digestive Surgery Unit Harrington-McLaughlin Heart and Vascular
University of Sao Paulo Medical School Institute Eugene P. Kennedy, MD
Sao Paulo, Brazil Cleveland, Ohio Associate Professor
Department of Surgery
Glenn R. Jacobowitz, MD Burkhard Kasper, MD Thomas Jefferson University
Associate Professor of Surgery Department of Neurology Philadelphia, Pennsylvania
Department of Surgery Epilepsy Centre
New York University School of Medicine University of Erlangen Jason K. Kim, MD
Vice-Chief, Division of Vascular Surgery Erlangen, Germany Assistant Professor of Surgery
New York University Langone Medical Department of Surgery
Center Ekkehard Kasper, MD, PhD University of Rochester Medical Center
New York, New York Co-Director, Brain Tumor Center Rochester, New York
Chief, Section of Neurosurgical
Garth R. Jacobsen, MD Oncology Young Bae Kim, MD
Department of Surgery Beth Israel Deaconess Medical Center Division Director, Division of Gynecologic Oncology
University of California San Diego Medical Boston, Massachusetts Department of Obstetrics and Gynecology
Center
Tufts Medical Center
San Diego, California Mukta V. Katdare, MD Boston, Massachusetts
Department of Surgery
Jay A. Johannigman, MD University of Chicago Medical Center
Professor of Surgery Masaki Kitajima, MD, PhD, FACS(hon),
Chicago, Illinois FRCS(hon), ASA(hon)
Chief, Trauma & Critical Care
Department of Surgery President
Yoshifumi Kato, MD, PhD International University of Health and Welfare (IUHW)
University of Cincinnati Associate Professor
Cincinnati, Ohio IUHW Mita Hospital
Pediatric General and Urogenital Surgery Minato-ku, Tokyo, Japan
Juntendo University School of Medicine
Daniel B. Jones, MD, MS, FACS Tokyo, Japan
Professor in Surgery V. Suzanne Klimberg, MD
Harvard Medical School Professor of Surgery and Pathology
Louis R. Kavoussi, MD Department of Surgery
Vice Chair of Surgery Wauldbaum Professor of Urologic Surgery
Office of Technology and Innovation University of Arkansas for Medical Sciences
Smith Institute for Urology Muriel Balsam Kahn Chair in Breast Surgical
Chief, Minimally Invasive Surgical North Shore-LIJ School of Medicine of Hofstra
Services Oncology
University Director of Breast Cancer Program
Beth Israel Deaconess Medical Chairman and Senior Vice President
Center Winthrop P. Rockefeller Cancer Institute
North Shore-LIJ Health System Little Rock, Arkansas
Boston, Massachusetts New York, New York

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xiii 16/11/11 1:54 AM

 xiv Contributors

Badrinath R. Konety, MD, MBA Lydia Lam, MD Daniel Leslie, MD

Professor and Chair Assistant Professor Department of Surgery
Department of Urologic Surgery Department of Surgery The University of Minnesota and Minneapolis VAMC
University of Minnesota Division of Acute Care Surgery and Surgical Minneapolis, Minnesota
Minneapolis, Minnesota Critical Care
USC Keck School of Medicine John I. Lew, MD, FACS
David A. Kooby, MD Physician Specialist Associate Professor of Surgery
Associate Professor of Surgery LAC-USC Medical Center The DeWitt Daughtry Family Department of Surgery
Division of Surgical Oncology Los Angeles, California University of Miami Leonard M. Miller School of
Director of Robotic/Minimally Invasive Gastroin- Medicine
testinal Cancer Surgery Program Gregory J. Landry, MD Attending Surgeon
Winship Cancer Institute Associate Professor Division of Endocrine Surgery
Emory University School of Medicine Department of Surgery University of Miami Health System
Atlanta, Georgia Division of Vascular Surgery Miami, Florida
Oregon Health & Science University
Jake E.J. Krige, MB, ChB, MSc, FACS, Portland, Oregon Carol M. Lewis, MD
FRCS, FCS(SA) Assistant Professor
Professor of Surgery Jacob C. Langer, MD Department of Head and Neck Surgery
Department of Surgery Professor University of Texas
University of Cape Town Health Sciences Faculty Department of Surgery MD Anderson Cancer Center
Head HPB Unit, Head Surgical Gastroenterology University of Toronto Houston, Texas
Department of Surgical Gastroenterology Chief, General and Thoracic Surgery
Groote Schuur Hospital Hospital for Sick Children Keith D. Lillemoe, MD
Cape Town, South Africa Toronto, Canada Surgeon-in-Chief
Department of Surgery
Venkataramu N. Krishnamurthy, MD Ian C. Lavery, MD Massachusetts General Hospital
Clinical Associate Professor Department of Colorectal Surgery Boston, Massachusetts
Department of Radiology and Vascular Surgery Cleveland Clinic Main Campus
University of Michigan Cleveland, Ohio Robert B. Lim, MD
Ann Arbor, Michigan Assistant Clinical Professor of Surgery
Simon Y.K. Law, MS, MA (Cantab), MBBChir, Department of Surgery
Irving L. Kron, MD FRCSEd, FCSHK, FHKAM, FACS University of Hawaii
Professor and Chair Professor of Surgery Chief of Metabolic Surgery
Department of Surgery Department of Surgery Tripler Army Medical Center
University of Virginia Hospital The University of Hong Kong Honolulu, Hawaii
Charlottesville, Virginia Honorary Consultant
Queen Mary Hospital Henry Lin, MD
Helen Krontiras, MD Hong Kong, China Minimally Invasive & Bariatric Surgeon
Associate Professor General Surgery Dept
Co-Director Anna M. Ledgerwood, MD National Naval & Walter Reed Army Medical Centers
UAB Breast Health Center Department of Surgery Bethesda, Maryland
Co-Director Wayne State University
Lynne Cohen Prevention Program for Women Detroit, Michigan Samuel J. Lin, MD
University of Alabama at Birmingham Assistant Professor of Surgery
Birmingham, Alabama Bernard T. Lee, MD Harvard Medical School;
Assistant Professor Department of Surgery
Robert D. Kugel, MD Department of Surgery Division of Plastic and Reconstructive Surgery
Surgeon, Inventor Harvard Medical School Beth Israel Deaconess Medical Center
Hernia Treatment Center Northwest Attending Staff Boston, Massachusetts
Olympia, Washington Division of Plastic and Reconstructive Surgery
Beth Israel Deaconess Medical Center Chung Mau Lo, MS, FRCS (Edin), FRACS, FACS
Michael E. Kupferman, MD Boston, Massachusetts Department of Surgery
Assistant Professor The University of Hong Kong
Department of Head and Neck Thomas W.J. Lennard, MB, BS, LRCP, MRCS, Queen Mary Hospital
Surgery MD, FRCS Hong Kong, China
MD Anderson Cancer Center Professor of Surgery
Houston, Texas Newcastle University James N. Long, MD
Consultant Surgeon in Endocrine and Breast Assistant Professor
Madhankumar Kuppusamy, Surgery Department of Plastic Surgery
MBBS, MRCS Royal Victoria Infirmary The Kirklin Clinic
Specialist Registrar England, United Kingdom University of Alabama at Birmingham
Department of Cardiothoracic Surgery Birmingham, Alabama
Royal Brompton & Harefield NHS Foundation Toni E. Lerut, MD, PhD
Trust Emeritus Professor of Surgery Marios Loukas, MD
London, United Kingdom Catholic University of Leuven Chair and Professor
Thoracoesophageal Fellow Emeritus Chairman Department of Anatomical Sciences
Department of Thoracic Surgery Department of Thoracic Surgery School of Medicine
Virginia Mason Medical Center University Hospitals Leuven St George’s University
Seattle, Washington Leuven, Belgium Grenada, West Indies

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xiv 16/11/11 1:54 AM

 Contributors xv

Donald E. Low, MD, FACS, FRCS(C) Laurie Maidl, RN, BSN, CWOCN David A. McClusky III, MD
Head, Thoracic Oncology and Thoracic Mayo Clinic Assistant Professor of Surgery
Surgery Rochester, Minnesota Department of Surgery
Department of General and Thoracic Surgery Emory University School of Medicine
Virginia Mason Medical Center Massimo Malagó, MD, PhD Atlanta, Georgia
Clinical Assistant Professor of Surgery Professor of Surgery
University of Washington School of Medicine Royal Free Hospital John B. McCraw, MD
Seattle, Washington Hampstead, London, England Department of Surgery
University of Mississippi Medical Center
Stephen F. Lowry, MD John C. Marshall, MD Jackson, Mississippi
Department of Surgery Professor
University of Medicine & Dentistry of New Jersey – Department of Surgery James Thomas McPhee, MD
Robert Wood Johnson Medical School University of Toronto Vascular Surgery Fellow
New Brunswick, New Jersey Attending Surgeon Department of Vascular and Endovascular
Departments of Surgery and Critical Care Surgery
Charles E. Lucas, MD Medicine Harvard Medical School
Professor St. Michael’s Hospital Brigham and Women’s Hospital
Department of Surgery Toronto, Canada Boston, Massachusetts
Wayne State University
Surgeon William A. Marston, MD Genevieve B. Melton, MD, MA
Detroit Receiving Hospital Professor and Chief Assistant Professor, Department of
Harper University Hospital Division of Vascular Surgery Surgery
Detroit, Michigan University of North Carolina School Division of Colon and Rectal Surgery
of Medicine Faculty Fellow, Institute for Health
Layla C. Lucas, MD Chapel Hill, North Carolina Informatics
Department of Surgery Jose M. Martinez, MD University of Minnesota
The University of Arizona Associate Professor of Surgery Minneapolis, Minnesota
Tucson, Arizona Department of Surgery
University of Miami Health System W. Scott Melvin, MD
James D. Luketich, MD Miami, Florida Director, Division of Gastrointestinal
Professor of Surgery Surgery
Chair, Department of Cardiothoracic Surgery Tara Mastracci, MD Department of Surgery
Director, Heart Lung Esophageal Surgery Institute Department of Vascular Surgery The Ohio State University
Chief, Division of Thoracic and Foregut Surgery Cleveland Clinic Professor of Surgery
Co-Director, Minimally Invasive Surgery Center Cleveland, Ohio Columbus, Ohio
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania Viraj A. Master, MD, PhD, FACS Matthew T. Menard, MD
Associate Professor Instructor
Junji Machi, MD, PhD Department of Urology Department of Surgery
Professor Emory University Harvard Medical School
Department of Surgery Attending Surgeon Associate Surgeon
University of Hawaii Grady Memorial Hospital Brigham and Women’s Hospital
Honolulu, Hawaii Emory University Hospital Boston, Massachusetts
Atlanta, Georgia
Robyn A. Macsata, MD Miguel A. Mercado, MD
Chief Laura E. Matarese, PhD, RD, LDN, Professor of Surgery
Department of Vascular Surgery FADA, CNSC Post-Graduate School of Medicine
Veterans Affairs Medical Center Associate Professor Universidad Nacional Autónoma de
Washington DC Division of Gastroenterology, Hepatology, and México
Nutrition Professor and Chairman
Robert D. Madoff, MD Department of Surgery
Professor Department of Internal Medicine
Brody School of Medicine Instituto Nacional de Ciencias Médicas y
Department of Surgery Nutrición “Salvador Zubirán”
University of Minnesota Department of Nutrition Science
East Carolina University Mexico
Minneapolis, Minnesota
Greenville, North Carolina
J. Scott Magnuson, MD David W. Mercer, MD
Department of Surgery Jack W. McAninch, MD Professor
Division of Otolaryngology-Head and Neck Professor Division of General Surgery
Surgery Department of Urological Surgery McLaughlin Professor and Chairman
University of Alabama at Birmingham University of California San Francisco Department of Surgery
Birmingham, Alabama Chief of Urological Surgery University of Nebraska Medical
San Francisco General Hospital Center
James W. Maher, MD San Francisco, California Omaha, Nebraska
Paul J. Nutter Professor and Chair
Division of General Surgery Jennifer M. McBride, PhD J. Wayne Meredith, MD
Virginia Commonwealth University Assistant Professor of Surgery Director
Professor of Surgery Cleveland Clinic Lerner College of Division of Surgical Sciences
Medical College of Virginia Hospitals Medicine Wake Forest School of Medicine
Richmond, Virginia Cleveland, Ohio Winston-Salem, North Carolina

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xv 16/11/11 1:54 AM

 xvi Contributors

Ingrid M. Meszoely, MD Gregory L. Moneta, MD John B. Mulliken, MD

Assistant Professor of Surgery Professor and Chief Professor of Surgery
(Surgical Oncology) Division of Vascular Surgery Harvard Medical School
Clinical Director Department of Surgery Director, Craniofacial Centre
Vanderbilt Breast Center Oregon Health & Science University Department of Plastic and Oral Surgery
VICC Member Portland, Oregon Children’s Hospital
Surgical Oncologist Boston, Massachusetts
Vanderbilt-Ingram Cancer Center Samuel R. Money, MD, MBA
Nashville, Tennessee Chair Gerhard S. Mundinger, MD
Department of Surgery Division of Plastic, Reconstructive, & Maxillofacial
Fabrizio Michelassi, MD Division of Vascular Surgery Surgery
Lewis Afterbury Stimson Professor and Mayo Clinic Johns Hopkins Hospital
Chairman Phoenix, Arizona University of Maryland Medical Center
Department of Surgery Baltimore, Maryland
Weill Cornell Medical College Stephen G. Moon, MD
Surgeon-in-Chief Department of Emergency Medicine Noriko Murase, MD
New York Presbyterian West Valley Hospital Associate Professor of Surgery
Hospital Dallas, Oregon Thomas E. Starzl Transplantation Institute
New York, New York University of Pittsburgh
John T. Moore, MD, FACS Pittsburgh, Pennsylvania
Mira Milas, MD Program Director, Surgery Residency
Director Program Erin H. Murphy, MD
Thyroid Center Chair Division of Vascular and Endovascular
Cleveland Clinic Department of Surgery Surgery
Cleveland, Ohio Exempla Saint Joseph Hospital University of Texas Southwestern Medical Center
Denver, Colorado at Dallas
Dallas, Texas
Miroslav N. Milicevic, MD, PhD, FACS
Thomas R. Moore, MD
Professor
Professor Philippe Nafteux, MD
Department of Surgery
Department of Reproductive Medicine Department of Thoracic Surgery
Belgrade School of Medicine
UC San Diego School of Medicine University Hospital Gasthuisberg
Head, HPB Surgery and Liver
San Diego, California Leuven, Belgium
Transplant
Clinical Center of Serbia
Wesley S. Moore, MD Govind Nandakumar, MD
Belgrade, Serbia
Professor and Chief Emeritus Assistant Professor of Surgery
Division of Vascular Surgery Department of Surgery
Joseph L. Mills, Sr., MD
University of California, Los Angeles Weill Cornell Medical College;
Professor
Staff Surgeon Assistant Attending Surgeon
Department of Surgery
Department of Surgery NewYork-Presbyterian Hospital/ Weill Cornell
University of Arizona Health Sciences Center
Los Angeles, California Medical Center
Chief, Vascular and Endovascular Surgery
New York, New York
Co-Director, Southern Arizona Limb Salvage
Katherine A. Morgan, MD, FACS
Alliance (SALSA)
Associate Professor April E. Nedeau, MD
University Medical Center
Section of Gastrointestinal and Laparoscopic Surgeon
Tucson, Arizona
Surgery Department of Vascular Surgery
Medical University of South Carolina Central Maine Heart and Vascular Institute
Petros Mirilas, MD, MSurg, PhD
Charleston, South Carolina Lewiston, Maine
Pediatric Surgeon-Microsurgeon
Clinical Professor of Surgical Anatomy and
A. James Moser, MD Mark R. Nehler, MD
Technique
Division of Surgical Oncology Associate Professor of Surgery
Centers for Surgical Anatomy & Technique
University of Pittsburgh School Chief
Emory University School of Medicine
of Medicine Division of Vascular Surgery
Atlanta, Georgia
Pittsburgh, Pennsylvania General Surgery Residency Program
Director
J. Gregory Modrall, MD
Eric W. Mueller, PharmD University of Colorado School of Medicine
Associate Professor of Surgery
Clinical Pharmacy Specialist, Critical Care Denver, Colorado
Division of Vascular and Endovascular Surgery
UC Health-University Hospital
Department of Surgery
Adjunct Assistant Professor of Pharmacy Jeffrey M. Nicastro, MD
Veterans Affairs North Texas Health Care
Practice Departments of Surgery and Surgical
System
University of Cincinnati Critical Care
University of Texas Southwestern Medical
Cincinnati, Ohio North Shore-Long Island Jewish Health
Center
System
Dallas, Texas
John T. Mullen, MD Staten Island, New York
Assistant Professor of Surgery
Ernesto P. Molmenti, MD, PhD, MBA
Department of Surgery Kelvin K. Ng, MS, PhD, FRCS (Edin)
Associate Professor of Surgery
Harvard Medical School Department of Surgery
Department of Surgery
Assistant Surgeon The University of Hong Kong
Division of Transplantation
Massachusetts General Hospital Queen Mary Hospital
Johns Hopkins Medicine
Boston, Massachusetts Hong Kong, China
Baltimore, Maryland

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xvi 16/11/11 1:54 AM

 Contributors xvii

Jeffrey A. Norton, MD H. Leon Pachter, MD Jack R. Pickleman, MD

Professor Chairman Maywood, Illinois
Med Center Line, Surgery Department of Surgery
General Surgery Member NYU School of Medicine K. Todd Piercy, MD
Cancer Center Langone Medical Center Section on Vascular and Endovascular Surgery
Stanford School of Medicine New York, New York Wake Forest University School of Medicine
Stanford, California North Carolina Baptist Hospital
Himanshu J. Patel, MD Winston-Salem, North Carolina
Michael S. Nussbaum, MD Associate Professor of Surgery
Chair, Department of Surgery Section of Cardiac Surgery Bertram Poch, MD
University of Florida College of Medicine-Jacksonville University of Michigan Medical School Department of Visceral Surgery
Surgeon-in-Chief Ann Arbor, Michigan Donauklinik
Shands Jacksonville Neu-Ulm, Germany
Jacksonville, Florida Jonathan P. Pearl, MD, FACS
Assistant Professor of Surgery Hiram C. Polk, Jr., MD
Lloyd M. Nyhus, MD (DECEASED) Uniformed Services University Ben A. Reid, Sr. Professor of Surgery Emeritus
Department of Surgery Bethesda, Maryland Department of Surgery
University of Illinois College of Medicine University of Louisville
Peoria, Illinois Andrew B. Peitzman, MD Louisville, Kentucky
Mark M. Ravitch Professor
Paul E. O’Brien, MD, FRACS Department of Surgery Alfons Pomp, MD, FACS, FRCSC
Emeritus Director University of Pittsburgh Leon C. Hirsch Professor
Centre for Obesity Research and Education Pittsburgh, Pennsylvania Vice Chairman, Department of Surgery
Monash University Chief, Section of Laparoscopic and Bariatric
Melbourne, Australia Rodrigo Oliva Perez, MD, PhD Surgery
Angelita and Joaquim Gama Institute Weill Medical College of Cornell University
Jill Ohland, MS, RN, CWOCN Colorectal Surgery Division New York Presbyterian Hospital
University of Sao Paulo School of Medicine New York, New York
Keith T. Oldham, MD Sao Paulo, Brazil
Professor and Chief Frank B. Pomposelli, MD
Department of Surgery, Division of Pediatric Kyle A. Perry, MD Professor of Surgery
Surgery Assistant Professor of Surgery Harvard Medical School
Medical College of Wisconsin; Division of General and Gastrointestinal Surgery Chief of Vascular and Endovascular Surgery
Surgeon-in-Chief The Ohio State University Beth Israel Deaconess Medical Center
Children’s Hospital of Wisconsin Columbus, Ohio Boston, Massachusetts
Milwaukee, Wisconsin
Glenn E. Peters, MD Jeffrey L. Ponsky, MD
Frank G. Opelka, MD Department of Surgery Oliver H. Payne Professor and Chairman
Professor, Vice Chancellor Division of Otolaryngology-Head and Neck Department of Surgery
Department of Surgery Surgery Case Western Reserve University School of Medicine
Louisiana State University Health Sciences Center University of Alabama at Birmingham Surgeon in Chief
New Orleans, Louisiana Birmingham, Alabama University Hospitals Case Medical Center
Cleveland, Ohio
Marshall J. Orloff, MD Henrik Petrowsky, MD
Distinguished Professor of Surgery, Emeritus Assistant Professor of Surgery Benjamin K. Poulose
Chair of Surgery, Emeritus Department of Surgery Assistant Professor
Department of Surgery Division of Liver and Pancreas Transplantation Division of General Surgery
University of California, San Diego Dumont-UCLA Transplant Center Vanderbilt University Medical Center
UCSD Medical Center David Geffen School of Medicine at UCLA Nashville, Tennessee
San Diego, California Los Angeles, CA
Kinga A. Powers, MD, PhD, FRCSC, FACS
Mark B. Orringer, MD Brian Peyton, MD Assistant Professor of Surgery
Professor Associate Professor of Surgery and Radiology Virginia Tech Carilion School of Medicine
Department of Surgery Department of Surgery Carilion Roanoke Memorial Hospital
Section of Thoracic Surgery University of Colorado School of Medicine Roanoke, Virginia
University of Michigan Health System Denver, Colorado
Ann Arbor, Michigan Vitaliy Y. Poylin, MD
Thai H. Pham, MD Instructor
C. Keith Ozaki, MD Assistant Professor Department of Surgery
Harvard Medical School Department of Surgery Harvard Medical School;
Department of Surgery Veterans Affairs North Texas Health Division of Colon and Rectal Surgery
Brigham and Women’s Hospital Care System Beth Israel Deaconess Medical Center
Boston, Massachusetts UT Southwestern Medical Center Boston, Massachusetts
Dallas, Texas
Soji Ozawa, MD, PhD Igor Proscurshim, MD
Professor Scott R. Philipp, MD Angelita & Joaquim Gama Institute
Department of Gastroenterological Surgery Department of Surgery Colorectal Surgery Division
Tokai University School of Medicine Vallejo Medical Center University of Sao Paulo School of Medicine
Japan Vallejo, California Sao Paulo, Brazil

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xvii 16/11/11 1:54 AM

 xviii Contributors

Aurora Dawn Pryor, MD, FACS Amy B. Reed, MD Eduardo De Jesus Rodriguez, MD, DDS
Professor of Surgery Chief, Vascular Surgery Associate Professor
Chief, General Surgery Penn State Heart and Vascular Institute Department of Surgery
Vice Chair for Clinical Affairs Penn State College of Medicine University of Maryland School of Medicine
Department of Surgery Penn State Hershey Medical Center Chief, Plastic, Reconstructive and Maxillofacial
Stony Brook University Medical Center Hershey, Pennsylvania Surgery
Stony Brook, New York R Adams Cowley Shock Trauma Center
Ari R. Reichstein, MD University of Maryland Medical Center
Motaz Qadan, MD, PhD, MRCS(Ed) Surgeon Baltimore, Maryland
Department of Surgery University of Wisconsin and Clinics
University of Louisville Madison, Wisconsin Alexander S. Rosemurgy, MD
Louisville, Kentucky Surgical Director
Feza H. Remzi, MD Center for Digestive Disorders
Arnold Radtke, MD, PhD Chairman Tampa General Hospital
Department of General and Thorax Surgery Department of Colorectal Surgery Tampa, Florida
University Hospital Schleswig-Holstein, Campus Kiel Digestive Disease Institute
Kiel, Germany Cleveland Clinic Raul J. Rosenthal, MD, FACS, FASMBS
Cleveland, Ohio Professor of Surgery
Janice F. Rafferty, MD Chairman, Department of Minimally Invasive Surgery
Professor Frederick Rescorla, MD The Bariatric and Metabolic Institute
Department of Surgery Lafayette L. Page Professor of Surgery Director, General Surgery Residency Program
University of Cincinnati Director Section of Pediatric Surgery Director, Fellowship in Minimally Invasive and
Surgeon Surgeon-in-Chief Bariatric Surgery
The Christ Hospital Riley Hospital for Children Cleveland Clinic Florida
Cincinnati, Ohio Indiana University School Weston, Florida
of Medicine
Bruce J. Ramshaw, MD Indianapolis, Indiana David A. Rothenberger, MD
Chairman Associate Director for Clinical Affairs
Department of General Surgery William O. Richards, MD, FACS Deputy Chairman and Professor
Halifax Health Ingram Professor of Surgical Sciences Department of Surgery
Daytona Beach, Florida Vanderbilt School of Medicine University of Minnesota Medical Center
Director of Laparoendoscopic General Minneapolis, Minnesota
Sowsan Rasheid, MD
Surgery
Assistant Professor
Medical Director Ornob P. Roy, MD
Department of Surgery
Center for Surgical Weight Loss Clinical Instructor
University of South Florida College of Medicine
Vanderbilt University Medical Center Department of Urology
Tampa, Florida
Nashville, Tennessee Arthur Smith Institute for Urology;
Todd E. Rasmussen, MD, FACS Clinical Instructor
Colonel USAF MC Richard R. Ricketts, MD Department of Urology
Chief Professor Long Island Jewish Medical Center
San Antonio Military Vascular Surgery Department of Surgery New Hyde Park, New York
Deputy Commander US Army Institute of Surgical Emory University
Research Department of Surgery Aaron Ruhalter, MD, FACS
Fort Sam Houston (San Antonio), Texas Children’s Healthcare of Atlanta Professor of Anatomy
Associate Professor of Surgery Atlanta, Georgia University of Cincinnati College of Medicine
The Uniformed Services University of the Executive Director of Medical Education
Health Sciences Paul F. Ridgway, MD, MMedSc, FRCSI Johnson & Johnson Endo-Surgery Institute
Bethesda, Maryland Associate Professor Cincinnati, Ohio
Professorial Surgical Unit
Bettina M. Rau, MD University of Dublin, Trinity College Karla Russek, MD
Associate Professor of Surgery Consultant HPB, Upper GI and General Research Professor
Department of General, Thoracic, Vascular and Surgeon Department of Minimally Invasive Surgery
Transplantation Surgery Department of Surgery Texas Endosurgery Institute
University of Rostock Adelaide & Meath Hospital Incorporating the San Antonio, Texas
Rostock, Germany National Children’s Hospital
Dublin, Ireland Robb H. Rutledge, MD, FRCPC
Arthur Rawlings, MD Associate Professor
Department of Surgery Bryce R.H. Robinson, MD Faculty of Medicine
Ellis Fischel Cancer Center Assistant Professor of Surgery Dalhousie University
University of Missouri Health Care University of Cincinnati Radiation Oncologist
University of Missouri Cincinnati, Ohio Halifax, Nova Scotia, Canada
Columbia, Missouri
Caron B. Rockman, MD Frederick C. Ryckman, MD
John E. Rectenwald, MD, MS Associate Professor Professor of Surgery
Associate Professor of Surgery Department of Surgery Department of Pediatric Surgery
Department of Surgery New York University Medical Center University of Cincinnati
Section of Vascular Surgery Attending Surgeon Sr. Vice President Medical Operations
University of Michigan Department of Vascular Surgery Cincinnati Children’s Hospital
Ann Arbor, Michigan New York, New York Cincinnati, Ohio

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xviii 16/11/11 1:54 AM

 Contributors xix

Bashar Safar Steven D. Schwaitzberg, MD J. Rüdiger Siewert, MD, FACS

Associate Professor of Surgery Klinikum rechts der Isar
Jacqueline M. Saito, MD Harvard Medical School Technical University
Assistant Professor of Surgery Chief of Surgery Munich, Germany
Division of Pediatric Surgery Cambridge Health Alliance
Washington University School of Cambridge, Massachusetts Ronald J. Simon, MD, FACS
Medicine Professor of Surgery
Attending Surgeon Michael F. Sedrak, MD NYU School of Medicine
Department of Pediatric Surgery Department of Surgery New York, New York
St. Louis Children’s Hospital University of California San Diego
St. Louis, Missouri San Diego, California Parul Sinha, MBBS, MS
Head and Neck Oncology Fellow
Atef A. Salam, MD Evelyn G. Serrano, MD Department of Otorhinolaryngology and Head
Professor of Surgery Department of Obstetrics & Gynecology Neck Surgery
Department of Surgery The Woman’s Group Washington University School of Medicine
Division of Vascular Surgery Tampa, Florida St. Louis, Missouri
Emory University School of Medicine Jatin P. Shah, MD, PhD(Hon), FACS,
Chief, Vascular Service FRCS(Hon), FRACS(Hon), FDSRCS(Hon) Allan E. Siperstein, MD
Atlanta VA Medical Center Professor of Surgery Department Chair
Atlanta, Georgia E. W. Strong Chair in Head and Neck Oncology Center for Endocrine Surgery
Department of Surgery Cleveland Clinic
Rodrigo Sanchez-Claria, MD Weil Medical College of Cornell University Cleveland, Ohio
Attending Chief, Department of Head and Neck Surgery
Department of General Surgery Memorial Sloan Kettering Cancer Center Lee J. Skandalakis, MD, FACS
Hospital Italiano de Buenso Aires New York, New York Clinical Professor of Surgical Anatomy and Technique
Buenos Aires, Argentina Centers for Surgical Anatomy and Technique
Sajani Shah, MD Emory University School of Medicine;
Martin G. Sanda, MD Assistant Professor of Surgery Attending Surgeon
Associate Professor of Surgery Department of Surgery Piedmont Hospital
Department of Surgery Tufts Medical Center Atlanta, Georgia
Division of Urology Boston, Massachusetts
Harvard Medical School Eila Skinner, MD
Beth Israel Deaconess Medical Center Samir Shah, MD, FACG Professor of Clinical Urology
Boston, Massachusetts Clinical Associate Professor of Medicine USC Keck School of Medicine
Division of Gastroenterology Los Angeles, California
Luigi De Santis, MD Brown University
Department of Internal Medicine Gastroenterology Associates, Inc Michael A. Skinner, MD
Stonybrook Medical Center Providence, Rhode Island Professor
Levittown, Pennsylvania Department of Pediatric Surgery
Claudie M. Sheahan, MD University of Texas Southwestern
John L. Sawyers, MD Assistant Professor of Surgery Vice-Chairman
Foshee Distinguished Professor of Louisiana State University Health Sciences Children’s Medical Center of Dallas
Surgery, Emeritus Center Dallas, Texas
Vanderbuilt University Medical Center Marrero, Louisiana
Nashville, Tennessee Joseph S. Solomkin, MD
Malachi G. Sheahan, MD Professor of Surgery Emeritus
Philip R. Schauer, MD Associate Professor of Surgery Department of Surgery
Professor of Surgery Louisiana State University Health Sciences Center University of Cincinnati College of Medicine
Cleveland Clinic Lerner College Marrero, Louisiana Cincinnati, Ohio
of Medicine Adam M. Shiroff, MD
Director Department of Surgery Carmen C. Solorzano, MD
Bariatric and Metabolic Institute University of Medicine & Dentistry of New Jersey Professor of Surgery
Cleveland Clinic Robert Wood Johnson Medical School Division of Surgical Oncology and Endocrine Surgery
Cleveland, Ohio New Brunswick, New Jersey Vanderbilt University
Nashville, Tennessee
Marc Schermerhorn, MD Gregorio A. Sicard, MD
Associate Professor Eugene M. Bricker Professor of Surgery Nathaniel J. Soper, MD
Department of Surgery Department of Vascular Surgery Service Loyal and Edith Davis Professor and Chair
Harvard Medical School Washington University School of Medicine Department of Surgery
Chief, Division of Vascular and Endovascular Executive Vice Chairman Northwestern University Feinberg School of Medicine
Surgery Department of Surgery Chair and Surgeon-in-Chief
Beth Israel Deaconess Medical Center Barnes-Jewish Hospital Northwestern Memorial Hospital
Boston, Massachusetts St. Louis, Missouri Chicago, Illinois

Bruce David Schirmer, MD Anton N. Sidawy, MD, MPH George C. Sotiropoulos, MD, PhD
Stephen H. Watts Professor of Surgery Professor and Chair Department of General, Visceral and
Department of Surgery Department of Surgery Transplantation Surgery
University of Virginia Health System George Washington University University Hospital Essen
Charlottesville, Virginia Washington, DC Essen, Germany

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xix 16/11/11 1:54 AM

 xx Contributors

William N. Spellacy, MD Charles J.H. Stolar, MD Sumeet S. Teotia, MD

Director Professor Assistant Professor
Department of Obstetrics & Gynecology Departments of Surgery and Pediatrics Department of Plastic Surgery
University of South Florida College Columbia University, College of Physicians and University of Texas Southwestern Medical Center
of Medicine Surgeons Dallas, Texas
Tampa, Florida Director, Pediatric Surgery and Surgeon-in-Chief
Morgan Stanley Children’s hospital/Columbia Oreste Terranova, MD
James C. Stanley, MD University Medical Center Department of Surgical and Gastroenterological
Professor of Surgery New York, New York Sciences
Marion and David Handleman Research Professor Geriatric Surgery Clinic
of Vasuclar Surgery William M. Stone, MD University of Padua School of Medicine
Associate Chair Division of Vascular Surgery Padua, Italy
Department of Surgery Mayo Clinic
Director and Marketing/Development Lead Phoenix, Arizona Robert W. Thompson, MD
Cardiovascular Center Departments of Surgery (Section of Vascular
University of Michigan Medical School René E. Stoppa, MD Surgery), Radiology, and Cell Biology and
Ann Arbor, Michigan Centre Hospitalier Physiology
University of Amiens Washington University School of Medicine and
Adam Stannard, BSc, MB, ChB, FRCS Amiens, France Barnes-Jewish Hospital
Senior Research Fellow St. Louis, Missouri
Academic Department of Military Surgery and Julianne Stoughton, MD, FACS
Trauma Instructor, Department of Surgery Gregory M. Tiao, MD
Royal Centre for Defense Medicine Harvard Medical School Assistant Professor
Birmingham, England Surgeon Division of Pediatric Surgery
Department of Vascular and Endovascular Surgery Associate Director
Benjamin W. Starnes, MD, FACS Massachusetts General Hospital Pediatric Surgery Training Program
Professor and Chief Boston, Massachusetts Surgical Director
Division of Vascular Surgery Liver Transplantation
University of Washington Stacey Su, MD Pediatric Surgeon
Seattle, Washington Assistant Professor Cincinnati Children’s Hospital Medical Center
Department of Surgery Cincinnati, Ohio
Thomas E. Starzl, MD, PhD Division of Thoracic Surgery
Distinguished Service Professor of Surgery University of Pennsylvania Carlos H. Timaran, MD
Thomas E. Starzl Transplantation Institute Philadelphia, Pennsylvania Associate Professor of Surgery
University of Pittsburgh School Department of Surgery
of Medicine David J. Sugarbaker, MD University of Texas Southwestern Medical
Pittsburgh, Pennsylvania Chief, Division of Thoracic Surgery Center
Brigham and Women’s Hospital Dallas, Texas
Steven M. Strasberg, MD Boston, Massachusetts
Pruett Professor of Surgery Nam. T. Tran, MD
Division of General Surgery Timothy M. Sullivan, MD, FACS, FACC Assistant Professor
Hepatobiliary-Pancreatic and Gastrointestinal Department of Vascular Surgery Division of Vascular and Endovascular Surgery
Surgery Section Minneapolis Heart Institute University of Washington
Carl Moyer Departmental Teaching Abbott Northwestern Hospital Attending Vascular Surgeon
Coordinator Minneapolis, Minnesota Division of Vascular and Endovascular Surgery
Washington University School of Medicine Harborview Medical Center
in St. Louis John D. Symbas, MD Seattle, Washington
St. Louis, Missouri Plastic Surgeon
Department of Surgery L. William Traverso, MD
Robert J. C. Steele, MD, FRCS Wellstar Kennestone Hospital Clinical Professor of Surgery
Head of Academic Surgery Marietta, Georgia Department of Surgery
Department of Surgery University of Washington
University of Dundee Panagiotis N. Symbas, MD Seattle, Washington
Professor of Surgery Emory University School of Medicine Director
Department of Surgery Atlanta, Georgia Center for Pancreatic Disease
Ninewells Hospital and Medical School St. Luke’s Health System
Dundee, United Kingdom Samuel Szomstein, MD Boise, Idaho
Clinical Assistant Professor of Surgery
Ezra Steiger, MD NOVA Southeastern University Donald D. Trunkey, MD
Professor Cleveland Clinic Florida Professor Emeritus
Department of Surgery Weston, Florida Department of Surgery
Cleveland Clinic Lerner College Oregon Health and Sciences University
of Medicine of Case Western Michael E. Tarnoff, MD, FACS Portland, Oregon
Reserve University Adjunct Associate Professor of Surgery
Consultant Department of Surgery Shawn T., MD
Department of Digestive Disease Tufts University School of Medicine Assistant Professor of Surgery
Institute Staff Surgeon Department of Surgery
Cleveland Clinic Tufts Medical Center University of Nevada School of Medicine
Cleveland, Ohio Boston, Massachusetts Las Vegas, Nevada

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xx 16/11/11 1:54 AM

 Contributors xxi

Robert Udelsman, MD, MBA Andrew A. Wagner, MD Steven Wexner, MD

Professor and Chairman Assistant Professor of Surgery/Urology Voluntary Professor of Colon, Rectal and General
Department of Surgery Department of Surgery Surgery
Yale University School of Medicine Harvard University Associate Dean for Academic Affairs
Surgeon-in-Chief Director of Minimally Invasive Urologic Surgery Department of Surgery
Yale-New Haven Hospital Beth Israel Deaconess Medical Center Florida Atlantic University
New Haven, Connecticut Boston, Massachusetts Boca Raton, Florida
Chief Academic Officer and Chair
A Kuezunkpa O. Ude Welcome, MD John C. Wain, MD, FACS Department of Colorectal Surgery
Assistant Professor of Surgery Department of Surgery Cleveland Clinic Florida
Department of Surgery Harvard Medical School Weston, Florida
Columbia University Division of Thoracic Surgery
New York, New York Massachusetts General Hospital Bruce G. Wolff, MD
Heidi Umphrey, MD Boston, Massachusetts Department of Colon and Rectal Surgery
Department of Radiology Brad W. Warner, MD Mayo Clinic
University of Alabama at Birmingham Jessie L. Ternberg Distinguished Professor of Rochester, Minnesota
Birmingham, Alabama Pediatric Surgery
Gilbert R. Upchurch Jr., MD Department of Surgery Mark C. Wyers, MD, FACS
Chief of Vascular and Endovascular Surgery Washington University School of Medicine Division of Vascular Surgery
William H. Muller, Jr. Professor Surgeon-in-Chief Beth Israel Deaconess Medical Center
University of Virginia Director of Division of Pediatric Surgery Boston, Massachusetts
Charlottesville, Virginia Department of Pediatric Surgery
St. Louis Children’s Hospital Atsuyuki Yamataka, MD, PhD
Dirk Van Raemdonck, MD, PhD St. Louis, Missouri Professor and Head
Department of Thoracic Surgery Department of Pediatric General & Urogenital
University Hospital Gasthuisberg Jennifer Y. Wang, MD Surgery
Leuven, Belgium Department of Surgery Junteno University School of Medicine
Division of Colon and Rectal Surgery Tokyo, Japan
Frank C. Vandy, MD San Jose Medical Center
Department of Surgery San Jose, California Richard A. Yeager, MD
Division of Vascular Surgery Department of Surgery
University of Michigan Medical School David I. Watson, MBBS, MD, FRACS Portland VA Medical Center
Ann Arbor, Michigan Head of Department Portland, Oregon
Department of Surgery
Luis O. Vásconez, MD Flinders University of South Australia
Professor of Surgery, Plastic Surgery Head of Oesophagogastric Surgery Unit Charles J. Yeo, MD
Vice Chair, Department of Surgery Flinders Medical Centre Samuel D. Gross Professor and Chairman
University of Alabama Medical Center Bedford Park, South Australia Department of Surgery
Birmingham, Alabama Jefferson Medical College
Julia Wattacheril, MD Philadelphia, Pennsylvania
Dionysios K. Veronikis, MD Assistant Professor of Medicine
Chief, Division of Gynecology Columbia University School of Medicine
Director Jerrold Young, MD, FACS
New York, New York
Urogynecology and Reconstructive Pelvic Surgery Voluntary Associate Professor of Surgery
St. John’s Mercy Medical Center Kaare J. Weber, MD The Daughtry Family Department of Surgery
St. Louis, Missouri Department of Surgery University of Miami Miller School of Medicine
Mount Sinai Medical Center Miami, Florida
Selwyn M. Vickers, MD Mount Sinai School of Medicine
Professor and Chair New York, New York
Department of Surgery Tonia M. Young-Fadok, MD, MS,
The University of Minnesota and Minneapolis VAMC FACS, FASCRS
Alejandro Weber-Sanchez, MD
Minneapolis, Minnesota Chair
Chief
Division of Colon and Rectal Surgery
Department of Surgery
Gary C. Vitale, MD Mayo Clinic
Hospital Angeles Lomas
Professor of Surgery Phoenix, Arizona
Huixquilucan, State of Mexico
Department of Surgery
University of Louisville Jon O. Wee, MD Herbert J. Zeh III, MD
Louisville, Kentucky Co-Director of Minimally Invasive Thoracic Surgery Division of Surgical Oncology
Guy R. Voeller, MD Division of Thoracic Surgery University of Pittsburgh School of Medicine
Professor of Surgery Brigham & Women’s Hospital Pittsburgh, Pennsylvania
Department of Surgery Harvard Medical School
Boston, Massachusetts Steven M. Zeitels, MD, FACS
University of Tennessee Health Science Center
Eugene B. Casey Professor of Laryngeal Surgery
Memphis, Tennessee
Martin R. Weiser, MD Department of Surgery
Daniel von Allmen, MD Associate Professor Harvard Medical School
Professor, Department of Surgery Department of Surgery Director
University of Cincinnati Weill Cornell Medical School Center for Laryngeal Surgery and Voice
Director, Division of General Surgery Associate Member Rehabilitation
Cincinnati Children’s Hospital Memorial Sloan-Kettering Cancer Center Massachusetts General Hospital
Cincinnati, Ohio New York, New York Boston, Massachusetts

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xxi 16/11/11 2:49 AM

 www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xxii 16/11/11 1:54 AM

 Preface

This book comes at a critical time in sur- bushels of potatoes, wine, butter, etc., that Dr. Down terrified colleagues, nurses
gery, a time the various external pressures which were offered as payment and were and at least one son-in-law without saying
have conspired to reduce surgery from a duly noted in that account book. Some did much; everyone knew his standards were
proud profession to a group of “employees”. not pay at all. When he died in 2001, Karen extremely high. On the day of his funeral his
It was not always so. My late father-in-law, and I went through the house and found brother and best friend Charles, a lawyer,
Dr. Howard I. Down, one of those to whom some of the most interesting gifts, and I told me that Howard was indeed very proud
the book is dedicated, was born on a farm might add, some of the worst liquor, obvi- of me and he asked if he could get copies of
near Odebolt, Iowa in 1901, one of ten chil- ously given as payment. For the most part the articles I had written and that his
dren on 640 acres of rich Missouri bottom- he operated daily, came home for dinner brother had discussed with him. As you can
land. All of the children survived into adult- with the family, and then returned to make imagine, it was wonderful to hear this from
hood – a remarkable achievement. The rounds. The only way Dr. Down could get his best friend but it would have been better
family still holds five-year reunions on that away on vacation was to get out of town. It to hear it while he was alive.
farmland which is owned as an investment took me a long time before I could live up to We were fortunate enough to obtain his
by Princeton University which generously the two trips Karen made with the family vast library which consisted of a large num-
allows the family visits. While the older when she was eleven and thirteen traveling ber of medical books among which were
boys worked the fields, as a young boy my to a variety of states so that he could get three books: Jergen Thorwald, “The Century
father-in-law was assigned to help out his away from his practice. of the Surgeon”; Owen and Sarah D. Wan-
sisters in the house. Working in the house Dr. Down lived very modestly in a three- gensteen, “The Rise of Surgery: From Empiric
allowed him ample opportunities to read bedroom, two-story house with one full- Craft to Scientific Discipline”; and Knut Hae-
and develop his desire for knowledge. All of bath in a very nice neighborhood. He was ger, “The Illustrated History of Surgery”.
the children were offered college as an op- highly respected and beloved. He sat on a This was a time when surgeons were re-
tion and all but one attended at least one number of boards while his wife was the vered for their daring, their inventiveness,
year. Howard decided to attend Morning- president of a number of organizations in- their interest in patients and what they did
side, a small Methodist college in Sioux City, cluding the YWCA and Planned Parent- to cure disease. Dr. Francis D. Moore, long-
then went on to medical school at North- hood. He loved music and was on the Board time chief at Brigham & Women’s Hospital,
western. He elected to train at the Mayo of the Sioux City Symphony. In this capacity made the cover of Time magazine with the
Clinic which he completed in 1932. He as a board member, Karen and I were in- caption “You’re lucky if they can operate”.
would tell me “they wanted to give me a vited to dine with Dr. Down and soprano They were feared but committed. They were
room” which meant they wanted him to Victoria de Los Angeles. One of Karen’s respected. They were surgeons! One of my
join the staff, but he wanted to return home fondest memories was watching Dr. Down mentors, Dr. Edward D. Churchill, my first-
to northwest Iowa to build a practice. In “conduct” Tchaikovsky’s Symphony #5 in year chief and long time chair of the depart-
fact, he was the first well-trained and expe- the family living room. He continued to op- ment of surgery at Massachusetts General
rienced surgeon in that vast area. On al- erate until late in life and then practiced as Hospital (MGH), believed in surgery and felt
most a weekly basis he, and later his part- a general internist until he was 80 years old. that surgery was the answer to disease. Dr.
ner, Martin Blackstone, and a nurse, rode He was a tall, attractive and quiet man who Claude Welch, Dean of Boston Surgeons
circuit, operating in various towns; return- never said much yet dominated a room and another one of my mentors believed
ing the following week to see how well the whether or not he spoke. During his long that an exploratory laparotomy was merely
patients fared under the care of their gen- career he served as governor of the College an extension of the physical exam. Dr.
eral practitioner. The practice expanded and President of the Iowa Surgical Society. Welch was a remarkable surgeon who per-
and eventually he established a general Every six months he returned to the Mayo formed the first 10 aneurysmectomies at
medical practice and a busy surgical prac- Clinic – his equivalent of CME. the Massachusetts General Hospital and
tice in Sioux City, population 85,000, which He never told Karen whether he ap- some of the first parathyroidectomies, in
then and now serves as a catchment area proved of me as a son-in-law. Probably the addition to being a superb and busy GI sur-
for prosperous and relatively well-to-do closest he came to doing so was after I gave geon. Dr. Robert Linton, another mentor
farmers. Appointments were made for “the grand rounds at one of his hospitals in and a giant in the field of vascular surgery,
day” not for a “specific time”. Patients Sioux City. As he walked me out to the tar- was a meticulous surgeon and taught me a
checked in, went shopping downtown and mac and just before I boarded the plane to great deal about the technique of surgery.
returned at the appropriate time. When Dr. return to Boston, without a word he stuffed He taught me to own my instruments. He
Down died at the age of 91 we found his ac- a quart of Johnny Walker Black Label under sharpened his own scissors so that he
count books. An office visit was 50¢. Many my arm. I must have done something right! would “feel with the scissors the differences
of the patients could not pay and later sent Speaking at his memorial service I reflected in tissue and be careful”. I have taken that
xxiii

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xxiii 16/11/11 1:54 AM

 xxiv Preface

much to heart and find that having my own independent professional who firmly ad- sent, it was kept stable by my lovely wife
familiar scissors and other instruments en- vanced ideas they believed in. Now, more Karen whom my friends call “my better
abled me to be a better technical surgeon. than 50% of surgeons are employed by hos- 7/8th”. To our children, Erich and Alexan-
Dr. Churchill was one of the wisest men pitals. Surgical training has been con- dra, of whom I am immensely proud and
I have ever met. If you asked him about the stricted so that surgical residents perform whose interests I share and I hope partially
chicken—and you could commit to the 50% fewer operations due to the 80-hour cultivated. Our son Erich is a space and as-
time to listen—he would begin with the work week. Yet the diseases for which we tronomy enthusiast due in part to our fam-
creation of the egg at the birth of the world. operate are the same and most of our pa- ily’s interest in astronomy. Our daughter,
He is not adequately credited for taking the tients are older with a greater number of Alexandra, a successful practicing veteri-
daring stance that he could recognize an co-morbidities. Greater technical and ana- narian, has expressed to me that this is the
applicant at the beginning of the surgical lytical skills are required to ensure a live pa- closest she could come to being a “3rd gen-
program and commit to finish them five tient at the end of an operative procedure. eration surgeon” without taking a lot of guff
years later. His rectangular program finally When will our surgical residents learn these from being my daughter. And I must men-
became the surviving form of the American skills? This the driving reason for this book. tion my daughter-in-law Hallie, and my
Surgical Residency Program. This is not to We need this book to teach how operations son-in-law Peter, both of whom have enthu-
take anything from Dr. Stewart Halsted and are performed – so that residents and siastically been welcomed into our family.
Johns Hopkins Hospital but Dr. Halsted was young attendings can have some under- Thank you to Bob Baker who was kind
not interested in meeting the surgical needs standing of the intricasies of operative pro- enough to take me, along with Dr. Lloyd Ny-
of the United States. He was interested in cedures. hus, in the 3rd edition; Dr. Baker, an attrac-
producing elite professors. In Cincinnati, Much has changed in the past five years tive, urbane and, “cool hand and head” who
Dr. George Heuer, a direct descendent of the as evidence of our results leads to decreased tolerated and aided the transformation of
Hopkins system and the first Christian Hol- mortality and morbidity and better out- the book from strictly an atlas to a textbook;
mes professor, Dr. Mont Reed, Dr. B. Nolan comes for our patients. Many changes in to the various assistant and associate edi-
Carter and Dr. Gunderson, who filled in surgery have occurred since our work on tors who do so well in the commentaries
during the war waiting for Dr. Carter to re- the 5th edition began eight years ago. The and in keeping the national and interna-
turn - they were all giants and products of Roux-en-y reconstruction following gas- tional views on track; to the hundreds of au-
the Hopkins program. They made enor- trectomy is generally agreed to be the best thors who humored me when I made “sug-
mous contributions to surgery: Dr. Heuer to reconstruction, better than the gastroduo- gestions” on the first drafts of their excellent
neurosurgery, Dr. Reed to wound healing denostomy (Billroth 1) and gastrojejunos- manuscripts; to the production staff at Lip-
and general physiology and, Dr. Carter to tomy (Billroth 2). The fall in parathyroid pincott most notably Brian Brown and Julia
early cardiothoracic surgery and perform- hormone is no longer utilized by everyone Seto who kept cool throughout what has
ing some of the first cardiac perfusion op- as the sine qua non for parathyroidectomy been a difficult and taxing production; sin-
erations in the United States. although it does seem it is necessary to cere thanks to Pat McGovern, Esq. and Rich-
While I dedicate this volume in part to achieve a 99% cure. Thyroid carcinoma is ard Glovsky, Esq., both of whom enabled the
my late father-in-law, Dr. Howard Down, I being treated as a malignancy and node dis- production of this edition without physical
dedicate it to all of those surgeons who section is part of the best practice. Cancer interruption; and finally, thank you to a
dominated American medicine for a cen- of the head and neck is being treated with most dedicated office staff, including Edith
tury – the century of the surgeon as Dr. chemotherapy and radiation even if nodes Burbank-Schmitt now in her second year of
Thorwald put it. They were surgeons who are negative – with a better outcome – and medical school, Ingrid Johnson who always
believed in the discipline, they were at the operations are less destructive. Patients pitched in and Abigail Smith who did a mag-
top of their game and looked up to by all as with carcinoma of the lung can undergo nificent job of research for the 6th edition as
being inventive, courageous and making less extensive resections with no sacrifice of well as the 5th—only better. I hope we have
American surgery the envy of the world as outcome and with minimally invasive tech- succeeded in producing a textbook of sur-
Germanic surgery was destroyed by World niques less pain and disability. In vascular gery that is also an atlas reflecting the latest
War II. I mourn the passing of that time. disease, minimally invasive techniques minimally invasive and other techniques as
We are no longer at the top of the heap. done to a considerable extent by vascular well as showcasing the views of many inter-
We are no longer the adventurous and rig- surgeons are accompanied by less pain and nationally known surgeons, and hopefully
orous group that were simultaneously disability. Eighty-five percent of vascular make up, at least partially, for the interfer-
feared and admired, who did things under cases are done endovascularly. ence with adequate training.
difficult conditions, but kept at it until they I owe immense gratitude to too many
had perfected operations that have since people and undoubtedly will inadvertently Josef E. Fischer
saved thousands of lives. In the early and miss mentioning all of them. First and fore- November 2011
middle stages of my career surgeons were most to my family: although I was often ab- Boston, Massachusetts

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xxiv 16/11/11 1:54 AM

 Contents xxv

Web-Only Chapters

Chapter 85: Selective Vagotomy, Antrectomy, and tals of any size. The stoma nurse helps with preoperative planning
Gastroduodenostomy for the Treatment of Duodenal of the operation, siting of the ileostomy or colostomy, help with
Ulcer e-1 difficult stomas, and care of patients with gastrointestinal cutane-
ous fistulas.
Lloyd M. Nyhus
Selective vagotomy, antrectomy and gastroduodenostomy for the Chapter 180: Operations on the Ureteropelvic
treatment of duodenal ulcer is an operation that is no longer done. Junction e-53
Very frequently parietal cell vagotomy has largely supplanted selective Frank Hinman, Jr.
vagotomy, but antrectomy and gastroduodenostomy are useful for car-
cinoma of the stomach with some slight modifications as pictured “Operations of the Ureteropelvic Junction” is another operation that
elsewhere in the book. This is a classic chapter, and it is included for has given way to minimally invasive and endourological procedures.
historical reasons but also because Dr. Nyhus, one of the originators of Dealing with the ureteropelvic junction in open fashion is an art
Mastery of Surgery wrote a superb chapter. It can be read with profit. form that will be applied to the minority of patients. Nonetheless, it
is important that one know how to do the operation if the occasion
Chapter 86: Selective Vagotomy and Pyloroplasty e-13 demands and the preservation of renal function is at stake.
Steven D. Schwaitzberg, John L. Sawyers, and William O. Richards
Chapter 194: Anterior and Posterior Colporrhaphy e-60
Dr. Steven Schwaitzberg has written an excellent chapter on selec- Dionysios K. Veronikis
tive vagotomy and pyloroplasty. However, as Dr. Schwaitzberg
pointed out to me himself, this is an operation that is no longer The chapter on anterior and posterior colporrhaphy presented
done very frequently, if at all. However, it is a chapter that eluci- here is a rather detailed chapter and one which can be read with
dates some points concerning surgery of the stomach, unfortu- profit. However, the vaginal floor and its repair has become much
nately no longer carried out with any great degree of regularity. It is more complicated and so anterior and posterior colporrhaphy, in
a chapter that can be read with significant profit. and of itself, are used less frequently. They may be used with opera-
tions for the prolapse of the rectum and they may be utilized in the
Chapter 139: Distal Splenorenal Shunts: Hemodynamics more sophisticated approach to cystocele and urethracele.
of Total versus Selective Shunting e-21 However, the anatomy which is described in the anatomical re-
pair, is valuable and can shed light in other specialties to the neces-
Atef A. Salam sity for having pelvic floor repair, for example, or come in useful as
The distal splenorenal shunt was advocated originally as an opera- stated in my commentary for repair of rectal prolapse.
tion for portal hypertension which had a lower rate of hepatic en-
cephalopathy as compared to the central splenorenal shunt (which
Chapter 196: Bassini Operation e-75
is useful in patients with significant ascites, patients on whom dis-
tal splenorenal is contraindicated), a claim which has not held up. Oreste Terranova, Luigi De Santis, and Flavio Frigo
In addition, recent data from randomized prospective trials seem Drs. Terranova, DeSantis and Frigo, as they have in the past, have
to conclude that the portacaval shunt is at least as good and per- contributed to the classic operation which started all repairs of in-
haps better as in regard to long term outcomes. (See commentar- guinal hernia by Dr. Edoardo Bassini. “The Bassini Operation”
ies on Chapters 137 and 138) probably is the first one that gained credence and has held for ap-
proximately 100 years or more. However, as the authors come to
Chapter 145: The Continent Ileostomy e-30 the conclusion that “The Bassini Operation” even carried out with
Eric J. Dozois and Roger R. Dozois repair of the transversalis fascia, as originally described by Bassini
and shown here in the original pictures, has a recurrence rate any-
This procedure was originally proposed as an alternative to Ileal where from 3–22% although it may fall as they say in the text below
Pouch Anal Anastomosis. However, as the pouch has become 1.5–2%. They come to the conclusion that while of historical inter-
the standard operation for ulcerative colitis—and in some hands, est and of interest as far as the anatomy of the inguinal canal, this
familial polyposis—very few now perform this procedure. operation as currently described in and of itself is no longer viable.
The Shouldice operation described elsewhere in this volume
Chapter 152: Care of Stomas e-37 may actually disagree with that particular conclusion. But accord-
Laurie Maidl and Jill Ohland ing to the authors, prosthetic material must be used in order to get
The care of stomas has become a nursing subspecialty, and the a reasonable recurrence rate. Thus, despite the importance of
presence of a stoma nurse is a very important part of most hospi- Bassini and his operation as it was originally described, this is no
xxv

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xxv 16/11/11 1:54 AM

 xxvi Web-Only Chapters

longer a contemporary utilization of surgery for inguinal hernia Chapter 200: Iliopubic Tract Repair of Inguinal
cause of the recurrence. and Femoral Hernia: The Posterior
It is presented on the website for historical interest as it really (Preperitoneal) Approach e-118
started everything. One may differ as to whether or not Shouldice
repair is useful or whether I use a variant of the Shouldice opera- Lloyd M. Nyhus
tion, sometimes with vicryl mesh and seem to have low recurrence Chapters 172 and 173 are two classic articles appearing from a
rates. However, the reader will decide from all of the repairs which golden age in surgery, the collaboration with Dr. Robert Condon
are made available in the hernia section. and Dr. Lloyd Nyhus. They deal with the anatomy first and fore-
most of the inguinal canal by two individuals who have made this
Chapter 197: Cooper Ligament Repair of Groin a major focus of their long and distinguished academic careers.
Hernias e-87 The anatomy is masterfully described and is well argued. Familiar-
Robb H. Rutledge ity with this approach is essential because there are times when
there is a hernia in the vicinity of the abdomen and anatomical
Dr. Robb Ruttledge is an excellent practitioner who preceded me in knowledge of this area will enable a repair to be done with less dif-
the Massachusetts General Hospital residency by a number of years. ficulty, thus preventing another operative procedure.
He is an exemplary gentleman and a superb surgeon who, despite These two classics have appeared in every previous edition and
being in private practice is highly academic in his approach. I con- they are included here on the website. At a time when most surgi-
sider him a friend. The Cooper’s ligament repair once was a staple of cal residents never learn the anatomy of the inguinal canal, which
herniorraphy. Indeed, when I was a resident, the Cooper’s ligament I find unfortunate, these two chapters are superb in how the
repair was the standard procedure we carried out at the Massachu- knowledge of surgical anatomy can lead not only to a concept but
setts General Hospital despite the fact that it is more painful and its also to performance of an excellent clinical operation at that time.
primary utility is in the area of femoral hernias. Dr. Ruttledge nicely
describes it. The chapter appeared in the fourth edition.
Chapter 204: Giant Prosthesis for Reinforcement
Chapter 198: The Shouldice Method of Inguinal of the Visceral Sac in the Repair of Groin and
Herniorrhaphy e-96 Incisional Hernias e-126
Robert Bendavid René E. Stoppa
The Shouldice Clinic declined to bring the operation up to date. It is The Stoppa procedure is good for bilateral hernia and has the ad-
still useful to review this procedure because it is, in its best sense, the vantage of a very low complication rate of inguinodynia, which oc-
descendent of the Bassini repair. It has largely been supplanted by curs in as many as 10% of groin prosthetic repairs. Patients with
the various mesh repairs and the Lichtenstein tension free repairs. severe inguinodynia are incapacitated and operative repair is suc-
cessfully only in up to 80% of patients.
Chapter 199: Iliopubic Tract Repair of Inguinal Hernia:
The Anterior (Inguinal Canal) Approach e-108
Robert E. Condon
A classic article on the standard repair of Inguinal Hernia.

www.medicalebookpdf.com

LWBK892_FM_Vol-1_pi-xxxvi.indd xxvi 16/11/11 1:54 AM

 Perioperative Care of the Surgical Patient I

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 1 10/28/11 10:14:32 PM

 1 Metabolic and Inflammatory Responses to
Trauma and Infection
Naji N. Abumrad, Igal Breitman, Julia Wattacheril, William J. Hubbard, and Irshad H. Chaudry

INTRODUCTION plasma catecholamine, cortisol and aldos- glomerular filtration increase and facilitate
terone levels inflicting tachycardia, tachyp- excretion of the nitrogenous by-products.
Surgery has its roots in providing care for nea, vasoconstriction, lower cardiac output, Cytokines released from macrophages and
those patients coping with injury or infec- lower oxygen consumption, lower basal adipokines released from adipose tissue re-
tion. In the last decade, an enormous amount metabolic rate, sodium and water retention, sult in disruption of capillary tight junc-
of data has been published, which describes translocation of blood from the peripheral tions, leading to vascular leak allowing fluid
the wide spectrum of illnesses that can re- to the central vital organs, and acute-phase and substrates to flow toward the avascular
sult following trauma or infection—from a protein (APP) production. If the organs sur- area of injury, as well as to the interstitium
minor, local reaction to surgery, to a sys- vive, there is transition from the “ebb” phase in other body parts.
temic stress response, to sepsis, to systemic to the “Flow” phase. The flow phase of the Manifestations of this hypermetabolic
inflammatory response syndrome (SIRS), stress response is characterized by explosive phase can be seen clinically in every postop-
and, finally, to multi-organ failure (MOF). metabolic activity, increasing immune ac- erative patient. Patients retain fluid and so-
This information has provided the basis for tivity, enhanced enzymatic activity, and tis- dium via concentrated urine, and redistrib-
many new concepts and techniques, which sue repair. This response is mediated by a ute blood flow to the vital organs, as well as
are now used daily in modern surgery. Having massive neuroendocrine flux involving the compensate for the intravascular depletion
a thorough understanding of the mecha- production and secretion of catecholamines, secondary to capillary leak and possible ex-
nisms leading to illness following trauma and antidiuretic hormone (ADH), cortisol, insu- ternal losses. If allowed to go unchecked,
infection is crucial for any practicing surgeon. lin, glucagon, and growth hormone (GH). this catabolic response would deplete en-
This understanding is the very hallmark of The increased adrenergic stimulation causes dogenous resources and become maladap-
transferring knowledge gained in research to an increase in the ratio of glucagon to insu- tive. Systemic inflammatory response, se-
innovative surgical care at the bedside. lin and, combined with the increased corti- vere metabolic depletion, and possible
sol and cytokines, induces the state of en- secondary infection can all cause damage
OVERVIEW hanced proteolysis and lipolysis. to vital organs that were not initially com-
The supply of amino acids comes from promised by the injury. Adult respiratory
Following extensive tissue damage or sys- catabolism of mostly skeletal muscle and distress syndrome (ARDS), renal insuffi-
temic insult, such as infection, hypoperfu- visceral organs. Some of these amino acids ciency, hepatic dysfunction, loss of gut epi-
sion, hypothermia, acid–base disturbance, are taken up by the liver as substrates for thelial barrier function, immunoparalysis,
pain or severe emotional stress, various gluconeogenesis and protein synthesis. and sepsis may develop and the multi-organ
physiologic and biochemical local and sys- Others are reserved for enzyme synthesis dysfunction can be fatal. Fortunately, with
temic alternations can be present and are and collagen deposition at the site of injury. appropriate support measures, the stress
referred to as “the stress response”. The sys- The energy needs of most other tissues are response nearly always resolves itself with-
temic alternations are mediated by a com- met by the availability of free fatty acids out complications.
plex signaling system, including afferent (FFA) and ketone bodies. These are made The intensity and duration of the flow
and efferent nervous signals, immunologi- available via enhanced lipolysis with re- phase roughly correlate to the extent and
cal and hormonal adaptations, and a sys- leased glycerol acting as a glucose precur- type of injury. The catabolic process usually
temic washout of locally produced sub- sor. The hepatic glucose production supplies peaks at about 48 to 72 hours post-injury. If
stances like cytokines and other mediators. the glucose obligatory tissues. the insult is resolved, it can lead to an ana-
The first reference to the stress response re- Clearly, this process of catabolism re- bolic state, dominated by insulin, GH, and
sulted from keen observations by Sir David quires an enhancement of blood flow to the insulin-like growth factor I (IGF-I) within
Cuthbertson in the 1930s who described a muscle, the liver, and the areas of injury. 5–10 days of injury. The change is associated
biphasic immune, inflammatory, and meta- Individuals present with tachycardia and with a flux of protein, fluid, and electrolytes
bolic response to injury. This was further tachypnea, peripheral edema, fever, hyper- returning to depleted intracellular space,
modified by Francis Moore in the 1970s. The glycemia, leukocytosis, increased O2 con- particularly the muscle. Interstitial edema
first short (⬍24 hours) hypometabolic phase sumption, increased CO2 production, in- fluid is reabsorbed and the excess fluid is
(termed “Ebb” by Cuthbertson) represents a creased minute ventilation, elevated resting eliminated with a brisk diuresis. As the cel-
coordinated response directed toward im- energy expenditure and negative nitrogen lular space re-expands, the need for electro-
mediate survival. It starts with the activa- balance. Consequently, the liver provides chemical equilibrium mandates the move-
tion of local coagulation and innate immune substrates through gluconeogenesis and ment of ions (K⫹, Mg2⫹ and PO42⫺) from the
system factors. While evidence of a systemic synthesis of ketone bodies, detoxifies ni- blood into the cells. Serum levels of these
response may be minimal in subjects with trogenous waste via the synthesis of urea ions decrease and require repletion. An-
mild injury, in an insult of sufficient magni- and elaborates a series of APPs that bind orexia and fatigue gradually resolve, and
tude, the local activation is followed by sys- metabolic by-products or limit the activity heart rate, respirations, and plasma glucose
temic inflammatory and endocrine re- of proteolytic enzymes secreted by acti- normalize. Nitrogen balance becomes posi-
sponses. These can present as surges in vated leukocytes. Renal blood flow and tive and homeostasis is restored.

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 2 10/28/11 10:14:33 PM

 Chapter 1: Metabolic and Inflammatory Responses to Trauma and Infection 3

INFLAMMATORY RESPONSE TLRs are the most prominent in the induc- fections; this polymorphism is also attributed
tion of immune and inflammatory responses. to the severity of SIRS. Although septic pa-

Perioperative Care of the Surgical Patient

The inflammatory response to injury involves tients with TLR-4 polymorphism have been
interplay between several hormones (cate- Toll-like Receptors shown to have reduced levels of circulating
cholamines and cortisol) and a large number The Toll signaling pathway was initially de- inflammatory cytokines and an increased
of mediators (cytokines and chemokines). scribed in Drosophila in 1985, with the hu- risk of bacterial infection, the associations of
The immune and inflammatory responses to man homologue identified in 1997. This fam- mortality with polymorphism in TLRs during
injury are predictable and well-orchestrated, ily of type I transmembrane receptors is sepsis are still controversial. New research
and adaptive series of events evolve leading characterized by an extracellular domain suggests that manipulation of TLR signaling
to maximize healing potential. A normal, bal- with leucine-rich repeats and a cytoplasmic pathways offers significant therapeutic po-
anced, and well-controlled inflammatory re- domain. At least 11 human TLRs have been tential, particularly in the treatment of organ
sponse in previously healthy patients almost identified, and each is known to detect a spe- injury accompanying sepsis, but this concept
always results in an uneventful recovery. cific PAMP and has a specific intracellular requires further exploration.
signaling pathway. TLR-1, 2, 4, 5, and 6 mainly
Innate Immune System recognize bacterial products, of which TLR2 G-Protein-Coupled Receptors
has been implicated in the signaling process These receptors initiate intracellular re-
The immune response can be divided into an of gram-positive bacteria. TLR4 is the main sponses through the associated guanosine
early innate and a later adaptive responses. receptor mediating the proinflammatory cy- triphosphate (GTP)-binding G protein.
The innate immune system is the first line of tokines’ response to LPS. TLR-3, TLR-7, and These receptors are activated by chemok-
defense and its principal components are TLR-8 are specific for viral detection and ines, proteolytic products of complement
the epithelial barriers, immune cells (phago- TLR-9 seems to be involved in both micro- proteins (e.g., C5a), and lipid mediators of
cytes such as neutrophils, macrophages and bial and viral recognition. inflammation (platelet-activating factor,
dendritic cells, and natural killer [NK] cells). TLRs seem to play a bridging role be- prostaglandin E, and leukotriene B4).
Tissue damage, or microorganisms invading tween the innate and the adaptive immune
one or more of the epithelial barriers, is im- systems. They are expressed on dendritic Complement
mediately recognized by the multiple com- cells and T-lymphocytes, as well as on a vari- The complement system consists of more
ponents of innate immunity. The mecha- ety of parenchymal cells (e.g., adrenals, liver, than 30 proteins, including serum, serosal,
nisms used by the innate immune system to and spleen). The adrenal-expressed TLRs in- and cell membrane proteins. Being part of
recognize nonself entities have been eluci- fluence the systemic inflammatory response the innate immune system, the comple-
dated only recently. The innate immune re- by their effect on cortisol secretion. Upon ment system does not require prior immu-
sponse derives from preexisting recognition sensing danger, the TLRs are activated on nization for activation; it is rapidly acti-
of pathogen-associated molecular patterns immune, competent, and endothelial cells vated in a nonspecific manner in one of
(PAMPs) or microorganism-associated mo- ultimately resulting in the translocation of three main pathways: classic, alternative,
lecular patterns (MAMPs). The best known nuclear factor (NF)-␬B. NF-␬B then migrates and mannan-binding lectin pathways. In
examples of PAMPs are lipopolysaccharides to the nucleus and mediates gene transcrip- the classical pathway, it is activated by an
(LPS) in gram-negative bacteria, lipote- tion and the production of inflammatory me- IgM or IgG antibody–antigen complex. The
ichoic acids in gram-positive bacteria, diators, such as chemokines, adhesion mole- alternative pathway does not rely on an
mannose-rich oligosaccharides in micro- cules, growth factors, and pro-inflammatory antibody–antigen complex; it is activated
bial glycoproteins, mannans, unmethylated cytokines, especially tumor necrosis fac- directly by bacterial cell wall components.
CpG sequences in bacteria, double-stranded tor-␣ (TNF-␣) and interleukin-1 (IL-1). The The mannan-binding lectin pathway is ho-
RNA in replicating viruses, glucans, and IL-1 and TNF-␣ receptors, after binding to mologous to the classical pathway, except
N-formylmethionine (bacterial eukaryotic their ligand, can further activate the same that the cascade is initiated by a mannan-
protein). signaling pathways amplifying the immune binding lectin protein, produced by the liver
The receptors that have evolved to rec- response (Figure 1). TLRs are also involved that can activate complement cleavage
ognize these PAMPs are called pattern- in the recognition of endogenous ligands, when binding to a pathogen surface. Acti-
recognition receptors, and these can func- which are released from damaged or dying vation of the complement cascade results
tionally be divided into endocytic receptors, cells, or come from a depredated extracellu- in the formation of products that act to lyse
which mediate internalization and phago- lar matrix. These molecules include lipids, microbes, activate platelets, stimulate his-
cytosis of microbes, and signaling recep- carbohydrates, proteins, and nucleic acids. tamine release, recruit neutrophils by
tors, which activate cellular signaling path- Extensive research has been conducted chemotactic action, and facilitate both
ways that induce the expression of a variety on whether genetic variations can be used to phagocytosis and bacterial killing through
of immune-response genes. The most im- identify patients at high risk of developing opsonization of bacteria and stimulation of
portant receptors that mediate endocytosis sepsis and organ dysfunction during severe neutrophil degranulation.
are the mannose receptors of the calcium- infection. Increasing evidence suggests that a Complement activation pathways are
dependent lectin family, which recognize genetic polymorphism in TLRs may influ- regulated by a large number of regulatory
terminal mannose and fucose residues of ence a patient’s outcome in sepsis. For ex- complement-control proteins, preventing
glucoproteins and glycolipids that are char- ample, a single nucleotide polymorphism of over-activation of the whole system; sys-
acteristic of microorganisms, as well as the TLR1 (TLR1–7202A/G) has been associated temic overwhelming activation of the sys-
scavenger receptors that bind to bacterial with higher organ dysfunction, increased tem can result in changes in hemodynamic
cell walls. Among these signaling receptors, gram-positive infections, and death by sep- parameters, leading to shock. Persistent ele-
the two main groups of receptors are sis. Patients with a TLR4 gene mutation, es- vation of the complement-derived chemot-
the Toll-like receptors (TLRs) and the G- pecially those involving TLR4, Asp299Gly allele axins C3a, C4a, and C5a have been correlated
protein-coupled receptors, of which the have a higher incidence of gram-negative in- with increased remote organ damage and

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 3 10/28/11 10:14:33 PM

 4 Part I: Perioperative Care of the Surgical Patient

HMGB1 was originally identified as a

chromatin-binding protein that exists ubiq-
uitously in the nucleus of all eukaryotic
cells. HMGB1 plays a critical role in stabiliz-
ing nucleosome formation and in regulating
transcription; it also plays an important role
in signaling following tissue damage. When
present in an extracellular location, HMGB1
can activate the innate immune system and
promote inflammation. It is passively re-
leased by necrotic, but not apoptotic cells as
well as actively secreted by immune cells,
macrophages, and NK cells upon activation
with TNF. HMBG1 acts as a chemokine and
is a chemoattractant for macrophages, neu-
trophils, and dendritic cells and causes the
secretion of several proinflammatory cytok-
ines (e.g., TNF, IL-1a, IL-1b, IL-1RA, IL-6;
IL-8, MIP-1a, and MIP2b) (Figure 2).
The role of HMGB1 in multi-organ dam-
age in severe sepsis was demonstrated in an
animal model. Inhibition of HMGB1 by spe-
cific antibodies protected mice from mor-
tality in both LPS-induced and cecal ligation
and puncture-induced sepsis. Furthermore,
administration of recombinant HMGB1
protein recapitulated severe sepsis by in-
ducing lethal organ dysfunction. Several
techniques have been developed to inhibit
the biological activity of HMGB1 in sepsis. A
protein fragment A-box, which contains the
DNA-binding domain of HMGB1, competes
with intact HMGB1 for binding to its cell
surface receptor, and exhibited a therapeu-
tic effect in sepsis models even when ad-
ministered after the onset of the diseases.
Ethyl pyruvate, a stable and nontoxic deriv-
ative of pyruvic acid, has been shown to
suppress HMGB1 release from macrophages
in vitro, reduce serum HMGB1 levels, and
improve survival in sepsis models in mice.

Adaptive Immune System

Adaptive immunity constitutes the second,
but more specific and efficient response to
Fig. 1. The proinflammatory signal transduction pathway. ACP, accessory membrane-spanning protein; invaders. It is subdivided into cellular and
IKK␣, inhibitory protein I␬B kinase ␣; IKK␤, I␬B kinase ␤ IL-1, interleukin-1; IL-1R, IL-1 receptor; IRAK, humoral immunity.
IL-1R-activated kinase; NIK, NF-␬B-inducing kinase; RIP, receptor-interacting protein; TNFR, tumor ne-
crosis factor receptor; TRADD, TNFR and associated death-domain protein; TRAF2, TNFR-associated Cellular Immunity
factor 2. (Modified from Baeuerle PA. Pro-inflammatory signaling last pieces in the NF-kappaB puzzle? Surgical insult leads to the activation of lo-
Curr Biol 1998;8:R19, with permission.)
cal host responses necessary for protection
against invading microorganisms and for
mortality following sepsis. Neutralization of leased either after a nonprogrammed cell the initiation of tissue repair. The sequence
C5a, using a monoclonal antibody, resulted death or by cells of the immune system. of events begins immediately after injury,
in improved survival and decreased organ Within this family of endogenous triggers with the activation of the coagulation
damage in animal models. are high mobility group box 1 (HMGB1), heat cascade and the initiation of the inflamma-
shock proteins (HSPs), defensins, cathelici- tory phase. Local mediators of inflamma-
Alarmins din, eosinophil-derived neurotoxin (EDN), tion, such as cytokines, histamine, kinins,
Activation of the immune system is trig- and others. These structurally diverse pro- and arachidonic acid metabolites, cause
gered by injury or trauma without evidence teins serve as endogenous mediators of in- increased capillary permeability, allowing
of a bacterial focus. This is mediated by nate immunity as chemoattractants and ac- immune cell infiltration (primarily neutro-
alarmins or PAMPs. The alarmins are re- tivators of antigen-presenting cells. phils, followed by monocyte/macrophages

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 4 10/28/11 10:14:33 PM

 Chapter 1: Metabolic and Inflammatory Responses to Trauma and Infection 5

matic injury also leads to a degree of sys-

temic inflammation. Depending on the

Perioperative Care of the Surgical Patient

magnitude of tissue damage, the local in-
flammatory process will cause washout of
pro-inflammatory mediators into the sys-
temic circulation and inflicts a systemic in-
flammatory process. The systemic leak of
cytokines leads to further activation of im-
mune cells, mostly polymorphonuclear leu-
kocytes (PMN) priming, more cytokine se-
cretion, activation of complement and the
coagulation cascade, and secretion of APPs
and neuroendocrine mediators. This sys-
temic inflammation is followed by a compen-
satory anti-inflammatory response, creating
a balance, which will have significant im-
pact on the clinical outcome. Hence, the
“right tuning” of systemic inflammation is
crucial for restoration of homeostasis. Se-
Fig. 2. Schematic of the chemokines-mediated process of polymorphonuclear leukocyte (PMN) recruit- vere inflammation may lead to tissue de-
ment and infiltration. Chemokines emanating from a source of injury and/or infection mediate the
struction in organs not originally affected
positively regulated expression of adhesion molecules. In this example, selectins and integrins cause
tumbling and adherence, respectively, of PMNs to the endothelial lumen wall. The adherent PMN then by the initial trauma by a process com-
moves through the wall by diapedesis and migrates along the chemokines gradient, eventually infiltrat- monly referred to as the multiple-organ
ing in and around the focus of injury. ROS, reactive oxygen species. dysfunction syndrome (MODS). A lesser in-
flammatory response (or too much anti-
inflammatory regulation) will induce a
state of immunosuppression during the
infiltration). Immune cell migration is a rolling leukocytes results in the modifica- vulnerable time of recovery, which can re-
complex process involving attachment to tion of the structure of a family of trans- sult in deleterious sepsis for the host.
the endothelial cells and extravasation reg- membrane proteins called “integrins,” al-
ulated by many substances, the most im- lowing for firm adherence of leukocytes to Cytokines
portant of which are the chemokines and the endothelial surface. Chemokines can Cytokines are small proteins, secreted by
adhesion molecules. Most of these media- then stimulate the extravasation and mi- systemic immune cells, macrophages, mono-
tors act in a paracrine fashion and they are gration of the cells to the wound space. cytes, or lymphocytes (mostly T-cells) and by
short-lived because of rapid metabolism. Finally, at the time of injury, the produc- diverse cell types at the site of injury. Cytok-
Therefore, serum measurements of these tion of pro-inflammatory cytokines and the ines are crucial mediators in cell immunity
mediators may not reflect their activity in expression of E-selectin, chemokines, and and inflammatory response. In healthy hu-
local tissues. integrin ligands on endothelial cells medi- mans, they are produced at low constitutive
TLR activation causes secretion of cy- ate the selective recruitment of cutaneous levels, reaching just picograms per milliliter
tokines (TNF-␣ and IL-1) and chemokines, lymphocyte antigen (CLA)-positive T-cells in plasma, and function in an endo-, para-,
especially by local macrophages. Chemok- into the wound. There, they recognize the or autocrine manner. Cytokine receptors are
ines are produced and secreted to the extra- antigen for which their receptor is specific expressed on the surface of the majority of
cellular matrix by activated leukocytes and and become activated. The local mac- human cells, and some soluble cytokine re-
by various skin cells (epithelial cells, fibro- rophages act as antigen-presenting cells ceptors are detectable in plasma at low lev-
blasts, and endothelial cells), and mediate and also express the costimulatory mole- els. Cytokines activate intracellular signaling
cell motility. The local microcirculatory cules that are essential for T-cell activation. pathways that regulate gene transcription.
inflammatory response is reflected by a After antigen binding, T-cells differentiate Examples include NF-␬B, activating protein
pronounced leukocyte accumulation and preferentially into Th1 subsets, and secrete 1 (AP-1), signal transduction- and transcrip-
adherence to the endothelial lining of post- interferon-gamma (IFN-␥), the major tion-activating factor 3 (STAT-3), and mem-
capillary and collecting venules. This re- macrophage-activating cytokine. The acti- bers of the CCAAT/enhancer binding protein
sponse is associated with an increase in vated macrophages remove debris from (C/EBP) family of transcription factors, in
microvascular permeability, indicating the dead cells to facilitate repair after the infec- particular C/EBP-␤ and ␦.
disruption of endothelial integrity. tion is controlled. The clearance of the de- The NF-␬B family of transcription factors
Cytokines act on endothelial cells and bris and the infectious organisms promotes is most often studied because of its central
induce the adhesion molecules. Leukocytes resolution of the inflammatory phase and role in the inflammatory process. Cytokines
express carbohydrate ligands to bind to E ensuing repair responses, which include influence immune cell activity, differentia-
and P endothelial selectins (a family of three formation of granulation, reepithelializa- tion, proliferation, and survival. These me-
single-chain transmembrane glucoproteins, tion, and neovascularization. The immune diators also regulate the production and
named L, E, and P selectins), a process called response then produces the cardinal signs activity of other cytokines in a watershed
“tethering.” These are low-affinity interac- of swelling, pain, erythema, and fever. manner. There is a significant overlap in bio-
tions and the leukocytes begin to roll along In the normal host response, these pro- activity among different cytokines.
to the endothelial surface due to the force of cesses are mostly limited to the site of Cytokines are not antigen-specific and
the flowing blood. Chemokine signaling on trauma; however, every substantial trau- their effect can be stimulatory or inhibitory.

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 5 10/28/11 10:14:39 PM

 6 Part I: Perioperative Care of the Surgical Patient

TNF, IL-1b, IL-6, IL-8, IL-12, and IFN-␥ are physiological effects, including increased after hip replacement; there are lower IL-6
the dominant stimulatory (or pro-inflam- permeability of endothelial cells. It also in- levels after laparoscopic than after open
matory) cytokines and IL-4, IL-10, and IL-13 duces the production of adhesion molecules, procedures, including cholecystectomy and
are considered inhibitory (or anti-inflam- such as selectins, platelet-activating factors, small-bowel and colonic resections. It has
matory). Those compounds acting in be- and intracellular adhesion molecules (ICAM). been shown in murine models that IL-6 is
tween cells of the immune system are called In addition, TNF increases the pro-coagu- an important mediator of inflammation,
interleukins, and those inducing chemot- lated activity of endothelial cells. and blocking IL-6 increases survival. Fur-
axis of leukocytes are referred to as chemok- The local effects of TNF can be physio- thermore, IL-6 is regarded as a prognostic
ines. Including about 50 chemokines and 30 logic, but the systemic effects often lead to marker of trauma patients with SIRS, sep-
interleukins, the number of characterized adverse outcomes. TNF has been identified sis, or MODS and as such has been used in
cytokines is now well in excess of 100. The as a principal mediator in septic shock. In the intensive care unit (ICU) setting as an
number of cytokines recognized continues the central nervous system (CNS), TNF indicator for the severity of the inflamma-
to grow, and a list of cytokines and their stimulates the release of corticotropin- tory responses that is relatively indepen-
function(s), origin, target cells, and proper- releasing hormone (CRH), induces fever, dent of bacterial infections.
ties is provided in the Cytokine Online and reduces appetite. In the liver, it stimu-
Pathfinder Encyclopedia (COPE) web site, lates production and secretion of APPs, and Chemokines
created by Dr. Horst Ibelgaufts (www.cope- also causes insulin resistance. Inhibition of Overall, 18 chemokine receptors and 43
withcytokines.de/cope.cgi). TNF by either anti-TNF antibodies or solu- chemokines have been described, demon-
During acute localized inflammation, ble receptors for TNF has become a strategy strating a sharing of receptors. Chemokines
connective tissue, endothelial cells, and lo- in the treatment of patients with chronic acts as attractants to almost all blood cell
cal immune cells are first to secrete pro- inflammatory diseases, but this strategy types of the innate and adaptive immune
inflammatory cytokines, mostly IL-1 and does not work in septic patients. response. In lower doses, chemokines act
TNF. Cytokines may leak to the circulation IL-1 was first described as endogenous mostly as chemoattractants, while in in-
and exceed the levels of soluble receptors, pyrogen over a half century ago, because it creased concentrations they can lead to cell
which results in systemic inflammation and caused fever when injected into rabbits. Af- activation, including cytotoxicity and even
possible development of SIRS and MODS. ter being secreted by monocytes, mac- respiratory burst. Their receptors have also
The monocyte/macrophage also produces rophages, or endothelial cells, it has a t½ of been detected in endothelial cells, keratino-
the only natural and well-characterized only 6 minutes. The two forms, IL-1␣ and cytes, and fibroblasts, suggesting that some
competitive cytokine antagonist, IL-1 re- IL-1␤, are regulated by different antigens, chemokines also contribute to the regula-
ceptor antagonist (IL-1ra), as well as liber- but both bind to the same IL-1RI. Binding tion of epithelialization, angiogenesis, and
ates soluble forms of TNF and IL-1 receptors to this receptor activates a signaling cas- tissue remodeling. The chemokine recep-
(IL-1RI) that are able to bind and neutralize cade that is shared also with IL-18 and tors belong to the family of G-protein-
TNF and IL-1, respectively. The t½ of circu- TLRs.The IL-1 is a potent pyrogen, which coupled receptors, and binding to these re-
lating unbound cytokines can vary from ⬍5 influences the hypothalamus to reset the ceptors leads to effects, including both
minutes to a few hours. temperature of the body and induces fever. chemotaxis and activation.
It is associated with local hyperalgesia. IL-1 IL-8 is a typical chemotactic cytokine
Interleukins has similar effects to TNF on the immune and its secretion is induced by IL-1, TNF-␣,
One of the best-described pro-inflamma- system following trauma. In fact, TNF and C5a, microbes and their products, hypoxia,
tory cytokines, TNF (previously known as IL-1 are often described as synergistically hyperoxia, and reperfusion. Interferons at-
cachectin) is mainly produced by mac- acting mediators. tenuate the expression of IL-8. It can be pro-
rophages and monocytes, and by T-cells, Similar to other cytokines, IL-6 is pro- duced in an early state of inflammation fol-
endothelial cells, fibroblasts, and adipose duced by a variety of cell types. It is detect- lowing trauma and can persist over a long
tissues. TNF is among the early cytokines able within an hour of trauma, and peaks at period of time, even weeks. It has the ability
secreted after trauma with a t½ ⬍ 20 min- 4–48 hours following surgery. The secretion to act as potent angiogenic factor, as a po-
utes. TNF acts through its receptors TNFR1 of IL-6 is induced by TNF and IL-1. IL-6 in- tent chemoattractant, and as an activator of
and TNFR2. duces a proliferation and differentiation of immune cells. IL-8 signaling also induces
TNF, through TNF-R1, activates the cas- B- and T-lymphocytes, activates NK cells the shedding of L-selectin from the neutro-
pase cascade and induces cell apoptosis, as and neutrophils, and inhibits its apoptosis. phil cell surface, and together with TNF-␣
well as induction of transcription factors IL-6 regulates the hepatic synthesis of APP, and IL-6 is responsible for the regulation of
(e.g., NF-␬B) and activation of the mitogen- such as C-reactive protein (CRP), fibrino- adhesion molecules on endothelial cells. It is
activated protein kinase (MAPK) pathways gen, complement factors, ␣-2 macroglobu- not the concentration of IL-8, itself, but the
both involved in cell proliferation, transcrip- lin, ␣1-antitrypsin, and others. IL-6 also in- development of a concentration gradient
tion of inflammatory genes, and anti-apop- duces the release of soluble TNF-R and IL-I that directs the cellular recruitment to the
tosis. Binding of TNF to TNFR2 leads to acti- receptor antagonist, and therefore plays a site of inflammation. There is also evidence
vation and proliferation of immune cells. dual role in the inflammatory response by that IL-8 can protect neutrophils against
TNF induces secretion of a variety of pro- acting as both a pro-inflammatory and an apoptosis, which could be one reason for
and anti-inflammatory cytokines (e.g., IL-6, anti-inflammatory mediator. IL-6 has a lon- prolongation of the inflammatory response
IL-8, IFN-␥, and IL-10), increases synthesis of ger t½ than TNF or IL-1, which makes it at the site of injury or infection. It has also
nitric oxide , activates the arachidonic acid easier to monitor, and seem to correlate been shown that IL-8 plays an important
pathway and induces activation of cyclooxy- with the magnitude of trauma. For example, role in the development of the ARDS.
genase and lipoxygenase enzymes. This leads despite similar procedure times, there is a Recently, a group of so-called silent
to the production of thromboxane A2 and greater degree of IL-6 elevation after ab- chemokine receptors has gained more atten-
prostaglandins E2, which have multiple dominal aortic and colorectal surgery than tion. These receptors can bind chemokines,

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 6 10/28/11 10:14:40 PM

 Chapter 1: Metabolic and Inflammatory Responses to Trauma and Infection 7

but do not evoke chemokine-related cell re- activation remains unclear. Various investi- routes: by increasing corticosteroid hormone
sponses, suggesting a role as decoy or scav- gators demonstrated the effects of comple- levels (activation of the HPA axis) and by ac-

Perioperative Care of the Surgical Patient

enger receptors. One member of this family ment (C5a) fragments, PGE2, coagulation tivation of the cholinergic anti-inflammatory
is the decoy receptor D6. D6 binds most in- factors (Factor XII), kinins (bradykinin), pathway. Evidence exists that hormones and
flammatory chemokines, except IL-8, and is and cytokines (TNF, IL-1, and IL-6). Increas- cytokines interact at several levels. For ex-
now known to be important in limiting the ing evidence has suggested that vagal path- ample, TNF-␣, IL-1, and IL-6 stimulate the
inflammatory response in different animal ways are utilized as the communication HPA axis resulting in the release of ACTH
models, allowing degradation of chemok- link between the peritoneal cavity and the and glucocorticoids (Figure 3). IL-1 also has
ines. Another important member is the CNS, especially during episodes of intraab- a direct enhancing effect on the adrenals.
Duffy Antigen Receptor for Chemokines dominal infection. It has been shown that The glucocorticoids secreted down-regulate
(DARC). DARC, first described as a blood many CNS effects induced by intraperitoneal cytokine release from macrophages in a neg-
group antigen, is also expressed by red blood administration of LPS or IL-1 ( fever, in- ative feedback mechanism. The negative
cells and endothelial cells. It binds angio- creased elaboration of adrenocorticotrophic feedback between glucocorticoids and cy-
genic chemokines, including IL-8. While D6 hormone [ACTH]) can be blocked or atten- tokines is one of the main mechanisms pro-
eliminates the cellular response to chemok- uated by subdiaphragmatic vagotomy. This tecting the organism from the possible dam-
ines, the DARC receptor seems to act more sensory arm can be activated by the pres- age from over inflammation.
to differentiate this response, and chemok- ence of IL-1 in peripheral tissues. Specific Reduced triiodothyronine (T3) levels af-
ines retain their biological activity after IL-1 binding sites have been revealed on ter treatment with TNF-␣ or IL-1 demon-
binding to this receptor. DARC on red blood glomus cells adjacent to the vagus nerve. strate another link between hormones and
cells seems to capture chemokines and is, IL-1 binding and an intact vagus nerve are cytokines. Hormones can also influence
therefore, supposed to prevent leukocyte ac- both required for the development of fever each other, as catecholamines increase cel-
tivation in the systemic circulation. On the following intraperitoneal administration of lular uptake of T3. The “low T3 syndrome” in
other hand, DARC on endothelial cells is re- low quantities of IL-1. sepsis and following trauma may be due to a
quired for leukocyte recruitment. combination of cytokine and catecholamine
Humoral Route effects. The complex interactions among
Cytokines Post-elective Surgery Cytokines are lipophobic molecules and do different mediators may explain, at least in
Elective surgery followed by an uneventful not have ready access to the CNS, since the part, why treatment directed against indi-
clinical course may induce only minor sys- blood brain barrier (BBB) excludes entry of vidual mediators following trauma or sepsis
temic inflammatory changes. As one could such proteins. An exception is in regions has not been successful.
expect, the acute-phase response, post- where the BBB is not well formed, such as
elective surgery, is proportional to the sur- around the circumventricular organs (CVOs), Immunosuppression Following Trauma
gery-related tissue trauma or to the severity the meninges and the choroid plexus. There More and more evidence is emerging that
of the procedures. Virtually, all mediators of may be active transport into specific regions the neurologic system plays a major role in
inflammation (cellular, cytokines, and APPs) of the brain of circulating cytokines by the the coordination of inflammatory and anti-
peak post-injury at about day 1 to 2 and then vascular endothelium. Alternatively, cytok- inflammatory immune response. While mi-
return to baseline levels by post-injury days ines may damage the integrity of the vascu- nor surgery is suggested to stimulate com-
6 to 7. Persistent postoperative pain, stress, lar endothelium that forms the BBB, enter ponents of the immune system, it is generally
or a second insult will change that pattern. the brain, and stimulate central neural agreed that after the acute-phase response,
circuits. Several factors have been impli- major surgery, and to a higher extent, major
THE NEURO-IMMUNE AXIS cated, most notably IL-1 and IL-6. Prosta- trauma cause immunosuppression that may
glandins, mostly PGE2, locally produced in render the host anergic to opportunistic in-
The systemic and even local inflammatory the hypothalamus in reaction to cytokines, fections. The initial response to surgical
responses posttrauma are regulated by the play a crucial role in inducing pyrexic reac- trauma is characterized by activation of the
nervous system. Considerable attention has tion, as known for many years from the abil- specific and nonspecific immune system’s
been given to the effectiveness of parasympa- ity of cyclooxygenase inhibitors to prevent release of pro-inflammatory cytokines (TNF,
thetic nerve stimulation in suppressing the fever. IL-1␤, IL-6, IL-18, and HMGB1 and more),
magnitude of the proinflammatory response, neutrophil activation, microvascular adher-
leading to coining of the term “inflammatory Efferent Regulation ence, as well as PMN and macrophage oxi-
reflex.” Like other reflex arcs, the inflamma- Following integration of afferent signals the dative burst, but this rapidly gives way to a
tory reflex is comprised of a sensory afferent CNS has two major effector/efferent arms state of depressed immune function.
arm and an efferent motor arm. that are used to regulate physiologic re- The production of immunoglobulins fall
sponses. The first is the activation of the and many patients become anergic as
hypothalamus-pituitary-adrenal (HPA) axis, assessed by delayed hypersensitivity skin
Afferent/Sensory Input to the Brain and the second is the direct activation of the testing. Defects in neutrophil chemotaxis,
During stress, afferent signals from the in- sympathetic system while suppressing the phagocytosis, and lysosomal enzyme con-
jury site can reach the CNS through two other parasympathetic “half ” of the auto- tent and respiratory burst have all been
main routes: the neural route, mostly by af- nomic nervous system. The CNS regulates reported. This condition is referred to as a
ferent vagal fibers, and through blood- the “level of ongoing inflammation” through compensatory anti-inflammatory response
borne inflammatory mediators. multiple pathways, both pro- and anti- syndrome; it is induced by multiple media-
inflammatory. The anti-inflammatory effect tors and affects all subtypes of immunity.
Neural Route was studied more thoroughly. The inflamma- The counter anti-inflammatory mechanism
The neural afferents present a rapid means tory opposing response suppresses the im- is as complex and multi-factorial as the pro-
to activate the CNS; the mechanism of their mune system through at least two main inflammatory one. It includes cytokines

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 7 10/28/11 10:14:40 PM

 8 Part I: Perioperative Care of the Surgical Patient

TNF␣ and IL-1␤ and truncate the inflam-

matory response.

Cell-Mediated Immune Dysfunction

Cellular immuno-incompetence (also called
“immune paralysis”) is induced by elevated
PGE2, IL-10, and other anti-inflammatory
mediators, mainly caused by the deactiva-
tion of monocytes. The central role of IL-10
and TGF␤ in inducing monocyte “immune
paralysis” is demonstrated by the up-
regulation of HLA-DR expression on mono-
cytes following the application of an IL-10
neutralizing antibody and the restoration
of macrophage antigen presentation by us-
ing TGF-␤ neutralizing antibodies.

Lymphocyte Dysfunction
Major surgical interventions are associated
with a significant decrease in total systemic
lymphocyte counts, including both CD4⫹
and CD8⫹ cells. This lymphocyte depression
correlates with the duration of the surgical
procedure and the volume of blood loss,
however, is not associated with the extent
of the trauma, the age of the patient, or the
type of intensive care intervention. These
events are accompanied (within 24 h) with
elevated IL-10 and increased frequency of
Fig. 3. Relationship between the hypothalamus–pituitary–gonad-adrenal (HPA) axis and the immune sys- apoptosis of CD4⫹ and CD8⫹ cells accom-
tem in physiological responses to injury. The HPA is a neuroendocrine system that also has bidirectional panied by marked down-regulation of anti-
communication with the immune system in homeostasis and in times of injury, giving the brain a major apoptotic factors such as Bcl-2. The impact
role in regulating endocrine and immune functions. The hormonal responses are apparent at three levels: of this immune dysfunction was under-
the hypothalamus, the pituitary, and the adrenals. It can be seen that organs are coupled with one another
scored by the fact that the rate of apoptotic
( functioning as a biologic oscillators), with the coupling being mediated by neural, hormonal, and cytokine
networks. Notably, cytokines and sex hormones are closely coupled in a counterregulatory fashion, which CD8⫹ cells significantly correlated with the
sheds light on the beneficial effects of sex hormones, especially ␤-estradiol, in responses to injury. manifestation of infectious complications
during the postoperative course.
A considerable number of studies have
shown that modulation of T-helper lym-
such as IL-10, TGF-␤, TNF-binding protein, activation of Jak-STAT pathways. Direct phocytes (Th cells) is also involved in the
and hormones such as corticosteroids, electrical stimulation of the peripheral va- development of immune suppression fol-
adrenaline, and ␣-melanocyte stimulating gus nerve in vivo during lethal endotoxemia lowing surgical trauma. The cells can be
hormone (␣-MSH). These act in concert with in rats inhibited TNF synthesis in liver, at- subdivided into two functionally distinct
local effectors, such as PGE2, HSPs, and APPs. tenuated peak serum TNF amounts, and subsets: Th1 and Th2, according to individ-
These factors interact to inhibit macrophage prevented the development of shock. Sev- ual functional parameters. Th1 cells may
activation and down regulate the synthesis eral reports have confirmed that the activa- support an inflammatory response by pro-
of pro-inflammatory cytokines. tion of this pathway, either by electrical ducing IL-2, IL-12, and IFN-␥, while Th2
stimulation of the vagus nerve or by admin- cells act as anti-inflammatory agents by se-
The Cholinergic istration of ␣7 selective drugs, is effective in creting IL-4, IL-5, IL-6, IL-10, and IL-13.
Anti-inflammatory Pathway ameliorating inflammation and improving Major trauma is associated with a shift of
The activation of the cholinergic pathway survival in a number of experimental mod- the Th1/Th2 balance toward a Th2 response.
leads to acetylcholine release in the reticu- els, such as sepsis, hemorrhagic shock, pan- Lymphocyte dysfunction may present as a
loendothelial system that includes the creatitis, and postoperative ileus. complete lack of response to external stim-
spleen, liver, lymphoid tissue, and GI tract. uli, that is, anergy.
Acetylcholine binds to an ␣7 subunit of the IL-6, As an Immunosuppressor
nicotinic acetylcholine receptor, expressed The massive and continuous IL-6 release The Second Hit Phenomenon
on tissue macrophages, to inhibit the re- accounts for the up-regulation of major The so-called two-hit model of inflamma-
lease of pro-inflammatory (TNF, IL-1␤, IL-6, anti-inflammatory mediators, such as glu- tory insult has become a commonly ac-
and IL-18), but not the anti-inflammatory cocorticoids, PGE2, IL-10, and TGF␤. IL-6 cepted paradigm. It takes place in many
cytokine IL-10. In macrophages, signaling stimulates the macrophage expression of common scenarios in which the patient has
through ␣7 attenuates TNF production anti-inflammatory mediators, such as IL-1RI to undergo a surgical procedure following
through a mechanism dependent upon in- antagonist and soluble TNF receptors. These initial trauma or suffers further insults due
hibition of NF-␬B nuclear translocation and bind to the pro-inflammatory cytokines to a complication. The second hit may be

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 8 10/28/11 10:14:40 PM

 Chapter 1: Metabolic and Inflammatory Responses to Trauma and Infection 9

sterile- (operation after trauma) or pathogen- CRH, thyrotrotropin-releasing hormone number of aspects of the immune response,
induced infection post-surgery. (TRH), gonadotropin-releasing hormone including antibody responses in vitro and

Perioperative Care of the Surgical Patient

Although influenced by many factors, (GnRH), growth hormone-relapsing hor- in vivo, phagocytic cell function, NK-cell ac-
the inflammatory and metabolic response is mone (GHRH), and dopamine. During tivity, chemokine-induced chemotaxis, the
relatively predictable. The immune reaction stress, the afferent signals from the injury development and function of T-cells in the
to further insults is not as consistent. Varia- site reach the hypothalamus through the thymus, and cytokine and cytokine receptor
tions in the competence of innate and adap- neural route (impulses are transferred from expression. Opiate-mediated immune effects
tive immune defenses become evident; there the cephalad to the ventral-posterior nu- have been postulated to result from either
is an innate immune tolerance and dimin- cleus of the thalamus) mostly by afferent direct interaction with opioid receptors on
ished adaptive immune capacity of response vagal fibers or through blood-borne inflam- cells of the immune system or indirectly
to a new antigen. On the other hand, the re- matory mediators. Humoral mediators through the activation of opioid receptors
current immunological activation causes a reach the hypothalamic-hypophysial portal within the CNS, and the resulting modula-
persistent systemic pro-inflammatory activ- capillaries in the median eminence through tion of HPA axis (cortisol) and the sympa-
ity that may lead to SIRS and MOF. The per- the anterior hypophyseal arteries. The cy- thetic nerve system activities. Although al-
sistent inflammation could take place only tokines can diffuse into the portal capillar- ternations in various aspects of immune
in some aspects of immunity and not in oth- ies, areas that are free from the BBB. function in patients exposed to opioid treat-
ers. An example of this is the, continuation ment were demonstrated in clinical practice
of coagulation system activation, even while Endogenous Opioids (Endorphins) (post-elective abdominal surgery, orthopedic
other pro-inflammatory activity is waning. Many of the mediators released during in- surgery, and in healthy volunteers), there are
Not infrequently, a prolonged stress state flammation of peripheral tissue are known no actual prospective clinical studies explor-
manifests diminishing amplitude, frequency, to elicit pain by activation of specialized pri- ing the possible interaction between expo-
and efficiency of autonomic and neuroen- mary afferent neurons called “nociceptors” sure to opiates and rates of infection.
docrine signaling. Disturbances in circadian (defined as “neurons preferentially sensitive
rhythmicity of neuroendocrine hormone se- to a noxious stimulus or to a stimulus which Hormonal Changes During
cretion are also observed during prolonged would become noxious if prolonged”). Noci- Acute and Chronic Surgical Illness
inflammatory illness. The attenuated hor- ceptor stimuli propagate through the dorsal There is a biphasic neuroendocrine re-
mone rhythmicity and signal amplitude may horn of the spinal cord to the supraspinal sponse to critical illness. The acute phase is
contribute to disordered metabolic and im- sites where a sensation of pain is eventually characterized by an actively secreting pitu-
mune functions. elicited. Various opioid peptides, such as itary; whereas, in prolonged critical illness,
␤-endorphin, met-enkephalin, dynorphin, there is a hypothalamic suppression of the
Systemic Inflammatory Response and endomorphins are produced and se- neuroendocrine axes.
Syndrome and Multiple Organ creted by the hypophysis, hypothalamus,
Dysfunction Syndrome and, as demonstrated most recently, locally Glucocorticosteroids
Cytokine-mediated inflammation is usually by leukocytes. Opioid peptides can bind to In a stress-free healthy human, cortisol is
short-lived and is resolved. In some cases, opioid receptors. The most studied opioid secreted from the zona fasciculata of the
however, cytokine production can become receptor groups are μ, ␬, and ␦. These recep- adrenal cortex, according to a diurnal pat-
excessive, and rather than resolving, inflam- tors are part of the G-protein-coupled re- tern. Cortisol release is controlled by ACTH
mation persists or even spreads, causing ceptors, which are synthesized in dorsal produced by the pituitary, in turn under the
damage in adjacent tissues. This hypermet- root ganglia and are transported intra- influence of the hypothalamic CRH. Corti-
abolic response, often called the SIRS, en- axonally. The opioid receptors are repre- sol itself exerts negative-feedback control
compasses excessive whole body inflamma- sented in the brain, spinal cord, sensory pe- on both hormones. Approximately 10% cor-
tion and is considered a major determinant ripheral nerve endings, and in the intestinal tisol is found free in the plasma. Of the re-
in the development of multiple organ dys- tract. Agonist binding elicits potent analge- mainder, 20% is bound to albumin, and 70%
functions (MODs), often with a lethal result. sia, a quality often used to treat pain, with is bound to cortisol-binding globulin. Only
The pathophysiology of SIRS and MODS is induction of external opioids. the free hormone, however, is biologically
explored in Chapter 8. The balanced activation of sympathetic active. Glucocorticoids exert their effects by
and parasympathetic pathways, as well as binding to and activating an intracellular re-
Endocrine Response HPA axis, in response to injury is crucial in ceptor protein. The cortisol–glucocorticoid
dynamic regulation of a host’s defense mech- receptor complex moves to the nucleus
Role of the Central Nervous System anisms. The endorphins are part of the coun- where it binds as a homodimer to DNA se-
The CNS response consists primarily of terregulatory system activated in a state of quences located in the promoter regions
three parallel, coordinated effects: fever, shock. The opioids enhance the parasympa- of target genes. In addition, the cortisol–
HPA axis activation, and sickness behavior thetic tone, balancing the increased sympa- glucocorticoid receptor complex may affect
(such as anorexia or somnolence). Follow- thetic drive. A meta-analysis review of the cellular function indirectly by binding to
ing integration of afferent signals, the hypo- literature concerning the use of opioid an- and modulating the transcriptional activity
thalamus has two major effector arms that tagonist (Naloxone) in clinical setup indicates of other nuclear transcription factors, such
are used to regulate physiological responses. that opiate antagonist treatment does im- as NF-␬B.
The first is the activation of the HPA axis prove mean arterial blood pressure in shock
and the second is the direct activation of patients. The mechanism involved in mediat- Cortisol During Stress
the sympathetic system, while suppressing ing the salutary effects of opiate antagonists Cortisol levels usually rise in the early phase
the other parasympathetic “half ” of the has not been completely elucidated. of critical illness. The excited neurons in
autonomic nervous system. At rest, the hy- Immune cells carry all three opioid recep- the hypothalamus release CRH and arginine
pothalamus secretes, in a pulsing manner, tors. Opioids have been shown to modulate a vasopressin (AVP) from their terminals

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 9 10/28/11 10:14:41 PM

 10 Part I: Perioperative Care of the Surgical Patient

into the capillaries of the hypothalamo- coids control mediator production predomi- impair the integrity of the HPA axis, such as
hypophysial portal system. CRH and AVP nantly through inhibition of transcription blunt normal response leading to either
act on CRH-1 and vasopressin-1␤ receptors factors, such as NF-␬B. Glucocorticoids also transient or, rarely, permanent adrenal in-
on the anterior pituitary to stimulate ACTH produce anti-inflammatory effects by en- sufficiency. This scenario can lead to a po-
secretion. Plasma ACTH levels rise directly hancing release of factors, such as IL-1RI an- tentially lethal condition. Refractory hy-
due to increased secretion and due to resis- tagonist, soluble TNF receptor, and IL-10. potension is the most common aspect of
tance to or inhibition of the negative-feed- Glucocorticoids also block the transcription acute adrenal insufficiency. Adrenal insuf-
back mechanism exerted by cortisol. Several of messenger RNA for enzymes required for ficiency should be suspected in any criti-
of the elevated cytokines have been shown the synthesis of some mediators (cyclooxyge- cally ill patient who has persistent hypoten-
to modulate cortisol production, either by nase-2 and iNOS). sion and hemodynamic instability that
directly affecting the hypothalamus/pitu- A rise in glucocorticoid concentrations persists despite adequate fluid resuscita-
itary (IL-1␣, IL-1␤, IL-6, and TNF-␣) or by plays an important role in improving hemo- tion and/or requires vasopressor support.
direct stimulation of the adrenal cortex dynamic levels, by inducing fluid and sodium Other nonspecific signs can include multi-
(IL-1␣, IL-1␤, and IL-6). Cytokines can also kidney retention. Glucocorticoids are also ple organ dysfunction, otherwise unex-
influence glucocorticoid receptor numbers required for the needed increased sensitivity plained hypoglycemia, hyponatremia, hy-
and affinity. During severe illness, corticos- of the cardiovascular system to vasocon- perkalemia metabolic acidosis, eosinophilia,
teroid-binding globulin levels are decreased, strictors. The reactivity to angiotensin II, epi- hyperdynamic circulation, and other pitu-
resulting in proportionate increases in the nephrine (Epi), and norepinephrine (Norepi) itary deficiencies (gonadotropin, thyroid,
free hormone. The diurnal variation in corti- contributes to the maintenance of cardiac and diabetes insipidus). Recently, much at-
sol secretion is lost in response to any type of contractility, vascular tone, and blood pres- tention had been focused on the so-called
acute illness or trauma. An appropriate acti- sure. These effects are mediated partly by the relative or functional adrenal insufficiency
vation of the HPA axis and cortisol in re- increased transcription and expression of of critical illness, a condition defined as
sponse to critical illness is essential for sur- the receptors for these hormones. Glucocor- subnormal adrenal corticosteroid produc-
vival. The adrenal gland does not store ticoids are required for the synthesis of Na⫹, tion in the absence of any structural defects
cortisol; therefore, increased secretion arises K⫹-ATPase, and catecholamines. The ef- of the HPA axis. The explanation for the de-
due to increased synthesis of cortisol from fects of glucocorticoids on synthesis of cate- velopment of this condition is hypothetical
its principal precursor, cholesterol. cholamines and catecholamine receptors exhaustion of the secretory adrenocortical
are partially responsible for the positive ino- reserve as a result of ongoing near-maximal
Cortisol Influence on tropic effects of these hormones. Glucocorti- stimulation. Other contributing factors
Post-trauma Physiology coids also decrease the production of nitric may include the suppression of cortisol and
The stress-induced hypercortisolism fosters oxide, a major vasorelaxant and modulator ACTH production by circulating cytokines
the acute provision of energy. Glucocorti- of vascular permeability. and other inflammatory mediators, as well
coids increase blood glucose concentra- During surgical procedures, such as lap- as the development of target tissue resis-
tions by increasing the rate of hepatic glu- arotomy, serum corticotropin and cortisol tance to glucocorticoids and/or adrenal
coneogenesis and inhibiting adipose tissue rise rapidly, peaking in the immediate post- cortex resistance to ACTH action. Currently,
glucose uptake. Hepatic gluconeogenesis is operative period. The magnitude of the the clinical significance of this condition is
stimulated by increasing the activities of postoperative increase in serum cortisol not clear and was only demonstrated in a
phosphoenolpyruvate carboxykinase and concentration is correlated with the extent setup of septic shock. Although corticoster-
glucose-6-phosphatase as a result of bind- of the surgery. From a normal secretion rate oid replacement therapy might also be ben-
ing of glucocorticoids to the glucocorticoid of 10 mg/day, cortisol production rate in- eficial to patients who have other critical
response elements of the genes for these en- creases to 75 to 150 mg/day following major illnesses in which there is evidence of rela-
zymes. Glucocorticoids also stimulate free surgery and can reach to 250 to 300 mg/day tive hypoadrenalism, no high-quality data
fatty acid release from adipose tissue and in severe stress. Unless there is a repeated from large randomized studies is available.
amino acid release from body proteins. Major insult, such as sepsis, the glucocorticoid As mentioned earlier, there is no clear
roles of these processes are to supply energy concentrations decline to baseline levels or current threshold definition for physio-
and substrate to the cell, which are required over the next 72 hours. This decline can of- logical “normal” and low cortisol plasma
for the response to stress and repair to injury. ten be noticed clinically as increased diure- concentration during critical illness. Since
The rise in glucocorticoids also protects sis, improved glucose control, and, occa- about 90% to 95% of plasma cortisol is
against excessive inflammation. The rise in sionally, increased pain. In critical illness, bound to protein, the routine decrease in
glucocorticoids during acute illness plays a the kinetics of the response differ from cortisol-binding protein and albumin fol-
crucial role in preventing hazardous over- those mentioned above: pain, fever, hypov- lowing critical illness makes it difficult to
stimulation of the immune system, including olemia, hypotension, and tissue damage all calculate and interpret the meaning of total
lymphocytes, NK cells, monocytes, mac- result in a sustained increase in corticotro- cortisol concentration. While the plasma
rophages, eosinophils, neutrophils, mast cells, pin and cortisol secretion and a loss of the proteins are low and there is a peripheral
and basophils. Glucocorticoids decrease the normal diurnal variation in these hor- increased resistance to cortisol, as often
accumulation and function of most of these mones. During severe illness, serum corti- happens in critical illness, the free cortisol
cells at inflammatory sites. Most of the sup- sol concentrations tend to be higher than levels are not a reliable reflection of either
pressive effects of glucocorticoids on immune even in patients undergoing major surgery total cortisol secretion or action. Many
and inflammatory reactions appear to be a (⬃30 μg/dL vs. 40–50 μg/dL). thresholds, below which adrenal insuffi-
consequence of the modulation of produc- ciency is likely to be present, have been sug-
tion or activity of cytokines, chemokines, Adrenal Insufficiency gested, ranging widely from 10 to 34 μg/dL.
eicosanoids, complement activation, and Critical illness is associated with activation Many textbooks and published articles
other inflammatory mediators. Glucocorti- of the HPA axis; however, many factors can state that the normal circulating cortisol

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 10 10/28/11 10:14:41 PM

 Chapter 1: Metabolic and Inflammatory Responses to Trauma and Infection 11

response to stress is a level ⬎18 to 20 μg/ is catalyzed by 5⬘ monodeiodinase (or type exerts both direct and indirect effects. It
dL. However, the choice of 18 to 20 μg/dL is 1 deiodinase) located in the kidney, the directly promotes muscle mass increase

Perioperative Care of the Surgical Patient

based primarily on the response to exoge- liver, and the muscle. TSH and T4 levels are through sarcomere hyperplasia, lipolysis,
nous high-dose ACTH stimulation and the elevated very briefly and subsequently re- protein synthesis, and liver gluconeogene-
response to insulin-induced hypoglycemia turn to “normal,” although in more severe sis. The indirect effects are mediated by in-
in nonstressed patients. illness, T4 levels can be decreased .The low creases in IGF-I. IGF-I bioactivity is regu-
The high-dose (250 μg) ACTH stimulation T3 levels persist beyond TSH normaliza- lated by several IGF-binding proteins and it
test, instead of random cortisol levels, is tra- tion, a condition referred to as “the low T3 has growth stimulation effects on a wide
ditionally used in ICU setup and is regarded syndrome.” The severity of illness is reflected variety of tissues. The pulsatile nature of GH
as the “gold standard” for adrenal testing. in the degree of the fall in serum T3 during secretion consists of peak serum GH levels
One should be aware, however, that although the first 24 hours after the insult. Further- alternating with virtually undetectable
this test can be informative as it relates to more, an inverse correlation between T3 troughs. During the first hours to days after
adrenal ability to react to excessive ACTH levels and mortality has been demon- an acute insult, the GH profile changes dra-
(cortical reserve), it does not reflect the in- strated. Other factors involved in the low-T3 matically. The amount of circulating GH
tegrity of the entire hypothalamic pituitary syndrome at the tissue level include low rises, with increased pulsatile peak secre-
adrenal axis. As a result, it may not be able to concentrations of thyroid hormone-binding tion and frequency. Concomitantly, a state
properly diagnose secondary adrenal insuf- proteins, and inhibition of hormone bind- of peripheral GH resistance develops, in
ficiency. A low-dose (1 μg) cosyntropin stim- ing, transport, and metabolism by elevated part, triggered by cytokines such as TNF␣
ulation test has been used to a small extent levels of glucocorticoids, FFA, and some and IL-6. These events are preceded by a
to diagnose secondary insufficiency in ICU commonly used medications (amiodarone, drop in circulating GH-binding protein,
setup. Other methods that have been sug- iodine contrast). It remains controversial which presumably reflects the functional
gested include calculated free cortisol index, whether development of the aforemen- GH receptor status. Theoretically, this con-
measuring salivary cortisol, or measuring tioned changes in thyroid metabolism re- stellation could enhance the direct lipolytic
other ACTH-dependent adrenal steroids flects a protective mechanism (attempt to and insulin antagonizing effects of GH, re-
(DHEA, DHEAS). None have yet become the reduce the elevated energy expenditure), or sulting in elevated fatty acid and glucose
gold standard in the clinical setup. The Sur- a maladaptive process during illness. levels in the circulation, whereas the indi-
viving Sepsis guidelines currently endorse In prolonged critical illness, a state of eu- rect, IGF-I-mediated somatotropic effects
the use of corticosteroids (200 mg of hydro- thyroid sick syndrome is usually present, in of GH are attenuated. As a result, costly
cortisone/day in divided doses) in patients which the pulsatile TSH secretion is dramat- anabolism, largely mediated by IGF-I and
who have refractory septic shock. Although a ically reduced and serum levels of both T4 considered less vital at this time, could be
reasonable recommendation, the authors and T3 are low. Reduced TRH gene expres- postponed. Hence, from a teleologic point
would point out that this is essentially based sion in the hypothalamus has been observed of view, this response to acute injury within
on a single study from a single center that in chronically ill patients who died, which is the GH axis seems appropriate in the strug-
has not yet been confirmed adequately. in line with the predominantly central origin gle for survival.
of the suppressed thyroid axis. Since the In contrast with the observations during
Vasopressin presence of euthyroid sick syndrome is as- the acute phase of critical illness, the pulsa-
Vasopressin, also known as ADH, is synthe- sociated with an increased mortality among tile release of GH is suppressed in patients
sized as a large prohormone in the hypo- critically ill patients, it could indicate an ab- who are critically ill for a prolonged time.
thalamus. The prohormone complex is erration that may delay recovery from acute The loss of pulsatile GH release contributes
transported to the posterior pituitary where illness and, therefore, would require inter- to the low levels of IGF-I in prolonged criti-
it is stored in granules. Vasopressin is re- vention. To date, however, a routine thyroid cal illness.
leased mainly in response to hyperosmolal- hormone therapy has not been demon- The administration of GH secretagogues
ity, hypotension, and hypovolemia, and has strated to improve clinical outcomes in crit- has been shown to increase IGF-I- and GH-
vasopressor and antidiuretic effects. Vaso- ically ill patients with normal previous thy- dependent IGF-binding protein levels. Since
pressin levels increase rapidly in the early roid function. If hypothyroidism is suspected the robust release of GH in response to GH
phase of certain stressful situations, such as clinically (hypothermia, bradycardia, respi- secretagogues excludes a possible inability
hemorrhagic and septic shock. With persis- ratory acidosis, pleural effusions, and failure of the somatotropes to synthesize GH, the
tence of the septic shock state, however, to wean), thyroid function should be mea- origin of the relative hyposomatotropism is
vasopressin falls to very low levels. sured and corrected. In a critically ill patient probably situated within the hypothalamus,
with hypothyroidism, central hypothyroid- through induced GHRH deficiency. The
Thyroid ism should be ruled out. “relative hyposomatotropism” is thought to
TRH secreted by the hypothalamus stimu- contribute to the pathogenesis of the “wast-
lates the pituitary to produce thyrotropin Growth Hormone ing syndrome” that characterizes prolonged
(TSH), which, in turn, regulates the synthe- The regulation of the physiological pulsatile critical illness. The “wasting syndrome” is
sis and secretion of thyroid hormones in release of GH by the somatotrope cells in believed to increase the rate of organ dys-
the thyroid gland. The thyroid hormones, in the anterior pituitary is highly complex. Hy- function, muscle weakness, prolonged me-
turn, exert feedback control on both TRH pothalamic GHRH stimulates, while soma- chanical ventilation, and length of stay in
and TSH secretions. The early response of tostatin inhibits the secretion of GH. But the ICU. Recombinant GH supplementation
the thyroid axis to a severe physical stress many other stimulating (ghrelin, andro- in surgical trauma and burn injury patients
consists of a rapid decline in the circulating gens, estrogen, hypoglycemia, sleep, fasting, has demonstrated nitrogen retention, in-
levels of T3 and a rise in rT3 levels, predom- and exercise) and inhibiting (circulating GH creased IGF-I levels, decreased length of
inantly as a consequence of altered periph- and IGF-I, hyperglycemia, and glucocorti- stay, and improved survival. As a result, GH
eral conversion of T4 to T3, a reaction that coids) factors have been identified. GH became widely used in the ICU, until two

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 11 10/28/11 10:14:41 PM

 12 Part I: Perioperative Care of the Surgical Patient

large randomized trials in 1999 noted in- prolactin are highest during sleep and lowest funiculi causes an increased activity in the
creased mortality associated with infection during the waking hours. Prolactin release is sympathetic preganglionic nerve fibers,
and organ dysfunction. Currently, the pos- predominantly under tonic inhibition by dop- which results in burst-pattern release of
sible use, correct dosage, and method of amine derived from hypothalamic dopamin- norepinephrine from the sympathetic post-
administration of GH/ILG-I in critically ill ergic neurons. Prolactin release is affected by ganglionic nerve terminals, as well as
patients are under investigation. a large variety of stimuli, the most important epinephrine (about 80% of the secretion),
being suckling, increased levels of estrogen, norepinephrine, and dopamine from the
The Gonadal Axis and stress. Several neuropeptides have been adrenal gland. The secretion of norepineph-
GnRH, secreted in a pulsatile pattern by the identified as prolactin-releasing factors. rine from nerve terminals is immediate fol-
hypothalamus, stimulates the release of These include TRH, oxytocin, vasoactive in- lowing the trigger (some of it originating
luteinizing hormone (LH) and follicle-stimu- testinal peptide (VIP), and neurotensin. from a spinal reflex arc). After secretion into
lating hormone (FSH) from the gonadotro- Prolactin is a well-known stress hor- the synaptic gap, norepinephrine is cleared
pes in the pituitary. In men, LH stimulates mone and is presumed to have immune-en- by reuptake into the nerve endings, degra-
the production of androgens (testosterone hancing properties. It increases the synthe- dation by the catechol-o-methyltransferase
and androstenedione) by the Leydig cells in sis of IFN-␥ and IL-2 by Th1 lymphocytes, or diffusion into the extra-synaptic space
the testes, whereas the combined action of and induces pro-inflammatory responses and blood. During stress, the latter mecha-
FSH and testosterone on Sertoli cells sup- and antibody production. While the main nism is the main source of circulating nor-
ports spermatogenesis. In women, LH also physiological functions of prolactin are re- epinephrine. In view of its richness in sym-
mediates androgen production by the ovary, lated to the mammary glands and the ova- pathetic nerve endings, the intestinal tract
whereas FSH drives the aromatization of an- ries, it has been shown to also have an im- is the main producer of norepinephrine
drogens to estrogens in the ovary. Sex ste- portant role in the innate and adaptive (40% of total body norepinephrine) and do-
roids exert a negative feedback on GnRH and immune response. Prolactin receptors can pamine (⬎50% of total body dopamine).
gonadotropin secretion. be found throughout immune system cells. Circulating epinephrine and norepineph-
Acute stress brings along an immediate Binding of prolactin to its receptor activates rine are degraded 5 to 10 times more slowly
fall in the serum levels of testosterone, even several signaling pathways, which include than when secreted into the synaptic gap
though LH levels are elevated. The en- the Janus kinase-signal transducer and acti- (20 to 30 s). Mechanisms of degradation of
hanced release of CRH and ␤-endorphin vator of transcription (Jak-Stat), the MAPK, circulating catecholamine are nonenzy-
suppresses GnRH release directly and indi- and the phosphoinositide 3 kinase (PI3K). matic (extra-neural uptake in the lung, kid-
rectly through the release of glucocorti- Activation of these cascades results in end- ney, and intestines, and neural uptake into
coids, which in turn also produce gonado- points such as differentiation, proliferation, postsynaptic sympathetic nerve endings),
tropin resistance at the gonads. Clinical survival, and secretion. and enzymatic (cytoplasmic monoamine-
data on the changes within the gonadal axis oxidase in sympathetic nerve endings, the
are scarce in critically ill women, as most Sympathetic Stress Response liver, kidney, stomach, and jejunum).
patients are older and thus in the meno- Adrenal catecholamine secretion is also
pausal state. It seems that in the days di- Physiology of Sympathetic Activation very rapid and it takes place within seconds
rectly following surgery, the FSH, LH, and The sympathetic reaction is activated by a of stimulation. Norepinephrine and epi-
estradiol levels decline, while the proges- vast range of stressful stimuli, including nephrine are stored in granules within the
terone and prolactin levels do not change both psychological and physical stressors. adrenal medulla and their exocytosis is ini-
significantly. The state of relative hypogo- Afferent neurons of the sympathetic system tiated by acetylcholine stimulation from by
nadism is often expressed in premeno- are multiple in quantity and quality the preganglionic sympathetic fibers that
pausal women by an unexpected metror- (chemoreceptors, baroreceptors, and vis- innervate the medulla. The normal resting
rhagia shortly after trauma. ceral receptors). The activity of autonomic rate of secretion by the adrenal medulla is
With prolongation of the disease, a more nerves is dependent on descending excit- about 0.2 μg/kg/min of epinephrine and
substantial hypogonadotropism in both men atory and inhibitory inputs from several ⬃0.05 μg/kg/min Norepinephrine. These
and women ensues. The circulating levels of brain regions, including the cortex and the quantities give rise to circulating levels of
testosterone become extremely low and are hypothalamus. A major source of excitatory catecholamines that in basal conditions are
often even undetectable; yet the mean LH drive to sympathetic preganglionic neurons enough to maintain the blood pressure near
concentrations and pulsatile LH release are comes from the rostral ventrolateral me- normal, even if all direct sympathetic path-
suppressed. Total estradiol levels in women dulla in the medulla oblongata. This region ways to the cardiovascular system are re-
are relatively low. Since exogenous GnRH is of the brain stem contains the cardiac, re- moved. During severe physical stress or
only partially and transiently effective in cor- spiratory, and vasomotor autonomic cen- sepsis, both plasma epinephrine and nor-
recting these abnormalities, the profound ters, and connects the upper brain area to epinephrine rise significantly.
hypoandrogenism must result from com- the spinal cord. Medullary neurons project Medullary epinephrine secretion is de-
bined central and peripheral defects. to the spinal cord to inhibit or excite sym- pendent not just on neural acetylcholine
pathetic activity. In addition, many brain stimulation, but also on the hormonal HPA
Prolactin stem nuclei that feed directly into these axis. The activity of phenylethanolamine N-
Prolactin is synthesized and secreted by pathways can modulate these activities. In methyltransferase (the rate-limiting en-
lactotrophs in the anterior pituitary gland. contrast to the parasympathetic nervous zyme in the conversion of norepinephrine
Prolactin levels are higher in females than system with its predominantly selective in- to epinephrine) is enhanced by high doses
in males, and the role of prolactin in male nervation of single effector organs, the sym- of glucocorticoids. The medulla is exposed
physiology is not completely understood. It pathetic system often reacts with a “mas- to uniquely high doses of glucocorticoster-
is physiologically secreted in a pulsatile and sive none organ specific discharge.” Increased oid directly through a cortical-medullary,
diurnal pattern. Plasma concentrations of traffic down the spinal cord via the lateral intra-adrenal portal vascular system.

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 12 10/28/11 10:14:41 PM

 Chapter 1: Metabolic and Inflammatory Responses to Trauma and Infection 13

The sympathetic system plays a crucial sudden increase in blood pressure) and by contribute to or induce neuromuscular
role in the maintenance of homeostasis dur- chemoreflex sensitivity (sympathetic reac- weakness and result in difficulty weaning

Perioperative Care of the Surgical Patient

ing the stress response, and the changes to tion to peripheral hypoxic or hypercapnic from mechanical ventilation. Other effects
this system affect almost every possible stimulus). It is not clear whether this may include changes in renal (polyuria), gas-
body system. The cardiac output increases phenomenon is an integral part of MODS trointestinal (intestinal paralysis), and met-
by ␤-receptor enhancement of heart rate or secondary to sedation, neuromuscular abolic (alkalosis) functions.
and myocardial contractility. Blood pressure blocking agents, catecholamines, and me- The point where the beneficial effects of
increases by ␣-receptor-mediated vasocon- chanical ventilation, all frequently used in adrenergic stress are limited by adverse
striction, and blood flow is redistributed in ICU setup. The reduction in physiological consequences varies individually depend-
favor of the more vital functions. Broncho- heart rate variability is one of the strongest ing on age and the presence of preexisting
dilatation, through the ␤2 influence, eases predictors of death in critically ill patients. comorbidities. It seems that prolonged
the need for increased minute ventilation. sympathetic stimulation carries a myotoxic
Thermoregulation is reset. The kidneys re- Adverse Effects of Adrenergic Stress and apoptotic effect on skeletal and cardiac
tain water and sodium, and secrete renin. It is undisputable that the adrenergic reac- muscles. This contributes to myopathy,
Bowel motility decreases. Based on these ef- tion is crucial to survive the insult of major muscle wasting, and difficulty in ventilatory
fects, Walter Cannon called the emergency- trauma or injury. However, in critical illness, weaning.
induced discharge of the noradrenergic sys- an overshooting influence of the sympa-
tem the “preparation for flight or fight.” thetic nervous system can become hazard- Metabolic Alterations
Adrenergic tone also plays a significant ous. This hazardous influence is exacerbated
role in regulating intermediary metabolism in the traditional setup of the ICU for pa- Injury and infection induce substantial
in the body. Epinephrine’s capacity to influ- tients requiring high-dose sympathetic sup- changes in carbohydrate, lipid, and protein
ence metabolism is 5 to 10 times greater port. Several organ systems may be affected. metabolism in most organs and tissues. The
than norepinephrine. Catecholamine- The heart seems to be most susceptible to short initial ebb response is characterized by
related hyperglycemia is induced by in- sympathetic overstimulation: detrimental an enhanced gluconeogenesis, glycogenoly-
creased liver glucose secretion, on one side, effects include impaired diastolic function, sis, and lipolysis to recruit the much needed
and by decreased peripheral intake of glu- tachycardia and tachyarrhythmia, myocar- energy. As the “stress response” continues,
cose, due to insulin resistance and inhibi- dial ischemia, apoptosis, and necrosis. Ad- the energy needs, lack of dietary input, and
tion of insulin secretion, on the other. Cat- verse catecholamine effects have also been the body’s limited available resources (glyco-
echolamines induce catabolism, leading to observed in other organ functions, such as gen) mandate the hypercatabolic state,
extensive lipolysis and protein breakdown, the lungs (pulmonary edema and elevated which is the focus of this section.
which are needed to supply energy for vital pulmonary arterial pressures), coagulation
functions and substrates for synthesis of (hypercoagulability and thrombus forma- Hypercatabolic Syndrome
various enzymes, antibodies, and glucose. tion), GI (hypoperfusion and inhibition of Hypercatabolic syndrome is a biochemi-
peristalsis), endocrinologic (decreased pro- cal state induced by increased circulating
Autonomic Dysfunction lactin, thyroid, and GH secretion) immune catabolic hormones (cortisol and cate-
The sophisticated sympathetic-parasympa- systems (immunomodulation and stimula- cholamines) and cytokines (TNF, IL-1␤)
thetic balance is maintained by several re- tion of bacterial growth), metabolism (in- on one hand, and decreased anabolic insu-
flex arches: arterial baroreflex, peripheral crease energy expenditure, hyperglycemia, lin effects on the other. The most impor-
arterial chemoreflex, central arterial catabolism, lipolysis, hyperlactatemia, and tant metabolic consequence of hypercata-
chemoreflex, and pulmonary stretch reflex. electrolyte changes), bone marrow (anemia), bolic syndrome is the skeletal and cardiac
These reflexes represent the major compo- and skeletal muscles (enhanced protein deg- muscle protein breakdown that releases
nents of blood pressure control and breath- radation and apoptosis). Catecholamines amino acids, which, in turn, supports in-
ing regulation. Aside from massive stimula- are known to increase O2 consumption dispensable body energy requirements but
tion, during critical illness, defects in the mainly through ␤1 and ␤2 receptors. In ad- also reduces skeletal and cardiac physio-
afferent and central pathways of the auto- dition, epinephrine-induced “overstimula- logic and metabolic functions (Figure 4).
nomic nervous system may develop. This tion” of ␤-mediated-aerobic glycolysis An abundance of substrate is provided
condition is referred to as “autonomic dys- through Na/K-ATPase stimulation contrib- to ensure the function of essential visceral
function.” This is seen mostly in ICU pa- utes to hyperlactatemia, independent of the organs, supply building blocks for tissue re-
tients suffering from MODS, sepsis, severe presence of hypoxia. Apart from their meta- pair, and support an upregulated and ex-
head and brain injuries, as well as Guillain– bolic effects, catecholamines are known to panding immunologic system, post-injury
Barré syndrome or myocardial infarction. have effects on the transcellular shift of elec- or during infection. The total body energy
Clinically, the heart rate, which is strongly trolytes. Epinephrine causes, at first, a tran- requirements during the hypermetabolic
influenced by the impact of sympathetic sient increase in potassium (mediated by ␣1 period are not necessarily substantially
and parasympathetic tones, is usually the and ␣2 receptor stimulation of hepatic cal- higher than in a normal state. Although the
most sensitive measure of autonomic dys- cium-dependent potassium channels), but REE is higher, the bed rest and diminished
function. Autonomic dysfunction is usually shortly thereafter, ␤2 and ␤3 receptor stim- physical activity compensates for that
expressed as restricted heart rate variabil- ulation of membrane-bound Na/K-ATPase change. Due to lack of dietary input in the
ity. Long recording (24 h) or short recording in skeletal muscle and other tissues, as well immediate posttrauma period, the meta-
(5 to 20 min) recording of heart rate will as activation of the renin–angiotensin– bolic energy requirements must be pro-
show narrow heart rate variations. Auto- aldosterone system, causes a decrease in vided by endogenous supply. Glucose is the
nomic nerve function could also be evalu- serum potassium and magnesium concen- main source of energy in normal physio-
ated by baroreflex sensitivity (increased va- trations. The electrolyte disturbances that logic circumstances. Endogenous glucose is
gal and reduced sympathetic tone following increase the risk of cardiac arrhythmias can supplied by the liver (to some extent also by

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 13 10/28/11 10:14:41 PM

 14 Part I: Perioperative Care of the Surgical Patient

the more extensive injuries and/or infec-

tions, one can see a urinary loss of up to 30
g nitrogen/day, which represents a degra-
dation rate of about 180 g protein or 900 g
muscle a day. Utilization of body protein
may prolong convalescence and even con-
tribute to mortality.
In contrast to fat, less than one-half of the
body’s protein can be mobilized before death
occurs, which means that only about 4 to
5 kg of protein (or 500 to 800 g of nitrogen)
can be degraded. This suggests that only
1,500 to 2,400 g of glucose could be synthe-
sized without an external source of glucose
and/or proteins (1 g of nitrogen can be
equated to hepatic synthesis of about 3 g of
Fig. 4. Interactions among (1) glucocorticoids, (2) tumor necrosis factor (TNF), and (3) interleukin-1 glucose). If the brain continued to oxidize
(IL-1) in the regulation of sepsis-induced muscle proteolysis. The effect of TNF on muscle proteolysis is 100 to 145 g of glucose each day during star-
mediated primarily by glucocorticoids, whereas IL-1 regulates muscle proteolysis by glucocorticoid- vation, survival would be limited to 10 to 20
independent pathway(s). (From Hasselgren PO. Protein Metabolism in Sepsis. Austin, TX: RG Landes; days. During “simple” fasting, the patient’s
1993, with permission.) body gradually adapts to use FFAs and ke-
tone bodies as the main energy source,
which decreases the daily glucose consump-
tion to about 30 to 40 g. This enables the
the kidney) mostly by using the glycogen protein turnover, mostly of skeletal and car- gradual decrease of the protein degradation
storage. The quantity of glucose stored as diac muscles. In healthy humans under rate to about 10 g/day of nitrogen after a
liver glycogen is about 65 g/kg of liver mass, physiologic conditions, approximately 250– week and about 5 g/day of nitrogen loss after
which is about 100 g glycogen for a normal 350 g of proteins are degraded each day. 3 weeks of starvation, allowing a much lon-
1,500 g adult liver. This amount of liver Most of the amino acids produced are re- ger survival period. (There are reports of up
glycogen is limited to approximately 1 to 1.5 used to synthesize new proteins, but some to 2 months of starvation with drinking.)
days of systemic glucose supply. So, about are lost (energetic purposes, secreted in Unlike in starvation, the posttrauma pa-
24 hours post-injury, the hepatic glucose urine or feces). The depleted protein is re- tients are exposed to the persistent influence
production has to change from hepatic gly- placed by dietary protein. of catecholamines, glucocorticoids, and glu-
cogenolysis to gluconeogenesis. An average In the post-injury period, the balance cagon. These catabolic hormones preclude a
human of 75 kg has roughly 15 kg of fat between muscle degradation and synthesis similar substantial reduction in protein deg-
stored in 16 kg of adipose tissue (the rest is is changed due to increasing influence of radation and the hypercatabolism of muscle
water) and 10 to 12 kg of protein suspended catabolic hormones and cytokines, and the and organ protein continues as part of the
in 60 kg of lean body mass, mostly muscle. limitations imposed by bed rest and lack of systemic inflammatory process.
Nearly all of the body fat is expendable dietary input. The muscle is not merely an
without serious adverse effects. Unfortu- organ restricted to movement or contrac- Mitochondria: The Center
nately, glucose synthesis by the liver to sup- tion; it also plays an important role in main-
ply the glucose-dependent metabolism is taining the general metabolism of the hu- of Metabolism
primarily from protein, not from fat. Unlike man body. Muscle mass is ⬃45% of the dry Although metabolic dysfunction post-
lipids or glucose, there is no bodily “protein weight of a healthy person, and most recep- trauma or as a result of infection affects
storage,” per se. The body protein compo- tors for insulin, cortisol, and glucagon are critical organs in a variety of ways, its gene-
nent consists of muscle protein, visceral located in the muscle. sis is generally linked to a single organelle,
organs, protein, and enzymes. Under nor- With mild to moderate injury, this cata- the mitochondrion (Figure 5). Mitochondria
mal circumstances, there is a continuous bolic response causes minimal debility. In are commonly referred to as the “power-

Fig. 5. Oxidative phosphorylation in mitochondria. The diagram depicts the enzymes and cofactors involved in oxidative
phosphorylation employed within the mitochondrion to produce ATP from a variety of substrates. Electrons are transferred
via a sequence of redox acceptors, ultimately being accepted by oxygen. The molecules that shuttle electrons are coenzyme Q
and cytochrome c. Gray shading denotes the points at which reactive oxygen species (ROS) may be liberated. ROS are promi-
nent in injury, and have the potential to do damage to biologic molecules, compromising cells and organs.

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 14 10/28/11 10:14:41 PM

 Chapter 1: Metabolic and Inflammatory Responses to Trauma and Infection 15

of vital (renal, hepatic, lung, and cardiac)

and nonvital (skeletal muscle) organ func-

Perioperative Care of the Surgical Patient

tions. These failures are exacerbated by per-
sistent hypotension, even in the face of
more than adequate volume resuscitation.
In most cases, these tissues exhibit a loss of
mitochondrial function. Cellular tissue ATP
levels will also fall, matched by a rise in
ADP and adenosine monophosphate
(AMP).
Although injuries vary greatly, serious
Fig. 6. Consequences of mitochondrial dysfunction in injury. Mitochondrial dysfunction has several injuries have common characteristics that
forms, the most important of which are the generation of reactive oxygen species (ROS) and the opening can unfavorably affect mitochondrial me-
of permeability transition pores. The transition pores release mitochondrial contents, which can cause
severe damage to the cell, such as induction of apoptosis as mediated by mitochondrial cytochrome c.
tabolism. Hemorrhage effectively produces
The combination of lung, heart, and vascular pathophysiology in injury can lead to mitochondrial dys- hypoxia, which initiates a cascade of re-
function by virtue of inadequate respiration, poor blood flow and vascular transport and delivery, which sponses that are directed toward adapta-
in turn adversely affects these same organs. tion to lowered oxygen, which, at the same
time, can be damaging to an already injured
body. Hypoxia and ischemia-reperfusion,
with their lowered oxygen availability to the
house of the cell.” The power is distributed and/or blood flow, lung oxygenation, glu- tissues, will drive the cells to depend on an-
via the high-energy phosphate bonds of ATP. cose transport, etc.), there is a rapid onset of aerobic glycolysis for their high-energy
This energy resides in the terminal phos- metabolic dysfunction. At the level of the phosphate production. This can initiate a
phate of ATP. When this bond (i.e., between mitochondrion, this dysfunction has many feedback situation, wherein lactic acid in-
the second and the third phosphates) is forms. One failure of the mitochondrion creases, effectively shutting down anaero-
cleaved, it releases a substantial amount of with immediate biochemical consequences bic glycolysis as an energy source. In this
energy (⬃7 kcal/mol ATP). ATP is thus a is the production of reactive oxygen species setting, FFA can also increase systemically,
safe and stable fuel, which contains a large (ROS). These products take numerous forms, probably from peripheral adrenergic stimu-
amount of energy that may be used to facili- such as superoxide, peroxides, nitric oxide, lation of lipolysis. Limited oxygen also com-
tate a wide variety of biologic processes. The and peroxynitrite. Since ROS are constitu- promises ␤-oxidation, the principal means
conversion of substrates (glucose, ketones, tively produced by mitochondria, neutraliz- of converting fats to energy. This, in turn,
fatty acids, lactate, etc.) to ATP is accom- ing compounds (antioxidants) such as glu- causes a similar “stacking up” of FFA, acyl
plished via a highly efficient process that tathione can buffer against the damage of coenzyme A (acyl CoA), acylcarnitines, and
uses oxygen. Although it is extremely effi- ROS (Figure 6). An additional consequence so on, which compromises the heart. Under
cient, the process is not absolutely perfect of mitochondrial dysfunction is spillage of these conditions, the heart and other tis-
as it has the capacity to “leak” electrons. As the contents of the mitochondrion into the sues are already at a disadvantage because,
a consequence, these free electrons can gen- cell’s cytoplasm. This is initiated at times by despite the high energy stored in fat, ␤-
erate oxygen-free radicals. Mitochondria “permeability transition pores,” which are oxidation cannot match the efficiency of
can increase the output of ATP in response transient structures that open in a fission carbohydrate metabolism. Thus, reoxygen-
to a variety of triggering events. These in- response to stress, enabling molecules ation, if it occurs, may take place in a setting
clude accumulation of ADP or the greater ⬍1,500 Da to move between inner mem- in which aerobic metabolism is not possi-
availability of “fuel” and oxygen. Cell-stimu- branes. Mitochondrial transition pore open- ble, because of large-scale diversion of me-
latory signals, such as the presence of in- ing can lead to swelling and rupture of the tabolism into the less efficient “backup”
creased Ca2⫹ in the cytoplasm, also stimu- mitochondria. This ultimately will allow modes of ␤-oxidation and anaerobic glyco-
late the mitochondria to generate more ATP. larger molecules, such as cytochrome C, to lysis. There is one additional consequence
These stimuli are tied to an increased de- enter the cytosol and trigger programmed of elevated lactic acid worth noting. As
mand for work from the body, be it muscu- cell death (apoptosis). Thus, besides failing mentioned previously, an intracellular flux
lar (heart or skeletal muscle contraction), to produce urgently needed ATP in times of of calcium will cause a demand for in-
biosynthesis (production of proteins by the crisis, the mitochondrion generates sub- creased ATP synthesis. The presence of
liver), cell division (immune responses or stances that do considerable, often irrepa- increased lactic acid in the cell will cause
tissue repair), or the generation of heat (re- rable, damage and, in the extreme, can cause calcium to enter the cytoplasm from the
sponse to hypothermia). Clearly, all of these death to itself and its host cell. This is the exterior, providing a spurious signal for in-
functions can be tied to the demands of stage in which insults of injury and infection creased workload at a time when the meta-
dealing with infection and injury. can wreak havoc on metabolism. bolic machinery is incapable of reacting
Under conditions of severe injury and appropriately. This has the untoward effect
Mitochondrial Dysfunction especially shock, there will very likely be se- of further depleting already low supplies of
The failure of mitochondrial energy produc- vere morphologic damage to the mitochon- ATP. Finally, regarding the lowered ATP sup-
tion lies not with the organelle itself, but dria. ATP levels will decline, ROS will in- plies, an obvious solution for treatment
with its various “supplies.” Unlike sugars or crease, exhausting the reserve of would be to administer agents/drugs that
fats, which are stored as glycogen or adipose antioxidants and damaging not only the increase ATP production under low-flow
tissue, respectively, there are no depot stores mitochondrion itself, but also other organ- conditions. However, such agents will not
of ATP. Thus, with a failure to deliver any of elles and molecules within the cell, includ- be effective if the microcirculation is mark-
the essential components (cardiac output ing DNA. There may be serious impairment edly impaired prior to its administration.

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 15 10/28/11 10:14:42 PM

 16 Part I: Perioperative Care of the Surgical Patient

Carbohydrate Metabolism mia in the posttraumatic patient, but usu- Insulin

ally the hyperglycemia is due to alterations Insulin levels vary depending on the phase
Glucose plasma concentration in healthy in glucose metabolism, secondary to the of injury. During the ebb phase, insulin lev-
subjects is strictly controlled. During the adaptive metabolic response. The synergis- els are reduced despite hyperglycemia. The
fed state, digested carbohydrates are deliv- tic activities of the HPA axis (catecholamines combined effects of catecholamines, soma-
ered to the liver, with galactose and fructose and glucocorticoids), pancreatic endocrine tostatin, glucocorticoids, and reduced pan-
rapidly converted into glucose. The glucose hormones (glucagon and insulin), and pro- creatic blood flow may reduce pancreatic
is either secreted to the circulation or used inflammatory cytokines are at the heart of ␤-cell sensitivity to glucose. During the flow
for storage in the form of glycogen or fat. An that change to glucose metabolism. phase, ␤-cells regain their sensitivity, and
increased post-prandial glucose level is fol- insulin concentrations rise. Despite increased
lowed by pancreatic ␤-cell insulin secretion, Increased Sympathetic Tone insulin concentrations, however, hypergly-
which enhances peripheral glucose utiliza- and Hyperglycemia cemia may persist due to peripheral insulin
tion, as well as glycogen and fat synthesis. In Elevated catecholamine levels post-injury resistance.
the fasted state, the plasma glucose origi- have a well established effect on glucose me- Insulin resistance: Insulin resistance is
nates mostly from hepatic output. Liver tabolism by a number of mechanisms. Epi- the inability of insulin to adequately stimu-
glucose production arises from glycogen nephrine directly promotes hepatic and late glucose uptake, mainly into skeletal
breakdown, synthesis from recycled carbons skeletal muscle glycogenolysis, and hepatic muscle, or to inhibit gluconeogenesis in the
(lactate and glycerol), and (to a much lesser gluconeogenesis independent of insulin or liver. Unlike in the case of chronic insulin
extent) de novo synthesis from amino acids glucagon concentrations. Dufour et al. dem- resistance, such as in type 2 diabetes, which
such as alanine. Under normal conditions, onstrated that under constant insulin con- takes years and even decades to develop, in-
the rates of liver glucose production and pe- centration, an increase of epinephrine plasma sulin resistance post-injury develops within
ripheral incorporation of glucose is matched concentration from 100 to 2,000 pmol/L hours or minutes of insult. This form of in-
exactly, keeping the plasma concentration (which is equivalent to the levels observed sulin resistance is called “acute insulin resis-
of glucose set within a very strict limit. during exercise at 60% to 80% of VO2max) was tance” and sometimes “stress diabetes” or
After being absorbed by peripheral cell followed by a 3-fold increase in glucose “critical illness diabetes.” There are numer-
tissue, the glucose is processed through gly- plasma concentration and a 2.5-fold increase ous studies on the development of chronic
colysis. The glycolysis yields three types of in liver glucose production. During the first insulin resistance, but little is known regard-
products: energy as ATP, pyruvate, and inter- hour of epinephrine infusion, glycogenolysis ing the pathophysiology of acute insulin re-
mediates for amino acid production. The was the source of 60% of glucose production sistance. Studies suggest that acute insulin
pyruvate can be further processed to water and later gluconeogenesis accounted for resistance is complex and might differ in a
and CO2 through the citric acid cycle for about 80%. tissue-specific manner, involving multiple
more ATP production, or be secreted to the Gluconeogenesis is further increased by causative factors and intracellular signaling
blood stream as lactate. Most glucose uptake catecholamines through the peripheral in- pathways.
is completely metabolized to CO2 and water. duction of lipolysis, which supplies the liver Insulin signaling is initiated by binding
with glycerol. In addition, epinephrine stim- of insulin to its receptor, followed by activa-
Pathophysiology of Hyperglycemia ulates pancreatic release of glucagon and tion of two main intracellular insulin signal-
in Critical Illness inhibits release of insulin, further contribut- ing pathways: the metabolic pathway (the
Early in the course of the stress response, ing to hyperglycemia. The catecholamines IRS/PI3K/Akt pathway) and the anabolic
serum glucose levels rise. Glucose availabil- also affect glucose disposal through in- pathway (MEK/ERK) pathway. The meta-
ity is needed to supply the immediate en- creased peripheral insulin resistance. bolic pathway involves the activation of glu-
ergy demand during the posttrauma hyper- cose transporter-4 (GLUT-4), which charac-
metabolism, especially for the explosive Hypercortisolism teristically is involved in the insulin-mediated
immune activity. Glucose utilization is in- Diabetes mellitus is very common (⬎50%) glucose transport into the skeletal muscle,
creased in multiple tissues, including liver, in patients with Cushing’s syndrome. The cardiac muscle, and adipose tissue.
spleen, small intestine, skin, and some typical elevated cortisol concentration Several tissue-specific mechanisms are
muscles. A common feature of some of found posttrauma promotes hyperglycemia involved in the development of insulin re-
these tissues is a high content of mac- through a number of mechanisms. In the sistance including alterations related to in-
rophages. Studies have shown that in the liver, cortisol stimulates phosphoenolpyru- sulin receptors, including impairment of
liver, the high glucose uptake reflects in- vate carboxykinase, the enzyme that cata- receptor expression, or binding or inhibition
creased utilization of glucose by Kupffer lyzes the rate-controlling step of gluconeo- of intermediaries involved in the insulin-
cells. However, because the overall rate of genesis. Cortisol also stimulates the activity signaling pathway for glucose uptake. Stud-
glucose secretion into the plasma exceeds of the enzyme glucose-6-phosphatase, ies investigating potential mechanisms of
the rate of glucose disposal, serum glucose which catalyzes the completion of the final skeletal muscle insulin resistance in experi-
levels are elevated. step in gluconeogenesis and glycogenolysis. mental animal models demonstrated de-
Hyperglycemia as a sequela of critical ill- Hepatic glucose production is further en- creased insulin signaling via the metabolic
ness commonly appears even in patients hanced by the excessive flow of substrates pathway following burn injury and reduced
who do not have diabetes mellitus. There to the liver, secondary to peripheral lipoly- GLUT4 mRNA and protein levels in rat adi-
are many preexisting conditions (diabetes sis and proteolysis. As with catecholamines, pose tissue during sepsis. Epinephrine has
mellitus, pancreatitis, cirrhosis, advancing glucocorticosteroid not only increases the been reported to enhance insulin resistance
age, and obesity) or possible iatrogenic amount of glucose secreted to the blood through inhibition of insulin binding,
causes (administration of corticosteroids, stream, but also induces increased insulin GLUT-4 translocation, and IRS-1(metabolic
sympathomimetics, total parenteral nutri- resistance. In this manner, it contributes pathway). Moreover, different tissues have
tion, or dextrose in excess) to hyperglyce- even more to hyperglycemia. been shown to develop various degrees of

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 16 10/28/11 10:14:44 PM

 Chapter 1: Metabolic and Inflammatory Responses to Trauma and Infection 17

insulin resistance and to be affected by dif- hepatic increase in glucose production sec- high rate of hypoglycemic episodes second-
ferent mechanisms. For instance, in rats, ondary to TNF can be blocked by an infu- ary to intense insulin therapy. A recent

Perioperative Care of the Surgical Patient

posttrauma, and as a result of hemorrhage, sion of phentolamine and propranolol, meta-analysis of 26 randomized trials that
there was a severe insulin resistance in skel- which suggests that most of the TNF effect included more than 13,500 patients showed
etal muscles, mild resistance in cardiac on the liver is secondary to adrenergic acti- that intensive insulin therapy had no overall
muscle and only minimal resistance in dia- vation. In addition to the effect on the coun- effect on mortality and resulted in an inci-
phragmatic muscle. The glucocorticoid re- terregulatory hormones, TNF may have a dence of hypoglycemia that was six times as
ceptor antagonist, RU486, was ineffective in direct effect on cellular glucose kinetics in high as that among patients not receiving
blocking acute insulin resistance in the muscle and adipose tissue. In myocyte and intensive therapy. In summary, the prepon-
liver. However, in contrast to the liver, block- adipocytes culture cells TNF-␣ may hold derance of available evidence suggests that
ing the rise in corticosterone levels by me- some direct responsibility for insulin resis- intensive insulin therapy, as compared with
tyrapone or blocking corticosterone action tance at the level of the insulin receptor and standard therapy, does not provide an over-
with RU486 prevents the development of through altered regulation of the insulin all survival benefit and is associated with a
acute skeletal muscle insulin resistance. signaling pathway, most probably by acti- higher incidence of hypoglycemia.
Some proinflammatory cytokines, in- vating an inhibitory serine phosphorylation
cluding TNF, decrease insulin signaling via of insulin receptor-1. Lipid Metabolism
the metabolic pathway. Administration of a Similar to TNF, IL-1 also can influence
TNF-␣ neutralizing antibody following carbohydrate metabolism. According to Lipids, as a class of biological molecules, are
trauma and hemorrhage in rodents reverses animal models, it seems that the IL-1␤ the most efficient at metabolic energy stor-
the acute insulin-resistant state in the liver, main effect is in inducing hypoglycemia by age. The energy yield from 1 g of fatty acid is
but not in skeletal muscle. binding the hypothalamic receptors. Other ⬃9 kcal, compared to 4 kcal from 1 g of car-
Thus, several tissue-specific mecha- factors also play a role in the regulation of bohydrates. Moreover, since lipids are hydro-
nisms seem to be involved in the develop- metabolism during infection and injury, in- phobic in nature, these molecules can be
ment of insulin resistance. cluding nitric oxide and prostaglandins. stored in a relatively water-free environment.
Carbohydrates, on the other hand, are hy-
Glucagon Glucose Control in ICU drophilic. This fact increases the total mass
Another counter-regulatory hormone of Persistent hyperglycemia is hazardous and of glycogen storage. For example, 1 g of glyco-
interest during stress of the critically ill is has been shown to impair wound healing, gen binds ⬃2 g of water, which translates to
glucagon. Glucagon, like epinephrine, is re- increase susceptibility to infections, and an actual 1.33 kcal/g stored. This means that
sponsible for increased glucose production even increase mortality. A single-center trial fat can actually hold more than six times the
through both gluconeogenesis and glycog- in Leuven, Belgium, published in the N Engl amount of energy per weight unit than gly-
enolysis. The action of glucagon alone is not J Med, emphasized the importance of tight cogen. As such, lipids, in the form of triglyc-
maintained over time; however, its action glucose and changed the approach to glu- erides (TGs), are the main source of stored
on gluconeogenesis is sustained in an addi- cose control in the ICU. In this study which energy. Lipids also play an important role in
tive manner with the presence of epineph- involved 1,548 patients, most of whom had many other cellular functions, such as syn-
rine, cortisol, and GH. Likewise, epineph- undergone cardiac surgery, patient hyperg- thesis of cell membranes, and production of
rine and glucagon have an additive effect on lycemia was aggressively treated with insu- steroid hormones, intracellular signal medi-
glycogenolysis. The important role of hy- lin, and glucose levels were kept in between ators as prostaglandins, fat-soluble hor-
perglucagonemia, present during sepsis, 80–110 mg/dL (4.4 to 6.1 mmol/L) as com- mones, and others. Fatty acids are either de-
was demonstrated in experiments in which pared with conventional insulin therapy, rived from diet or synthesized in the liver
the hormone was blocked by infusion of so- which has a target blood glucose level of 180 from carbohydrates. Dietary lipids absorbed
matostatin in septic rats, and the elevated to 200 mg/dL (10.0 to 11.1 mmol/L). This ap- as fatty acids form into TG and are trans-
rate of glucose production was reduced to proach significantly reduced mortality from ported as chylomicrons. These newly synthe-
control levels. 8% in the controls to 4.6% in the experimen- sized FFAs as well as those derived from diet
tal group. The benefit of intensive insulin are converted to TG in the liver, a process
Cytokines therapy is particularly apparent in those called esterification. The nonsoluble esteri-
Pro-inflammatory cytokines have a hyperg- who required intensive care for more than fied, hepatic TG are packaged into the solu-
lycemic affect through stimulation of the 5 days. However, the study was criticized be- ble very low density lipoproteins (VLDL) and
release of counter-regulatory hormones, in- cause of serious hypoglycemia that occurred secreted into the blood. Triglycerides are
cluding cortisol, epinephrine, norepineph- in 5% of the patients. In addition, the study mainly stored in adipocytes in distinct ana-
rine, and glucagon. The most extensively was not blinded, and the mortality in the tomic locations, such as fat tissue or diffused
studied cytokine in terms of regulation of control group was highly relative to that in with other tissue types, including muscle or
carbohydrate metabolism is TNF. Changes other cardiac surgical centers. A subsequent liver. The endothelial enzyme lipoprotein li-
in glucose metabolism during endotoxemia study by the same group that included 1,200 pase hydrolyzes circulating TGs back to fatty
and sepsis can be reproduced by in vivo ad- medical ICU patients failed to reduce over- acids, enabling their diffusion into the cells
ministration of TNF, which results in in- all mortality and was associated with even a of peripheral tissues.
creased hepatic production of glucose, higher rate of serious hypoglycemia (18.7%). Hydrolysis TGs within adipocytes into
hyperglycemia, and stimulated glucose uti- Number of additional studies including the FFA and glycerol is known as lipolysis,
lization by macrophage-rich tissues and the Normoglycemia in Intensive Care Evalua- which is stimulated by various hormones.
diaphragm. The effect of TNF on glucose tion–Survival Using Glucose Algorithm Reg- Some examples are glucagon during fasting/
kinetics is dose dependent, with relatively ulation (NICE-SUGAR) trial that included hypoglycemia, epinephrine, norepineph-
modest doses causing hyperglycemia and 6,104 patients and 42 centers failed to dem- rine, and possibly cortisol during stress,
larger doses inducing hypoglycemia. The onstrate a benefit in mortality and had a and GH during anabolism. These hormones

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 17 10/28/11 10:14:44 PM

 18 Part I: Perioperative Care of the Surgical Patient

bind to cell-surface receptors that are cou- and glucagon, and under substantial influ- been observed with regularity that over-
pled to the activation of adenylate cyclase ence by pro-inflammatory cytokines, exces- feeding, especially by parenteral access,
upon ligand binding. The result is activation sive peripheral lipolysis and mobilization of causes enhanced steatohepatitis and a de-
of cAMP-dependent protein kinase, which, FFAs is observed. Likewise, a concomitant teriorating prognosis for ICU patients.
in turn, activates the intracellular version increase in the de novo synthesis of FFAs
of lipoprotein lipase, known as hormone- takes place in the liver. The FFAs are used as Protein Metabolism
sensitive lipase (HSL). The net result of the an alternative, available energy source for
action of these enzymes is FFA and glycerol. the peripheral tissue in a time of need, Proteins contribute to both structure (skel-
The FFAs diffuse from adipose cells, com- which spares much needed glucose reserves etal muscle) and the function (enzymes) of
bine with albumin in the blood, and are for use by the nervous system and erythro- the body. The absolute amount of protein
thereby transported to other tissues where cytes. TNF was found to play a major role in depends on the age, weight, disease state,
they are transported into cells. Fatty acids enhancing peripheral lipolysis and hepatic and nutritional status of the patient. Skeletal
are the most efficient source of energy for synthesis of FFAs. TNF also has an inhibit- muscle mass represents 30% to 50% of total
most cell types. For example, catabolism of ing effect on peripheral lipoprotein lipase, body protein, is greater in men than women,
1 mol of a six-carbon fatty acid through the which causes a peripheral resistance to TG and declines with age. Between the ages
citric acid cycle to CO2 and H2O generates resulting in increased lipemia. Other cytok- 20 and 80, total muscle cross-sectional area
44 mol of ATP, compared with the 38 mol ines, including IL-1, IFN-␣, ␤, and ␥, may declines about 40%. Following injury, the in-
generated by catabolism of 1 mol of the six- also influence lipid metabolism. creased urinary excretion of nitrogen from
carbon carbohydrate glucose. At the same time, while the organism re- the body is roughly related to the extent of
In the normal state, glucose is the domi- cruits its energy sources, there is a para- the injury. Nitrogen is primarily lost in the
nant contributor of energy production. Ac- doxical increase in liver esterification of form of urea, which represents about 85% of
tive glucose metabolism down regulates FFA FFAs to TG. A number of contributing fac- the urinary nitrogen loss, although this pro-
oxidation, thereby channeling those fatty ac- tors play a part in this paradox: portion varies widely. Creatinine, ammonia,
ids into TG stores in the muscle, liver, and uric acid, and amino acids are also found in
1. FFA flux is elevated to higher level than
adipose tissue. However, in the fasted state, the urine in larger quantities than normal
the oxidation rate of the body, which ex-
FFA is the dominant contributor of energy following injury. The nitrogen molecule is
poses the liver to an excess of FFAs.
production. The main breakdown of fatty ac- used as a surrogate marker of protein be-
2. Both glucose and FFA levels simultane-
ids for energy happens within the mitochon- cause of the fixed relation between the two
ously increase in blood plasma. This hy-
dria in a process called ␤-oxidation, as it oc- substances (6.25 g protein to 1 g of nitrogen).
perglycemia leads to increased hepatic
curs by recurrent oxidation of the fatty acid Thus, the net loss or gain of body protein is
glucose uptake and metabolism, which
chain, at the ␤-carbon position. The rate of determined by nitrogen balance, and this is
leads to inhibition of CPT-I and fatty
FFAs oxidation is determined by the rate of a general measure of the catabolic state.
acid oxidation, leading to more accumu-
transfer into the mitochondria. Medium- Maintenance of protein within an indi-
lation of hepatic pool FFAs.
and short-chain fatty acids can enter the mi- vidual tissue is a balance between rates of
3. The increased ␤-adrenergic stimulation
tochondria without difficulty, but the major- protein synthesis and breakdown. Synthe-
causes increased peripheral glycolysis
ity, which make up the long-chain fatty acids, sis and breakdown are often mismatched
with concomitant production of pyru-
must be transferred actively through the mi- during catabolic states, resulting in organ
vate, which exceeds its utilization by
tochondrial outer membrane. This process protein loss or gain. The catabolic response
the mitochondria. The pyruvate–lactate
starts with the fatty acid reacting in the cy- occurs by a relative increase of breakdown
equilibrium results in excessive secre-
tosol with ATP and coenzyme A to become a over synthesis. Protein turnover responds
tion of lactate to the blood even without
fatty acyl-CoA. The fatty acyl-CoA is trans- to injury and infection in a manner that re-
any hypoxia or hypoperfusion. This lac-
ferred to the mitochondria via the carnitine distributes body protein to satisfy its needs.
tate is metabolized by the hepatocytes,
palmitoyltransferase enzyme system (CPT-I, The synthesis rate is decreased in “nones-
increasing either gluconeogenesis or the
CPT-II). This is the crucial point in the regu- sential” tissues (e.g., limb skeletal muscle or
citrate production through the Krebs
lation of the FFA oxidation rate. Glucose gut) and is maintained or enhanced in tis-
cycle, and possibly the de novo fatty acid
availability and metabolism control the oxi- sues where work is increased (respiratory
synthesis, thereby also contributing to
dation of fatty acyl-CoA by regulating CPT-I and cardiac muscle, lung, liver, and spleen).
the inhibition of FFA oxidation or TG
activity via changes in malonyl CoA concen- These events result in translocation of pro-
synthesis in the liver.
tration (malonyl CoA is a regulator of CPT-I tein from skeletal muscle to the visceral or-
and its activity is dependent on the activity The result of this process is an enhanced gans (primarily liver, spleen, and heart),
of acetyl CoA carboxylase [ACC]). ACC, in liver TG synthesis causing hypertriglyceri- which are vital for survival.
turn, is regulated by changes in the concen- demia and often accumulation of hepatic Two amino acids, alanine and glutamine,
tration of citrate, which is activator and pre- TG that leads to a fatty liver. The reduced account for approximately 50% to 75% of the
cursor. Citrate is the intermediate product activity of the enzyme lipoprotein lipase in amino acid nitrogen released from skeletal
of glucose metabolism through the Krebs the muscle and the adipose tissue decreases muscle. Alanine is used as a building block
cycle. Once inside mitochondria, the fatty the clearance of lipoproteins, leading to for various proteins and it is an important
acyl-CoA undergoes ␤-oxidation until the worsened hypertriglyceridemia. The clini- glucose precursor. Glutamine plays a very
entire chain is cleaved into acetyl CoA units, cal significance of this hyper lipidemia, hy- important role during the stress response.
which, in turn, enter the citric acid cycle. pertrigliceridemia, and the tendency for Similar to alanine, glutamine is also a gluco-
fatty liver during critical illness is not com- neogenesis substrate, but it mainly serves as
Lipid Metabolism During Critical Illness pletely clear. However, these findings have a primary substrate for immune cells and
During a critical illness, under the increased important implications to the management enterocytes as both rely on glutamine for
influence of hormones such as epinephrine of nutrition support in these patients. It has optimal function and energy production.

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 18 10/28/11 10:14:44 PM

 Chapter 1: Metabolic and Inflammatory Responses to Trauma and Infection 19

Glutamine also participates in acid–base with bidirectional signaling via different me- complement system components, and in-
homeostasis, and serves as a precursor for diators. These mediators modify the meta- flammatory (CRP, serum amyloid A), anti-

Perioperative Care of the Surgical Patient

glutathione, an important intracellular anti- bolic pathway of hepatocytes to support inflammatory (␣1-antitrypsin and ␣1-
oxidant. In critically ill patients, the intra- amino acid uptake, ureagenesis, increased antichemotrypsin), and various other proteins
muscular concentration of glutamine may synthesis of coagulant factors, complement (e.g., haptoglobin and ceruloplasmin). The
fall by as much as 80% to 90%. Part of this factors, APPs, and anti-proteolytic enzymes concentration of other liver-derived proteins,
drop is due to accelerated outward trans- particularly albumin, is reduced in sepsis
port and partly due to a decrease in glu- Immunological Function (negative APP). In a rat model of chronic sep-
tamine de novo synthesis. Glutamate serves The liver contains the largest mass of mac- sis, studies showed that albumin synthesis
as the precursor for both glutamine and ala- rophages (Kupffer cells) in the body and it was actually increased within 4 days of initia-
nine. Under a variety of circumstances, the plays a crucial role in the inflammatory re- tion of sepsis. It seems that the decreased
formation of alanine from glutamate is the sponse, both as a source of inflammatory circulating levels of albumin reflect increased
preferred pathway, leading to depletion of mediator and as a target organ for the ef- leak of albumin to the extravascular com-
glutamate availability for glutamine synthe- fects of the inflammatory mediators. The partment and possibly an increased rate of
sis. It has been hypothesized that the tissue interaction between hepatocytes and degradation, but not a reduced synthesis.
requirements for glutamine may outstrip Kupffer cells plays a key role in the regula- The enhanced synthesis of all these APPs is
the body’s ability to produce this amino acid. tion of the acute-phase response. Kupffer regulated by the Kupffer cell-derived cytok-
Hence, a relative deficiency state exists char- cells are pivotal in the hepatic response to ines and is a part of the complex systemic
acterized by a fall in glutamine concentra- sepsis. Once activated, Kupffer cells are and local changes needed to defend the
tions in both plasma and tissue compart- a major source of soluble mediators of sep- host. For instance, ␣1-antitrypsin has anti-
ments. Thus, glutamine is considered a sis, including pro-inflammatory cytokines, proteinase activity and inactivates excess
conditional essential amino acid. chemokines, nitric oxide, reactive oxygen extracellular elastase and other proteases
products, and eicosanoid mediators. Kupffer that are produced by activated leukocytes in
Muscle Catabolism cells are also important in preventing the sepsis. Additional hepatic APP scavengers
The story of muscle in the stress response is dissemination of bacteria and endotoxins include ceruloplasmin and ␣2-macroglobu-
the story of protein degradation and wast- from the portal circulation to the systemic lin, which inactivate reactive oxygen radicals.
ing. Accelerated catabolism of muscle pro- circulation. In an animal model, 5 minutes One of the key factors of APP is the CRP. CRP
tein is a universal problem in critically ill after intravenous injection, 50% of radiola- functions as part of the innate immune sys-
patients; loss of muscle mass and strength is beled endotoxin is localized in the Kupffer tem. Its main role is in binding to a phospho-
secondary to protein breakdown due to the cells. Hepatocytes play not only a crucial choline expressed on the surface of dying
metabolic needs. The typical prolonged bed metabolic role, but also an immune role. cells and some bacteria, causing activation
rest and inactivity play a large role in muscle Hepatocytes exhibit receptors for most of of the complement system (classical path-
wasting. Muscle wasting may impair recov- the soluble mediators of sepsis, including way) and promotion of phagocytosis by mac-
ery if severe enough and certainly limits the endotoxin, cytokines, inflammatory media- rophages. The CRP level is elevated within
return of patients to normal function after tors, and vasoactive substances. Studies in hours of the insult; it peaks at about 48 hours
recovery. Plank et al. demonstrated the rats showed that treatment with gadolinium post-injury. The measurement of CRP plasma
changes in total body protein over a 21-day chloride, which blocks Kupffer cell function, level has become a common and reliable tool
period, following onset of sepsis or major resulted in clearance of circulating endo- for the evaluation of the extent of a patient’s
trauma. They noted that losses were great- toxin with endotoxin secreted in bile, where inflammatory process.
est during the first 10 days, amounting to it was inactivated and secreted in the feces.
approximately 1.0% of total body protein The liver is also a major site for removal of Hypercoagulation
per day during both sepsis and trauma. To- bacteria from the systemic circulation. During the stress response, the liver pro-
tal protein lost over the study period aver- About 70% of radio-labeled E. coli and 96% motes a hypercoagulable state by the en-
aged 1.21 ⫾ 0.13 kg in sepsis patients and of P. aeruginosa are localized in the liver 10 hanced synthesis of coagulation factors,
1.47 ⫾ 0.20 kg in trauma patients. Approxi- minutes after intravenous injection. such as fibrinogen, prothrombin, factor
mately 70% of the total protein loss came Hepatic endothelial cells are in contact VIII, von Willebrand, and, at the same time,
from skeletal muscle. This loss occurred in with Kupffer cells and hepatocytes and in- decreased synthesis of protein C and anti-
sepsis patients during the first 10 days and teract with both. The endothelial cells par- thrombin III. The increased CRP plasma
in trauma patients in the first 5 days. After ticipate in the inflammatory reaction by level also promotes the expression of tissue
these intervals, more of the protein loss was secreting pro-inflammatory cytokines (IL-1 factor, the initial activator of the extrinsic
derived from the nonmuscle tissues. and IL-6). They also play an important role clotting system, by mononuclear cells and
in the regulation of the hepatic, and to some neutrophils. Promotion of coagulation ca-
Liver extent, systemic circulation. The liver sinu- pacity by the liver is needed in case of tissue
soids, which are analogous to tissue capil- injury and possible excess consumption of
The liver plays a major role in a number of laries, are lacking smooth muscle cell; coagulation factors, but it is also responsi-
critical aspects of the stress response. It is therefore, the liver capillary flow is instead ble for many fatal thrombotic and throm-
the central metabolic organ coordinating regulated by NO and CO, which are released boembolic complications.
the cardinal changes in glucose, protein, and by the sinusoidal endothelium.
lipid metabolism. The hepatic cell types that APP are plasma proteins primarily of he- Liver Dysfunction During
are involved in liver response to sepsis and patic origin; their plasma levels increased by Critical Illness
SIRS include Kupffer cells, hepatocytes, and at least 25% following sepsis, injury, or in- The unusually high metabolic and inflamma-
sinusoidal endothelial cells. These cell types flammation. The APPs consist of coagulation tory needs present during severe illness must
communicate in a paracrine fashion and and anti-coagulation (␣2-macroglobulin), be addressed by a liver that may already be

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 19 10/28/11 10:14:44 PM

 20 Part I: Perioperative Care of the Surgical Patient

compromised due to stress (shock and sep- capacity to repair denatured/injured pro- died in ICU due to sepsis. They found ste-
sis), a situation that may lead to liver dysfunc- teins and serve as part of the cells’ own re- atosis in 33.2% patients, signs of hypoxic
tion. Liver dysfunction can be divided into pair system. HSPs serve as one of the most liver damage and cholestasis in 13.2% and
two: primary and secondary. In normal phys- highly conserved mechanisms of cellular 14% respectively. Koskinas et al. reported
iologic conditions, post-prandial splanchnic protection, are found in virtually all living on end-stage pathologic changes in the liver
blood flow accounts for up to 30% of total organisms, and are a key part of cellular re- of 15 septic patients dying in the ICU. His-
cardiac output. During the stress response sponse to stress. Enhanced HSP expression, tology of liver biopsy specimens showed
period after a severe tissue trauma or sepsis, using transgenic mice or by a mild stress portal inflammation in 73.3%, centrilobular
the portal flow, which arises from the before the insult, has been shown to be cy- necrosis in 80%, lobular inflammation in
splanchno-mesenteric vascular bed, is sub- toprotective in experimental models of sep- 66.7%, and hepatocellular apoptosis in
ject to disproportionate vasoconstriction sis and other types of stress. Increased ex- 66.6%. Various degree of steatosis was ob-
(under the influences of ␣-adrenergic and pression of HSPs has been detected in a served in 11/15 (73.3%) of patients.
renin–angiotensin stimulus). A physiologic variety of clinical settings. In patients with
compensatory process (referred to as hepatic severe trauma, a correlation was shown be- Intestine
arterial buffer response) of inverse changes in tween survival and the ability to mount a
hepatic blood flow in response to changes in higher HSP. Our understanding of intestinal barrier
portal flow takes place, but this response of function biology, its potential clinical im-
the hepatic artery is often altered during se- Glutathione portance, as well as the pathophysiology
vere sepsis or shock, compromising hepatic Cellular glutathiones play an important and consequences of gut barrier failure has
blood flow. Hepatic dysfunction that occurs role in the cells’ ability to reduce cellular changed considerably over the course of
in the hours after the insult or onset of sepsis damage, which is initiated by the typically time. Now, it is clear that the intestinal mu-
can be viewed as a primary dysfunction and high oxidative stress present during severe cosa functions physiologically as a local de-
is most likely linked to hypoperfusion. The illness. In an animal model of sepsis, a six- fense barrier to prevent bacteria and endo-
outcome of such acute liver dysfunction can fold increase in de novo synthesis of gluta- toxin, which normally are present within
be catastrophic with disseminated intravas- thione by hepatocytes was demonstrated in the intestinal lumen, from escaping and
cular coagulation, reduced hepatic lactate the first 2 days of sepsis. In contrast to acute reaching extra-intestinal tissues and organs.
and amino acid clearance with metabolic phases proteins, persistence of stress re- More recently, it has become apparent that
acidosis, decreased gluconeogenesis, and sponse throughout the course of sepsis in the gut can become a pro-inflammatory or-
glycogenolysis with subsequent hypoglyce- rats (4 days after infection) led to depletion gan and that gut-derived factors, liberated
mia. These effects are potentially fatal. of liver glutathione. The mechanism of late after periods of splanchnic hypoperfusion,
Secondary hepatic dysfunction is be- glutathione depletion is not clear; one hy- can lead to acute distant organ dysfunction,
lieved to be caused by spillover of bacteria pothesis is that it is secondary to selenium playing a role in the development of multi-
or endotoxin and the subsequent activation depletion. Selenium is an essential cofactor ple organ failure.
of inflammatory cytokines and mediators for glutathione peroxidase activity and it Initial interest in gut barrier failure and
in the absence of circulatory changes. Mild has been shown that depletion of that mi- bacterial translocation was based on clini-
cholestasis is a common sign of secondary cronutrient in sepsis is associated with in- cal observations that trauma, burn, and
liver dysfunction during critical illness. It is creased morbidity and mortality. The sele- critically ill patients, especially those
often an isolated finding secondary to intra- nium requirement in sepsis increases in developing MODs, frequently had life-
hepatic cholestasis caused by rapid down- parallel with increased glutathione peroxi- threatening bacteremias with enteric or-
regulation of transporter proteins, such as dase activity and glutathione turnover. Re- ganisms in the absence of an identifiable
NTCP (a basolateral sodium-dependent bile cent randomized and placebo-controlled focus of infection. These clinical observa-
salt transporter) and multidrug-resistant trials indicated that high-dose selenium tions resulted in a large body of work inves-
protein 2 (MRP2), which is a canalicular an- supplementation can improve outcome in tigating the relationships among gut barrier
ionic conjugate transporter, and a bile salt sepsis and septic shock. function, intestinal bacterial flora, systemic
pump. host defenses, and injury in an attempt to
Steatohepatitis delineate the mechanisms by which bacte-
Heat Shock Proteins Another important factor related to liver ria contained within the GI tract can trans-
One of the hepatic mechanisms to deal with dysfunction in critically ill patients is ste- locate to cause systemic infections. From
the stress and avoid a secondary liver dys- atohepatitis. The liver in critically ill pa- these and subsequent studies, the current
function is dramatic up-regulation of liver tients faces an increased flux of FFA, amino role of the gut and gut barrier function in
synthesis of HSPs. The HSPs are a group of acids, and carbon-3 compounds, such as the prevention and potentiation of systemic
proteins discovered during the 1960s in lactate and glycerol, together with condi- infections and MODS have evolved.
drosophila cells that were exposed to sub- tions of hyperglycemia and hyperinsuline-
lethal temperature. Although named heat mia. The hepatic capacity of FFA oxidation Gut Barrier and
shock proteins after their discovery, HSPs and secretion seems to be inhibited, and Bacterial Translocation
actually serve as general survival proteins TGs accumulate in hepatocytes leading to
by increasing cellular resistance against a steatosis. Steatohepatitis in critically ill pa- Intestinal barrier function can be seen to be
vast range of stressors and not just elevated tients has been reported mostly in relation of major importance when one considers
temperatures. In normal physiological con- to artificial nutrition, especially total par- that the distal small bowel and colon con-
ditions, HSPs act as regulatory intra-cellu- enteral nutrition. Torgersen et al. have re- tain enormous concentrations of bacteria
lar proteins, stabilizing other proteins in cently reported in a retrospective study the and endotoxin. Under certain clinical cir-
proper formation by chaperoning proteins pathological findings of a postmortem ex- cumstances, intestinal barrier function be-
across cell membranes. HSPs have the ploration performed on 235 patients who comes impaired, resulting in the movement

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 20 10/28/11 10:14:44 PM

 Chapter 1: Metabolic and Inflammatory Responses to Trauma and Infection 21

of bacteria and/or endotoxin to the sys- route by which patients are fed may influ- survival during resuscitation. J Cell Mol Med
temic tissues. This process of bacteria and ence the immune-inflammatory and meta- 2009;13(9B):3774–3785.

Perioperative Care of the Surgical Patient

their products crossing the intestinal mu- bolic response to injury as well as the inci- Cruickshank AM, Fraser WD, Burns HJ, et al. Re-
sponse of serum interleukin-6 in patients un-
cosal barrier and spreading systemically dence of infectious complications and dergoing elective surgery of varying severity.
has been termed bacterial translocation. thereby modulate clinical outcome. Al- Clin Sci 1990;79:161–5.
The underlying mechanisms of how and un- though bacterial translocation has been Cruickshank AM, Fraser WD, Burns HJ, et al. Re-
der what circumstances bacteria contained demonstrated consistently in experimental sponse of serum interleukin-6 in patients un-
within the gut translocate across the mu- animal models, results of clinical human tri- dergoing elective surgery of varying severity.
cosal barrier have been studied extensively als failed to find bacteria or endotoxin in the Clin Sci 1990;79(2):161–5.
Cuthbertson D, Tinstone WT. Metabolism dur-
in a number of animal models. Although portal blood of severely injured patients and ing the postinjury period. Adv Clin Chem 1969;
both an intact epithelial barrier and a nor- its occurrence in humans is uncertain. One 12:1–55.
mal functioning immune system are impor- possible explanation to resolve these dis- Cuthbertson DP. Observations on the disturbances
tant for adequate gut barrier function, it concordant results is that gut-derived fac- of metabolism produced by injury to the limbs.
appears that an intact mucosa will prevent tors contributing to systemic inflammation Quart J Med 1932;1:233–44.
bacterial translocation even in rats with se- and organ injury is reaching the systemic Czermak BJ, Sarma V, Pierson CL, et al. Protec-
lectively impaired cell-mediated immunity. circulation via the mesenteric lymphatics tive effects of C5a blockade in sepsis. Nat Med
1999;5:788–92.
Reduced splanchnic blood flow, leading to rather than the portal venous system. One de Diego AMG, Gandía L, García AG. A physi-
an ischemia–reperfusion-mediated gut in- important conceptual consequence of the ological view of the central and peripheral
jury has been shown to be a key factor in gut–lymph hypothesis is that the lung rather mechanisms that regulate the release of
the loss of mucosal barrier function and than the liver would be the first major vas- catecholamines at the adrenal medulla. Acta
bacterial translocation in models of ther- cular bed to be exposed to gut-originated Physiol 2008;192:287–301.
mal injury, hemorrhagic shock, and endo- mesenteric lymphatic factors (mesenteric de Jonge WJ, van der Zanden EP, The FO, et al.
Stimulation of the vagus nerve attenuates mac-
toxemia. In these models, mucosal injury lymph reaches the systemic circulation via rophage activation by activating the Jak2-STAT3
appears secondary to a gut ischemia– the thoracic duct, which empties into the signaling pathway. Nat Immunol 2005;6(8):844–
reperfusion injury, which is mediated, in part, subclavian vein and hence the pulmonary 51. Epub 2005 July 17. Erratum in: Nat Immunol
by xanthine oxidase-generated oxidants. circulation). There is extensive clinical and 2005;6(9):954.
experimental evidence showing that after Dellinger RP, Carlet JM, Masur H, et al. Surviving
hemorrhagic shock, trauma, or a major burn sepsis campaign guidelines for management of
Nutrition and Gut Barrier severe sepsis and septic shock. Crit Care Med
The area of nutrition received increasing injury, the gut releases pro-inflammatory 2004;32:858–73.
clinical and experimental attention during and tissue injurious factors that lead to Dietz A, Heimlich F, Daniel V, et al. Immunomodu-
the past two decades. In fact, the recogni- acute lung injury. lating effects of surgical intervention in tumors
tion of the concept of gut barrier failure and of the head and neck. Otolaryngol Head Neck
bacterial translocation was one of the major Surg 2000;123:132–9.
impetuses leading to the initiation of early SUGGESTED READINGS Dünser W, Walter R. Hasibeder. Sympathetic Over-
stimulation During Critical Illness: Adverse Ef-
enteral feeding of patients shortly after in- Agnese DM, Calvano JE, Hahm SJ, et al. Human fects of Adrenergic Stress Martin. J Intensive
jury. The optimal functional and structural toll-like receptor 4 mutations but not CD14 Care Med 2009;24(5): 293–316.
integrity of the GI tract depends on whether polymorphisms are associated with an in- Dunne A, O’Neill LA. The interleukin-1 receptor/
or not the gut is fed enterally. Enteral feed- creased risk of gram-negative infections. J Toll-like receptor superfamily: signal transduc-
ing supports intestinal structural integrity Infect Dis 2002;186:1522–5. tion during inflammation and host defense. Sci
by maintaining mucosal mass, stimulating Andersson U, Wang H, Palmblad K, et al. High STKE 2003;2003:re3.
mobility group 1 protein (HMG-1) stimulates Fliers E, Guldenaar SF, Wiersinga WM, et al. De-
epithelial cell proliferation, maintaining vil- proinflammatory cytokine synthesis in human creased hypothalamic thyrotropin-releasing
lus height, and promoting the production of monocytes. J Exp Med 2000;192:565–70. hormone gene expression in patients with
brush border enzymes. Functional integrity Annane D, Sebille V, Charpentier C, et al. Effect non-thyroidal illness. J Clin Endocrinol Metab
of the mucosa also is supported by enteral of treatment with low doses of hydrocortisone 1997;82:4032–6.
feeding in several ways, through the mainte- and fludrocortisone on mortality in patients Glaser F, Sannwald GA, Buhr HJ, et al. General
nance of tight junctional integrity between with septic shock. JAMA 2002;288:862–71. stress response to conventional and laparoscop-
Ayala A, Meldrum DR, Perrin MM, Chaudry IH. ic cholecystectomy. Ann Surg 1995;221:372–80.
the intestinal epithelial cells, stimulation of The release of transforming growth factor-beta Goehler LE, Relton JK, Dripps D, et al. Vagal para-
blood flow to the gut, and the production following haemorrhage: its role as a media- ganglia bind biotinylated interleukin-1 re-
and release of a variety of endogenous tor of host immunosuppression. Immunology ceptor antagonist: a possible mechanism for
agents, such as cholecystokinin, gastrin, 1993;79:479–84. immune-to-brain communication. Brain Res
bombesin, and bile salts, all of which exert Barnes PJ, Karin M. Nuclear factor-kappa-B: a piv- Bull 1997;43(3):357–64.
major trophic effect on the intestinal epi- otal transcription factor in chronic inflamma- Guarini S, Altavilla D, Cainazzo MM, et al. Ef-
thelium. In fact, experimental evidence ex- tory diseases. N Engl J Med 1997;336:1066–71. ferent vagal fibre stimulation blunts nuclear
Beutler B, Milsark IW, Cerami AC. Passive immuni- factor-kappaB activation and protects against
ists that nutrition has a profound impact on zation against cachectin/tumor necrosis factor hypovolemic hemorrhagic shock. Circulation
gut barrier function. Enteral feeding pre- protects mice from lethal effect of endotoxin. 2003;107(8):1189–94.
serves intestinal barrier function better Science 1985;229(4716):869–71. Hendrik S, Dirk H, Joachim W, et al. The Altera-
than parenteral feeding. Enterally fed ani- Bianchi ME. DAMPs, PAMPs and alarmins: all we tion of Autonomic Function in Multiple Organ
mals survived a septic challenge better than need to know about danger. J Leukoc Biol 2007; Dysfunction Syndrome. Crit Care Clin 2008;
animals fed an identical diet parenterally. 81:1–5. 24:149–63.
Boeuf B, Poirier V, Gauvin F, et al. Naloxone Hildebrandt U, Kessler K, Pistorius G, et al.
This experimental observation has been for shock. Cochrane Database Syst Rev 2003 Granulocyte elastase and systemic cytokine
verified in several prospective randomized (Issue 4), CD004443. response after laparoscopic-assisted and open
clinical studies involving burn and trauma Cai B, Chen F, Ji Y, et al. Alpha7 cholinergic-agonist resections in Crohn’s disease. Dis Colon Rectum
patients. These studies indicate that the prevents systemic inflammation and improves 1999;42:1480–6.

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 21 10/28/11 10:14:44 PM

 22 Part I: Perioperative Care of the Surgical Patient

Hildebrandt U, Kessler K, Plusczyk T, et al. Com- chemokine decoy receptor D6. Eur J Immunol Salomon F, Cuneo RC, Hesp R, et al. The effects of
parison of surgical stress between laparoscopic 2005;35:1342–6. treatment with recombinant human growth
and open colonic resections. Surg Endosc Meakins JL, Pietsch JB, Bubenick O, et al. Delayed hormone on body composition and metabo-
2003;17:242–6. hypersensitivity: indicator of acquired failure of lism in adults with growth hormone deficiency.
Höllt V. Opioid peptide processing and recep- host defences in sepsis and trauma. Ann Surg N Engl J Med 1989;321:1797–803.
tor selectivity. Annu Rev Pharmacol Toxicol 1977;186:241–50. Scaffidi P, Misteli T, Bianchi ME. Release of chro-
1986;26:59–77. Michalaki M, Vagenakis A, Makri M, et al. Dissocia- matin protein HMGB1 by necrotic cells triggers
Hoebe K, Janssen E, Beutler B. The interface be- tion of the early decline in serum T3 concentration inflammation. Nature 2002;418:191–5.
tween innate and adaptive immunity. Nat Im- and serum IL-6 rise and TNF␣ in nonthyroidal Schmidt H, Müller-Werdan U, Hoffmann T, et al.
munol 2004;5(10):971–4. illness syndrome induced by abdominal surgery. Autonomic dysfunction predicts mortality in
Hoshino K, Takeuchi O, Kawai T, et al. Cutting J Clin Endocrinol Metab 2001;86:4198–205. patients with multiple organ dysfunction syn-
edge: Toll-like receptor 4 (TLR4)-deficient mice Molina PE, Abumrad NN. Differential effects of drome of different age groups. Crit Care Med
are hyporesponsive to lipopolysaccharide: evi- hemorrhage and LPS on tissue TNF, IL-1 and 2005;33(9):1994–2002.
dence for TLR4 as the Lps gene product. J Im- associated neurohormonal and opioid altera- Schmidt H, Werdan K, Müller-Werdan U. Auto-
munol 1999;162:3749–52. tions. Life Sci 2000;66:399–409. nomic dysfunction in the ICU patient. Curr
Huber-Lang M, Sarma VJ, Lu KT, et al. Role of C5a Molina PE. Stress-specific opioid modulation of Opin Crit Care 2001;7(5):314–22.
in multiorgan failure during sepsis. J Immunol haemodynamic counter-regulation. Clin Exp Schwandner R, Dziarski R, Wesche H, et al. Pep-
2001;166:1193–9. Pharmacol Physiol 2002;29:248–53. tidoglycan- and lipoteichoic acid-induced cell
Huston JM, Gallowitsch-Puerta M, Ochani M, et Moore FD, Olsen KH, McMurry JD. The body cell activation is mediated by toll-like receptor 2.
al. Transcutaneous vagus nerve stimulation mass and its supporting environment. Philadel- J Biol Chem 1999;274:17406–9.
reduces serum high mobility group box 1 lev- phia: WB Saunders; 1978. Shatney CH, Benner C. Sequential serum comple-
els and improves survival in murine sepsis. Crit Mukaida N. Pathophysiological roles of inter- ment (C3) and immunoglobulin levels in shock/
Care Med 2007;35(12):2762–8. leukin-8/CXCL8 in pulmonary diseases. Am J trauma patients developing acute fulminant
Jamieson T, Cook DN, Nibbs RJ, et al. The chemokine Physiol Lung Cell Mol Physiol 2003;284:L566–77. systemic sepsis. Circ Shock 1985;16:9–17.
receptor D6 limits the inflammatory response Naito Y, Fukata J, Tamai S, et al. Biphasic changes Slag MF, Morley JE, Elson MK, et al. Hypothyrox-
in vivo. Nat Immunol 2005;6:403–11. in hypothalamic-pituitary-adrenal function inemia in critically ill patients as a predictor of
Kiechl S, Lorenz E, Reindl M, et al. Toll-like recep- during the early recovery period after major high mortality. JAMA 1981;245:43–5.
tor 4 polymorphisms and atherogenesis. N Engl abdominal surgery. J Clin Endocrinol Metab Stein C, Schafer M, Machelska H. Attacking pain
J Med 2002;347:185Y192. 1991;73:111–7. at its source: new perspectives on opioids. Nat
Klava A, Windsor AC, Farmery SM, et al. Interleu- Naito Y, Tamai S, Shingu K, et al. Responses of Med 2003;9:1003–8
kin-10. A role in the development of postop- plasma adrenocorticotropic hormone, cortisol, Takala J, Ruokonen E, Webster NR, et al. Increased
erative immunosuppression. Arch Surg 1997; and cytokines during and after upper abdomi- mortality associated with growth hormone
132:425–9. nal surgery. Anesthesiology 1992;77:426–31. treatment in critically ill adults. N Engl J Med
Kloosterman T, von Blomberg BM, Borgstein P, Oppenheim JJ, Yang D. Alarmins: chemotactic ac- 1999;341:785–92.
et al. Unimpaired immune functions after tivators of immune responses. Curr Opin Immu- Taylor BE, Buchman TG. Is there a role for growth
laparoscopic cholecystectomy. Surgery 1994; nol 2005;17:359–65. hormone therapy in refractory critical illness?
115:424–8. Parrish WR, Rosas-Ballina M, Gallowitsch-Puerta Curr Opin Crit Care 2008;14(4):438–44.
Labuz D, Berger S, Mousa SA, et al. Peripheral an- M, et al. Modulation of TNF release by choline The FO, Boeckxstaens GE, Snoek SA, et al. Activa-
tinociceptive effects of exogenous and immune requires alpha7 subunit nicotinic acetylcho- tion of the cholinergic anti-inflammatory path-
cell-derived endomorphins in prolonged in- line receptor-mediated signaling. Mol Med way ameliorates postoperative ileus in mice.
flammatory pain. J Neurosci 2006;26:4350–58. 2008;14(9–10):567–74. Gastroenterology 2007;133(4):1219–28.
Lamberts SW, Bruining HA, de Jong FH. Corticos- Pavlov VA, Ochani M, Yang LH, et al. Selective Tilg H, Trehu E, Atkins MB, et al. Interleukin-6
teroid therapy in severe illness. N Engl J Med alpha7-nicotinic acetylcholine receptor ago- (IL-6) as an anti-inflammatory cytokine: in-
1997;337:1285–92. nist GTS-21 improves survival in murine en- duction of circulating IL-1 receptor antagonist
Lorenz E, Mira JP, Frees KL, et al. Relevance of mu- dotoxemia and severe sepsis. Crit Care Med and soluble tumor necrosis factor receptor p55.
tations in the TLR4 receptor in patients with 2007;35(4):1139–44. Blood 1994;83:113–8.
gram-negative septic shock. Arch Intern Med Riedemann NC, Neff TA, Guo RF, et al. Protective Turnbull AV, Rivier CL. Regulation of the hypo-
2002;162:1028–32. effects of IL-6 blockade in sepsis are linked to thalamic-pituitary-adrenal axis by cytokines:
Luce JM. Physicians should administer low-dose reduced C5a receptor expression. J Immunol Actions and mechanisms of action. Physiol Rev
corticosteroids selectively to septic patients 2003;170:503–7. 1999;79:1–71.
until an ongoing trial is completed. Ann Intern Rittner HL, Brack A, Stein C. Pain and the immune Ueo H, Honda M, Adachi M, et al. Minimal in-
Med 2004;141:70–2. system. Br J Anaesth 2008;101:40–4. crease in serum interleukin- 6 levels during
Maier SF, Goehler LE, Fleshner M, et al. The role of Rivkind AI, Siegel JH, Lettleton M, et al. Neutro- laparoscopic cholecystectomy. Am J Surg 1994;
the vagus nerve in cytokine-to-brain communi- phil oxidative burst activation and the pattern 168:358–60.
cation. Ann N Y Acad Sci 1998;840:289–300. of respiratory physiologic abnormalities in the Ulloa L, Ochani M, Yang H, et al. Ethyl pyruvate
Maldonado LS, Murata GH, Hershman JM, et al. Do fulminant post-traumatic adult respiratory dis- prevents lethality in mice with established le-
thyroid function tests independently predict sur- tress syndrome. Circ Shock 1991;33:48–62. thal sepsis and systemic inflammation. Proc
vival in the critically ill? Thyroid 1992;2:119–23. Robert C, Kupper TS. Inflammatory skin diseases, Natl Acad Sci USA 2002;99:12351–6.
Mantovani A, Bonecchi R, Locati M. Tuning in- T cells, and immune surveillance. N Engl J Med van Westerloo DJ, Giebelen IA, Florquin S, et al.
flammation and immunity by chemokine se- 1999;341(24):1817–28. The vagus nerve and nicotinic receptors modu-
questration: decoys and more. Nat Rev Immu- Rogers TJ, Peterson PK. Opioid G protein-coupled late experimental pancreatitis severity in mice.
nol 2006;6:907–18. receptors: Signals at the crossroads of inflam- Gastroenterology 2006;130(6):1822–30.
Marik PE, Zaloga GP. Critical care review Adrenal mation. Trends Immunol 2003;24:116–21. Venet F, Bohe J, Debard AL, et al. Both percentage
Insufficiency in the critically ill: a new look at Rot A. Contribution of Duffy antigen to chemokine of gammadelta. T lymphocytes and CD3 ex-
an old problem. Chest 2002;122:1784–96. function. Cytokine Growth Factor Rev 2005; pression are reduced during septic shock. Crit
Martinez dlT, Buracchi C, Borroni EM, et al. Pro- 16:687–94. Care Med 2005;33:2836–40.
tection against inflammation- and autoan- Rouhiainen A, Kuja-Panula J, Wilkman E, et al. Vermes I, Beishuizen A, Hampsink RM, et al.
tibody-caused fetal loss by the chemokine Regulation of monocyte migration by amphot- Dissociation of plasma adrenocorticotropin
decoy receptor D6. Proc Natl Acad Sci USA erin (HMGB1). Blood 2004;104:1174–82. and cortisol levels in critically ill patients:
2007;104:2319–24. Sakharova OV, Inzucchi SE. Endocrine assess- possible role of endothelin and atrial natri-
Martinez dlT, Locati M, Buracchi C, et al. In- ments during critical illness. Crit Care Clin 2007; uretic hormone. J Clin Endocrinol Metab 1995;
creased inflammation in mice deficient for the 23:467–90. 80:1238–42.

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 22 10/28/11 10:14:45 PM

 Chapter 1: Metabolic and Inflammatory Responses to Trauma and Infection 23

Wang H, Bloom O, Zhang M, et al. HMG-1 as a late essential regulator of inflammation. Nature Yang H, Ochani M, Li J, et al. Reversing established
mediator of endotoxin lethality in mice. Science 2003;421(6921):384–8. sepsis with antagonists of endogenous high

Perioperative Care of the Surgical Patient

1999;285:248–51. Wurfel MM, Gordon AC, Holden TD, et al. Toll-like mobility group box 1. Proc Natl Acad Sci USA
Wang H, Liao H, Ochani M, et al. Cholinergic Receptor 1 Polymorphisms Affect Innate Im- 2004;101:296–301.
agonists inhibit HMGB1 release and improve mune Responses and Outcomes in Sepsis. Am
survival in experimental sepsis. Nat Med 2004; J Respir Crit Care Med 2008;178:710–20.
10(11):1216–21. Wurtman RJ. Stress and the adrenocortical control
Wang H, Yu M, Ochani M, et al. Nicotinic ace- of epinephrine synthesis. Metabolism 2002;51(6,
tylcholine receptor alpha7 subunit is an Suppl 1):11–14.

EDITOR’S COMMENT ponent, although there may be components with- in liver failure. Massive destruction, catabolism of
out which the inflammatory response will not skeletal muscle to the point where the abilities of
take place, or at least will not resemble what we the patient to move and breathe are threatened
This is an encyclopedic chapter concerning the actually see now. Therefore I get a little depressed, is also part and parcel of this response. I assume
metabolic and inflammatory components of when I go to surgical meetings, and particularly that in the evolutionary component, skeletal
trauma and infection. It is probably the most when I see a bright young man or woman pre- muscle is seen as less valuable to the organism
complete and encyclopedic chapter that has ever senting a paper as if to say that this is the holy than, for example, heart, brain, kidneys and liver;
been written in any literature including both grail of inflammatory and metabolic response however, continued destruction of lean body
surgical and medical literature. As will be clear to injury or trauma. It is highly unlikely that it mass, of which these latter are all part, is part and
to the reader, there are an enormous number of is, and some bit of modesty probably should be parcel of the hypermetabolic response.
components to the inflammatory and metabolic maintained. Let us go through the components The other major destructive impulse, at least
response to trauma and infection. To a consider- in outline form and point out some of the issues it seems to me it is, is the widespread capillary
able extent, they are synergistic. The most promi- that have come to light. I would urge the reader leak and the opening up of tight junctions of the
nent of the classics that we deal with are the cy- to bear in mind that, as the result of these vari- capillaries and also perhaps enlargement of the
tokines, interleukins and transporting factors, if ous components which seemingly come together, pores or the spaces in the endothelium, which
you will, such as NF-kB. Many of them have very MODS (multiple organ dysfunction syndrome) keep material in the circulating compartment.
short half-lives, such as TNF with a half-life of and SIRS (systemic inflammatory response syn- The capillary leak would deplete if allowed to go
20 minutes and then among the cytokines IL-1 drome) accrue. This is covered nicely in Chapter on, and if it does go on, endogenous resources and
with a half-life of 6 minutes. The entire process is 8 by Dr. Marshall, and I do like his approach, that is maladapted as the author says. The systemic
to a considerable extent integrated and combines much of what happens to patients we in fact cre- inflammatory response, severe metabolic deple-
to have a series of responses, which indicate in ate by the way we take care of them. tion, and possible secondary infection all cause
the response what the organism perceives, in this In the overview, the authors present a list damage to vital organs, but were not initially
case the human organism, is the degree of insult. of the immune, inflammatory and metabolic compromised by the injury. These include adult
For ordinarily elective surgery, for example, of responses to injury. It starts as a local activa- respiratory distress syndrome, which I believe
rather small invasiveness, there is a programmed tion but then is followed shortly thereafter by a has two components, the first is the capillary leak
response, which I will discuss, but it is small, and systemic inflammatory and endocrine response. and the second is the use of excessive crystalloid
it is temporary. If the surgery is larger, or if there These can be manifest to us as surges in plasma in resuscitation. Happily, many people taking care
is an infectious postoperative complication, or if catecholamine, cortisol and aldosterone levels of patients with severe injury and with infection
this is a moderate traumatic episode, the cytok- resulting in tachycardia, tachypnea, vasocon- now realize that the continued resuscitation of pa-
ines, interleukins, Toll receptors and other pro- striction, reduced cardiac output, lower oxygen tients who are suffering from a capillary leak is not
cesses begin to bring about a response which is consumption, lower basal metabolic rate, sodium helpful and contributes not only to ARDS but re-
close to life-threatening. and water retention, translocation of blood from nal insufficiency, hepatic dysfunction, loss of duct
On the other hand, a number of these very the peripheral to the central vital organs, and epithelial-barrier function, immunoparalysis and
same factors which bring about the response, acute-phase protein production. This is the “ebb” the multi organ dysfunction after sepsis develops,
which, when it gets out of hand, is deleterious, phase originally proposed by Sir David Cuthbert- which can be fatal. The stress response, however,
on the obverse side of the response aid in the son in the 1930s. If the organism and the organs with the appropriate support and provided the
survival mechanism of the organism, such as survive, we then transition to a “flow” phase. The stress response is not complicated by later infec-
acute-phase protein synthesis. Other aspects of duration and the number of organs involved re- tion usually resolves without complication. The
the response include the release of neutrophils ally depends on, first, how extensive the injury or catabolic process usually peaks at 48 to 72 hours
over a few hours, in which it is proposed that insult is and, second, whether or not the organs post injury.
10 billion are released, which have a half-life of have survived the initial ebb phase. The stress re- If the catabolic response is resolved it then
approximately a few hours and then undergo sponse here is, as the authors say, “characterized leads to the beginnings of an anabolic state with
apotosis or programmed cell death, which brings by explosive metabolic activity,” which is “medi- insulin, growth hormone, insulin like growth
about a utilization of some of the components of ated by a massive neuroendocrine flux involving factor 1, and perhaps insulin like growth factor
neutrophils to participate in synthesis of various the production and secretion of catecholamines, 2 within five days of injury, as the author says.
proteins and other components which aid in the antidiuretic hormone, cortisol, insulin, glucagon The mechanistic change is a flux of protein, fluid,
healing and in the positive response to trauma and growth hormone. The increased adrenergic and electrolytes returning to the depleted cellu-
and the metabolic and inflammatory response stimulation causes an increase in the glucagon lar space, particularly muscle, and cellular space
which helps the organism survive. In the initial to insulin ratio and, combined with . . . cortisol expands.
complex from a rather minor injury or compara- and cytokines, induces the state of enhanced pro- There is much that is new in this chapter,
tively minor surgery, or even slightly more major teolysis and lipolysis.” This is the nub of the issue. which has not made its appearance in the stan-
surgery which goes well and does not have any There are other parts that will be covered by Dr. dard textbook of surgery. These include from this
postoperative complications, the entire duration Hasselgren in Chapter 2 and by Dr. Marshall in point on a number of headings, including “The
is 1–2 days. It then subsides. Chapter 8. Innate Immune System”, which include the “Toll
One of the problems in this area is what I call Furthermore, a critical part of the issue here Like Receptors”, which are the Toll-signaling
the “holy-grail syndrome”. It will be obvious after is that there is no inactive store of protein. The pathway initially described in Drosophila in 1985,
reading this chapter that it is highly unlikely that storehouse for protein, as we know it, is the mus- as the author says and finally recognized in hu-
there is a “holy grail”. There may be some com- cle. The protein content of organs such as heart, mans in 1997; at least 11 human toll-like recep-
ponents of the inflammatory response which are liver or kidneys may also “store this protein”, tors have been identified. These, which have not
critical or central to the response, but, to my way when the stress is high enough, and may lead to received a great deal of recognition in the con-
of thinking, there is no central or essential com- the failure of the organ and then the organism, as temporary surgical literature at least appears

(continued)

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 23 10/28/11 10:14:45 PM

 24 Part I: Perioperative Care of the Surgical Patient

to play an adaptive role on adaptive immune regulated by different antigens, IL-1␤ is the more be initial trauma and a complication may result,
systems. They are expressed on dendritic cells, common and more involved in what its role is. which may be the second hit. The second hit may
T-lymphocytes, a number of parenchymal cells, IL-6 is another popular cytokine, as it were, and it be sterile, for example the need for an operation
including adrenals, liver and spleen and which peaks and 4 to 48 hours. It is induced partially by in general, or it may be infectious with a pathogen
in the adrenal-expressed TLRs (toll-like recep- TNF and partially by IL-1. Its function is operant induced infection. Whatever causes the second
tors), the systemic inflammatory response. NF-kB, by the proliferation and differentiation of 〉 and hit, however, has now become synonymous with
which is a major facilitator to all of this migrates T-lymphocytes. It also regulates the synthesis of the development of MODS. This is further cov-
from the cytoplasm, where it usually resides with another acute phase protein, such as C-reactive ered in Chapter 8. There is a very extensive dis-
the destruction of the inhibiting IkB and trans- protein and fibrinogen and other complement cussion of hormonal relationships in trauma and
migrates to the nucleus. Here, it mediates gene factors. One of the significant findings of laparo- inflammation, but I do want to mention adrenal
transcription and the production of inflamma- scopic procedures is that there is less elevation of insufficiency, which may occur in prolonged stay
tory mediators, such as chemokines, adhesion IL-6 following laparoscopic cholecystectomy as in the ICU. The point is that one must think about
molecules, tumor necrosis factor, interleukin-1, well as abdominal, aortic, and colorectal surgery. this in order to rule it out. Patients with transient
and TNF-␣ receptors. Similarly, small bowel and colonic resections car- adrenal insufficiency basically may have a de-
Other new terminology, which will be new or ried out laparoscopically have lower elevations creased blood pressure, decreased urine output,
at least unfamiliar to the average surgeon read- of IL-6. Another feature of IL-6 is that it seems to other inexplicable hypoglycemia, hyponatremia,
ing this chapter includes complement, which is have a prognostic significance in patients with hyperkalemia metabolic acidosis, eosiniphilia,
recognizable, except for the fact that what is new SIRS, sepsis, or MODS and has been tested in the and a hypodynamic circulation as well. To think
is that the complement system consists of more ICU in this regard and has come to be a prognos- of adrenal insufficiency should give one a very ag-
than 30 proteins. These are divided into three tic indicator. gressive response to this. A 250 microgram ACTH
main pathways: Of the chemokines, these have not had much stimulation test, which is recognized as being of
presence, on the surgical scene at least, and there a very high level, is probably the best way to tell
1. classic
are 18 chemokine receptors and 43 chemokines. whether the patient has a hypoadrenal response.
2. alternative
Their role is still being elucidated, but some have This seems to be much more accurate than ran-
3. mannan-binding lectin pathways.
suggested that some of these are “decoy recep- dom cortisol levels.
Another relatively new term is alarmins, tors”. Another hormonal deficiency that can oc-
which is triggered by injury or trauma without A major and relatively novel discussion in a cur after prolonged ICU stay is hypothyroidism.
evidence of a bacterial focus. They are released surgical text is the neuro-immune axis. We re- There is a low T3 syndrome, and interestingly
after a non-programmed cell death or by cells main very concerned about what the accurate enough, there is an inverse correlation between
of the immune system. Heat shock proteins, de- sensory input to the brain is during stress. We T3 levels and mortality. In prolonged critical ill-
fensins, cathelicidin, eosinophil-derived neuro- know that there are neural routes, mostly by ness, an “euthyroid sick syndrome” may present,
toxin (EDN), and others. There are a number of afferent vagal fibers and then there are blood- in which the TSH exhaustion is what would best
systems which ordinarily do not receive a great borne inflammatory mediators. Elsewhere in this be identified, and there would be reduced TSH se-
deal of attention in a standard textbook version volume we have called attention to the fact that cretion and reduced levels of T3 and T4. Low TRH
of the acute phase reaction. These are systems vagal pathways pass from the peritoneal cavity to expression in the hypothalamus has been seen in
such as the adaptive immune system, which is a the CNS and in a paper that appeared in Science patients who have been chronically ill, as if this
secondary and more efficient response to invad- in 2000 as discussed elsewhere, there was a ben- particular function has been depleted.
ers, and which is made up of cellular immunity. efit to subdiaphragmatic vagotomy. The stimulus The sympathetic nerves and the whole sym-
The cellular immunity is the cellular response of for the vagus is activated it seems, at least in part pathetic system are extremely important in pro-
the organism, namely the patient that is a local by IL-1 in peripheral tissues. IL-1 binding and an longed trauma and stress. The catecholamine
host response against invading organisms. Local intact vagus nerve seem to be required for the immune secretion from the adrenals takes place
mediators of inflammation, such as cytokines, generation of the fever following intraperitoneal within seconds of stimulation. Since both Norepi-
histamine, kinins, and arachadonic acid metabo- IL-1. However, vagotomy alone does not block the nephrine and Epinephrine are stored in granules
lites allow increased capillary leakage, which in effects of various cytokines on CNS despite the within the adrenal medulla and their exocytosis
this sense is a good thing as it allows diapedesis protective character of the blood brain barrier. is initiated by acetylcholine secretion in the adre-
of cells to infiltrate into the site of injury. These However, in the third ventricle the blood brain nal medulla. The sympathetic system is involved
are primarily neutrophils and also to a lesser barrier may be deficient and thus there may be in almost every possible body system, which is
extent monocyte macrophages. The humeral places where the cytokine may damage the cen- important in the response to trauma, including
community is much more diffuse and involves tral blood brain barrier, giving results of continu- cardiac output, myocardial contractility, main-
toll-like receptor activation, which causes secre- ing inflammation. tenance of blood pressure, bronchodilatation,
tion of cytokines including our friends TNF and We have talked about the afferent effects of thermoregulation, retention of water and sodium
IL-1 and the chemokines, especially derived from the neuro-immune axis, but one should not lose in the kidneys, and not paradoxically—almost
macrophages. There are a variety of other compo- sight of the fact that there is an efferent regulation purposefully—decrease in bowel motility. The
nents in this including cytokine receptors, which going through the sympathetic and suppressing dysfunction of the adrenal system, such as exhaus-
are on the surface of the majority of human cells the parasympathetic portion of the autonomic tion, probably presages a poor outcome.
and intracellular signaling pathways that regulate nervous system. Metabolic alterations are extremely impor-
gene transcription. We have already heard of the Another novel discussion is the immunosup- tant, but there is one concept here, which is also
nuclear factor-kB (NF-kB) activating protein AP1 pression following trauma, which we have been brought on in Chapter 8, that is mitochondrial
and the C/EBP family of transcription factors, in aware of in a vague way and find that there is dysfunction. The mitochondrial dysfunction may
particular C/EBP-␤ and ␦. a cholinergic anti-inflammatory pathway and be the result of failure of the mitochondrial energy
NF-kB is studied because it is central in the some cytokine immunosuppressant such as IL-6. production but less and less likely so. The basic is-
inflammatory process as a transcription fac- Immune dysfunction may also be cell mediated sue appears to be the failure of adequate supplies
tor once its inhibitor has been metabolized and cellular immunoincompetence, which is also to the mitochondria. ATP is not contained in a
will translocate to the nucleus. The number of defined as immune paralysis, may be induced by depot. Any of the components such as glucose,
cytokines is legion but the important ones for PGE2, IL-10 and other anti-inflammatory media- fat, other sugars, and protein to mitochondria
our purposes, TNF, IL-1␤, IL-6, IL-8, IL-12 and tors. IL-10 and TGF␤ may induce monocyte im- because of decreased cardiac output and blood
IFN-␭, are pro-inflammatory cytokines and IL-4, mune paralysis. Another form of dysfunction is flow, oxygenation by the lung, glucose transport
IL-10, and IL-13 are considered to be inhibitory lymphocyte dysfunction, in which T-helper lym- leads to a rapid onset of mitochondrial dysfunc-
or anti-inflammatory. Interleukin-1 is ancient phocytes may also be involved in immunosup- tion. If the mitochondrial transitional pore open-
as compared with some of these other factors pression following surgical trauma. ing are open, large molecules such as cytochrome
as it was described as a pyrogen a half century In the development of SIRS and MODS, the C can enter the cytosol and trigger apoptosis—
ago. It does have a short half life of six minutes, “second hit phenomenon” has become part of programmed cell death. This results in the failure
as mentioned earlier. Of the two forms, IL-1␤ is our normal language. For example, there may to produce ATP in a period of crisis.

www.medicalebookpdf.com

LWBK892_c01_p001-024.indd 24 10/28/11 10:14:45 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 25

The following two areas which should be ferent mediators. One of the most important Summary: In short, I think we have come a

Perioperative Care of the Surgical Patient

emphasized are glucose control in the ICU and functions of the liver is the large mass of mac- long way from Sir David Cuthbertson’s first de-
the liver, in particular, the failure of protein me- rophages (Kupffer cells) and the role they play scription of biphasic immune inflammatory and
tabolism. Glucose control in the ICU is not new, in the inflammatory response. Th ey are both metabolic response to injury, as it was elucidated
but the emphasis on it is. Maintaining blood as a source of inflammatory mediators and the by Dr. Frannie Moore in probably the best book
glucose in sick patients in the ICU is beneficial. target cells for the effects of the inflammatory and most influential surgery book The Metabolic
However, the question is how low does the blood mediators. They produce a large number of the Care of the Surgical Patient. We have begun to un-
sugar have to be maintained. There is a gradually soluble mediators of sepsis, including proin- derstand more of the critical components in what
evolving agreement that using a superior level of flammatory cytokines, chemokines, nitric ox- takes place. It is extremely complicated and there
120 mg/dl of glucose leads to too frequent occur- ide, reactive oxygen products, and eicosanoid is no “A ha” moment in what happens to patients
rence of hypoglycemia, which is damaging. Most mediators. Kupffer cell dysfunction in close as- as they get critically ill. Likewise, there is no
of us are ready to accept the target of 150 mg/dl, sociation with hepatocytes is one of the main “magic bullet” to protect them from what seems
although some believe it should be higher at 180 common pathways to death when the liver is to be an increasingly difficult support system as
to 200 mg/dl. dysfunctional. There is a nice discussion of liver they go into a downward spiral of MODS, with or
Finally, hepatic failure. In addition to mi- dysfunction and critical illness. without SIRS.
tochondrial failure, probably the sine-qua-non Finally, I would simply like to mention that As I said at the beginning of my discussion,
of evolving death is due to hepatic failure. Th e the authors concentrate on the intestine and the I think this is a superb chapter, probably the
hepatic cells, which are involved are the Kupffer intestinal barrier. Despite the flood of papers in best and most encyclopedic that has ever been
cells and closely related to them and to the he- the ‘90s concerning the breakdown of the intes- written and I am especially pleased to have my
patocytes are the sinusoidal endothelial cells. tinal barrier, I remain somewhat unconvinced. good friend Professor Naji N. Abumrad be its
These cells are in contact in a paracrine fash- I believe that the intestinal barrier remains intact author.
ion, and have bidirectional signaling via dif- until agonal times. J.E.F.

2 Perioperative Management: Practical Principles,

Molecular Basis of Risk, and Future Directions
Per-Olof Hasselgren, Jeremy W. Cannon, and Josef E. Fischer

INTRODUCTION PERIOPERATIVE EVALUATION this information is gathered, a periopera-

AND MANAGEMENT tive management plan can be fashioned by
Preparing patients for surgery has grown the surgeon often with input from the pa-
increasingly complex as the severity of The perioperative period is defined as the tient’s primary care physician and possibly
chronic illness within our patients has time from preoperative workup through the other specialty consultants in fields such as
worsened even as the options for manag- first 30 days of postoperative care. From cardiology, geriatrics, and anesthesiology.
ing these conditions in the perioperative the patient’s perspective, a surgical proce- The following sections review many of the
period have expanded. In addition, over dure and the perioperative period are often issues that arise during the perioperative
the past decade, the process of surgical a momentous occasion, which involves sig- period and provide a recommended ap-
care in the operating room (OR) and after- nificant loss of personal control. As such, proach based on current evidence.
wards has been refined in a number of re- the surgeon’s responsibility is to engender
spects aimed at improving patient safety trust that the decision to operate is sound SCREENING TESTS IN GENERALLY
and quality of care. Throughout this peri- and that every measure to ensure the
operative time, the patient’s physiology is patient’s safety throughout the periopera-
HEALTHY PATIENTS
taxed to tolerate the surgical insult and tive course is taken. For patients with no or few comorbidities, a
then to heal the operative site. This chap- A careful preoperative history, review of selective preoperative testing approach is
ter summarizes our perioperative man- systems, and physical examination will re- advised (Table 2). Laboratory testing options
agement approach from the time the deci- veal preexisting medical conditions and include a complete blood count (CBC), elec-
sion to operate is made through the risk factors known to worsen surgical out- trolyte and renal function tests, serum glu-
operative and postoperative course. Th e comes. This process can be facilitated by a cose, liver function tests (LFT), coagulation
most recent evidence on risk minimiza- screening questionnaire structured to trig- studies, urinalysis, and pregnancy test. With
tion is reviewed in order to provide sur- ger the patient’s memory about significant the exception of pregnancy test, these stud-
geons a practical approach to assuring as medical illnesses or previous perioperative ies can be obtained within several months of
safe a surgical course as possible. The experiences (Table 1). Findings during this the planned procedure. Patient’s age has
physiologic underpinnings of the response evaluation then guide the array of labora- been identified as a minor predictor of mor-
to injury are also discussed along with ar- tory studies and additional tests needed to bidity and mortality although this seems to
eas for future investigation aimed at re- more specifically assess the patient’s risk of be related more to the associated comor-
ducing the perioperative patient risk. an adverse perioperative event. Once all of bidities that develop with advancing age.

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 25 10/28/11 10:15:09 PM

 26 Part I: Perioperative Care of the Surgical Patient

C
Consequently, age alone should not be used ing urinary tract infection (UTI). However,
Table 1 Preoperative Screening iin determining the types of preoperative even with treatment, patients with an as-
Questionnaire
ttests to obtain with the exception of a base- ymptomatic preoperative UTI develop more
1. Do you usually get chest pain or liline hemoglobin (Hb) for those over 65 years postoperative infections, and the cost–bene-
breathlessness when you climb up two u
undergoing major surgery and any patient in fit ratio of prosthetic infection prevention
flights of stairs at normal speed?
2. Do you have kidney disease?
w
whom significant blood loss is anticipated. with routine urinalysis screening does not
3. Has anyone in your family (blood The cost of an added white blood cell and clearly favor testing the asymptomatic pa-
relatives) had a problem following an pplatelet count is often minimal; so these are tient. Patients of childbearing age should have
anesthetic? ooften obtained as part of the baseline Hb. Be- a urine or serum pregnancy test, which many
4. Have you ever had a heart attack? ccause renal insufficiency strongly correlates institutions require as a matter of policy.
5. Have you ever been diagnosed with an w
with poor perioperative outcomes, identify- Additional basic testing options include a
irregular heartbeat? iing patients with occult renal disease is essen- 12-lead electrocardiogram (EKG), PA and lat-
6. Have you ever had a stroke? ttial. No consensus exists on the indications eral chest x-ray (CXR), and pulmonary func-
7. If you have been put to sleep for an ffor such testing, but it has been suggested tion test (PFT). We reserve these tests almost
operation, were there any anesthetic tthat a BUN and Cr should be obtained in pa- exclusively for patients with prior history of
problems?
8. Do you suffer from epilepsy or seizures?
ttients over 50 years of age scheduled for in- cardiovascular or cardiopulmonary disease.
9. Do you have any problems with pain, ttermediate or high-risk surgery or when pe- With regards to PFT, these are only obtained
stiffness, or arthritis in your neck or jaw? rrioperative hypotension is considered likely in patients with dyspnea in whom a thor-
10. Do you have thyroid disease? oor when nephrotoxic medications are ough history and physical examination fails
11. Do you suffer from angina? pplanned. Routine electrolyte, serum glucose, to reveal the source of this complaint. Our
12. Do you have liver disease? aand LFT are not recommended in healthy approach to obtaining these additional tests
13. Have you ever been diagnosed with heart ppatients. Patients with a history of a bleeding is also summarized in Table 2.
failure? ddisorder or an associated illness, which can
14. Do you suffer from asthma?
15. Do you have diabetes that requires
rresult in abnormal coagulation function RISK ASSESSMENT AND
sshould have coagulation studies performed. MANAGEMENT IN PATIENTS WITH
insulin?
O
Otherwise, routine testing of the partial
16. Do you have diabetes that requires
tthromboplastin time, prothrombin time, and CHRONIC MEDICAL ILLNESS
tablets only?
17. Do you suffer from bronchitis? iinternational normalized ratio (INR) is not The most common preexisting medical con-
rrecommended. Routine urinalysis testing is dition requiring perioperative risk assessment
Adapted from Hilditch et al. (2003). a matter of ongoing debate. On one hand, pa- and management is either known or sus-
ttients scheduled to have a surgical prosthesis pected cardiovascular disease. Other com-
iimplanted may be at an increased risk for mon preexisting conditions that are amenable
wound or implant infections from a preexist- to risk modification include pulmonary dis-
eases, renal insufficiency, liver failure, diabe-
tes mellitus, immunosuppression, and hema-
ttologic conditions. The surgeon’s goal should
Table 2 Preoperative Laboratory Testing Indications bbe to minimize the impact of these conditions
oon the surgical outcome while using a surgical
Laboratory test Indication aand anesthetic approach, which avoids any
CBC Age ⱖ 65 ⫹ major surgery; anticipated significant blood loss ffurther deterioration of the involved organ
ssystem and the patient. In each case, commu-
Renal function Age ⱖ 50 ⫹ major surgery; suspected renal disease; anticipated
hypotension; planned nephrotoxic agents; poorly controlled
nication between the surgeon and the pri-
n
hypertension mary care physician or medical specialists in-
m
vvolved in the patient’s care is essential while
Serum electrolytes Routine testing not recommended ppreparing such patients for surgery.
Serum glucose Routine testing not recommended
Liver function Routine testing not recommended CCardiovascular
Nutrition labs History of unintentional weight loss; chronic GI illness C
Cardiovascular events are responsible for
Coagulation studies Routine testing not recommended oone-third to one-half of perioperative
Urinalysis Routine testing not recommended ddeaths, and of the patients who present for
noncardiac surgery, nearly one-third have a
n
Pregnancy test Women of childbearing age kknown diagnosis of cardiovascular disease.
Additional basic tests Indication Consequently, cardiovascular risk stratifi-
C
ccation and modification are fundamental
EKG Vascular surgery planned; history of cardiovascular disease; poorly
controlled hypertension tto the perioperative care of many patients.
Patients with a good functional status
CXR Age ⱖ 50 ⫹ AAA or upper abdominal/thoracic surgery; history of have a low risk of perioperative cardiovas-
h
cardiopulmonary disease ccular complications. This can be assessed
PFT Unexplained dyspnea bby determining the types of daily routines
tthe patient can perform, which translate
CBC, complete blood count; GI, gastrointestinal; EKG, electrocardiogram; CXR, chest x-ray; PFT, pulmonary iinto multiples of the amount of oxygen con-
function tests.
ssumed while seated at rest (1 MET). Patients

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 26 10/28/11 10:15:09 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 27

a management, the rates of such compli-

and
Table 3 Revised Cardiac Risk Index and Associated Rates of Significant ccations after subsequent noncardiac surgery
Perioperative Cardiovascular Events

Perioperative Care of the Surgical Patient

have dropped significantly. A stress test af-
h
Risk factor Comment tter MI or an episode of unstable angina reli-
High-risk surgery Intraperitoneal, intrathoracic, or supra-inguinal vascular aably identifies patients who will benefit
procedures ffrom revascularization. Those who have no
Ischemic heart disease History of myocardial infarction, history of a positive eevidence for at-risk myocardium have a low
exercise test, current complaint of chest pain consid- llikelihood of reinfarction with noncardiac
ered to be secondary to myocardial ischemia, use of ssurgery and can likely be taken for surgery
nitrate therapy, or ECG with pathological Q waves within 4 to 6 weeks.
w
History of heart failure History of congestive heart failure, pulmonary edema, or Preexisting essential hypertension is a
paroxysmal nocturnal dyspnea; physical examination ccommon medical problem among patients
showing bilateral rales or S3 gallop; or chest radiograph ffacing surgery. Good blood pressure control
showing pulmonary vascular redistribution ((⬍140/90 mm Hg in most patients or
History of cerebrovascular disease History of transient ischemic attack or stroke ⬍130/80 mm Hg in patients with DM or CKD)
⬍
Insulin therapy for diabetes iis ideal. However, national guidelines do not
Preoperative serum Cr ⬎ 2 mg/dL rrecommend delaying surgery unless the pa-
ttient’s blood pressure is over 180/110 mm Hg.
Risk of perioperative cardiac complications including cardiac death, nonfatal MI, and
nonfatal cardiac arrest based on the number of risk factors (% [95% CI]).
Patients with poorly controlled hypertension
P
0 0.4 [0.1 to 0.8] have an increased risk of perioperative blood
h
ppressure lability, arrhythmias, and myocar-
1 1.0 [0.5 to 1.4] ddial ischemia. Such patients should have an
2 2.4 [1.3 to 3.5] EKG and renal function testing and should be
E
3 5.4 [2.8 to 7.9] eevaluated for secondary hypertension prior
tto elective surgery if this workup has not been
Adapted from Lee et al. (1999) and Devereaux et al. (2005). ppreviously performed. Then, improved blood
MI, myocardial infarction; CI, confidence interval. ppressure control should be pursued for 6 to 8
w
weeks prior to surgery if the urgency of the
iindicated procedure permits.

who are unable to walk up two flights of risk for adverse perioperative cardiovascu-
steps or four blocks (⬎4 METs) have an in- lar events, their use has, to date, not been
Pulmonary
creased risk of postoperative cardiovascular shown to improve patient outcomes. Patients with a known diagnosis of chronic
events. In addition to functional status, car- Based on the coronary artery revascular- obstructive pulmonary disease (COPD),
diovascular risk scoring systems are useful ization prophylaxis (CARP) trial and the DE- asthma, upper respiratory tract infections,
in quantifying the risk of a major periopera- CREASE-V pilot study, prophylactic coronary pneumonia, or other pulmonary conditions
tive cardiovascular event. The Revised Car- revascularization by percutaneous coronary warrant special attention. In addition to an
diac Risk Index (RCRI) is the tool we prefer intervention (PCI) or coronary artery bypass assessment of the patient’s smoking status,
given its simplicity and validation in multi- grafting does not appear to alter postopera- pulmonary functional baseline, need for sup-
ple clinical studies Table 3. tive outcomes. Accordingly, the current ACC/ plemental oxygen, and current pulmonary
In addition to basic laboratory studies, AHA guidelines recommend preoperative medications, use of a pulmonary risk index
patients with cardiovascular disease should PCI only in patients with an acute coronary can aid in the quantification of the periop-
have a baseline EKG. Additional testing op- syndrome for whom PCI is independently erative risk of respiratory failure (Table 4).
tions include transthoracic echocardiogra- indicated. Patients who undergo coronary Patients with pulmonary risk factors should
phy, exercise or chemical stress testing with revascularization with a bare metal stent have a preoperative CXR supplemented by
or without supplemental echocardiography should have surgery delayed for 4 to 6 weeks PFTs in those with unexplained dyspnea.
or radionuclide myocardial perfusion imag- but no more than 12 weeks when the inci- There is no role for routine preoperative ar-
ing, and coronary angiography. The 2007 dence of stent restenosis begins to rise. Con- terial blood gas testing. The benefits of peri-
American College of Cardiology/American versely, patients who have a drug-eluting operative smoking cessation are discussed
Heart Association (ACC/AHA) guidelines stent (DES) placed should have surgery de- below. If the patient has had a recent deterio-
reflect the most current recommended ap- layed for a year if possible while the patient is ration in pulmonary function in the recent
proach to the use of these additional stud- on dual antiplatelet therapy. Aspirin should past due to a reversible cause, elective sur-
ies (Fig. 1). Alternative algorithms have be continued in the perioperative period if at gery should be deferred until the patient re-
been proposed by the American College of all possible, and thienopyridine therapy (e.g., turns to their prior baseline. Patients with
Physicians (ACP) and by Fleisher and Eagle. clopidogrel) should be resumed as soon as COPD should be managed with an inhaled
In general, if the patient’s cardiovascular possible after surgery to minimize the risk of anticholinergic (e.g., ipratropium) and as
disease warrants immediate intervention stent thrombosis. needed inhaled beta-agonists. Patients with
(i.e., the cardiovascular symptoms are more Patients with unstable angina or a recent asthma should be maintained on their home
pressing than those that prompted surgical MI bear special consideration. Historic stud- medication regimen unless their current
consultation), additional studies are war- ies suggested that a significant and persis- symptom control is poor. In these cases, a
ranted. Although these algorithms serve to tent risk of reinfarction or death existed for step-up in therapy in the perioperative pe-
identify and further evaluate patients up to 6 months after an acute MI. However, riod is warranted. Prophylactic administra-
deemed to be at either intermediate or high with improved perioperative monitoring tion of glucocorticoids to asthmatics is not

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 27 10/28/11 10:15:09 PM

 28 Part I: Perioperative Care of the Surgical Patient

Functional capacity greater tan or

equal to 4 METs without symptoms

† †

†
†

Fig 1. 2007 ACC/AHA algorithm for the perioperative cardiovascular management of patients aged 50 and above undergoing non-
cardiac surgery (Adapted from Fleisher et al. 2007.) *Active cardiac conditions include unstable or severe angina, MI between 7 and
30 days prior, decompensated heart failure, significant arrhythmia, severe aortic stenosis, or symptomatic mitral stenosis. †Low risk
surgery includes endoscopic procedures, superficial procedures, cataract surgery, breast surgery, and ambulatory surgery; interme-
diate risk surgery includes intraperitoneal/intrathoracic surgery, carotid endarterectomy, head and neck surgery, orthopedic sur-
gery, and prostate surgery; vascular surgery includes aortic and other major vascular surgery (except carotid endarterectomy) and
peripheral vascular surgery. ‡Clinical risk factors are similar to the revised Cardiac Risk Index factors in Table 3 and include history
of ischemic heart disease, cerebrovascular disease, compensated or prior heart failure, diabetes mellitus, and renal insufficiency.

required unless they are maintained on sys- prepared to participate in early and aggres- the use of those with potential nephrotoxic
temic or high-dose inhaled steroids. In pa- sive postoperative lung expansion. effects. In addition, in the perioperative pe-
tients at high risk for perioperative pulmo- riod, intravascular volume status can be
nary complications, consideration should more difficult to gauge in this patient popu-
be given to use of spinal or epidural anesthe-
Renal lation; so we are aggressive with employing
sia over general anesthesia. Long-acting Chronic renal insufficiency with a serum Cr all available monitors to assure adequate
neuromuscular blockade (e.g., pancuronium) of ⱖ2 mg/dL is an independent predictor of intravascular volume to include use of a
should be avoided. If a laparoscopic surgical postoperative cardiac complications. In ad- pulmonary artery catheter in some cases.
option is available, this should be used over dition, the surgical team must take special Patients with end-stage renal disease
open surgery if possible. For postoperative care to avoid further kidney injury in these (ESRD) require coordination of perioperative
risk mitigation, an epidural catheter for an- patients by maintaining euvolemia, taking care between the surgical team, the anesthe-
algesia should be planned in these patients, appropriate precautions to avoid contrast- sia team, and nephrology. Preoperative elec-
and preoperative incentive spirometry teach- induced nephropathy, and by appropriately trolytes should be obtained in close proxim-
ing should be conducted so the patient is dosing all medications while minimizing ity to the procedure to ensure the serum

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 28 10/28/11 10:15:10 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 29

c be considered for surgery after careful

can
Table 4 Arozullah Respiratory Failure Index and the Associated Risk of
ppreoperative evaluation. Reports of hernior-
Respiratory Failurea

Perioperative Care of the Surgical Patient

rrhaphy outcomes in these patients (both
Preoperative predictor Points umbilical and inguinal) suggest that these
u
Type of surgery ooperations can be performed safely. Simi-
Abdominal aortic aneurysm 27 llarly, cholecystectomy has been reported in
Thoracic 21 ppatients with cirrhosis for a range of indica-
Neurosurgery, upper abdominal, peripheral vascular 14 ttions, and recent reports indicate that the
Neck 11 llaparoscopic approach is safe and appears
Emergency surgery 11 tto have improved outcomes when compared
Albumin ⬍3 g/dL 9 with open cholecystectomy. The preopera-
w
ttive preparation of these patients should fo-
BUN ⬎30 mg/dL 8 ccus on minimizing ascites, correcting vita-
Partially or fully dependent functional status 7 min deficiencies (especially vitamin K), and
m
History of COPD 6
aassessing for and correcting malnutrition.
Age
⬎70 years 6 EEndocrinopathies and Obesity
60 to 69 years 4 D
Diabetes mellitus is a common medical con-
Class Points Risk of respiratory failure (%) ddition present in up to 20% of surgical pa-
1 ⱕ10 0.5 ttients. As shown in Table 3, insulin-requiring
2 11 to 19 1.8 to 2.1
ddiabetes is a marker for increased postoper-
aative cardiac morbidity in the RCRI. Historic
3 20 to 27 4.2 to 5.3 gglycemic control is a known marker for post-
4 28 to 40 10.1 to 11.9 ooperative infections (pneumonia, wound
5 ⬎40 26.6 to 30.9 iinfection, UTI, and sepsis), and poor periop-
eerative glycemic control has been shown to
Adapted from Arozullah et al. (2000). ccorrelate with surgical complications and
a
Respiratory failure is defined as either mechanical ventilation for ⬎48 hours after surgery or reintubation and ddeath. Thus, careful attention must be paid
mechanical ventilation after initial postoperative extubation. bby the surgical team to cardiac risk modifi-
ccation in diabetic patients and to glucose
management throughout the entire periop-
m
erative period to assure optimal outcomes.
potassium is within normal limits and that In general, patients with mild cirrhosis A reliable measure of historic glycemic
there are no significant derangements in the (Child’s A or MELD ⬍ 10) tolerate surgery control over the previous 3 months is the he-
other values. If the patient is on hemodialy- well while patients with fulminant hepatic moglobin A1C (Hb A1C). If the Hb A1C is ⬎ 7%,
sis or peritoneal dialysis, the timing of pre- failure, severe hepatitis, extrahepatic com- postoperative infections are increased while
and postoperative dialysis should be decided plications, and advanced cirrhosis (Child’s C a preoperative glucose level of ⬎200 mg/dL
upon in advance. Patients who are on the or MELD ⬎ 15) are likely to have a poor is associated with an increased rate of post-
cusp of requiring renal replacement therapy postoperative outcome and should have operative deep wound infections. Perioper-
(RRT) require similar surveillance and coor- surgery delayed until their liver function can ative management of oral hypoglycemics
dination in the event that transient RRT is be optimized or they undergo a liver trans- and insulin is discussed below (see section
required for postoperative electrolyte man- plantation if possible. Patients with moder- on “Medication Management”).
agement, volume overload, or azotemia. ate cirrhosis (Child’s B or MELD 10 to 15) Patients with hypothyroidism should con-
tinue on their baseline medication regimen
Liver throughout t the postoperative period. Those
Table 5 Use of the MELD Score who w are nil per os (NPO) can have these med-
Patients with preexisting hepatic failure are for Preoperative Risk ications i safely held or converted to IV supple-
at increased risk for complications and death Assessment in Patients mentation m if a prolonged period of fasting is
after surgery. The Child–Turcotte and Child– with Cirrhosis anticipated.a Those with hyperthyroidism un-
Pugh classification schemes were originally Mortality (%) dergoing d surgery should achieve a euthyroid
developed to estimate the risk of death after MELD Score 7-day 30-day 90-day state s before surgical intervention and their
portal-caval shunting and have since been 0 to 7 1.9 5.7 9.7 antithyroid a medications should be continued
validated as a good estimate for death follow- up u until the time of surgery. If urgent surgery
ing a range of other surgeries. More recently, 8 to 11 3.3 10.3 17.7 is i required in a thyrotoxic patient, consulta-
the model for end-stage liver disease (MELD) 12 to 15 7.7 25.4 32.3 tion t with an endocrinologist is warranted.
score has also been used to assess periopera- 16 to 20 14.6 44.0 55.8 Obesity has been extensively evaluated as
tive risk in these patients (Table 5). An online a risk factor for poor perioperative outcomes.
calculator, which uses the patient’s age, ASA 21 to 25 23.0 53.8 66.7
Recent R evidence suggests that, in fact, there
class, and MELD score to calculate 7-day, ⱖ26 30.0 90.0 90.0 is i a so-called “obesity paradox” in that such
3-day, 90-day, 1-year, and 5-year predicted patients p have fewer complications than con-
mortality is also available at http://www. Adapted from Teh et al. (2007).
MELD, model for end-stage liver disease.
trols. t The exceptions to this paradox are
mayoclinic.org/meld/mayomodel9.html. wound w and thromboembolic complications

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 29 10/28/11 10:15:10 PM

 30 Part I: Perioperative Care of the Surgical Patient

including deep venous thrombosis (DVT) (e.g., lupus anticoagulant). If the patient’s lating factors reverse the neutropenia, they
and pulmonary embolism (PE). personal family history is strongly suggestive do not reliably reduce hospital length of stay
of an undiagnosed coagulopathy, consider- or culture-positive infections.
ation should be given to testing for von Wille-
Malnutrition brand’s disease using the triad of plasma von Rheumatologic
Preoperative malnutrition has been recog- Willebrand’s factor (VWF) antigen, plasma
nized as an important risk factor for postop- VWF activity, and factor VIII activity. Patients Patients with rheumatologic diseases have a
erative morbidity and mortality for over 70 who carry a diagnosis of von Willebrand’s high incidence of associated cardiovascular
years. Quantification of the degree of malnu- disease should be pretreated in consultation disease as well as unique pathology, which
trition and the correction of severe malnu- with a hematologist with either desmopres- increases the risk of perioperative complica-
trition preoperatively remain an important sin (DDAVP) for minor surgery if the patient tions. Patients with rheumatologic condi-
part of surgical management. Assessment of has previously responded or with VWF con- tions are often maintained on immune-mod-
nutritional status begins with a thorough centrate for major surgery. Patients with mild ulating medications such as glucocorticoids,
history and physical examination paying hemophilia A or B can similarly be pretreated methotrexate, and so-called biologic agents
careful attention to dietary changes, evi- with DDAVP while those with severe hemo- that interfere with the action of TNF and IL-1.
dence of malabsorption, and evidence for philia can be treated with specific factor con- The perioperative management of these med-
loss of lean body mass. The Subjective Global centrates (Factor VIII or IX) or activated Fac- ications is discussed in section on “Medica-
Assessment has been used to facilitate this tor VII in the presence of inhibitors. Patients tion Management.” In patients with rheuma-
evaluation. Laboratory testing should in- with thrombocytopenia (e.g., those with in- toid arthritis, lateral cervical spine films with
clude albumin, transferrin, and prealbumin herited thrombocytopenic purpura) should flexion and extension should be obtained
to assess the long-term, intermediate-term, have a preoperative platelet transfusion tar- within a year of surgery to assess for atlanto-
and short-term nutritional state of the pa- geting a minimum of 50,000/μL. axial subluxation. Patients with ankylosing
tient, respectively. If the patient is found to spondylitis with severe kyphotic deformities
be severely malnourished, surgery should be Malignancy and may be difficult to intubate, and thoracic cav-
delayed so that supplemental nutrition can ity restriction may require postoperative ven-
be administered. Enteral supplementation
Immunocompromise tilator support. Thus, preoperative anesthesia
is preferred if the patient can tolerate this Patients with malignancy and those on im- and critical care consultations should be con-
route; otherwise, parenteral nutrition (PN) munosuppressive medications or with an in- sidered. Likewise, patients with scleroderma
should be initiated. In this population, im- herited or acquired immunocompromised can present special anesthetic challenges, in-
provements in nutritional status are as- state frequently undergo surgery. The preop- cluding a small oral aperture, difficult intra-
sessed at regular intervals until surgery is erative evaluation should proceed as de- venous access, a propensity for vasospasm,
deemed safe (after 7 to 15 days in some stud- scribed above guided by the patient’s other prolonged response to local anesthetics, and
ies). Supplemental nutrition is then contin- medical conditions and nutritional status. a significant risk of aspiration due to esopha-
ued postoperatively until the patient can For patients on chemotherapy, the timing of geal dysmotility. In addition, preoperative de-
meet their caloric needs independently. the last dose of chemotherapy, the projected tection of pulmonary or myocardial involve-
cell count nadirs, and planned future therapy ment is essential; so consideration should be
should be discussed with the patients and given to obtaining PFTs, an arterial blood gas,
Coagulopathy their oncologist. For patients with HIV, a his- and echocardiography in addition to a CXR
Patients with inherited coagulopathies and tory of an AIDS-defining illness and their and EKG. Patients with psoriatic arthritis
those who are maintained on therapeutic an- current medication regimen should be elic- should be advised of the risk for a psoriatic
ticoagulation present special challenges with ited. Laboratory testing should include a CBC flare at both the surgical and the remote sites.
regards to achieving and maintaining post- with differential, chemistries, renal function, In addition, these patients may be at in-
operative hemostasis. Perioperative manage- and liver function studies. If malnutrition is creased risk for postoperative infection. Pa-
ment of anticoagulant and antiplatelet med- suspected by history and physical examina- tients with systemic lupus erythematosus
ications is discussed below (see section on tion, nutrition labs should be obtained. Pa- (SLE) are at increased risk for postoperative
“Medication Management”). The most com- tients with HIV should have a CD4 and a viral wound infection, renal insufficiency, and
mon intrinsic coagulopathies in surgical pa- load obtained as the former is a surrogate for thrombotic complications, including pulmo-
tients are von Willebrand’s disease and the immunocompetence while the latter has nary embolism. SLE patients with active dis-
hemophilias. Patients with chronic renal in- been specifically correlated with increased ease and imminent vital organ failure can be
sufficiency also have some baseline degree of perioperative complications at a level of treated with intravenous immunoglobulin in
platelet dysfunction. The surgical review of 30,000 copies/mL or greater. Patients with the perioperative period.
systems should specifically focus on a predi- neutropenia should have surgery delayed if at
lection for prolonged epistaxis, easy bruising, all possible. For those with neutropenia in PREOPERATIVE BEHAVIORAL
and any bleeding complications during pre- the postoperative state, development of fever
vious surgeries. If this evaluation is negative should prompt treatment with broad-spec-
MODIFICATION
for a bleeding history and the physical ex- trum antibiotics and, in some cases, an anti- In addition to risk modification interventions
amination does not reveal any petechiae or fungal agent as well. The role of colony stimu- discussed above, a number of preoperative
stigmata of chronic renal or liver disease, lating factors in neutropenic patients is behavioral modification strategies have been
routine testing of coagulation studies is not limited to those with additional indicators investigated in an attempt to improve surgical
indicated. If these studies are obtained and that prolonged neutropenia will be poorly outcomes. The most widely published inter-
are abnormal, a mixing study is required to tolerated such as poor functional status, poor ventions include smoking cessation, preoper-
determine whether the abnormality is the nutrition, an open wound, or active infection. ative weight loss, and various preoperative
result of a factor deficiency or an inhibitor It has been shown that although these stimu- exercise regimens (so-called prehabilitation).

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 30 10/28/11 10:15:10 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 31

Historic evidence suggested that smoking regimen should be resumed or revised in Cr clearance ⬍50 mL/min. Bridging antico-
cessation within 8 weeks of surgery actually consultation with their primary care physi- agulation with either intravenous heparin

Perioperative Care of the Surgical Patient

results in increased pulmonary complica- cian or medical specialist. or therapeutic low-molecular-weight hepa-
tions, presumably from bronchorrhea. On Because of the risk of hemorrhage with rin should be used in patients at high or in-
the other hand, several smaller studies indi- surgical intervention, the management of termediate risk for a thromboembolic event.
cate that some complications such as wound outpatient therapeutic anticoagulation in For many indications including atrial fibril-
infections and seromas are reduced if smok- the perioperative period bears special men- lation, individual patient risk stratification
ing cessation occurs as early as 4 weeks prior tion. Patients are maintained on anticoagula- should be conducted to determine the need
to surgery although these studies have been tion for a range of indications from the man- for bridge therapy. Bridge therapy with hep-
inadequately powered to detect differences agement of thromboembolic events to arin should be held 4 to 5 hours prior to sur-
in pulmonary complications. anticoagulation for prosthetic heart valves. gery while low-molecular-weight heparin
Although obesity is associated with an The indication for anticoagulation dictates should be held 24 hours prior. As mentioned
overall increase in cardiovascular disease the need for therapeutic “bridge” therapy above, postoperative resumption of bridge
as well as perioperative wound and throm- with a short acting agent while both the sur- therapy or oral anticoagulants depends on
boembolic complications, the effect of pre- gical procedure and the indication for antico- the risk of postoperative bleeding but gener-
operative weight loss on these risks has not agulation are used to develop a postoperative ally can be considered after 24 hours.
been well studied. In patients preparing for anticoagulation plan. For patients with me- Patients on antiplatelet therapy also com-
bariatric surgery, preoperative weight loss chanical heart valves, the 2006 ACC/AHA monly face noncardiac surgery. The avail-
has been correlated with more durable guidelines are the most straightforward to ability of thienopyridines (e.g., clopidogrel)
postoperative weight loss. However, im- apply. In a patient with a bi-leaflet mechani- and the significant increase in DES implan-
proved perioperative surgical outcomes in cal aortic valve and no additional risk factors tation have also made the scenario of dual
terms of fewer surgical complications, car- for hypercoagulability (e.g., atrial fibrillation antiplatelet therapy in the surgical patient
diovascular events, or pulmonary compli- or previous thromboembolism among oth- increasingly common. Patients on antiplate-
cations have yet to be documented for ers), warfarin can be held 48 to 72 hours prior let therapy should have a careful history
either bariatric surgery or other surgical to surgery with an INR checked on the day of taken to determine their indication for
procedures in the obese population. surgery targeting less than 1.5. All other pa- treatment—primary prevention versus pro-
Because functional status correlates tients (e.g., those with mechanical mitral phylaxis against stent thrombosis. As de-
strongly with cardiovascular and pulmo- valves and those with additional risk factors scribed above, in patients with coronary
nary complication rates, several groups for thromboembolism or hypercoagulability) stents, the timing of surgery should take into
have investigated the benefits of specifically should be managed with bridge therapy. consideration the type of stent and the age
targeting improved functionality in the pre- These guidelines recommend the use of ther- of the stent. Similarly, the risk of hemorrhage
operative period. Recent evidence suggests apeutic heparin during this time although from the surgery should be considered. Cat-
that a simple regimen of daily walking and therapeutic low-molecular-weight heparin is aract surgery is often performed in the pa-
deep breathing exercises improves exercise included in other guidelines. Postoperatively, tient on aspirin as is coronary artery bypass
capacity in patients awaiting abdominal in patients who do not require bridge therapy, grafting. If aspirin is held, this should be 7 to
surgery, an effect that is preserved postop- warfarin is resumed 24 hours after surgery. 10 days prior to surgery and then resumed
eratively. Similarly, preoperative inspiratory Those on bridge therapy have their anticoag- when surgical hemostasis is assured, typi-
muscle training appears to result in fewer ulation resumed as soon as the bleeding risk cally within or at 24 hours of the operation.
pulmonary complications and a shorter permits, usually at 24 hours after surgery. The use of clopidogrel or another thienopyri-
hospital stay. In all other conditions for which patients dine either alone or in combination with
are on therapeutic anticoagulation, the pe- aspirin should be elicited as well. Some lim-
MEDICATION MANAGEMENT rioperative management of this regimen re- ited data in the vascular surgery literature
quires an estimate of the bleeding risk from suggests that with careful attention to he-
Adult patients facing surgery are often tak- surgery and the risk of a perioperative mostasis, even major vascular operations
ing a number of medications for manage- thromboembolic complication. There are can be done on dual antiplatelet therapy if
ment of their chronic medical conditions. no guidelines to inform practice, but some necessary with no significant increase in pe-
Prior to surgery, a complete list of all medi- general practice recommendations can be rioperative bleeding complications.
cations and herbal supplements must be made from the current literature on this Patients with rheumatologic diseases as
obtained from the patient and reconciled topic. Patients with a recent episode of ve- well as many other conditions ranging from
with the most recent list of medications in nous or arterial thromboembolism should reactive airway disease to inflammatory
their medical record. The most common have surgery delayed for at least 1 month if bowel disease are maintained on systemic
outpatient medications and their recom- at all possible. Minor surgery (e.g., outpa- glucocorticoids. Although historically, these
mended perioperative management are tient herniorrhaphy or cataract surgery) can patients were given additional steroid doses
summarized in Table 6. In general, essential be done safely in patients on warfarin so in the perioperative period—so-called stress
medications are continued through surgery long as the INR is at the low end of the thera- dose steroids—recent evidence has called
with any doses due at the time of surgery peutic range. Those undergoing major sur- this routine practice into question. Patients
taken with a sip of water. Essential medica- gery should have warfarin therapy withheld who have been on prednisone doses of 20 mg/
tions and those with a significant risk of re- approximately 5 days prior to surgery with day (or the equivalent of another agent) for 3
bound effects (e.g., beta blockers and cloni- an INR checked on the day of surgery. Those weeks or more or who have a Chushingoid
dine) are continued in an enteral, parenteral, on the orally available direct thrombin in- appearance should be presumed to have hy-
transdermal, or inhaled form during the hibitor dabigatran (Pradaxa) should have pothalamic–pituitary–adrenal (HPA) sup-
early postoperative period. As soon as fea- this withheld 1 to 2 days before surgery if re- pression, which will require supplemental
sible, the patient’s outpatient medication nal function is normal or 3 to 4 days with a steroid dosing. For patients on lower doses,

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 31 10/28/11 10:15:11 PM

 32 Part I: Perioperative Care of the Surgical Patient

Table 6 Perioperative Management of Outpatient Medications and Herbal Supplements

Medication class Comment
Cardiovascular Medications
Beta blockers and non-dihydropyridine calcium channel Acute withdrawal of beta blockers can increase morbidity and mortality. Continue
blockers perioperatively. Consider substituting a beta blocker in patients taking non-
dihydropyridine calcium channel blockers.
Alpha-2 agonists Acute withdrawal can precipitate rebound hypertension although this is usually at
higher oral doses. Continue perioperatively.
ACE inhibitors, ARBs Generally continue perioperatively when blood pressure is stabilized and renal
function is at baseline. Consider holding one preoperative dose in patients with a
low baseline blood pressure.
Dihydropyridine calcium channel blockers Resume when blood pressure has stabilized.
Diuretics Resume when blood pressure has stabilized and renal function is at baseline.
Statins Withdrawal may increase perioperative cardiovascular events. Continue periopera-
tively.
Other lipid lowering agents Increased risk of myopathy perioperatively with some (e.g., niacin); others interfere
with GI absorption (e.g., colestipol). Hold perioperatively.
Agents Affecting Hemostasis
Aspirin Balance individual patient risk of cardiovascular event versus the consequences of
a bleeding complication. Hold for 7 to 10 days preoperatively if bleeding would
cause significant morbidity. Resume when hemostasis is adequate (e.g., within
12 to 24 hours of surgery).
Thienopyridines (e.g., clopidogrel and ticlopidine) If given for a DES placed within the past year, consider delaying surgery. Hold for 5
to 10 days preoperatively if bleeding would cause significant morbidity. Resume
when hemostasis is adequate (e.g., within 12 to 24 hours of surgery).
Dipyridamole Hold for 2 days preoperatively if bleeding would cause significant morbidity.
NSAIDs/COX-2 Inhibitors Hold NSAIDs for 24 to 72 hours preoperatively. COX-2 inhibitors have minimal
effect on platelet function but have potential for renal toxicity and can lead to
cardiovascular events.
Heparin/LMWH Management depends on the indication and dose. Administer prophylactic doses
preoperatively if indicated according to the patient’s risk profile for a VTE
complication; Therapeutic doses are generally held for 6 to 12 hours preopera-
tively and are resumed when hemostasis is assured postoperatively (usually
within 12 to 24 hours).
Warfarin See discussion in the body of the chapter for recommendations on holding and
resuming warfarin.
Dabigatran See discussion in the body of the chapter for recommendations on holding and
resuming dabigatran (Pradaxa).
Pulmonary Medications
Inhaled bronchodilators Continue perioperatively
Leukotriene inhibitors (e.g., montelukast [Singulair]) Resume when tolerating oral medication
Theophylline May cause arrhythmias and neurotoxicity. Hold perioperatively.
Diabetic Medications
Insulin See discussion in the body of the chapter. Determine the sensitivity factor for
patients using an insulin pump.
Oral hypoglycemics Hold on the morning of surgery. Resume when tolerating a regular diet and risk of
returning to NPO status is minimal. Ensure normal renal function prior to
resuming metformin.
Other Endocrine/Hormonal Agents
Thyroxine (T4) Can be safely held for 5 to 7 days postoperatively; resume when tolerating oral
medications. Parenteral dose is approximately 80% of the oral dose
Oral contraceptives, HRT, and selective estrogen receptor In patients at increased risk for VTE, discontinue 6 weeks preoperatively. Resume
modulators (e.g., tamoxifen) when the risk of VTE has resolved.
Glucocorticoids See discussion in the body of the chapter.
(continued )

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 32 10/28/11 10:15:11 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 33

Table 6 Perioperative Management of Outpatient Medications and Herbal Supplements (Continued)

tientt
al Patient
Medication class Comment

Pati
Rheumatologic Agents

gical
th Surgical
Surgi
Antirheumatic agents There is no definitive increased risk of wound complications with these agents.
Methotrexate can be continued preoperatively in patients with normal renal

Care off the

function; sulfasalazine and azathioprine should be held for 7 days preoperatively;
hydroxychloroquine can be continued periopeartively; biologic agents (e.g.,

tive Care
etanercept [Humira] and rituximab [Rituxin]) should be held for 7 or more days
preoperatively.

PPerioperative
ati
Gout agents Hold on the morning of surgery. Resume when tolerating oral medications.

erioper
Neurologic Agents and Chronic Opioids

i
Antiepileptic agents Continue perioperatively. In patients at low risk of a generalized seizure, resume
when tolerating oral medications. In patients at increased risk, administer a
parenteral antiepileptic agent.
Anti-Parkinson agents Anti-Parkinson agents increase the risk of perioperative hemodynamic lability and
arrhythmias while abrupt withdrawal may result in neuroleptic malignant
syndrome and worsening of Parkinsonian symptoms. Dopamenergic agents
should be tapered to the lowest possible dose 2 weeks preoperatively and
restarted at this dose postoperatively.
Chronic opioids Patients on methadone should have their maintenance dose continued periopeart-
ively. Methadone can be given subcutaneously or intramuscularly (at 1/2 to 2/3 of
the usual dose divided into two to four equal doses) for patients who cannot
tolerate oral medications.
Psychotropic Medications
SSRI May interfere with platelet aggregation; so balance the risk of bleeding against the
risk of exacerbating the underlying disorder.
MAOI Management of an MAOI perioperatively should involve consultation with an
anesthesiologist and the patient’s psychiatrist.
Lithium Consider checking thyroid function tests preoperatively. Continue perioperatively;
monitor for nephrogenic DI and serum lithium levels.
Antipsychotics Continue with caution in patients at risk for exacerbation of psychosis; monitor QT
interval; be aware of drug–drug interactions.
Anxiolytics Continue perioperatively if used on a chronic, routine basis.
Psychostimulants (e.g., methylphenidate [Ritalin]) Hold on the day of surgery. Resume when the patient is stable.
Other
Herbal medications Some are associated with an increased risk of MI and stroke (ma huang), bleeding
(ginko, ginseng, and garlic), hypoglycemia (ginseng), or altered drug effects. Hold
for 7 days preoperatively.

ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; NSAID, nonsteroidal anti-inflammatory drug; LMWH, low-molecular-weight heparin; HRT, hormone
replacement therapy; VTE, venous thromboembolism; SSRI, selective serotonin reuptake inhibitor; MAOI, monoamine oxidase inhibitor; DI, diabetes insipidus; MI, myocardial
infarction.

our usual approach is to resume their home blocker or statin in patients with cardiovas- these results, the ACC/AHA released a fo-
dose or the equivalent in the postoperative cular risk factors in the immediate preop- cused update to their perioperative guide-
period and observe for hemodynamic insta- erative period. Enthusiasm for initiation of lines in 2009, which recommend against the
bility or significant malaise as a trigger for beta blockers around the time of surgery initiation of high-dose beta blockade with-
supplemental steroid dosing. An alternative has been recently tempered by the results of out dose titration in beta-blocker-naïve pa-
strategy is to perform specific testing for the POISE trial and a subsequent meta- tients undergoing surgery. Similarly, the in-
HPA suppression using either high- or low- analysis, which indicated that although this dications for perioperative statin initiation
dose ACTH stimulation testing. Those who practice reduces the incidence of periopera- in those without classic indications for lipid
respond normally will likely not need supple- tive MI, the incidence of perioperative stroke lowering therapy have been clarified by re-
mental steroid dosing postoperatively. is increased and all-cause mortality is either cent studies. These indicate that vascular
There has been some recent interest in increased or, at best, unchanged (although surgery patients likely benefit from this in-
perioperative risk reduction through initiat- the dose of beta blockade in the POISE trial tervention with fewer episodes of myocar-
ing new medications around the time of was moderately aggressive at 200 mg of ex- dial ischemia and a lower perioperative car-
surgery. Examples include starting a beta tended release metroprolol daily). In light of diac death rate.

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 33 10/28/11 10:15:12 PM

 34 Part I: Perioperative Care of the Surgical Patient

PREOPERATIVE SPECIALTY RISK REDUCTION IN THE resulted in the introduction of the Universal
CONSULTATION IMMEDIATE PERIOPERATIVE Protocol for Preventing Wrong Site, Wrong
Procedure, Wrong Person Surgery in 2004.
Patients with complex or refractory medical PERIOD This protocol consists of three components:
problems may benefit from preoperative con- Multiple interventions and quality improve- preoperative verification of patient informa-
sultation by a general medical internist, geri- ment measures have been advanced in re- tion, surgical site marking to prevent ambi-
atrician, or other medical specialist. Studies cent years to reduce the risk of adverse guity with unilateral procedures, and con-
evaluating patient outcomes and utilization events in the OR ranging from wound infec- ducting a presurgical timeout to review the
of medical resources with this practice have tions to wrong-site surgery. This section re- planned procedure and resolve any con-
generated mixed results. However, provided views some of the processes that now rou- cerns. Many hospitals promote use of the
the consultant’s role is clearly delineated in tinely occur as a result of these initiatives final presurgical time out as an opportunity
the initial request and the consultant makes and the management decisions that are for the entire OR team to review the surgical
evidence-based recommendations, surgeon most often made from the time the patient plan and to confirm that all necessary medi-
satisfaction is high and the surgical patient’s enters the preoperative area until the surgi- cations have been given. Despite (or perhaps
care is likely to improve. It should be evident cal intervention commences. In our view, because of) this increased emphasis on pa-
from the discussion above that asking a medi- surgeons should continue to take a leading tient safety, the number of reported wrong-
cal consultant to “clear” a patient for surgery role in directing the surgical team during site procedures has steadily increased since
is a nonsequitur. Instead, the surgeon should this time in the patient’s care as it sets the the introduction of the Universal Protocol.
ask specific questions relating to risk stratifi- stage for the entire postoperative course. The anticipation by proponents of this cul-
cation and perioperative management of par- ture of safety is that as the number of reports
ticular disease processes or medications. With SURGICAL CHECKLIST AND rise and the freedom to raise safety concerns
this approach, the consultant’s input is more in the OR disseminates, the frequency of
likely to be useful to the surgeon and the surgi-
PREOPERATIVE TIMEOUT major errors will decrease significantly.
cal team in making decisions on surgical tim- Increased awareness of wrong-site surgery The Safe Surgery Saves Lives Study Group
ing and perioperative management strategies. led to a summit to address this problem in has recently evaluated an intraoperative
Postoperatively, continued involvement of 2003 and 2007. Attended by leaders from checklist developed from the World Health
these consultants or a medical hospitalist can, multiple surgical organizations and the Joint Organization (WHO) guidelines for improv-
in some cases, improve the care of the patient Commission on Accreditation of Healthcare ing perioperative surgical safety. The 19-
and should be considered by the surgeon. Organizations (JCAHO), the 2003 summit item checklist used by this group (Fig. 2)

SURGICAL SAFETY CHECKLIST (FIRST EDITION)

Before induction of anaesthesia Before skin incision Before patient leaves operating room

SIGN IN TIME OUT SIGN OUT

PATIENT HAS CONFIRMED CONFIRM ALL TEAM MEMBERS HAVE NURSE VERBALLY CONFIRMS WITH THE
• IDENTITY INTRODUCED THEMSELVES BY NAME AND TEAM:
• SITE ROLE
• PROCEDURE THE NAME OF THE PROCEDURE RECORDED
• CONSENT SURGEON, ANAESTHESIA PROFESSIONAL
AND NURSE VERBALLY CONFIRM THAT INSTRUMENT, SPONGE AND NEEDLE
SITE MARKED/NOT APPLICABLE • PATIENT COUNTS ARE CORRECT (OR NOT
• SITE APPLICABLE)
ANAESTHESIA SAFETY CHECK COMPLETED • PROCEDURE
HOW THE SPECIMEN IS LABELLED
PULSE OXIMETER ON PATIENT AND FUNCTIONING ANTICIPATED CRITICAL EVENTS (INCLUDING PATIENT NAME)

DOES PATIENT HAVE A: SURGEON REVIEWS: WHAT ARE THE WHETHER THERE ARE ANY EQUIPMENT
CRITICAL OR UNEXPECTED STEPS, PROBLEMS TO BE ADDRESSED
KNOWN ALLERGY? OPERATIVE DURATION, ANTICIPATED
NO BLOOD LOSS? SURGEON, ANAESTHESIA PROFESSIONAL
YES AND NURSE REVIEW THE KEY CONCERNS
ANAESTHESIA TEAM REVIEWS: ARE THERE FOR RECOVERY AND MANAGEMENT
DIFFICULT AIRWAY/ASPIRATION RISK? ANY PATIENT-SPECIFIC CONCERNS? OF THIS PATIENT
NO
YES, AND EQUIPMENT/ASSISTANCE AVAILABLE NURSING TEAM REVIEWS: HAS STERILITY
(INCLUDING INDICATOR RESULTS) BEEN
RISK OF >500ML BLOOD LOSS CONFIRMED? ARE THERE EQUIPMENT
(7ML/KG IN CHILDREN)? ISSUES OR ANY CONCERNS?
NO
YES, AND ADEQUATE INTRAVENOUS ACCESS HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN
AND FLUIDS PLANNED WITHIN THE LAST 60 MINUTES?
YES
NOT APPLICABLE

IS ESSENTIAL IMAGING DISPLAYED?

YES
NOT APPLICABLE

Fig 2. Perioperative checklist. (Adopted from the WHO guidelines for safe surgery, 2008.)

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 34 10/28/11 10:15:12 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 35

emphasizes communication between the lines stratify patients into low-, moderate-, shortly postoperatively. This therapy should
patient and all the various surgical team and high-risk categories based principally be continued through the inpatient course

Perioperative Care of the Surgical Patient

members in the immediate preoperative on the nature of the surgical procedure—an in most cases. High-risk general surgical pa-
period and then focuses the team on criti- approach that relies on overall group risk tients, who have undergone major oncologic
cal decisions and communication points in assessment as opposed to individual risk surgery should also be considered for ex-
the OR and at the conclusion of the proce- assessment. Although some investigators tended chemoprophylaxis for up to 28 days,
dure. Use of this checklist in eight different have attempted to develop individual pa- even as an outpatient.
hospitals in eight countries resulted in tient risk assessment models, to date, none
fewer postoperative complications, includ- of these models have been validated. In fact, POSTOPERATIVE ILEUS
ing death. This report and others highlight it appears with few exceptions that the
the importance of communication between principal predictor of risk is the primary PREVENTION
the surgeon, anesthesiologist, OR nurse, reason for the patient’s hospitalization. Patients undergoing bowel resection are at
surgical technician, and the patient to en- Mechanical thomboprophylaxis includes risk for development of a postoperative
sure that the planned surgical procedure is intermittent pneumatic compression de- ileus. The recent availability of peripherally
conducted safely and unplanned intraoper- vices, venous foot pumps, or graduated acting mu-opioid receptor antagonists
ative contingencies are readily identified compression stockings. These modalities (PAM-OR) such as alvimopan (Entereg) al-
and well managed. have been shown to reduce the risk of DVT lows surgeons to preemptively treat patients
in numerous patient populations. However, at risk for postoperative ileus. The first dose
PREVENTION OF DEEP they have not been demonstrated to reduce is given orally from 30 minutes to 5 hours
the rate of PE or death, and compliance with prior to surgery and is then continued dur-
VENOUS THROMBOSIS their use is often poor in the postoperative ing the inpatient course. Use of this preven-
Venous thromboembolic (VTE) complica- period. Nonetheless, they are at low risk pre- tive strategy appears to result in earlier re-
tions are an all too common perioperative ventive measure that can be initiated prior turn of bowel function by multiple measures
complication. Over half of surgical patients to induction of anesthesia in most surgical and shorter inpatient hospital length of stay.
are at moderate risk or greater for VTE patients. Those patients at moderate to high Use of chronic narcotics is a contraindica-
events in the postoperative period, and PE risk of VTE should be considered for chemo- tion to use of this medication, and hospitals
is still the most common preventable cause prophylaxis starting preoperatively within 2 that wish to offer this medication must par-
of hospital death. In a recent study of surgi- hours of surgery. If the patient is to receive ticipate in the ENTEREG Access Support
cal inpatients in 358 hospitals in 32 differ- an epidural catheter, local policies should be and Education (E.A.S.E.™) Program.
ent countries, although 64.4% of patients developed weighing the risk of VTE versus
were found to be at-risk for VTE, only 58.5% an epidural hematoma as detailed in the WOUND INFECTION
of patients received appropriate VTE pro- American Society of Regional Anesthesia
phylaxis. The American College of Chest and Pain Medicine (ASRA) evidence-based The Surgical Care Improvement Project
Physicians Evidence-based Clinical Practice guideline on regional anesthesia in the pa- (SCIP) sought to reduce postoperative com-
Guidelines (8th edition) on the Prevention tient receiving antithrombotic or throm- plications (primarily SSI and VTE) by 25%
of Venous Thromboembolism have been bolytic therapy. In patients at moderate and from 2006 to 2010. This broad-based initia-
used to establish local policies in many hos- greater risk of VTE perioperatively, chemo- tive supported by numerous national organi-
pitals and serve as a benchmark for best prophylaxis should be started or resumed as zations used a number of quality measures
practice in this area (Table 7). These guide- soon as bleeding risk is acceptably low, often to achieve this goal by promoting evidence-
based practice. SCIP quality measures spe-
cific to perioperative infectious complica-
tions include timely administration of
pprophylactic antibiotics (within 1 hour prior
Table 7 Summary of the Level of Thromboembolism Risk and Recommended tto the incision), use of appropriate antibiot-
VTE Prophylaxis in Hospitalized Patients from the American College of
Chest Physicians Evidence-Based Clinical Practice Guideline on the iics for SSI prophylaxis, timely discontinua-
Prevention of Venous Thromboembolism (8th Edition) ttion of prophylactic antibiotics (within 24
hours of the end of the operation for noncar-
h
Risk group Group characteristics DVT risk without prophylaxis Suggested prophylaxis ddiac surgery or 48 hours for cardiac surgery),
Low Minor surgery in ⬍10% No specific prophylaxis; aand appropriate hair removal (no hair re-
mobile patients early, “aggressive” moval or use of clippers). Additional SCIP
m
ambulation measures relating to infectious complica-
m
Moderate Most general surgery 10% to 40% LMWH, LDUH BID or ttions include use of intraoperative tempera-
patients TID, fondaparinux tture management, early removal of indwell-
Moderate VTE risk and Mechanical prophylaxis iing urinary catheters, and glycemic control
high bleeding risk oon the morning after surgery in cardiac pa-
High Major trauma, SCI 40% to 80% LMWH, fondaparinux, ttients. Evidence of the impact of compliance
warfarin (INR 2 to 3) w
with these measures is just now emerging—
High High VTE risk and Mechanical prophylaxis iinitial reports suggest that while global com-
bleeding risk ppliance may result in a small reduction in SSI,
ccompliance on individual measures results
From Geerts et al. (2008). iin little or no improvement in SSI rates.
LMWH, prophylaxis dose low molecular weight heparin; LDUH, low-dose unfractionated subcutaneous heparin;
VTE, venous thromboembolism; SCI, spinal cord injury; INR, international normalized ratio. Recommended perioperative antimicro-
bbial prophylaxis regimens are periodically

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 35 10/28/11 10:15:12 PM

 36 Part I: Perioperative Care of the Surgical Patient

updated in several publications including closely spaced fascial bites resulting in a su- POSTOPERATIVE RISK
Treatment Guidelines from the Medical ture to wound length ratio of ⱖ4:1 may re- MINIMIZATION
Letter (2009). The role of several additional duce the incidence of SSI. Likewise, there is
SSI reduction strategies have been clarified growing interest in using antibiotic-coated Relative to preoperative office visits and OR
in the recent literature, including topical suture material that may also reduce the time, the postoperative course typically
antisepsis, the role of mechanical bowel rate of wound infections. represents the time in which the patient
preparation (MBP) for colorectal surgery, Oxygen supplementation in the immedi- has the most direct contact with the health-
fascial closure techniques, and periopera- ate postoperative period has also been evalu- care system. This poses both advantages
tive oxygen supplementation. A recent study ated by several randomized controlled trials, and disadvantages—the patient is immedi-
comparing skin antisepsis with a chlorhexi- including the recently published Periopera- ately at hand so that care can be directly
dine–alcohol preparation versus betadine tive Oxygen Fraction (PROXI) study. Although monitored, although as the complexity of
in a range of clean contaminated surgical the original US-based study demonstrated the system and the duration of contact in-
cases demonstrated significantly reduced increased infections in the oxygen-treated creases, so to does the possibility of error.
SSI rates with the use of chlorhexidine– group and the PROXI study showed no ben- The overall goals of this phase of care should
alcohol. However, there was no description efit to 80% O2 supplementation for 2 hours be to restore the patient to their preopera-
of whether the betadine was allowed to dry, postoperatively, three other studies have tive functional level or to an even higher
and a betadine–alcohol preparation was shown a benefit to various types of O2 sup- functional level as quickly as possible while
not included in the study. In addition, use of plementation. Consequently, pooled analysis minimizing iatrogenic events and nosoco-
chlorhexidine-containing solutions is not of these results still falls in favor of perioper- mial infections. Recent advances in postop-
recommended for preparation of exposed ative hyperoxia although the likely benefit is erative care include the introduction of
mucosal surfaces and alcohol-based prepa- relatively small. clinical care pathways, development of a
rations are generally considered too risky systematic approach to care provider hand-
for use in emergency operations where INTRAOPERATIVE offs, recognition of the importance of early
enough time may not be afforded for the al- mobilization even in an intensive care unit
cohol to dry prior to the use of electrocau-
RESUSCITATION (ICU) setting, refinement of our use of post-
tery. Nonetheless, chlorhexidine–alcohol Inappropriate management of intravenous operative organ support devices and moni-
preparation appears to be a good choice for fluid volumes during surgery can result in a tors, and clarifying the management goals
a range of surgical procedures. number of postoperative complications for chronic illnesses (e.g., diabetes mellitus)
MBP has been a mainstay of periopera- ranging from ranging from pulmonary and in the postoperative time period.
tive surgical practice aimed at reducing renal dysfunction to anastamotic failure
anastamotic and wound complications for and sepsis. Achieving the appropriate bal- CLINICAL PATHWAYS
decades. However, systematic study by mul- ance of adequate intravascular volume and AND HANDOFFS
tiple investigators and subsequent meta- oxygen delivery during the surgical proce-
analyses have not convincingly demon- dure has proven difficult, however. This dif- Clinical pathways are tools which incorpo-
strated any benefit to this practice with ficulty arises for many reasons, mostly be- rate evidence-based practice guidelines into
respect to either of these complications. In cause direct measures of intravascular a timeline, which is then tracked so that de-
fact, there may be a slight reduction in volume and end-organ perfusion are not viations can be monitored. Hospitals and
anastamotic leakage when preoperative readily available while estimates of intraop- clinical services may develop these pathways
MBP is not performed, although, as of 2003, erative bleeding and insensible losses are to communicate expected postoperative
MBP was still widely practiced by colorectal notoriously inaccurate. Furthermore, a events to patients and support staff while en-
surgeons. Current guidelines leave the use standard nomenclature for the various fluid suring the consistent use of evidence-based
of MBP to the discretion of the surgeon for administration strategies is lacking, leading practice for a given disease process. They are
open low anterior resection and all laparo- to imprecise and variable definitions from best applied to common surgical procedures
scopic colonic procedures where the site of study to study. Recognizing these limita- within moderate- to high-volume centers.
the tumor may not be immediately obvious tions, it has become clear that either too Examples include coronary artery bypass
and where intraoperative colonoscopy may much or too little intravenous fluid admin- graft surgery, laparoscopic Roux-en-Y gastric
be required. For all other colonic resections, istration of any type is harmful. In major bypass, and laparoscopic cholecystectomy.
preoperative MBP can be safely eliminated. abdominal operations where additional Use of these pathways has been shown to
Fascial closure techniques for abdomi- monitoring is justified, a “goal-directed” ap- standardize patient care while reducing
nal operations have also been evaluated proach based on surrogates for intravascu- length of hospital stay and use of resources
over many years searching for the optimal lar volume measurement (e.g., esophageal with improved patient satisfaction.
method, which reestablishes abdominal Doppler measurement of changes in peak Multiple forces within healthcare from
domain while minimizing the risk of post- aortic stroke velocity or arterial waveform resident work hour restrictions to changing
operative wound complications ranging variability) while monitoring indicators of practice models have increased the fre-
from superficial wound infections to com- oxygen consumption such as ScvO2 is ap- quency of patient handoffs between provid-
plete dehiscence with evisceration. Most pealing. Combining this approach with a ers. This represents both a time when criti-
studies evaluating fascial closure methods relatively restrictive (but not too restrictive) cal information can be reviewed and
use incisional hernia as the primary end- background of intravenous fluid adminis- summarized and a time where lapses in
point, and until recently, SSI was thought to tration (e.g., 8 to 12 mL/kg/h) appears to communication can ultimately lead to poor
not be affected by the technique of fascial balance the various risks of respiratory fail- patient care. Approaches to minimizing the
closure. However, a recent study suggest ure, renal insufficiency, wound infections, latter include use of a standardized ap-
that when using a running absorbable su- congestive heart failure, and postoperative proach to handoffs such as the Situation-
ture technique, relatively small (5 to 8 mm), arrhythmia. Background-Assessment-Recommendation

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 36 10/28/11 10:15:13 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 37

model, specific training on how to perform a on clonidine should have this resumed early quate calories due to critical illness but the
comprehensive patient handoff, and proc- in the postoperative course. Angiotensin- gastrointestinal system is functional, en-

Perioperative Care of the Surgical Patient

tored simulation training on performing converting enzyme (ACE) inhibitors and teral support is preferred. In cases where
handoffs. There is emerging evidence that angiotensin receptor blockers (ARBs) are enteral support is not possible or only par-
such efforts do indeed avoid lapses in pa- generally resumed when intravascular vol- tial enteral support can be achieved, PN is
tient care. ume shifts have subsided and renal func- used. When this strategy is chosen, care
tion is shown to either remain at baseline or must be taken to meticulously care for the
returns to baseline. Similarly, after major central venous catheter to avoid blood-
POSTOPERATIVE MONITORING surgery, diuretics are resumed when the pa- stream infections, glycemic control should
AND MANAGEMENT OF CHRONIC tient is ready to mobilize fluid or the patient be maintained in a “reasonable” range as
is determined to have little risk for becom- described above often with insulin added to
MEDICAL ILLNESSES ing excessively dehydrated. the PN mix, protein doses are initially esti-
Postoperatively, patients with chronic med- Patients with chronic pulmonary condi- mated based on the patient’s diagnosis and
ical illnesses require monitoring of these tions should be resumed on their home other chronic conditions and then adjusted
illnesses and a plan for resuming their regimen of inhaled beta agonists and anti- to avoid azotemia, and fat is used sparingly
home medication regimen. Our general ap- cholinergics via metered dose inhaler or balancing the avoidance of fatty acid defi-
proach to postoperative medication man- nebulizer either orally or in-line with the ciency against the immunosuppressive ef-
agement in patients with chronic medical ventilator. Inhaled and systemic glucocorti- fects of long-chain fatty acids and the con-
conditions is included in Table 6. Regarding coids for control of reactive airway disease cern that cholestasis and PN-associated
postoperative monitoring, selecting the ap- should similarly be continued postopera- hepatic injury may result from intravenous
propriate level of monitoring usually de- tively. Leukotriene inhibitors (e.g., montelu- fat formulations currently available in the
pends on local hospital policies and unit kast [Singulair]) can be resumed when the United States.
expertise. In some cases, the type of surgery patient is taking oral medications. Theo- Patients with rheumatologic conditions
will dictate the level of care required such phylline should be discontinued periopera- should generally have their medications re-
as craniotomy patients who need frequent tively given its narrow therapeutic window. sumed with the initiation of a postoperative
neurologic exams or vascular surgery pa- Surgical intervention can result in poor diet. Patients taking methotrexate should
tients require frequent pulse checks in a glycemic control in diabetic patients or can have normal renal function confirmed be-
specialized unit. Patients on a mechanical unmask insulin resistance in patients not fore this agent is restarted. Patients with a
ventilator universally undergo postopera- previously known to be diabetic. Much at- history of gouty arthropathy should have
tive care in an ICU for some period of time. tention has been given to glycemic control colchicine or any hypouricemic agents re-
For patients who do not require specialized in the perioperative period over the past de- sumed when they can tolerate oral medica-
checks or a ventilator, the patient’s chronic cade. Initial enthusiasm for tight glycemic tions. If a gout flare occurs postoperatively
illnesses and the extent of surgery will guide control has been tempered by the recogni- in a patient who is an NPO, management
the need for postoperative monitoring. In tion of the significant deleterious effects of options include intravenous ketorolac (Tor-
recent years, enthusiasm for the use of pul- hypoglycemic events which, in some cases, adol), intra-articular steroid injections, or
monary artery catheter for routine postop- negate the benefits of tight control. Current systemic steroids.
erative monitoring in certain patient popu- recommendations aim for “reasonable”
lations has waned in the absence of any control over normoglycemia in the postop- EARLY MOBILIZATION
demonstrable benefit and significant risks erative period generally defined as most
of complications, including pulmonary ar- readings below 180 to 200 mg/dL. One ben- Although bed rest was historically routinely
tery embolism and rupture in addition to efit of this movement is that surgeons and prescribed after surgical interventions, the
incorrect management decisions made due surgical units are now much more familiar negative side effects of this practice ranging
to misinterpretation of available data. with the management options for patients from pressure sores to osteopenia have
Other monitoring decisions are discussed with hyperglycemia in both the fasted and been recognized for decades. As discussed
below individually in the context of each the partially fasted state ranging from insu- in the next section, loss of lean body mass is
specific organ system. lin infusions to resumption of subcutane- associated with a range of adverse out-
Patients with known cardiovascular dis- ous insulin regimens. Patients on oral hypo- comes in the postoperative period, and en-
ease should be considered for telemetry glycemics can generally be managed with a forced bed rest has been shown to reduce
monitoring. Some recommend a postopera- short-acting insulin administered on a slid- lean body mass and total body strength in
tive 12-lead EKG and a single set of cardiac ing scale until oral intake has reliably re- healthy adults. In fact, prolonged weakness
enzymes in these patients as well although turned when most of these agents can be is now recognized as one of the most dura-
this practice is not universal. These patients restarted. One exception is metformin, ble and troublesome side effects of critical
should have beta blockers and statins re- which should not be resumed until renal illness. Efforts to minimize this complica-
sumed as soon as feasible in the postopera- function is proven to be normal and there is tion by increasing postoperative mobility
tive period. For patients with essential hy- little risk of significant intravascular vol- have been advanced in a number of patient
pertension, target blood pressures are ume shifts, which is generally proximate to populations, including cardiac surgical pa-
relaxed to avoid hypoperfusion with inter- the time of discharge. tients, patients undergoing elective colon
vention warranted if systolic pressures trend Postoperative nutritional support is resection, and in those with respiratory fail-
around 180 mm Hg or diastolic pressures sometimes required if patients were se- ure on ventilator support. These interven-
rise to 100 to 110 mm Hg. These patients verely malnourished preoperatively or if tions range from passive range of motion
should have pain and other causes of ele- bowel function does not return within a exercises performed by family members
vated blood pressure, such as urinary reten- week of surgery. Options include enteral and bedside nurses to lengthy training ses-
tion ruled out as well. Patients chronically and PN. If the patient is unable to take ade- sions with physical therapists depending

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 37 10/28/11 10:15:13 PM

 38 Part I: Perioperative Care of the Surgical Patient

on the patient’s clinical condition and toler- primary disease, a number of ICU-associ- patients may need care in the ICU, a situa-
ance. These interventions have been shown ated conditions promote muscle wasting tion that in itself commonly aggravates
to reduce loss of lean body mass while ac- and weakness. Such conditions include re- muscle wasting (Fig. 4).
celerating postoperative recovery and re- duced physical activity, prolonged bed rest, Weight loss in cancer patients reflects
ducing ventilator and ICU days. side effects of treatment with various drugs not only loss of muscle mass, but also deple-
(in particular glucocorticoids and neuro- tion of adipose tissue. The loss of body weight
muscular blocking agents), sedation, me- in these patients, however, closely reflects
MUSCLE WASTING IN chanical ventilation, and altered nutritional the loss of muscle tissue and strength. The
status. The term “intensive care unit-ac- pronounced loss of muscle in cancer pa-
SURGICAL DISEASE quired weakness” (ICUAW) has been used to tients is an important factor why these pa-
illustrate the fact that certain aspects of tients have reduced mobility and quality of
INTRODUCTION muscle weakness are unique for patients in life. In addition, impaired response to
the ICU. Recent aspects of muscle wasting chemo- and radiotherapy has been reported
Proteins in skeletal muscle undergo con-
in critical care have been published recently. in cancer patients with pronounced muscle
stant synthesis and degradation (protein
Because sepsis is a common condition ne- cachexia. Studies suggest that in patients
turnover). Under normal conditions, pro-
cessitating care in the ICU and is an impor- with nonresectable pancreatic cancer, death
tein homeostasis is maintained by equal
tant cause of muscle wasting, a substantial occurs with 25% to 30% of body weight.
rates of synthesis and degradation. When
amount of recent information with regard Pneumonia and other pulmonary complica-
this balance is perturbed, loss of muscle
to cellular and molecular mechanisms is re- tions, at least in part reflecting wasting of
mass may occur. Muscle wasting can be
lated to sepsis-induced muscle wasting. Al- respiratory muscles, are common causes of
caused by reduced protein synthesis, in-
though different mechanisms may be in- death in patients with advanced cancer.
creased protein degradation, or a combina-
volved in the loss of muscle mass in different The most significant consequences of
tion of these changes; the relative role of
disease states, there is evidence that muscle muscle wasting and weakness during criti-
these changes probably differs between dif-
wasting shares many (albeit not all) mecha- cal illness cared for in the ICU include diffi-
ferent catabolic conditions. Different pro-
nisms regardless of underlying cause. culty to wean the patient from ventilatory
teins have different rates of turnover (short-
support, recurrence of respiratory failure
and long-lived proteins) and may be
CLINICAL CONSEQUENCES after extubation, and inability to ambulate
regulated individually. In order for increased
due to profound weakness (even quadriple-
protein degradation to result in muscle OF MUSCLE WASTING gia). These manifestations reflect the fact
wasting, the degradation needs to affect a At least three different aspects of muscle that the wasting can affect both respiratory
large pool of cellular proteins. Contractile wasting are important in the surgical care. (diaphragm and intercostal muscles) and
proteins (the myofibrillar proteins actin First, patients may present with evidence of extremity muscles. Although loss of muscle
and myosin) make up a large portion of muscle wasting having already occurred, mass is probably the most important cause
muscle proteins and in various muscle including patients with advanced cancer of muscle weakness in the ICU, the weak-
wasting conditions, the degradation of (Fig. 3) or elderly patients with sarcopenia. ness can also be caused by peripheral neu-
myofibrillar proteins is increased, at least Second, patients may present with a condi- ropathy, initially described in the setting of
in part explaining why these conditions re- tion that typically results in loss of muscle sepsis and multiorgan failure. Indeed, criti-
sult in loss of muscle mass and strength. mass, such as sepsis and severe injury, in cal illness myopathy (CIM) and critical ill-
particular head and burn injury. Third, ness polyneuropathy (CIP) are commonly
MUSCLE WASTING IN
SURGICAL PATIENTS
Muscle wasting occurs in a number of dif-
ferent disease states commonly cared for by
surgeons, including cancer, severe injury
(in particular head injury and severe burn
injury), and sepsis. Other conditions in
which loss of muscle mass occurs include
uremia, diabetes, heart failure, and AIDS.
Muscle atrophy in elderly patients (sarcope-
nia) may affect quality of life by reducing
the capacity to perform daily physical ac-
tivities and by increasing the risk of falls
and fractures. Sarcopenia may also increase
the risk of postoperative complications in
elderly patients undergoing surgery.
Although some of the conditions associ-
ated with loss of muscle mass (such as sep-
sis) are involved in muscle wasting and
weakness seen in patients in the ICU, criti- Fig 3. Patients with advanced cancer frequently develop severe muscle wasting and weakness. The pa-
cally ill patients cared for in the ICU have tient shown in this figure was a 59-year-old man with metastasizing gastric cancer who had lost ap-
their own set of characteristics with regard proximately 35% of his normal body weight during his illness (Picture kindly provided by Dr. Maurizio
to muscle atrophy. Thus, in addition to the Muscaritoli, Department of Clinical Medicine, Sapienza-University of Rome, Rome, Italy.)

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 38 10/28/11 10:15:13 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 39

DIAGNOSIS OF MUSCLE WASTING

Perioperative Care of the Surgical Patient

The diagnosis of muscle wasting and weak-
ness is commonly obvious from bedside
clinical observations. Patients will also ex-
perience and complain of weakness when
trying to ambulate or use upper extremity
muscles. Respiratory muscle weakness typi-
cally manifests itself as difficulty weaning
the patient from the ventilator or respira-
tory failure after extubation. Objective mea-
sures of muscle atrophy can be obtained
from various imaging tests such as CT, MRI,
or ultrasound.
Although the diagnosis of muscle wast-
ing and weakness is commonly obvious
from simple clinical observation, more so-
Fig 4. Patients with critical illness cared for in an intensive care unit (ICU) are at risk of developing phisticated methods are also available and
muscle wasting and weakness. Mechanical ventilatory support adds to the risk of muscle wasting. Be- can be used if more objective assessment is
cause muscle wasting and weakness increase the need for ventilatory support, a vicious circle is created. needed, such as in the research setting. Such
methods include objective measurements
of muscle strength, electrophysiological
tests, and muscle biopsy. Various methods
described as two separate entities although restrictions in daily functioning were re- to assess respiratory muscle strength and
the muscle weakness can also be caused by ported in ⬎50% of survivors of critical ill- function have been described, including
a combination of CIM and CIP, so-called ness with restricted ability to walk being magnetic phrenic nerve stimulation.
critical illness neuromyopathy. the most commonly impaired physical qual- When muscle biopsy is performed, the
Importantly, mechanical ventilatory sup- ity of life. It is obvious that loss of muscle histopathological picture is typically char-
port in itself results in wasting and weakness mass and weakness acquired during critical acterized by reduced fiber size (atrophy)
of the diaphragm and other respiratory mus- illness have long-lasting effects in patients and changes in fiber type. Electron micros-
cles. Studies suggest that muscle weakness surviving ICU care with important personal copy may reveal sarcolemmal changes, dis-
occurs early during mechanical ventilation and socioeconomic consequences. ruption of the sarcomere, disintegration of
with ⬎50% of ICU patients showing evi- Z-disks, and morphological changes of mi-
dence of neuromuscular abnormalities after ACUTE QUADRIPLEGIC tochondria (including swelling and loss of
5 to 7 days of mechanical ventilation. Septic membrane structures) and loss of mito-
shock was a predictor of respiratory muscle
MYOPATHY chondria. Of note, reduced muscle-specific
weakness in some reports. One consequence A special condition sometimes seen in pa- force generation may exist in the absence of
of respiratory muscle weakness is difficulty tients in the ICU is acute quadriplegic myo- atrophy although in most cases of muscle
to wean the patient from ventilatory support pathy. This condition is caused by a specific weakness, the loss of muscle strength is
resulting in prolonged need for mechanical decrease, or even an almost complete loss, probably associated with morphological
ventilation thus creating a vicious circle. An- of thick filament muscle proteins (myosin) abnormalities in skeletal muscle.
other vicious circle is created by weakness of and is characterized by a sometimes dra-
extremity muscles. Thus, weakness of pe- matic clinical picture of complete paralysis. MECHANISMS OF
ripheral muscles prevents ambulation re- The quadriplegia is typically symmetric and MUSCLE WASTING
sulting in prolonged bed rest. Bed rest in it- affects both proximal and distal muscle
self promotes loss of muscle mass and there groups, whereas muscles innervated by the Loss of muscle mass during various cata-
is evidence that this effect of inactivity is po- cranial nerves are not affected. The progno- bolic conditions is regulated at multiple lev-
tentiated by underlying disease. Bed rest is a sis is usually good if the patients survive the els as illustrated in Fig. 5. Circulating factors
potent mechanism of muscle wasting and a underlying disease but recovery of muscle (including proinflammatory cytokines and
rapid and profound loss of muscle mass has strength may require several months. Al- glucocorticoids) as well as regulators that
been documented even in healthy volun- though the mechanisms of acute quadriple- act in an autocrine or a paracrine fashion
teers during bed rest with the loss of 1% to gic myopathy are not fully understood at (e.g., myostatin) participate in the regula-
1.5% of quadriceps strength per day. present, there is evidence that the synthesis tion of muscle mass in different conditions
Muscle weakness in patients cared for in of myosin is blocked at the transcriptional characterized by muscle wasting. When the
the ICU is commonly long-lasting with level concomitant with stimulated degra- balance between anabolic factors, for ex-
weakness significant enough to cause prob- dation of the protein. A number of risk fac- ample, insulin and insulin-like growth fac-
lems walking being present up to 5 years tors for development of acute quadriplegic tor 1 (IGF-1), and catabolic factors, for ex-
after the stay in the ICU. The persistent myopathy have been identified and include ample, TNF␣, corticosteroids, and possibly
weakness clearly reduce the quality of life in treatment with corticosteroids and neuro- myostatin, is perturbed, muscle mass may
these patients, sometimes manifesting it- muscular blocking agents (perhaps the be lost. Although both reduced protein syn-
self as difficulty to walk and inability to per- most important risk factors), mechanical thesis and increased protein degradation
form other seemingly trivial tasks. In some ventilation, immobilization, and probably may contribute to muscle wasting, there is
studies, long-term weakness and important sepsis as well. evidence that in sepsis, severe injury, and

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 39 10/28/11 10:15:14 PM

 40 Part I: Perioperative Care of the Surgical Patient

and activity are not universally upregu- 20 years. In this mechanism, proteins are
lated during muscle wasting conditions degraded inside the multicatalytic 26S pro-
(but may actually even be downregulated). teasome after having been targeted for the
This is important to keep in mind when in- proteasome by conjugation of multiple
terpreting results from studies in which ubiquitin molecules. The ubiquitination of
inhibition of myostatin was tested in protein substrates is regulated by multiple
the prevention and treatment of muscle enzymes, including the ubiquitin activating
wasting. enzyme (E1), ubiquitin-conjugating en-
zymes (E2s), and ubiquitin ligases (E3s). The
length of the ubiquitin chain conjugated to
PROTEOLYTIC MECHANISMS the protein destined for the proteasome can
INVOLVED IN MUSCLE be edited by deconjugating enzymes that
also play an important role for the protea-
BREAKDOWN some-dependent proteolysis. Among the
Intracellular proteins are degraded by mul- factors regulating the ubquitination of pro-
tiple proteolytic mechanisms. It is beyond teins and subsequent degradation by the
the scope of this chapter to give a detailed proteasome, ubiquitin ligases are particu-
description of the different proteolytic path- larly important because they account for
ways participating in the breakdown of in- substrate specificity, thereby deciding which
tracellular proteins and they will be dis- protein(s) will be degraded. The muscle-
cussed only briefly here. More extensive specific ubiquitin ligases atrogin-1 (also
reviews of muscle proteolysis during muscle called MAFbx) and MuRF1 play important
wasting conditions have provided else- roles in muscle wasting caused by a number
where. Typically, three major proteolyic of different catabolic conditions, including
pathways account for the degradation of sepsis, severe injury, and cancer. Increased
cellular proteins: lysosomal, calcium-depen- expression of atrogin-1 and MuRF1 is com-
dent, and ubiquitin-proteasome-dependent monly used as a “molecular marker” of mus-
pathways. Lysosomal degradation of pro- cle wasting (although this is probably an
teins is regulated by intralysosomal enzymes oversimplification because there are multi-
(cathepsins) in an acidic environment. Early ple examples of conditions where there is
studies performed mainly in hepatocytes not a close correlation between changes in
provided evidence that components of the the expression of atrogin-1 and MuRF1 and
cytoplasm can be taken up in so-called au- changes in protein breakdown rates).
tophagosomes that are subsequently taken Although most early information regard-
up and degraded by lysosomes. Importantly, ing the role of the ubiquitin–proteasome
recent reports suggest that autophagic/ pathway in muscle wasting was generated
lysosomal degradation plays an essential in experimental animals with different
Fig. 5. Muscle wasting in various catabolic con- role in the degradation of muscle proteins models of sepsis, burn injury, cancer, and
ditions, including cancer, sepsis, and severe in- during various conditions characterized by uremia, there is evidence that similar mech-
jury, is regulated at multiple levels. Anabolic fac- muscle wasting. anisms are involved in patients. For exam-
tors including insulin and IGF-I are reduced, and Among calcium-dependent mechanisms, ple, it is almost 15 years ago that the gene
catabolic factors including cytokines and gluco- calpain-regulated protein degradation plays expression of ubiquitin was reported to be
corticoids are increased. These changes result in
an important role. Previous studies suggest upregulated in skeletal muscle from pa-
altered cell signaling and expression and activity
of transcription factors and nuclear cofactors that calpain-dependent mechanisms may tients with sepsis and several subsequent
that regulated genes involved in muscle prote- be involved in the initial step of myofibrillar reports have confirmed that the ubiquitin–
olysis. Loss of muscle mass, muscle weakness, protein disassembly and cleavage, at least in proteasome pathway is activated in patients
and fatigue are the ultimate results of the mo- muscle wasting caused by sepsis. In other with sepsis and other catabolic conditions
lecular events set in motion by the catabolic studies, evidence was found that increased as well, including cancer and burn injury.
conditions. Reproduced by permission from calpain activity in catabolic muscle is mainly
Aversa et al., Critical Reviews in Laboratory and caused by decreased activity of the endoge-
Clinical Investigations. nous calpain inhibitor calpastatin. It should TRANSCRIPTION FACTORS
be noted that the role of calpains in muscle
cancer, the loss of muscle mass mainly re- wasting is somewhat controversial. Other
AND MUSCLE WASTING
flects stimulated protein breakdown. studies suggest that caspase-3 participates Because the expression of atrogin-1 and
Although initial reports of pronounced in the early release of myofilaments from the MuRF1 as well as other molecules involved
muscle hypertrophy in myostatin-deficient sarcomere during muscle wasting caused by in the regulation of muscle mass, such as
cattle are strong indicators that myostatin uremia. It is possible that the roles of cal- molecules regulating the expression and ac-
is a potent-negative regulator of muscle pains and caspases vary in different muscle tivity of the autophagosome and the lyso-
mass, the role of myostatin in muscle wast- wasting conditions. somal enzyme cathepsin L, is upregulated at
ing during various catabolic conditions is Ubiquitin-proteasome-dependent deg- the transcriptional level in atrophying mus-
somewhat controversial. Several reports in radation is probably the proteolytic mecha- cle, it is not surprising that a great deal of at-
the literature, including a recent study in sep- nism that has attracted most interest in the tention has been paid to the potential role of
tic rats, suggest that myostatin expression field of muscle wasting during the last 15 to transcription factors and nuclear cofactors

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 40 11/15/11 3:06:55 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 41

involved in the regulation of gene transcrip- in future studies to determine whether these involved in muscle wasting, including some
tion. Genes that are upregulated in muscle transcription factors are involved in muscle of the genes in the ubiquitin–proteasome

Perioperative Care of the Surgical Patient

wasting conditions are commonly referred to wasting in critically ill patients as well. pathway. Studies suggest that reduced ex-
as “atrogenes.” Among transcription factors pression and activity of both PGC-1␣ and ␤
that are involved in the regulation of muscle NUCLEAR COFACTORS may induce muscle atrophy, at least in part
mass, early studies provided evidence that secondary to increased expression of the
NF-␬B may play an important role, at least in
AND MUSCLE WASTING ubiquitin-ligases atrogin-1 and MuRF1. In
muscle wasting associated with sepsis. In In addition to being regulated by transcrip- recent experiments, the expression of
more recent studies, muscle-specific genetic tion factors, gene transcription is also influ- PGC-1␣ and ␤ was substantially downregu-
manipulation of the expression and activity enced by various nuclear cofactors (coacti- lated in skeletal muscle during sepsis in
of NF-␬B-regulated muscle mass at least in vator or repressor proteins) and proteins in rats concomitant with increased expression
part by influencing the expression of MuRF1 the transcriptional machinery. Although of atrogin-1 and MuRF1. In the same study,
(but not atrogin-1) and the rate of protea- transcription factors bind to DNA in a se- overexpressing PGC-1␤ in cultured muscle
some-dependent protein degradation. Other quence-specific fashion, they typically lack cells reduced the expression of atrogin-1
reports have also provided support for a role enzymatic activities required for modifica- and MuRF1, providing further support to
of NF-␬B in muscle wasting. tion of chromatin, unwinding of DNA, and the concept that PGC-1 cofactor may regu-
Forkhead Box O 1 (FOXO1) and FOXO3a recruitment of RNA polymerase. In con- late muscle mass at least in part by regulat-
are additional transcription factors that trast, several nuclear cofactors exert enzy- ing the expression of atrogin-1 and MuRF1.
participate in the expression of muscle matic activities and influence gene tran- Similar to transcription factors, most of
wasting-related genes, including atrogin-1 scription by modifying chromatin or by the evidence suggesting a role of p300,
and MuRF1, and were found in recent stud- changing the structure and function of HDACs, and PGC-1 cofactors has been gen-
ies to play an important role in the develop- transcription factors or other nuclear co- erated in animal models of muscle wasting
ment of muscle atrophy. In recent experi- factors. The function of some of the nuclear or in cultured muscle cells and it remains to
ments, evidence was found that FOXO1 may cofactors is also to serve as docking sites be determined whether similar mecha-
be particularly important for muscle wast- for other proteins that are recruited to tran- nisms are involved in patients with muscle
ing in sepsis and other critical illness. Inter- scription factors thereby influencing gene wasting. The observations are important,
estingly, recent studies suggest that FOXO transcription. however, because they suggest that it may
transcription factors regulate the transcrip- In recent studies, the nuclear cofactor be possible in the future to prevent or treat
tion of autophagy-related genes providing p300 was found to regulate glucocorticoid- muscle wasting by targeting small mole-
further support for the important role of induced atrophy of cultured muscle cells cules based on an increased understanding
FOXOs in muscle wasting. and the role of p300 may at least in part re- of the molecular regulation of processes in-
An additional group of transcription fac- flect its interaction with muscle wasting- volved in muscle wasting.
tors that are involved in muscle wasting are related transcription factors. Because an
members of the family of C/EBP transcrip- important function of p300 is to exert his- PREVENTION AND TREATMENT
tion factors, in particular C/EBP␤ and ␦. In tone acetyl transferase (HAT) activity, the
recent experiments, the expression as well observations suggest that hyperacetylation
OF MUSCLE WASTING
as DNA binding activity and transcriptional may be involved in muscle wasting. This hy- In some patients with muscle wasting, cor-
activity of these transcription factors were pothesis was supported by the observation recting the underlying cause of the catabolic
increased in skeletal muscle during sepsis that the expression and activity of the his- response will ameliorate the metabolic
and after treatment with glucocorticoids. tone deacetylases SIRT1, HDAC3, and changes in skeletal muscle. There are situa-
In addition, genetic evidence suggests that HDAC6 are reduced in skeletal muscle dur- tions, however, when the cause of muscle
C/EBP␤ is involved in glucocorticoid-in- ing gluococorticoid- and sepsis-induced cachexia cannot always be corrected or is
duced atrophy of skeletal muscle cells. muscle wasting. In other experiments, difficult to treat. For example, patients with
Of note, the activity of transcription fac- treatment of cultured muscle cells or ex- advanced cancer cannot always be cured
tors can be regulated at different levels. perimental animals with the HDAC inhibi- from their disease and in those patients, the
First, the abundance of the transcription tor trichostatin A (TSA) resulted in in- accompanying muscle wasting may become
factors may be increased in catabolic mus- creased expression of the ubiquitin ligase a significant factor reducing quality of life
cle as found for FOXO transcription factors atrogin-1 and stimulated protein break- and may even contribute to death. Patients
and C/EBP␤ and ␦. Second, the transcrip- down. Taken together, the observations dis- with severe and protracted sepsis who de-
tion factors may form complexes with other cussed here suggest that hyperacetylation velop multiple organ failure and require long
transcription factors or with nuclear cofac- of transcription factors and probably other stay in the ICU, frequently on the ventilator,
tors. Finally, and perhaps most important, cellular proteins as well may be involved in are another group that may benefit from
the activity of transcription factors can be muscle wasting. Indeed, acetylation is more specific treatment of the catabolic re-
regulated by posttranslational modifica- evolving as an important posttranslational sponse in skeletal muscle. Patients with
tions, including phosphorylation, ubiquit- modification that may even rival other post- burn injury develop severe muscle wasting
ination, and acetylation. translational modifications, such as phos- even when the burn is managed by experts.
Taken together, multiple studies suggest phorylation, in the regulation of many cel- AIDS is an additional example of a condition
that several transcription factors may be in- lular metabolic events. that cannot always be treated successfully
volved in the regulation of muscle mass dur- Another group of nuclear cofactors that and where effective treatment of muscle
ing various muscle wasting conditions. Most has been implicated in muscle wasting re- wasting would greatly benefit the patients.
of these observations have been made in cently are members of the PPAR␥ co- Finally, the growing population of elderly
animal models of muscle atrophy and in cul- activator-1 (PGC-1) family. There is evidence people makes the prevention and treatment
tured muscle cells and it will be important that PGC-1␣ and ␤ are repressors of genes of sarcopenia increasingly important.

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 41 10/28/11 10:15:16 PM

 42 Part I: Perioperative Care of the Surgical Patient

n
neuromuscular and physical function by HORMONAL TREATMENT
Table 8 Strategies for Prevention e
early mobilization of patients in the ICU.
and Treatment of Muscle Hormones that have been used to reduce
Wasting and Weakness S
Studies suggest that early mobilization re-
s
sults in decreased ICU and total hospital the catabolic response in skeletal muscle
Ambulation l
length of stay and decreased duration of include growth hormone (GH) and IGF-1.
Exercise v
ventilatory support. These hormones exert an anabolic effect by
Nutritional intervention stimulating protein synthesis and inhibit-
The involvement of physical therapists
Enteral versus parenteral ing protein breakdown in skeletal muscle.
Supplements
a active and passive exercises are addi-
and
t
tional important strategies that should be Although there was an early enthusiasm for
Glutamine
Branched-chain amino acids e
employed to prevent and treat muscle wast- treatment of critically ill patients with GH,
Hormonal treatment i and weakness. In general, resistance
ing some of that enthusiasm was stifled by re-
IGF-1 (
(strength) training is considered the most ports of increased mortality in ICU patients
Growth hormone (GH) e ective exercise for slowing the rate of loss
eff treated with GH (possibly caused by subop-
Insulin o muscle mass and to improve muscle
of timal control of hyperglycemia). Subse-
Androgens s
strength (as opposed to aerobic exercise quent studies in burn patients suggest,
“Biological” treatment t
training, which may be more beneficial however, that treatment with GH is safe
Cytokines and anticytokines f
from a cardiovascular standpoint). Even (provided blood glucose levels are moni-
Antioxidants p
passive exercise of extremity muscles bed- tored carefully) and may reduce the cata-
Myostatin inhibition s
side in patients who are sedated may be bolic response in skeletal muscle.
Nitric oxide inhibitors b
benefi cial and slow the process of muscle In addition to GH, there is evidence that
Deacetylation (HAT inhibition or HDAC a
atrophy. IGF-1 may exert muscle-sparing effects in
activation) critical illness. For example, there is evi-
dence that treatment of burn victims with
IGF-1 preserves muscle mass and improves
NUTRITIONAL INTERVENTION clinical outcome. In animal experiments,
Different strategies employed to prevent The role of nutritional support in the pre- protein synthesis in muscle from septic rats
or treat muscle wasting are summarized in vention and treatment of muscle wasting is was stimulated by IGF-1, whereas protein
Table 8. Some of these strategies have been less clear. Although it is well documented breakdown was not influenced by the hor-
tested in patients, whereas other modali- that starvation and malnutrition will result mone, even at high concentrations, sug-
ties are still experimental (or even specula- in loss of muscle mass, the effects of nutri- gesting that muscle proteolysis becomes
tive). Although mechanisms underlying loss tional intervention in critically ill patients resistant to the effects of IGF-1 during sep-
of muscle mass may differ between various with regard to muscle wasting have been sis. Because, at the same time, the regula-
muscle wasting conditions, there are also disappointing, at least in patients with sep- tion of protein synthesis by IGF-1 was unaf-
multiple similarities that make strategies to sis. Several previous reports suggested ben- fected by sepsis, it is likely that the
prevent and treat muscle weakness appli- eficial effects of early nutritional support, in sepsis-induced resistance of protein break-
cable in several conditions. particular enteral nutritional support, as down to IGF-1 reflects a postreceptor event.
they relate to overall clinical outcome, Interestingly, in other studies, treatment of
length of stay in the ICU, survival rates and burned rats with IGF-1 stimulated protein
AMBULATION AND EXERCISE infectious complications, but there is little synthesis and inhibited protein breakdown
Because bed rest and inactivity are potent evidence that nutritional intervention pre- without evidence of resistance to the hor-
mechanisms of muscle atrophy, it is not vents of reverses muscle wasting. mone. Thus, muscle wasting in different
surprising that attempts have been made to Based on early studies in experimental catabolic conditions may respond differ-
prevent muscle wasting by early ambula- animals, there has been a great deal of in- ently to IGF-1, probably at least in part re-
tion and exercise. By nature, of course, pa- terest in the field of nutritional supplements flecting different mechanisms involved in
tients in the ICU, frequently sedated and on to prevent the loss of muscle mass. In par- muscle wasting in different disease states.
mechanical ventilator, cannot always am- ticular, supplementation with glutamine The anabolic effects of IGF-1 at least in
bulate or exercise. Even in patients without and branched-chain amino acids (especially part reflect stimulated PI3K/Akt signaling
significant contraindications for ambula- leucine) has been used in this context. Re- with downstream phosphorylation and ac-
tion, however, that aspect of the care is not cent studies suggest that the leucine me- tivation of mTOR-regulated protein synthe-
always prioritized. One reason for this may tabolite ␤-hydroxy-␤-methylbutyrate may sis. It is possible that PI3K/Akt signaling is
be lack of resources (it requires the involve- be able to inhibit loss of muscle mass in involved in the inhibition of muscle prote-
ment of physical therapists and nursing various catabolic conditions, including olysis as well. For example, PI3K/Akt-regu-
personnel to ambulate the patients) but cancer, but its role in the treatment of criti- lated phosphorylation of FOXO transcrip-
probably also concerns for safety to mobi- cally ill patients in the ICU remains to be tion factors results in inactivation of FOXOs
lize critically ill patients with complex sur- defined. Other nutritional supplements and downregulated expression of atrogin-1
gical wounds, intravenous and intra-arterial that have been used in critical care include and MuRF1. The enzyme glycogen syn-
lines, feeding tubes, and still on mechanical arginine, ␻-3 polyunsaturated fatty acids, thase-3␤ (GSK-3␤) is an additional down-
ventilator. Interestingly, several recent stud- and RNA. Overall, however, the role of nu- stream target of the PI3K/Akt signaling
ies, including randomized controlled trials, tritional intervention, including supple- pathway; increased phosphorylation of
have documented the safety and feasibility mentation with glutamine, branched-chain GSK-3␤ results in its inactivation, an im-
of early ambulation and mobility in the ICU, amino acids, and other substances, in the portant effect considering that activation of
even in patients requiring mechanical ven- prevention and treatment of muscle wast- GSK-3␤ is probably involved in burn- and
tilatory support, and have shown improved ing in critical illness, remains unclear. sepsis-induced muscle wasting.

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 42 10/28/11 10:15:16 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 43

The influence of insulin on muscle pro- jury. In several of those studies both short- cofactor p300 and reduced expression and
tein synthesis and degradation is similar to and long-term beneficial effects were re- activity of HDACs. Taken together, these

Perioperative Care of the Surgical Patient

that caused by IGF-1. In fact, some of the ported with regard to muscle mass, strength, changes set the stage for increased acetyla-
signaling of IGF-1 and insulin may be caused and function. tion of cellular proteins. The potential role
by a nonselective binding to and activation Selective androgen receptor modulators of hyperacetylation in muscle wasting was
of the insulin and IGF-1 receptors, which in (SARMs) are a relatively new class of com- supported by upregulated expression of
part explains why the metabolic effects of pounds that have been suggested to be ben- atrogin-1 and increased muscle proteolysis
the hormones are similar. Interestingly, we eficial for the treatment and prevention of after treatment of rats with the HDAC in-
reported previously that septic muscle be- muscle wasting without the potential car- hibitor TSA. Based on these observations, it
comes resistant to insulin with regard to diovascular and prostate cancer risks often may be speculated that inhibition of acety-
regulation of protein degradation but re- associated with androgen therapy. Although lation may reduce loss of muscle mass in
tains its sensitivity to insulin’s regulatory experiments in rats suggest that some of the catabolic conditions, at least catabolic con-
effects on protein synthesis (identical to the SARMs exhibit anabolic effects in skeletal ditions in which there is evidence of hyper-
response to IGF-1 in septic muscle). Al- muscle, the effects of these drugs on muscle acetylation. Interestingly, the recent devel-
though the mechanisms of sepsis-induced wasting in ICU patients are not known. opment of small molecules that can
resistance to IGF-1 and insulin in skeletal stimulate HDAC activity (resulting in re-
muscle are not fully understood, cytokine- BIOLOGICAL TREATMENT duced acetylation of cellular proteins) may
and glucocorticoid-induced alterations of provide an opportunity to test whether
receptor-associated docking proteins may Most “biological” treatments are experi- muscle wasting can be treated or prevented
be involved. Interestingly, studies suggest mental and await clinical trials. Some of the by reducing the level of acetylation. It may
that ghrelin may have muscle-sparing ef- potential treatments discussed here can also be speculated that treatment with res-
fects, possibly secondary to stimulation of even be considered speculative. veratrol, a compound that has both antioxi-
the GH/IGF-1 axis. The biological treatment that has proba- dant and HDAC stimulatory effects, may be
Recent studies suggest that tight glucose bly attracted most interest and that may be an additional avenue worth trying to pre-
control by the administration of insulin im- closest to definitive clinical trials is the one vent muscle wasting in critical illness. Im-
proves survival of patients in the ICU. In ad- aimed at inhibiting myostatin, for example, portantly, the recent development of small
dition to improved survival, other effects, with myostatin antibodies. The rationale for molecules specifically targeting and inhib-
including reduced infectious complications this treatment is previous observations that iting p300/HAT activity may offer an addi-
and length of stay in the ICU have also been myostatin is a strong negative regulator of tional way to reduce hyperacetylation (and
ascribed to tight glucose control protocols. muscle growth and development. Myostatin protein breakdown) in catabolic muscle.
It has also been suggested that tight glucose is a member of the transforming growth fac-
control may inhibit ICU-acquired muscle tor ␤ family that is produced in skeletal NUTRITIONAL ASSESSMENT
weakness. It should be noted that although muscle and probably exerts most of its ef- AND THE NEED FOR
the initial reports on the beneficial effects fects in muscle by autocrine and paracrine
of tight glucose control were received with mechanisms. The potential role of myosta-
NUTRITIONAL SUPPORT
great enthusiasm and resulted in changes tin in muscle wasting has been supported by It would have been fun to write this section
in the care of critically ill patients, recent studies in which the expression of myosta- in the early 1970s, but unfortunately I did
studies have challenged the initial reports tin was increased in skeletal muscle during not have the opportunity. At that time, nu-
finding no evidence of beneficial effects of various catabolic conditions. It should be trition and nutritional support was wonder-
this protocol. Some studies have even re- noted, however, that the role of myostatin fully exciting. Stanley Dudrick had just
ported increased mortality in ICU patients may vary in different catabolic conditions wowed the world in the late 1960s by show-
on a tight glucose control protocol, at least since its expression is not universally up- ing beagle puppies that had never eaten
in some cases reflecting the development of regulated in all muscle wasting conditions. keeping up with puppies that were fed nor-
significant hypoglycemia. The potential For example, in recent experiments, myo- mal chow and were eating. I think the thing
benefits of tight glucose control in the ICU statin expression was not increased but was that really did it was the baby who had not
with regard to prevention of muscle wast- actually significantly decreased in skeletal been fed and yet seemed to have fairly nor-
ing and weakness need to be tested in ran- muscle during sepsis in rats. Unchanged or mal development. I was fortunate enough to
domized controlled trials. even decreased expression of myostatin has be involved in the evolution of total paren-
There is solid evidence in the literature been reported in other catabolic conditions teral nutrition (TPN) and to set, with Dudrick
that androgens, such as testosterone, regu- as well. Thus, antimyostatin treatment may and others, some of the parameters by which
late muscle mass in humans. Although the not be beneficial in all conditions character- nutritional support was carried out.
use of testosterone by athletes has attracted ized by loss of muscle mass. When I was still a resident, Ron Abel,
a great deal of attention (and controversy), Other biological treatments that have who was an intern on the pediatric surgical
testosterone has also been used in certain been reported in animal experiments to service, told me about a young surgeon
patient groups to improve muscle mass and have beneficial effects on muscle mass and named Stanley Dudrick who was doing ex-
function, such as older men with normal or function include treatment with interleu- periments with dogs and finally with babies
low testosterone levels and HIV-infected kin-15, anti-TNF␣ antibodies, antioxidants, to support them without eating at all. I and
men with low serum testosterone. The best and nitric oxide inhibitors. The effects of the rest of the residents were somewhat in-
and most extensive support for a beneficial these treatments in patients with muscle credulous but Ron Abel suggested that we
effect of testosterone, as well as the ana- wasting conditions are not known. invite him up to speak. I do not recall that
bolic steroid oxandrolone, with regard to Recently, sepsis-induced muscle wasting we ever got anyone’s permission but that
muscle wasting in critical illness has been in rats was associated with increased ex- was one of the wonderful things about the
generated in patients with severe burn in- pression and HAT activity of the nuclear Mass General Hospital and being there—it

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 43 10/28/11 10:15:16 PM

 44 Part I: Perioperative Care of the Surgical Patient

was no holds barred but a spirit of adven- a good part of my first 3 years on the faculty and go to enteral nutrition. Not that there’s
ture, of learning, and in progress in surgery taking care of TPN patients, first as a con- anything wrong with enteral nutrition, but I
by doing things that you thought could be sultant and later, when they were admitted would venture to say that with the inappro-
done. We did have the Super Chief Year, to my service, from the eastern half of the priate use of excessive osmolar nutritional
which was probably, with that at Hopkins, United States. Since it was new, we had as aspects, there are probably more deaths
the best training ground for any young, aca- many as 70 patients in the hospital either as with enteral nutrition and pneumatosis and
demic surgeon; unfortunately, it is no more. consults or under my aegis on my service. I bowel necrosis than there are in patients
In about 1968, I was asked to try to put did not have a resident but I had lots of fel- who get TPN. What has happened to TPN is
together some type of nutritional support lows who had come from all over the world that it is no longer a surgical discipline. If it
group so that we could start supporting pa- and they helped me by making rounds and is staffed at all, it is some reluctant gastro-
tients by hyperalimentation. A year prior to writing notes, and so on. enterologist who takes this on. Surgeons
this, Dr. Dudrick had accepted our invita- There were many missed opportunities. are basically excluded or have excluded
tion and had come to speak in the hallowed Research money was very plentiful. Al- themselves from the management of the
Bigelow Amphitheater. I am not certain that though the companies were competitive, patient. The goal is to put people on TPN for
too many people came. I do not think they they were pretty good about giving young, as little time as possible and then to transi-
realized what they were about to listen to, aggressive, mostly surgical investigators tion to enteral nutrition. This is not a bad
but if Stanley was disappointed, he did not money for doing research in TPN. Unfortu- idea but it is an idea that may never happen
show it and was magnanimous with his time nately, the research was not of high quality because patients may not be able to accept
as usual and taught us how to put in subcla- and most of it could never be funded by the sufficient support by enteral nutrition.
vian lines. We did have one pharmacist who NIH, although some of it was. Instead of
was interested and who had heard about competing, we should have gotten together RISKS AND NUTRITIONAL
what was going on at the University of Penn- and in fact we might have—there was an
sylvania at that time, and he agreed to make organization known as SPIA (the Society of
SUPPORT
up the solution in his spare time after hours. Parenteral Alimentation), which was a 30- For the past three editions, the approach to
I will tell you that we did just about every- member organization by invitation only nutritional support and nutritional assess-
thing wrong. We had too many calories (we that had an annual meeting and a different ment has been in particular a European ap-
did not have fat), we gave people far too format: only five papers, 2 hours each, ma- proach. In the third and fourth editions,
much volume and too much glucose. Every- terial which had never been published, and Graham Hill, from the UK and working in
body looked Cushingoid but in fact we did if you used any of it, you were thrown out, Australia as Chair of a Department of Sur-
get some fistulas to close and we certainly never to be invited again. One person did gery, did wonderful things introducing en-
did support patients who could not or would and was never invited back. There were teral and PN in Australia. His approach is
not eat, with very few in the latter. One of other opportunities lost. We failed to get particularly European. In the fifth edition,
these days I will write up my experiences in CPT codes for initial assessment, nutri- Peter Soeters, who spent several years with
dealing with patients with anorexia nervosa, tional support, daily visits and ordering of me in the laboratory and wrote the classic
and that was an interesting adventure, the bottles, and judging the electrolytes. We review of gastrointestinal cutaneous fistu-
which said a little bit about some of the cen- could have done a lot to maintain the field las, wrote about the risk assessment and
tral nervous system mechanisms involved. and to reproduce ourselves. But we were nutritional support, again with a strictly Eu-
The first problem was how to take care of too busy competing with each other be- ropean cast. Unfortunately, it is not that way
the patients. By that time, it was known that cause we were all young and, to a certain in this country, and the concepts, which are
the subclavian insertion site of the catheter extent, we were all male rhinoceroses com- well-regarded, that Graham Hill and Peter
needed addressing (Dr. Robert Linton, whom peting for Lord knows what. It did not hap- Soeters and his coworkers put forth in pre-
I consulted on this, said we should leave it pen, and we did not reproduce ourselves. vious editions are all true and are all brought
open with nothing on it—maybe we should The problem now as I see it is that TPN has to bear. However, they are not the approach
have done that, although it seemed unlikely become something that you use until you that we use in this country and so it is time
that with the bedclothes scraping on it that can get rid of the catheter. The reason for to take a strictly American approach.
the catheter site would remain sterile.) The this is because catheter infection has be- How do these approaches differ? To me,
floor nurses were stretched much too thin come a bugaboo on all services and, in ad- the difference between the American point
and were terribly disinterested in doing this, dition to causing death and metastatic in- of view and the European approach (and, I
so we needed a TPN nurse, since that was fection elsewhere, costs at least $63,000 per might add, that of Australia and New Zea-
the mechanism that was seen to keep the line infection. The TPN nurse, who metasta- land) is the role of albumin and what does it
sepsis rate at a reasonably low level. I cannot sized to an IV nurse, no longer exists. The represent. Most of us can pick out a mal-
recite the story of how I got the $40,000 that TPN nurse has been a casualty of hospital nourished patient prior to operation. This
enabled us to hire Rita Colley, who was our efficiency. It only takes the prevention of was well proven in the Virginia (VA) study
first TPN nurse, and whom I recruited from two line infections a year to actually pay for as carried out by the University of Pennsyl-
the ICU after she took care of one of my sple- the salary and benefits of a TPN nurse, vania team, largely at the VA, and showing
norenal shunts dying of hepatic failure, but whose job it is to go endlessly around all the that patients who had lost between 10% and
she was terrific as far as her care of the pa- units and teach people aseptic technique 15% of their body weight over 3 or 4 months
tients and actually trained the whole hospi- and how to avoid line infection. As I said are at risk. The essence of operative risk as
tal in the care of these patients. More about earlier, TPN is something that you put in determined in the United States is a loss of
this will be discussed later. when you are desperate and you try to pre- lean body mass, and Dr. Hasselgren has
Once I finished my residency and got an vent line infection if you can without ade- once again written an interesting section
NIH grant, it was about liver disease and quate help, especially in the ICU, and then immediately before this. It is lean body mass
not about TPN, although I must say I spent you get the line out as quickly as possible that we are trying to salvage and stop from

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 44 10/28/11 10:15:16 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 45

being broken down for energy. And yet it is Whenever we say risk assessment, we prospective, double-blind study. N Engl J
more than that. Serum albumin and trans- are talking about operative risk and status Med 1973;288:695–9). The introduction of

Perioperative Care of the Surgical Patient

ferrin, which we largely use as indicators of of lean body mass. Lean body mass is that TPN nurses in Cincinnati, where the status
nutritional adequacy, albumin being a rapid operant amount of protein, which carries of TPN was actually dismal, decreased the
turnover protein with a half-life of approxi- out the various functions that we character- sepsis rate from 27% to 0.78%, which I think
mately 20 days, allegedly tell us about the ize as being important in patients. To have a is about the lowest it can be. Unfortunately,
health of lean body mass. The European low serum albumin means your lean body most physicians dealing with TPN now re-
point of view is that albumin is not so much mass is deficient and you may lack certain gard it as something to use emergently and
a characteristic of malnutrition but of in- enzyme systems and other systems of de- to get rid of as quickly as possible and to
flammation. Although we do not think fense, which make the difference between switch to enteral nutrition.
about this that way in the United States, al- survival and death. Let us now consider I am not terribly certain that this is a
bumin level in the serum is largely deter- what we can do about a patient whom we bad way to go about things, but certainly in
mined by the percentage of extravascular believe to be at risk and whose perforce has the ICU one does need line care. In general,
albumin since it is the rate of degradation deficiencies not only in lean body mass, but either a port or a subclavian line has the
rather than the rate of synthesis which is also in those proteins, which we associate lowest rate of sepsis. Internal jugular lines
the biggest determinant of serum albumin. with the synthesis of lean body mass and in the ICU, particularly in patients with a
This was shown by Rothschild at his labora- thus perhaps survival. We can also count in tracheostomy, will experience high rates of
tory at the New York, VA in the late 1950s these proteins that may be deficient with sepsis because it is almost impossible to
and early 1960s in which he showed that pa- weight loss the immunological armamen- keep a dressing on, especially with trach
tients with cirrhotics who often presented tarium of the body various enzymatic and ties and everything else. Line sepsis in the
with low serum albumins did so not be- defense mechanisms that are within the ICU, in addition to all the other disasters, is
cause they were not making it but because body and the ability to synthesize phago- often a fatal coup de grace. This is particu-
the percentage of extravascular albumin to cytes and immunological cells, which may larly unfortunate, as a well done TPN pro-
which the rate of catabolism related was in extremis not be able to be synthesized. gram may not only attract patients with
more important in determining the level of Remember that there are 10 billion neutro- high degrees of reimbursement, but also
serum albumin. The European point of view phils released each day and programmed to decrease the operative risk in a given pa-
is that a low albumin, again brought about die within a few hours by apoptosis. Some tient, as will be detailed.
by increased catabolism rather than de- of the products of dying neutrophils may There is a cottage industry as far as line
creased synthesis, is usually the result of contribute to the resynthesis of valuable dressings are concerned. It is difficult for
longstanding, chronic infection or, if not an protein and defense mechanisms. Not to me to believe that the small, rather chintzy
infection, inflammation, and this is the sig- have these puts the organism at risk. instruments, which contain chlorhexidine
nature of a low serum albumin, not so much Before we discuss the actual mechanism and some of the various other things, which
starvation, not so much decreased synthe- of nutritional supplementation, let us first are supplied in kits are efficacious in pre-
sis, but increased degradation because of discuss the status within hospitals where it vention of line sepsis. In a well-run unit, it
the percentage of extravascular albumin is mostly carried out. In an effort to save should be possible to have a line sepsis rate
and its rate of degradation. The Europeans money, hospitals have largely done away of less than 1%. I do not know whether any
may be correct and it may all be about in- with IV nurses and especially specific nurses of these proprietary preparations and kits
flammation. And it may be that inflamma- who are targeted for the delivery of TPN. have ever approached that, nor does it seem
tion poorly characterized, which is the sine Lest hospitals think that the provision of that it has even been demanded, lest we
qua non of patients who are in poor meta- TPN nurses is merely for the benefit of the play Russian roulette with what the hospi-
bolic shape and even poorer metabolic doctors, it is first and foremost for the ben- tal administration shovels over, and it is
shape to survive operation, are most at risk efit of the patients and secondarily for the usually based on price. Not surprisingly,
because of the mechanism which a low se- benefit of the hospital. A bad episode of line when one bases a product on price, one
rum albumin then brings forward. sepsis in a patient costs about $63,000 to usually gets the cheapest, most ineffica-
I am not sure about this. However, I like 76,000 by the time one deals with blood cul- cious product.
to think that in addition to degradation and tures, perhaps in times in the ICU, various
the percentage of extravascular albumin, diagnostic aspects and 2 weeks of hospital- OPERATIVE RISK
there is a component of albumin synthesis ization as one gets the line sepsis under
and certainly in transferrin levels in the se- control. Thus, TPN is something to be As is detailed in the early part of this chap-
rum, there is a component of transferrin avoided, not surprisingly because Lord ter, operative risk is the sum of various risk
synthesis such as Kuvshinov, which I showed knows what the infection rate is. Some ad- factors that are summated in detailing what
in our Southern Surgical Association pre- ministrators have yet to be convinced that kind of complication may occur in a patient
sentation in 1992. line sepsis can be avoided by excellent nurs- who is going to be operated on. It is bad
Thus, we have come full circle. In 1936 at ing care but it needs to be continuous and enough that we do not do anything about
the University of Pennsylvania and indepen- TPN nurses need to make their way from operative risk when the patient is emergent,
dently in the University of Edinburgh, it was unit to unit, emphasizing the care of lines to in which case we can just decrease opera-
shown that a high level of serum albumin which it is directly related. This is not rocket tive risk by keeping the room warm, by
equaled survival following gastrectomy. It science. This has been known since a paper keeping the patient appropriately trans-
was thought that this represented increased in the New England Journal of Medicine that fused, by having a high degree of oxygen-
synthesis, and perhaps it does. However, our team published in 1973 (Abel RM et al. ation, etc., but this is basically trying to stop
one must keep an eye over one’s shoulder to Improved survival from acute renal failure the horse after the horse has left the barn. If
think about albumin as being degraded and after treatment with intravenous essential one has some time, however, as far as oper-
hence the depressed serum albumin level. L-amino acids and glucose—results of a ative risk and one deals with the nutritional

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 45 10/28/11 10:15:16 PM

 46 Part I: Perioperative Care of the Surgical Patient

status, there are some guidelines that are to estimate this by calculating the resting has been previously discussed and the
pretty reasonable. metabolic expenditure. According to the author believes that the amount and du-
Harris Benedict equation, basal metabolic ration of this PN should be approximate-
1. Patients who have lost 10% to 15% of
rate and essentially what patients need can ly 5 or 6 days, at which time we should
their body weight over the previous 4
be computed using the following equa- see the patient feeling better and serum
months are at risk.
tions: transferrin increasing.
2. This is a fairly well worked out number,
Males 66.5 ⫹ (13.8 ⫻ weight in kg) 2. When the alimentary tract is obstructed
as demonstrated by Mullen and his co-
⫹ (5 ⫻ height in cm) or with prolonged ileus postoperatively
workers at the University of Pennsylva-
⫺ (6.8 ⫻ age in years) and nutrition is not possible in the post-
nia in a tediously done VA study.
Females 665 ⫹ (9.6 ⫻ weight in kg) operative period.
3. The period of time necessary to recon-
⫹ (1.9 ⫻ height in cm) 3. One must be careful to indicate PN in
stitute the patient’s nutritional status is
⫺ (4.7 ⫻ age in years) obstructive GI malignancy. One must
probably between 5 to 7 days.
make certain that the incidence and the
4. Serum albumin should be 3.3 g/dL (a Thus, one can get a reasonably accurate duration of the PN is short and that the
value of 3.5 g/dL is better). estimate of not only the caloric require- patient has the possibility of an opera-
When I was the Chief Resident on the ments, but also how it might be adminis- tion without increasing the rate of the
Surgical Services at Mass General, we found tered and, utilizing 6.25 ⫻ the number of growth of the tumor. I firmly believe that
that if we gave PN for 3 days before he was calories, some idea of what the constituents malignancy with obstruction without
taken to the OR, there was a trend toward of TPN might be. any hope of removing the tumor is not
improvement, although what we found out What kind of energy requirements do we an indication for PN. I also believe that
was not statistically significant. From that need? I generally believe that at least in sick PN to foster chemotherapy is not appro-
study we determined that we could (a) iden- people, most of the calories should be sup- priate unless the patient has a markedly
tify the patient at risk and (b) probably do plied as glucose. Yes, one does need a modi- responsive tumor, such as a lymphoma
something about the operative risk by sup- cum of fat, but I believe this to be in the or a lymphosarcoma.
plementing PN for probably 5 days prior to range of 25 to 40 mL of a fat emulsion three 4. Short bowel syndrome. The limits of
operation. Furthermore, 5 days was the times per week to provide essential fatty ac- short bowel syndrome have been rea-
point at which serum transferrin began to ids. I believe that large doses of fatty acids sonably defined, and when patients have
improve and most importantly, the patient may be harmful, and it would be difficult had a massive small bowel volvulus and
began to feel better. Thus we adopted 5 days for patients and their immunological func- only have less than 36 cm of small bowel
as the time that the patient needed to re- tions to tolerate it. with an ileocecal valve, there is an indi-
store lean body mass and the protein func- cation for PN. One must try very hard
tions thereof. In the VA study carried out by CALORIE TO NITROGEN RATIO to save the ileocecal valve, which one
Mullen, they found that after 10 days of sup- usually can do, with the ileocolic vessel
Calorie to nitrogen ratio is normally 6.25,
plementation the patient had been depleted. branch so that 2 cm is sufficient. In addi-
that is, 6.25 cal/g of nitrogen. The amount of
I had always believed that carrying it out for tion, if the ileocecal valve’s blood supply
protein that we need is 1.5 g protein/kg/
longer increased the risk of line sepsis espe- is problematic, it is worthwhile if there
day, which some have suggested to be the
cially today and especially for the line con- is any omentum left, to wrap the anasto-
upper limit of normal. It may be, but cer-
tamination which I fear most, which is that mosis in omentum and suture it around
tainly in certain protein-losing enteropa-
of yeast. Thus, TPN for 5 days, in adequate the ileocecal valve to heal. Others have
thies, the loss is increased so what we would
amounts, with or without fat, and in said that there is less than 3 m of small
say in respect to nitrogen is that there is a
amounts which provided patients with ade- bowel remaining, which is 9 ft, which
range of 0.25 to 2.0 g nitrogen/kg/day. Some
quate amounts of fatty acids was sufficient. in my humble opinion is far too much.
patients have protein needs much higher
What kind of patients will show im- There may be times when the patient
than those with normal metabolic pro-
provement? The VA study again showed has suffered a vascular episode so that
cesses. For example, patients with inflam-
that patients with mild malnourishment the bowel is not really normal, but in
matory bowel disease may lose 0.5 to 1.0 g
(i.e., 5% to 10% of body weight) or moderate general if the patient has 64 in. or 2 m of
protein/kg/day in the stool. I agree with the
malnourishment (with approximately 10% small bowel, even without the ileocecal
recommendations made by Professor Hill
of body weight) benefited from the stand- valve, anastomosis of distal transverse
in the previous edition:
point of TPN replacing lean body mass, but colon or the sigmoid colon, it should be
this particular improvement was negated 1. For maintenance, prescribe 1.0 to 1.5 g possible to ultimately wean from TPN.
by the increase in line sepsis. Patients with protein/kg/day. 5. Enterocutaneous fistula. Enterocutane-
10% to 15% weight loss would benefit, as 2. For a hypercatabolic patient, prescribe ous fistula with the large bowel, which
the improvement in outcome was not obvi- 1.5 to 2.0 g protein/kg/day. can often be managed with enteral nu-
ated by line sepsis or other complications of 3. For those with excessive losses, prescribe trition, but a high output small bowel
TPN. up to 2.5 g protein/kg/day. fistula is an excellent indication for PN.
One can generally expect that between
WHAT IS NEEDED FOR TOTAL INDICATIONS FOR PN 33% and 38% of those patients whose
anatomy is favorable (not obstructed,
ENERGY REQUIREMENT 1. PN is useful either in patients who can- no stricture, reasonable small bowel)
It is highly unlikely that many patients will not or will not eat, or in patients who will ultimately heal without the need for
be in hospitals that have a research func- cannot eat adequate amounts. It is also operation.
tion that enables them to determine the used in patients who are ill or who are 6. Inflammatory bowel disease. Particu-
total energy requirements. Thus, it is better about to undergo elective surgery. This larly in Crohn’s disease, TPN itself may

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 46 10/28/11 10:15:17 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 47

prove to be healing and will quiet down the needle not be any more than 10° to TPN SOLUTIONS
the inflammation. When a fistula com- the horizontal. If one misses the 10° to

Perioperative Care of the Surgical Patient

plicates Crohn’s disease, even with in- the horizontal, one will not get a pneu- Most hospitals have TPN solutions, which
fliximab, it is my experience that the mothorax. After the needle enters the are made up and ordered by a system of pre-
fistula may close but it will reopen. My subclavian vein, one immediately takes a pared solutions. The average physician
approach is to allow the fistula to close, larger needle by the seldinger technique, whose patient needs it only check the box
let the abdominal wall calm down, treat which is prepared, looks at how far in and, based on electrolyte values, the addi-
infection, and then operate and resect the number 22 needle is, and passes the tives to the patient’s TPN. In this way, errors
the area of the fistula. seldinger needle into the vein. A wire is in TPN are omitted. The most likely errors
7. Patients with major intra-abdominal then introduced through this needle and occur in the lack of monitoring of solutions
sepsis or inflammatory processes such the catheter is then placed over the wire. and the failure to make up, for example, for
as pancreatitis, and in general when the The suture, which is absorbable but of GI losses including the loss of chloride in
gut is not usable, are excellent candi- sufficient dimensions such as a 3-0 pds, nasogastric tube drainage and/or the loss
dates. is then used to sew the catheter in place. of enteral contents in patients with gastro-
The IV is then hooked up; I generally at intestinal cutaneous fistulas. A particular
that point ask the TPN nurse to dress the area of loss that most do not pay much
PLACING A CENTRAL catheter. attention to is both the energy and the
VENOUS CATHETER 8. Infusion is done with 5% dextrose in sodium loss of a hepatobiliary fistula. The
saline and a CXR is obtained, mak- sodium content as well as some other elec-
A catheter may be placed by an internal trolytes of both a biliary and a pancreatic
jugular route, an external jugular route, or a ing certain the catheter is in the right
place. The operator should examine the juice loss is particularly energy-dependent
subclavian route. I do not favor a peripher- because it is hypertonic to the plasma. This
ally inserted central catheter (PICC) line as x-ray themselves. The tip of the catheter
should be at the junction of the superior means that patients who lose large amounts
I believe that the infection rate is consider- of bile and pancreatic juice may lose fluids
ably higher and it is more uncomfortable vena cava and the right atrium. If the
catheter is in place and there is no pneu- with a sodium content of up to 180 as com-
for the patient. I prefer to place the subcla- pared to a plasma, which contains a sodium
vian line myself with the following tech- mothorax and the bottle is lowered and
the blood comes back into the catheter, of 140. Potassium loss to excess is uncom-
nique. mon but may occur. One of the maneuvers,
the TPN can be hung and usually starts
1. The patient should be supine in bed and at 40 cc/hour. Care we have previously which helps in managing such patients is to
three chucks or a small roll should be dealt with. take the fluid loss and send it to the labora-
placed longitudinally between the pa- tory for their analysis. Clearly, this must by
tient’s shoulder blades. done by consulting with the laboratory so
2. The patient’s shoulders should be thrust
SUSPECTED CATHETER SEPSIS that the material, if it contains particulate
back and relaxed. A small IV injection of The fever curve of catheter sepsis is usually matter, can be spun down and the superna-
valium for patients who are agitated or a very low grade fever of several days before, tant analyzed.
nervous is often helpful. followed by a fever spike and rigors. It may Calcium and phosphorus need to be
3. The arms are at the side and the neck is or may not be associated with a high white carefully adjusted. Hypophosphatemia is
turned slightly to the opposite side. count and there is not another source of manifest usually by a somewhat bizarre
4. After being prepped and draped, the sepsis. One takes blood cultures from the symptomatology beginning with numbness
patient should be placed at a 30° Tren- catheter and also from a remote spot so to in the lower jaw and in the skin around the
delenburg. If the external jugular veins make certain that, if there is a positive blood mouth and may, if untreated, end with hy-
cannot be visualized, then a crystalloid culture, it is not a contaminant around the pophosphatemic coma. This usually occurs
or plasma (depending on the patient’s catheter. If this is correct, then after the when the serum phosphorus reaches the
need) should be utilized to make certain starting of a peripheral IV, the catheter is level of 0.5 mEq/L. Failure to be aware of its
that the veins are of a proper diameter. withdrawn and the tip is cultured. If a fun- existence may be extremely damaging.
5. A careful prep of both sides, usually with gus is suspected, an ophthalmological ex- Other deficiencies may occur in multivi-
povidone iodine followed by chlorhexi- amination for candida in the eye fundus is tamins and bizarre amino acid patterns in
dine after the povidone iodine is washed also necessary. If the sepsis occurs without the plasma. When, for example, MVI was
off with alcohol, is carried out. The op- prior prodrome when the new bottle is unavailable because of the FDA from a sin-
erator should be totally gowned and hung, the bottle is removed, the catheter is gle source, patients presented with a meta-
draped, as should everyone else in the left in place, and the TPN is cultured; it bolic acidosis, which resembled the meta-
room, with a mask and a hat. is very rarely the source of sepsis. bolic acidosis of dead bowel, and more than
6. The patient is allowed to relax and the If the catheter is a source of sepsis, 24 to one patient was explored looking for dead
shoulders dropped downward. 48 hours must elapse with adequate antibi- bowel until amino acid patterns were ob-
7. I usually find the subclavian vein with a otic coverage before another catheter is at- tained and were bizarre, with large amounts
number 22 needle, which is placed just tempted. If a fungemia is present, then one of hydroxyproline and proline and it be-
at one-third of the clavicle. I anesthe- must look for other sources of nutrition not came obvious that we were not dealing with
tize the periosteum of the clavicle and including glucose and one must try espe- dead bowel but with a shortage of various B
aim for one finger breadth above the cially hard to use enteral nutrition. One can vitamins. Some of the trace metals need to
sternal notch. With practice, one injects only be certain that sepsis is no longer exis- be added and one must be aware of chro-
the xylocaine and/or Marcaine and one tent when one has 2 weeks of adequate mium, which has an additive effect to insu-
feels the pop as the needle enters the therapy. If the therapy is not adequate, it lin. Absence of chromium may lead to un-
subclavian vein. It is important that may take 6 weeks for sepsis to subside. controlled blood sugars and chromium is

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 47 10/28/11 10:15:17 PM

 48 Part I: Perioperative Care of the Surgical Patient

part of the multivitamin and trace element window when the patient is in bed does not teral nutrition as currently given in various
solution, which is usually added to the TPN. help patients get off TPN and begin oral in- hospitals, I believe have a higher incidence
Other rare occurrences include selenium, take. of mortality than in TPN. The reason is the
which has been rarely reported as it is so failure to understand the concept of the
ubiquitous that deficiency almost never oc- MANAGEMENT OF TPN challenged bowel. To begin with, much of
curs. Zinc, however, particularly in patients enteral nutrition is given into the stomach,
with liver disease and in patients with diar- DURING OPERATION especially in the elderly. The elderly patients’
rhea and inflammatory bowel disease, may For some reason, most surgeons who have stomach may not take or tolerate hyperos-
be a real problem and one must be aware of patients on TPN stop the infusion before molar feeds as easily as younger patients. In
the tendency of patients with large amounts the operation and give patients 10% dex- addition, loss of motility, especially on the
of diarrhea to be zinc deficient. The symp- trose. I am not sure why they do this, espe- evening and night shift when patients are
tomatology here is a pustular rash, which is cially since it is not necessary. Patients can unattended, often leads to aspiration, pneu-
usually perioral and a rash around the skin. tolerate TPN during operation quite well monia, and death. A well-run enteral nutri-
Zinc levels are difficult to measure and take but because of the stresses the rate needs to tion unit will stop feedings at 9 p.m. (or ear-
a long time, and if one sees a pustular rash be decreased. The rate should be slowed on lier) and the patient should remain elevated
around the mouth (this is usually where it the day before operation and by midnight at 45°, which is difficult.
first appears), it is better to add zinc to the previous to the operation; the rate should Another problem with enteral nutrition
solution particularly in patients who have be slowed again to 40 cc/h, at which time from my standpoint is the failure to under-
profound diarrhea with inflammatory bowel there will be no hypoglycemia, which one stand hyperosmolality and its effect on the
disease. chances when one decreases TPN at a time bowel. The manufacturers’ guidelines for
when patients have a lot of insulin. After starting enteral nutrition take very little ac-
the operation is completed, one can then count of the hyperosmolality of many tube
CALORIE TO NITROGEN RATIO feedings and will start tube feedings on a
increase TPN to 60 cc/hour on the first
Calorie to nitrogen ratio is still a matter of night and carefully monitor glucose with hyperosmolality of 400 or 500. In patients in
some discussion. I personally believe that patients who may require insulin prior to the ICU or in elderly patients, this requires
the traditional calorie to nitrogen ratio, resuming the previous rate. Hyperglycemia an increase in cardiac output and increase
which is utilized in most institutions is in- in the postoperative period may very well in blood flow to the bowel to dilute the hy-
correct (reference). I believe the calorie to mean infection some place, anastomotic perosmolar material by secreting free wa-
nitrogen ratio should not be 28, in which leak, or a latent wound infection and one ter. The elderly bowel may not be able to do
there are 28 cal/g of nitrogen, but rather it must be completely vigilant to this particu- this and if one starts hyperosmolar tube
should be considerably higher, perhaps 35 lar aspect. feedings without being certain that the
or 42. However, an attempt to get individu- bowel can tolerate it, it leads to pneumato-
als to change this has been like swimming RELATIONSHIP BETWEEN TPN sis, bowel necrosis, and death. Starting hy-
upstream. The calculations are simply in- poosmolar tube feedings with a strength of
correct, as we pointed out years ago. It may AND ENTERAL NUTRITION 150 mOsm/L and gradually increasing it so
explain why it is difficult to add real lean If TPN were delivered in a way in which the that it never exceeds 280 mOsm/L will pre-
body mass to patients with TPN without nursing follow-up of patients had adequate vent any pneumatosis or hyperosmolar-
vigorous exercise. line care, there would not be such a rush to related deaths from bowel necrosis. At times
The other issue is the administration of get patients off of TPN and onto enteral nu- one cannot give as much bowel or enteral
TPN and whether it is continuous over 24 trition. The good Lord intended patients to feeds as is necessary to maintain the patient
hours or perhaps there should be a break in take food orally, and indeed one of the char- totally, and in this case, one should opt for a
the cycle. Traditionally, TPN is given in one acteristics important to the way food is ad- combined enteral and parenteral nutri-
of two ways: either continuously 24 hours a ministered is that calories and protein must tional support.
day or overnight. Most hospitals do not be cleared by the gut and must pass through
have the staff nor do they have any desire to the liver. The liver will clear at least 75% of
cycle TPN. This is particularly important
HEPATIC FAILURE
the glucose presented to it in the portal
when patients, for example, have healed vein. It is controversial as to whether the The administration of conventional amino
gastrointestinal cutaneous fistulas and liver should do this or in fact requires the acid mixtures to patients with hepatic en-
have to get started eating. Not surprisingly, passage of most of the calories and amino cephalopathy and an impaired liver will al-
after 30, 60, or 90 days of not having signifi- acids into it to maintain its function. I be- most certainly lead to worsening of hepatic
cant oral intake, continuing TPN 24 hours a lieve that the liver is dependent on first pass encephalopathy. The reason is that hepatic
day will remove what little appetite such in- clearance of 75% of glucose and many other encephalopathy is thought by many (in-
dividuals have. Stopping the TPN during nutrients, and failure to do so will contrib- cluding myself) to lead to high levels of phe-
the day will enable the patient to have a lit- ute to hepatic dysfunction. So the case can nylalanine and other aromatic amino acids
tle more appetite, and it is often very diffi- be made for enteral nutrition, not the least and tryptophan, while not total tryptophan
cult to get people started eating. The use of of which is hepatic health. On the other but free tryptophan, across the blood/brain
alcohol prior to meals, bringing outside hand, the adage that enteral nutrition has barrier, and results in derangement of the
meals, having families bring in favorite far fewer complications than TPN is simply central nervous system neurotransmitters.
foods, and trying to get patients to eat not true. In TPN, line sepsis and some inci- Since the aromatic amino acids gain entry
something other than the unappetizing dences of electrolyte abnormalities are the into the brain by competing with the
hospital food, often delivered late and cold, principal complications. Patients certainly branched-chain amino acids, a different so-
and especially in patients who do not have do die from line sepsis; they should not, but lution has been proposed and has been in
great mobility to have the tray put on the they do. However, the complications of en- use since the 1970s. For some reason, in

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 48 10/28/11 10:15:17 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 49

many American hospitals, the vested inter- which was very rigid, but in fact it was rapid recovery from acute renal failure, and
ests of gastroenterologists make certain shown in chronic renal failure patients to in fact the addition of the eight essential

Perioperative Care of the Surgical Patient

that patients do not receive this solution, I decrease the frequency of dialysis. As far as amino acids only, which keep down the
believe, because they did not think of this I can recall and as far as I am aware, there BUN, should help the recovery from renal
idea. Randomized prospective trials have were no studies that suggested that the fre- failure. In fact, in a 1973 publication in the
clearly shown an improvement in outcome, quency of dialysis was decreased, which New England Journal of Medicine, the late
including close to improved survival in pa- was true, but that this frequency of dialysis Dr. Ron Abel and the rest of the team with
tients receiving a high branched-chained, decrease resulted in an improved outcome. the addition of the renal consulting unit at
low aromatic amino acid ratio in TPN. There The essential amino acids were the amino the Mass General Hospital carried out a
is also reluctance to utilize large amounts acids, which could not be synthesized by randomized prospective trial of the essen-
of this solution when the studies have the body. There were some additional es- tial amino acids and hypertonic dextrose
clearly shown that, when one gets to upper sential amino acids from the standpoint of versus isocaloric hypertonic dextrose alone.
levels of amino acid infusion, between 80 the inability to synthesize it such as argin- That randomization was not particularly
and 120 g/24 hours, the results are better. ine, and some have advocated using a more helpful to getting it accepted because, as it
Fat should not be used as an energy source complete formula. The problem is that most later turns out, we probably could have in-
in patients with liver disease because they situations in which one is using an essential cluded a small dose or an isonitrogenous
do not metabolize it. Glucose is the pre- amino acid regimen involved surgical pa- dose of nonessential amino acids and actu-
ferred fuel and one needs to watch glucose tients in acute renal failure. The addition of ally had a much more acceptable random-
intolerance. In other countries, the use of any other amino acid other than the eight ized prospective trial. Be that as it may, the
high branched-chained, low aromatic that have become the standard decreases results of that particular study were star-
amino acids is very widespread and is part the efficacy as far as the lowering of BUN, tling. The use of essential amino acids and
of the armamentarium, but in the United which is an essential part of the regimen. hypertonic dextrose versus caloric equiva-
States, for the most part, this is not routine Unfortunately, the way most dialysis cen- lent dextrose resulted in increased survival
therapy. In patients with impaired hepatic ters are set up within hospitals and in re- in the group of patients receiving essential
function, a high branched-chained, low ar- spect to patients in the ICU, like so many amino acids. Because of some conflicts on
omatic amino acid ratio may result in im- other things that happen in ICUs such as Dr. the editorial board, not all the data were
provement in liver function and survival in Marshall has so correctly pointed out, dialy- published. For example, the study showed
patients who otherwise might die. Such so- sis is on a schedule and it really does not that in patients with pneumonia receiving
lutions have been tested both parenterally matter if the patient needs dialysis or not. essential amino acids in hypertonic dex-
and orally, and except for the two studies in In other words, if a patient is given essential trose, survival was higher than in those pa-
which the individuals have done the study amino acids and that results in a slower rise tients not receiving essential amino acids.
insist on using fat as the caloric source de- in BUN so that the level of BUN does not rise Other critical illness factors were also
spite evidence that this is not efficacious, to the level where the patient needs dialy- shown to be less lethal, such as GI bleeding
the results have all been positive. It is of in- sis, the patient gets dialyzed anyway be- and other things that complicate renal fail-
terest that the Cochrane collaboration cause there is a schedule, and for those of ure. It is of little question that at least in
chose as chair of the committee in the you who have been in dialysis units, the way that study, a carefully controlled random-
branched-chain-enriched amino acid solu- in which dialysis is done is in such a way ized prospective trial, that patients with
tion, the one who was the lead author in that I cannot believe that it is not injurious hypertonic dextrose were inferior to pa-
this study showed a lack of efficacy because to an already damaged kidney. Most of the tients getting essential amino acids in hy-
of the use of fat. He was chair of a four-man time when I visit a patient who is getting pertonic dextrose in acute renal failure,
committee and therefore the Cochrane col- dialysed while making rounds, the bed is at mostly in a surgical setting (reference).
laboration, despite of all of the evidence a 45° vertical with the head down, the pa- Subsequently, Dr. Herbert Freund, later
that indicates that use of aromatic deficient tient’s blood pressure is 60 mm Hg, and the the Chair of the Hebrew University Depart-
and high branched-chain amino acid solu- dialysis is proceeding at the same rapid ment of Surgery at Mount Scopus, tried to
tions are efficacious was given an equivocal pace as depleting the intravascular volume conduct a study in which a diluted solution
review. Use of oral branched-chain amino because the all-important schedule needs of standard amino acids was compared
acids, notably in Europe, has shown im- to be obeyed. Assuming that the patient has with the essential amino acids. Although
provement in long-term encephalopathy in acute renal failure for some time and the there was some indication that the out-
patients with chronic liver disease as well. provision of appropriate nutrition and the come might be better, the study was insuf-
patient is gradually beginning to make new ficiently powered to provide a definitive
RENAL FAILURE protein in the kidney and perhaps repair answer. Thus, our recommendation for pa-
some of the damage of acute renal failure, tients in acute renal failure is that a solu-
Renal failure especially in surgical patients you cannot convince me that the way that tion consisting of 35% dextrose and 16 g
is an unfortunate concomitant of critically dialysis is done, with hypotension and no essential amino acids/L does seem to con-
ill patients. To say that it complicates their supervision, actually aids the patient’s re- fer some type of survival advantage in these
management is an understatement. Ap- covery. That is why, at least in surgical pa- critically ill patients. The management
proximately 40 years ago, there was a Gior- tients, the use of essential amino acids is so could be helped if the way in which dialysis
dano Giovanetti diet, which was intended important. The glucose regimen is usually was done was altered so that if patients did
for oral patients with chronic renal failure. about 35%. The essential amino acid load is not need dialysis, they would not be sub-
The purpose was to avoid dialysis. In these quite small, about 16 g/L, much lower than jected to a hypotensive event every other
studies, high biologic value protein such as the 40 g/L that is usually given in hyperali- day for 3 hours, thus perhaps decreasing
egg yolk and other types of protein, which mentation solutions. There is evidence that the essence of recovery from acute renal
had little waste nitrogen, were part of a diet, decreasing the protein load may aid more failure aided by essential amino acids.

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 49 10/28/11 10:15:17 PM

 50 Part I: Perioperative Care of the Surgical Patient

RESPIRATORY FAILURE patients who are in cardiac failure and who

Table 9 Daily Vitamin Requirements
require parenteral nutritional supplemen- for Enteral Feedinga
There has been an attempt to have a respi- tation should get the standard solution.
ratory solution in patients with acute respi- One should make an attempt to make cer- Vitamin Daily Requirement
ratory failure who need nutritional support. tain that the solution is concentrated. Thiamin 1.2 mg
Because of some data that John Kinney
Riboflavin 1.3 mg
brought to our attention, the focus seemed
to center on the amount of glucose that was GLUTAMINE Niacin 16 mg
given, which appeared to increase arterial For a while the research field went through a Folic acid 400 µg
CO2 and thus perhaps delay the weaning of period in which glutamine was thought to be Pantothenic acid 5 mg
these patients from the ventilator. the best thing since sliced bread. There were
In fact, this was a very good example of large contracts written and there was an at- Vitamin B6 1.7 mg
how a specific event with a few patients tempt to include glutamine in various amino Vitamin B12 2.4 µg
treated in a certain way was generalized to acid solutions. Experiments in our labora- Biotin 30 µg
the entire group of patients with respira- tory in rats (which may not be completely
tory failure. The patients who got a high transferrable to humans) carried out by Choline 550 mg
dose of glucose early on suddenly, without a Dr. Michael Nussbaum utilizing 2% oral glu- Ascorbic acid 90 mg
gradual ramp up, did increase their CO2 and tamine and 2% parenteral glutamine clearly Vitamin A 900 µg
actually by the numbers it made their respi- indicated that, as far as the effects on the fit-
ratory failure worse. However, this was a ness of the gut wall and presumably other Vitamin D 15 µg
very small group of patients who were put aspects of gut function, oral glutamine was Vitamin E 15 mg
on TPN suddenly. They were septic and their quite efficacious but no effect was seen on Vitamin K 120 µg
CO2 went up markedly so that they got a parenteral glutamine. Since that time, glu-
larger dose of glucose than they should tamine has been utilized in enteral formula- a
Prescriptions must be individualized per patient
have. As near as I can tell after reviewing tions but as far as I’m aware, a glutamine- needs.
the data, there is no reason to utilize a solu- containing solution has not really gained
tion for respiratory failure unless the rou- popularity in patients who require PN.
tine management of patients who are septic fight infection and to recover from a big op-
and in respiratory failure is to give them eration by nutritional means. Is 20 g of pro-
large doses of glucose. As far as I am aware,
IMMUNOLOGICALLY tein equivalent enough to skew the results? I
that no longer occurs and so there is no rea- ACTIVE SOLUTIONS am not certain. It would be nice if somebody
son to give a “respiratory failure solution.” Unfortunately, despite the fact that one of would repeat the study and make it isoni-
the holy grails in PN is to have come up with trogenous, but I doubt very much whether
a solution, which is beneficial to patients that will ever happen.
CARDIAC FAILURE who are infected or who have lower ability to
Earlier studies in nutrition carried out by respond to infection, there has been no suc- COMPLICATIONS
Starling in 1912 suggested that the heart cessful attempt as far as I’m aware to get a
was spared the ravages of starvation. A parenteral solution for patients who require I have mentioned many of the complica-
careful look at these experiments revealed nutritional support in defense against infec- tions of nutritional support. Tables 9 and
that Starling utilized two cats, one of which tion. There have been solutions, mostly en- 10 show most of the complications that ex-
was starved and the other was not. The un- teral, that include various components such ist, most of which have been dealt with.
fortunate cat that was starved was sacri- as glutamine, nucleic acids and other such However, there will always be complica-
ficed at a later date and it was found that its solutions which seem to have some efficacy, tions that one has never seen before, such
heart did not change remarkably during but as far as I am aware there is no commer- as when we first saw chromium deficiency
this period of starvation. Since then these cial solution which is currently available. The
experiments have been repeated and it does glutamine-enriched solution in patients who
appear as if after a prolonged period of time
Table 10 Daily Trace Elementsa
underwent large operations when they were
that starvation does effect the heart in simi- malnourished and treated with enteral nu- Trace Element Daily Requirement
lar fashion to the way it effects other pro- trition, which was chaired by the late Bob Chromium 30 µg
tein and other lean body mass, only much Bower and who was a senior author of that
more slowly. In an initial attempt to devise study, indicates that there was a 5-day length Copper 0.9 mg
a solution for cardiac failure, our team put of stay, which was shorter in the group re- Fluoride 4 mg
together a concentrated solution of amino ceiving glutamine and the various other im- Iodine 150 µg
acids and glucose and administered it to munologically active solutions enterally.
patients in congestive failure who could not There does seem to be some valid dispute Iron 18 mg
eat. Our conclusion was that, since we did over the results, since the two solutions were Manganese 2.3 mg
not see any change in cardiac parameters not given in isonitrogenous fashion and Molybdenum 45 µg
after 4 weeks, but we did see some changes there was a difference of about 20 g of amino
in cardiac parameters after 6 weeks, that acids/day. Be that as it may, and it could be Selenium 55 µg
any beneficial effect in cardiac failure in influential in this particular result, it does Zinc 11 mg
giving nutritional support was bound to be seem as if this is a rather interesting and I a
prolonged and probably was not going to be believe almost monumental study, suggest- Prescriptions must be individualized per patient
needs.
particularly useful. This does not mean that ing that one can manipulate the ability to

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 50 10/28/11 10:15:17 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 51

in patients with diabetes and the inability cancer are well known and have been nicely may well be a membrane problem, in
to actually control blood glucose. However, described in Chapters 1 and 2 (Fig. 6). The which there may be:

Perioperative Care of the Surgical Patient

I am unaware of PN complications in the cytokines and mediators and hormones have (a) Disordered submembrane space
past 5 years, which are due to either trace also been elucidated and possibly also myo- (b) Insufficient transport mechanisms
elements or other nutritional components statin in sepsis, although Dr. Hasselgren has (c) A pathological increase in processes
that have specific complications. Table 9 already stated that in experiments in his that depend on the cytoskeleton
deals with the most common, most of which laboratory myostatin levels in sepsis are structure
we have already dealt with. probably low. The counterregulatory hor- 4. It has not been widely publicized, although
mones, mediated cytokines, etc., have been I think most of us are aware that the cell is
dealt with in great detail. They also break not a bag. It has an internal structure, and
Our Inability to Support Patients down in sepsis and probably in cancer, the internal structure is surrounded by a
Nutritionally with Sepsis and namely involving MuRF-1 and sometimes cell membrane. There are excrescences
Cancer: A Hypothesis atrogin-1, have also been elucidated. There is from the cell membrane, which break it
one aspect, however, of nutritional support into subcompartments arising from the
One of the things that we have discussed in which has not been involved, and that is the membrane, which provide order into the
the past two chapters is the influence of cytoskeleton and the proximity of various interior of the cell, which we call a cy-
metabolism on the outcome in really sick enzymatic systems and sources of fuel for toskeletal structure. It may be, and this
surgical patients. As we have discussed nu- these enzymatic systems and not the three- unfortunately is a teleological argument,
tritional support and TPN, it becomes clear, dimensional space relationship and its effect that there are various biochemical reac-
and this has been stated in Chapters 1 and on certain critical enzymatic and hormonal tions that organize the cell, so that the
2, that there was still a group of patients interactions. A number of months ago, I pro- reactions that are necessary may proceed
that we have not been able to support met- posed (Fischer JE, Nutritional support: we better if there is a special relationship be-
abolically and nutritionally, and that is the have failed in our ability to support patients tween two enzymatic or metabolic pro-
patient with far-advanced cancer, in whom with sepsis and cancer, Surg Clin North Am cesses because they are adherent to the
there is a very expressive photograph ear- 2011;91:641–51) the reason why, despite all cell membrane. Thus, if there is a deviant
lier in Chapter 2, and the patient with sep- of our successful efforts in nutritional sup- pathophysiological mechanism and two
sis, in whom overwhelming sepsis seems to port over the last 40 years, we have not been other mechanisms that are attached to
have an accelerated effect on the lysis of successful in maintaining patients and de- the cells are adjacent to each other in the
lean body mass for, it seems, gluconeogen- creasing their proteolysis in sepsis and can- cytoskeletal structure, these pathological
esis and the source of amino acids for cer. The hypothesis involves the following: processes may be increased by the prox-
acute-phase protein. Nonetheless, despite imity of these enzymatic processes and
all our efforts, these two classes of patients, 1. There is ineffective glycolysis, which re- by the ready availability of fuel to run the
mainly the septic patient and the patient sults in an insufficient generation of ATP. enzymatic processes.
with far advanced cancer, stand as excep- 2. Under normal circumstances, fat admin- 5. One may then ask the following ques-
tions to an otherwise reasonably successful istration for nutritional support decreases tion: in sepsis and cancer are there any
program of supporting them metabolically. glycolysis in sepsis and cancer—but the cytoskeletally related processes that
The two sources of calories in all patients “switch” that shuts off glycolysis in this might explain some of the aberrant phe-
that we generally give are carbohydrate case does not seem to work. nomena seen in these two diseases?
(glucose, generally) and fat. Carbohydrate as 3. There appears to be a continued need 6. What is the meaning of aerobic gly-
it is administered to patients is bimodal— for gluconeogenesis from protein—the colysis? Aerobic glycolysis is a process
it either increases ATP production by inability to get glucose into certain cells involving sodium–potassium ATPase,
glycolysis or under certain hormonal cir-
cumstances ends up in glycogen for energy Sepsis
storage. Glycolysis is universal. The brain re-
quires glucose as do red cells exclusively, but
under certain circumstances the brain can Mediators
switch over from glucose to ketone bodies to
support it. The kidney can do this as well.
Also, it is a sensitive negative feedback sys- Transcription Nuclear CounterRegulatory
Glucocorticoids Cytokines
Factors Cofactors hormones myostatins
tem, so that, when intracellular ATP is high,
glycolysis is down, and, when it is low, glyco-
lysis proceeds. The synthesis of ATP results
from a base of phosphoenolpyruvate plus Gene Regulation
ADP to form pyruvate and ATP. Under nor-
mal circumstances, when we give sources of Atrogin-1
fuel, such as long-chain fatty acids, they are Mu RF-1
metabolized, and in the presence of acetyl
coenzyme A, these are also important fuels Muscle Proteolysis
for ATP production and can decrease glycol- Calpain
ysis but not by themselves, and only when
ATP levels are sufficiently high. Muscle Wasting
The hormonal environments which exist
in distressed patients with either sepsis or Fig 6. The factors involved in muscle breakdown and muscle wasting.

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 51 10/28/11 10:15:17 PM

 52 Part I: Perioperative Care of the Surgical Patient

which takes place in an area adjacent to block for circulating glucose in the first zamine, an alpha blocker, and propranolol,
the cell membrane and produces lactate. place, which in sepsis is certainly well a beta blocker, in hemorrhaged dogs, both
Lactate is usually an end product, and we known. In the second place, it suggests that plasma catecholamines and hyperlactemia
are accustomed to viewing lactate as be- perhaps the mechanism by which glycogen were reduced. More recently, our laboratory
ing an indicator of dead or dying cells or is kept at a high level is somewhat deficient has shown that the production of lactate in
an incomplete end product of metabo- either because of spatial problems, which is vitro from extensor digitorum longus mus-
lism of glucose. The failure to process unlikely, or more likely because of a trans- cle in shocked, burned, or septic rats was
lactate further via the classic Kreb cycle port block at the cell membrane. Thus, it decreased when ouabain was used to block
means that the process of aerobic glycol- may be that the only glucose that can get the activity of sodium potassium ATPase.
ysis results in only eight ATPase produced easily into the cell is when amino acids or Although this was known somewhat previ-
per molecule of glucose rather than the other substrates get into the cell and are ously, and indicated that the sodium potas-
normal 32–36, if the process continued metabolized to glucose and then to glyco- sium ATPase was essential for the produc-
through a Cori cycle. Aerobic glycolysis is gen. If this hypothesis is correct, the differ- tion of lactate, we went on to show that the
stimulated by epinephrine and produces ence between the glucose, which is blocked regulatory cascade controlling glycogen
lactate. Every intern and resident, at least at the cell membrane, and the relatively free breakdown was often dependent on adenyl
on the surgical service, knows that, when availability of intracellular amino acids, cyclase stimulated by epinephrine and me-
blood lactate is higher, there is something which are broken down by proteolysis and diated by the activation phosphorylase B
dead, because lactate is usually the result then to glucose by intracellular gluconeo- Kinase to phosphorylase B to glycogen plus
of an anaerobic end product. This is not genesis, makes the source of the glycogen an organic phosphate and finally to glucose-
necessarily the case, and the production dependent on muscle-protein breakdown. 6-phosphate. Furthermore, the stimulation
of lactate by aerobic glycolysis is because Does lactate always mean dead bowel, of lactate production and extensor digito-
of the proximity of stored glycogen, which hypoperfusion, or inadequate oxygenation? rum longus either by epinephrine or by
fuels sodium potassium ATPase, which It is pretty clear that, whereas traditionally amylin could be inhibited by ouabain. Thus
is spatially related to or close to the cell high blood lactate has been associated with James and colleagues working in our labo-
membrane. When aerobic glycolysis is hypertension, hypoperfusion and hypoxia, ratory proposed the following hypothesis:
stimulated by epinephrine (Fig. 7), which under certain circumstances blood lactate
then releases glycogen, it is close to the elevation does not mean these things. In 1. Within cells, oxidative and glycolytic en-
enzymatic system of sodium potassium the burn patient, 2 weeks after the burn, if ergy production can proceed in separate
ATPase and yields a final end product of one were to look at lactate as an indication compartments intracellularly.
eight ATPs per molecule of glucose. that resuscitation is not completed, it 2. Most lactate production occurs in mus-
would be dangerous because continued re- cle and the source of the calories and
Not surprisingly, the absence of 32 ATP
suscitation with high volume of fluids may fuel is glycogen.
per molecule of glucose likely produces an
be injurious and in fact blood pressure, 3. Most lactate production is linked to aer-
energy shortage. Because of the shortage of
pulse, urine output, and PO2 are normal at obic glycolysis, which in turn is linked to
ATP, increased gluconeogenesis results,
that time. The question has been raised, sodium potassium ATPase.
and, when this happens, the glucose pro-
how does this happen? The answer is, if this 4. Epinephrine and, to a lesser extent, insu-
duced is transported to certain sites within
theory is correct, resuscitation in the face of lin stimulate sodium potassium ATPase
the cell, avoiding the cell membrane block
normal blood pressure, pulse, urine output, to maintain membrane polarity and
in glucose uptake, and when it is synthe-
and PO2 may be harmful, with which most muscle contraction. This then supposed
sized to glycogen, those sites probably are
people would agree but is due to still high that the sodium potassium pump func-
different from the sites normally circulating
circulating epinephrine. One way in which tion on glycolysis is likely associated
glucose, if it gets into cell and it gets into
this might be explained is by some experi- with a degree of compartmentalization.
the liver. There is a membrane transport
ments done by Sir Miles Irving (1967 to1969) This had been previously suggested by
that, after alpha and beta blockade in hem- Paul and his coworkers, who suggested
If this hypothesis is correct:
orrhaged dogs, as published in the Hunte- an association of glycolytic enzymes and
Gluconeogenesis rian lectures, combination of phenoxyben- calcium ATPase, or sodium–potassium

Glycogen Ouabain Inhibits Epi- and Amylin-stimulated

Lactate Production in Sk. Muscle
Increase in Lactate Production

Aerobic glycolysis 8ATP Epinephrine Amylin

16 16

Lactate
(µmol/g × hr)

12 12
(−) Ouabain

Glucose 8 8 (−) Ouabain

4 4
Glycogen
(+) Ouabain (+) Ouabain
0 0
Aerobic glycolysis 5× 10−9 5× 10−8 5× 10−7 5× 10−6 10−9 10−8 10−7 10−6
[Epinephrine] (M) [Amylin] (M)
Fig. 7. Brief outline of a futile cycle which may be
involved in the metabolic derangements of sepsis Fig. 8. Epinephrine and amylin separately stimulate lactate production, but they are blocked by ouabain
and cancer. demonstrating that sodium/potassium ATPase must be active.

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 52 10/28/11 10:15:18 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 53

Cell membrane in a disordered glucose metabolism,

which we know exists in sepsis and

Perioperative Care of the Surgical Patient

cancer (Fig. 9).
5. Also, this hypothesis unifies the effects
Pyruvate of epinephrine on these cells, which was
traditionally viewed as stimulating two
entirely different processes—increasing
G-6-P G-6-P Glycogen stores sodium potassium ATPase and sepa-
rately increasing glycogen phosphory-
lase, which indirectly increased lactate
ATP Pyruvate production, thus increasing pumping-
membrane hyperforce correlation. What
LDH
our laboratory suggested was that these
two processes are linked because of the
Lactate
cytoskeleton and because of proximity of
both to the cell membrane, in the same
area (Fig. 10).
Cell membrane 2K+ Lactate
Proteolysis and Sepsis in Cancer
Fig. 9. This figure attempts to show the two mechanisms, which are closely linked because of the
cytoskeletal structure of the cell. It also attempts to show that the glucose derived from glycogen is pref- In a normal organism, protein synthesis and
erentially from gluconeogenesis derived from amino acids. degradation and in this case muscle synthe-
sis and degradation are matched, and no net
breakdown of protein takes place, and no
synthesis takes place unless in the presence
ATPase at the plasma membrane, the or either epinephrine or ouabain, an of exercise and increased caloric and protein
segment of which is shown in the figure. increase in lactate resulted in the de- intake. However, in cachexia brought on by a
This was supported by the effects of glyco- crease in glycogen, and, when epineph- variety of stimuli, not the least of which are
gen and the production of lactate—when rine and ouabain were both added to sepsis and cancer, muscle breakdown far ex-
ouabain is added, glycogen remains in- the bath, the lactate production was ceeds muscle protein synthesis. The reasons
tact, and for the most part lactate pro- largely blocked, whereas glycogen con- for this have been previously detailed, in
duction is diminished (Fig. 8). This in- centrations were maintained. It may which it appears that the normal mecha-
dicates that sodium potassium ATPase be possible to explain these effects nisms of protein breakdown were seen as
stimulated by epinephrine is at least by some differential blockage of the bad, but perhaps not always, in the initial
partially responsible for lactate produc- actions of insulin—for example, if the phases of injury and sepsis, for example, in-
tion. In fact, as in the figure, when glyco- glucose used by glycolysis is not blocked creased production of acute-phase protein
gen remaining versus lactate production in other areas such as glycogen storage. by amino acids derived from muscle break-
is expressed as glucose equivalence after In that sense, the differential effects of down might mean the difference between
incubation in the presence or absence insulin might conceivably participate death and survival. It is only with the coming
of the ICU, in which prolonged muscle break-
down takes place, under which terms in the
past the patient would have been dead, that
this becomes something which is not benefi-
Effect of Epi ± Ouabain on Glycogen and cial. If we could support our patients in the
Lactate Production ICU in such a way that we could derive the
Epi / Ouabain Glycogen Lactate
benefits of both muscle breakdown and min-
imizing the breakdown, if by manipulating
− − various fuels, so that it would not be neces-
sary to have proteolysis to maintain these
essential functions, muscle breakdown
+ −
might be decreased. We now understand the
mechanisms of proteolysis a lot more than
− + we did in the past, and the mechanisms have
been well described in the second section of
+ + this chapter by Professor Hasselgren.

Myostatin
30 20 10 0 10 Myostatin has achieved some notoriety, and
Glycogen remaining Lactate produced the most exciting thing about myostatin
(Expressed as glucose equivalents) research is that, if one uses the myostatin
Fig. 10. Note that when glycogen is broken down by epinephrine, the final product is lactate, despite antibody in certain catabolic situations, the
the fact that hypoxia is not present. When sodium/potassium ATPase is blocked by ouabain, glycogen catabolism and protein breakdown de-
remains intact. creases. This has not gotten from the animal

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 53 11/15/11 3:06:56 PM

 54 Part I: Perioperative Care of the Surgical Patient

to the human type of experiment, and as oleate that strongly stimulated insulin ac- REFERENCES
stated earlier it would be nice if in sepsis tion in muscle and the liver as well. They
and in cancer myostatin were increased. called this molecule a cytokine and pro- Arozullah AM, Daley J, Henderson WG, et al.
Multifactorial risk index for predicting post-
There has been more positive data from posed a mechanism of action, which in- operative respiratory failure in men after ma-
animal experiments in cancer, especially in volves specific fatty acid-binding protein jor noncardiac surgery. The National Veterans
the use of the antimyostatin antibody. It is that then binds intracellular fatty acids and Administration Surgical Quality Improvement
too early to tell whether or not myostatin conveys them, as it were, to their ultimate Program. Ann Surg 2000;232(2):242–53.
can be a summative aspect of support of pa- cellular destination. Publication in Cell by A validated respiratory failure scoring tool.
tients in the ICU. Cao in 2008 excited enough that Olefsky, a Devereaux PJ, Goldman L, et al. Perioperative
cardiac events in patients undergoing noncar-
well-known metabolic investigator, wrote a diac surgery: a review of the magnitude of the
Possible Avenues of Support of very favorable editorial as to the possibility problem, the pathophysiology of the events and
Patients with Sepsis and Cancer that a lipokine might increase sensitivity in methods to estimate and communicate risk.
muscle and liver to insulin despite insulin CMAJ 2005;173(6):627–34.
If the hypothesis concerning cytoskeletal resistance. Comprehensive review of adverse perioperative
proximity and different types of glucose However, the sad part is that no one has cardiac events.
and different destinations of glucose is been able to repeat what Cao published, Fleischmann KE, Beckman JA, et al. 2009 ACCF/
AHA focused update on perioperative beta
true, then the appropriate way in which we and the status of lipokines is very much in blockade. J Am Coll Cardiol 2009;54(22):2102–28.
might decrease muscle proteolysis is to doubt. Update to the 2007 ACC/AHA guidelines focused
provide substrate for gluconeogenesis, I am not certain that this hypothesis is specifically on perioperative beta blocker ini-
which openly goes to glycogen, and which correct, and I think proving it would be very tiation and management.
is not derived from muscle-protein break- difficult. However, I believe that only Fleisher LA, Beckman JA, et al. ACC/AHA 2007
down. Initially what seems most likely is, if through our increased understanding of guidelines on perioperative cardiovascular
evaluation and care for noncardiac surgery.
you could overcome the metabolic block to metabolism and what happens in sepsis J Am Coll Cardiol 2007;50(17):1707–32.
glucose getting into a cell in the presence and cancer and to intracellular metabolism Comprehensive evidence-based guidelines on
of sepsis and perhaps in cancer, in cancer it and to the interaction of different substrates pre-operative cardiovascular evaluation and
might be that it is not glucose not getting and nutrients can we solve the problem of perioperative management of patients with
into the cell but the fact that the presence cancer cachexia and sepsis cachexia and cardiovascular disease.
of the cancer “sops up,” as it were, all of the maintain patients who are so afflicted. Geerts WH, Bergqvist D, et al. Prevention of ve-
nous thromboembolism: American college
glucose available, so there is nothing really of chest physicians evidence-based clinical
to get into the cell in the form of glucose
and nothing that goes to glycogen, allow-
CONCLUSION practice guidelines (8th Ed.). Chest 2008;133(6
Suppl):381S–453S.
ing sodium potassium ATPase to have its There is little question that PN and its in- Guidelines on the use of thromboprophylaxis in
first priority, which is keeping membrane troduction by Dudrick, followed by the unit surgical and medical inpatients.
integrity and the cell membrane function- at the Mass General Hospital, which I orga- Hilditch WG, Asbury AJ, et al. Validation of a pre-
ing properly. In sepsis, the answer might be nized based on his work, was a startling anaesthetic screening questionnaire. Anaesthe-
sia 2003;58(9):874–7.
to provide a fuel, either protein or some and remarkable advance in perisurgical One example of a validated pre-operative screen-
other type of substrate which might get to care in patients who could not or would not ing questionnaire used to identify patients who
glucose in the proper place to keep the gly- eat with some beneficial results. The enthu- have pre-existing conditions associated with
cogen stores fueled. Amino acids get past siasm of young surgeons, their involvement adverse perioperative events.
the cell membrane, and there is no such in PN and the research they were doing, Lee TH, Marcantonio ER, et al. Derivation and
block as there is to glucose. Internal gluco- was really a wonderful thing to watch and prospective validation of a simple index for
prediction of cardiac risk of major noncardiac
neogenesis from protein might explain the be part of. Money was plentiful. TPN and surgery. Circulation 1999;100(10):1043–9.
accelerated decrease in proteolysis in an nutrition and immunology were the hot Manuscript detailing the derivation of the Revised
effort for the cell to keep its first priority, topics. Unfortunately, we were our own Cardiac Risk Index
and that is cellular integrity. Alternatively, worst enemy by tolerating pretty shady Smetana GW, Macpherson DS. The case against
there might be other fuels, which get into work, as well as shoddy, with the abun- routine preoperative laboratory testing. Med
the cell, and which do not have the block to dance of funds available. We did not band Clin North Am 2003;87(1):7–40.
their entry, and they can also keep glyco- together and put aside our differences as Review of pooled data on preoperative laboratory
tests used to estimate positive and negative like-
gen full and sodium potassium ATPase humans for the greater good. In addition, lihood ratios for a postoperative complication.
functioning. Some have proposed that doing research and being head of a TPN Teh SH, Nagorney DM, et al. Risk factors for mor-
beta-hydroxybutyrate might be one such team was thought of as not being suffi- tality after surgery in patients with cirrhosis.
substrate, which might be utilized. In fact, ciently attractive to get the attention of Gastroenterology 2007;132(4):1261–9.
this might be a key, because one of the most young surgeons. They felt like surro- Restrospective study used to determine the rela-
problems that we have in sepsis is the fat/ gates and they felt as if they were not part tionship between MELD score and periopera-
tive mortality.
glucose switch. of the mainstream of surgery. That was not Treatment Guidelines from The Medical Letter
true, and a lot of progress was made over (2009). Antimicrobial prophylaxis for surgery.
The Fat/Glucose Switch that period of time and the young people, 2009;82:47–52.
I think, were recognized for their innova-
Traditionally, if fat is given, glucogenesis tions. However, it did not last and I think SUGGESTED READINGS
and proteolysis do not cease to occur in that is particularly unfortunate. I would Aversa Z, Alamdari N, Hasselgren PO. Molecules
sepsis. A new type of hormone, if you will, hope that we could figure out some way modulating gene transcription during muscle
was recently described by Cao and cowork- that we could entice people to do this again wasting in cancer, sepsis, and other critical ill-
ers, which he identified as C16:1N7 palmito as part of nutritional support. ness. Crit Rev Clin Lab Sci 2011; 48:71–86.

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 54 10/28/11 10:15:18 PM

 Chapter 2: Perioperative Management: Practical Principles, Molecular Basis of Risk, and Future Directions 55

Burckhart K, Beca S, Urban RJ, et al. Pathogenesis Hasselgren PO. Muscle wasting. In JL Vincent and Larsson L, Li X, Edstrom L, Eriksson LI, et al.
of muscle wasting in cancer cachexia: targeted JB Hall (eds.) Encyclopedia of Intensive Care Acute quadriplegia and loss of muscle myosin

Perioperative Care of the Surgical Patient

anabolic and anticatabolic therapies. Curr Opin Med 2011; in press. in patients treated with nondepolarizing neu-
Clin Nutr Metabol Care 2010;13:410–6. Hasselgren PO, Alamdari N, Aversa Z, et al. Cor- romuscular blocking agents and corticoster-
Callahan LA, Supinski GS. Sepsis-induced myopa- ticosteroids and muscle wasting: role of tran- oids: mechanisms at the cellular and molecular
thy. Crit Care Med 2009;37(Suppl):S354–67. scription factors, nuclear cofactors, and hy- levels. Crit Care Med 2000;28:34–45.
Hasselgren PO. Ubiquitination, phosphorylation, peracetylation. Curr Opin Clin Nutr Metab Care Schweickert WD, Hall J. ICU-acquired weakness.
and acetylation - triple threat in muscle wast- 2010;13:423–8. Chest 2007;131:1541–9.
ing. J Cell Physiol 2007;213:679–89.

EDITOR’S COMMENT unfortunate corporate decision that was made that SSI in a hospitalization may not be paid for
with Entereg because they wanted to sell it in in the future. In the commentary on Chapter 7, I
Europe. We had completed three first class ran- have outlined largely based on the lovely review
Among the various means of improvement in domized prospective trials, in which Entereg was paper in the Annals of Surgery, spring/summer
preparing patients for operation, operative risk compared against the standard treatment and 2011, by J. Wesley Alexander and Dr. Joe Solomkin
is part and parcel of nutritional status. In two gave improvements in discharge between 14 and and Mike Edwards, of the 15 to 18 processes in
different places in the chapter, the first fairly cur- 22 hours, enough to be worthwhile economically which one can really decrease surgical site infec-
sory and the second more detailed, we spoke of because the pills were going to be priced at about tion. I think it is fair to say that there are very few
the need to take patients who have an albumin 250 dollars apiece. Some genius got the idea that institutions in which those 15 to 18 processes are
which is below three, who certainly are at risk, they should do a randomized multicenter and standardized in order to minimize surgical site
and give them nutritional support, either par- multi country prospective trial to see whether infection. As far as bowel prep is concerned, as I
enteral, which is easier, or enteral, which some- Entereg decreased the time in the hospital and have said, it is rare for anybody to defend a non-
times takes longer. We enumerated the data that speeded up the discharge. There was only one absorbable antibiotic bowel prep, but I believe
suggested that five days of parenteral nutrition, problem, and that is the fact that discharge, cer- it is worthwhile is when one has an obstructed
which is the time when transferrin begins to in- tainly in the UK, where many of the patients were, stomach with food matter in it, which may con-
crease and the patient begins to feel better, seems and in some of the other countries, is not a medi- tain clostridia, in which case I think the oral
to be sufficient. In a time when care of catheters cal decision but is a social decision. Indeed, in administration of nonabsorbable antibiotics is
is not paramount in many hospitals, getting the the UK, for example, the time between the order worthwhile to prevent clostridial myositis. As far
patient to the operating room before line sepsis for discharge and the time that the patient actu- as mechanical bowel preps are concerned, I fail to
supervenes is very important. ally made it through the front door was as long understand how having the clean bowel can yield
The prevention of venous thrombosis and sub- as 120 hours. This, as one might expect, actually a higher incidence of surgical site infection, but I
sequent pulmonary emboli is very important and killed the entire study, and it took a long time for am prepared to be enlightened. Whether or not
may in fact avoid mortality. While we still insist Entereg to be approved by the FDA, much longer any of the randomized prospective trials that ran-
on giving subcutaneous heparin, and that may than it had stuck with the three studies. It is prob- domize mechanical bowel prep vs. no bowel prep
be the best way to forestall venous thrombosis, I ably a good drug and probably can decrease the makes sense, I’m not sure. One finds that in, and
will point out that, in Chapter 6 by Dr. Hamdan length of stay, which may be as long as 16 hours, I have commented on this before, that patients
and Dr. Everson, there is quite a nice exposition and whether or not that is sufficient for the eco- who are on a golytely bowel prep, for example, as
on eight or so of the new anticoagulants As yet, nomics of running hospitals at 500 dollars a day compared to patients who are theoretically not
we are unfamiliar with many of their properties, for the medication remains to be seen. However, supposed to have a bowel prep, they both have
but a lot of the properties that they put into that if one institutes clinical pathways and fast-track the same degree of cleanliness; about 42% of them
chapter suggest that they might be better for the surgery—in the latter one avoids opiates at all are basically “clean.” Now I can understand one
patient and easier to control, particularly as com- and minimizes the fluid postoperatively, using side of the fact that the cleanliness of the bowel
pared with Warfarin. I believe that in the near fu- colloid fluid—I believe that the discharge is about prep that Golytely™ is about 42%, which is disap-
ture, it will require surgeons to be quite familiar as rapid as one can have it, and therefore an im- pointing as a percentage, but I can tell you that
with the new range of anticoagulants and to take provement with a new opioid-receptor blocker is each time I get colonoscoped, it is very difficult
advantage of their characteristics. probably not going to work. In addition, while it for me to finish the Golytely™. Then why is the
As far as smoking is concerned, I am fully in may improve discharge time by a few hours, un- cleanliness of the bowel in patients who are alleg-
agreement that, if one can get a patient to stop less it decreases the length of stay by one day, it edly not on golytely the same percentage, about
smoking, and there is sufficient time for them to is highly unlikely that this will be economically 42%? I think the reason for this may be that these
stop smoking with whatever aids the need and feasible for widespread use. patients, believing that they are going to have an
stop smoking for eight weeks prior to operation, Bowel prep has become a controversial area operation and the bowel may be involved, decide
that may spare them a postoperative pneumonia. with some studies that suggest that a mechanical to take milk of magnesia or magnesium citrate on
I don’t know how many patients can do this, but bowel prep actually may yield a larger number of their own, and they too are 42% clean. I do think
I have not had a great deal of good fortune with complications. In actual fact, I do not believe that that, speaking to surgeons who do laparoscopic
it. They have an addiction, and addictions are dif- there are very many people at this point in time colectomy for example, it is much easier for them
ficult to break; perhaps nicotine pills, nicotine who believe that an antibiotic bowel prep is of to grasp the bowel when the bowel is clean.
patches, and things like that can help, but my any consequence, and because clostridia difficile Fluid resuscitation. Having been around and
own experience has been very disappointing. may be harmful. First of all, there is no evidence conducting mortality-and-morbidity conferences
With respect to postoperative ileus, I was in- that the antibiotic bowel prep is good for any- when Dr. Tom Shire’s concept of resuscitating the
volved early in the Alvimopan, commonly called thing including decreasing SSI. Decreasing SSI third space became de rigeur, that was the time
now Entereg, and the attempt to decrease post- seems to be entirely a result of not only the appro- that we began to see ARDS. I think there is now
operative ileus. The science and the hypothesis priate antibiotics given at the appropriate time so evidence from a number of places that massive
concerning prevention of postoperative ileus is that the blood levels are elevated at the time of amounts of crystalloid in the absence of col-
very good. What they hope to do is to have an incision, but also maintaining those blood levels loid red cells, plasma and albumisol and other
antagonist to the mu-opoid receptor, which is a for the entire duration of the operation even if it colloid-containing solutions probably damages
narcotic receptor in the bowel, and which actu- is longer. Furthermore, there is a lot more to de- the lung and leads in no small part to ARDS. I
ally gives patients the ileus. There are two such creasing the surgical site infection as is evident know that this will elicit a rage reaction from cer-
anti-ileus drugs. The one that’s been around the in reading Chapter 7, a very nice chapter by Dr. tain people, but I do believe that we have over-
longest, Alvimopan, now called Entereg is a com- Solomkin, and the fact that most people agree done fluid resuscitation, and, when one walks
mittee that I chaired in the early years when the that SSI prevention is important. Indeed, the fed- into the ICU and sees an individual who has re-
research was going on. This to me was a most eral government has basically come out and said ceived enormous amounts of crystalloid before

(continued)

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 55 10/28/11 10:15:18 PM

 56 Part I: Perioperative Care of the Surgical Patient

red cells and colloid-containing solutions were genes and the genetic activities related to muscle ICU, which is one of the reasons patients con-
available, the fact that their tissues are edema- wasting include atrogin-1 and MuRF1. These tinue to lose muscle mass. I know that there on
tous to casual inspection means to me that their genes play a major role in the activation of sub- the floors and in the ICU there is an attempt to
lungs are probably edematous as well. stances and in the control of substances such as get patients up out of bed, so that at least some
In the section on muscle breakdown, the the autophagosome and the lysosomal enzyme muscle activity will take place, but what one usu-
critical issue is that there is no storage protein. cathepsin-L, which is important in muscle wast- ally gets is two nurses, one supporting the patient
Storage protein is muscle. The myofibrils are a ing. A central component is NF-kB, which is reg- on either side with ski tracks in the dust, and I am
very rich source of protein, and therefore muscle ulated by MuRF1 and, once activated, and once not sure how much really gets done. Although we
breakdown provides protein in the starving indi- its inhibitor I-kB is metabolized and disposed of, are pretty good at supplying various substrates,
vidual, or a patient who is critically ill in the ICU NF-kB then migrates to the nucleus and begins my own hypothesis, vide infra, is that there is
is likely to have a major contribution of muscle the process of regulating muscle breakdown. something wrong with our ability to support pa-
myofibrils breakdown. Unfortunately, muscle Atrogin-1 is not involved in this particular part tients with cancer and sepsis, and this has been
needs to work, and patients’ movements, their of the metabolic process, but it is elsewhere. Also going on for about 40 years. The concept that
getting up, their walking, their breathing all de- involved are some of the favorite genes, Forkhead- ß-hydroxy-ß-methylbutyrate can perhaps be uti-
pend on an adequate amount of muscle, which Box-O-1 (or FOXO1) and FOXO3a, also involved lized in cancer and sepsis to support the organ-
happens to be unfortunately functional. One does as muscle-wasting genes, as is the transcription ism is an interesting one, but I know no reason
see, every now and then, patients who are abso- factor C/EBP, which is also activated by these metabolically why it should be favored.
lutely ghastly, as Fig. 3 shows, and this is what various genes and also brings about increased Insulin is important, but prevention of hy-
happens when one doesn’t worry about the lean activity of the corticoids. There are multiple tran- poglycemia is perhaps more important. There
body mass. Ultimately, if starvation continues, scription factors, as Dr. Hasselgren illustrates, have been various ways in which insulin and
and patients are not resuscitated nutritionally but there is no magic bullet. The real question is, tight control of insulin is theoretically useful,
as best they can, then not only muscle but liver, if these are responsible for muscle breakdown, but I think the consensus that has developed is
heart, spleen probably, and kidneys all participate why don’t we have a magic bullet that can stop that one should tolerate a blood sugar of some-
in the need requiring protein for muscle break- it, and why is the multiplicity necessary, or is the place between 80 and 150 and not try and make
down and to provide substrate for rapid-turnover multiplicity of mechanisms for muscle break- it between 70 and 120, because the incidence of
proteins and acute protein synthesis. The major down a means of defending the organism, so that hyperglycemia is too high and particularly dan-
issue in nutrition in patients that are critically ill protein is available for acute-phase protein? I do gerous. The presentation of insulin under these
is, can we sustain their lean body mass for func- not know, but there must be a very good reason circumstances is probably a good thing anyway,
tion purposes, for acute-phase protein, for de- why we will take active functioning protein and but it does seem as if the tight control of glucose
fense against infection, etc.? break it down. will result in a lesser incidence of infection.
We have known for a long time, perhaps for We may substitute nutrition, and we do un- Inability to support patients nutritionally
15 or 20 years, that ubiquitin is upregulated in derstand a great deal about it, and we also have a with cancer and sepsis and as far as myostatin
skeletal muscle in sepsis. The genetic control of pretty good idea of what components are needed, is concerned and some of the other reasons why
ubiquitin and some of the other cytokines and but without insulin, and without exercise to re- myostatin may or may not be involved and the
the transcription factors has been well eluci- store protein to muscle, restoration of lean body hypothesis concerning this are in the latter part
dated to a greater extent over the past five years, mass will not take place. Exercise is also a neces- of the chapter.
and this represents a real change. Specifically, the sary component, and we can’t do exercise in the J.E.F.

3 Enteral Nutrition Support

Ezra Steiger and Laura E. Matarese

INTRODUCTION is often faced with serious decisions about absorptive mucosa, prevention of stasis and
what, how, and when to feed these patients. bacterial overgrowth, as well as immune reg-
Stressful conditions such as surgery are of- Recent technological advancements in en- ulation. As a result, efforts have been focused
ten characterized by hypermetabolism, de- teral formulations and equipments have on using the GI tract whenever possible.
pletion of protein stores, impaired immune made it possible to provide EN to a variety
function, and delayed recovery. Provision of of patients in many different settings. This
adequate nutrition to the surgical patient is chapter reviews the evidence for the use of ROUTE OF FEEDING: ENTERAL
vital in order to ensure optimal outcomes. EN, timing of feedings, specific nutrients, VERSUS PARENTERAL
Traditionally, nutrition was regarded as ad- and the various aspects that are important
junctive care designed to provide nutrients to consider with this intervention. The question of route of feeding, that is, the
to support the patient during the periopera- use of enteral versus parenteral feedings is
tive state. Recently, nutrition has evolved to largely academic primarily due to the physi-
become a medical intervention, specifically ROLE OF THE ological benefit associated with using nor-
designed to attenuate the metabolic re- mal digestive and absorptive pathways. In
sponse to stress, to prevent oxidative cellu-
GASTROINTESTINAL TRACT practice, if the GI tract is functional, acces-
lar injury, and to modulate the immune re- Historically, it was thought that the GI tract sible, and safe to use, EN is preferred over
sponse. Enteral nutrition (EN), the provision was quiescent following surgical interven- parenteral nutrition (PN). PN can be used
of nutrients via the gastrointestinal (GI) tion and that the primary role of the gut was in conjunction with EN. The two are not
tact, nonvolitionally through a feeding tube digestion, absorption, and secretion. It is now mutually exclusive. However, enterally sup-
or catheter is recommended for patients evident that the gut is an important meta- plied nutrients experience first-pass me-
who cannot meet their nutrient needs bolically active organ and plays a vital role in tabolism in the liver, which promotes
through voluntary oral intake. The surgeon nutrient transport, exposure of nutrients to their efficient utilization. The presence of

www.medicalebookpdf.com

LWBK892_c02_p025-056.indd 56 10/28/11 10:15:18 PM

 Chapter 3: Enteral Nutrition Support 57

nutrients in the small intestine supports INDICATIONS/ However, some of the potential barriers to
the functional integrity of the gut by main- EN can be circumvented with careful selec-
CONTRAINDICATIONS

Perioperative Care of the Surgical Patient

taining tight junctions between the intra- tion of enteral access device, formula, and
epithelial cells, stimulating blood flow, and EN should be considered after assessment of route of administration.
inducing the release of trophic endogenous nutritional risk (see Chapter 2) and the ability
agents (e.g., cholecystokinin, gastrin, bomb- of the patient to consume adequate nutri-
esin, and bile salts). Luminal nutrients also tion. The presence and degree of malnutri- SPECIAL CLINICAL
help to maintain normal intestinal pH and tion should be established since malnour- CIRCUMSTANCES
microbial flora, while specific nutrients ished patients tend to have higher rates of
contained in enteral formulas, such as glu- morbidity and mortality and longer hospital- Reperfusion Injury and
tamine and short-chain fatty acids, serve as izations than adequately nourished patients. Low Flow States
a fuel source for the intestine. Luminal nu- EN provided orally or delivered via a feed-
trients are potent stimulators of enterocyte ing tube is the method of choice for those in- Reperfusion injury and low flow states in
growth and intestinal adaptation. From a dividuals with adequate digestive and absorp- which hypoperfusion of the GI tract is sus-
practical standpoint, enteral formulas can tive capacity of the GI tract, but have clinical pected must be considered when initiating
mimic the normal diet and supply intact conditions in which oral intake is impossible, enteral feedings. Certain clinical conditions
nutrients such as fiber, whole proteins, di- inadequate, or unsafe to use. Specific indica- frequently observed in critically ill patients
peptides, and specialized fatty acids, which tions for EN include psychiatric disorders, such as hypovolemia, hypotension, and
cannot be supplied parenterally. severe dysphagia or esophageal obstruction, hemorrhagic and septic shock pose a risk
The beneficial effects of EN when com- neurologic impairment, major burns or for low splanchnic blood flow that can lead
pared to PN are well documented in numer- trauma, organ system failure, ration or che- to GI dysmotility, increased mucosal per-
ous prospective randomized controlled tri- motherapy, acquired immunodeficiency syn- meability, endotoxemia, and multiple sys-
als involving a variety of patient populations, drome, and low output enterocutaneous fis- tem organ failure. Preservation and reper-
including major surgery, trauma, burns, tulas. However, determining which patients fusion injury may also occur following
head injury, and acute pancreatitis (Table 1). should receive a feeding tube is more complex intestinal and multivisceral transplantation
The most consistent beneficial outcome and requires consideration of several factors potentially delaying the return of bowel
from the use of EN compared with PN is a including the patient’s clinical status, diagno- function and initiation of enteral feeding.
reduction in infectious morbidity. A reduc- sis, prognosis, risk–benefit ratio, discharge Unfortunately, a disproportionate vasocon-
tion in mortality has not been clearly dem- plans, quality of life, ethical considerations, striction occurs in response to the insult
onstrated. Other outcome variables include and the patient/family wishes. sustained during critical illness. A 3% to 5%
significant reductions in hospital length of Although few, there are some contrain- reduction of blood volume can result in a
stay and cost of nutrition intervention. dications to enteral feeding, which relate 50% to 70% shunt of visceral blood flow.
pprimarily to the presence and degree of This raises concern that initiation of EN
m
malnutrition, the patient’s ability to con- would be poorly tolerated by an underper-
Table 1 Benefits of Enteral ssume adequate nutrition by mouth, and the fused intestine or may result in intestinal
Nutrition ischemia. Intestinal ischemia is a potential
iintegrity and functional capacity of the GI
Physiological ttract. These can be considered as relative but rare complication of EN, occurring in
■ Preservation of GI mucosal integrity oor absolute contraindications. EN, either ⬍1% of cases. It appears to be more com-
■ Support of gut-associated lymphoid tissue ssupplementation via mouth or via enteral mon with surgical jejunostomies, but has
(GALT) and mucosa-associated lymphoid ffeeding tube, is not indicated in those indi- been reported with the use of nasojejunal
tissue (MALT) for preservation of mucosal tubes.
immunologic functions
vviduals who are well nourished, are able to
eeat by mouth, or do not have a functional GI Despite these concerns, there is evi-
■ Preservation of gut barrier function
ttract that can be safely accessed (Table 2). dence that with appropriate patient selec-
■ First-pass metabolism in the liver
■ Stimulates release of cholecystokinin
tion, careful initiation, and close monitor-
■ Attenuation of the catabolic response ing, EN can be used successfully in these
■ Maintenance of digestive and absorptive ppatients. Continuous infusion of enteral
capabilities of the GI tract Table 2 Contraindications to ffeedings at a very low rate can be employed
■ Augmentation of cellular antioxidant
Enteral Nutrition w
while receiving nutrition support parenter-
systems ■ Nonoperative mechanical GI obstruction, aally until full volume of tube feeding can be
■ Decreased incidence of hyperglycemia which cannot be bypassed with a feeding aachieved. EN may be provided guardedly to
when compared with PN tube ppatients who are receiving low doses of
■ Formulas contain nutrients not available ■ Intractable vomiting or diarrhea
refractory to medical management ppressor agents, while observing for signs
in PN form (i.e. fiber)
■ Severe GI malabsorption oof intolerance or gut ischemia. There are
Infectious ■ Adynamic ileus ccertain situations in which EN should be
■ Significantly lowered risk of infectious ■ Distal high-output fistulas, which cannot w
withheld until the patient is stabilized. For
morbidity be bypassed with a feeding tube tthose patients requiring significant hemo-
■ Improved wound healing ■ Severe GI bleed
■ Inability to gain access to the GI tract ddynamic support including high-dose cate-
Cost–benefit ■ Need is expect for ⬍5 to 7 days for ccholamine agents, alone or in combination
■ Shorter length of hospital stay than with malnourished patients or 7 to 10 days if w
with large volume fluid or blood product
PN adequately nourished rresuscitation to maintain cellular perfu-
■ Less expensive than PN ■ Aggressive nutrition intervention is not ssion, EN should be withheld until the pa-
■ Less complicated procedures and consistent with prognosis or patient ttient is fully resuscitated and/or stable. EN
equipment wishes iintended to be infused into the small bowel

www.medicalebookpdf.com

LWBK892_c03_p057-065.indd 57 10/28/11 3:42:53 PM

 58 Part I: Perioperative Care of the Surgical Patient

should be withheld in patients who are hy- Retention of the ileocecal valve may play and oral nutrition is initiated. A polymeric
potensive (mean arterial blood pressure a role in absorption and transit time follow- formula, which is high in protein and low in
⬍60 mm Hg), particularly if catecholamine ing massive small-bowel resections. The potassium, is utilized as there is no data to
agents (e.g., norepinephrine, phenyleph- ileocecal valve is thought to control the re- suggest significant malabsorption of the in-
rine, epinephrine, and dopamine) are being lease of fluid, electrolytes, and nutrients into testinal allograft. A fiber-containing formula
used to maintain hemodynamic stability. the colon and to prevent the reflux of colonic is used if the patient develops diarrhea. The
material back into the small bowel. If the low potassium content is necessary because
Enteral Nutrition in Altered ileocecal valve is lost, transit time through tacrolimus can cause hyperkalemia.
Intestinal Anatomy the proximal gut may be increased, and loss
of fluid and nutrients may be greater. Nutri- ENTERAL NUTRITION IN THE
Patients who have had intestinal anatomy ents contained in the enteral formula must
altered by surgical resection, reconstruc- have adequate contact time with the intesti-
INTENSIVE CARE UNIT
tion, or replacement with intestinal or mul- nal mucosa. In addition, colonic bacteria The underlying metabolic responses to early
tivisceral allografts can be fed enterally. can reflux and colonize the small bowel enteral feeding and the derived clinical ben-
This often represents the first step toward worsening diarrhea and nutrient loss. eficial outcomes have been well described
obtaining nutritional autonomy from PN. In Preservation of the colon is extremely for the intensive care unit (ICU) patient. Se-
patients with short-bowel syndrome, EN important for fluid and electrolyte absorp- cretory IgA, gut-associated lymphoid tissue
provided as the sole source of nutrition or tion. In addition, bacteria in the colon me- (GALT), and mucosal-associated lymphoid
in conjunction with oral feeding has been tabolize carbohydrate and soluble fiber into tissue (MALT) are stimulated by enteral
shown to result in increased net absorption short-chain fatty acids. These aid in fluid feeds and help fight infection locally in the
of lipids, proteins, and energy compared and electrolyte absorption, provide a source gut and at distant sites as well. In a system-
with oral feeding. For the patient with of energy, and stimulate intestinal adapta- atic review and analysis of 12 randomized
short-bowel syndrome a number of factors tion. Likewise, an intact stomach, pancreas, prospective controlled trials, Lewis et al.
will influence tolerance to EN. The length of and liver will play a role in digestion and showed a significant reduction in infections
the remnant bowel is the most important absorption. and hospital length of stay with the use of
factor in determining whether a patient can Although the length of the remnant immediate postoperative tube feeding or
be transitioned to EN. Adults with ⬎100 cm bowel is critical for successful EN, the health aggressive early oral nutrition versus stan-
of small bowel ending in stoma or ⬎60 cm of the remaining intestine is also an impor- dard therapy. EN has even been successfully
of small bowel anastomosed to the colon tant consideration. If the mucosa of the used in trauma patients with an open abdo-
can generally be weaned from PN onto EN remaining bowel is diseased (i.e., Crohn’s men. Although GI motility is impaired in
and eventually to oral diet. The site and ex- disease and radiation enteritis) absorption critically ill postoperative patients, the use
tent of the surgical resection will also im- will be impaired. of prokinetic agents alone or in combina-
pact the patient’s ability to digest and ab- Following surgical resection, the bowel tion and opiate antagonists and a multifac-
sorb. Digestion and absorption of most adapts. This is both an anatomical and a eted change in clinical practice aided the
nutrients occurs in the duodenum and functional adaptation. The adaptive period delivery of adequate EN support to critically
proximal jejunum, while the distal 100 cm is thought to continue for 2 to 3 years. Thus, ill and postoperative patients. Recent EN
of ileum is responsible for absorption of vi- the extent of intestinal adaptation will also and PN clinical guidelines for critically ill
tamin B12 and bile salts. With jejunal resec- affect the patient’s ability to tolerate EN. patients were published by the European
tions, adequate absorption generally occurs Medications are essential for patients Society of Parenteral and Enteral Nutrition
unless there is ⬎75% resected largely due with altered GI anatomy during EN therapy. (ESPEN) and the American Society of Par-
to adaptation occurring in the ileum. There Antidiarrheal agents can be used to prolong enteral and Enteral Nutrition (ASPEN)
is preserved absorption of vitamin B12 and transit time. Pancreatic enzymes and bile jointly with the Society of Critical Care
bile salts. Gastrin levels increase resulting acid sequestrates can be used to enhance Medicine (SCCM). The guideline publica-
in gastric hypersecretion with ensuing low absorption. Bacterial overgrowth, common tions have extensive bibliographies con-
intraluminal pH, inactivating pancreatic in short-bowel syndrome, can be treated taining all the studies that were analyzed
enzymes. These patients generally have with antibiotics or probiotics. and graded for levels of evidence by a multi-
normal transit through the gut and most A standard isotonic polymeric formula disciplinary group of clinical experts in the
will be able to tolerate EN. The conse- containing intact proteins, glucose polymers, field. Grades of recommendations were
quences of an ileal resection are more se- and a mixture of LCT (long chain triglycer- made based on levels of evidence with
vere. There is adequate calorie and fluid ides) and MCT (medium chain triglycerides) Grade A recommendations in the ESPEN
absorption if there is ⱖ60 cm jejunum should be utilized for most patients with com- guidelines based on either a meta-analysis
anastomosed to the colon. Malabsorption promised gut. Formulas that also contain sol- of randomized controlled trials or at least
of bile salts and vitamin B12 also occurs. uble fiber are especially useful in patients with one randomized controlled trial and Grade
The loss of bile salts will result in fat malab- an intact colon in order to improve absorptive B recommendations were based on either a
sorption, steatorrhea, and loss of fat- function and to serve as a source of energy. well-designed controlled trial without ran-
soluble vitamins. In addition, there is poor Intestinal and multivisceral transplanta- domization or a well-designed nonexperi-
jejunal adaptation, rapid intestinal transit, tion has become a therapeutic option for mental descriptive study. The lowest grade
and small-bowel bacterial overgrowth. those individuals with permanent intestinal was C while Grade A recommendations for
Peptide YY, released from L cells in distal failure who fail PN or intestinal rehabilita- the ASPEN/CCM guidelines were supported
ileum and colon, slows gastric emptying tion efforts. A jejunostomy tube is placed di- by at least two large randomized trials with
and intestinal transit. With distal ileal and rectly into the allograft at the time of surgery clear-cut results and a low risk of false-pos-
colonic resections, this feedback inhibition and EN commences within the first 1 to 2 itive and/or false-negative error and Grade
is lost. weeks. As the EN is advanced, PN is reduced B recommendations were supported by just

www.medicalebookpdf.com

LWBK892_c03_p057-065.indd 58 10/28/11 3:42:54 PM

 Chapter 3: Enteral Nutrition Support 59

one such large randomized trial. The lowest (⬍100 cm of small intestine), and severe GI accidental displacement is helped with the
possible recommendation grade was E, bleeding. Hypoperfusion associated with use of a nasal bridle and the risk of nasal

Perioperative Care of the Surgical Patient

which was similar to the ESPEN Grade C. In low flow states had previously led to the be- necrosis is minimized by using umbilical
the ESPEN surgery enteral nutrition publi- lief that an underperfused intestine would tape instead of a red rubber catheter.
cation, there were 36 guidelines developed not be able to tolerate enteral feedings. Nasogastric tube feedings in the postop-
of which 12 were category A. In the ESPEN However, more recently, it has been pro- erative patient are of concern if there is im-
intensive care enteral nutrition publication, posed that EN is possible in some patients paired gastric emptying and high gastric
there were 21 guidelines of which 6 were with low flow states and may even be ben- residuals that could lead to vomiting and
category A. The ASPEN/CCM guidelines eficial. In both of these publications, how- aspiration. Although there is poor correla-
were developed for both EN and PN in the ever, it is noted that the patient must be tion between gastric residual volumes and
adult ICU patient for whom there were 72 carefully and frequently monitored for signs the risk of aspiration, gastric residual vol-
guidelines 11 of which were graded A or B. of ischemic bowel clinically, radiologically, umes ⬎200 to 500 mL should alert the clini-
Only those recommendations with strong and by laboratory studies. However, the cian to institute measures to minimize the
levels of supportive evidence are reviewed early diagnosis of ischemic bowel is very risk of aspiration such as elevating the head
in this section. For those patients with se- difficult and EN should be withheld until of the bed, avoiding bolus infusion, con-
vere malnutrition (weight loss ⬎10% in the the patient is stable. Despite the advantages sider the use of a promotility agent such as
preceding 6 months, BMI ⬍18.5 kg/m2, and of EN over PN, parenteral nutrition should erythromycin or a narcotic antagonist such
Subjective Global Assessment of C or serum not be avoided when EN support cannot be as naloxone and alvimopan, and consider
albumin ⬍3.0 mg%) consideration should given or when EN cannot meet energy and the use of post-pyloric feeding. In addition,
be given to providing nutrition support for protein requirements. When energy and the use of chlorhexidine mouthwash could
10 to 14 days prior to major surgery. Both protein requirements cannot be met by en- reduce the risk of ventilator-associated
sets of guidelines made strong well-sup- teral feeding alone a combined EN and PN pneumonia.
ported recommendations to initiate nor- support program should be considered to Diarrhea associated with tube EN is com-
mal food intake or enteral feeding early af- prevent the negative outcomes of prolonged mon and is multifactorial. It is commonly
ter GI surgery and that EN is the preferred cumulative negative energy balance. associated with magnesium or sorbitol-
route of nutrition support over PN. Tube containing medication, antibiotics, infec-
feedings should be started within 24 hours tions such as Clostridium difficile, and intol-
after surgery for patients undergoing major
Enteral Access Devices erance of the formula. Infectious and
head and neck surgery or major GI surgery Access to the GI tract can be obtained at the inflammatory etiologies, fecal impaction,
for cancer. In addition, it should be initiated patient’s bedside, in the radiology depart- and medications should be ruled out before
early in patients with severe trauma and in ment, in the endoscopy suite, or in the op- starting antidiarrheals. Changing to an iso-
those patients who came to surgery mal- erating room. The anticipated length of tonic, lactose-free solution with soluble fiber
nourished. Strong consideration should be time that EN is required and the potential may be of help, but some authors suggest
given to inserting a jejunostomy or nasoje- risk of aspiration will determine the type of limiting soluble fiber. If diarrhea persists, the
junal feeding tube at the time of major ab- feeding device needed and its modality of volume of enteral feeding should be reduced
dominal surgery to facilitate postoperative placement. Short-term feeding can be ac- until it is tolerated and the unmet kilocalo-
EN. The presence of bowel sounds, passage complished with nasogastric or nasoenteral ries and protein needs are provided by PN.
of flatus, or passage of stool is not required feeding tubes that are usually made of poly- When enteral access is required for 4 or
to start EN. Immune-modulating enteral urethane and are 8 to 12 French in diame- more weeks feeding tubes can be placed en-
solutions containing arginine, nucleotides, ter; long-term feeding tubes such as those doscopically, laparoscopically, fluoroscopi-
and omega-3 fatty acids are superior to placed percutaneously are made of silastic cally, or by open abdominal surgery. The
standard enteral formulas in significantly and are 18 to 28 French in diameter (gas- morbidity and mortality of feeding tubes
reducing duration of mechanical ventila- trostomy tubes) or 8 to 12 French in diame- placed by open surgery as the sole reason for
tion, infectious morbidity, and hospital ter (jejunostomy tubes). Silicone material is the operation is high primarily due to the
length of stay for patients having major generally preferred for long-term feeding patient’s underlying medical conditions.
elective surgery, trauma patients, and surgi- tubes, because it resists irritation and does A number of techniques for surgical gas-
cal ICU patients. Glutamine should be stiffen. trostomies have been described. At the time
added to enteral formulas given to burn The tip of the feeding tube should be po- of laparotomy, for other reasons, the most
and trauma patients. These guidelines and sitioned in the stomach, duodenum, or common approach to gastrostomy tube
the supporting literature favor the early in- proximal small intestine. Despite several placement is the Stamm procedure. The
stitution of postoperative EN for surgical techniques described to correctly place introduction of percutaneous endoscopic
patients in the ICU setting; however, there feeding tubes, nasogastric or nasoenteral gastrostomy (PEG) revolutionized the tech-
is no uniformity of agreement and no clear feeding tube position should be confirmed nique of obtaining long-term enteral access
definition of “early.” Ultimately, the surgeon radiologically prior to starting tube feeding. and greatly reduced the associated morbid-
has to make a clinical decision to start early In the critically ill patient needing tem- ity and mortality in properly selected pa-
EN based not only on these recommenda- porary enteral feeding, concerns over risk tients. Beneficial outcomes with the use of
tions, but also on each patient’s condition of aspiration have encouraged the use of PEGs have been reported for head and neck
and special circumstances. Relative con- post-pyloric feeding tube placement. cancer patients and stroke and head trauma
traindications to EN include expectation of In addition, post-pyloric feeding has patients, while its use in patients with de-
early resumption of oral intake in a previ- been shown to allow for the delivery of more mentia is controversial.
ously well-nourished patient, mechanical kilocalories and protein with less vomiting There have been many techniques de-
intestinal obstruction, irresolvable severe compared to nasogastric tube feeding. Main- scribed to gain access to the jejunum for EN.
diarrhea, severe short-bowel syndrome taining nasoenteral tube position without At the time of surgery, for other reasons, the

www.medicalebookpdf.com

LWBK892_c03_p057-065.indd 59 10/28/11 3:42:54 PM

 60 Part I: Perioperative Care of the Surgical Patient

Witzel jejunostomy or a modification thereof long-term EN, it may be advisable to con- transit time. These have been added to
is the most commonly used technique. sider the use of a commercially available enteral formulas to prevent constipation,
Gastrojejunal tubes are used when gas- blenderized product derived from whole especially in the long-term enterally fed pa-
tric decompression is needed as well as foods. tients. But this has not been clearly demon-
jejunal feeding occurs in patients with strated in controlled trials. Some enteral
impaired gastric motility with normal Hydrolyzed Formulas formulas have incorporated blends of solu-
small-bowel motility and absorption. These ble and insoluble fibers to promote healthy
tubes can be placed at the time of surgery Hydrolyzed formulas, also known as predi- gut microflora. In a randomized, double-
or laparoscopically. gested, chemically defined, elemental, or blind, crossover trial, the use of a fiber-
semielemental formulas, contain protein in containing enteral formula resulted in a
the form of short-chain peptides and free significant increase in fecal short-chain
ENTERAL FORMULAS amino acids, carbohydrate as glucose oligo- fatty acids, as well as fecal microbiota in pa-
Once a decision has been made to initiate saccharides, and fat in varying combina- tients requiring long-term EN.
enteral feedings and access has been estab- tions of long- and medium-chain triglycer-
lished, an appropriate formula must be se- ides. These formulas were designed for
lected. The selection of an enteral formula is patients with malabsorption and pancreatic Disease Specific
based on matching the patient’s clinical sta- insufficiency since they require minimal di- There are a variety of formulas that have
tus, GI function, and nutritional require- gestion for absorption. There is limited data been developed for use in disease-specific
ments with the nutritional composition of comparing these hydrolyzed formulas with conditions. The macronutrient portion and,
a formula. There is a plethora of enteral standard polymeric feedings. Studies com- in some cases, the micronutrients have
formulas available to the clinician. Although paring the use of standard formulas with been altered to allow for better tolerance
there is no standard terminology, these for- hydrolyzed formulas in patients with when there are metabolic derangements
mulas can be classified according to the ma- Crohn’s disease and critical illness found no due to disease.
cronutrient sources, and are referred to as significant difference in mortality, infec- Diet is a crucial component in the man-
polymeric or hydrolyzed. They can be further tions complications, and diarrhea. However, agement of diabetes mellitus (DM). Several
divided into standard, fiber-supplemented, patients with acute pancreatitis receiving enteral formulas have been developed for
disease-specific, and immune-modulating. a hydrolyzed formula had a significantly use in these patients in order to improve
reduced hospital length of stay (23 ⫾ 2 vs. glycemic control. The composition of these
27 ⫾ 1, P ⫽ 0.006) compared with those formulas has been designed to mimic the
Polymeric Formulas who received a standard formula. Clinical dietary modification used in the treatment
Polymeric formulas are the most common trials to support the routine use of hydro- of DM and includes a mixture of soluble and
formulas used for hospitalized, long-term lyzed formulas are limited. However, in pa- insoluble fibers, 30% to 40% carbohydrate,
care, and ambulatory patients. They con- tients with malabsorption who do not toler- and 40% to 50% fat. Carbohydrate sources
tain nutrient profiles that mimic a healthy ate standard polymeric formulas, hydrolyzed include complex forms such as oligosaccha-
diet designed to meet the dietary reference formulas should be considered. rides, fructose, and cornstarch. The fat con-
intake for most nutrients. Protein consti- tent is higher in monounsaturated fatty ac-
tutes 12% to 20% of total calories and is pro- Fiber-Supplemented Formulas ids (MUFA) and lower in polyunsaturated
vided as intact protein from eggs, milk, pu- and saturated fatty acids. There are few
reed meat, or protein isolates from casein, Many of the polymeric formulas have been randomized controlled trials evaluating
whey, soybean, or egg white. Carbohydrate, supplemented with purified fiber in order the use and outcomes of diabetic formulas.
which comprises the majority of the calo- to promote bowel regularity, both to con- Glycemic and lipid control in hospitalized
ries, is supplied as corn syrup solids, hydro- trol diarrhea and to prevent constipation. patients with type 2 diabetes was evaluated
lyzed cornstarch, or maltodextrin. Fat is The fiber content of these formulas varies using a high carbohydrate versus a low car-
included in these formulas as a source of es- considerably both in amount and in type. bohydrate high-monounsaturated-fat con-
sential fatty acids, fat-soluble vitamins, and Functionally, fiber is classified by its solu- tent DM formula. The enteral formula with
energy. There are a variety of oils used in- bility in water. Soluble fibers such as pectin lower carbohydrate and higher monoun-
cluding borage, canola, corn, fish, safflower, and hydrolyzed guar gum absorb water to saturated fat had a neutral effect on glyce-
and sunflower oil. Polymeric formulas con- form a gelatinous substance. They prolong mic control and lipid metabolism in type 2
tain a full compliment of vitamins, miner- gastric emptying and are rapidly fermented diabetic patients compared with a high-
als, electrolytes, and trace elements in 1 to by colonic bacteria to short-chain fatty acids. carbohydrate and a lower-fat formula. In a
2 L. These formulas are available in various The research evaluating fiber-containing randomized, double-blind, controlled, mul-
concentrations ranging from 1.0 to 2.0 kcal/ enteral formula in the management of diar- ticenter trial, a low-carbohydrate, high-
mL. The high calorically dense formulas can rhea has not demonstrated consistent re- MUFA DM formula resulted in a reduction
be used for those patients requiring fluid sults. A meta-analysis of five randomized in insulin requirements (⫺6.0 vs. 0.0 units,
restriction. Concentrated formulas may controlled trials, failed to demonstrate any P ⫽ 0.0024), fasting blood glucose (⫺1.59
also be useful in patients with high caloric significant effects of fiber on diarrhea in en- vs. ⫺0.08 mM/L, P ⫽ 0.0068), and HbA1C
requirements, bolus feeding, and cyclic or terally fed patients (OR ⫽ 0.61, P ⫽ 0.07). (⫺0.8 vs. 0.0, P ⫽ 0.0016). Although statisti-
nocturnal feeding since a smaller volume is The lack of consistent results may be due to cally significant, the clinical significance of
needed to meet nutrient requirements. Due differences in the amount and type of fibers these results remains debatable. These for-
to the synthetic nature of these formulas, used in each of the studies. mulas have also been suggested for use in
they may lack some of the phytochemicals Insoluble fibers such as soy polysaccha- critically ill patients. In one study, use of
and other nutrients that are present in food. ride pass largely unchanged. They increase these formulas in hyperglycemic ICU pa-
For those individuals who will remain on fecal weight, soften the stool, and shorten tients resulted in improved glycemic control

www.medicalebookpdf.com

LWBK892_c03_p057-065.indd 60 10/28/11 3:42:54 PM

 Chapter 3: Enteral Nutrition Support 61

and decreased insulin requirements, but no amino acids (AAA) resulting in hepatic en- sion of nutrition in chronic obstructive
difference in infectious complications, ICU cephalopathy (HE). The abnormal plasma pulmonary disease (COPD) and acute respi-

Perioperative Care of the Surgical Patient

length of stay, ventilator duration, or mor- amino acid patterns are characterized by ratory distress syndrome (ARDS). The stud-
tality. Overall, the use of DM formulas can elevated levels of methionine and aromatic ies comparing the effects of pulmonary
influence blood glucose levels, but the clini- amino acids, phenylalanine, tyrosine, free products with standard enteral formulas
cal significance of using these formulas re- tryptophan and decreased levels of BCAA, have been conflicting. Angelillo and col-
mains to be proven. leucine, isoleucine, and valine. The two leagues demonstrated reduced carbon di-
Renal formulas have been developed to groups of amino acids compete for trans- oxide production and respiratory quotient
provide optimal nutrition to patients with a port across the blood–brain barrier and in ambulatory COPD patients with hyper-
reduced capacity for clearance of various there is increased uptake of AAA by the capnia when supplied with a high-fat pul-
metabolites. These formulas are typically brain. These AAA act as false neurotrans- monary formula. In hospitalized ventilator
lower in total protein, but enhanced with mitters in the central nervous system and patients, carbon dioxide levels and ventila-
increased amounts of essential amino acids contribute to HE. Hepatic formulas have in- tory time were significantly reduced in
and histidine in order to minimize uremic creased amounts of BCAA and decreased patients receiving a high-fat pulmonary
symptoms. Some of these formulas have in- amounts of AAA in order to normalize the formula compared to a standard enteral
creased levels of protein for use while on amino acid pattern and improve or reverse formula. Others have found conflicting
dialysis. They are also calorically dense for HE. The ability of BCAA enteral formulas to results. In ambulatory COPD patients re-
fluid management and contain reduced lev- enhance tolerance to dietary protein im- ceiving a high-fat formula, no significant
els of potassium, magnesium, and phos- prove neurological symptoms has been differences in respiratory quotient were
phorus compared with standard formulas. evaluated in several studies. In a prospec- demonstrated. Differences in carbon diox-
Some of these formulas do not contain vita- tive randomized double-blind trial, the ef- ide production and respiratory quotient
mins or trace elements; others contain fects of an oral BCAA supplement with ei- may be a result of overfeeding rather than
reduced amounts or only water-soluble ther an isonitrogenous standard protein or the composition of the formula. Talpers
vitamins. In a prospective randomized trial, an isocaloric carbohydrate supplement et al. provided ventilated patients with
Abel and colleagues demonstrated reduced were evaluated on mortality, disease dete- varying amounts of carbohydrate (40%,
morbidity and increased survival rate for rioration, and the need for hospital admis- 60%, and 75%) or total calories (1.0, 1.5, and
patients receiving parenteral essential sion in patients with advanced cirrhosis. 2.0 times the basal energy expenditure).
amino acids plus 70% dextrose as compared The patients who receive the supplemental There was no significant difference in vCO2
with those receiving only 70% dextrose. Al- BCAA showed a decrease in death and liver among the different carbohydrate regimens;
though there are no clinical trials compar- failure (P ⫽ 0.039). The BCAA-enriched however, vCO2 increases significantly as the
ing the efficacy of enteral renal formulas group demonstrated greater improvement total caloric intake increases. These data
with standard products, they may be useful in nutritional status. There was no signifi- suggest that it is more important to avoid
in some clinical situations. This will depend cant difference in encephalopathy between overfeeding than to alter the carbohydrate
on the degree of renal function, the pres- the groups. There was a higher dropout rate and fat concentration of the formula.
ence or absence of renal replacement ther- in the treatment group. When the results ARDS, which is characterized by hypox-
apy (RRT), nutritional status, and nutrient were evaluated on “intent to treat” basis emia, results from a cascade of events
requirements. Patients receiving RRT have there was no statistically significant differ- involving alveolar macrophages and the
increased protein requirements and do not ence in mortality between the groups. The release of proinflammatory eicosanoids. A
require fluid restriction. In the absence of initial findings of a Cochrane Review of specialized enteral formula containing bor-
elevated levels of potassium, magnesium, BCAA demonstrated an improvement of HE age and fish oils as a source of omega-3 fatty
and phosphorus, patients on dialysis should when compared to controls. However, when acids and g-linolenic and eicosapentaenoic
continue to receive a standard or high-pro- including only trials with adequate sample acids plus increased antioxidants has been
tein formula. However, renal formulas may sizes and good methodological quality, formulated specifically for use in ARDS and
be useful in those circumstances where there is no difference in HE, survival, or ad- acute lung injury. The metabolism of the
RRT is delayed or must be avoided all to- verse events. Based on the conflicting re- omega-3 fatty acids leads to an increased
gether. In addition, when there is persistent sults in a limited number of studies, the production of prostaglandins of the 1 series
hyperkalemia, hypermagnesemia, and hy- routine use of BCAA-enriched hepatic en- and leukotrienes of the 5 series, promoting
perphosphatemia a specialty renal product teral formulas is not indicated. However, an anti-inflammatory and vasodilatory
may be useful. Despite the lack of controlled those patients who are refractory to routine state. Vasoconstriction, platelet aggrega-
clinical trials demonstrating improved out- medical therapy for HE and are unable to tion, and neutrophil accumulation are re-
comes with use of renal formulas, nutrition tolerate standard protein formulas without duced when the eicosanoids balance favors
intervention can reduce the degree of pro- precipitation of HE, the use of BCAA formu- anti-inflammatory rather than proinflam-
tein depletion. For patients intolerant to las is warranted. matory mediators. In a multicenter ran-
standard formulas or for those whom dialy- Malnutrition, common in patients with domized trial, patients receiving the spe-
sis must be delayed, the use of specialty re- pulmonary disease, can adversely affect re- cialized ARDS formula showed a significant
nal formulas will allow provision of nutri- spiratory function. Overfeeding, particu- improvement in oxygenation, fewer days of
ents until dialysis can be instituted or renal larly with high carbohydrate formulas can mechanical ventilation, and reduced ICU
function improves. result in increased carbon dioxide produc- stays when compared to the control group
Patients with liver dysfunction present tion and precipitate respiratory failure. receiving a standard formula. Similar re-
unique challenges in that they are often Specialized pulmonary formulas have sults have been reported in other trials in-
malnourished but intolerant to provision of been developed, which contain increased cluding a reduction in mortality. Although
protein due to an imbalance of branched amounts of fat and decreased concentra- the use of pulmonary enteral formulas for
chain amino acids (BCAA) and aromatic tions of carbohydrate to allow for the provi- COPD is not strongly supported by the

www.medicalebookpdf.com

LWBK892_c03_p057-065.indd 61 10/28/11 3:42:54 PM

 62 Part I: Perioperative Care of the Surgical Patient

evidence to date, use of formulas in ARDS ringe over a short period of time, usually 5 maintaining GI tract integrity. It is the pre-
and acute lung injury should be considered. minutes or less. Generally, the patient is fed ferred technique for supporting surgical
Nutrition can influence the immune re- a volume of 250 to 500 mL of feeding four to patients pre- and postoperatively when ac-
sponse. Immune-modulating formulas con- six times daily. Feedings provided by this cess to a functional intestinal tract can be
tain varying amounts of specific nutrients method may result in adverse GI effects due safely achieved. Using laparoscopic, endo-
such as omega-3 fatty acids, glutamine, to the sudden delivery of a large, hyperos- scopic, radiologic, and bedside insertion
arginine, nucleotides, and/or antioxidants molar formula. Intermittent feedings are techniques intubation of the intestinal
thought to improve the immune response administered over a longer period of time, tract for feeding purposes can be achieved
and enhance the anti-inflammatory pro- generally 20 to 30 minutes, using a feeding in virtually any patient making EN the first
cess. Numerous studies have been con- container and gravity drip. Due to the lon- choice for nutrition support of the surgical
ducted on a variety of patients using differ- ger infusion time, there are generally less GI patient.
ent immune-enhancing products and side effects with intermittent infusion. Bo-
various outcome parameters. In order to lus and intermittent methods are usually SUGGESTED READINGS
evaluate these results and formulate a con- reserved for gastric feeding because the
Abel RM, Beck CH, Abbott WM, et al. Improved
clusion, several meta-analyses have been stomach can act as a reservoir to handle
survival from acute renal failure after treat-
conducted. Beale and colleagues conducted relative large volumes of formula over a ment with intravenous essential L-amino acids
a systematic review of studies including short time. Although the large lumen of and glucose. Results of a prospective, double-
1,557 critically ill patients, which demon- gastrostomy tubes allow for easy adminis- blind study. N Engl J Med 1973;288:695–9.
strated significant reductions in infection, tration with these techniques, they can also Als-Nielsen B, Koretz RL, Kjaergard LL, Gluud
ventilator days, and hospital length of stay, be given through small bore nasogastric C. Branched-chain amino acids for hepatic
but no effect on mortality, in those patients tubes. Bolus and intermittent feedings are encephalopathy. Cochrane Database Syst Rev
2003;(2):CD001939.
who received immune-enhancing formulas. the most physiologic method of adminis- ASPEN Board of Directors and Standards Com-
Another meta-analysis of studies involving tration because they mimic normal eating mittee. American Society for Parenteral and
the use of immunonutrition in critically ill and allow the gut to rest between feedings. Enteral Nutrition. Definition of terms, style,
surgical and trauma patients was associ- In addition, they are the easiest to adminis- and conventions used in ASPEN guidelines and
ated with a significant decrease in the inci- ter requiring very little equipment. standards. Nutr Clin Pract 2005;20:281–5.
dence of wound complications and hospital Feedings can be delivered continuously Balzano G, Zerbi A, Braga M, et al. Fast-track
recovery programme after pancreatico-
length of stay in patients undergoing GI slowly over 12 to 24 hours, usually with an duodenectomy reduces delayed gastric empty-
surgery and in those with critical illness. enteral feeding pump. The use of a pump is ing. Br J Surg 2008;95:1387–93.
However, there were no differences in mor- more desirable than gravity drip because a Berger MM, Chiolero RL. Enteral nutrition and
tality or incidence of pneumonia. Similar constant infusion rate can be sustained and cardiovascular failure: from myths to clinical
results were demonstrated in elective surgi- accidental bolus delivery is less likely to oc- practice. JPEN 2009;33:702–9.
cal patients by Heyland et al. in which they cur. In general, continuous administration Berger MM, Mustafa I. Metabolic and nutritional
reported a reduced incidence of infectious is usually tolerated best and may be neces- support in acute cardiac failure. Curr Opin Clin
Nutr Metab Care 2003;6:195–201.
complications, with no benefit on mortal- sary when patients cannot tolerate bolus or Boullata J, Nieman Carney L, Guenter P, eds. AS-
ity. It has been suggested that the arginine intermittent methods. Transpyloric feed- PEN. Enteral Nutrition Handbook. Silver Spring:
content of the immune-enhancing formula ings require continuous infusion because The American Society of Parenteral and Enteral
may be a factor in the increased mortality the small bowel cannot act as a reservoir Nutrition; 2010.
associated with the use of these formulas in for large volumes of feeding delivered within Braga M, Gianotti L, Gentilini O, et al. Early
selected critically ill patients. In spite of a short time. Enteral formulas are initiated postoperative enteral nutrition improves gut
oxygenation and reduces costs compared
extensive research, no clear evidence of at full strength at 10 to 40 mL/h and ad- with total parenteral nutrition. Crit Care Med
clinical advantages exists, although some vanced to the goal rate in increments of 10 2001;29:242–8.
studies identified specific patients in whom to 20 mL/h every 8 to 12 hours as tolerated. Braunschweig CL, Levy P, Sheean PM, Wang X,
these formulas offer benefits. Currently, it is Tube feedings can be cycled for patients et al. Enteral compared with parenteral nutri-
recommended that these formulas can be who are transitioning from tube to oral tion: a meta-analysis. Am J Clin Nutr 2001;74:
used in major elective surgery, trauma, feeding, in an attempt to stimulate appetite, 534–42.
Buchman AL, Scolapio J, Fryer J. AGA technical
burns, head and neck cancer, and critically or for those receiving home EN, to allow review on short bowel syndrome and intes-
ill patients on mechanical ventilation, with bowel rest and time off the pump. The feed- tinal transplantation. Gastroenterology 2003;
caution in patients with severe sepsis. ings may be administered at night and dis- 124:1111–34.
continued during the day to afford the pa- Byrnes MC, Reicks P, Irwin E, et al. Early enteral
INITIATION AND tient greater mobility and an opportunity to nutrition can be successfully implemented in
eat. They may also be infused continuously trauma patients with an “open abdomen.” Am
ADMINISTRATION TECHNIQUES in an intermittent fashion to accommodate J Surg 2010;199:359–63.
Doig GS, Simpson F, Finfer S, et al. Nutrition
EN should be initiated in a patient, particu- the patient’s lifestyle and wishes. Guidelines Investigators of the ANZICS Clinical
larly in the critically ill, who is unable to Trials Group. Effects of evidence-based feeding
maintain volitional intake. EN is not with- guidelines on mortality of critically ill adults: a
out potential complications and requires
CONCLUSION cluster randomized controlled trial. JAMA 2008;
proper administration and monitoring. The EN support is a safe and efficacious way of 300:2731–41.
choice of method of administration is dic- feeding patients who are unable to eat. It Elia M, Engfer MB, Green CJ, et al. Systematic re-
view and meta-analysis: the clinical and physi-
tated by the type and site of access. Tube has become not only a food replacement ologic effects of fibre-containing enteral formu-
feedings can be administered via bolus, in- alternative, but also through special for- lae. Aliment Pharmacol Ther 2008;15:120–45.
termittent, or continuous methods. Bolus mulations can support the metabolic needs Fischer JR. The role of plasma amino acids in he-
feedings are administered by gravity or sy- of the critically ill surgical patient while patic encephalopathy. Surgery 1975;78:276–90.

www.medicalebookpdf.com

LWBK892_c03_p057-065.indd 62 10/28/11 3:42:54 PM

 Chapter 3: Enteral Nutrition Support 63

Gauderer MW, Stellato TA. Gastrostomies: evolu- Matarese LE, Costa G, Bond G, et al. Therapeutic Pontes-Arruda A, Aragao AM, Albuquerque JD. Ef-
tion, techniques, indications and complica- efficacy of intestinal and multivisceral trans- fects of enteral feeding with eicosapentaenoic

Perioperative Care of the Surgical Patient

tions. Curr Prob Surg 1986;23:661–719. plantation: survival and nutritional outcome. acid, ␥-linolenic acid, and antioxidants in
Gramlich L, Kichian K, Pinilla J, et al. Does enteral Nutr Clin Pract 2007;22(5):474–81. mechanically ventilated patients with severe
nutrition compared to parenteral nutrition McClave SA, Heyland DK. The Physiologic re- sepsis and septic shock. Crit Care Med 2006;
result in better outcomes in critically ill adult sponse and associated clinical benefits from 34:2325–33.
patients? A systematic review of the literature. provision of early enteral nutrition. Nutr Clin Rassias AJ, Ball PA, Corwin HL. A prospective
Nutrition 2004;20:843–8. Pract 2009;24:305–15. study of tracheopulmonary complications
Heidegger CP, Romand JA, Treggiari MM, et al. Is McClave SA, DeMeo MT, DeLegge MH, et al. associated with the placement of narrow-
it now time to promote mixed enteral and par- North American Summit on aspiration in the bore enteral feeding tubes. Crit Care 1998;2:
enteral nutrition for the critically ill patient? critically ill patient: consensus statement. JPEN 25–28.
Intensive Care Med 2007;33:963–9. 2002;26:S80–S85. Schneider SM, Giarard-Pipau F, Anty R, et al. Effects
Heyland DK, Dhaliwal R, Drover JW, et al.; Cana- McClave SA, Lukan JK, Stefater JA, et al. Poor va- of total enteral nutrition supplemented with a
dian Critical Care Clinical Practice Guidelines lidity of residual volumes as a marker for risk multi-fibre mix on faecal short-chain fatty acids
Committee. Canadian clinical practice guide- of aspiration in critically ill patients. Crit Care and microbiota. Clin Nutr 2006;25:82–90.
lines for nutrition support in mechanically Med 2005;33:324–30. Schutz T, Herbst B, Koller M. Methodology for the
ventilated, critically ill adult patients. JPEN McClave SA, Martindale RG, Vanek VW, et al. development of the ESPEN guidelines on en-
2003;27:355–73. Guidelines for the provision and assessment teral nutrition. Clin Nutr 2006; 25:203–9.
Heyland DK, Novak F, Drover JW, et al. Should im- of nutrition support therapy in the adult criti- Seder CW, Janczyk R. The routine bridling of na-
munonutrition become routine in critically ill cally ill patient: Society of critical care medi- sojejunal tubes is a safe effective method of re-
patients? A systematic review of the evidence. cine (SCCM) and American society for par- ducing dislodgement in the intensive care unit.
JAMA 2001;286:944–53. enteral and enteral nutrition (ASPEN). JPEN Nutr Clin Pract 2008;23:651–4.
Hsu CW, Sun SF, Lin SL, et al. Duodenal vs. gastric 2009;33(3)277–316. Simpson F, Doig GS. Parenteral vs. enteral nutri-
feeding in medical intensive care unit patients: Melis M, Fichera A, Ferguson MK. Bowel necro- tion in the critically ill patient: a meta-analysis
a prospective randomized clinical study. Crit sis associated with early jejunal tube feeding: of trials using the intention to treat principle.
Care Med 2009;37:1866–72. a complication of postoperative enteral nutri- Intensive Care Med 2005;31:12–23.
Joly F, Dray X, Corcos O, et al. Tube feeding improves tion. Arch Surg 2006;141:701–4. Singer P, Theilla M, Fisher H, et al. Benefit of an
intestinal absorption in short bowel syndrome Metheny NA, Schallom L, Oliver DA, Clouse RE. enteral diet enriched with eicosapentaenoic
patients. Gastroenterology 2009;136:824–31. Gastric residual volume and aspiration in criti- acid and gamma-linolenic acid in ventilated
Kreymann KG, Berger MM, Deutz NEP, et al. ES- cally ill patients receiving gastric feedings. Am J patients with acute lung injury. Crit Care Med
PEN Guidelines on enteral nutrition: intensive Crit Care 2008;17:512–9. 2006;34:1033–8.
care. Clin Nutr 2006;25:210–23. Multivisceral Transplantations at a Single Center. Tiengou LE, Gloro R, Pouzoulet J, et al. Semi-
Kudsk KA. Current aspects of mucosal immunol- Major advances with new challenges. Ann Surg elemental formula or polymeric formula: is
ogy and its influence by nutrition. Am J Surg 2009;250(4):567–81. there a better choice for enteral nutrition in
2002;183:390–8. Peter JV, Moran JL, Phillips-Hughs J. A meta- acute pancreatitis? Randomized comparative
Lewis SJ, Egger M, Sylvester PA, Thomas S. Early analysis of treatment outcomes of early enteral study. JPEN 2006;30:1–5.
enteral feeding versus “nil by mouth” after gas- versus early parenteral nutrition in hospitalized Ukleja A. Altered GI motility in critically ill pa-
trointestinal surgery: systematic review and patients. Crit Care Med 2005;33:213–20. tients: current understanding of pathophysiol-
meta-analysis of controlled trials. BMJ 2001;323: Petrov MS, Loveday BPT, Pylypchuk RD, et al. Sys- ogy, clinical impact, and diagnostic approach.
773–6. temic review and meta-analysis of enteral nu- Nutr Clin Pract 2010; 25:16–25.
Lochs H, Dejong C, Hammarqvist F, et al. ESPEN trition formulations in acute pancreatitis. Brit J Weimann A, Braga M, Harsanyi L, et al. ESPEN
guidelines on enteral nutrition: gastroenterol- Surg 2009;96:1243–52. guidelines on enteral nutrition: surgery includ-
ogy. Clin Nutr 2006;25:260–74. Pohl M, Mayr P, Mertl-Roetzer M, et al. Glycaemic ing organ transplantation. Clin Nutr 2006;25:
Mack LA, Kaklamanos IG, Livingstone AS, et al. control in type II diabetic tube-fed patients 224–44.
Gastric decompression and enteral feeding with a new enteral formula low in carbohy- Yang G, Wu XT, Zhou Y, et al. Application of di-
through a double-lumen gastrojejunostomy drates and high in monosaturated fatty acids: etary fiber in clinical enteral nutrition: a meta-
tube improves outcomes after pancreaticoduo- a randomized controlled trial. Eur J Clin Nutr analysis of randomized controlled trials. World
denectomy. Ann Surg 2004;240:845–51. 2005;59:1121–32. J Gastroenterol 2005;11:3935–8.

EDITOR’S COMMENT describe the current American hospital system. tality than patients who were well nourished. We
Here, the environment is actually cold, unappe- still haven’t learned it. Yes, enteral nutrition may
tizing food is presented in a casual manner and is be preferred under certain circumstances, but if
This is an excellent chapter with enormous data- not within reach of the patient (e.g., if the patient the patient cannot eat or cannot get adequate
base and references that are worthwhile. Unfor- is bed-ridden, the food is placed on the window amounts of nutrition enterally, then parental nu-
tunately, enteral nutrition has become a slogan, sill, without an attendant to help the patient trition is essential.
and in one of the quoted papers, the statement eat), and the kitchen and the quality of food is At a time when hospitals are under pressure,
is made that parental nutrition should never thought of as a place where money can be saved. parental nutrition administration gets more dan-
be given if enteral nutrition is possible. The pa- However, it is absolutely necessary and clear that gerous. When the TPN nurses or IV nurse teams
tients who were dealt with in that particular if the patient is not adequately nourished, he have been cut back and care of catheters has been
paper (Kulick D and Dean D. Am Fam Physician becomes malnourished, then all diseases have largely abandoned to whatever the floor will or
2011;83:173–83) clearly are not patients whom mortality, which need not be present, and if the will not do, then the infection rate of catheters
we normally deal with in an hospital setting, and patient has a complication, the nutritional defi- goes up dramatically. Under those circumstances,
indeed, if I were a family physician, I certainly ciency is even worse. This is something that was intestinal enteral nutrition is preferred, if possi-
would want to make certain that the patients are learned in 1936, when Studley, from the Univer- ble. Especially in the ICU, where a patient’s blood
receiving adequate food presented in an appetiz- sity of Pennsylvania, and his coworkers brought flow is compromised by being on pressors, hypo-
ing manner, and when the patients are infirm, attention to the fact that malnourished patients volemia, or intrinsic vascular disease, the use of
individuals would be available to feed the patient (with low serum albumin) with a gastrectomy indiscriminant enteral nutrition, especially when
if the family was not. Unfortunately, that does not that were malnourished had a much higher mor- given according to manufacturer’s guidelines, is a

(continued)

www.medicalebookpdf.com

LWBK892_c03_p057-065.indd 63 10/28/11 3:42:54 PM

 64 Part I: Perioperative Care of the Surgical Patient

lethal weapon. A number of individuals, includ- come up for 20 days, and that depends more on did result in a better outcome. I know there have
ing the author of this chapter, have recognized the amount of extravascular interstitial albumin, been criticisms of this study, but given the nature
the concept of the challenged bowel, that is the which is more directly related to the rate of degra- of the population, this nutritional supplement,
bowel in which blood supply and blood flow is dation than it does of albumin synthesis. which is a proprietary mixture (Impact), appeared
diminished. If one considers an elderly patient I would not use silastic tubes for a gastrostomy to be efficacious at improving mortality and de-
with some stenosis of the superior mepenteric tube or an 8-French for a jejunostomy tube. While creasing length of stay in critically ill post-surgical
artery and gives him enteral nutrition in a hyper- softer at body temperature, these tubes tend to patients. There may be differences on this, but it is
osmotic fashion, such as many manufacturers be hard and may erode, including resulting in unlikely to have a better study, which was multi-
promote in their guidelines, or if enteral nutri- enlargement of the gastrostomy or jejostomy site center. Knowing Dr. Bower as well as I did, and our
tion is started and the caregivers do not gradually and resulting in cellulitis or overgrowth of granu- offices being almost adjacent, I know the difficulty
increase the osmolality given to an ischemic or a lation tissue. I tend to use a 12 or 14 rubber latex he had with producing a first-class study.
potentially ischemic small bowel, I would submit nephrostomy tube and an 18 or 20 nephrostomy However, now having spoken my piece, let me
that, perhaps, enteral nutrition is more danger- tube made of light brown latex for a gastrostomy now review seven algorithms concerning enteral
ous than parental nutrition, despite the increase tube. The tube is soft at body temperature, and nutrition, which I believe that if adequate enteral
in the sepsis, and results in a higher mortality will not do much damage as far as erosion is con- nutrition can be supplied, entirely is perfectly ap-
with pneumatosis and finally perforation and cerned. I would also caution when doing gastros- propriate, provided one is cautious in increasing
death. The authors have done a good job in doing tomy feedings, which I mention only to condemn, the osmolality (in my own case, I never exceed an
the calculations regarding the problem with the if one cannot get something distal, either by a osmolality of 280 milliosmoles when enteral ma-
“challenged bowel” with respect to blood flow. feeding jejunostomy under local, which is easy to terial was given into the gut, and I am especially
In the event that the small bowel undergoes do, or a nasoenteric tube, which is probably safer careful in patients who may have a challenged
resection, for whatever reason, in a life-saving set- for reasons that are not clearly understood with bowel as far as blood supply, especially those on
ting, it is worthwhile trying to save the few centi- respect to necrotizing enterocolitis, but I would pressors or in the ICU as the authors state).
meters of ileum, which can be saved. The water- stop gastrostomy feedings in the evening when
shed of the area between the terminal ileum and the patient can no longer be kept upright with 1. In critical illness, blood flows are decreased as
the cecum is often irregular, depending on where nursing supervision because of cuts in nursing mentioned very well in this chapter and high
the last branch of the ileocolic vessel inserts on staff, which suppose that people get better during osmotic material, which is often promoted in
the distal ileum. While the authors have stated the night, then get sick the next morning. the manufacturer’s instructions, will prob-
that absorption of vitamin B12 and other impor- There are a number of specialized solutions ably directly result in pneumatosis and maybe
tant nutritional entities is within the last 100 cm, that have, perhaps, a beneficial effect. The first bowel necrosis.
a patient of mine, described by Schreflan M et al. one is the amino acids formula for what is basi- 2. This high osmotic syndrome of pneumatosis
(SGO 1976;143:757–62), actually demonstrated an cally a Giordano/Giovanetti diet. This is the es- probably occurs more frequently in jejunos-
adequate Schilling test within 9 months of having sential amino acid–enriched diet, which Wilmore tomy feeding as compared to nasal enteric
had only 36 cm of small bowel remaining with a and Dudrick first introduced, and it remained for feedings as the authors mention for reasons
small portion of ileum in the ileocecal valve. This Abel and his coworkers, including myself, to show that are not entirely clear.
patient ultimately got off TPN within 2 years. an improvement in survival as well as survival 3. TPN is perfectly reasonable in any and all set-
While fiber is the biochemical antecedent of following a randomized prospective trial. (Abel tings provided glycemia is avoided and the
butyrate, and acetoacetate and other ketone bod- RM et al. NEJM 1973;288:695–99) to the politics of catheter gets excellent care. Both of these
ies are excellent sources of calories and fuel for the New England Journal, this study, which had a are now challenged as hospitals cut back the
the colon, one must be careful not to fall into the tremendous amount of data was not published in monitoring of TPN administration.
trap of limiting lipids to medium chain triglyc- its entirety, and included, for example, improved 4. One of the basic features which is very rea-
erides, as often one hears. Long chain triglycer- survival in patients that have pneumonia and sonable in patients receiving enteral nutrition
ides may be an adequate source of fats in certain other worthwhile data. is that the liver gets first pass at the nutrients
characterizations, but they should not be the sole I agree with the authors as far as the branched and thus promotes appropriate and econom-
source of fat. chain amino acids and the improvement in he- ic processing as well as in acute illness short
I would take issue that patients who are mal- patic encephalopathy, and studies have shown, turnover and acute care proteins.
nourished, as manifest by a low serum albumin, especially those of Marchesini, who has published 5. In some circles, unfortunately, as is evidenced
and one assumes, transferrin and retinol-bind- extensively on this in improvement and survival. by one of the papers in The Family Practice
ing protein and thyroxin-binding prealbumin, I must mention that the branched chain amino Journal, it is said that TPN is almost never in-
should not be operated on electively until 10 to acids only are useful, and there are a number of dicated. It certainly is if one cannot achieve a
14 days of nutritional support, presumably with studies that demonstrate this, when given with reasonable caloric intake. Nor does this mean
enteral nutrition. I beg to differ. According to an glucose as the caloric base. In the two studies in that TPN should start immediately with full
early study, carried out on the ward service at the which fat was used as a significant caloric base, replacement; it needs to be taken up slowly in
Massachusetts General Hospital, patients who the branched chain amino acids did not show patients receiving TPN so they are not flood-
were malnourished would tolerate 3 days of pa- efficacy. It is, therefore, interesting that, in Refer- ed with glucose and protein. It takes a while
rental nutrition and have a small, but not statisti- ence 118, the Cochran database used with a lipid to get adjusted to a nutritional onslaught.
cally significant, improvement in outcome after caloric base, which is not efficacious as it appears, 6. In every decade, for one reason or another,
only 3 days. In other studies, it did appear as if the is a principal participant in the Cochran review of there appears to be another attempt to in-
transferrin began to increase within 5 days of the branch chain amino acids; the study by a senior stitute hypocaloric feeding, whether it is be-
initiation of safe parental nutrition in malnour- author of one of the two studies of the branched cause glucose supposedly decreases lysis of
ished patients, and the patient felt better. Thus, chain amino acids (Prof. Gluud) was negative. fat and fat needs to be utilized, or because
we adopted that 5 days of parental nutrition was Clearly, either the people who appointed him of something about insulin. It is no different
appropriate, since it wasn’t that long that one ran were unfamiliar with the literature, or this was a now. There is another attempt to advocate for
the danger of a line infection, and yet, one got a deliberate attempt on the Cochran organization hypocaloric feeding but I do not believe that
discernable improvement, not only in some of to have a negative outcome. You cannot con- if one takes care of preventing glycemia that
the short-term nutritional parameters, but also, vince me that one of the really staunch partisans there is any particular role in hypocaloric
importantly, the patient felt better. Thus, I would against the branched chain amino acids would feeding providing that one monitors the pa-
suggest shortening the days of preoperative pa- give an unbiased review, as far as efficacy. tient sufficiently.
rental nutrition (I have no data on enteral nutri- There are also studies, as the utilizing impact I would call attention to some of the recent
tion) to 5 or 6 days, since that is when transferrin a nutritionally reasonable supplementation with studies, including the propositous that ap-
improves, and I believe that is the appropriate utilizing various immuno-nutrition, and a nation- peared in Nature in the year 2000 that vagal
time. Ten to fourteen days is long and unlikely wide randomized perspective trial conducted by stimulation has certain beneficial effects in
to be approved in the brave new world of what my good friend (Robert Bower) indicating that im- response to injury and that probably nutri-
follows in U.S. health care. The albumin will not muno-nutrition, especially in critically ill patients, tional support in some way is associated with

www.medicalebookpdf.com

LWBK892_c03_p057-065.indd 64 10/28/11 3:42:54 PM

 Chapter 4: Cardiovascular Monitoring and Support 65

this. There is much more data that is being ac- and I doubt very much whether the protein will glucose in the stool and this is the cause of their

Perioperative Care of the Surgical Patient

cumulated rapidly and I would urge the reader end up being synthesized to new protein. How- diarrhea. I found this with several patients, most
to keep track of this particular initiative, most ever, the medical patient is usually, in our current of whom probably have slightly sloughed mucosa
of which is in the basic science literature. setting, malnourished, chronically ill and this is as a result of their illness. The dipstick for urine
7. Attempts to decrease infection by maintain- not a single episode, this is yet another episode testing is quite adequate for this and could be seen
ing normal glycemia have variable results. in an ongoing illness. I agree wholeheartedly that at least in one patient; she had a glucose output of
Suffice it to say, that if one is trying to main- nutritional support needs to be administered in 3/6 despite the fact that she was not receiving any
tain normal glycemia, I would aim for an up- both settings. It does take a while to get up to a enteral feedings at all. This also explains why she
per level glucose of 150 as far as blood glucose reasonable level with parental nutrition, or even had repetitive episodes of yeast acquiring flucon-
is concerned. Attempts to utilize insulin to enteral nutrition and maintenance of blood sugar azole, which seemed to be harbored because of
maintain normal glycemia at below 120 usu- of 150 will decrease infection. However, I do not the presence of glucose in the diarrhea.
ally result in some hypoglycemia episodes believe that there is anything magical about less Finally, we have an interesting experiment
that are not healthy for the patient. than 800 calories of glucose improving fat utiliza- on intestinal function and neonatal entero-
tion. I do not see the advantage for this. colitis in pre-term pigs by Sylborg et al. (JPEN
In speaking of the variable hypothesis Another approach that has previously been 2011;35:32–42). The concept of the paper is inter-
of hypocaloric support, Burke et al (JPEN mentioned in this paper is by Doina Kolick and esting. What they did was to try and utilize dif-
2010;34:546–48) have proposed that “early feed- Darwin Deen (Specialized nutritional support. ferent nutritional support medications as well as
ing post-injury may have positive influence on Am Fam Physician 2011;83:173–83). These family normal colostrum in trying to prevent neonatal
the duration of intensity of systemic inflamma- physicians are obviously referring to different pa- enterocolitis. The experimental design violates
tory response.” They propose that this is especially tients other than the usual hospitalized surgical what I was taught by Julius Axelrod, who won the
useful when coupled with intensive insulin ther- patients in whom they state that parental nutri- Nobel Prize in 1970, and it is that one must do an
apy to maintain normal glycemia at less than 150. tion should be used only is enteral nutrition is not experiment with one variable so one gets a yes
Whether or not this is enteral nutrition or paren- feasible. I am not sure exactly what they mean, but or no answer. In this experiment, in addition to
tal nutrition, it is difficult to get adequate enteral certainly in the chronically ill medical patients, the number of abbreviations that are absolutely
nutrition especially with regards to protein. The both are likely to be needed. These are not the sur- hopeless and really detract from the paper, in
authors, given the current guidelines for increas- gical patients in the ICU. These are patients who each group there were three different diets given
ing enteral nutrition, therefore propose a hypoca- likely can eat and should be encouraged to eat, in different orders. The results were that colos-
loric parental nutrition with modest amounts of but given the limitations of how food is likely to be trum seemed to be the most protective against
glucose amounting to 60% to75% resting meta- served in most of our hospitals, they may end up neonatal enteral colitis but it is impossible to
bolic expenditure and with at least one gram needing enteral or parental nutritional support. determine whether or not this is a beneficial ef-
of protein per kilogram as intravenous amino Patients with enteral support often have di- fect of anything but the colostrum given the order
acids to provide “early metabolic support.” They arrhea. My experience with this is that they are and the number of diets given. Yes, colostrum is
propose that this should promote protein’s com- probably given a high osmolality and, therefore, important and probably protective but for any of
ponent to the postinjury inflammatory response will excrete glucose or what you have into the in- the other diets, which include parental nutrition
and I believe that it has absolutely no research testinal lumen to try to achieve caloric normality. followed by a minimal enteral nutrition or full en-
support. They also invoke the lesser amount of Therefore, it comes as some surprise that Ferrie teral normal feeding, the only thing that is true
glucose for enabling fat break down and the uti- and Daley carry out a trial of lactobacillus as an was that colostrum seemed to be somewhat pro-
lization of lipids. I believe we have been through example of a pro-biotic in an effort to reduce the tective, independent of whatever diet was used
this drill before and, with absolutely no evidence, diarrhea (JPEN 2011;35:43–49). in these pigs. That, of course, is unfortunate but
that even reducing the glucose to essentially neg- The study says nothing about possible enteral it should be no surprise. Dr. Axelrod would say,
ligible amounts in the posttraumatic state actu- causes of diarrhea such as hyperosmolality. Inulin if he were confronted with this experiment, he
ally encourages the use of lipid. was given as the carrier and I do not know about would use his favorite nickname for these types
There is, of course, a difference between the its effect on diarrhea but lactobacillus was in- of experiments and he would call them Swedish
surgical patient and the medical patient. In the cluded mixed with the Inulin in capsulate form. experiments because there were many variables
surgical patient, as the authors point out, there is They found that after a week of treatment of and at the end of the day, one could hardly tell
generally a well-nourished individual with a de- the pro-biotic group, there was a slight increase what the outcome was. It is too bad Dr. Axelrod
fined injury from which the patient for the most of diarrhea in the treated group and less for the is not alive; if he were he would undoubtedly call
part will recover. The attempt here is to decrease placebo group, although this was not statistically the authors and repeat the same adage he did to
the amount of catabolism and protein break- significant. me for the better part of two years: a single exper-
down, something which I am not certain one can One of the things that one must be careful of iment, a single variable, and a yes or no answer.
do easily with hypocaloric glucose and with pro- when dealing with the patients who have diarrhea This paper does not mean those criteria.
tein. Protein is likely to be broken down for energy with enteral feeds is that they are not putting out J.E.F.

4 Cardiovascular Monitoring and Support

Irving L. Kron and Gorav Ailawadi

INTRODUCTION diovascular system involves an assessment these parameters is accompanied with an

of four major components: cardiac func- increase in the cost, complexity, and risks
Cardiovascular monitoring and support tion, peripheral and pulmonary vascular associated with the use of these monitor-
are essential to the care of surgical pa- tone, intravascular volume status, and ox- ing devices. Therefore, the decision to uti-
tients. The goals of cardiovascular moni- ygen metabolism. Accurate and thorough lize these technologies must be deter-
toring are to ensure adequate tissue oxy- evaluation of these four components is a mined based on the need and usefulness
genation and perfusion intraoperatively prerequisite to the proper application of of the data compared to the risks and
and postoperatively. Monitoring of the car- cardiovascular support. Measurement of costs.

www.medicalebookpdf.com

LWBK892_c03_p057-065.indd 65 10/28/11 3:42:54 PM

 66 Part I: Perioperative Care of the Surgical Patient

s
surgical practice. Blood pressure is prone to Furthermore, these methods provide a con-
Table 1 Physical Signs of Organ- aabrupt changes as a result of anesthesia, venient source for frequent arterial blood
Specific and Systemic
Perfusion surgical
s procedures, changes in volume sta- sampling, both in the operating room and
ttus and cardiac function, and underlying in mechanically ventilated patients in the
Physical sign Implication ssurgical illnesses. As arterial blood pressure intensive care unit. For these reasons, inva-
Obtundation Impaired cerebral iis an indirect marker of systemic perfusion sive blood pressure monitoring is recom-
perfusion and
a a direct marker of hemodynamic sta- mended in patients that are or expected to
Oliguria Impaired renal perfusion ttus, diligent monitoring of this parameter is become hemodynamically unstable, includ-
eessential to early detection and treatment ing those undergoing major abdominal,
Flat jugular veins Intravascular volume
depletion, impaired oof cardiovascular instability. vascular, or cardiothoracic procedures. In
systemic perfusion addition, any major surgical operation in
N
Noninvasive Methods patients with a history of coronary artery
Weak or absent Impaired regional or IIn addition to continuous ECG, noninvasive disease, congestive heart failure, aortic
pulse(s) systemic perfusion
bblood pressure measurement is considered stenosis, or poorly controlled hypertension
Cool, pale, or Impaired systemic tthe standard intraoperative cardiovascular are also an ideal setting for use of direct
mottled skin perfusion monitor for the majority of patients under-
m blood pressure measurement techniques.
ggoing routine surgery. Noninvasive methods Direct blood pressure measurement is
of arterial blood pressure determination performed with an indwelling intra-arterial
PHYSICAL FINDINGS should be considered indirect because no catheter connected to fluid-filled high-
measurements are actually made with a de- pressure tubing and a transducer. The zero
Cardiovascular monitoring involves a clini- vice within the arterial lumen itself. Instead, reference point for the transducer is at the
cal assessment of organ-specific and sys- such measurements are made with an inflat- level of the right atrium, which corresponds
temic perfusion (Table 1). Physical signs are able cuff (sphygmomanometer), around the to the midaxillary line at the fourth inter-
notoriously unreliable in estimating the ad- arm or leg and inflated to a pressure suffi- costal space. If the transducer is positioned
equacy of tissue perfusion, particularly in cient to compress the underlying artery. below the level of the right atrium, the re-
anesthetized or critically ill patients. There- With the auscultatory method gradual cuff sultant pressure will be spuriously elevated.
fore, physical findings should be interpreted deflation permits the artery to reopen and Conversely, if the transducer is situated
in the context of the patient and adjunct in- thus produce Korotkoff sounds; systolic and above the right atrium, the displayed blood
formation obtained from more sophisti- diastolic blood pressure are determined by pressure will be falsely low.
cated monitoring techniques. the pressure at which these sounds appear The contour of the arterial pressure
and then disappear, respectively, during cuff waveform in the aorta differs from that
Electrocardiography deflation. Alternatively, the oscillometric in the peripheral arteries (Fig. 1). As the
method relies on the principle of plethys-
Continuous monitoring of the electrocar- mography, in which the pulsatile pressure
diogram (ECG) is the most sensitive, rapid, changes in the underlying artery are sensed
and cost-effective modality for detecting by the inflated cuff. The most popular auto-
disturbances of cardiac rate, rhythm, and mated oscillometric blood pressure device
conduction. Such disturbances are com- in clinical use is the Dinamap (GE Health-
mon during general anesthesia, in critical care, UK), which is capable of measuring sys-
illness, and especially in patients with a his- tolic, diastolic, and mean arterial pressures.
tory of arrhythmias or coronary artery dis- Although practical and noninvasive, these
ease. In these settings, ECG monitoring indirect techniques are limited by the fre-
should be routinely employed. quency of measurements and can be inaccu-
Another feature of continuous ECG mon- rate. For example, the use of an inappropri-
itoring, ST-segment monitoring, is quite re- ately small cuff in relation to the size of the
liable for the early detection of myocardial limb (width of cuff ⬍50% circumference) will
ischemia and infarction. Leads II and V5 are yield a spuriously elevated blood pressure
most commonly monitored, as these two reading. Both methods can be limited in the
leads together can detect ⬎90% of intraop- setting of hypotension and the oscillometric
erative ischemic events in high-risk patients. devices have been little studied in the inten-
Intraoperative ST-segment monitoring has sive care setting. Therefore, in cases of sus-
become a standard practice in patients at tained or expected hemodynamic instability,
high cardiac risk. Any electrical disturbances noninvasive blood pressure monitoring tech-
of the heart detected on continuous ECG niques should be abandoned in favor of more
monitoring (ST-segment changes, T-wave accurate and reliable invasive methods.
abnormalities, arrhythmias, etc.) should
prompt a 12-lead ECG to confirm and fur- Invasive Methods
ther characterize the abnormality. Invasive blood pressure monitoring pro-
vides a direct and accurate assessment of
Blood Pressure Measurement arterial pressure. The advantage of this ap-
proach is the rapid detection in fluctuations
Blood pressure is the most commonly mon- in blood pressure and immediate feedback Fig. 1. The appearance of the arterial pressure
itored cardiovascular parameter in current on interventions to correct hemodynamics. waveform at various sites in the circulation.

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 66 10/28/11 10:53:59 PM

 Chapter 4: Cardiovascular Monitoring and Support 67

propagating pressure wave migrates from arteries are less often utilized as a result Pitfalls in Invasive Blood
the aortic root to the periphery, the sys- of their small diameter and lower success- Pressure Monitoring

Perioperative Care of the Surgical Patient

tolic pressure gradually increases such ful cannulation rates. The brachial artery There are potential sources of error in the
that the peak systolic pressure in the radial should be avoided since this vessel has no interpretation of data provided by invasive
artery can be 20 mm Hg higher than that collateral blood supply and thrombosis arterial pressure monitoring systems. As
in the proximal aorta. Thus, the propaga- of it could yield severe forearm and hand discussed above, erroneous blood pressure
tion of blood into peripheral tissues is ischemia. readings result from improper position of
determined by the mean arterial pressure, the transducer vis-à-vis the right atrium. In
not the systolic pressure. This increased Complications of Arterial Cannulation. The addition, the monitoring system is vulner-
systolic pressure in the distal arterial tree most common complication associated able to artifacts that distort the contour of
is due to less vascular elastic tissue and with all sites of arterial cannulation is the arterial waveform and display false
greater impedance, which is transmitted thrombosis. The risk of this complication blood pressure readings. An overdamped
in a retrograde direction from vascular increases with the duration of cannulation; system is caused by a partial thrombus
bifurcations and the artery–arteriolar the risk of radial artery thrombosis may be within the catheter, air bubbles within the
junction. Such systolic amplification is es- as high as 29% in vessels cannulated for ⬎4 tubing or transducer, or kinking of the cath-
pecially prominent in more diseased, less days. However, the risk of clinically signifi- eter or tubing. The result is an attenuation
compliant peripheral arteries, which is the cant distal ischemia is ⬍1%, as most throm- of the peak systolic pressure and an overes-
physiologic basis for isolated systolic hy- bosed vessels tend to recanalize. Arterial timation of diastolic pressure, yielding a
pertension in the elderly. Amplification of catheter insertion sites should be routinely spuriously reduced pulse pressure. Con-
peak systolic pressure in peripheral arter- inspected for signs of ischemia, the pres- versely, underdamping or ringing occurs
ies is counterbalanced by a narrowing of ence of which mandates immediate cathe- with extraordinarily long lengths of tubing
the systolic waveform; the net result is ter removal. Signs of arterial insufficiency and is characterized by augmentation of
that mean arterial pressure is unchanged. distal to the site of catheter removal may the peak systolic pressure and a blunting of
As a result, when peripherally placed in- persist for several hours as a result of vasos- the diastolic pressure, producing a falsely
tra-arterial catheters are employed, mean pasm. However, ischemia persisting beyond elevated pulse pressure. It is important to
arterial pressure is the most accurate esti- 6 hours after catheter removal is an indica- note that with either an overdamped or
mate of central arterial (i.e., aortic) tion for surgical exploration with an eye to- underdamped system, the mean arterial
pressure. ward thrombectomy and vessel repair. In pressure is unaffected. Hence, if there is ever
addition to the duration of cannulation, any doubt as to the fidelity of an invasive
Radial Artery Cannulation other risk factors for catheter-induced ar- arterial pressure monitoring system, only
The radial artery at the wrist is the most terial thrombosis include use of a larger the mean pressure readings should be
common site for insertion of an intra-arte- catheter, insertion during shock, multiple considered reliable. Finally, it should be
rial catheter. The advantages of this site are needle passes and/or careless insertion mentioned that in intensely vasoconstricted
that the vessel is fairly superficial and easily technique, infusion of vasoconstricting patients, such as those undergoing treat-
palpable, it is of adequate diameter to ac- agents, and a small recipient vessel. Other ment with ␣1-agonists, invasive blood
cept a standard-size catheter (18- or 20- clinically important complications of arte- pressure readings via the radial artery may
gauge), and the area is easy to keep clean. rial catheterization are infection, bleeding, be significantly lower than central aortic
To facilitate cannulation of the radial ar- and cerebral embolism. The incidence of lo- pressure.
tery, the wrist should be hyperextended to cal wound infection is 10% to 15% for radial
keep the thenar eminence out of the way artery catheters, but systemic infectious CENTRAL VENOUS CATHETERS
and to bring the vessel to a more superficial complications of such catheters are rare.
location. Vessel entry is performed with a Efforts to reduce the infection rate of radial Cannulation of the central venous circula-
percutaneous Seldinger technique utilizing artery catheterization include avoidance of tion allows rapid volume infusion through
either a composite catheter-over-needle a cutdown technique, replacement of the large-bore catheters, central administra-
device or the standard seeker needle and connector tubing every 48 hours, routine tion of certain drugs (e.g., cardiotonic and
guidewire. Successful vessel entry is her- sterile dressing changes to the insertion vasoactive agents), infusion of parenteral
alded by a flash of arterial blood in the cath- site, and prompt removal of obviously in- nutrition, passage of pacing electrodes into
eter hub. At this point, it is important to fected catheters. However, in the absence of the right heart, and monitoring of central
advance the needle another 0.5 to 1 mm to local or systemic infection, scheduled cath- venous pressure (CVP). Central venous
ensure that its beveled tip is entirely within eter changes are not necessary. Significant catheters can be a useful adjunct for moni-
the vessel lumen and not partially within its bleeding complications are most commonly toring fluid status and helping to diagnose
wall. The catheter or guidewire may then be associated with femoral and axillary artery low urine output states. CVP, or right atrial
safely advanced into the vessel. Historically, lines, particularly in coagulopathic pa- pressure, is an estimate of right ventricular
the Allen test has been used prior to radial tients. For this reason, the radial artery is preload. Hence, a decreased CVP may indi-
arterial cannulation to evaluate ulnar ar- the preferred site of arterial catheterization cate hypovolemia. An elevated CVP can oc-
tery supply to the hand; however, it is now in the presence of a bleeding diathesis. Al- cur in a variety of settings, including hyper-
generally believed that this test does not al- though exceedingly rare, improper flushing volemia, increased intrathoracic pressure,
ways predict ischemic complications from of arterial lines has resulted in emboliza- positive pressure ventilation, pulmonary
radial artery cannulation. Other potential tion of air, thrombi, and liquids to the cere- hypertension, right heart dysfunction, and
sites for arterial cannulation include the bral circulation. This complication can be left heart dysfunction. In a few conditions,
femoral and axillary arteries, both of which avoided by employing small-volume, low- the CVP can be unreliable for predicting left
have the advantages of central arterial ac- pressure flushes and evacuating all air from heart filling pressures. Normal CVP values
cess and a low thrombotic rate. The pedal the tubing and transducer assembly. range from 0 to 8 mm Hg and should be

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 67 10/28/11 10:54:00 PM

 68 Part I: Perioperative Care of the Surgical Patient

measured at end-expiration in both the me- ous tissues, and periosteum of this area just
chanically ventilated and spontaneously CAROTID PULSE below the clavicle should be infiltrated with
breathing patient. The normal CVP tracing 1% lidocaine. The classic method for ac-
has three positive waves (a, c, and v waves) A
X
C
V
cessing the subclavian vein is the Seldinger
and three negative deflections (x, y, and z Y technique. With the patient in the Trende-
VENOUS PULSE X
waves, Fig. 2). These waveforms reflect tri- lenburg position, the needle should be ad-
cuspid valvular function as well as right HEART SOUNDS vanced just beneath the clavicle toward the
atrial and ventricular size, compliance, and S1 S2 suprasternal notch. To avoid causing a
contraction. Characteristic abnormalities pneumothorax, it is very important to
of the central venous waveforms may be EKG maintain a needle trajectory that is parallel
P QRS T
seen in a variety of conditions, including to the floor. Return of free-flowing venous
tricuspid stenosis and regurgitation, dys- Fig. 2. Central venous waves and descents. A,c,v, blood indicates entry into the lumen of the
rhythmias, and atrial septal defect. x,y,z. subclavian vein. At this point, the needle
should be advanced a few millimeters to
ensure that its beveled tip is completely
Subclavian Vein Cannulation within the vessel lumen. A J-tip guidewire is
eters at this site have a lower infection rate
All central venous cannulas should be than the internal jugular (IJ) approach. The then carefully passed through the needle. If
placed with strict sterile technique includ- subclavian vein originates lateral to the undue resistance is encountered upon pas-
ing sterile preparation of the site, wide ster- first rib (Fig. 3). During its course, it passes sage of the wire, both the needle and the
ile draping to cover the patient and bed en- anterior to the first rib and directly poste- wire should be removed and the process re-
tirely, and requiring the operator to wear rior to the clavicle. The external landmarks peated. If vessel puncture is unsuccessful
sterile gown and gloves and all personnel in for the site where the vein passes between with the technique described above, a more
the patient room with hat and masks. The the first rib and the clavicle are: (a) the junc- cephalad direction of the needle may prove
infraclavicular approach to the subclavian tion between the medial and middle thirds successful; occasionally, the subclavian vein
vein is fairly consistent with regard to ana- of the clavicle and (b) the lateral edge of the is displaced superiorly by the apex of the
tomic landmarks, the exit site is more com- sternocleidomastoid muscle where it in- lung, particularly in emphysematous pa-
fortable to the patient, and indwelling cath- serts into the clavicle. The skin, subcutane- tients. After the wire has been confidently

Digastric muscle (anterior belly)

Mandible
Mylohyoid muscle
Stylohyoid muscle Hyoid bone

External carotid artery Thyroid gland

Internal carotid artery External jugular vein
Superior thyroid vein
Thyroid cartilage
Common carotid
artery
Sternocleidomastoid (SCM)
muscle Left vagus nerve
Internal jugular
Cricoid cartilage
vein (IJV)
Sternothyroid muscle Deep cervical
lymph node
Brachial plexus
Middle thyroid vein
Trapezius muscle Brachial plexus

External jugular Thoracic duct

vein (EJV)
Omohyoid muscle Subclavian vein
(inferior belly) Thyroid gland
Trachea
Recurrent laryngeal
Inferior thyroid vein nerve
Left brachiocephalic
Anterior view vein

Fig. 3. Anatomy of the neck. Note the relationship of the subclavian and internal jugular (IJ) veins. (From Moore KL, Dalley AF.
Clinically Oriented Anatomy, 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005, with permission.)

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 68 10/28/11 10:54:00 PM

 Chapter 4: Cardiovascular Monitoring and Support 69

p
pulse at the base of the neck (Fig. 3). How- and embolization of catheter or guidewire
Table 2 Approximate Distance from e
ever, one should be aware that not infre- fragments. With regard to the latter, these
Skin Exit Site to Junction of

Perioperative Care of the Surgical Patient

Superior Vena Cava and q
quently this vein may lie directly anterior or objects can usually be retrieved through a
Right Atrium (to Facilitate e deep to the carotid artery, thus increas-
even second catheter, but rarely require a sterno-
Correct Positioning of i the risk of inadvertently puncturing the
ing tomy. A potentially fatal complication of
Central Venous Catheters) l
latter. With the patient in the Trendelenburg central venous catheterization is venous air
p
position and his/her head rotated to the embolism. The risk of this dreaded compli-
Vessel Distance (cm) c
contralateral side, the triangle formed by cation is increased in patients with a low
Right subclavian vein (H/10) ⫺ 2 t two heads of the sternocleidomastoid
the CVP, in whom the pressure inside the vein
Right internal jugular vein (H/10) m
muscle is identified. A needle is inserted at may become lower than atmospheric pres-
t apex of this triangle, keeping the carotid
the sure during spontaneous inspiration. Air
Left subclavian vein (H/10) ⫹ 2 p
pulse medial to the course of the needle. The may enter the central venous system
Left internal jugular vein (H/10) ⫹ 4 n
needle is slowly advanced toward the ipsi- through defects in the catheter, the un-
l
lateral nipple at a 45-degree angle to the capped port(s) of the catheter, and the un-
H, patient height in cm. s
skin. If venous blood is not obtained after covered end of the needle during vessel
o pass of the needle to 5 cm, the needle
one puncture. The clinical scenario may be one
s
should be withdrawn and oriented in a of acute dyspnea and hypoxia, rapidly pro-
advanced into the central venous circula- slightly more medially. Once the operator is gressing to hypotension and cardiac arrest.
tion, the needle is removed, the skin exit certain of needle entry into the lumen of the If venous air embolism is suspected, the pa-
site is enlarged with a scalpel blade, and a IJ (e.g., return of deoxygenated blood with- tient should be immediately placed in the
vascular dilator is passed over the wire. out arterial pulsations), Seldinger technique left lateral decubitus and Trendelenburg
Great care should be taken during dilator is used to insert the catheter. positions, and an attempt made to with-
passage, as the dilator is quite stiff and can draw air through the central venous cathe-
easily perforate a central vein if forcefully ter. Although pneumothorax can occur
advanced. It is best to dilate slowly and pro-
Femoral Vein Cannulation after either subclavian or IJ catheterization,
gressively, frequently ensuring that the wire The femoral vein can be cannulated rather the risk is higher via the subclavian approach.
moves freely within the dilator and is not easily and expediently, and in select circum- Inadvertent subclavian artery puncture is
being bent as it is forced against the wall of stances is the preferred route for central also a risk of the subclavian approach;
a central vein. It is critical to maintain con- venous access. Examples include victims of however, unless the patient is coagulo-
trol of the guidewire especially during ma- burns to both sides of the neck and upper pathic, immediate withdrawal of the needle
neuvers to advance the dilator and the chest, trauma patients encumbered with and 5 to 10 minutes of digital pressure is
catheter. Once the subcutaneous tract and cervical spine immobilization devices, and sufficient treatment. The most common
the hole into the vessel are dilated, the certain patients with acquired obstruction complication of IJ catheterization is carotid
catheter is threaded over the guidewire; the or congenital anatomic anomalies of the artery puncture. If the carotid artery is en-
latter can then be removed. For most types superior vena cava. The disadvantages of tered with the probe needle, it should be
of indwelling central venous catheters, the the femoral approach are a 10% risk of ve- promptly removed and direct pressure
catheter tip should be situated at the junc- nous thrombosis, the need for the patient maintained on the area for 10 minutes. If it
tion of the superior vena cava and right to remain supine and immobile, and a is apparent that the carotid artery has been
atrium. Table 2 is a useful guide for estimat- higher risk of catheter infection. The femo- cannulated with the dilator or catheter,
ing the distance to this junction from the ral vein is the most medial structure in the these devices should not be removed
skin exit site for each of the subclavian and femoral sheath, lying just medial to the blindly, particularly in an anticoagulated
IJ venous approaches. femoral artery. Puncture of the femoral vein patient. To do so could produce serious
is performed by first palpating the arterial airway-threatening hemorrhage. It may be
Internal Jugular Vein Cannulation pulse 2 cm below the inguinal ligament. At safer to remove the dilator or catheter via
a point 1 to 2 cm medial to the femoral direct surgical exposure, followed by suture
The IJ vein is an alternative to the subclavian pulse, the needle is advanced at a 45-degree repair of the artery. Methods to remove ca-
vein for central venous cannulation. The ad- angle through the skin until venous blood is rotid artery catheters using arterial closure
vantages of this site over the subclavian ap- encountered. If the femoral pulse is nonpal- devices or covered stent grafts have been
proach are a lower incidence of thrombosis, pable, the femoral vein can be located at a described. Other complications unique to IJ
a substantially decreased risk of pneu- point 1 to 2 cm medial to the junction of the catheterization include Horner syndrome,
mothorax, and, especially on the right side, medial and middle thirds of the inguinal brachial plexus injury, and phrenic nerve
a straighter course to the right atrium. ligament. palsy.
Shortcomings of the IJ approach are that it The topic of indwelling central venous
is more uncomfortable for the patient, car- Complications of Central catheter infections deserves special men-
ries the risk of carotid artery puncture, and Venous Cannulation tion, since this is an all-too-common and
has a higher reported infection rate due to In general, the complications of central ve- clinically important issue. Catheter-related
its proximity to aerodigestive secretions. nous catheter insertion are either mechani- infections are second to pneumonia as
Perhaps the most significant disadvantage cal or infectious. Complications ascribed to causes of nosocomial septicemia in criti-
of the IJ approach is that the vessel is less both the subclavian and IJ approaches in- cally ill patients, and such infections con-
consistent in its anatomic relationships, clude venous thrombosis, transient cardiac tribute significantly to morbidity, mortality,
thus making it somewhat more of a “blind” arrhythmias from ventricular irritation by and length of hospital stay. Risk factors
procedure. In approximately 70% of individ- the catheter or guidewire, cardiac or cen- for catheter infections include immuno-
uals, the IJ lies anterolateral to the carotid tral vein perforation, thoracic duct injury, suppression, multilumen catheters, elderly

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 69 10/28/11 10:54:01 PM

 70 Part I: Perioperative Care of the Surgical Patient

patients, insertion under emergent condi- care of critically ill surgical patients. Gen- Pulmonary Artery Catheter Insertion
tions or cutdown technique, and long dura- eral indications for use of the PA catheter
tion of catheter in the same site. It is be- include characterization and management Prior to insertion, the balloon should be
lieved that the skin insertion site is the of shock states and perioperative monitor- tested for defects by inflating it with 1.5 mL
dominant source of the microorganisms ing of patients at high risk for hemodynamic of air, all lumens should be flushed with
causing catheter-related infections. Organ- instability. With specific regard to the latter, sterile saline, and the distal port connected
isms migrate from the skin insertion site examples of such patients include those to a pressure transducer and an oscillo-
along the fibrin peel that forms around the with significant cardiovascular disease, ad- scope monitor. As described for invasive
catheter, eventually colonizing the intra- vanced age, and significant burns or trauma, blood pressure monitoring, the pressure
vascular catheter tip. A catheter-related in- as well as those undergoing a surgical pro- transducer must be zeroed at the level of
fection is diagnosed by semiquantitative cedure associated with increased risk of he- the right atrium. The PA catheter is first
culture when 15 or more colonies of the modynamic disturbances. Clearly, in such placed through a sterile sheath to facilitate
same pathogen grow from the catheter tip. patients clinical evaluation alone is inaccu- future manipulations, and is then inserted
There may or may not be accompanying rate. Furthermore, as cardiac function can through a large-bore (7 or 8 French) intro-
signs of local infection (e.g., erythema, pu- be impaired for a variety of reasons in criti- ducer in the subclavian or IJ vein. If neces-
rulence, tenderness, or warmth at skin in- cally ill surgical patients, a central venous sary, a femoral vein approach may also be
sertion site) or systemic inflammation (e.g., catheter is an unreliable surrogate for esti- used. During insertion, pressure waveforms
fever or leukocytosis). Catheter-related in- mating left-sided filling pressures in such are monitored continuously via the distal
fection is a prelude to catheter-related sep- individuals. port to identify the intravascular location of
ticemia, which is defined as growth of the the catheter tip (Fig. 4). With the balloon
same organism from a peripheral blood cul- fully deflated, the catheter should be in-
Pulmonary Artery Catheter Features serted to a distance of 15 cm, where the
ture and the catheter tip.
Replacing central venous catheters at The PA catheter is 100 to 110 cm in length CVP tracing of the superior vena cava or
regularly scheduled intervals has not been and usually has three lumens: a distal lu- right atrium appears. At this point, the bal-
shown to decrease the risk of catheter- men, which opens at the catheter tip into loon is slowly inflated with 1.5 mL of air and
related infections. However, the following the PA for measurement of PA pressures, PA the catheter is advanced into the right
guidelines are recommended: (a) If there wedge pressure (PAWP), and cardiac out- ventricle. The characteristic right ventricu-
are clear signs of infection at the skin exit put; a proximal lumen 30 cm from the tip, lar waveform is normally one of a pulsatile
site, the catheter should be promptly re- which communicates with the right atrium systolic pressure of 15 to 30 mm Hg and a
moved and, if clinically indicated, a new and is used for measurement of CVP; and a diastolic pressure equal to CVP. With fur-
catheter should be inserted at a fresh site; third lumen approximately 15 cm from the ther advancement, the catheter should
(b) when a catheter-related infection is sus- tip, which can be used for infusion. In addi- reach the PA, as identified by an abrupt in-
pected (with or without signs of local exit tion, the basic catheter is equipped with a crease in diastolic pressure while systolic
site infection), the catheter should be ex- temperature-sensing thermistor a few cen- pressure remains unchanged. As the cathe-
changed over a guidewire; (c) if the tip of timeters proximal to the catheter tip, as ter is manipulated farther into the pulmo-
any catheter replaced via guidewire ex- well as a 1.5-mL balloon surrounding the nary arterial system, the systolic waveform
change grows ⬎15 colonies of a pathogen tip. Newer PA catheters are able to provide disappears and gives way to the character-
in semiquantitative culture, the existing continuous monitoring of cardiac output, istic pulmonary artery wedge (PAW) trac-
catheter should be removed and replaced at measurement of right ventricular ejection ing. Under normal circumstances, the
a new site; and (d) any catheter placed fraction (RVEF), and continuous assess- PAWP is similar to the PA diastolic pressure
emergently and without strict sterile tech- ment of mixed venous oxygen saturation (6 to 12 mm Hg). With the appearance of
nique should undergo guidewire exchange. (Svo2). the PAW tracing, the balloon is deflated,

PULMONARY ARTERY
CATHETERS
In 1970, Swan and colleagues introduced
the concept of bedside right heart catheter-
ization via manipulation of a flexible
balloon-tipped catheter into the pulmonary
artery (PA). Despite being used for nearly
three decades as a monitor for the cardio-
vascular assessment and management of
critically ill patients, there has been a great
deal of recent controversy over whether the
inherent risks and expense of using a PA
catheter are justified by the clinical benefits
of the information it provides. Unfortu-
nately, many previous studies that ques-
tioned its use suffer from methodological Fig. 4. Pressure waveforms recorded during advancement of a pulmonary artery (PA) catheter through
flaws and/or failure to include surgical pa- the right atrium (RA), right ventricle (RV), and PA, and ultimately into the pulmonary artery wedge
tients. Notwithstanding such controversy, (PAW) position. In this case, the catheter is inserted via the left subclavian vein. Approximate distances
this device remains a valuable tool in the shown are from catheter tip to insertion site.

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 70 10/28/11 10:54:01 PM

 Chapter 4: Cardiovascular Monitoring and Support 71

whereupon the pulsatile PA waveform confounds the use of PA diastolic pressure when the tip of the PA catheter is improp-
should reappear. If not, the catheter may be as a surrogate of PAWP and it is essential to erly positioned within the lung. Three phys-

Perioperative Care of the Surgical Patient

advanced too far into a PA branch (i.e., patient management that PAWP be deter- iologic lung zones have been described
“overwedged”) and should be withdrawn mined, the authors have had success utiliz- based on pulmonary arterial, alveolar, and
slightly with the balloon deflated. When the ing portable fluoroscopic guidance to ma- venous pressures. Alveolar pressure exceeds
tip of the catheter is in the proper position, nipulate the catheter into the wedge both arterial and venous pressures in zone
the inflated balloon obstructs antegrade position. 1, and exceeds venous pressure in zone 2. As
flow through the PA branch in which it is a result, in zones 1 and 2 PAWP is actually
lodged. This creates a continuous station- Pitfalls in Interpretation of Pulmonary more a reflection of airway pressure than
ary blood column from the catheter tip to Artery Wedge Pressure left atrial pressure. Only in zone 3 PAWP is
the left atrium, such that the pressure mea- There are several sources of potential error accurately reflective of left atrial pressure
sured through the distal port should be in interpreting PAWP (and CVP). As men- and not subject to the confounding effects
equivalent to left atrial pressure. Since un- tioned in the section on invasive arterial of alveolar pressure. In the supine patient,
der normal circumstances left atrial pres- pressure monitoring, the transducer must zone 3 represents the region of the lung
sure is equivalent to left ventricular end-di- remain at the level of the right atrium for posterior to the left atrium, which is the
astolic pressure (LVEDP), PAWP is used as pressure measurements to be valid. This is most dependent area of the lung. Since zone
an estimate of LVEDP (i.e., left ventricular especially important in measuring right 3 has the greatest blood flow, the air-filled
preload). heart pressures, as the magnitude of the re- balloon tip of the PA catheter will most of-
sultant error in the pressure reading due to ten float into this zone. However, clues that
Pitfalls in Pulmonary Artery transducer malposition is greatest in low- the PA catheter tip is not positioned within
Catheter Insertion pressure systems. zone 3 are: (a) the presence of marked respi-
A potential difficulty encountered during A source of error in correlating PAWP ratory variation on the PAW tracing; (b) if
PA catheter insertion is failure of the cath- with left ventricular (LV) preload involves the positive end-expiratory pressure (PEEP)
eter to advance into the PA. This is caused changes in intrathoracic pressure. Pressures is increased and the PAWP increases by 50%
by coiling of the catheter in the right ven- measured by the PA catheter are intravascu- or more of the increased PEEP; and (c) if the
tricle, and is most often a result of the cath- lar pressures, whereas the most accurate PAWP is greater than the pulmonary artery
eter being advanced too rapidly and force- estimate of actual LV filling pressure is diastolic pressure (PADP). The presence of
fully. A simple and often successful solution transmural pressure. Transmural pressure is any of these criteria should prompt reposi-
to this problem is to advance the catheter equal to the difference between intravascu- tioning of the catheter. It is important to
more slowly and continuously, avoiding lar pressure and intrathoracic pressure. At note that any condition that decreases
thrusting. This technique takes full advan- end-expiration intrathoracic pressure is pulmonary vascular pressure (e.g., hypov-
tage of the balloon-flotation characteristics normally equivalent to atmospheric pres- olemia) or increases alveolar pressure (e.g.,
of the PA catheter, allowing it to float gently sure and thus considered negligible. For this high PEEP) can reduce the total area of
with the stream of blood across the pulmo- reason, PAWP should only be determined at physiologic zone 3 in the lung, even if the
nary valve. end expiration for both spontaneously catheter tip is positioned posterior to the
Another common problem of PA cathe- breathing and mechanically ventilated pa- plane of the left atrium.
terization is failure to obtain a PAW tracing. tients (Fig. 5). However, in certain patho- Mitral stenosis creates another pitfall in
Although, in most cases, the reason for this logic states (e.g., adult respiratory distress correlating PAWP with LV preload. In this
is uncertain, it may be due to a faulty bal- syndrome, high positive-pressure ventila- condition, there is a pressure gradient be-
loon or eccentric inflation. After several un- tory settings, and tension pneumothorax), tween the left atrium and ventricle, such that
successful attempts to obtain a PAW wave- intrathoracic pressure may be significantly left atrial pressure is higher than LV end-
form, the catheter should be removed and increased and produce a spurious increase diastolic pressure. Therefore, although PAWP
the balloon retested. If the balloon is not in intravascular pressure (i.e., PAWP). In does reflect left atrial pressure in mitral
the source of the problem, there are two op- this setting, the increased PAWP does not stenosis, it cannot be used as an accurate
tions. First, if the patient does not have reflect a true increase in LV preload, since predictor of LV preload in this condition.
known pulmonary hypertension, the PA di- the physiologically more accurate transmu- In the presence of normal LV compli-
astolic pressure can be monitored as an es- ral pressure remains unchanged. ance, PAWP provides an accurate estima-
timate of PAWP. However, in cases in which Another situation in which PAWP does tion of LV end-diastolic volume and thus
the presence of pulmonary hypertension not accurately reflect LV preload occurs preload. However, in conditions associated
with decreased LV compliance (e.g., ven-
tricular hypertrophy and myocardial isch-
emia), PAWP may be high even in the face of
a normal or even decreased preload. Hence,
PAWP is not a reliable index of LV preload in
the setting of a poorly compliant ventricle.
The physician who uses a PA catheter to
assist in the management of critical illness
should bear in mind the above-mentioned
shortcomings of PAWP in estimating LV
Fig. 5. Pulmonary artery wedge (PAW) tracing with the usual cyclical respiratory variations. PAW pres- preload. In situations in which PAWP is an
sure should be measured at end-expiration. This corresponds to the peak of the wedge tracing for spon- unreliable index of left heart filling pres-
taneously breathing patients (point A) and the valley of the tracing for patients undergoing positive- sures, there are other modalities currently
pressure ventilation (point B). available to estimate LV preload. These

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 71 10/28/11 10:54:01 PM

 72 Part I: Perioperative Care of the Surgical Patient

alternative modalities, such as transesoph- index (CI) and systemic vascular resistance In such individuals, many of whom have
ageal echocardiography (TEE) or RVEF ob- index (SVRI), respectively. It is important to significant fluid requirements in the face of
tained from the newer fast-response PA mention that in assessing response to treat- high positive-pressure ventilatory require-
catheters, are discussed in detail below. ment interventions, trends in each of the ments, evaluation of preload by conven-
With these concerns of causing an injury to hemodynamic indices listed in Table 3 are tional parameters (e.g., PAWP) is particu-
the PA during wedging of the balloon tip of more clinical importance than a single larly unreliable.
and due to uncertain accuracy in certain reading.
cases, many intensivists do not interrogate Cardiac Output
wedge pressures routinely and simply fol- Right Ventricular Ejection Fraction Cardiac output, an index of cardiac perfor-
low the PADP in critically ill patients. In 1986, a modified PA catheter was mance, is defined as the product of heart
developed for bedside evaluation of right rate and stroke volume. Stroke volume, in
Hemodynamic Variables heart function. The device consists of a turn, is determined by preload (PAWP),
When used appropriately and knowledge- fast-response thermistor, which permits afterload (systemic vascular resistance
ably, the PA catheter is capable of generat- thermodilution measurement of RVEF and [SVR]), and the contractile state of the
ing a great deal of information on cardio- right ventricular end-diastolic volume heart. As a result, all of these factors just
vascular status. The more commonly (RVEDV). This technology provides a direct must be considered when interpreting
utilized hemodynamic variables obtained measurement of preload based on volume changes in cardiac output (CO) and in mak-
by the PA catheter are listed in Table 3. rather than estimating preload by pressure ing therapeutic decisions to optimize this
While many of these variables are measured criteria (e.g., CVP and PAWP). This concept parameter (see section “Cardiovascular
directly, others must be derived by a calcu- is particularly important in the setting Support”).
lation. A few parameters, such as cardiac of positive-pressure ventilation, in which The thermodilution method for deter-
output and systemic vascular resistance, pressure-derived estimates of preload can mining CO was introduced into clinical
can be normalized for differences in body be inaccurate. The RVEF thermodilution practice by Ganz and colleagues in 1971.
size by dividing the patient’s body surface catheter has been especially useful in resus- This method is based on the indicator-
area in square meters, thus yielding cardiac citation of multiply injured trauma victims. dilution principle, in which an indicator is
injected into the circulation and the CO is
ddetermined by the rate of change of the
Table 3 Hemodynamic Variables Obtained by the Pulmonary Artery Catheter cconcentration of indicator in the blood-
sstream. The indicator may either be a dye
Variable Derivation Range of normal values ((dye-dilution method) or a fluid at a tem-
Central venous pressure (CVP) N/A 0–8 mm Hg pperature above or below that of the blood
((thermodilution method). With regard to
Pulmonary artery systolic N/A 15–30 mm Hg
pressure (PASP)
tthe latter, 10 mL of an iced or room tem-
pperature crystalloid solution (e.g., normal
Pulmonary artery diastolic N/A 6–12 mm Hg ssaline) is rapidly injected into the right
pressure (PADP) aatrium via the proximal port of the PA cath-
Mean pulmonary artery N/A 10–16 mm Hg eeter. The cold solution then cools the blood
pressure (MPAP) w
with which it mixes in the right heart. As
Pulmonary artery wedge N/A 6–12 mm Hg tthe cool blood flows into the PA, the therm-
pressure (PAWP) iistor near the tip of the catheter senses the
Cardiac output (CO) N/A 4.0–8.0 L/min cchange in blood temperature over time.
FFrom this data, a computer generates a
Cardiac index (CI) N/A 2.5–4.5 L/min/m2 tthermodilution curve; the area under this
Right ventricular ejection N/A 45–50% ccurve is inversely proportional to the CO.
fraction (RVEF) E
Explained differently, with low blood
Mixed venous oxygen saturation N/A 70–80% ttransit times through the right heart, the
(Svo2) lless the blood will be cooled by the cold so-
Systemic vascular resistance 80 ⫻ [(MAP ⫺ CVP)/CO] 900–1,400 dynes · s · cm⫺5
llution. As a result, the thermistor will de-
(SVR) ttect a lower magnitude of temperature
cchange over time, and the computer will
Systemic vascular resistance 80 ⫻ [(MAP ⫺ CVP)/CI] 1,600–2,400 dynes · s · cm⫺5 · m2 ttranslate this information into a higher dis-
index (SVRI)
pplayed CO.
Pulmonary vascular resistance 80 ⫻ [(MPAP ⫺ PAWP)/ 150–250 dynes · s · cm⫺5 There are a number of pitfalls in the
(PVR) CO] tthermodilution method of CO measure-
Pulmonary vascular resistance 80 ⫻ [(MPAP ⫺ PAWP)/CI] 200–400 dynes · s · cm⫺5 · m2 m
ment. For example, the injection must be
index (PVRI) ccompleted within 4 seconds to yield an ac-
Oxygen delivery (Do2) CI ⫻ 13.4 ⫻ Hgb ⫻ Sao2 520–570 mL/min · m2 ccurate CO measurement. To reduce vari-
aability and improve accuracy, it is recom-
Oxygen consumption (Vo2) CI ⫻ 13.4 ⫻ Hgb ⫻ (Sao2 ⫺ 110–150 mL/min · m2 m
mended that the CO be determined from
Svo2) tthe average of three different injections, all
Hgb, hemoglobin; N/A, not applicable; Sao2, arterial oxygen saturation. oof which should be initiated at the same
ppoint in the respiratory cycle. In tricuspid

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 72 10/28/11 10:54:02 PM

 Chapter 4: Cardiovascular Monitoring and Support 73

regurgitation, the cold solution is trans- the oxygen saturation of a pulmonary arte- ters of oxygen metabolism is to maintain an
ported both antegrade and retrograde rial blood sample drawn through the distal adequate Do2, so that Vo2 remains supply

Perioperative Care of the Surgical Patient

across the valve, producing a spuriously low port of the PA catheter. Alternatively, con- independent and adequate tissue oxygen-
CO. Tricuspid regurgitation can be a com- tinuous in vivo Svo2 monitoring via reflec- ation is ensured. However, attempts to
mon source of error in CO determination in tance spectrophotometry has recently been achieve supranormal Do2, while once be-
critically ill patients, as many such individ- made possible. This in-line oximetric tech- lieved to improve outcome in critically ill
uals will have high right-sided heart pres- nique, which is facilitated by a specialized patients, have not proven beneficial.
sures from acute lung disease and high PA catheter equipped with an accessory fi-
positive-pressure ventilatory settings. Ac- beroptic system, eliminates the cumber- Blood Lactate Levels
curacy of the thermodilution method for some task of drawing serial PA blood sam- The use of blood lactate levels is a valuable
measuring CO is also limited in states of ples and provides new data points at adjunct in the management of both medi-
severely impaired cardiac performance. In 5-second intervals. The indications for use cal and surgical patients. The use of lactate
such states, the system experiences diffi- of this device are similar to those described levels can be used to guide therapy as well
culty in accurately differentiating very low for continuous CO monitoring. as gauge illness severity in trauma, postop-
COs (below 2.0 mL/min), especially with Svo2 reflects the discrepancy between erative patients, as well as in other critically
the use of room temperature injectates. A total body oxygen delivery (Do2) and oxygen ill surgical patients. As a practical matter,
partial solution to this problem is to use consumption (Vo2). Alternatively, this rela- the ready availability of blood gas analyzers
iced injectates in patients with poor cardiac tionship is expressed as Svo2 ⫽ Do2/Vo2. with immediate lactate turnaround in-
function. Finally, the presence of intracar- Since Do2 ⫽ CO ⫻ hemoglobin (Hgb) ⫻ ar- creases the utility of lactate measurement
diac shunts confounds interpretation of CO terial oxygen saturation (Sao2), changes in to the clinician.
obtained by thermodilution. In both right- Svo2 must reflect a change in CO, Hgb, Sao2, When tissue demands for oxygen exceed
to-left and left-to-right shunts, the recorded and/or Vo2. Hence, a low Svo2 (⬍60%) indi- supply, anaerobic metabolism begins and
CO is erroneously high. cates a systemic Do2/Vo2 imbalance caused metabolic acidosis results. Pyruvate is un-
Recent technologic advances have made by one or more of the following: depressed able to enter the Krebs cycle and undergo
possible the continuous measurement of cardiac function, anemia, arterial hypox- oxidative phosphorylation secondary to
CO, which obviates the labor-intensive task emia, or hypermetabolism. A critically ill inadequate oxygen supply. In states in
of manually injecting fluid. Some of the patient with a decreasing Svo2 should which lactate production exceeds the ca-
newer models of PA catheters are equipped prompt investigation of the four parameters pacity for clearance by the liver, kidneys,
with an accessory thermal filament approx- mentioned above, with an aim toward a and skeletal muscle, elevated blood lactate
imately 20 cm from the catheter tip. This specific therapeutic intervention. Svo2 levels result. Hyperlactatemia may occur in
filament emits heat, which warms the sur- monitoring is an effective method for early the setting of adequate tissue perfusion
rounding blood. The thermistor located at detection and subsequent correction of de- such as with catecholamine administra-
the catheter tip detects changes in blood rangements of these four parameters. tion, alkalosis, or states of increased meta-
temperature over time in the same manner As Table 3 indicates, the normal range bolic activity (i.e., sepsis and burns). In
as described above for the cold fluid injec- for Do2 is 520 to 570 mL/min · m2, while for these cases, the body’s buffering mecha-
tate method. A computer measures the av- Vo2 it is 110 to 150 mL/min · m2. Thus, under nisms may compensate for any fall in pH. In
erage CO over a 3-minute interval and dis- normal physiologic conditions, Do2 exceeds states of poor tissue perfusion, the body’s
plays new values every 30 to 60 seconds. Vo2 by a 5:1 ratio and Vo2 is independent of buffering capacity is overwhelmed and
The ideal clinical scenario for use of con- Do2 (i.e., supply independent). In a normal, metabolic acidosis results.
tinuous CO monitoring is the patient with healthy individual Vo2 remains indepen- Substantial data exist for the use of se-
extreme hemodynamic lability who requires dent over a wide range of Do2 values. Vo2 rial lactate measurement as an endpoint
frequent adjustments in cardiovascular can remain in the normal range even at for resuscitation in surgical patients. In ad-
support. lower Do2 ranges, because as Do2 falls the dition, initial lactate levels and lactate
tissues respond by increasing the amount clearance rates have been used to predict
Indices of Oxygen Metabolism of oxygen they extract. However, increased mortality rates in the intensive care unit
Since the ultimate goal of cardiovascular oxygen extraction compensates only up to a setting. Failure to normalize lactate levels
monitoring is to ensure adequate tissue ox- point. If Do2 continues to fall below a criti- within 96 hours uniformly predicted mor-
ygenation, it is imperative that critically ill cally low level, as in cardiogenic shock, Vo2 tality. Serial lactate measurement can also
patients, particularly those suffering from will begin to decrease and become depen- be used as a sensitive marker of perfusion in
shock, be monitored for disturbances in dent on Do2 (i.e., supply dependent). In this the ongoing management of hemodynami-
oxygen metabolism. Indeed, it has been scenario, CO, Hgb, and Sao2 should be ex- cally unstable patients.
demonstrated that in such patients this ap- amined and optimized to restore the sup-
proach translates into improved survival. ply-independent relationship between Do2 Complications of Pulmonary
There are a variety of parameters reflecting and Vo2. In septic shock, metabolic de- Artery Catheters
the status of systemic oxygen metabolism, mands are dramatically increased and Vo2
all of which can be measured with the PA must therefore rise concomitantly to meet Although extremely useful, the PA catheter
catheter. Svo2 represents the oxygen satura- these demands. However, if Do2 does not is not a harmless tool with a number of po-
tion of “mixed” blood from three central rise proportionately, Vo2 will become tential complications. Thus, the PA catheter
veins: the superior vena cava, inferior vena limited by Do2 and supply dependency will should be used only when the benefit of the
cava, and coronary sinus. Normal Svo2 val- ensue. In general, a sudden decrease in information provided by it outweighs its po-
ues range from 60% to 80%. This parameter Svo2 heralds a developing supply-dependent tential consequences. Similarly, when the
may be determined in vitro by measuring situation. The goal of monitoring parame- data obtained from a PA catheter are no

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 73 10/28/11 10:54:02 PM

 74 Part I: Perioperative Care of the Surgical Patient

longer clinically useful, it should be promptly the catheter in its existing position. If pooling, PAWP decreases and conse-
removed. these measures fail, emergent pulmonary quently a decreased CI often results. Svo2
In addition to adverse effects of central resection is indicated. Should a pseudoan- is reduced by the same mechanism as in
venous cannulation, complications directly eurysm develop following clinical resolu- hypovolemic shock.
ascribed to PA catheter insertion process tion of a ruptured PA, this can most
are primarily cardiac dysrhythmias. Prema- often be managed with endovascular coil TRANSESOPHAGEAL
ture ventricular contractions are quite embolization. ECHOCARDIOGRAPHY
common as the catheter tip traverses the
right ventricle. These dysrhythmias almost Over the past two decades TEE has as-
always resolve spontaneously after the
Hemodynamic Profiles of Shock sumed an increasingly vital role in the he-
catheter is advanced into the PA. Rarely, Although the hallmark of all shock states modynamic evaluation of surgical patients.
ventricular tachycardia and fibrillation can is a deficit in tissue oxygenation, each type In recent years the disciplines of general,
occur, but usually resolve with electrical of shock has its characteristic hemody- vascular, and trauma surgery, as well as
cardioversion. New right bundle branch namic profile (Table 4). The PA catheter is surgical critical care, have embraced TEE
block may occur in up to 3% of patients un- a useful instrument for generating these as an integral diagnostic device for evalua-
dergoing PA catheterization. This conduc- hemodynamic data to assist in differenti- tion of the heart, aorta, and pericardial
tion disturbance is normally of a benign ating between the various shock states. In space. As a result of its portability, TEE is
and transient nature, but in patients with hypovolemic shock, the primary problem readily available for use in the intensive
preexisting left bundle branch block, com- is reduced intravascular volume, as re- care unit, emergency department, or oper-
plete heart block may result. Therefore, a flected by a decreased PAWP. As a result of ating room.
transthoracic pacemaker should be imme- the decreased preload, CI is likewise de- TEE is favored over transthoracic
diately available when advancing a PA cath- creased. The peripheral vascular tone in- echocardiography (TTE) for the cardiovas-
eter in a patient with known left bundle creases in response to increased endoge- cular assessment of surgical patients for a
branch block. nous catecholamines, yielding an increased variety of reasons: (a) Logistically, TEE is
Complications related to PA catheter SVRI. In this case, Do2 is markedly less more practical for intraoperative use; (b)
residence in the circulation include throm- than tissue oxygen extraction resulting in TEE offers better visualization of the left
boembolism of the central veins, right heart a fall in Svo2. The hallmark of cardiogenic atrium and descending aorta; (c) critically
chambers and valves, and PA. Various de- shock is a reduced CI, yielding a high PAWP ill trauma and postoperative surgical pa-
grees of venous thrombosis may occur in and SVRI. The net result is a decrease in tients often have interfering dressings, cen-
over half of individuals with a PA catheter Svo2. Conversely, early septic shock is char- tral venous catheters, thoracostomy tubes,
in place, and when identified mandates acterized by a hyperdynamic state and ex- and chest wall abnormalities rendering TTE
catheter removal and anticoagulation. Au- treme loss of vascular tone, producing a difficult or impossible; and (d) a mechanically
topsy studies of patients dying with indwell- profound decrease in SVRI and an increase ventilated patient who is difficult to properly
ing PA catheters have identified right-sided in CI. Early in sepsis, Svo2 rises as a result position for optimal acoustic windows pre-
valvular injury as well as endocarditis. of the hyperdynamic state, peripheral vas- cludes an adequate TTE examination.
Another infrequent complication is cular shunting, and impaired tissue oxy- TEE provides excellent anatomic detail
catheter knotting within the right ventricle. gen uptake. Late septic shock is compli- of the cardiac chambers and valves. It can be
Risk factors for this include a dilated right cated by cardiac failure, as indicated by a used to evaluate global and regional cardiac
ventricle and advancing long lengths of decreased CI. As the heart fails in the face wall motion abnormalities, valvular struc-
catheter too forcefully and quickly. A clue to of ongoing septic shock, the PAWP rises ture and function, vegetations, cardioembo-
the presence of a knotted intraventricular and the SVRI may increase or decrease, de- lic sources, and intravascular volume status.
catheter is difficulty encountered in its pending upon which condition predomi- In addition, TEE permits clear visualization
removal. Most knotted catheters can be nates. A falling Svo2 in prolonged septic of the pericardial space, and is therefore of
successfully removed with the assistance of shock is an ominous sign that heralds an benefit in evaluation of pericardial effusions.
fluoroscopy and angiographic techniques. extreme deficit in tissue oxygenation. Fi- Furthermore, since the esophagus lies di-
The most serious and potentially life- nally, neurogenic shock is characterized rectly adjacent to the descending aorta, the
threatening complication of PA catheter- by a primary deficit of vascular tone (i.e., latter structure is particularly amenable to
ization is PA rupture. The reported fre- low SVRI). As a result of peripheral blood visualization with TEE.
quency of this unfortunate complication is
approximately 1 in 800 catheterizations,
with an attendant mortality of ⬎50%. Risk
Table 4 Hemodynamic Profile for Each Type of Shock
factors for PA perforation include pulmo-
nary hypertension, anticoagulation, and Type of shock PAWP CI SVRI Svo2
hypothermia. In addition, advancement of Hypovolemic f ↓ ↑ ↓
the catheter with the balloon fully deflated,
as well as overinflation of the balloon, par- Cardiogenic ↑ ↓ ↑ ↓
ticularly in the “overwedged” position, pre- Early septic f ↑ ↓ ↑
dispose to this complication. Massive he-
Late septic ↑ ↓ ↓ or ↑ ↓
moptysis usually heralds the onset of this
devastating complication. Treatment con- Neurogenic f ↓ or ↔ ↓ ↓
sists of isolation of the contralateral lung
CI, cardiac index; PAWP, pulmonary artery wedge pressure; Svo2, mixed venous oxygen saturation; SVRI, systemic
with selective endobronchial intubation, vascular resistance index.
initiation of PEEP, and maintenance of

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 74 10/28/11 10:54:02 PM

 Chapter 4: Cardiovascular Monitoring and Support 75

TEE has proven itself as an essential tool of drugs have the distinct advantages of a output, and pulse pressure. In addition, it
in the critical care unit, especially in the set- rapid onset and short duration of action, reduces right ventricular end-diastolic

Perioperative Care of the Surgical Patient

ting of unexplained hypotension. Detection while having anticipated and manageable pressure and LVEDP, as well as systemic and
of cardiac contractile dysfunction and wall adverse effects. pulmonary vascular resistances, all with
motion abnormalities suggestive of myo- minimal change in heart rate. Dobutamine
cardial ischemia are important findings may also exert favorable metabolic effects
that prompt specific treatment. The diag-
INOTROPIC AGENTS on compromised or ischemic myocardium.
nosis of new intraoperative segmental wall Inotropic agents are usually administered Coronary perfusion pressure is augmented,
motion abnormalities was found to be a in an attempt to improve cardiac perfor- coronary artery vasodilation occurs, and
more sensitive indicator of myocardial isch- mance and thus preserve vital organ perfu- diastolic perfusion time is lengthened. The
emia than ECG monitoring. In addition, left sion. There are several conditions in which increased oxygen requirements of positive
ventricular end-diastolic volume can be these agents are indicated. Inotropic sup- inotropy are countered by the favorable
closely approximated with TEE, and is more port is frequently used in the surgical inten- effects of ventricular unloading in both sys-
reliable than PAWP in evaluating preload. sive care unit setting to treat patients in the tole and diastole. As a result, coronary
The limitations of PAWP for assessing pre- septic or posttraumatic state. Suboptimal blood flow and myocardial perfusion is in-
load are discussed in the section on PA cardiac output in these settings leads to in- creased in proportion to or exceeding any
catheters. A final application of TEE to crit- adequate tissue perfusion, manifested by increases in myocardial Vo2.
ical illness is in patients with both unex- elevated lactate levels, decreased Svo2, and Traditionally, dobutamine has been pri-
plained hypotension and hypoxia, in whom multiorgan failure. In addition, short-term marily considered a myocardial ␤1-agonist,
a bedside TEE examination is an accurate inotropic therapy is frequently needed dur- while having minimal effects on peripheral
and rapid technique for detecting pulmo- ing major surgical procedures (cardiac and vascular ␣1- and ␤2-receptors. However,
nary emboli. noncardiac) for patients with chronic heart this mechanism has been debated as more
The most common indication for TEE failure. Short-term cardiac support may recent studies have demonstrated an in-
in trauma patients is the assessment of also be needed for patients with acute heart crease in cardiac output in the absence of
blunt cardiac injury. Disruption of the car- failure, such as after acute myocardial in- enhanced ventricular contractility after ra-
diac chambers, valvular injury, coronary farction. Furthermore, inotropic support cemic dobutamine infusions. Instead, pe-
artery thrombosis, and the echocardio- may be indicated as a “pharmacologic ripheral ␤2 stimulation augmented cardiac
graphic stigmata of myocardial contusion bridge” for patients who are awaiting more output by reducing systemic vascular resis-
may be visualized with TEE. Also, since se- definitive treatment, such as coronary ar- tance. At the same time, stimulation of the
vere myocardial contusion and cardiac tery bypass surgery, valve repair/replace- ␣-receptors potentiated an increase in car-
tamponade from blunt cardiac trauma ment, ventricular assist device placement, diac output by reducing venous capacitance
may present with identical clinical fea- or cardiac transplantation. Finally, inotro- and thus increasing venous return. The
tures, TEE is a valuable imaging modality pic support is commonly used in the early combined properties of B1-mediated inot-
for differentiating between these two. period after cardiac surgery, in an attempt ropy and B2-induced afterload reduction
Finally, in experienced hands TEE has been to optimize postoperative cardiac function make dobutamine an ideal agent for treat-
shown to have high sensitivity and speci- until the heart fully recovers from cardio- ing the failing heart.
ficity to diagnose blunt aortic injury and pulmonary bypass. The typical dose of dobutamine ranges
can be performed rapidly in an unstable from 2 to 20 μg/kg/min. Infusion rates be-
patient in the emergency room or operat- Beta-Adrenergic Receptor Agonists tween 5 and 15 μg/kg/min predominantly
ing room. cause an increase in cardiac contractility,
␤-Adrenergic agonists function by binding peripheral vasodilation, and a dose-depen-
cell surface ␤-receptors and activating dent increase in heart rate. This dose range
CARDIOVASCULAR SUPPORT guanine nucleotide-bound protein. This in is commonly used in patients with ad-
The goals of cardiovascular support of sur- turn activates adenylate cyclase, which vanced heart failure, cardiac failure compli-
gical patients are to maintain adequate tis- catalyzes the synthesis of cyclic adenos- cating septic or traumatic shock, or cardio-
sue oxygenation and organ perfusion. The ine 3⬘5⬘ monophosphate (cAMP). cAMP- genic shock after an acute myocardial
achievement of these goals requires effec- dependent protein kinases phosphorylate infarction, or for hemodynamic support fol-
tive clinical management and technical intracellular proteins, resulting in intracel- lowing cardiac surgery.
support. As mentioned in detail earlier in lular calcium influx and enhanced myocar- There are a few limitations of dobu-
this chapter, a variety of cardiovascular dial contraction. To varying degrees, tamine. Higher doses may cause tachycar-
monitors are available to facilitate interpre- ␤-agonists enhance both myocardial con- dia, leading to an imbalance of myocardial
tation of hemodynamic status. Once moni- tractility (inotropy) and diastolic relax- oxygen supply and demand. At higher heart
toring is properly established, cardiovascu- ation (lusitropy) and increase heart rate rates diastolic myocardial perfusion time
lar support can be initiated in a safe and (chronotropy). shortens, while myocardial Vo2 increases.
effective manner. Agents used to support Although uncommon, atrial and ventricu-
hemodynamics fall into three general cate- Dobutamine lar arrhythmias may occur, particularly at
gories: (a) inotropic agents, which strengthen Dobutamine is a synthetic catecholamine higher doses.
the cardiac contraction and thereby in- existing as a racemic mixture of two stere-
crease cardiac output and Do2; (b) vasodila- oisomers. The ␣-adrenergic activity resides Dopamine
tors, which decrease vascular resistance; in the levo-isomer, while the ␤-adrenergic As a biochemical precursor of epinephrine,
and (c) vasopressors, which may be used to activity is expressed in the dextro-isomer. dopamine activates ␣- and ␤-receptors in
elevate blood pressure in acute situations of Dobutamine is very effective in augmenting addition to dopamine 1 and 2 (DA1 and
profound hypotension. All of these groups cardiac contractility, stroke volume, cardiac DA2) receptors. DA1-receptor activation

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 75 10/28/11 10:54:02 PM

 76 Part I: Perioperative Care of the Surgical Patient

leads to renal, mesenteric, coronary, and resistance and a subsequent rise in arterial in serum creatinine, blood urea nitrogen,
cerebral arterial vasodilation, while DA2- blood pressure. In addition, there is a dose- free water clearance, and fractional excre-
receptor activation inhibits endogenous dependent rise in heart rate and an in- tion of sodium, while causing an increase in
norepinephrine release. Dopamine has creased propensity toward arrhythmic epi- urine output, creatinine clearance, and os-
long been purported to act in a dose- sodes. molar clearance.
dependent fashion. At low doses (1 to 3 μg/ Because of its significant cardiac stimu- In summary, clinical experience with
kg/min), it predominantly stimulates DA1 latory and vasoconstrictive effects, epi- norepinephrine in patients with septic shock
receptors, producing renal artery vasodi- nephrine assumes an important role in the suggests that it can effectively increase blood
lation. This so-called renal dose of dop- treatment of septic shock, especially if the pressure without causing deterioration in
amine is touted to improve renal blood shock state is manifested by both a low car- CI or end-organ function. Norepinephrine
flow and urine output in patients at higher diac output and low systemic vascular resis- doses of 0.01 to 3 μg/kg/min have consis-
risk for acute renal failure, such as those in tance. However, epinephrine should be used tently been shown to improve hemodynamic
septic shock or those undergoing major cautiously because of its vasoconstrictive variables in the large majority of patients
surgical procedures who have preexisting properties, tachycardia, arrhythmogenic with septic shock.
renal artery stenosis or chronic renal in- potential, and increased risk of myocardial
sufficiency. Because of the splanchnic va- ischemia. Isoproterenol
sodilatory properties associated with DA1 A synthetic catecholamine, isoproterenol,
activation, low-dose dopamine infusion Norepinephrine possesses potent ␤-agonist properties.
may improve intestinal perfusion during Norepinephrine is a potent catecholamine Significant increases in cardiac output,
mesenteric ischemia. exerting both ␣- and ␤-adrenergic activity. myocardial contractility, and chronotropy
At moderate doses (3 to 6 μg/kg/min) It typically results in a significant increase all result from myocardial ␤1-stimulation.
cardiac B1-receptors are stimulated, lead- in mean arterial pressure secondary to its Peripheral ␤2-activation causes peripheral
ing to enhanced ventricular contractility vasoconstrictive effects while causing little vasodilation, which decreases afterload
with minimal effect on heart rate and blood change in heart rate. It has some inotropic and thereby facilitates an increase in
pressure. However, at higher doses (⬎6 μg/ effects and will slightly increase cardiac out- cardiac output and pulse pressure. Usual
kg/min) peripheral ␣1-receptor stimulation put. It is typically used in patients with pro- indications for isoproterenol infusions are
occurs, causing vasoconstriction and eleva- found hypotension in a setting of adequate limited to situations in which enhance-
tion of blood pressure. With escalating volume resuscitation. Norepinephrine has ment of both heart rate and contractility
doses dopamine produces tachycardia. traditionally been utilized in patients with are desired, such as for early postoperative
Dopamine should be used cautiously in septic shock or following severe neurologic support of the denervated, bradycardiac
patients with coronary artery disease. In events with hypotension from decreased transplanted heart. A major advantage of
addition to substantial increases in heart systemic vascular resistance (with pre- isoproterenol is that it directly decreases
rate, higher doses of dopamine also cause served cardiac output). There were histori- pulmonary vascular resistance. Thus, this
increased ventricular wall stress, which can cal concerns that further vasoconstriction agent is also beneficial in right ventricular
cause further perturbations in myocardial may worsen the shock syndrome and perfu- failure and chronic pulmonary hyperten-
oxygen supply/demand. This drug also has sion, thus leading to end-organ ischemia sion. However, because of its potent
a dose-related arrhythmogenic effect. More- (especially renal hypoperfusion resulting in ␤-adrenergic activity, myocardial oxygen
over, dopamine is not as effective in pa- oliguria and renal failure). However, several demand is increased and tachycardia-
tients who are catecholamine depleted, recent studies investigating norepinephrine induced diastolic coronary filling is de-
since its effect is based on the release of en- in septic shock suggest that it can success- creased. Therefore, isoproterenol is con-
dogenous catecholamines. It is important fully increase blood pressure without caus- traindicated in patients with ongoing
to note that at least two recent randomized ing the feared deterioration in organ func- coronary ischemia.
trials comparing dopamine to norepineph- tion and in fact, may be the preferred agent
rine for treatment of sepsis do not demon- for sepsis. It has been shown that when car-
strate any greater renal protective effect diac output is maintained, treatment with
Phosphodiesterase Inhibitors
with dopamine. In fact, there has been some norepinephrine alone has no negative ef- Phosphodiesterase III inhibitors (PDIs) are
suggestion of greater renal injury in those fects on splanchnic tissue oxygenation. Nor- a unique category of inotropic drugs. These
patients treated with dopamine. epinephrine effects on serum lactate levels agents inhibit myocardial cAMP phospho-
in patients with septic shock have been diesterase activity, thus increasing cellular
Epinephrine studied. Tissue oxygenation, as assessed in concentrations of cAMP and improving the
Epinephrine is an endogenous catechola- several studies by serum lactate levels in pa- myocardial contractile mechanism. In addi-
mine secreted by the adrenal medulla. tients with septic shock, does not worsen, tion to enhancing ventricular performance,
Pharmacologically, epinephrine stimulates and may even improve with norepineph- the increased cAMP in vascular smooth
␤1-, ␤2-, and ␣-receptors in a dose-dependent rine. Clearly, there has been concern regard- muscle causes peripheral vasodilation and
manner. At lower doses of infusion (0.01 to ing the effects of norepinephrine on the kid- reduced resistance.
0.1 μg/kg/min), ␤-receptors are primarily ney. In the setting of hypotension and
stimulated, leading to increased cardiac hypovolemia during hemorrhagic shock, Amrinone
contractility and heart rate (myocardial ␤1), many vasoconstrictors, including norepi- Amrinone is the prototypical PDI. This
as well as peripheral vasodilation (periph- nephrine, may have several harmful effects agent concomitantly improves cardiac per-
eral ␤2). At higher infusion rates (⬎1 μg/ on renal function. However, in hyperdy- formance and decreases systemic vascular
kg/min), peripheral ␣-adrenergic stimula- namic septic shock, norepinephrine has resistance. However, due to the absence of
tion produces increased systemic vascular been shown to cause a significant decrease catecholamine effects, there are minimal

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 76 10/28/11 10:54:03 PM

 Chapter 4: Cardiovascular Monitoring and Support 77

associated increases in heart rate. As a re- (1.0 to 1.25 mmol/L). As a result of altered preload independently enhances the myo-
sult, amrinone does not affect myocardial protein binding, acid–base status, and cardial oxygen supply/demand ratio. Vaso-

Perioperative Care of the Surgical Patient

oxygen demand. An additional advantage of other circulating factors, ionized calcium dilators are also useful in the setting of
amrinone is that it reduces pulmonary vas- levels are frequently diminished during poorly controlled hypertension in the early
cular resistance. As a result, this agent can shock. Other causes of reduced ionized cal- postoperative period. In such cases, a re-
be particularly effective in patients with left cium include chronic renal failure, blood duction in blood pressure is desirable to
heart failure complicated by pulmonary hy- transfusions (containing calcium binding reduce the risk of bleeding from operative
pertension as well as in right ventricular citrate), and cardiopulmonary bypass. sites.
failure. Amrinone is frequently used in com- While patients with mildly or moderately
bination with other inotropic agents. Al- reduced ionized calcium levels may main- Nitroprusside
though these combined agents act through tain a normal cardiac output and blood
different mechanisms, they exert potentia- pressure, those with severely reduced levels Nitroprusside is an effective vasodilator
tive effects in enhancing myocardial con- frequently have significant hypotension and acting on venous and arterial vascular
tractility. cardiac contractile dysfunction. Therefore, smooth muscle in both the systemic and the
Amrinone is typically initiated as a patients with decreased ionized calcium pulmonary vascular beds. Systemic venodi-
0.75 mg/kg loading dose over several min- levels usually manifest an immediate car- lation reduces blood pressure by decreasing
utes, followed by an infusion that is diovascular improvement from parenteral venous return and thus CVPs. Arterial vaso-
started at 5 μg/kg/min and can be titrated calcium administration. dilation reduces afterload, thereby decreas-
to 20 μg/kg/min. Although lower rates of ing blood pressure and at the same time
infusion usually do not have much effect Levosimendan enhancing cardiac output. Nitroprusside
on blood pressure, higher infusion rates Levosimendan is a new inotrope that is yet has the advantage of an extremely rapid on-
may lead to profound vasodilation. Other to be approved in the USA, but is approved set of action, effectively lowering blood
drawbacks of this agent are its long half- in Europe. It works as a calcium-sensitizing pressure within seconds to minutes. Simi-
life (3.5 h), its potential for causing ar- agent as it enhances the cardiac myocyte larly, its effects rapidly dissipate after de-
rhythmias (particularly supraventricular), function by binding to cardiac troponin C, creasing or terminating the infusion, per-
and the risk of thrombocytopenia with improving its response to calcium. The net mitting precise titration of the desired blood
prolonged infusions. effect on the heart is inotropy and lusitropy pressure.
(cardiac relaxation). In vascular smooth Infusion rates of nitroprusside typically
Milrinone muscle cells, the net effect is coronary and begin at 0.5 μg/kg/min and can be titrated
Milrinone is a newer PDI frequently used in peripheral vasodilation resulting in de- upward until the desired blood pressure is
the operating room and in the critical care creased cardiac preload and afterload. A achieved. Hypotension may develop, par-
setting. The drug’s mechanisms of action small randomized trial comparing levosim- ticularly in patients with inadequate filling
and hemodynamic effects closely parallel endan to dobutamine demonstrated a non- pressures, thus stressing the need for con-
those of amrinone. However, the potency of significant 6.4% reduction in mortality in tinuous arterial blood pressure monitoring
milrinone is 10 to 30 times higher than am- cardiac surgery patients with levosimen- during nitroprusside therapy. Because ni-
rinone, which translates into smaller doses dan. A second randomized trial demon- troprusside is degraded by light exposure,
used and fewer side effects. In addition, strated shorter intensive care stay and less the infusion bag must be wrapped in alumi-
since thrombocytopenia is unusual, ar- vasopressor use with levosimendan com- num foil or other opaque materials.
rhythmias are less frequent, and the half- pared to milrinone in cardiac surgery pa- A very rare but potentially serious side
life is much shorter with milrinone (1.5 to tients. Preclinical studies in models of sep- effect of nitroprusside is cyanide toxicity.
2 h), this agent is currently the preferred sis demonstrate improved hemodynamic This complication usually accompanies ex-
PDI for clinical use. The usual loading dose and metabolic parameters with this novel cessive dosages (⬎3 μg/kg/min) used over a
of milrinone is 50 μg/kg infused over 10 drug compared to existing inotropic agents. prolonged period of time (⬎72 h). Nitrop-
minutes, followed by a continuous infusion However, human trials, thus far, only dem- russide is metabolized by red blood cells
rate of 0.375 to 0.75 μg/kg/min. It is useful onstrate reduced lactate levels but no dif- and the liver to cyanide and thiocyanate,
in patients who are unresponsive to ␤-ago- ferences in mortality with levosimendan both of which inhibit aerobic metabolism.
nists, and does not significantly increase compared to dobutamine. Larger multi- Toxicity is manifested by lactic acidosis from
myocardial O2 demand. institutional trials are currently underway. anaerobic tissue metabolism, as well as ele-
vated Svo2 as the result of a disturbance in
oxidative phosphorylation. Clinically, toxic-
Ionized Calcium VASODILATORS ity is manifested as tremors, hypoxia, nau-
Calcium is a major regulatory cation that Parenteral vasodilators are useful in treat- sea, and disorientation. The diagnosis is
plays a central role in muscular contraction ment of the failing ventricle. These agents confirmed with serum cyanide or thiocya-
and relaxation by regulating the actomyo- reduce both preload and afterload, thus re- nate levels. The treatment is immediate ces-
sin contractile apparatus. In addition to be- ducing metabolic demands of the myocar- sation of nitroprusside and administration
ing critical to optimal myocardial contrac- dium. Arterial vasodilation decreases after- of hydroxocobalamin, which converts cya-
tion, calcium is important for maintenance load, which decreases the systolic workload nide to cyanocobalamin.
of vascular tone by mediating contraction of the heart and allows it to eject more ef-
of vascular smooth muscle. Ionized calcium fectively. By causing venodilation, these
is the physiologically active fraction that drugs also reduce preload and thus myo-
Nitroglycerine
circulates in the blood. Ionized calcium lev- cardial wall tension. By the mechanisms By acting directly on vascular smooth mus-
els generally range from 4.0 to 5.0 mg/dL just mentioned, a reduction in afterload or cle, nitroglycerine predominately causes

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 77 10/28/11 10:54:03 PM

 78 Part I: Perioperative Care of the Surgical Patient

venodilation, while possessing some arte- increases arterial oxygenation by redis- pertension undergoing cardiac surgery re-
rial vasodilatory properties as well. An im- tributing blood flow to well-ventilated re- spond from inhaled Epoprostenol with re-
portant attribute of nitroglycerine is that it gions and thereby improving ventilation/ duced pulmonary pressure and improved
dilates coronary arteries; hence, this agent perfusion mismatch. This is in contrast to right ventricular function. With inhaled ad-
is preferable to nitroprusside in patients intravenous vasodilators (e.g., nitroprus- ministration, there is no evidence of plate-
with coronary artery disease. Both large side), which may exacerbate the ventila- let dysfunction or increased risk of bleed-
and small coronary arteries are dilated, tion/perfusion mismatch by nonselectively ing. The toxicity profile is quite low, although
which results in enhanced blood flow to dilating the entire pulmonary vasculature it does cause mild systemic vasodilation
vulnerable subendocardial myocardium. bed. and resultant hypotension.
Postoperatively, nitroglycerine is also One of the most important clinical uses
effective in preventing coronary artery va- of inhaled NO is in the treatment of ARDS. VASOPRESSORS
sospasm. Patients with ARDS characteristically suffer
Nitroglycerine is available in intrave- from pulmonary arterial hypertension, in- Vasopressor therapy is usually reserved for
nous, oral, sublingual, and topical forms, all trapulmonary shunting, and reduced arte- patients in septic or neurogenic shock
of which are commonly used in the periop- rial oxygenation. Inhaled NO in patients whose blood pressure fails to respond to
erative setting in patients at risk for myo- with ARDS reduces pulmonary arterial volume resuscitation. In these settings, pe-
cardial ischemia. Intravenous infusion of pressure and increases arterial oxygenation ripheral vasoconstriction may increase sys-
nitroglycerine is typically started at a rate by decreasing intrapulmonary shunting, all temic vascular resistance and blood pres-
of 5 to 20 μg/min. The dose may be increased in the absence of systemic vasodilation. sure, thus improving coronary and cerebral
every few minutes in 10 μg increments until Inhaled NO is also extremely effective in blood flow. Another common setting in
the desired blood pressure or improvement neonates with persistent pulmonary hyper- which these agents are used is in the peri-
in angina is achieved. Nitroglycerine has a tension of the newborn. By reducing pul- operative maintenance of blood pressure
low risk of serious toxicity. Headache, nau- monary arterial pressure and improving that has been artificially lowered by general
sea, dizziness, tachyphylaxis, and hypoten- arterial oxygenation, inhaled NO often cir- or regional anesthetics.
sion are adverse effects associated with this cumvents the need for extracorporeal mem-
drug. brane oxygenation. Another major clinical Vasopressin
application of inhaled NO is in patients with
Inhaled Pulmonary Vasodilators severe pulmonary hypertension, right ven- Vasopressin, also termed antidiuretic hor-
tricular failure, and hypoxemia following mone, is a peptide hormone produced in
Inhaled Nitric Oxide certain cardiothoracic surgical procedures. the hypothalamus and stored in the poste-
Pulmonary hypertension can be character- Examples include valvular surgery, coro- rior lobe of the pituitary gland. Numerous
ized by an increase in pulmonary vascular nary artery bypass, implantation of ventric- organ systems have been shown to be af-
resistance, pulmonary arterial wall thicken- ular assist devices, heart transplantation, fected by vasopressin. In the brain, vaso-
ing, and right ventricular dysfunction, which and lung transplantation. pressin acts as a neurotransmitter mediat-
results in impaired oxygen exchange. The The toxic effects of inhaled NO remain to ing thermoregulation, nociception, and
goal of patients with clinically significant be completely defined. Concentrations of release of adrenocorticotropic hormone.
pulmonary hypertension is to improve right ⬎20 ppm in patients for several weeks have Moderate doses of vasopressin cause vaso-
ventricular function without increasing been used without any apparent untoward dilation in the pulmonary vasculature,
myocardial oxygen demand or compromis- effects. However, there are concerns that whereas higher doses stimulate pulmonary
ing the hemodynamic function of the sys- methemoglobinemia and tachyphylaxis vasoconstriction. Hematologically, vaso-
temic circulation. Experimental models may complicate prolonged NO therapy. pressin has several effects on thrombosis
have shown that inhaled nitric oxide (NO) and hemostasis, including promotion of
reverses hypoxic pulmonary vasoconstric- Inhaled Epoprostenol platelet aggregation and release of both fac-
tion without affecting systemic hemody- Inhaled epoprostenol (prostacyclin, PGI2) tor VIIIa and von Willebrand factor from
namic function. has been used increasingly in patients with the vascular endothelium. In the distal tu-
NO is a naturally occurring local vaso- pulmonary hypertension. The mechanism bule and collecting duct of the kidney, vaso-
dilator synthesized by the vascular en- of action is via countering the effects of pressin stimulates water resorption, pro-
dothelium. Its synthesis is mediated by the Thromboxane A2. In addition to its function ducing concentrated urine. High vasopressin
activity of NO synthase on the amino acid as a platelet inhibitor, epoprostenol is a po- levels stimulate smooth muscle contraction
l-arginine. NO activates guanylate cyclase, tent vasodilator with a very short half-life in both the uterus and the gastrointestinal
which generates cyclic guanosine 3⬘5⬘- (25 min), like NO. However, because it is less tract and promote hepatic glycolysis. Fi-
monophosphate (cGMP). The latter causes costly than NO, many centers utilized in- nally, elevated concentrations of vasopres-
relaxation of adjacent vascular smooth haled epoprostenol as a first-line agent for sin produce vasoconstriction in vascular
muscle. Upon entering the bloodstream, reversible pulmonary hypertension. While smooth muscle cells.
NO binds hemoglobin with a high affinity there is data to suggest that inhaled NO has Vasopressin plays a critical role in the
and is quickly inactivated. Therefore, the greater beneficial effects in neonates and regulation of fluid balance. It is released in
molecule is essentially devoid of any sys- children, there is little data to support any response to a decrease in blood volume and
temic effects. Inhaled NO reaches pulmo- superiority over inhaled epoprostenol in an increase in osmolarity. Two distinct re-
nary vascular smooth muscle by diffusion adults. It is increasingly being used after ceptor subtypes mediate the principal end-
through ventilated alveoli, causing relax- cardiothoracic surgery in select patients organ effects. The V1 receptor is present on
ation of adjacent pulmonary arteries. This including those undergoing lung transplan- vascular smooth muscle cells throughout
concept is important in patients with in- tation and post-cardiopulmonary bypass. the body, particularly in the skin, skeletal
trapulmonary shunts, because inhaled NO Specifically, patients with pulmonary hy- muscle, and thyroid gland vasculature. The

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 78 10/28/11 10:54:03 PM

 Chapter 4: Cardiovascular Monitoring and Support 79

majority of end-organ effects are mediated sion. The dosing range of 0.01 up to 0.1 U/ Metaraminol will also cause venoconstric-
by the V1 receptor. The direct vasopressor min is most effective with vasodilatory tion and pulmonary vasoconstriction. Unlike

Perioperative Care of the Surgical Patient

effects are a result of V1-mediated intracel- shock without causing significant adverse norepinephrine and phenylephrine, it is a
lular signal transduction. G protein-coupled effects. Vasopressin is inactivated and me- long-acting agent, with effects lasting from
activation of phospholipase C results in the tabolized by the kidney and liver; 5% to 15% 20 to 60 minutes. Clinical indications for
release of calcium from the sarcoplasmic is excreted in the urine. Possible adverse ef- metaraminol parallel those of phenyleph-
reticulum and a subsequent increase in pe- fects of therapeutic vasopressin include de- rine. However, the use of metaraminol has
ripheral resistance. The V2 receptor is pres- creased cardiac output, angina, myocardial decreased because of the immediate and
ent in the distal and collecting tubules of ischemia, ventricular dysrhythmia, bron- short-acting effects of phenylephrine.
the glomeruli and promotes water resorp- chial constriction, and splanchnic isch- Metaraminol may cause cardiac arrhyth-
tion. These effects are mediated by an in- emia. mias, particularly in patients with myocar-
crease in intracellular levels of cyclic ade- dial infarctions and in patients receiving
nosine monophosphate and by activation volatile anesthetics, such as halothane,
of protein kinase A. A third receptor, V3, is
Phenylephrine which sensitize the heart to catecholamines.
located in the posterior lobe of the pituitary Phenylephrine is a pure ␣1-agonist. It is a
gland. potent pulmonary and systemic vasocon-
Under normal physiologic conditions, strictor without significant direct cardiac
INTRA-AORTIC BALLOON
endogenous vasopressin levels are below effects. This drug has a rapid onset and COUNTERPULSATION
the vasoactive range. Septic shock-associ- short duration of action. Because of its pure Despite the recent availability of left ven-
ated exhaustion of neurohypophyseal stores ␣-adrenergic effects, phenylephrine can in- tricular assist devices and other new de-
secondary to intense and prolonged stimu- crease systemic vascular resistance and vices to support the failing heart, the intra-
lation, as well as impairment of baroreflex- blood pressure without causing arrhyth- aortic balloon pump (IABP) remains the
mediated stimulation of vasopressin release, mias. Thus, this is a useful vasopressor if mainstay of mechanical ventricular sup-
often lead to inappropriately low levels of arrhythmias are complicating the therapy port. The basic physiologic principle behind
endogenous vasopressin. Low doses of ex- of inotropic agents such as dopamine or the IABP, counterpulsation, was first de-
ogenous vasopressin stimulate the vascular norepinephrine. Phenylephrine is the drug scribed in 1958 by Harken. In 1962, Moulo-
V1 receptors and have been shown to pro- of choice when pure vasoconstriction is de- poulos et al. proposed the use of a single-
duce a significant rise in mean arterial pres- sired in cases of septic shock and neuro- chambered IABP in the descending thoracic
sure in septic shock, often leading to the genic shock. Phenylephrine is often the aorta to achieve counterpulsation. Coun-
discontinuation of traditional vasopressors. drug of choice administered intraopera- terpulsation is based on the premise that
Clinical evidence suggests that vasopressin tively during general or regional anesthe- reducing LVEDP improves ventricular func-
therapy may be an available alternative or sia. In addition, phenylephrine infusion tion. The mechanism of action of the IABP
adjunct for patients in septic shock as well can be extremely useful in maintaining involves rapid balloon inflation with helium
as refractory vasodilatory shock after car- blood pressure in patients with epidural during diastole (concurrent with aortic
diopulmonary bypass. As such, vasopressin anesthesia postoperatively as these pa- valve closure). The balloon remains inflated
is often a first-line agent for patients with tients often develop profound vasodilation until onset of systole, at which time the bal-
sepsis or vasodilation after cardiopulmo- secondary to the local anesthetics used in loon rapidly deflates. Balloon inflation
nary bypass. Vasopressin has been used the pump. The dose for infusion ranges raises diastolic pressure within the proxi-
clinically to treat a variety of disorders, both from 20 to 200 μg/min. mal aorta, causing improved coronary and
as an antidiuretic and as a vasoconstrictor. cerebral perfusion during diastole. With the
According to the new Advanced Cardiac rapid balloon deflation during systole, there
Life Support standards as outlined by the Metaraminol is a sudden volume loss (equivalent to the
American Heart Association, vasopressin is Metaraminol (Aramine) is an older indirect- volume of the balloon) in the aorta result-
now a first-line drug in the treatment of acting sympathomimetic amine with hemo- ing in decreased afterload against which
ventricular tachycardia/fibrillation refrac- dynamic actions similar to norepinephrine. the heart must work (Fig. 6) Direct effects
tory to initial defibrillation. With its use in Systolic and diastolic blood pressures are in- on the heart include improving coronary
advanced life support and in vasodilatory creased predominately by vasoconstriction. artery blood flow, and decreasing afterload
shock, vasopressin is gaining popularity for
use in treating critically ill patients. Other
uses of vasopressin include diabetes insipi-
dus and gastrointestinal bleeding. Desmo- B
pressin, a synthetic, longer-acting analog of
D E
vasopressin with minimal vasopressor ac-
tivity, has been used to treat nocturnal en- C
uresis, hemophilia A, and von Willebrand
disease.
Vasopressin is distributed throughout A
the extracellular space. With a half-life of 10
to 35 minutes, the pressor effects after a Normal Augumented
single dose last about 30 to 60 minutes.
When the goal is to maintain continuous
hemodynamic support, vasopressin must Fig. 6. Intra-aortic balloon pump (IABP) counterpulsation results in diastolic augmentation (A) and
be given by continuous intravenous infu- afterload reduction (B).

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 79 10/28/11 10:54:03 PM

 80 Part I: Perioperative Care of the Surgical Patient

resulting in improved cardiac output and and/or renal failure. Careful and accurate thoughtful consideration before its imple-
less myocardial oxygen demand. Early IABP placement of the IABP is necessary to pre- mentation.
insertion can decrease the size of the po- vent occlusion of the visceral vessels with Clinical predictors of increased risk are
tential infarct area following coronary oc- each cardiac cycle. A rare and dreaded com- stratified into major, intermediate, or mi-
clusion. plication of the IABP is aortic dissection. As nor. Major predictors include unstable coro-
The clinical indications for the IABP such, the IABP should be placed under fluo- nary syndromes, decompensated heart fail-
have expanded over the past several years. roscopic or echocardiographic (TEE) guid- ure, significant arrhythmias, or severe valve
There are many situations in the critical ance. In addition, the balloon can produce disease. Intermediate predictors include
care setting in which temporary ventricular lower limb ischemia as it is placed through mild stable angina, previous myocardial in-
support of the failing heart is needed. It has the femoral vessels and can occlude iliac farction with stable compensated heart
been shown that early application of the blood flow, which is usually relieved by bal- function on appropriate medical therapy,
IABP in patients who have experienced loon removal. Removal of the balloon must compensated heart failure, and diabetes
acute myocardial infarctions reduces the be carefully performed to eliminate the risk mellitus. Minor predictors include advanced
severity of cardiogenic shock and improves of distal embolization from a dislodged age, minor electrocardiographic changes,
patient survival. The IABP is often employed thrombus. Finally, thrombocytopenia and low functional capacity with no other inter-
preoperatively in high-risk patients with hemolysis can occur as a result of hemato- mediate or major risk factors, history of
acute cardiogenic shock and/or unstable logic trauma produced by the IABP. stroke, or uncontrolled hypertension. Pro-
angina prior to cardiac surgery. In this set- cedural risk can also be classified as high,
ting, IABP decreases perioperative morbid- CARDIOVASCULAR RISK intermediate, or low. High-risk procedures
ity and mortality. Although it is assumed include emergent operations in elderly pa-
that patients requiring IABP use in the car- An often difficult issue for surgeons is tients, aortic or major vascular procedures,
diac surgical setting are a higher-risk group whether to pursue an aggressive cardiac and prolonged operations with large fluid
of patients, the overall survival rates for pa- evaluation for patients before considering shifts. Intermediate-risk procedures would
tients undergoing myocardial revascular- noncardiac operations. With an aging popu- include carotid endarterectomy; head and
ization procedures who required the use of lation, more patients with unrecognized neck procedures; intraperitoneal, intratho-
the IABP are similar to patients who did not coronary artery disease are referred for these racic, and orthopedic procedures; and pros-
require this device. types of surgical procedures. It remains true tate surgery. Low-risk procedures include
The IABP has also been used more re- that operative morbidity and mortality are endoscopy, superficial procedures, cataract
cently in patients with septic shock. As a most often direct results of cardiac compli- surgery, and breast and soft tissue opera-
result of myocardial depressants that cir- cations, and the proper recognition of the “at tions. Based on this evaluation of clinical
culate in advanced septic states, cardiac risk” patient is important in limiting these and procedural risk, many patients require
output can diminish significantly. Berger et postoperative cardiac problems. no further testing if the overall risk is judged
al. examined the use of the IABP in septic Quite often, elderly patients referred for to be low or may need further noninvasive
patients with decreased ventricular func- surgical intervention have not had adequate assessment if the overall risk is intermedi-
tion. Adequate cardiac output was main- health care evaluation and the challenge for ate. There may also be some patients who
tained in such patients and permitted ap- the surgeon is to accurately assess the car- are easily identified as being best served by
plication of more traditional treatment diac risk in a timely manner before per- coronary angiography. However, this group
modalities for septic shock, such as fluid forming an operative procedure. The sur- is the minority and consideration should be
resuscitation. Another potential use of the geon should take a thoughtful approach to given with respect to the urgency of the in-
IABP has been reported in experimental preoperative cardiac screening rather than tended operation. A diagnosis of significant
models of blunt chest trauma. Saunders simply referring the patient to a cardiolo- coronary artery disease that may require
and Doty produced blunt chest injury in gist. A thorough history and physical ex- percutaneous intervention or surgical coro-
dogs and demonstrated that early applica- amination should be performed to uncover nary revascularization will delay the initial
tion of the IABP improves ventricular func- any signs or symptoms of underlying car- planned procedure.
tion following myocardial contusion. The diac disease. Symptoms such as chest pain, Risk assessment strategies for preopera-
clinical application of the IABP to blunt shortness of breath, or dyspnea on exertion tive evaluation of patients before noncar-
chest injuries, particularly in the multi- should be thoroughly interrogated with diac operation were reviewed comprehen-
trauma patient, may also prove beneficial specific attention to frequency, character, sively in the American College of Cardiology
in select patients. precipitating causes, and duration. Family (ACC)/American Heart Association (AHA)
Absolute contraindications to use of the and social histories are very important and Task Force on Practice Guidelines on preop-
IABP include severe aortic insufficiency and should be noted. A thorough physical ex- erative cardiovascular evaluation for non-
acute aortic dissection. Aortic aneurysms, amination of all organ systems is equally cardiac operations. The published guide-
atherosclerotic aortas, aortoiliac occlusive important. Chest radiographs and ECGs lineswereevidence-basedandrecommended
disease, or mild aortic insufficiency are rel- should be reviewed closely. Beyond the rou- the use of a combination of an initial clinical
ative contraindications. Known complica- tine office evaluation, there are a myriad of evaluation and functional testing in certain
tions of the IABP include bleeding, infec- noninvasive, invasive, functional, and ana- patient subsets. High-risk clinical variables
tion, and balloon leak or malfunction. tomic imaging modalities to further quan- include recent MI, history of diabetes melli-
Arterial injury can occur especially during tify cardiac function. These tests may help tus, poor functional status, decompensated
guidewire and/or balloon advancement. identify patients with underlying silent car- heart failure, significant arrhythmias, and
Embolization to the visceral and renal ves- diac disease who may be in need of further severe valvular disease. Noninvasive testing
sels can occur from thrombus on the bal- treatment. As with any decision in health is most useful in patients who have more
loon or from atherosclerosis in the thoracic care, the risk to benefit ratio of a diagnostic than one clinical risk factor and are sched-
aorta and can lead to intestinal ischemia study or therapeutic intervention deserves uled to undergo intermediate- or high-risk

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 80 10/28/11 10:54:03 PM

 Chapter 4: Cardiovascular Monitoring and Support 81

operations. Noninvasive testing includes of death, with a 17% incidence of severe artificial heart. Implications for vascular con-
resting ECG, echocardiography, treadmill cardiovascular complications. Patients in tribution of inotropic agents to augmented

Perioperative Care of the Surgical Patient

exercise stress testing, stress perfusion im- the lowest risk group had a 0.2% incidence ventricular function. Circulation 1991;84:
1210.
aging, and dobutamine stress echocardiog- of death and a 0.7% incidence of severe car- Blackbourne LH, Cope JT, Tribble RW, et al. The
raphy. These tests help further quantify diovascular complications. With the ad- cardiovascular system. In: O’Leary JP, ed. The
cardiac function and help identify patients vances made in anesthesia and medical physiologic basis of surgery, 2nd ed. Baltimore:
with underlying silent cardiac disease care, this data is mentioned more for a his- Williams & Wilkins; 1996.
who may be in need of further work-up or torical perspective. However, these studies Frostell C, Fratacci MD, Wain JC, et al. Inhaled
treatment. still provide a basis for presurgical evalua- nitric oxide. A selective pulmonary vasodilator
reversing hypoxic pulmonary vasoconstriction.
When assessing cardiovascular risk in tion today. Circulation 1991;83:2038.
the noncardiac surgical setting, the Gold- Several important factors should be Ganz W, Donoso R, Marcus HS, et al. A new tech-
man Cardiac Risk factors should be dis- considered when patients are screened. nique for measurement of cardiac output by
cussed. This multifactorial index was de- One obvious consideration is the urgency of thermodilution in man. Am J Cardiol 1971;27:
veloped for preoperative identification of the operation. Patients who undergo ur- 392–6.
patients at risk from major perioperative gent/emergent surgery have a two- to five- Gattinoni L, Brazzi L, Pelosi P, et al. A trial of goal-
cardiovascular complications. The data fold increased rate of experiencing a cardio- oriented hemodynamic therapy in critically ill
patients. N Engl J Med 1995; 333:1025.
was obtained retrospectively from 1,001 vascular complication than patients who Hogman M, Frostell CG, Hedenstrom H, et al. In-
patients over 40 years of age undergoing undergo comparable surgery on an elective halation of nitric oxide modulates adult human
noncardiac surgery. By multivariate dis- basis. There may also be times when the re- bronchial tone. Am Rev Respir Dis 1993;148:1474.
criminant analysis, nine independent sig- sults of screening will not affect the deci- Johnson SB, Sisley AC. The surgeon’s use of transe-
nificant correlates of life-threatening and sion to operate but may assist in alerting sophageal echocardiography. Surg Clin North
fatal cardiac complications were identified. the anesthesia and surgical teams about Am 1998;78:311.
Marino PL. The ICU book. 2nd ed. Baltimore:
These were preoperative third heart sound the degree of risk. Currently, high-risk pro- Williams & Wilkins; 1998.
or jugular venous distention; myocardial cedures carry a risk of nonfatal MI or car- McNelis J, Marini CP, Jurkiewicz A, et al. Prolonged
infarction in the preceding 6 months; more diac death of 5% or more. Intermediate risk lactate clearance is associated with increased
than five premature ventricular contrac- procedures carry a combined risk of 1% to mortality in the surgical intensive care unit. Am
tions per minute documented at any time 4% and low-risk procedures carry a com- J Surg 2001:182:481.
before operation; rhythm other than sinus bined risk of ⬍1%. Moulopoulos S, Topaz S, Kolff W. Diastolic balloon
pumping (with carbon dioxide) in the aorta: a
or presence of premature atrial contrac- mechanical assistance to the failing circula-
tions on preoperative ECG; age over SUGGESTED READINGS tion. American Heart Journal 1962;63:669.
70 years; intraperitoneal, intrathoracic, or Rossaint R, Falke KJ, Lopez F, et al. Inhaled nitric
aortic operation; emergency operation; im- Bender JS. When is the pulmonary artery catheter oxide for the adult respiratory distress syndrome
portant valvular aortic stenosis; and poor needed in care of the surgical patient? Advances [see comments]. N Engl J Med 1993;328:399.
medical condition. Patients in the highest in Surgery 1999;32:365. Saunders CR, Doty DB. Myocardial contusion: ef-
Berger RL, Saini VK, Long W, et al. The use of dia- fect of intra-aortic balloon counterpulsation on
risk group (based on a point scale given to stolic augmentation with the intra-aortic bal- cardiac output. J Trauma 1978;18:706.
the risk factors) had a 56% incidence of loon in human septic shock with associated Swan HJC, Ganz W, Forrester JS, et al. Catheter-
death, with a 22% incidence of severe car- coronary artery disease. Surgery 1973;74:601. ization of the heart in man with use of a flow-
diovascular complications. Patients in the Binkley PF, Murray KD, Watson KM, et al. Dobu- directed balloon-tipped catheter. N Engl J Med
intermediate risk group had a 4% incidence tamine increases cardiac output of the total 1970;283:447.

EDITOR’S COMMENT unteers, usually in the battlefield, have resulted not resuscitating with crystalloid in the field, but
in a minimalization of the coagulopathy. Studies maintaining a modest blood pressure to keep the
have now shown that massive resuscitation with patient alive until they can get to a center where
Military experience has always been of value in crystalloid is harmful as it results in a higher in- they can receive red cells and plasma popular-
civilian practice, and the two wars, which are cur- cidence of ARDS and renal failure, and perhaps ized in part by Ken Maddox now seems to have
rently in progress in both Iraq and Afghanistan, poor outcomes. This is of particular interest and gained some threshold acceptance and indeed
have been helpful in the sense of knowing how satisfaction to me because when the hypothesis we can expect that fewer and fewer patients will
to resuscitate patients who have had a degree of of resuscitating the third space came into vogue receive the massive volumes of crystalloid in the
trauma, particularly by IED that we have never in the late 1970s and early 1980s, I noted that we future especially prior to reaching the emergency
seen before in which individuals who have lost were seeing a relatively large number of patients room. I know that there will be naysayers in this
both legs and an arm are now being returned to with ARDS that we had not previously seen. The particular point of view, but you cannot convince
civilian life and perhaps a useful existence. use of large volumes of crystalloid, which the me because of the history of seeing ARDS simul-
One area which seems to have benefited mantra proposed to resuscitating the third space taneous with the administration of enormous
dramatically is the resuscitation with respect to left many of our patients looking like beached amounts of crystalloid.
volume, particularly when there is a large volume whales and it was not difficult to make the con- What should we accept as the sine qua non
of blood lost. If nothing else, the consensus that nection that if their interstitial tissues looked of adequacy of resuscitation? Since the authors
has been arrived at is that crystalloid should be like this perhaps their lungs looked like that as say in their introduction that we are interested in
avoided if possible and that the best formula that well. The true believers denied this and so for 30 four parameters—cardiac function, both periph-
most people can agree on is early resuscitation years we have been resuscitating the third space, eral and pulmonary vascular tone, intravascular
with a 1:1 resuscitation with cells and plasma but also resulting in an unfortunate number of volume status, and oxygen metabolism—what
and a minimalization of crystalloid. If all else patients with ARDS some of who have died. This is the surrogate for these four important com-
fails, fresh whole blood unprocessed from vol- no longer appears to be the vogue. The concept of ponents? I agree with the authors who point out

(continued)

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 81 10/28/11 10:54:03 PM

 82 Part I: Perioperative Care of the Surgical Patient

that a peripherally placed intra-arterial cath- internal jugular central line except, perhaps, in stabilization. If the patient’s bleeding or injury is
eter as measured mean arterial pressure is the patients with tracheostomies, because it is ex- such that massive transfusion is anticipated they
most accurate estimate of central arterial, that traordinarily difficult to keep the dressing clean do propose early red cells and plasma at a ratio
is, aortic pressure. This perhaps is the most im- if there is a tracheostomy. I place the catheter approaching 1:1 with the red cells, an approach
portant statement in this well-written chapter. utilizing a #22 needle to infiltrate the area with which I entirely agreed with as stated above the
The mean arterial pressure as measured by an 1% Xylocaine and use this needle to find the sub- 1:1 ratio with red cells, preferable fresh red cells
unobstructed radial artery catheter will give clavian vein which one most always can. I use a or fresh whole blood has been associated with
you as much information as all the other things point approximately one-third of the way from improved outcome. In septic patients “goal-di-
that we measure as to the adequacy of cardiac the central part of the suprasternal notch to the rected resuscitation” is proposed in which con-
function and resuscitation. This is good because end of the clavicle and aim for one finger breath tinuing resuscitation takes place until venous
some of the other parameters that we have dealt above the suprasternal notch. At no time should oxygen saturation is normalized. However, they
with in the past such as a Swan–Ganz catheter the needle be more than 10 degrees steeper than do say that the most important aspect is the eti-
and a pulmonary artery wedged pressure while the horizontal because that is when one gets ology of the hypotension and if septic it needs
sometimes useful have actual been getting a bad into trouble hitting the subclavian artery or to be treated promptly with drainage if possible
reputation because of the complications and resulting in a pneumothorax when hitting the and the bleeding must stop. Other than the fact
of the fact that they do not seem to add a great apex of the lung. If you keep the needle no more that they do nod in the direction of crystalloid
deal. than 10 degrees steeper than the horizontal you resuscitation I have no argument with this par-
Thus, we get to central venous pressure. As may not find the vein, but you will not find the ticular approach.
pointed out by Raymond C. Roy in an editorial lung either. The head should be turned slightly With failing cardiac reserve, intra-aortic bal-
in J Anesth Analg 2010;111(3):591–2, if we have to the opposite side and the arms should be at loon pumping is often instituted. Rubino AS et
to adapt central venous pressure, the guidelines the patient’s side. Once the line is in place it is al. (Int J Cardiol 2010, published online) ana-
for utilizing CVP as a basis for increasing, main- critically important that it receives first-class lyzed transit time flow measurements and the
taining, or restricting fluid administration if the care by specially trained nurses who change the contemporary changes in coronary resistance
CVP is ⬍8 mm of mercury, 8 to 12 mm of mer- dressing every other day with chlorhexidine or obtained during 1:1 intra-aortic balloon pump-
cury, or ⬎12 mm of mercury, respectively, the povidone-iodine around the entrance point to ing in 144 consecutive patients both before and
measurement of CVP needs to be very accurate. the catheter. It is simply not true that catheters its cessation in patients receiving prophylactic
A recently published protocol to reduce the risk that are longer in duration have a higher infec- aortic balloon pumping before isolated coro-
of clinically relevant venous air embolism during tion rate. It does seem that once they are past nary bypass grafting, which in these 144 pa-
neurosurgical interventions in the semi-sitting 7 to 10 days if they are not septic by that time tients were 348. When they lactate flow during
position recommends maintaining the CVP be- good care will keep them not septic for a long intra-aortic balloon pumping and compared it
tween 4 and 9 mm Hg. In addition, when we carry time. with intra-aortic balloon pumping cessation
out hepatic resections to minimize blood loss, it The authors also indicate that blood should there is a greater percent decrease in resistance
has been common practice to perform liver re- be measured regularly. Howard James and I have and greater increase in average maximum
sections with a CVP ⬍5 mm Hg. However, there (James JH et al. Am J Physiol 1999;277:176–86; diastolic and mean flows. Both arterial and se-
is a problem. The fact is that in measuring CVP James JH et al. Lactate is an unreliable indica- quential saphenous vein grafts showed better
and using CVP rather than pulmonary artery tor of tissue hypoxia in injury or sepsis. Lancet flow rates and greater reduction in coronary
wedge pressure, it is essential that the zeroing 1999 Aug 7;354:505–8) proposed that blood resistance compared with single venous grafts.
point should be agreed upon and it should be lactate does not necessarily mean anaerobic Accordingly, they propose that the graft flow
extremely accurate. Dr. Roy goes into quite a dia- conditions or hypoperfusion. Aerobic glycolysis reserve during 1:1 intra-arterial by-pass grafts
tribe concerning the appropriate way of zeroing may be stimulated by epinephrine and sepsis on in all normally functioning grafts have higher
CVP catheters. However, he is correct. If we are both insulin and glycolysis. Continuing to follow values in single or sequential saphenous vein
going to base many of the decisions of resuscita- blood lactate if it is elevated in response to epi- grafts. Their hypothesis basically states that
tion on a central venous pressure it is important nephrine as in burns for a long time, or in other intra-aortic balloon pumping includes graft
that it should be accurate and that the CVP must situations, may result in overresuscitation. In flow reserve by lowering coronary resistance
be adjusted accordingly by resuscitation. How- burns, blood epinephrine is up for approximately in functioning grafts. Arterial and sequential
ever, observation of centering the zero point of 2 weeks, after the patient has been appropriately venous grafts apparently showed a greater re-
CVP in an intensive care unit is a rather casual resuscitated and yet in some units the resuscita- duction in coronary resistance than single sa-
exercise. Thus, if one is going to rely on this mea- tion continues, which may result in a pulmonary phenous grafts. Quite frankly, I am not certain
surement it had better be accurate and Dr. Roy’s edema. exactly what does this mean and what is its
opinion is that if this is going to occupy a central Fouche Y et al. (Crit Care Med 2010;38: significance.
position in our resuscitation it had better be ac- S411–20) deal with surgical resuscitation follow- As this chapter shows nicely both resuscita-
curate and it is not. ing trauma, which is appropriate since this orig- tion as far as the type of fluid utilized depending
Drs. Kron and Ailawadi go into some detail inates from the Adams Cowley Shock Trauma on the setting and the type of monitoring as well,
about the placement of a central venous cath- Center at the University of Maryland medical the evaluation of the success of whatever manip-
eter and I agree that it is important because one system in Baltimore. They are concerned about ulations and therapies are now being utilized is
can do a great deal of damage. I prefer to place intravascular hypovolemia at the time of anes- undergoing a renaissance of interest in to what
the patient in 20% Trendelenburg on a towel roll thesia induction and propose that central ve- exactly are we doing. I think that this is an excel-
between the clavicle vertically in bed using three nous pressure and crystalloid be used to moni- lent advance as we have for too long taken what
rolled up “chucks,” which give in most people tor patient euvolemic prior to induction; they we do in the intensive care unit, perhaps one of
just the right amount of elevation of the spinal also state that fluid resuscitation should be dif- the most important areas where we care for pa-
column so that when the shoulders are thrown ferent in patients who are bleeding and in septic tients, too much for granted and perhaps with
back it gives an easy point of entry for a central patients. In trauma patients who are actively outcomes that are not as favorable as we might
venous catheterization. In addition, a subcla- bleeding they propose a low blood pressure to see being monitored.
vian line will result in less infection than the facilitate clot formation (which I doubt) and J.E.F.

www.medicalebookpdf.com

LWBK892_c04_p066-082.indd 82 10/28/11 10:54:03 PM

 Chapter 5: Pulmonary Risk and Ventilatory Support 83

5 Pulmonary Risk and Ventilatory Support

Perioperative Care of the Surgical Patient

Jay A. Johannigman, Bryce R.H. Robinson, Eric W. Mueller, and Richard D. Branson

INTRODUCTION respiratory failure to 27% in those with re- anesthesia and surgery. Paralysis during
spiratory failure. Development of postoper- surgery results in a cephalic movement of
The pulmonary system includes a complex ative respiratory failure requiring mechani- the diaphragm in the dorsal lung as a con-
milieu, which includes the conducting air- cal ventilation results in an increased length sequence of the weight of the abdominal
ways, pulmonary parenchyma, the alveolar of stay from 4.5 to 28 days. The definition of contents. Controlled positive-pressure ven-
capillary interface, an intricate mechanism a postoperative pulmonary complication is tilation results in preferential ventilation of
for control of breathing, complex muscular often elusive. Radiographic atelectasis fol- nondependent (ventral) lung units. As pul-
interplay, and elaborate defense mecha- lowing cardiothoracic surgery is common, monary blood flow is gravity dependent,
nisms. Yet, despite the sophistication of the but rarely results in pulmonary symptoms intraoperative ventilation exacerbates V/Q
respiratory system, pulmonary complica- or morbidity. This results in both overre- inequalities and promotes dorsal atelecta-
tions are the single most common source of porting and underreporting of pulmonary sis. General anesthesia has also been shown
morbidity in the critically ill surgical pa- complications. The literature reveals an in- to inhibit intrinsic pulmonary defense
tient. Postoperative pulmonary complica- cidence of pulmonary complications from mechanisms including altered alveolar
tions include atelectasis, bronchospasm, 2% to 19% after general surgical procedures macrophage function, disruption of the
bronchitis, pneumonia, exacerbation of and 8% to 39% following cardiothoracic mucociliary escalator, and diminished sur-
chronic lung disease, and pulmonary em- surgery. factant release. Severe chronic lung disease
bolism (PE) (Table 1). Uniformly, these Postoperative pulmonary complications continues to be a barrier to more complex
complications result in a predictable set of occur most commonly in those undergoing open thoracoabdominal procedures. The
symptoms including tachypnea, hypox- major abdominal and/or thoracic proce- evolution of minimally invasive surgery has
emia, and hypercapnia followed by respira- dures. Other risk factors include advanced facilitated postoperative pulmonary func-
tory failure each of which are associated age, history of chronic obstructive pulmo- tion and recovery in such patients. Pain
with increased morbidity and mortality. nary disease (COPD), history of obstructive control including epidural catheter analge-
Arozullah and colleagues found the need sleep apnea (OSA), use of nasogastric tubes, sics has also reduced morbidity in patients
for reintubation and/or mechanical venti- malnutrition, renal failure, and duration of with major thoracic injury. Comparisons of
lation occurred in only 3% of patients in the anesthesia. Diaphragmatic dysfunction, laparoscopic to open procedures demon-
VA database of almost 100,000 postopera- ventilation-perfusion (V/Q) mismatching, strate that in some cases (cholecystectomy
tive patients. Importantly, mortality in this and a reduction in functional residual ca- and esophageal cancer) pulmonary compli-
group increased from 1% in those without pacity (FRC) routinely occur after general cations are reduced, while in other proce-
dures pulmonary complications are un-
cchanged. This chapter includes sections on
Table 1 Common Postoperative Pulmonary Complications and Risk Factors ppulmonary anatomy and physiology, risk
aassessment, and management of acute
Common complications following general surgery Preoperative risk factors llung injury (ALI) including mechanical ven-
Pulmonary embolus COPD ttilation, prevention and treatment of
vventilator-associated pneumonia (VAP),
Obstructive sleep apnea Advanced age
aand adjunctive surgical measures to treat
ARDS Smoker ccomplex intrathoracic infections.
Ventilatory failure (PaCO2 60 mm Hg, pH 7.20) Pulmonary hypertension
Atelectasis Obstructive sleep apnea ANATOMY AND
Infection–pneumonia Bronchitis Malnutrition PHYSIOLOGY
Bronchospasm Obesity The lungs lie lateral to the mediastinum in
Aspiration of gastric contents tthe thoracic cavity. The lung surface is cov-
eered by a single cell layer of pleura, which
Exacerbation of chronic pulmonary disease Intraoperative risk factors
aalso lines the parietal surface. A minute
Common complications following cardiothoracic Thoracic or upper abdominal aamount of pleural fluid is present to lubri-
surgery incision ccate the lung/thorax interface reducing
Bronchopleural fistula General anesthesia ffriction. The pleural space under normal
Duration of anesthesia/surgery ccircumstances is not a space at all, but can
markedly increase in disease states. The
m
Pleural effusion Emergent procedures
rright lung has three lobes and the left has
Phrenic nerve injury ttwo, including the lingula, and each lobe
Sternal wound infection and dehiscence ccontains two to five segments with tertiary
Empyema bbronchi, which can be visualized by bron-
cchoscopy. The basic functioning unit is the
Arrhythmias aalveolus. The terminal alveolar unit is a

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 83 10/28/11 8:41:24 PM

 84 Part I: Perioperative Care of the Surgical Patient

grape-like cluster of individual air sacs of- atelectasis, pneumonia, ALI, and acute re- pired CO2. In ARDS, VD/VT predicts mortal-
ten sharing a common wall surrounded spiratory distress syndrome (ARDS). The ity, as values 0.7 are associated with
by a web of capillaries, giving the lung its shunt fraction can be estimated by mea- 80% mortality.
elastic nature. Ventilation-perfusion in the surement of the alveolar-arterial (A-a) O2
lungs based on an upright model divides gradient. This is defined as: PULMONARY MECHANICS
the lung into three zones. In zone I (the up-
per lung fields), alveolar pressure is greater
A-aO2 gradient  (PB  PH2O)  FIO2 AND LUNG VOLUMES
 PaCO2 PaO2.
than both arterial and venous blood pres- There are several lung volumes and capaci-
sure resulting in a high V/Q ratio. When This is normally 10 mm Hg, but mark- ties used to describe mechanical function
ventilation is greater than perfusion, dead edly increases in disease, which limits gas of the lung, respiratory muscles, and chest
space results. In zone II (mid lung zones), exchange across the alveolar capillary wall (Fig. 1). Most of these are measured
arterial pressure is greater than alveolar membrane. The ratio of PaO2/FIO2 is com- during pulmonary function testing. Tidal
pressure, which is greater than venous pres- monly used to assess the severity of pulmo- volume (VT) is the amount of air exchanged
sure and V/Q is well matched. In zone III nary dysfunction in disease states such as per breath during normal breathing. Vital
(lower lung fields), the vascular pressures ALI, ARDS, and pneumonia in the mechani- capacity (VC) is the amount of air exchanged
exceed alveolar pressure and V/Q is low. cally ventilated patient. The normal value is from peak inspiration to maximal expira-
When perfusion exceeds ventilation, shunt over 500. A value 300 indicates ALI and tion. FRC is the amount of residual air in
results. The typical intensive care unit (ICU) 200 indicates ARDS, when observed con- the lung after maximal expiration. Compli-
patient nursed supine causes the zones to currently with bilateral infiltrates on chest ance of the lung is a measure of elasticity
shift horizontally and V/Q dependent on x-ray and a pulmonary capillary wedge and is defined as change in volume/change
gravity. In this case, the lungs are consid- pressure 18 mm Hg. The calculation of in- in pressure. During mechanical ventilation,
ered to be nondependent (ventral) or de- trapulmonary shunt requires a pulmonary dynamic compliance is measured as the dif-
pendent (dorsal). Ventilation perfusion artery catheter, mixed venous blood from ference between peak inspiratory pressure
matching during ALI helps to explain the the pulmonary artery, and the measure- (PIP) and PEEP/VT. Static compliance is
effects of positive end-expiratory pressure ment of cardiac output. measured as the difference in plateau pres-
(PEEP) and changes in position (prone) on The PaCO2 normally is responsible for sure and (Pplat) and PEEP/VT. Dynamic
arterial oxygenation. Lymph drainage from central respiratory drive by CO2 diffusion compliance includes the effects of airway
the lungs occurs through the hilar and me- across the blood–brain barrier, producing a resistance and lung compliance, while
diastinal lymph nodes to the thoracic duct decrease in cerebrospinal fluid pH and an static compliance estimates alveolar pres-
via the mediastinal lymphatics. increase in minute ventilation. Normal sure and lung elasticity alone. Plateau pres-
The critical function of the lung is gas PaCO2 is 35 to 45 mm Hg, but can be ele- sure is important in both lung expansion
exchange, specifically oxygen extraction vated by disorders in the control of breath- and lung injury in ARDS. Data suggest that
from the atmosphere and transfer to the ing and in ALI and ARDS by dead space. for every increase in plateau pressure of
intravascular space, and elimination of car- Physiologic dead space is defined as the 6 cm H2O, the development of ARDS (in pa-
bon dioxide. The latter is virtually depen- dead space to tidal volume ratio (VD/VT), tients initially without ARDS) increases by
dent on minute ventilation (respiratory which is normally 0.3 owing to the anatom- 50%. Pressure–volume curves can be pro-
rate), while oxygen transport is dependent ical dead space. VD/VT is calculated as duced, which demonstrate the beginning of
on the fractional inspired oxygen concen- alveolar recruitment (lower inflection point)
VD/VT  PaCO2  PECO2/PaCO2
tration (FIO2), transport across the alveolar- and alveolar overdistention (upper inflec-
capillary membrane, and V/Q matching. where PaCO2 is used as an approximate for tion point), and can be used to guide the
Blood oxygen content is determined pri- alveolar CO2 and PECO2 is the mixed ex- choice of VT and PEEP. The pressure–volume
marily by hemoglobin concentration and
percent oxygen saturation, while oxygen
dissolved in plasma contributes minutely.
Oxygen tension in the alveolus is described
by the following alveolar air equation:
PAO2  [(PB  PH2O)  FIO2]  PACO2/RER
where PB is the barometric pressure, PH2O is
the partial pressure of water vapor, which is
constant under alveolar conditions at 47
mm Hg, PCO2 is the alveolar CO2 concentra-
tion, and RER is the respiratory exchange
ratio (normally 0.8).
The arterial partial pressure of CO2
(PaCO2), readily available on routine blood
gas measurement, can be substituted for
PACO2. Normal PAO2 in room air is 95 to
100 mm Hg and PaO2 is 85 to 95 mm Hg. The
degree of V/Q mismatching will determine
the shunt fraction of unsaturated blood.
Shunt fraction is normally 2% to 5%, but
can be significantly increased in the face of Fig. 1. Standard measurements of lung volumes.

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 84 10/28/11 8:41:25 PM

 Chapter 5: Pulmonary Risk and Ventilatory Support 85

curve is not a standard of care and should be c

chodilators, to determine the degree of re-
used cautiously. Table 3 Preoperative Assessment vversibility of the airway disease. A significant
of Pulmonary Risk

Perioperative Care of the Surgical Patient

rresponse has been defined as either a 12% or
History: Shortness of breath, dyspnea on 00.2 L or more from baseline. Tests for lung
PREOPERATIVE exertion, fever, yellow or discolored vvolume and diffusing capacity are more
ASSESSMENT sputum, smoking (current or past), ccomplex and not routinely done for most pa-
COPD history
Although the ability of preoperative assess- ttients. An FEV1 50% of predictive value,
ment of pulmonary function to predict the Physical exam: Comfort of breathing, aand resting hypoxemia and hypercarbia have
incidence of pulmonary complications respiratory rate, thoracic excursion, bbeen shown to be associated with increased
temperature, use of accessory muscles ppostoperative pulmonary morbidity. The
postoperatively in a given patient is good, to breathe, skin color, digital clubbing,
these assessments are not commonly per- AAmerican Association of Anesthesiologists
wheezing, rales, rhonchi on auscultation
formed. Frequent excuses for not perform- ((ASA) has developed the ASA Class system,
ing preoperative testing include inadequate Chest x-ray: Hyperaeration, flattening of wwhich can be useful in predicting intraoper-
diaphragm, increase in width of lung fields, aative and postoperative morbidity and mor-
understanding of what test can be pre- parenchymal changes
dicted, the absence of guidelines detailing ttality (Table 4). This system relies more on
which test should be performed and in Arterial blood gas: Hypoxemia, hypercarbia ooverall physical condition of the patient, not
what populations, and the utility of preven- Pulmonary function testing: Elevated FRC, oon the results in individual measurements.
tative postoperative care in all patients or reduced FVC and FEV1, reduced FEF
just in high-risk patients. 25–75% PREOPERATIVE
In emergency or nonelective surgery ASSESSMENT OF
preoperative assessment is useless as the
The National Lung Health Program has rec-
PULMONARY RISK
surgical procedure must be undertaken re-
ommended routine use of spirometry by The National Surgical Quality Improvement
gardless of the risk. Complete pulmonary
primary care physicians. Program represents the most significant ef-
function tests (PFTs) include lung volumes,
The primary maneuver during spirome- fort in identifying preoperative risk (Table 5).
spirometry, maximal respiratory pressures,
try is the forced vital capacity (FVC) where Factors associated with increased pulmo-
diffusing capacities, and oximetry (Table 2).
the patient inhales to total lung capacity and nary morbidity include age over 60, low se-
However, office-based observations such as
then exhales out as fast and as long as pos- rum albumin, renal failure, smoking, history
ease of breathing, use of accessory muscles,
sible. FVC is the difference between total of COPD, high American Society of Anesthe-
ability to blow out a match with a wide-
lung capacity and reserve volume. The forced siology (ASA) score, anesthetic time of
open mouth, and stair climbing are helpful
expiratory volume over the first second is 180 minutes or more, and type of operation.
indicators of pulmonary reserve (Table 3).
referred to as the FEV1 and reflects degree of In the VA study, over 180,000 patients were
Hypoxia or CO2 retention on arterial blood
obstruction, usually as a consequence of studied. Postoperative respiratory failure
gas measurements is also useful in patients
smoking. The ratio of FEV1/FVC is also re- was defined as the requirement for mechan-
with known chronic pulmonary disease.
ported in addition to the maximal voluntary ical ventilation for more than 48 hours post-
Development of office-based spirometry
ventilation (MVV). The MVV is the maximal operatively, or reintubation and mechanical
has allowed those physicians with an inter-
amount of ventilation over a 10- to 12-second ventilation after postoperative extubation.
est in treating such disorders to immediate
period, and can vary tremendously with the This study more appropriately predicts post-
results and treatment can often be initiated
fitness of the patient and the effort. Pre- operative respiratory failure, not postopera-
early based on such testing. The objectives
dicted values for each of these parameters tive pulmonary complications. The study did
of PFTs are to describe dysfunction and se-
can be calculated based on height, weight, not consider other findings such as atelecta-
verity, and to assess long-term prognosis as
and body mass index. Based on the observed sis, pneumonia, or PE in the absence of
endorsed by the American Thoracic Society.
values, a percent of predicted value is ob- mechanical ventilation. The study included
tained, and is most easily interpreted. These noncardiac procedures done under general
tests
t can be performed before and after or regional anesthesia. The rate of postoper-
Table 2 Pulmonary Function Tests pharmacologic
p intervention such as bron- ative respiratory failure was just 3%. Point
Lung volumes: Total lung capacity (TLC)
Vital capacity (VC)
Reserve volume (RV) Table 4 ASA Physical Status Classification and Rate of Postoperative
RV/TLC Complications
Spirometry: Forced vital capacity (FVC) Rate of pulmonary
Forced expiratory volume over the first ASA class Definition complications (%)
second (FEV1) I A normally healthy patient 1.2
FEV1/FVC
Maximum voluntary ventilation (MVV) II A patient with mild systemic disease 5.4

Maximal respiratory pressures: Maximal III A patient with severe systemic disease, but it is not 11.4
inspiratory pressure (PImax) incapacitating
Maximal expiratory pressure (PEmax) IV A patient with incapacitating systemic disease that 10.9
Diffusing capacity: Diffusing capacity of lung is a constant threat to life
for carbon monoxide (DLCO) V A patient not expected to survive 24 h without NA
Alveolar volume (VA) surgery
Oximetry: O2 saturation VI A brain dead patient donating organs NA

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 85 10/28/11 8:41:25 PM

 86 Part I: Perioperative Care of the Surgical Patient

complications.
c These include chronic respi- tient has known pulmonary hypertension,
Table 5 Veterans Affairs Pulmonary r
ratory disease, cardiac comorbidities, and determining their preoperative response to
Risk Index
s
select surgical procedures. The most signifi- vasodilator therapy may be useful in man-
Type of surgery (abdominal aortic aneurism c will be reviewed here.
cant aging postoperative complications.
 thoracic  neurosurgery, upper
abdominal, or peripheral vascular  head
and neck) The COPD Patient Asthma
C
COPD is an independent risk factor for the Although some evidence suggests that pa-
Emergency surgery d
development of postoperative pulmonary tients with asthma are at greater risk for
Serum albumin 3.0 g/L c
complications following both thoracic and postoperative pulmonary complications,
Blood urea nitrogen 30 mg/dL n
nonthoracic surgery. COPD is characterized more recent studies have failed to corrobo-
Partially or fully dependent functional status
b airflow limitation and has been classi-
by rate this impression. Preoperatively, pa-
fied into five stages according to the Global tients should continue to use their inhaled
History of chronic obstructive pulmonary I
Initiative for Chronic Obstructive Lung medications to optimize peak expiratory
disease (COPD)
D
Disease (GOLD). The small airways from flow. Intraoperatively, tracheal intubation
Age (60) r
resected lung tissue of COPD patients dem- and dry anesthetic gases may trigger bron-
o
onstrate inflammatory leukocytes in both chospasm in these patients. Short-acting
t lumen and the walls. The severity of in-
the 2-agonists typically control this problem.
filtration correlates with the GOLD stage,
values were assigned to these various factors indicating the chronic inflammatory status Smoking
and five classes of patients were then devel- of the lungs, which is often steroid resistant. A history of smoking increases the risk of
oped based on their scores. Class IV and V Physiologically, COPD is characterized by pulmonary complications for patients un-
patients had predicted risks of 11% and 30%, decreased FEV1, alveolar hypoventilation, dergoing any type of surgery. Patients who
respectively for development of postopera- reduction in alveolar capillary diffusing ca- are current smokers have even greater risk.
tive respiratory failure, which closely pacity, hypoxemia, and/or hypercarbia. The
matched the incidence from both phases of GOLD guidelines state that COPD is present Age
the study. Class I patients, which comprised when the FEV1 is 80% of predicted and Patients 65 years of age undergoing non-
almost half of the study population, had only FEV1/FVC is 0.7. thoracic surgery are at increased risk of
a 0.5% risk of respiratory failure. postoperative pulmonary complications.
Preoperative pulmonary risk has been Pulmonary Hypertension
studied thoroughly in patients who undergo Pulmonary hypertension (defined as a right Obstructive Sleep Apnea
thoracotomy and lung resection. Of major ventricular systolic pressure of 35 mm Patients undergoing surgery should be
importance is the estimate of residual lung Hg) is a significant and often overlooked screened for OSA. Preoperative evaluation
function to minimize the risk of permanent preoperative risk. In patients undergoing for OSA can be a simple list of questions for
pulmonary dysfunction resulting in ventila- noncardiac surgery having a New York the patient and their bed partner as to snor-
tor dependence. Lung cancer often occurs Heart Association functional class 2, a ing, periods of apnea, and disrupted sleep
concurrently with COPD. Even when other history of pulmonary embolus, or OSA post- pattern. Preoperative polysomnography has
risk factors are accounted for, the presence operative pulmonary and cardiac compli- not been shown to assist in preventing post-
of COPD is the predominant risk factor for cations are substantially increased. Postop- operative complications. A study of 170 pa-
postoperative pulmonary complications erative congestive heart failure, cardiac tients undergoing bariatric surgery found
following thoracotomy. Lung volume is ac- ischemic events, arrhythmias, strokes, re- that only 15% of patients were diagnosed
tually reduced by thoracotomy alone, and spiratory failure, hepatic dysfunction, renal with OSA, however, the actual incidence
typically FEV1 is reduced by 10% after lobec- dysfunction, and the need for postoperative was 77%, as documented by polysomnogra-
tomy and by 30% after pneumonectomy. inotropic or vasopressor support are known phy. In the general surgical population, the
Methods for determining postoperative postoperative complications in this group. incidence of OSA has been estimated to be
function after lung resection include PFTs, Postoperative respiratory failure is the most as low as 1% and as high as 9%. A plethora of
CT, and lung scanning. Split perfusion lung common complication. studies have demonstrated that the pres-
scanning has been found to be most accu- Preoperatively, risk factors in patients ence of OSA correlates closely with increased
rate, as other methods consistently under- with pulmonary hypertension include postoperative morbidity and mortality. Sleep
estimate postoperative residual lung func- right-axis deviation on the ECG, right ven- disturbances are exaggerated after surgery
tion. A predicted FEV1 of at least 700 mL has tricular hypertrophy, or a history of pulmo- and general anesthesia. The early preopera-
been used as a cutoff for resectability. With nary embolus. When inhaled nitric oxide tive treatment of OSA with continuous posi-
regard to prediction of postoperative mor- (iNO) is unavailable, use of intraoperative tive airway pressure (CPAP) may reduce
bidity and mortality, the inability to climb epinephrine, or having a right ventricular these risks.
two flights of stairs and a percentage of pre- systolic pressure/systolic BP ratio of 0.66
dicted DLCO (derived from lung scan) 40% also tends to increase perioperative mor-
have consistently been shown to be associ-
Perioperative Therapies to Prevent
bidity and mortality. Postoperative Complications
ated with adverse clinical outcome. Pulmonary hypertension patients un-
able to walk 332 m during a 6-minute A number of interventions for reducing
Patients at Risk for Postoperative walk test have a higher mortality rate than postoperative pulmonary complications
Pulmonary Complications those who can. The presence of a pericar- have been explored (Table 6). These inter-
dial effusion, the presence of septal shift, or ventions should begin preoperatively, and
A number of chronic disease states are as- an enlarged right atrium on echocardio- continue through the intraoperative, peri-
sociated with greater risk of pulmonary gram also predicts worse outcomes. If a pa- operative, and postoperative periods. These

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 86 10/28/11 8:41:25 PM

 Chapter 5: Pulmonary Risk and Ventilatory Support 87

techniques
t have generated variable out- morbidity and mortality, especially in pa-
Table 6 Preoperative Preparation c
comes and failed to favor one surgical ap- tients that have additional risk due to inher-
of the High-Risk Patient

Perioperative Care of the Surgical Patient

p
proach over the other. However, common ent comorbidities.
Identification that patient is at high risk s
sense and clinical experience seems to fa- When clinical outcomes are critically
Reduce or stop smoking v laparoscopic techniques.
vor evaluated, the benefits of regional techniques
Treat associated infection with antibiotics become less clear. In a meta-analysis of 141
Maximize lung function with medication and L
Lung Expansion Maneuvers smaller randomized trials that included
exercise
Regional anesthetic and appropriate sedation
L
Lung expansion maneuvers have been advo- 9,559 patients, Rodgers et al. demonstrated a
Postoperative epidural analgesia c
cated to decrease the risk of complications significant reduction in postoperative mor-
b counteracting the adverse effects of sur-
by tality for those patients that underwent
g
gery on pulmonary mechanics, which pre- neuraxial blockade. Furthermore, significant
dispose patients to atelectasis and retained reductions in the odds of obtaining a deep
interventions should be carried out regard- secretions. Deep-breathing exercises, incen- vein thrombosis (DVT), PE, blood product
less of the risk of the development of PPCs. tive spirometry, intermittent CPAP, and non- transfusion, pneumonia, and respiratory de-
invasive ventilation have all been advanced pression were found in the blockade group.
Smoking Cessation as methods for lung expansion. Studies have Rigg et al. examined the impact of epidural
Patients enrolling in a smoking cessation failed to demonstrate the advantage of one use during the operative and postoperative
program 6 to 8 weeks prior to elective ortho- technique over another and interestingly, period in high-risk patients undergoing ma-
pedic surgery required less frequent postop- several studies have shown that incentive jor abdominal or thoracic procedures when
erative mechanical ventilation. A number spirometry has no advantage over deep- compared to a cohort receiving only sys-
of other studies with varying durations of breathing exercises alone. In summary, the temic analgesia. This prospective, random-
smoking cessation and operative interven- techniques used for lung expansion appear ized trial of 915 patients demonstrated no
tions have demonstrated mixed results. It to be equally effective in preventing postop- difference in 30-day mortality. Of multiple
appears that in order to reduce postopera- erative pulmonary complications. CPAP may morbid conditions that were examined post-
tive pulmonary complications, smoking be helpful in patients who are unable to per- operatively, only the rate of respiratory fail-
cessation must begin a minimum of 6 weeks form deep-breathing exercises and in pa- ure was significantly reduced in those with
prior to the operation. tients with OSA and/or obesity. epidural use. In this group, there was a re-
duction in pain scores during the first 3 days
Preoperative Corticosteroids Use of Regional Anesthesia of infusion though there was also a signifi-
and Bronchodilators Anesthesia is often classified into two: gen- cant decrease in systolic blood pressure and
Preoperative treatment with a -agonist eral anesthesia and regional anesthesia. maximal heart rate.
and methylprednisolone for 5 days, may re- General anesthesia refers to techniques The implementation of such techniques
duce the incidence of bronchospasm dur- that depress the central nervous system by in an elective surgical setting needs to be
ing intubation in patients with asthma and a gaseous and/or intravenous delivery. Re- first discussed preoperatively with both the
bronchial hyperactivity. This is more effec- gional anesthesia refers to the delivery of patient and in consultation with the anes-
tive in patients naive to routine -agonists pharmaceuticals directly to the spinal cord thesiology team. Strong contraindications
than those on long-term therapy. or nerves to locally anesthetize afferent and for placement include clotting defects and
efferent neuronal pathways. Effective re- local sepsis at the insertion site. Clotting
Anesthesia and Analgesia gional anesthesia for major thoracic, ab- disorders, whether acquired or inherent, in-
Anesthetic agents may contribute to the dominal, and limb surgery often requires crease the risk of epidural hematoma for-
development of PPCs by decreasing respira- the injection of these drugs into the suba- mation. Infection at the site of placement
tory muscle tone and augmenting airway rachnoid space (spinal anesthesia) or into or in the locality of insertion could lead to
closure promoting atelectasis. Comprehen- the epidural space (epidural anesthesia) to spinal seeding and abscess formation. Pa-
sive reviews comparing the effect of general create a neuraxial blockade. tients with poor cardiac function should be
anesthesia and spinal anesthesia on post- The use of neuraxial blockade for major evaluated closely in light of the heightened
operative complications in patients under- general surgical procedures is well estab- risk of cardiac dysfunction that may occur
going nonthoracic surgical procedures have lished though the additional benefits it may due to the spinal sympathetic block of
found no difference in the rate of postoper- confer is controversial. These benefits are neuraxial local anesthetics. Such patients
ative pneumonia. A meta-analysis evaluat- thought to originate through the attenuation may benefit from only narcotic infusions or
ing the incidence of postoperative pneumo- of the neuroendocrine stress response that the removal of local anesthetics at the first
nia in patients undergoing hip surgery is reported during surgical interventions. signs of hypotension or bradycardia.
found no differences based on anesthetic When compared to patients undergoing
technique. Despite conventional wisdom, systemic analgesia, the use of regional tech-
regional anesthesia has not been clearly es- niques is associated with a decrease in PROPHYLAXIS FOR VENOUS
tablished as an approach for reducing PPCs. plasma levels of cortisol, catecholamines, THROMBOEMBOLISM AND
Patients receiving pancuronium and those and proinflammatory cytokines. The reduc-
tion of spinal sympathetic stimulation in
PULMONARY EMBOLISM
with residual blockade have an increased
incidence of postoperative pneumonia. the perioperative setting has presumed Venous thromboembolism (VTE), the for-
advantages for coagulation, cardiovascular, mation of clot in the larger extremity or
Surgical Techniques pulmonary, gastrointestinal, and immuno- central veins, and PE, emboli from a large
Studies examining the incidence of post- logic functions. Such techniques are appeal- vein thrombus that occludes the pulmonary
operative pulmonary complications using ing in that a blunted stress response during artery tree, continue to be major health is-
laparoscopic techniques compared to open this period may translate into a reduction in sues in the United States. These clots effect

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 87 10/28/11 8:41:26 PM

 88 Part I: Perioperative Care of the Surgical Patient

r
risks or previous VTE, evidence exists that
Table 7 Risk Factors for Development of Venous Thromboembolism cchemoprophylaxis with LMWH be consid-
Disease-specific risks ■ Surgery eered after discharge for up to 28 days.
■ Trauma (major trauma or injury to a lower extremity) Recommendations for prophylaxis for sur-
■ Cancer active or occult ggical subspecialty patients do exist. The foun-
■ Venous compression by tumor or hematoma ddation of these recommendations is com-
■ Inflammatory bowel disease monly based on the risk factors accumulated
m
■ Nephrotic syndrome bby the patient and not the type of surgical pro-
■ Myeloproliferative disorders ccedure to be performed. For high-risk patients
■ Paroxysmal nocturnal hemoglobinuria undergoing vascular, laparoscopic, and tho-
u
■ Inherited or acquired thrombophilia
rracic surgery, the routine use of LMWH,
Comorbid risks ■ Immobility, lower extremity paresis LLDUH, or fondaparinux is recommended.
■ Previous VTE Those undergoing inpatient bariatric proce-
■ Increased age ddures often required higher doses of LMWH
■ Pregnancy and the postpartum period
oor LDUH than those given to nonobese pa-
■ Acute medical illness
■ Obesity ttients. For surgical patients that require criti-
ccal care who are at a moderate risk of VTE, the
Drug and treatment risks ■ Cancer treatment (hormonal, chemotherapy, angiogenesis rrecommendation is for routine prophylaxis
inhibitors, radiation)
with LMWH or LDUH. Higher-risk surgical
w
■ Estrogen-containing oral contraceptives or hormone
replacement therapy ccritical care patients (often major trauma or
■ Selective estrogen receptor modulators oorthopedic surgery) will require LMWH.
■ Erythropoiesis-stimulating agents A great deal of evidence has accumu-
■ Central venous catheterization llated for the prophylaxis of the traumati-
ccally injured patient. By the nature of a ma-
jjor trauma, these patients are considered
high risk for the development of VTE. As
between 350,000 and 600,000 Americans general surgical patients accrue based on such, routine thromboprophylaxis with
annually and are directly or indirectly re- the presence of obesity, cancer, increasing LMWH is currently recommended. In those
lated to 100,000 deaths over such a period. age, use of general anesthesia, duration of patients in whom the bleeding risk of
This crisis has grown to such a magnitude surgery, presence of postoperative infec- chemoprophylaxis is too great, mechanical
that a “Call to Action” was issued by the Sur- tion, and mobilization. The pathophysio- prophylaxis is to be started until LMWH
geon General of the United States in 2008. logic basis of these risks is Virchow’s triad can be initiated. For many, the risk of PE in
The rationale for the prevention of VTE and of vascular endothelial damage, venous sta- this patient population is too high to rely
PE is based on the premise that almost all sis, and blood hypercoagulability. The me- solely on stocking and/or pneumatic com-
hospitalized patients have at least one risk chanical methods of prophylaxis such as pression devices. The insertion of inferior
factor for formation and that approximately specifically graduated compression stock- vena cava filters is growing in popularity as
40% have three or more (Table 7). ings, intermittent pneumatic compressions a means to direct a method of mechanical
Without thromboprophylaxis, the rate of devices, and venous foot pumps have been prophylaxis above the common anatomical
VTE is 10 to 40% in medical and surgical appealing due to the lack of bleeding risk area of DVT formation. This attractiveness
populations (moderate risk) with a rate as associated with such devices. Although the has spilled over to many patient subsets
high as 40% to 60% following major orthope- rate of DVT is lower with the use of these that have failed or cannot undergo the risk
dic surgical interventions or major traumatic devices, no mechanical thromboprophy- of chemoprophylaxis and/or full anticoagu-
injury (high risk). Vast amounts of irrefut- laxis option has been studied in such rigor- lation for known DVT or PE. However, these
able evidence exist stating that VTE and PE ous detail to impact PE or death rate, and filters predispose patients to an increase
are preventable entities. Based on these the quality of such trials is often debated. risk of DVT in the lower extremities by re-
works, timely evidence-based clinical prac- Current recommendations for those re- ducing venous flow. Even more alarming is
tice guidelines exist for the prevention of ceiving major general surgical procedures the incredibly low retrieval rate of these fil-
VTE and are the basis for this brief review. focus on the early use of low-dose unfrac- ters from patients with reversal factors for
The prevention of VTE begins with the tionated heparin (LDUH), low-molecular- the formation of DVT. Many await large,
institutional-wide identification of moder- weight heparin (LMWH), or fondaparinux. prospective, multicenter studies to delin-
ate- to high-risk surgical patients. A formal, Both LDUH and LMWH have been demon- eate the indication for filter use in those
written policy for thromboprophylaxis and strated to reduce the rate of symptomatic patient subsets that require chemoprophy-
strategy for adherence has clear benefit. and asymptomatic VTE by 60%. In higher- laxis that is otherwise contraindicated.
Low-risk surgical patients, those undergo- risk patients undergoing oncologic surgi-
ing outpatient-type procedures, have no ad- cal procedures, three times a day dosing of
ditional thromboembolic risk and likely LDUH and LMWH, or manufacture-recom- DIAGNOSIS AND
need nothing more than early and frequent mended dosing of fondaparinux, is recom- MANAGEMENT OF
ambulation. Most general surgical proce- mended. The use of mechanical methods VENTILATOR-ASSOCIATED
dures incur a moderate risk of VTE though along with chemoprophylaxis is encour-
a high risk is often assigned to hip or knee aged in any high-risk patient. The use of
PNEUMONIA
operations, major trauma patients, and these agents, both mechanical and phar- Ventilator-associated pneumonia (VAP) is
moderate risk patients with multiple indi- maceutical, is to be used until discharge the most common infectious complication
vidual risk factors. Risk factors for VTE in from the hospital. In patients with high in critically ill surgical patients. Between

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 88 10/28/11 8:41:26 PM

 Chapter 5: Pulmonary Risk and Ventilatory Support 89

30% and 60% of mechanically ventilated pa- logic diagnostic strategy using quantitative threshold in this study had a sensitivity of
tients will develop VAP varying between sur- lower respiratory tract culture for definitive 89% and specificity of 100%. Most data in

Perioperative Care of the Surgical Patient

gical population and diagnostic strategy. diagnosis can effectively differentiate VAP critically ill surgical patients, primarily
Critically ill trauma patients are at the high- from noninfectious systemic inflammatory trauma, support a diagnostic threshold of
est risk of developing VAP followed by gen- response syndrome (SIRS) or ARDS. Quanti- 100,000 cfu/mL with consideration for us-
eral surgical, cardiothoracic, burn, and tative respiratory tract cultures, if possible, ing a threshold of 10,000 cfu/mL for P.
neurosurgical patients. Although the attrib- should be done before initiation of empiric aeruginosa in more severely injured or ill
utable mortality in surgical patients is de- antibiotic therapy and can be obtained using patients. As the progression of antibiotic re-
bated, VAP is independently associated with noninvasive endotracheal aspirate (EA), sistance continues to challenge the fight
prolonged mechanical ventilation, and ICU bronchoscopic protected specimen brush against infectious complications, it may be
and hospital lengths of stay. In addition, the (PSB), or bronchoscopic/non-bronchoscopic reasonable to consider a more specific diag-
excess cost of each episode of VAP exceeds bronchoalveolar lavage (BAL). Meta-analyses nostic strategy to avoid unnecessary antibi-
$40,000. Risk factors for the development of and large studies comparing EA and BAL are otic use. Nevertheless, contemporary guide-
VAP include patient comorbidities such as limited by clinical diagnostic defaults and line consensus and expert opinion stress
diabetes mellitus, malnutrition, alcoholism, relevant exclusion criteria, specifically pa- the imperative of using a diagnostic thresh-
immunosuppression, and COPD. Concomi- tients at risk of more pathogenic organisms old (e.g., 10,000 or 100,000 cfu/mL for BAL)
tant surgical risks include immunosuppres- (e.g., Pseudomonas aeruginosa, methicillin- rather than the specific threshold used.
sive effects of injury, breakdown of natural resistant Staphylococcus aureus [MRSA]). Empiric antibiotic therapy for VAP should
epithelial barriers by incision or instrumen- One of the more objective investigations was be guided by ICU-specific ecology, antibio-
tation, manipulation of the alimentary tract, a large, randomized study in Spain that dem- gram data, and the presence of risk factors
and prophylactic antibiotic therapy. Al- onstrated an invasive strategy using bron- for multidrug-resistant (MDR) organisms.
though lack of association between pneu- choscopic BAL (invasive) to obtain quantita- Commonly defined MDR risk factors include
monia and antacids or histamine-2 antago- tive lower respiratory tract culture associated previous hospitalization or antibiotic use
nists has been settled by meta-analysis, with decreased unnecessary antibiotic use within 30 days, chronic hemodialysis, ad-
independent associations between proton and decreased mortality compared to a strat- mission from long-term care facility, or im-
pump inhibitor use and community- and egy using quantitative EA (noninvasive). munosuppression. The most objective MDR
hospital-acquired pneumonia have revived Consequently, concern persists surrounding risk factor influencing VAP pathogen preva-
debate surrounding gastric alkalinization potential upper respiratory tract contamina- lence is the duration of index hospitalization
for stress-related mucosal injury (SRMI) tion during noninvasive sampling and resul- before developing VAP. Using a day cutoff,
prophylaxis. Nevertheless, the Institute for tant false-positive culture. usually between 5 and 7 days, allows catego-
Healthcare Improvement (IHI) recommends The concept of quantitative culture for rization of early- versus late-onset VAP.
SRMI prophylaxis along with VTE prophy- the diagnosis of VAP is not novel. In 1975, Empiric antibiotic therapy should differ
laxis, daily wake-up from sedation, head of Polk performed serial quantitative cultures between early-onset VAP without other
bed elevation, and daily assessment for extu- in EA in 97 surgical patients. He reported MDR risk factors compared to late-onset
bation as a bundle of interventions to dimin- low false-positive and false-negative rates or early-onset VAP with MDR risk factors
ish the risk and sequelae of VAP. Prevention when 100,000 colony-forming units (cfu)/ (Table 8). Generally, patients without MDR
of VAP using these and other evidence-based mL was used as the diagnostic threshold. risk factors who develop early-onset VAP are
interventions (e.g., hand hygiene, oral care, Although debate persists around the appro- at risk for community-associated pathogens
and infection control) should be routine in priate diagnostic threshold for BAL, it has such as Haemophilus influenza, methicillin-
the management of critically ill patients. been repeatedly demonstrated that the sensitive S. aureus (MSSA), alpha- or beta-
The diagnosis and management of VAP threshold magnitude is inversely propor- hemolytic Streptococcus spp., and limited-
in critically ill surgical patients includes: tional to sensitivity and proportional to resistance enteric gram-negative bacilli (e.g.,
(a) a combination of clinical suspicion and specificity, i.e., a lower threshold has fewer Escherichia coli and Klebsiella spp.). There-
quantitative, lower respiratory tract culture; false-negative, but higher false-positive, fore, less broad-spectrum empiric antibiotic
(b) timely initiation of adequate (i.e., active whereas a higher threshold has fewer false- therapy is recommended. Institutions with
against identified pathogen) empiric antibi- positive, but higher false-negative results. In high rates of community-acquired MRSA
otic therapy; (c) antibiotic de-escalation or a prospective study in critically ill trauma may need to consider anti-MRSA in these
discontinuation based on quantitative cul- patients, Croce et al. noted that there is a patients. In contrast, patients with late-
ture; and (d) appropriate duration of defini- poor predictability between clinical evi- onset VAP or those with MDR risk factors are
tive antibiotic therapy (Fig. 2). Interdisci- dence of pneumonia and quantitative BAL at risk for P. aeruginosa, MRSA, Enterobacter
plinary, evidence-based, institution-specific culture. All enrolled patients received em- spp., resistant E. coli or Klebsiella spp., and
protocol implementation improves diag- piric antibiotic therapy based on clinical Acinetobacter spp. Because of the breadth of
nostic accuracy, increases the frequency of suspicion; however, patients with final resistance mechanisms and bacterial classi-
adequate empiric antibiotic therapy, and quantitative BAL culture growth 100,000 fications (i.e., gram staining) encountered in
decreases unnecessary antibiotic use. cfu/mL were considered to have noninfec- these VAP episodes, a combination of anti-
There are two broad strategies for the di- tious SIRS and had their empiric antibiotic MRSA and anti-pseudomonal therapy is rec-
agnosis of VAP: clinical and bacteriologic. therapy discontinued. Based on subsequent ommended. Reasonable options for MRSA
Because traditional clinical criteria for VAP investigation for VAP, the false-negative rate include vancomycin (weight-based dosing)
(e.g., new or changing infiltrate on chest ra- for quantitative BAL in this subset of pa- or linezolid, particularly for isolates wherein
diograph (CXR), macroscopically purulent tients was 7%. There was no difference in vancomycin minimum inhibitory concen-
sputum production, elevated white blood mortality between patients with false-nega- tration (MIC) exceeds 1 μg/L or if the patient
cell count, and elevated temperature) are tive and true-positive BAL. Overall, quanti- experiences vancomycin intolerance. Em-
overly sensitive and nonspecific, a bacterio- tative BAL and associated diagnostic piric antibiotic therapy for gram-negative

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 89 10/28/11 8:41:26 PM

 90

LWBK892_c05_p083-099.indd 90
Suspected VAP

WBC >11,000 or 10%

New or changing infiltrate Temperature >101°F Purulent sputum Hypoxia
bands

At least 3 clinical signs Less than 3 clinical signs

Continued surveillance
Begin empiric antibiotics
and pulmonary toilet

BAL Signs and symptoms increase

proceed to empiric antibiotics

www.medicalebookpdf.com
<105 cfu/mL organisms ≥105 cfu/mL organisms

Continue antibiotics and

Discontinue antibiotics
adjust to culture results

Fig. 2. Diagnosis and treatment algorithm for suspected ventilator-associated pneumonia.

10/28/11 8:41:26 PM
 Chapter 5: Pulmonary Risk and Ventilatory Support 91

2
28-day mortality between the groups. On
Table 8 Empiric Antibiotic Regimens for Ventilator-Associated Pneumonia ssubgroup analysis, VAP relapse and mortality

Perioperative Care of the Surgical Patient

VAP classification Antibiotic Dosage, intravenousa
rremained equivalent between groups for VAP
ccaused by MRSA and lactose-fermenting
Early-onset without MDR Ceftriaxone 2 g every 12–24 h ggram-negative bacilli. Conversely, patients
risk factors (choose Ampicillin/ 3 g every 6 h with non-lactose-fermenting gram-negative
w
one) Sulbactam 400 mg every 24 h
VAP, primarily P. aeruginosa, who received
V
Moxifloxacin 500–750 mg every 12–24 h
Levofloxacin 1 g every 24 h 8 days of therapy had significantly higher
Ertapenem rates
r of VAP relapse (32.8% vs. 19.0%). How-
ever,
e of the patients who had a VAP relapse,
Late-onset or early-onset Primary Agent
those
t who received 15 days of therapy were
with MDR risk factors Cefepime 2 g every 8–12 h (consider infusion over 4–6 h
(one primary agent, if suspect higher MIC Pseudomonas 1.5 1 times more likely to have an MDR patho-
one combination aeruginosa) gen g as the cause of the subsequent VAP.
agent, if necessary, and Piperacillin- 3.375–4.5 g every 6 h (consider every 8 h In a concurrently conducted before-and-
one anti-MRSA agent) Tazobactamb infused over 4 h if suspect higher MIC after,
a case-matched, single-center pilot
P. aeruginosa) study,
s antibiotic duration was compared in
Imipenem 500 mg every 6 h two t groups of critically ill trauma patients
Meropenem 1 g every 8 h withw bronchoscopically diagnosed VAP
Combination Agent (BAL( 100,000 cfu/mL): a control group
Tobramycin 7 mg/kg every 24 h whose
w antibiotic duration was at the dis-
Amikacin 25 mg/kg every 24 h cretion
c of the ICU service and a study group
Ciprofloxacin 400 mg every 8 h who w underwent repeat BAL after 3 days of
Anti-MRSA adequate
a antibiotic therapy. If pathogen
Vancomycin 15–20 mg/kg every 8–12 h (consider goal g
growth on repeat BAL culture was 10,000
serum trough concentration 15–20 μg/L) c
cfu/mL, then definitive antibiotic therapy
Linezolid 600 mg every 12 h was w discontinued. Compared to control pa-
t
tients, study group patients received signifi-
VAP, ventilator-associated pneumonia; MDR, multidrug resistance; MIC, minimum-inhibitory concentration;
MRSA, methicillin-resistant Staphylococcus aureus.
c
cantly shorter durations of definitive anti-
a
Dosage for patients with creatinine clearance above 60 mL/min. b
biotic therapy (9.8 3.8 days vs. 16.7 7.4
b
Consider deescalating to piperacillin (i.e., without tazobactam) 4 g every 4–6 h for piperacillin-sensitive P. aerugi- d
days; P  0.001) with no difference in VAP
nosa based on final susceptibility results. r
recurrence or in-hospital mortality. Cor-
r
roborating the results of the French trial,
s
study patients with non-lactose-fermenting
gram-negative bacilli more often received
bacilli should include an anti-pseudomonal such as prolonged or continuous beta-lac- longer durations of therapy because of per-
beta-lactam antibiotic and maximize the tam infusions, aerosolized beta-lactam or sistence of significant growth on repeat
probability of initially covering P. aeruginosa aminoglycoside therapy, and monitoring of BAL, whereas 95% of all other pathogens
based on local antibiogram. In institutions real-time pulmonary antibiotic concentra- had 10,000 cfu/mL on repeat BAL and
with low empiric resistance (e.g., 10%), it tions may be advantageous and are under were treated for 8.8 3.3 days. Results of
is reasonable to consider monotherapy anti- broader investigation. these studies support contemporary guide-
pseudomonal therapy, whereas institutions The optimal duration of antibiotic therapy line recommendations for antibiotic dura-
with unacceptable resistance rates should for VAP is unknown, particularly in patients tion in patients with VAP: most patients
employ a combination of anti-pseudomonal with non-lactose fermenting gram-negative who receive adequate empiric antibiotic
beta-lactam plus aminoglycoside or anti- bacilli (e.g., P. aeruginosa). Historically, anti- therapy and demonstrate reasonable clini-
pseudomonal fluoroquinolone. Subsequent biotic durations between 14 and 28 days were cal or microbiologic response should receive
to final culture result, empiric antibiotic recommended for all patients with VAP. As 7 to 8 days of antibiotic therapy, whereas
therapy should be promptly deescalated to with most typical bacterial infections, con- patients with non-lactose-fermenting gram-
the narrowest, organism-appropriate defini- temporary evidence demonstrates that negative bacilli may require 14 days of anti-
tive regimen. This includes appropriate shorter antibiotic durations result in similar biotic therapy.
beta-lactam (rather than vancomycin) for patient outcomes, decrease antibiotic use,
MSSA, monotherapy beta-lactam for sus- and may limit the progression of MDR. More-
ceptible P. aeruginosa, monotherapy carbap- over, low specificity of clinical response pa- PATHOPHYSIOLOGY AND
enem for extended-spectrum beta-lactamase rameters (e.g., white blood cell count, tem- TREATMENT OF ACUTE
(ESBL)-producing gram-negative bacilli, perature, and sputum production) injects RESPIRATORY DISTRESS
and vancomycin for most MRSA strains. Un- unacceptable subjectivity into the assess- SYNDROME
less obligated by MDR pathogens, mono- ment of antibiotic duration. A landmark trial
therapy intravenous aminoglycoside therapy in France randomized 400 mostly critically ill ARDS is an acute inflammatory lung injury
should be discouraged because of decreased medical patients with bronchoscopically di- that was first described by Ashbaugh and
clinical response and increased mortality. A agnosed VAP (BAL 10,000 cfu/mL) to 8 or colleagues in 1967. This syndrome is charac-
key consideration to empiric and definitive 15 days of adequate antibiotic therapy re- terized by hypoxia, diffuse “ground-glass”
antibiotic therapy regimens is the use of ap- gardless of clinical response. Overall, there pulmonary infiltrates on chest x-ray, and de-
propriate dosages to achieve acceptable pul- was a significant decrease in antibiotic-free creased lung compliance in the absence of
monary tissue concentrations. Strategies days with no difference in VAP recurrence or ongoing heart failure. The reported incidence

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 91 10/28/11 8:41:26 PM

 92 Part I: Perioperative Care of the Surgical Patient

A B
Fig. 3. Characteristic chest radiograph (CXR) (A) and CT scan (B) in a patient with severe ARDS following multiple trauma.

of ARDS ranges between 1.5 and 13.5 per ■ The presence of a risk factor associated ■ Primary versus secondary ARDS
100,000 population, with a mortality rate of with the generation of ARDS ■ Early versus late ARDS
27% to 60%. Forty years after the initial de- ■ The role of extrapulmonary changes in
scription, the mortality associated with The observed clinical sequelae of ARDS compliance
ARDS remains high and is often part of the results from ventilation-perfusion (V/Q) in-
equalities, specifically intrapulmonary The ensuing sections will attempt to dis-
sequence of multiple organ failure (MOF).
shunt (perfusion in the absence of ventila- tinguish these differences with specific at-
Recent investigations have suggested that
tion). Gravitational forces acting on the tention to the surgical patient with ARDS.
the mortality associated solely to ARDS is
declining to a range of 30%. Assuming that edematous lung induce consolidation in de-
the finding of reduced mortality in ARDS is pendent lung regions altering distribution
of ventilation and worsening V/Q matching.
Primary Versus Secondary ARDS
genuine, the cause is undoubtedly multifac-
torial. Over the past decades, improvements (Fig. 3). The preponderance of disease in de- The distinguishing characteristic between
in understanding the pathogenesis of sepsis pendent lung regions complicates mechani- primary and secondary ARDS is related to
and multiorgan dysfunction, development cal ventilation, leads to maldistribution of direct (primary) or indirect (secondary)
of improved surveillance and treatments tidal volume, and promotes ventilator-in- lung injury. The most common cause of di-
for infection, appreciation of the role of ap- duced lung injury (VILI). rect lung injury is pulmonary infection
propriate nutrition, and changing concepts A more detailed and sophisticated ap- (pneumonia). Other primary insults lead-
in ventilatory support have likely all con- proach to the various “types” of ARDS is ob- ing to ARDS include aspiration, barotrauma,
tributed. In addition, the development of tained by understanding additional defini- near-drowning, and inhalation injury. The
consistent protocol-based approaches to tions that further refine the etiology and majority of these etiologies are witnessed in
the management of ARDS, as shown by the pathophysiology of ARDS. More impor- the MICU. Surgical causes of direct ARDS
ARDS Network (ARDSNet) trial, appears tantly, these discriminators highlight im- include pulmonary contusion, lung lacera-
to improve outcome. Finally, advances in portant differences in the very broad cate- tion, and bronchial injury. In all cases, di-
ventilator technology, including airway gory, that is, ARDS. By understanding the rect lung injury is characterized by an in-
graphics packages and improved dynamic evolution and key derangements present in sult, which impacts on the alveolar (as
monitoring capability have provided the the various “forms” of ARDS, the clinician opposed to the capillary) side of the alveo-
practitioner with a more precise under- may more appropriately tailor the clinical lar/capillary interface.
standing of the dynamic interplay between response to the specific patient needs. An Indirect lung injury can be related to sep-
patient and machine. understanding of the various “forms” also sis, shock, massive transfusion/resuscita-
The hallmark clinical symptom of ARDS allows one to understand that surgical pa- tion, fat/PE, pancreatitis, peritonitis, and
is hypoxemia refractory to oxygen therapy. tients with ARDS are often quite different SIRS. In this instance, the defining injury is
The defining characteristics of ARDS re- from medical patients with ARDS. Under- on the capillary side of the alveolar/capillary
main those established by the American standing these distinctions both explains interface and a majority of these patients re-
European consensus group and consist of traditional differences in management ceive their care in an SICU. The pathophysi-
the following: strategies between the MICU and the SICU, ology of ARDS is an area of significant con-
as well as aids in the appropriate bedside tinuing research as patients with these
■ Diffuse interstitial edema management concepts. The key compo- multiple risk factors do not always go on to
■ A PaO2/FiO2 ratio of 200 nents to understanding the various “forms” develop ARDS. The “trigger” for the sequence
■ No evidence of cardiogenic edema of ARDS include the following: of ALI to SIRS to ARDS to MOF is an unsolved

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 92 10/28/11 8:41:27 PM

 Chapter 5: Pulmonary Risk and Ventilatory Support 93

scientific question and demonstrates vari- tocols and surrogates to respiratory sup- trials that received widespread interest
able expression among patients. Most inves- port studied as well. The outcome of most included ventilator management trials in-

Perioperative Care of the Surgical Patient

tigators believe that increased lung capillary of these trials demonstrates a degree of im- vestigating lower tidal volume ventilation
permeability with subsequent alveolar capil- provement in oxygenation and limitation in and higher PEEP. In the low tidal volume
lary leak occurs from a complex inflamma- VILI, but with little impact on mortality of trial, an improved survival rate was ob-
tory response to a primary event. The diag- established ARDS or prevention of ALI. served when limiting ventilator tidal vol-
nosis is made clinically, with most treatment Pharmacologic studies have been even less umes to 6 mL/kg of idealized body weight.
focused on respiratory support. promising with no approved agent cur- Success was attributed to decreasing volu-
rently for treatment of this disease. Other- trauma related to traditional higher tidal
Early Versus Late ARDS wise, no major difference has been achieved volumes. This trial was halted early with
with a series of failed or terminated clinical 861 subjects noting a decrease in mortality
A second key characteristic that aids in dis- trials primarily focused on the inflamma- from 39.8% to 31% when comparing high to
tinguishing the “forms” of ARDS is the dis- tory phase. Table 9 summarizes many of the low tidal volume ventilation. It is important
tinction of early versus late ARDS. Early supportive and pharmacologic modalities for the practitioner to remember that the
ARDS is a dynamic disease entity during with their results. tidal volume utilized in this trial is the ide-
which lung edema may be quite variable, The ARDSNet was established to facili- alized body weight (determined solely by
the lung itself is often recruitable, and com- tate the development of effective therapeu- gender and patient height). The second
pliance may be nearer normal values. Late tic protocols for the treatment of ARDS. The ventilator management trial examined the
ARDS is a form of the disease, which is more National Heart, Lung, and Blood Institute of role of low and high PEEP with lower tidal
static in nature, less responsive to thera- the National Institutes of Health (NIH) initi- volumes in patients with ARDS. No survival
peutic recruitment maneuvers (e.g., PEEP ated a clinical network in 1994 to carry out benefit was noted with the addition of
and prone positioning), and more likely to multicenter clinical trials of novel thera- higher PEEP than achieved by lower tidal
be chronic and slowly changing. peutic agents for ARDS. This network con- volumes alone.
Numerous clinical trials with various sists of 19 clinical centers representing More recent data from the ARDSNet
treatment protocols have been performed 44 hospitals and institutions, as well as the group suggests that fluid restriction based
with the goal of supportive therapy to de- NIH and the National Library of Medicine on pressure data from a central venous
crease VILI, improve oxygenation, and de- (www.ardsnet.org). Current treatment of catheter is superior to more aggressive fluid
crease the number of ventilator days. Simi- ARDS is primarily supportive, with the goal strategies. This trial also noted no advan-
larly, there have been additional trials of of minimizing further lung injury and al- tage to use of a pulmonary artery catheter
pharmacologic agents (including surfac- lowing spontaneous resolution of the pro- in the management of fluids in ARDS. The
tants), which reduce the inflammatory cess. There remains some controversy as to role of steroids in late ARDS remains con-
response without increasing infectious what constitutes the best supportive mea- troversial. However, recent studies have
complications and, therefore, potentially sures and there is yet no current effective demonstrated that steroids in late ARDS
attenuate the severity of the clinical course. treatment for the pathophysiologic de- can be associated with an increased inci-
There have been a variety of ventilator pro- rangement of ARDS. The first ARDSNet dence of infection and mortality.

Table 9 Supportive and Pharmacologic Interventions for ARDS

Respiratory supportive measures Pharmacological interventions
Intervention Result Intervention Result
Prone ventilation Improved oxygenation Corticosteroids No early benefit, ? late benefit
in fibroproliferative phase.
May increase mortality in
select groups.
Permissive hypercapnia Decreased barotrauma, ? survival benefit Surfactant No benefit
Pressure control ± inverse Decreased barotrauma, few randomized studies, Pentoxifylline/ No benefit
ratio ventilation commonly used for “rescue” when Lisofylline
conventional ventilator modes fail
High frequency modes of Decreased barotrauma, but little aggregate data Ketoconazole No benefit
ventilation available on treatment trials for ARDS
Extracorporeal Mixed results in adults, institution dependent Antioxidants Minimal if any benefit
cardiopulmonary bypass
(ECMO)
Inhaled nitric oxide No improvement in survival, improved oxygenation Anti-adhesion molecules ? minimal benefit
Recruitment maneuvers and Recruitment maneuvers have been shown to Prostaglandin Mixed results, some survival
increased PEEP increase PaO2 and improve lung compliance but benefit
have not decreased mortality. Higher PEEP is
associated with a shorter duration of ventilation
but no change in mortality based on a meta-
analysis

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 93 10/28/11 8:41:27 PM

 94 Part I: Perioperative Care of the Surgical Patient

In trauma patients, experience from the ideal body weight to maintain a plateau surrogate of alveolar pressure. This assump-
conflict in Iraq and Afghanistan has dem- pressure 30 cm H2O. Ideal body weight tion is simplistic and may often be mislead-
onstrated that initial hypotensive resusci- should be determined through the mea- ing in the surgical patient. More appropri-
tation followed by a 1:1:1 ratio of blood to surement of height (height is the major de- ately, the main determinant of lung
plasma and platelets results in a reduced terminant of lung volume, not weight) us- overdistension should be considered as re-
incidence of ARDS. Our experience in civil- ing the following equations: lated to the transalveolar distending pres-
ian trauma at the University of Cincinnati sure (alveolar pressure minus chest wall
appears to confirm this finding. Men  IBW  50 2.3 (height in pressure). This important distinction is one
inches  60) of the critical distinctions that must be rec-
A Practical Approach to ARDS Women  IBW  45.5 2.3 (height in ognized by the surgical intensivist. The sur-
inches  60) gical patient often differs from their medi-
Ventilatory management of the surgical pa- cal counterpart due to striking changes in
tient with ARDS should follow the princi- Direct ARDS rarely requires PEEP 12 chest and abdominal compliance prompted
ples of lung protection. The approach to cm H2O as higher pressures result in overd- by surgical interventions and large volume
ventilation should begin with a determina- istension and a paradoxical response, with fluid resuscitation. The surgical patient
tion of the mechanism of injury and the oxygenation worsening at higher PEEP. This with reduced chest wall compliance as a
pattern of pulmonary involvement (direct observation is a reflection of the patchy/ consequence of fluid resuscitation, abdom-
vs. indirect ARDS). The patient with direct isolated nature of early direct ARDS. Indi- inal distension, or obesity frequently re-
ARDS resulting from postoperative pneu- rect ARDS commonly requires PEEP up to quires a plateau pressure higher than 35 cm
monia commonly has patchy infiltrates on 20 cm H2O (diffuse widespread changes in H2O in order to sustain an appropriate
CXR and moderate hypoxemia. The patient pulmonary compliance) and similar adjust- transalveolar distending pressure. Transal-
with indirect ARDS following multiple ment of tidal volume based on IBW. Mea- veolar distending pressure can be estimated
trauma, hypotension, and massive blood surement of the pressure volume curve of by measurement of airway plateau pressure
transfusion will demonstrate a pattern of the respiratory system can be useful in de- minus the esophageal or intra-abdominal
diffuse alveolar infiltrates on CXR and pro- termining the lower and upper inflection pressure. Recent studies by Talmor and as-
found hypoxemia. In each instance, the points corresponding to the initiation and sociates have demonstrated that this mea-
goals of ventilation should prioritize limit- end of alveolar recruitment (Fig. 4). During surement algorithm may significantly im-
ing plateau pressures, tidal volumes based the last decade, a number of newer ventila- pact on the management strategy of surgical
on ideal body weight of 6 mL/kg, and PEEP tors have incorporated the ability to con- patients with ARDS. Talmor’s group exam-
sufficient to reduce FIO2 0.60. duct an automated pressure/volume curve ined surgical patients meeting the consen-
Despite the success of the ARDSNet trial, at the bedside. This relatively simple proce- sus criteria for the definition of ARDS that
the adjustment of ventilatory parameters dure requires the establishment of (tempo- the management of PEEP was randomly
based solely on rules for tidal volume and rary) muscular paralysis but in return may distributed between an algorithm utilizing
PEEP belies the complexity of ventilator provide significant clinical information re- the Acute Respiratory Distress Syndrome
management and the disease process. In garding the lower and upper inflection Network standard of care recommenda-
patients with direct ARDS, PEEP should be points of the lung. tions versus an algorithm that adjusted
adjusted to maintain oxygenation and tidal Plateau pressure as measured during an PEEP according to measurements of esoph-
volume adjusted between 4 and 8 mL/kg of inspiratory pause has been employed as a ageal pressure. This study was halted early
after the enrollment of 61 patients second-
ary to the demonstration of a significant
improvement in the ratio of partial pressure
of arterial oxygen to the fraction of inspired
Overdistention oxygen (PaO2/FiO2 ratio) at 72 hours in the
esophageal pressure-guided group. This ef-
fect was persistent over the entire follow-up
time (24, 48, and 72 h). This study lends sup-
UIP port to the contention that surgical patients
with elevated intra-abdominal pressures
( fluid resuscitation, bowel distension, sur-
Volume

LPVS
gical changes, etc.) and/or noncompliant
chest walls may respond in a fundamentally
different fashion to increases in PEEP as
compared to the patient with direct ARDS
Derecruitment and preexisting chronic lung disease. Fur-
LIP ther investigations of this modality must be
conducted, but it appears to be straightfor-
ward and to offer significant opportunity
for improvement in ventilator management
Pressure techniques. Considerable controversy re-
Fig. 4. Pressure volume curve of the respiratory system demonstrating the lower inflection point (LIP) mains (and continues) regarding the ideal
representing the start of alveolar recruitment and the upper inflection point (UIP) representing the end mode of ventilation and type of ventilator
of alveolar recruitment. Identification of these landmarks allows rapid adjustment of PEEP and tidal breaths delivered for the surgical patient.
volume to maximize gas exchange and limit ventilator-induced lung injury (VILI). Volume control breaths provide constant

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 94 10/28/11 8:41:27 PM

 Chapter 5: Pulmonary Risk and Ventilatory Support 95

flow and assure a constant minute ventila- at the alveolar level. Given that the normal ued hypoxemia. Prone positioning has
tion (but varying peak pressure). Pressure diffusion process favors CO2 elimination by a shown to be effective in improving the

Perioperative Care of the Surgical Patient

control breaths may improve oxygenation 20-fold difference, a shortened expiratory PaO2/FiO2 ratio for up to 10 days and can be
by virtue of increased mean airway pres- phase is usually not problematic. Reverse I/E discontinued when gas exchange benefits
sure, but this modality cannot guarantee ratios vary from 1:1 to 4:1 based on the sever- are no longer seen.
tidal volume consistency. Either of these ity of hypoxia. Caution should be exercised iNO may improve oxygenation by selec-
techniques can be used to provide lung pro- when increasing the I/E ratio. Often, the in- tive pulmonary vasodilation and subse-
tection, but neither is lung protective per crease in PaO2 is offset by the decrease in quent improvement in V/Q. Several trials of
se. The volume and pressure delivered to cardiac output with a resulting fall in oxygen iNO have demonstrated an improvement in
the patient should follow the guidelines delivery. the PaO2/FiO2 ratio, but all have failed to
presented above. If these considerations are Recent advances in ventilator mechan- demonstrate any survival benefit.
understood, then there is no specific advan- ics and sophistication have created the op- All of the above maneuvers (pressure
tage of one ventilator modality breath type portunity for the clinician to conduct bed- volume curves, prone positioning, recruit-
over the other. Choices for modes of venti- side pressure/volume curve analysis to ment maneuvers, and iNO) are correctly
lation multiply with each passing year (and establish the optimum PEEP level. Estab- understood as adjuncts in the management
with increasing sophistication of mechani- lishing a pressure/volume curve requires a of ARDS. Individually, each of these maneu-
cal ventilators), but the seminal issue re- short period of chemical paralysis in order vers has been demonstrated to improve
mains the clinical decision to provide either to eliminate the variability imposed by some aspects of the pulmonary dysfunction
full ventilatory support or allow spontane- spontaneous respiratory effort. Once this is associated with ARDS (V/Q mismatch, hy-
ous breathing. In the critically ill patient established, the ventilator will complete a poxemia, atelectasis, alveolar overdisten-
requiring heavy sedation and/or paralysis, constant flow maneuver while simultane- sion, etc.), but none have been associated
full ventilatory support with continuous ously evaluating circuit pressure and vol- with an improvement in mortality. It is up
mandatory ventilation (often called assist ume delivered. This pressure/volume curve to the clinician to ascertain when, which,
control) is usually required. In the previ- represents the global compliance of the re- and for how long all of these maneuvers
ously healthy patient with moderate hy- spiratory system as well as allowing for the may be combined in the individual patient
poxemia, spontaneous breathing may be detection of the upper and lower inflection with ARDS. Managing ARDS is a dynamic
promoted through the use of either syn- points. In an ideal situation, PEEP is set at process, which requires vigilance and un-
chronized intermittent mandatory ventila- (or slightly above) the lower inflection point. derstanding of the pathophysiology of the
tion (SIMV) or airway pressure release venti- This establishes an end expiratory pressure, disease. Protocol-driven treatment can be
lation (APRV). Maintenance of spontaneous which prevents repetitive alveolar collapse useful as a starting point, but modification
breathing improves V/Q matching, en- at the end of each ventilatory cycle. The up- of protocols to meet the needs of the criti-
hances venous return, and improves car- per inflection point establishes the upper cally ill surgical patient must be employed
diac output. To date, there is no compelling plateau pressure limit, which will aid in the to maximize success.
evidence, which demonstrates an advan- elimination of alveolar overdistension. This
tage of one technique over the other. technique allows the clinician to establish POSTOPERATIVE
Following the establishment of initial ventilator parameters, which allows for
ventilator settings an assessment of intra- “ventilating between the points.” To date,
VENTILATORY SUPPORT
vascular volume status should be accom- the utility of setting PEEP and plateau pres- Postoperatively, the surgical patient may re-
plished, and fluid replacement and inotropic sures via the utilization of modern ventila- quire mechanical ventilation for respiratory
support implemented as required to pro- tor pressure/volume curves has yet to be muscle weakness, pneumonia, prolonged
mote effective ventilator management. Re- established despite the intuitive nature of effects of anesthesia, or chronic lung dis-
cruitment maneuvers to assess the degree of this practice. If hypoxemia persists, a trial ease (COPD). The principles of ventilation
potential alveolar recruitment and improve of prone positioning is warranted. Prone for ARDS apply for the most part in these
gas exchange are warranted if gas exchange positioning improves the distribution of in- patients. In the patient without chronic
does not improve immediately. This can be spired volumes via alteration(s) in pleural lung disease, ventilation at a tidal volume of
accomplished by increasing PEEP to 30 cm pressure gradients. In addition, prone posi- 6 to 8 mL/kg of IBW, which maintains pla-
H2O for 40 seconds. Recruitment maneuvers tioning changes the physical relationship of teau pressure 30 cm H2O should be used.
are generally more effective in indirect than recruited versus collapsed lung segments Recent evidence suggests that patients re-
direct ARDS. An improvement in oxygen- as well as the physical location of displacing quiring mechanical ventilation for reasons
ation and reduction in the minute ventila- entities such as the heart. These combined other than ALI, are more likely to develop
tion to maintain the current CO2 elimination effects result in more efficacious pressure ALI if plateau pressures are excessive. The
are seen when the maneuver is successful. If gradients that favor recruitment. The dura- odds ratio of developing ALI is 1.5 for every
the beneficial effects of recruitment maneu- tion of prone position should be based on 6 cm H2O increase in plateau pressure.
vers are short lived, increasing levels of PEEP patient tolerance as judged by edema for- Spontaneous breathing should be encour-
following the maneuver are recommended mation and need to perform assessments aged and a PEEP of 5 cm H2O should be con-
to maintain recruitment. The normal ratio of or care procedures in the supine position. sidered the minimum value. PEEP should
inspiration to expiration (I/E) allows for a Ideally, a period of 9 to 12 hours prone be adjusted to maintain adequate arterial
two to three times longer expiratory phase should be interspersed with 4 to 6 hours su- oxygen saturation (92%).
during gas exchange. Failure of increased pine. Current evidence on the effects of The patient with COPD represents a par-
PEEP to improve oxygenation can often be prone positioning on outcomes is contra- ticular challenge. Noninvasive ventilation
overcome by a reversal of the I/E ratio. In- dictory. When prone positioning can be ac- (ventilation via a face mask) can prevent the
creasing the inspiratory phase allows a complished safely, the improvements are need for intubation, reduce hospital stay,
greater period of time for oxygen exchange worth the risk in the patient with contin- and mortality in this patient population.

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 95 10/28/11 8:41:27 PM

 96 Part I: Perioperative Care of the Surgical Patient

Much of this work is in the nonsurgical pa- 5. f/VT 105 (measured while breathing ■ Anxiety, Airway abnormalities, (meta-
tient, but a trial of noninvasive ventilation spontaneously with respiratory rate off bolic) Alkalosis
may be warranted in the absence of abdom- and pressure support off, for 1 min) ■ Neuromuscular disease, use of Neuro-
inal distension in the cooperative surgical muscular blockers
If the patient passes the first 1-minute
patient. Keys to the success of noninvasive ■ Sepsis, Sedation
trial, then an SBT of 30 to 120 minutes is
ventilation include use of a full face mask, ■ Nutrition (under- and overfeeding)
performed. The trial is successful if the pa-
choice of a motivated, cooperative patient, ■ Opiates, Obesity
tient tolerates 30 to 120 minutes of sponta-
use of pressure support or CMV, and a time ■ Thyroid disease
neous breathing. The trial may be termi-
period for respiratory therapist and nurse
nated if any of the following adverse events Weaning failure typically results as a
to acclimate the patient to the system. Suc-
occurs: consequence of an imbalance between re-
cess with noninvasive ventilation can be
judged by monitoring pulse oximetry and 1. Respiratory rate is 35 for 5 minutes. spiratory neuromuscular capacity and
evaluating patient comfort and rate of 2. SpO2 90% for 30 seconds. respiratory load. This imbalance leads to
breathing. Failure to alleviate air hunger 3. Heart rate increases 20% for 5 min- respiratory muscle failure. Common causes
generally indicates failure and endotracheal utes. of respiratory muscle failure include dy-
intubation should be completed prior to re- 4. Systolic blood pressure 180 mm Hg or namic hyperinflation, respiratory acidosis,
spiratory collapse. PEEP at low levels (5 to 90 mm Hg for 1 minute. decreased oxygen delivery, malnutrition,
8 cm H2O) should be used in the patient 5. Agitation, anxiety, or diaphoresis (com- excessive CO2 production, increased dead
with COPD to overcome terminal airway pared to baseline) lasting 5 minutes. space ventilation, increased respiratory
collapse, promote more complete alveolar system impedance, and intrinsic PEEP.
Patients who tolerate an SBT without Other causes of weaning failure include
emptying, and improve the ability of the pa-
adverse events have a 90% chance of suc- a decreased output of the respiratory con-
tient to trigger the ventilator. Set PEEP helps
cessfully remaining off the ventilator for trol center caused by oversedation, neuro-
overcome intrinsic PEEP and reduces the
48 hours. logic dysfunction, or use of narcotic drugs.
effort required to initiate inspiration.
Determining the ability of the patient to Cardiovascular dysfunction may also im-
protect the upper airway following extuba- pede weaning and left heart failure has
LIBERATION FROM tion remains a subjective observation. been demonstrated to be a cause of wean-
MECHANICAL VENTILATION Clearly, patients who are awake and ori- ing failure in COPD. Myocardial ischemia
ented are likely to remain extubated longer may occur during weaning due to increased
Discontinuing mechanical ventilation in- than those who are obtunded. The decision oxygen consumption of the respiratory
cludes the processes commonly known as to extubate a patient who has successfully muscles and stress.
weaning and extubation. These terms are completed an SBT, but has an altered men- Electrolyte abnormalities, acid–base dis-
often confused, but are quite different tal status remains an exercise in physician turbances, and unrecognized infection are
events. One implies removal of the ventila- judgment. The use of tracheostomy in these also occasionally seen. Acidosis is commonly
tor and the other implies removal of the selected cases may prove beneficial. Gener- seen as a cause of weaning failure, but meta-
artificial airway (usually an endotracheal ally speaking, in the head-injured patient if bolic alkalosis can also depress respiratory
or tracheostomy tube). Consequently, a the Glasgow Coma Score (GCS) is 8, tra- drive. After fluid resuscitation with lactated
patient can be ready for discontinuing ven- cheostomy can facilitate discontinuation of ringers, metabolic alkalosis is a common
tilatory support without being ready for ventilation and decrease the rate of ventila- finding. Critical illness polyneuropathy is in-
extubation (i.e., a deeply comatose patient tor-associated complications. If GCS is 8, creasingly recognized as a potential cause of
who is unable to clear secretions or main- patients can frequently be successfully extu- weaning failure. This syndrome has been re-
tain an adequate airway). Numerous re- bated. Tracheostomy can also facilitate ven- ported in up to 20% of ventilator-dependent
ports now clearly demonstrate that the tilator discontinuation in the elderly trauma patients. Critical illness polyneuropathy is
timing of discontinuation of mechanical patient or patient with COPD by reducing more common in patients with sepsis and the
ventilation is best determined through the work of breathing, enhancing secretion re- use of corticosteroids and neuromuscular
use of a screening technique and daily spon- moval, and improving patient comfort. blocking agents increase the incidence dra-
taneous breathing trials (SBTs). matically. This combination, which is com-
Weaning Failure mon in the asthmatic patient who requires
Evaluating Weaning Readiness The most common cause of weaning failure mechanical ventilation, places that popula-
is likely an underestimation of the ability of tion at significant risk for polyneuropathy.
The most recent literature suggests that a
patients to adequately support their own Improper ventilator settings may also
protocol of daily screening for weaning
oxygenation and ventilation. Prior to wean- interfere with weaning. Proper setting of
readiness and an SBT are the best modali-
ing attempts, the underlying cause, which sensitivity and matching of ventilator flow
ties for determining weaning readiness. The
resulted in institution of mechanical venti- output to patient demand is necessary to
daily screen consists of evaluating the over-
lation, must be alleviated. Ely and others eliminate patient/ventilator asynchrony.
all condition of the patient through the use
have developed a pneumonic to describe the Asynchrony, leading to tachypnea in the pa-
of five criteria.
difficult to wean patient, “WHEANS NOT.” tient with COPD can result in worsening
1. Patient coughs when suctioned suggest- This allows the clinician to evaluate the hyperinflation, increased triggering effort,
ing intact gag reflex many potential causes of weaning failure: and impede weaning.
2. No continuous infusions of sedatives or Nutritional state may also affect weaning
vasopressors (hemodynamic stability) ■ Wheezes readiness. Malnourished patients may have
3. PaO2/FIO2 200 (FIO2 0.50) ■ Heart disease, Hypertension reduced respiratory muscle strength, blunted
4. PEEP 8 cm H2O ■ Electrolyte imbalance responses to hypoxemia and hypercarbia,

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 96 10/28/11 8:41:27 PM

 Chapter 5: Pulmonary Risk and Ventilatory Support 97

and electrolyte abnormalities. Adequate the risk of pneumonia, allowed earlier ment in patients in whom operative inter-
nutrition should be provided early with an weaning, and was associated with few days vention represents a high risk. The theoretic

Perioperative Care of the Surgical Patient

emphasis on isocaloric feeding. Overfeed- in the ICU. Tracheostomy was initially per- concern of increased bleeding has been
ing with carbohydrate calories has been im- formed at the bedside when first described, suggested as a relative contraindication.
plicated in weaning failure and generally but because of occasional disastrous cases The preferred method of treatment for re-
includes not only excessive carbohydrate of lost airway and significant bleeding was tained hemothorax by the authors is VATS,
calories, but also a total caloric intake in ex- then advocated to be performed in the op- as it has been found to be a safe and effec-
cess of patient requirements. erating room. This is still the safest place for tive alternative to open thoracotomy for
a patient who is stable enough for trans- the management of retained hemothorax.
AIRWAY MANAGEMENT port. However, bedside percutaneous tra- The highest rate of success was obtained in
cheostomy has become a safe and standard patients who underwent VATS within 3 to
Establishing a patent airway via intubation procedure. This procedure allows for earlier 5 days postinjury. VATS has also been use-
or surgical access is an essential skill of the tracheostomy and in some cases facilitates ful in the treatment of persistent posttrau-
surgical intensive care team. Airway man- discontinuation of mechanical ventilation. matic pneumothorax by mechanical pleur-
agement facilitates mechanical ventilation, After removal from the ventilator, the cuffed odesis. The rate of conversion to an open
allows for improved removal of secretions, tracheostomy can be down-sized over a few procedure increases daily for each day be-
and can aid in the discontinuation of ventila- weeks followed by decannulation. yond 5 days postinjury. Once a fibrotic peel
tion. Airway management should be under- has been established or evidence of empy-
taken under the supervision of the most ema is seen on CT, most patients will require
skilled person available and the method of MANAGEMENT STRATEGIES open thoracotomy for decortication of the
access dictated by patient condition. General FOR RETAINED HEMOTHORAX entrapped lung segment. Patients who have
indications for intubation including hypox- AND EMPYEMA required mechanical ventilation in these
emia, hypercarbia, altered mental status, scenarios will often wean quickly after reex-
and respiratory muscle weakness are not al- Hemothorax is frequent occurrence follow-
pansion of the involved lung. Microorgan-
ways clinically practical. Generally speaking, ing blunt and penetrating trauma. The stan-
isms cultured from empyemas are often S.
the astute clinician can determine who needs dard management of a hemothorax is drain-
aureus and differ from concomitant intra-
to be intubated by clinical observation. age via a closed-tube thoracostomy. Most of
bronchial cultures, implying that these col-
Endotracheal intubation with the largest these patients are managed effectively with
lections are seeded from skin through the
internal diameter (ID) tube (7.0 to 7.5 mm this treatment; however, in a small percent-
chest tube itself. Chest tubes should there-
for women and 8.0 to 8.5 for men) is the pre- age (5% to 10%), the chest tube fails to com-
fore be placed with sterile technique when-
ferred method of airway control. Larger pletely evacuate the entire hemothorax. A
ever possible.
tubes allow bronchoscopy, facilitate secre- retained collection can then lead to a fibrotic
tion removal, and reduce the work of breath- collection with entrapped lung and/or an
ing. Nasotracheal intubation should be empyema. Treatment options include place- SUGGESTED READINGS
avoided unless there is a contraindication to ment of additional chest tubes, enzymatic Arozullah AM, Daley J, Henderson WG, et al.
endotracheal intubation. This is due to fre- debridement, video-assisted thoracoscopy Multifactorial risk index for predicting post-
quent traumatic insertion through the tur- (VATS), or thoracotomy with decortication. operative respiratory failure in men after ma-
binates, increased incidence of sinusitis, CXRs are of limited utility in the diagnosis of jor noncardiac surgery. The National Veterans
need for a smaller ID tube, tortuous path retained hemothorax. Pulmonary contu- Administration Surgical Quality Improvement
that effectively reduces in vivo resistance, sion, atelectasis with lobar collapse, or infil- Program. Ann Surg 2004;232(2):242–53.
trates can appear as persistent opacities on Biere SS, Cuesta MA, Van Der Peet DL. Minimally
and patient discomfort. Nasotracheal intu- invasive versus open esophagectomy for can-
bation is often performed in the field, and CXR making the diagnosis of retained he- cer: a systematic review and meta-analysis.
conversion to an endotracheal tube is advo- mothorax difficult with this study alone. Minerva Chir 2009;64(2):121–33.
cated in those patients thought to require Computed tomography (CT) of the chest is Branson RD, Johannigman JA. What is the evi-
prolonged mechanical ventilation. Elective the preferred method for confirming the di- dence base for the newer ventilation modes?
endotracheal intubation should be accom- agnosis. CT has been shown to be very ac- Respir Care 2004;49(7):742–60.
curate in the prediction of the amount of re- Brower RG, Lanken PN, MacIntyre N, et al. Nation-
plished in a controlled environment with al Heart, Lung, and Blood Institute ARDS Clini-
adequate patient sedation and paralysis if tained fluid and assisting with nonoperative cal Trials Network. Higher versus lower positive
necessary, and rapid sequence intubation versus operative decision making. end-expiratory pressures in patients with the
can be used if appropriately trained person- There remains some controversy in the acute respiratory distress syndrome. N Engl J
nel are immediately available. Following choice of management following failure of Med 2004;351(4):327–36.
tube placement, appropriate position should initial chest tube drainage for hemothorax. Croce MA, Fabian TC, Mueller EW, et al. The ap-
be verified by the presence of carbon dioxide Placement of a second CT is a reasonable propriate diagnostic threshold for ventilator-
associated pneumonia using quantitative cul-
in expired gas. This can be accomplished by option if positioning of the primary CT was tures. J Trauma 2004;56(5):931–4.
capnography or by CO2 detector, a device not deemed adequate. Typically, a second Evans SE, Scanlon PD. Current practice in pul-
that changes color in the presence of CO2. CT has the highest rate of success when monary function testing. Mayo Clin Proc 2003;
Auscultation of bilateral breath sounds can placed early (72 h) following injury. A few 78(6):758–63.
be helpful, but misleading. Verification by small series have demonstrated a benefit to Johansson M, Thune A, Nelvin L, et al. Random-
CXR should eventually be performed. enzymatic treatment with urokinase or ized clinical trial of open versus laparoscopic
streptokinase. Both enzymes work by clot cholecystectomy in the treatment of acute
Tracheostomy has been traditionally ad- cholecystitis. Br J Surg 2005;92(1):44–9.
vocated for those patients who fail weaning lysis and require serial treatments. This Richardson JD, Cocanour CS, Kern JA, et al. Periop-
over the first 2 weeks of illness. Rodriguez type of treatment strategy offers the advan- erative risk assessment in elderly and high-risk
has shown that early tracheostomy reduced tage of continued nonoperative manage- patients. J Am Coll Surg 2004;199(1):133–46.

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 97 10/28/11 8:41:27 PM

 98 Part I: Perioperative Care of the Surgical Patient

EDITOR’S COMMENT is 40% to 60% following major orthopedic surgi- promoted by Dr. Tom Shires. I do recollect rail-
cal operations or major traumatic injuries (high ing against the practice, when I was chair at Cin-
risk). Irrefutable evidence exists suggesting that cinnati, of generous or overgenerous crystalloid
Respiratory support is one of the critical issues VTE and pulmonary embolism are preventable resuscitation rather than colloid or cells or some
in patient care. In the intensive care unit (ICU), entities. Timely evidence-based clinical practice other type of resuscitation, rendering patients
respiratory support is what goes on principally guidelines exist for the prevention of VTE and are who looked like beached whales. I figured that
and depending on how expertly or inexpertly it the basis of this brief review. There should be an if the patientsí exterior looked as if the fluid had
is done, problems with systemic blood pressure institutional-wide identification of moderate- to accumulated in the interstitial tissue, what was
and perfusion can occur. A variety of newer mo- high-risk surgical patients and thromboprophy- different about the lung? And ARDS was indeed
dalities have been tried in an attempt to get bet- laxis should be a part of prevention of this initia- something that kept the patient in the ICU for a
ter perfusion and cause less damage to the lung. tive. Although there is a move to put in umbrellas longer period of time when we tried to diurese
Damage to the lung, also mentioned in Chapter 8 in the vena cava, this has less acceptance then them. My argument met with no avail and it is-
by Dr. John Marshall, is brought about by supine one would think because it does require a proce- nít until recently that people began to take a look
nursing. This has a distribution of blood flow that dure which is not without complications. at the resuscitation practices of excessive crys-
makes the lung more difficult to ventilate and As we shall see in some of the other papers talloid and withheld it until colloid, blood, and
provides greater damage during the process of in the discussion, ventilator-associated pneu- other blood components can be utilized thus
ventilation. One way of dealing with this damag- monia, or VAP, is one of the most common infec- avoiding the practice of flooding the patient with
ing form of ventilation is prone nursing, which tious complications in the treatment of patients crystalloid with prolonged ARDS in their lungs.
many of the more contemporary units are do- in the ICU, and indeed, there has been a great This does seem to have some effect and delays in
ing. Another alternative which the authors refer deal of effort in trying to prevent VAP. The at- crystalloid resuscitation probably for the benefit
is neuraxial blockade, which results in a lower tributable mortality is not clear; many of these of the patient.
systemic pressure as well as other indications of patients have numerous other comorbidities. Taking everything into concern, there is now
stress. Since neuraxial blockade actually refers to The excess cost of each episode of VAP exceeds a lot of work to try and idealize the management
the afferents, the sensory afferents that feel pain, $40,000, according to the authors. Diabetes mel- in the ICU and specifically in VAP.
etc., and since the other alternative is a rather litus, malnutrition, alcoholism, immunosuppres- A precise and thoughtful review of evidence
irregular or perhaps an infusion of narcotics, a sion, chronic obstructive lung disease, and many concerning VAP was recently published by Lorente
neuraxial blockade that prevents sensory input other usual suspects contribute to VAP. Gastric et al. (Am J Respir Crit Care Med 2010;182:870–76).
may provide some survival as well as a decreased alkalinization is thought to be essential to pre- They review various evidence-based guidelines as
expense and decreased time on the ventilator. vent stress-related mucosal injury prophylaxis, well as those that are not evidence-based includ-
Rogers et al. (BMJ 2000;321:1493) reported a yet it is not clear whether PPIs, proton pump ing endotracheal tubes with ultrathin cuff mem-
meta-analysis of reduction of postoperative mor- inhibitors, are the best agents. Antacids and his- branes, endotracheal tubes with low-volume/
tality and morbidity with epidural or spinal an- tamine-2 antagonists seem to have a better way low-pressure cuff, devices with continuous moni-
esthesia resulting from an overview of random- to go. We will discuss VAP a little later. The use of toring of the endotracheal tube cuff pressure, a
ized trials. In brief, these authors reviewed 141 antibiotics in patients who are infected and in- device to remove biofilm from the inner lumen of
smaller, randomized trials that included a total fection being one of the major reasons for these the endotracheal tube, saline instillation before
of 9,559 patients. The specific reduction in post- patients being in the ICU have provoked a lot of tracheal suctioning, and length of time before
operative mortality with neuraxial blockade re- work in bacteriologic diagnosis of VAP, which is doing tracheostomy. Guidelines diverge on the
sulted in significant reduction in the odds of deep diagnosed by a bronchoalveolar lavage >100,000 use of heat and moisture exchanges or heated
vein thrombosis, pulmonary embolism, blood cfu/mL. The study group underwent repeat BAL humidifiers and the use of an endotracheal tube
product transfusion, pneumonia, and respiratory after 3 days of adequate antibiotic therapy, and coated with antimicrobial agents. The review is
depression in the blockade group. However, all do if the pathogen growth on this repeat BAL cul- extensive and deals with the final end point of
not agree. Rigg et al. (Lancet 2002;359:1276–82) tures was <10,000 cfu/mL, then definitive anti- whether or not adopting of certain changes gives
randomized epidural use during the operative biotic therapy was discontinued. Study patients a higher or lower incidence or no effect at all of
and postoperative patients undergoing major ab- received significantly shorter durations of defini- VAP. This effort has been multinational and has
dominal or thoracic procedures as compared to a tive antibiotic therapy (9.8 days vs. 3.8 days vs. had as participants The 100,000 Lives Campaign
cohort receiving only systemic analgesia. About 16.7 days), with no difference in VAP recurrence endorsed by leading U.S. agencies and societies,
915 patients were included in this prospective, or hospital mortality. However, the French trial which established the ventilator bundle to reduce
randomized trial and there was no difference suggested that non-lactose-fermenting Gram- the incidence of VAP and other adverse events
in 30-day mortality. Of all of the parameters ex- negative bacilli more often received longer dura- (Berwick DM et al. JAMA 2006;295:324–27 as well
amined in this randomized trial, only the rate tions of therapy because of significant growth on as others.) The authors tried to categorize their
of respiratory failure was significantly reduced repeat BAL. The results of these various studies findings by those that they thought was excellent
with those in epidural use. There was a reduction support contemporary guideline recommenda- and that for which they could not make recom-
of pain scores during the first 3 days of infusion, tions for antibiotic duration in patients with mendations. Various groups have established a
although there was also a significant increase of VAP. It is generally believed that patients with a Pan-European VAP guideline as well as a Euro-
systemic blood pressure, and maximal heart rate reasonable clinical or microbiological response pean care bundle and then new guidelines were
probably indicated a lesser degree of stress. This should receive 7 to 8 days of antibiotic therapy, also referred. These are prominently displayed
is common in this sick group of patients. whereas patient with non-lactose-fermenting in this manuscript. There are also new strate-
Another major threat in ICUs is venous Gram-negative bacilli may require 14 days, which gies with the potential to prevent VAP, but these
thromboembolism (VTE) and pulmonary embo- at least in my observation is rarely carried out. have not been mentioned in either of the current
lism. These thromboses affect 350,000 to 600,000 Thus, the shorter duration leads to relapse and guidelines or in European care bundle. These
Americans annually and are directly or indirectly probably mortality. strategies include the use of an endotracheal
related to 100,000 deaths over this period. The One of the most common reasons why pa- tube with an ultrathin cuff membrane presum-
Surgeon General was so disturbed that a “Call tients spend time in the ICU is because of ARDS, ably avoiding material pooled above the endotra-
to Action” was issued in 2008. The rationale for the credit to this was given in 1967 to Ashbaugh cheal tube from getting into the lungs and then
increased attention to the prevention of VTE is and Petty, then at the University of Colorado, for to take a tracheal tube with a low pressure/low
based on the premise that almost all hospitalized describing this entity. In actual fact, John Burke volume cuff, a device for continuous monitoring
patients have at least one risk factor for throm- of the Massachusetts General Hospital first de- of cuff inflation pressure, a device for removing
boembolism, and that approximately 40% have scribed this in a publication(Burke JF et al. Ann biofilm formation, and a review of the practice of
three or more risks as indicated in Table 7 of this Surg 1963;158:581–92). He called it high-output saline instillation before tracheal suction. In ad-
chapter. Without thromboembolism prophylaxis, respiratory failure and in fact it is the same en- dition, although there are not many such papers,
the rate of VTE is 10% to 40% in medical and sur- tity. In addition, ARDS seem to coincide with an analysis of the time of tracheostomy has also
gical populations at moderate risk, and the rate the practice of “resuscitating the third space” as been studied.

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 98 10/28/11 8:41:28 PM

 Chapter 5: Pulmonary Risk and Ventilatory Support 99

The gold standard is, of course, randomized which can be put on automatic evaluation. The years 2002 and 2006. They defined prolonged me-

Perioperative Care of the Surgical Patient

controlled trials and meta-analysis; if there are authors conclude by saying that the intracuff chanical ventilation as a 21-day cutoff. Incidence
no reservations of benefits, harms, and costs, pressure should be maintained between 20 and was calculated using all ICU admissions and
measures are defined as “worth considering,” and 30 cm of water, and although the cuff pressure ventilated ICU admissions as denominators. The
if the benefit is supported by studies other than was better controlled with the automatic device, outcomes for mortality and hospital resource use
randomized controlled trial and meta-analysis or there is currently insufficient evidence to make were compared with the prolonged nonmechani-
if there are minor uncertainties about the ben- a definitive recommendation concerning its cal ventilation cohort. The length of ICU stays
efits, harms, and costs, the measure is defined as use. The device to remove biofilm formation as beyond 21 days was used to model the effect of
“more research needed.” Extensive studies and well as saline instillation before tracheal suction establishing a weaning unit in terms of unit occu-
meta-analyses are quoted in the papers. Of the have their detractors and their adherents, but pancy rates, admission refusal rates, and health
measures not reviewed in the guideline, endo- although saline instillation may be a temporary care costs.
tracheal tube with an ultrathin cuff membrane option in very thick secretions, it did not rise to Out of 8,290 ICU admission episodes, 7,848
was reviewed by Dezfulian and colleagues, Am J the level of a recommendation. were included in the analysis. Mechanical ven-
Med 2005;118:11–18, who analyzed endotracheal Many intensivists believe that in patients who tilation was required during 5,552 admission
tubes with subglotttic secretion drainage (SSD) in it seems will go on for a long period of time that episodes, of which 349 required prolonged me-
896 patients from five studies. Patients intubated early tracheostomy provides some benefit. This chanical ventilation. The incidence of prolonged
with a tube with SSD had a lower risk for VAP due unfortunately is not the case, and in a random- mechanical ventilation was 4.4 per 100 ICU ad-
to a reduction of early onset pneumonia. Four ized prospective trial as well as a meta-analysis missions, and 6.3 per 100 ventilated ICU admis-
of the five studies recruited patients who were by Blot F, Intensive Care Med 2008;34:1779–87, sions. An astounding number, 29.1%, of all gen-
thought to require more than 72 hours of me- who actually did a study despite their own feel- eral ICU beds days were occupied by patients
chanical ventilation. After the meta-analysis, a ings, 125 patients who required more than 7 utilizing prolonged mechanical ventilation. They
study published by Bouza E and colleagues, Chest days of mechanical ventilation were random- spent longer time in the hospital after ICU dis-
2008;134;938–46, randomized 714 cardiac sur- ized to receive either prolonged intubation or charge (median 17 vs. 7 days, P < 0.001) and had
gery patients who received mechanical ventila- early (within 4 days) tracheotomy. There were higher hospital mortality (40.3% vs. 33.8%, P =
tion with SSD or conventional tube; there was no no differences in these groups in mortality, VAP 0.02). For this particular region where approxi-
significant difference in this group between VAP incidence, duration of mechanical ventilation, mately 70 prolonged mechanical ventilation
incidence in the intubation with or without SSD. ICU stay, sedation use, or laryngeal or tracheal patients were treated each year, a weaning unit
However, in patients receiving mechanical venti- complications. The only additional point was with a capacity of three beds appeared most ef-
lation for more than 48 hours, the patients with that there was greater comfort afforded by early ficient at an occupancy rate of 73% and poten-
SSD presented a lower SSD incidence (26.7% vs. tracheotomy. tial cost savings of £344,000. Thus, these authors
47.5%, P = 0.04), a shorter length of ICU stay, me- Others disagree. The meta-analysis recently concluded that 1 in every 16 ventilated patients
dian 7 days versus 17 days, P = 0.01, and reduced published by Durbin and colleagues (Durbin CG requires prolonged mechanical ventilation in
hospital antibiotic costs from €1.2 million versus Jr et al. Respir Care 2010;55:76–87) included 641 their region and they use an enormous number
€1.9 million, P < 0.01. patients from seven randomized or quasi-ran- of health care resources. Establishing such a
Another strategy that may prevent VAP is to domized studies which compared early tracheo- weaning unit could potentially reduce acute bed
have an endotracheal cuff which folds with the stomy either with late tracheostomy or with pro- occupancy, from 8% to 10%, and reduce overall
various parts of the trachea and prevents mate- longed endotracheal intubation. No significant treatment costs. In addition, as the ages of the
rial from running past the endotracheal tube and differences were found with the risk of pneumo- population prolong, mechanical ventilation is
the cuff and into the lungs. Ultrathin membranes nia or mortality. However, by restricting the anal- expected to increase and therefore this would
have a thickness of 7 μm compared to the usual ysis to three randomized trials, comparing early save even more than the aforementioned health
<50 μm with a conventional polyvinyl chloride tracheostomy (performed within the first 5 days) care savings.
cuff. Different shapes of endotracheal tubes were versus late tracheostomy, a reduction in mortality Several papers have undertaken the study of
also studied and perhaps a high-volume/low- and ICU stay was found with early tracheostomy. what happens to patients after ARDS. In particu-
pressure cuff would better conform to the trachea I am not certain whether this is statistically cor- lar, Herridge MS et al. and the Canadian Critical
to prevent leakage of fluid below the cuff. Con- rect. If one is doing a meta-analysis from seven Care Trials Group (N Engl J Med 2011;364:1293–
trast studies have indicated that due to folds, all trials, one should continue to do the trials in all 304) obtained critical care follow-up data on a
conventional HVLP endotracheal tubes showed seven and not select out a group according to the group of 109 survivors of ARDS at times up to 5
additional contrast within the cuff area. Thus, kind of results that one wants. Lorente et al., who years after discharge from the ICU. The patients
although no direct recommendation could be are previously quoted, conclude by saying that were evaluated at 3, 6, and 12 months and at 2,
made, it is promising. A similar thing can be said they believe the use of an endotracheal tube with 3, 4, and 5 years after discharge from the ICU.
about the tapered shape. Taken with all the evi- an ultrathin and tapered-shaped cuff and coated At each visit, patients were interviewed and ex-
dence, incorporation of an ultrathin membrane in an antimicrobial agent can reduce the risk of amined; they underwent pulmonary-function
cuff and a tapered shape cuff could be defined as VAP. The combination of both of these features tests, 6-minute walk tests, resting and exercise
“worth considering.” with SSD, they believe, offers an attractive way to oximetry, chest imaging, and a quality-of-life
Continuous monitoring of cuff pressure optimize VAP prevention. evaluation. They also reported on their use of
has made its way into several ICUs in an effort They further conclude that the early tracheo- health care services. These authors found that
to provide less leakage of material from the stomies should be considered in patients with an there was a significant functional disability in
glottis and the pharyngeal area into the lungs. anticipated length of mechanical ventilation for these patients. At 5 years, the median 6-minute
There was a trend as evidenced by Rello and col- more than 7 days, based on the reduction of me- walk distance was 436 m which was 76% of the
leagues (Rello J et al. Am J Respir Crit Care Med chanical ventilation and length of ICU stay and predicated distance and the Physical Compo-
1996;154:111–15) in which there was a higher mortality and on patient comfort. nent Score on the Medical Outcomes Study 36-
incidence of risk of VAP among patients with Lone and Walsh (Crit Care 2011;15:R102), item Short-Form Health Survey was 41 with a
persistence intracuff pressure below 2 cm of working in a center with many patients requir- mean norm score matched for age and sex, 50.
water. Among intubated patients not receiving ing prolonged mechanical ventilation, raised the Younger patients had greater level of recovery
antibiotics, persistence intracuff pressure below question as to whether or not prolonged mechan- than older patients, but neither group returned
20 was independently associated with a risk of ical ventilation is likely to increase and if so trans- to the predicted level of physical function at 5
VAP; however, the cuff pressure should be main- ferring patients to specialized weaning units may years. Pulmonary function, surprisingly, was
tained under 30 cm of water to prevent tracheal improve the outcomes and reduce costs. normal to near-normal. A constellation of other
injury. There are many ways of determining In order to study this, a retrospective cohort physical and psychological problems developed
cuff pressure, whether done manually or when study was undertaken using a database of admis- or persisted in patients and family caregivers for
there is actually a machine connected to the cuff sions to three ICUs in a U.K. region between the up to 5 years.

(continued)

www.medicalebookpdf.com

LWBK892_c05_p083-099.indd 99 10/28/11 8:41:28 PM

 100 Part I: Perioperative Care of the Surgical Patient

The authors concluded that exercise limita- 6-minute walk tests that showed that they were material may be difficult to address later. They
tion, physical and psychological sequelae, de- substandard and remained so throughout the 5 reason that early thoracoscopy may improve the
creased physical quality of life, and increased costs years. outcome is because of the fact that there is not
and use of health care services are important leg- In spite of the persistent physical limitation, much of an incision and much of what needs
acies of severe lung injury. An accompanying edi- 78% of these patients were able to return to work to be done is done through thoracoscopy ap-
torial in the same issue of The New England Jour- by 1 year after ICU discharge and the percentage proaches.
nal of Medicine by Jesse B. Hall and John P. Kress of those working rose to 94% by the 5-year mark. They conducted a retrospective review of 88
entitled “The Burden of Functional Recovery They make several other comments including the stable patients with penetrating wounds of the
from ARDS” (N Engl J Med 2011;364(14):1358–59) prevention of neuromuscular dysfunction in ICU chest initially treated with chest tube and who
noted that the near-normal lung function at 1 survivors which would likely be “an arduous task” had retained a hemothorax beyond 48 hours.
year persisted without deterioration at the 5-year but “some evidence suggests that it is possible. Twenty-seven of these patients underwent an
mark. Thus, it appears that it is safe to conclude Reducing bed rest with early mobilization while early video-assisted thoracoscopy (VATS). In
that near-normal recovery of lung function can the patient is in the ICU is a reasonable starting contrast, no activity other than observation
be expected relatively early in the average ARDS point.” was undertaken in the remaining 55, although
survivor with no evidence of subsequent dete- Finally, Naveed Ahmed and Raphael Chung the chest tubes were manipulated or additional
rioration. Similarly, the mental component score studied the role of early thoracoscopy for man- ones placed. They found that early VATS re-
of the Medical Outcomes Study 36-item Short- agement of penetrating wounds of the chest (Am duced the length of stay (4.3 vs. 9.4 days), days
Form Health Survey appeared to approach near- Surg 2010;76:1236–39). They point out that most in the ICU (1.3 vs. 3.2), and open thoracotomy
normal. However, the SF-36 physical component non-life-threatening, penetrating wounds of the (0 vs. 7). They conclude that a chest tube alone
scores plateaued at the 2-year mark and never chest are treated with a chest tube alone. They undertreats a non-life-threatening, penetrating
reached the levels seen in the normal population. raise the inadequacies of this treatment because wound of the chest and this is correctable by
This emphasis coincides with the results of the missed injuries, retained hemothorax, or foreign timely VATS.
J.E.F.

6 Hemorrhagic Risk and Blood Components

Allen Hamdan and Amy Evenson

INTRODUCTION hepatitis B, ⬎4 million hepatitis C, and was obviously not screened at that time.
160,000 HIV infections per year. Up to 20% Soon after, nucleic acid amplification tech-
Although surgeons often rely on the exper- of donated blood is not tested for trans- nology was adapted for detection of this
tise of pathologists, hematologists, and missible infections and 25% of maternal virus and the threat was essentially re-
blood bank personnel, some of the subtle- deaths can be linked to blood loss and moved. Current screening practices include
ties regarding use of blood components are incumbent issues related to the blood review with the potential donor of risk fac-
critical to a surgeons’ complete care of the supply. tors as well as history of transmittable in-
patient. Therefore, it is important to have It is clear from studies that paid donors fectious disease such as hepatitis C and B,
an understanding of the basics of hemosta- are more likely to conceal information HIV 1 and 2, HTLV I and II, malaria, babe-
sis, the clotting cascade, and fibrinolysis, as about risky behavior. In a number of coun- siosis, and Chagas disease. Blood is also
well as common disorders and coagulation tries, achieving a donor base that is at screened for indications of underlying in-
abnormalities that may be encountered. In least 50% altruistic is a difficult target to fection.
addition, it is crucial to understand the reach. The Pan-American Health Organi- Although most surgeons view hemosta-
risks and benefits of transfusion therapy, zation funded by the Gates Foundation, sis as the appropriate suture and knot, clear
the complications of said therapy, and has attempted to ensure that the region’s knowledge of the clotting cascade is criti-
particular situations where issues may be blood supply is screened for hepatitis and cal. It is very important to understand the
expected to occur. Finally, a description HIV, as well as other endemic problems types of factors or blood products that
of heparin-induced thrombocytopenia such as Chagas disease. In addition, cen- should be administered at any given time
and the use of new anticoagulants are pro- tralized blood collection systems have and what the potential issues/contraindi-
vided. obvious advantages over small or local cations may be. Since each product ordered
It is accurate to state that many sur- banks. from the blood bank carries some risk, at
geons take for granted the safety of the An episode from 2002 in this country is least a basic facility with their uses is ex-
U.S. blood supply, but lessons learned in illustrative of potential problems even pected. Part of the overall care of the pa-
other countries are illustrative. Approxi- when the blood is extensively tested. There tient is based on the evaluation of preexist-
mately 80% of the world’s population has are new viruses that become endemic and ing “bleeding” disorders as well as those
access to only 20% of the safe blood sup- especially if the time from incubation to de- that may be acquired from complications
ply. For instance, in places such as Latin velopment of disease is long (Creutzfield- related to surgery or new underlying dis-
America, where donations are often non- Jacob), identification and screening can be ease processes. Finally, understanding the
altruistic (i.e., done for livelihood pur- difficult. In 2002, about 4,200 people were use and/or complication of the omnipres-
poses), infection with human immunode- infected with mosquito-borne West Nile ent heparin (mainly related to heparin-
ficiency virus (HIV) and hepatitis is not virus. During this time, there were 23 cases induced thrombocytopenia), as well as the
uncommon. Transfusion of unsafe blood of transfusion-transmitted infection and myriad novel anticoagulants is part of ex-
products accounts for up to 16 million seven related deaths due to this virus, which cellent surgical care.

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 100 10/28/11 10:15:44 PM

 Chapter 6: Hemorrhagic Risk and Blood Components 101

COMPONENTS OF NORMAL action with negatively charged surfaces. found naturally on endothelial surfaces and
HEMOSTASIS There are multiple overlaps and amplifica- contains a critical pentasaccharide that in

Perioperative Care of the Surgical Patient

tion steps, partly based on autocatalytic na- part mediates the physiologic action of
Hemostasis relies on a dynamic, minute-by- ture of certain factors. The remainder of the antithrombin. This allows the endothelial
minute interactive process between plate- pathway follows along with the extrinsic cells to have already activated antithrombin
lets and coagulation complexes. When cells mechanisms. on their surface allowing destruction of ex-
are injured, tissue factor (TF) is released To understand the extrinsic pathway, cess thrombin in the general circulation.
and this activates the extrinsic pathway. the critical role of tissue factor or thrombo- Activated protein C (APC) joins with
This damage of the endothelium of blood plastin needs to be delineated. Tissue factor protein S on phospholipid surfaces and
vessels exposes the underlying collagen to is an integral membrane glycoprotein that causes the proteolysis of Factors Va and
platelets and thus, activates them. In the is not typically expressed on vascular en- VIIIa. Of note, protein S functions to am-
blood, tissue factor forms a complex with dothelial cells, but is noted on skin, vascu- plify the effects of activated protein C. This
activated Factor VIIA. This complex subse- lar adventitia, and organ surfaces. Typically, is critical because this complex inactivates
quently activates IX and X. At the same tissue factor is exposed to flowing blood both prothrombinase and the intrinsic
time, stimulated platelets change their only after endothelial damage. Cell lysis X-ase. Elucidation of the importance of APC
shape, externalizing among other enzymes, leads to activation of tissue factor, which is can occur with understanding of the hema-
the procoagulant phospholipid platelet fac- normally in a dormant state. It may also cir- tologic condition, Factor V Leiden, in which
tor 4 (PF4). Coagulation proteins can thus, culate in the blood in microvesicles, typi- the arginine in Factor V is replaced by glu-
assemble on the surface of the platelets al- cally of stimulated macrophages. These mi- tamine, thus making it not susceptible to
lowing acceleration of coagulation reac- crovesicles can then fuse with and initiate cleavage by activated protein C. This leads
tions. Dormant platelets do not express coagulation-activated platelets. The end to promotion of a potentially hypercoagu-
binding sites for coagulation factors. von product of TF’s interactions, which are lable state. When heterozygous, this can be
Willebrand factor (vWF) is responsible for complex, is activated Factors X and IX. “dormant,” until one develops an inflamma-
platelet adhesion by binding to glycopro- Since Factor X is at the center of all coagu- tory state (infection, trauma, and surgical
tein IB. Fibrinogen forms bridges between lation reactions, it is critical that both path- injury) in which the acute phase reactant
platelets by binding to glycoprotein IIB/IIIA ways lead to the production of Xa. This is C4B-binding protein (compliment system)
and adjacent stimulated platelets. This made even more apparent if one focuses on is increased. Since this binds freely circulat-
leads to a platelet plug being formed. Fac- the extrinsic pathway alone, since the ing protein S, the likelihood of thrombosis
tor Xa can now activate Factor V. Ionized amount of TF generated is fairly limited, is enhanced.
calcium and prothrombin now complex on partly due to the presence of tissue factor Protein C and S primarily function as cir-
the platelet lipid surface to initiate the cat- pathway inhibitor. culating anticoagulants; thus, as will be de-
alyzation that leads to the formation of scribed further in this chapter, they become
thrombin. CONTROL MECHANISMS AND critical during periods when thrombosis ex-
All coagulation, regardless of whether it ceeds fibrinolysis. This can be seen in a
is related to extrinsic or intrinsic pathway
TERMINATION OF CLOTTING number of scenarios but it is easy to under-
requires thrombin. Thrombin, among other For any organism to have the ability to have stand when you note that Coumadin, the
things, acts to cleave fibrinopeptide A from flowing blood, heal wounds, and stop bleed- most widely used anticoagulant, is initially a
the alpha chain of fibrinogen and fibrino- ing, as stated above, a very intricate set of procoagulant since it inhibits protein C and
peptide B from the beta chain. This release of checks and balances needs to be in place. If S (short half-life) before it effects the clotting
fibrinopeptides allows formation of fibrin hemostasis, which is part of wound healing cascade factors. This is one of the main rea-
monomers, which cross-link. Thrombin, in and tissue remodeling, was allowed to go sons patients with active heparin-induced
addition, activates Factor XIII, which affects unfettered, patients would not survive after thrombocytopenia should not receive Cou-
a number of coagulation processes. These any injury. Thus, innate pathways have been madin until they are fully anticoagulated
include acceleration of cross-linking of fibrin developed to aid in both clot elimination with direct thrombin inhibitors (DTIs).
to make the clot harder, activation of plate- and fibrinolysis. In addition, these are Plasminogen, a precursor to plasmin,
lets, as well as Factors V and VIII. It also changing second by second at a molecular forms a ternary complex with fibrin and
cross-links other plasma proteins such as level and do not just remain stagnant until TPA. This leads to generation of a very ac-
fibronectin and incorporates them into the some event such as a trauma occurs. Anti- tive proteolytic plasmin, which destroys
clot. What is apparent is that many com- thrombin, heparans, activated protein C fibrin, fibrinogen, and a number of other
plexes/mechanisms are interacting at a and S, and tissue plasminogen activator plasma proteins and clotting factors. When
given time, but derangement of just one key (TPA) are a few of the critical factors in- plasmin is active, it leads to release of fibrin
component can lead to disastrous problems. volved in halting further clot, its elimina- degradation products; this is what is mea-
The intrinsic pathway basically requires tion, and eventual fibrinolysis. sured in the d-dimer laboratory test. TPA
the formation of XIa from XI. This involves Antithrombin is circulating plasma pro- itself is an endothelial cell enzyme that cir-
changes on the vascular surface and starts tease inhibitor with two functional sites, culates as a complex with its inhibitor plas-
with XIIa converting XI to Xia, which in a so-called reactive center and heparin- minogen activator inhibitor one (PAI-1).
turn converts IX to IXa. The combination of binding site. It forms equimolar irreversible TPA recognizes lysine residues on the fibrin
IXa, X, calcium, and VIIIa on the platelet complexes with a majority of enzymes in clot and when it binds, this aligns TPA with
surface forms the x-ASE complex, which the clotting cascade including thrombin, Xa plasminogen directly on the fibrin surface
then catalyzes the conversion of Factor X to and IXa. The binding of endogenous or ex- making its efficacy increase exponentially.
Xa. The process can occur by the contact ogenous heparins or heparans to the active Urokinase is also a plasminogen activator
activation system with Factor XII and site produces a conformational change. and, whereas TPA initiates and continues in-
prekallikrein, and also by thrombin’s inter- The glycosaminoglycans heparan sulfate is travascular fibrinolysis urokinase functions

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 101 10/28/11 10:15:45 PM

 102 Part I: Perioperative Care of the Surgical Patient

mainly in the extravascular space. PAI-1 is function versus a coagulation factor defi- taken in a multidisciplinary approach in-
made both by platelets and endothelial ciency. Petechiae, superficial ecchymoses, cluding hematologists and blood bank phy-
cells. In those deficient in PAI-1 significant mucocutaneous bleeding, and purpura are sicians for optimal outcomes.
bleeding can develop when the normal suggestive of platelet or blood vessel abnor-
mechanisms are overwhelmed by things malities, while deep tissue hematomas and Congenital Disorders of Platelets
such as trauma. It is aggressively released hemarthroses implicate inherited defects
by activated platelets and probably ac- in coagulation factors.
and Coagulation Factors
counts for the fact that platelet-rich clots In the absence of identified risk factors, Congenital defects of platelet number and
seen in arterial thrombus are much harder patients may proceed to minor procedures function are rare. A history of abnormal
to lyse than the cell-poor thrombus noted without formal laboratory evaluation of he- bleeding and easy bruisability is often pres-
in venous clots. mostatic parameters. General screening tests ent with abnormal tests of platelet function
are recommended for more invasive proce- (bleeding time or PFA-100) discovered on
PREOPERATIVE dures or in the setting of concerns raised on evaluation. Glanzmann thrombasthenia is
EVALUATION FOR history and physical examination. Initial test- an autosomal recessive disorder resulting
ing of platelet count, prothrombin time (PT), in an abnormal glycoprotein IIb/IIIa recep-
BLEEDING RISK and activated partial thromboplastin time tor that prevents platelet clumping. Treat-
Many patients at risk for perioperative (aPTT) may identify some patients at risk for ment with platelet transfusion or recombi-
bleeding complications can be identified perioperative bleeding and distinguish be- nant Factor VIIa may be required for
through the performance of a complete tween defects of platelets and coagulation hemostasis. Bernard-Soulier syndrome re-
personal and family history and physical factors. Peripheral blood smear will provide sults from a defect in the glycoprotein Ib–IX
examination. Basic screening and confir- insight into platelet number and morphology. complex that prevents platelets from ad-
matory testing may be performed as indi- Bleeding time has long been recommended hering to blood vessel walls. Storage pool
cated by findings on this initial evaluation. as a comprehensive test of platelet and blood disorders refer to specific deficiencies
Appropriate perioperative management of vessel hemostatic functions, although it is not within platelet granules that result in poor
patients with bleeding disorders depends uniformly offered at all centers due to the re- platelet aggregation. One such example is
on identifying those patients at risk and de- sources involved in performing the test as Wiskott-Aldrich syndrome, an X-linked re-
fining the defect in coagulation pathways well as variation in technical factors in per- cessive disorder that is also associated with
that may be present. formance of the test. The Platelet Function immunodeficiency. Other storage pool dis-
Initial discussion with the patient cen- Analyzer (PFA-100) is a more standardized orders include Chediak-Higashi syndrome,
ters on the occurrence of prior serious test of platelet function and is increasingly Hermansky-Pudlak syndrome, and throm-
bleeding problems related to injuries, den- available. Prothrombin time tests for integrity bocytopenia-absent radius syndrome. Plate-
tal procedures, surgical procedures, or men- of the extrinsic pathway and is used to moni- let transfusion is often required but may
struation and childbirth in women. Of par- tor the effects of Warfarin. Due to variability result in production of antihuman leuko-
ticular concern are episodes of spontaneous, in assays, the PT is usually reported as an in- cyte antigen antibodies or antibodies to the
excessive, or delayed in onset. A family his- ternational normalized ratio (INR). aPTT missing receptors, resulting in rapid de-
tory of bleeding episodes should be elicited, tests the intrinsic pathway of coagulation struction of the transfused platelets.
although a negative family history does not and is used to monitor heparin effects. An von Willebrand disease (vWD) is the
entirely exclude an inherited coagulation elevated aPTT may suggest heparin effect or most common inherited bleeding disorder
disorder due to the occurrence of spontane- deficiency of any factor, except VII and XIII. and results from defects in vWF, a glycopro-
ous mutations and incomplete penetrance Concern for deficiency of specific coagulation tein responsible for platelet adhesion to
of certain conditions. Prior history of iron- factors may be assessed by testing for specific vascular subendothelium as well as car-
responsive anemia or need for transfusions factors or factor inhibitors. Fibrinogen activ- riage of Factor VIII. Multiple subtypes have
as well as history of thyroid, liver, or kidney ity may be measured while testing for abnor- been identified with variable clinical pre-
disease may suggest a bleeding diathesis. mal fibrinolysis and is assessed by measuring sentation. Type I is the most common form,
Review of prescription and over-the-counter fibrin and fibrinogen degradation products resulting in a decreased quantity of vWF.
medications may also reveal patients at risk (FDP). Measurement of d-dimers reflects Type II vWD results from an abnormal con-
for perioperative bleeding. While prescrip- presence of clot as breakdown of previously figuration of the glycoprotein. Type III is
tion anticoagulants such as aspirin, clopi- cross-linked fibrin is required. Findings of the the most severe form with essentially no
dogrel, and Warfarin are well known to in- various tests of coagulation are described vWF activity. Type I vWD responds to ad-
crease bleeding risk, many frequently used with the disorders described below. ministration of DDAVP, while types II and
nonprescription medications, vitamins, and III require cryoprecipitate or Factor VIII re-
dietary supplements can also interfere with COMMON COAGULATION placement.
hemostatic mechanisms. Nonsteroidal anti- Clinically important deficiencies of most
inflammatory agents, vitamin E, ginkgo bi-
DISORDERS factors in coagulation have been reported.
loba, ginseng, garlic, and echinacea have all Acquired bleeding disorders are much more The most common disorders are hemo-
been associated with an increased risk of common than congenital deficiencies in philia A and B resulting from defects in Fac-
bleeding. In addition, use of antibiotics may coagulation. A review of common bleeding tors VIII and IX, respectively. Both forms of
alter the gut flora metabolism of vitamin K disorders serves to outline the use of preop- hemophilia are X-linked recessive disorders
while malnutrition or malabsorption may de- erative screening and diagnostic testing as with up to 20% of cases representing spon-
crease the synthesis of vitamin K-dependent well as appropriate management to mini- taneous mutations with no prior family his-
coagulation factors. mize morbidity and mortality following tory. Percent of factor level present deter-
Physical examination help distinguish surgical procedures. Management of these mines the severity of presentation with
between disorders of platelet number and uncommon conditions should be under- severe cases associated with ⬍1% activity,

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 102 10/28/11 10:15:45 PM

 Chapter 6: Hemorrhagic Risk and Blood Components 103

moderate cases with 1% to 5% activity, and this chapter) is a growing cause of morbidity recombinant Factor VIIa to immediately re-
mild cases with 5% to 50% activity. Severe and mortality in medical and surgical verse the INR (Grade 1 C).”

Perioperative Care of the Surgical Patient

cases manifest spontaneous hemorrhage in patients. Acquired inhibitors of many coagulation
joints, muscles, and soft tissues; moderate Uremia is associated with increased factors have been described. The most com-
cases have less spontaneous bleeding but bleeding due, at least in part, to platelet mon of these acquired inhibitors are Factor
may have prolonged bleeding after trauma dysfunction. This dysfunction is thought to VIII inhibitors. Patient with hemophilia A
or surgery; and mild cases are often not sus- be multifactorial and include abnormal may develop antibodies due to repeated ex-
pected until bleeding occurs after invasive glycoprotein expression, platelet granule posure to exogenous Factor VIII. Other risk
procedures. Both forms of hemophilia pres- function, and prostaglandin and throm- factors for development of anti-factor VIII
ent with normal platelet counts, normal boxane metabolism in combination with antibodies include pregnancy, rheumatoid
PT/INR, and prolonged aPTT; reduced fac- uremic toxins, anemia, and abnormal en- arthritis, malignancy, medications, and sys-
tor levels are discovered on further testing. dothelium. Dialysis to correct uremia and temic lupus erythematosus. Bleeding may
Treatment with specific factor concentrates administration of 1-deamino-8-D-arginine be spontaneous or following tissue trauma
or fresh frozen plasma (FFP) is required to vasopressin (DDAVP) are both recom- and is often severe. Initial testing demon-
prevent bleeding during and after proce- mended to counter altered platelet func- strates a prolonged aPTT while inhibitor
dures. Mild cases of hemophilia A may also tion in renal failure. Liver disease has a screening via mixing tests are required to
be treated with DDAVP, which causes the multitude of effects on the coagulation sys- identify the presence of an inhibitor. The
release of Factor VIII into the circulation. tem (see below) including platelet function Bethesda assay confirms presence of Factor
Specific formulas are available to guide dos- and number. Acute hepatitis may cause VIII inhibition through the use of serial dilu-
ing of replacement therapies in the periop- transient thrombocytopenia while cirrho- tion of patient plasma. Treatment of Factor
erative setting. Correction of factors must sis may lead to portal hypertension, hyper- VIII inhibition requires immunosuppression
be maintained in the postoperative setting splenism, and resultant thrombocytopenia. using prednisone, cyclophosphamide, intra-
to avoid delayed onset of bleeding. Qualitative defects in platelet aggregation venous immunoglobulin, or plasmapheresis
Spontaneous and postprocedure bleed- are also seen in chronic liver disease. Im- to remove the antibody. Administration of
ing due to abnormal fibrinolysis has been mune-mediated thrombocytopenic pur- DDAVP and exogenous Factor VIII at high
described. Absence or abnormalities of fi- pura, thrombotic thrombocytopenia pur- doses may overcome the inhibitor; recom-
brinogen, plasminogen activator inhibitor-1 pura, and systemic lupus erthematosus binant factor VIIa may be required in cases
(PAI-1) deficiency, and alpha-2-antiplasmin also commonly cause decreased platelet with high titers or significant bleeding. An-
deficiency may all lead to prolonged bleed- counts. Treatment of these etiologies of tibodies to prothrombin, thrombin, and
ing. The diagnosis and management of thrombocytopenia may include platelet Factors V, VII, IX, X, XI, and XIII have been
these disorders is beyond the scope of this transfusion, steroids, or splenectomy de- described. Treatment for these disorders in-
text and consultation with experts in he- pending on the clinical circumstances and cludes administration of FFP or factor con-
matology is advised in managing patients presence of bleeding. centrates if available; immunosuppression
with these conditions in the perioperative may also be required to suppress or remove
setting. Disorders of Coagulation Factors the antibody.
and Mixed Abnormalities Chronic liver disease results in multiple
Acquired Disorders of Platelets defects in coagulation. All factors except
Acquired deficiency of vitamin K leads to Factor VIII and vWF are produced by the
and Coagulation Factors poor carboxylation of Factors II, VII, IX, and liver including the vitamin K-dependent
Qualitative and Quantitative X. Vitamin K is found in green, leafy vegeta- Factors II, VII, IX, and X. As described above,
Platelet Deficiencies bles and in synthesized by gut flora. Defi- portal hypertension resulting from cirrho-
Numerous medications and medical condi- ciencies can occur in malnutrition or mal- sis leads to hypersplenism and thrombocy-
tions may decrease the number or function absorption, alteration of gastrointestinal topenia as well as qualitative defects in
of platelets. Therapeutic antiplatelet agents flora after antibiotic use, and during Warfarin platelets. Coagulopathy of liver disease is
are in wide use for their cardiovascular and therapy. Low levels of vitamin K-dependent multifactorial and may be reflected in ele-
anticoagulation effects. Aspirin, clopidogrel, factors are reflected in an elevated PT/INR. vated PT/INR and decreased platelet counts
nonsteroidal anti-inflammatory drugs, Bleeding due to an elevated PT/INR due to and function. Management of bleeding in
dipyridamole, and GP IIb/IIIA antagonists vitamin K deficiency may be corrected patients with chronic liver disease often re-
(abciximab, eptifibatide) all induce thromb- quickly with FFP, or more slowly with ad- quires administration of platelets, FFP, vita-
asthenia by altering the ability of platelets to ministration of oral or subcutaneous vita- min K, and modulation of portal hyperten-
aggregate. Combination therapy using mul- min K. Intravenous administration of vita- sion with pharmacologic agents (octreotide,
tiple antiplatelet agents together or with min K may result in allergic-type reactions, vasopressin) or hemodynamic maneuvers
Warfarin is common and worsens bleeding although the actual number with current (transjugular intrahepatic portosystemic
complications. In addition to direct inhibi- purified micellar preparations is exceed- shunting).
tion of platelet function, many medications ingly low. Current recommendations of Massive transfusion related to traumatic
are associated with thrombocytopenia via The American College of Chest Physicians injury results in multiple perturbations of
predictable or idiopathic mechanisms. Ce- (2008) are as follows: “For the use of vita- the coagulation system. Dilution of plate-
phalosporins, penicillin, H2-antagonists, min K to reverse a mildly elevated INR, we lets and clotting factors is uncommon out-
digoxin, amiodarone, furosemide, pheny- recommend oral rather than subcutaneous side of large-volume resuscitation, often
toin, and tricyclic antidepressants are administration (Grade 1 A). For patients defined as more than 10 units of blood or
all commonly used medications that can with life-threatening bleeding or intracra- replacement of the entire blood volume
cause thrombocytopenia. Heparin-induced nial hemorrhage, we recommend the use within 24 hours. Administration of FFP,
thrombocytopenia (discussed elsewhere in of prothrombin complex concentrates or cryoprecipitate, and platelets can generally

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 103 10/28/11 10:15:45 PM

 104 Part I: Perioperative Care of the Surgical Patient

be guided by results of platelet counts, PT/ significant decrease in circulating platelets, Familiarity with the American College of
INR, aPTT, and fibrinogen levels. In signifi- rarely leads to hemorrhagic events, but pre- Chest Physicians consensus conference on
cant trauma, data suggest that administra- dominantly causes venous thrombosis such DVT prophylaxis and use of heparin is im-
tion of red blood cells, FFP, and platelets at as DVT and pulmonary embolism. It can portant.
a ratio of 1:1:1 results in a survival benefit. less commonly lead to major arterial events,
Other factors to consider include hypo- such as MI, stroke, and limb ischemia. The Pathogenesis
thermia due to patient exposure and ad- mortality rate can be as high as 30% to 50%.
ministration of cold products: increasing The incidence of HIT is highest with bovine The centerpiece of the described events is
ambient temperature, active warming of heparin and unfractionated heparin (UFH) PF4. PF4 is a positively charged protein
infused products, and extracorporeal rewarm- and less with low molecular heparin. found in all platelet alpha granules and on
ing to maintain normothermia will improve It is important to think of HIT as a syn- numerous cell surfaces, especially those of
coagulopathy. Acidosis from poor tissue drome that involves both clinical and sero- platelets and endothelial cells. Heparin
perfusion will also worsen coagulopathy. logic findings. One must differentiate be- molecules have a very high affinity for this
Principles of damage-control laparotomy tween what some use as a “grab-bag,” the molecule. How avid heparin is in relation to
address these issues and call for minimal term in which patients develop a nonim- PF4 depends on the heparin chain link or
surgical procedure (i.e., stapling bowel to mune system mediated and asymptomatic molecular weight and its degree of glyca-
control fecal spillage, packing for hemosta- short-term drop in platelet count during tion. This is the key reason that the larger
sis, and temporary abdominal closure) and heparin use—sometimes referred to as HIT UFH poses a higher risk than the smaller,
active resuscitation with warming, correc- type 1, in contradistinction to HIT type II or more “pure” LMH.
tion of acidosis, and support of coagulation HITT (heparin-induced thrombocytopenia After binding of exogenously delivered
parameters in the intensive care unit prior with thrombosis). For the true syndrome to heparin to PF4, a conformational change
to definitive surgical management. occur, the patient will have a documented develops and new epitopes are exposed
Disseminated intravascular coagulopa- drop in platelet count plus or minus active leading to a generation of the classic hepa-
thy (DIC) represents a disordered state of acute thrombosis (venous or arterial), in rin-PF4 antibodies. Once the antibodies are
microvascular thrombosis coupled with sys- addition to either identification of heparin- generated (usually IgG), they bind to the
temic fibrinolysis and subsequent hemor- dependent antibodies or a positive Sero- aforementioned heparin–PF4 complex. A
rhagic complications. Microangiopathic tonin release assay (SRA). One, however, somewhat complex multimolecular reac-
hemolysis may also occur due to microvas- cannot make the mistake of minimizing the tion then occurs in which platelets are acti-
cular thrombi and shear forces affecting red findings of decreased platelet count and vated via their FCY2 A receptors to discharge
blood cells. Infections, injury, malignancy, positive antibodies but no current throm- their microparticles leading to release of an
trauma, burns, and obstetric complications bosis. This may just reflect the early identi- additional significant amount of PF4. This
may initiate DIC via exposure to procoagu- fication of the disease process and throm- condition, some describe as “platelet storm,”
lant substances, thus stimulating diffuse bosis may ensue over the next days to leads to ensuing platelet consumption with
thrombin and fibrin production. Coagula- weeks. resultant thrombocytopenia and develop-
tion factors and platelets are consumed Estimates vary, but up to 1 in 100 pa- ment of a nascent prothrombotic state. In-
while fibrinolytic mechanisms are also acti- tients who receive UFH for 5 days or more terestingly, bleeding events even when
vated leading to diffuse bleeding. Laboratory will develop HIT. The culture of surgery and platelet counts are ⬍20 u/mL are rare. The
abnormalities reflect consumption of fac- medicine has led to inappropriate and om- platelet microparticles lead to excessive
tors and platelets with elevated PT/INR and nipresent use of heparin in patients in situ- thrombin generation and thrombosis. In ad-
aPTT, decreased fibrinogen and platelets, ations, where it is probably not needed, i.e., dition, the complexes can interact with
and evidence of fibrinolysis with elevated IV flushes and subcutaneous heparin in ev- monocytes leading to tissue factor produc-
fibrin degradation products and d-dimer. ery patient who is in the hospital regardless tion and then more antibody-mediated en-
Support with blood products is often re- of risk profile. This accounts for over 12 dothelial damage and clot production.
quired but resolution of DIC requires identi- million patient uses and up to 1 trillion The frequency of development of heparin-
fication and treatment of the underlying units administered per year. Especially in PF4 antibodies depends on the patient pop-
cause. Multisystem organ failure may re- surgical patients, thrombocytopenia is ulation, the type of heparin, duration of
quire supportive measures including intuba- common. However, this is most often due to therapy, and the antibody detection method.
tion with mechanical ventilation, hemody- platelet depletion with blood loss, not HIT. It is much more commonly seen in surgical
namic monitoring and support, dialysis for Although UFH is one of the most commonly patients, especially after cardiovascular pro-
renal failure, antibiotics, and surgical debri- used drugs as described above, even among cedures, when compared to medical pa-
dement of devitalized tissue. In the absence surgeons there is lack of clarity of what is tients. Bovine heparin also increase the risk
of bleeding complications, some advocate actually contained when the medication is compared to porcine heparin and it has also
for therapeutic heparinization to counter injected. UFH is basically a very heteroge- been clearly established that LMWH will
microvascular thrombosis, although data is neous group of glycosoaminoglycans that produce these antibodies much less fre-
lacking on this recommendation. can weigh anywhere from 3,000 to 30,000 quently than standard UFH, due to the
Da and is made from animal sources. Low- smaller and more uniform heparin moieties.
Heparin-Induced Thrombocytopenia molecular-weight heparin (LMWH), on the It is also important to know that the de-
other hand, is a much more refined product velopment of the IgG against heparin/PF4
Heparin-induced thrombocytopenia was derived from UFH by enzymatic processes, does not guarantee that the patient will
first described in 1962, just slightly ⬍30 making it less heterogeneous, more uni- progress to full-blown HIT. When aggres-
years after the institution of the clinical use form, and thus less antigenic. Part of the sively sought out, antibodies will develop in
of heparin. Sequelae of HIT, even though understanding of HIT is its prevention by up to 60% of patients undergoing cardiac
the syndrome involves development of a avoiding heparin when it is not necessary. surgical procedures, but the frequency of

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 104 10/28/11 10:15:45 PM

 Chapter 6: Hemorrhagic Risk and Blood Components 105

true HIT is generally estimated to be 2.5%. A stopped. In general, this does not apply to be considered a substitute even though it
specific subcategory that shows an excep- patients who are receiving intravascular has a much lower rate of causing HIT. Daily

Perioperative Care of the Surgical Patient

tionally high rate of HIT is in cardiac trans- catheter flushes. This, however, does not platelet counts should be monitored look-
plant recipients. Another somewhat contra- imply that patients who receive only small ing for the nadir and eventual rise to above
dictory finding is that although orthopedic doses cannot develop HIT. Routine HIT an- 150,000 or at least a stable new plateau. In
patients are less likely to develop the anti- tibody testing is not recommended in all addition, in those patients even without
bodies than patients after CABG, as a gen- patients who receive heparin outside labo- clinical signs, lower limb ultrasounds
eral rule they are twice as likely as such pa- ratory signs or clinical findings that point should be performed serially to identify oc-
tients to develop HIT. In general, there are a to the potential diagnosis. In those patients cult DVTs. Although somewhat controver-
few explanations for the observation that with platelet counts falling by ⬎50% and/or sial, in patients with a negative venous du-
antibodies plus platelet drop does not al- when a thrombotic event occurs within plex and no current thrombotic events or
ways equal thrombosis. The first relates to 2 weeks of heparin therapy (maximum skin lesions, alternative anticoagulation
timing—the identification of the serology 100 days), HIT should be suspected and should be strongly considered mainly for
and lab abnormality can predate the devel- evaluated. the fact that a significant percentage will
opment of thrombosis by days to weeks. Patients on Coumadin at the time of the “convert” and develop thrombosis when
Secondly, there may be subclinical throm- diagnosis of HIT should be reversed with followed for several weeks. Obviously, pre-
bosis that develops and resolves such as a intravenous or oral vitamin K. This is to pre- vention of potential thrombotic events has
small tibial vein DVT. Finally, we have not vent the clinically relevant “hypercoagula- to be balanced by the risk of aggressive an-
been able to identity for sure which subset ble” state produced by the inhibition of ticoagulation in early postoperative pa-
of patients will have the lab abnormalities Protein C and S. It is often first manifested tients especially with agents that often do
and never develop thrombosis. Thus, the by skin necrosis in patients given Couma- not have an “antidote.”
surgeon must be vigilant and the base treat- din. Reversal of course is only done when Warfarin therapy in general should not
ment on factors detailed below does not the patient is already fully anticoagulated be instituted until the platelet count has
consider this a minor problem or inconse- by another appropriate measure such as substantially recovered to at least to a level
quential lab abnormality. the DTI Argatroban. This can be counterin- of 150 ⫻ 10 9th/L. In addition, the non-
tuitive and easily missed. Platelet transfu- heparin anticoagulant should be continued
General Recommendations/Findings sions, although there has been recent evi- until the platelet count has reached a stable
dence questioning this dogma, in the absence plateau, and INRs are in the appropriate
The “starting” platelet count is not the of significant active bleeding regardless of target range. This generally results in a min-
platelet count the night before heparin is the nadir of platelet count, should not be imum overlap of at least 5 days.
instituted but the highest registered value given prophylactically. Since platelets are
over the prior 2 weeks. In addition, it is im- the key to activating and promoting the Key Features and Potential Pitfalls of
perative to identify the potential use of thrombotic nature of the syndrome, adding
heparin over the preceding 100 days, even if new platelets to the already deranged path-
Identification and Treatment of HIT
just administered as an IV flush, due to the way can be disastrous and is usually done, 1. Platelet count drop of ⬎50%.
amnestic response of a second dose. incorrectly but in good faith, to treat the ab- 2. Platelet count typically ⬍150 ⫻ 109/L
DVT, PE, arterial occlusion, or combined normal lab numbers. but ⬎20 ⫻ 109/L.
arterial/venous thrombosis may be seen. In General measures include cessation of 3. Platelet drop generally seen 5 to 15 days
addition, it is easy not to consider as part of all heparin products including flushes, re- after initiation of dose.
the complete spectrum of problems other serving the use of platelets for emergencies, 4. Do not miss rapid onset in which the
manifestations such as skin lesions identi- treatment with alternative anticoagulants first and potentially small dose of hepa-
fied at the sites of heparin injection or ana- plus or minus platelet inhibition with drugs rin causes immediate drop in platelet
phylactoid reactions that occur after hepa- such as Plavix. Other possible treatment count in those patients who have active
rin bolus. It is also important to note that modalities outside the scope of this chapter antibodies from another recent heparin
in a sizeable number of HIT patients, the include plasmapheresis, which has an un- treatment—often a previous admission.
thrombotic event occurs days before the proven role, but in small series may show 5. Another condition referred to as de-
platelet count falls to levels that raise decreased mortality rate if started very layed onset HIT in which the platelet
awareness and can significantly predate its quickly, and high-dose intravenous gamma counts will drop more than 2 weeks
diagnosis. The contrary is also true, further globulin given to suppress the heparin anti- after the heparin is stopped. Generally,
complicating matters. The other clinical bodies, which has been shown to be suc- the platelet drop is less severe.
scenario that can mask the identification of cessful treatment in a few case reports. 6. Patients diagnosed with HIT without
HIT is seen in patients being treated with thrombosis at initial finding still have
UFH for a VTE. Later in their course when a ⬎20% chance of developing throm-
they develop progression of the thrombus,
Treatment of HIT bosis at a later date even after heparin
either with more proximal progression or a Patients with HIT should have their hepa- cessation.
DVT identified at another site, this can be rin stopped immediately and, in general, be 7. The risks still persist after the platelet
misdiagnosed as heparin failure but may in treated with non-heparin anticoagulants counts return to normal, especially if a
fact reflect development of HIT necessitat- including Danaparoid, Lepirudin, Arga- patient is not on a DTI.
ing cessation of heparin and institution of a troban, Fondoparinux, and Bivalirudin. 8. Thrombosis can occur in either the ve-
DTI. Some of those drugs do not have indica- nous or the arterial systems and in any
Patients receiving UFH at therapeutic tions for HIT in the United States and will location. The venous events are gener-
doses should have platelet counts moni- be discussed with more specifics in the an- ally considered to be fourfold increased
tored every 3 days until the heparin is ticoagulant section. LMWH should never over arterial thrombosis.

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 105 10/28/11 10:15:45 PM

 106 Part I: Perioperative Care of the Surgical Patient

9. Among patients with HIT and throm- amputation or thrombosis. Malignan- it can provide large quantities of autologous
bosis, 10% will require limb amputation cy increases thrombotic risks 13-fold blood and blood products rapidly. This has
and are subjected to a mortality rate of and women are more likely to suffer been used in operations where blood loss is
up to 50%. ischemic stroke as their outcome than large such as liver transplant and ruptured
10. The severity of the thrombocytopenia is men. aortic aneurysm. Basically, blood is aspi-
an independent predictor of composite rated from the surgical field, anticoagulant
is mixed, the aspirated blood is collected in
a reservoir, when adequate amount is pres-
HIT Features
eent it is pumped into a centrifuge, concen-
Platelet Drop by 50% 20% can develop thrombosis at later date from ttrated and washed with an isotonic saline
initial lab Dx solution,
s and then put into an infusion bag
PC ⬍ 150,000 but ⬎ 20,000 Risk persists even if PC normal (if not on DTI) tthat can be delivered directly and quickly to
Severity of drop predicts complications tthe patient. Approximately 225 mL of red
ccells, typically, with a hematocrit of 50% can
Drop starts 5 days after first dose (as long as Venous thrombosis 4-fold ⬎ arterial
14 days) Malignancy increase risk 13X be
b processed in a short period of time. It
may be particularly important in patients
m
Drop acute with recent exposure and Ab Amputation rate 10% with massive blood loss, in those patients who
w
Mortality 50% (late recognition/incomplete aare Jehovah’s Witness (have to discuss with
treatment)
each
e patient), and in those patients in which
ccross-match compatible blood is not ob-
tained. Complications such as air embo-
Transfusion Therapy given to the patient when their transfusion lism, coagulopathy, infection, and the fact
is needed postoperatively. that malignant cells have been seen in shed
This is one of the most complex issues any Although it may ease the patient’s mind, blood have to be factored into its use. It
surgeon can be involved with, since there the use of autologous blood is considerably typically has not shown decrease in abso-
are a myriad of products available all with more expensive than allogenic blood, and lute mortality when used routinely in surgi-
their own indications and contraindica- Medicare does not generally reimburse for cal procedures such as in repair of abdomi-
tions. In addition, the potential deleterious its use. In addition, a number of clinical tri- nal aortic aneurysm, but clearly it decreases
effect of blood products likely from an im- als have shown that due to both the lower the need for allogenic blood transfusions.
munomodulatory role has been elucidated starting hematocrit (repetitive phlebotomy)
across a number of surgical fields. and likely a more liberal transfusion policy
In general, the degree of anemia that since “it’s your own blood,” leads to a much
Massive Transfusion
now triggers transfusion of blood cells has higher rate of transfusion among patients Massive transfusion is variably defined as
changed from a hematocrit of 30 to now a participating in preoperative autologous replacement of ⬎50% of a patient’s blood
hematocrit closer to 21, especially in donation. It is fair to say that currently this volume in 24 hours or transfusion of ⬎10
younger patients. This is clearly not true in modality should only be used in a specified units of red blood cells. Complications in-
patients with coronary artery disease and patient population and clearly not in pa- clude development of coagulopathy, he-
other major vascular conditions, but there tients who could have negative effects from modilution, hypothermia, acidosis, and
are no universal guidelines. Each hospital donation such as those with heart failure, DIC. In addition, acute lung injury second-
often has its own transfusion policies. There unstable angina, recent MI, and aortic ary to congestion from fluid overload, in-
is also no absolute ratio that is appropriate stenosis. flammation, and increased permeability is
when performing transfusion of numerous For the purpose of interest, a few com- seen. This can also occur from transfer of
products such as RBCs, platelets, and FFP. ments on acute normovolemic hemodilu- leukocyte antibodies from donated blood
tion or so-called intraoperative hemodilu- leading to an immune-mediated, transfu-
Autologous Donation/Normovolemic tion should be made. This was a blood sion-related lung injury.
conservation technique developed in the
Hemodilution/Cell Savage l970s in which blood was removed from a
patient after induction, while euvolemia
Packed Red Blood Cells
Due to the AIDS epidemic in the l980s, pa-
tient’s and surgeon’s interest in preopera- was maintained by using crystalloid or col- The trial by Hébert and colleagues com-
tive blood donation has expanded. This loids. The patient’s blood was anticoagu- pared a restrictive transfusion strategy with
likely peaked in the l990s when preopera- lated, maintained, and then reinfused if the maintenance of hemoglobin between 7 and
tive donation accounted for up to 6% of patient needed it during or after the surgi- 9 g/dL in 418 versus 420 patients in which
all blood collected in the United States. cal procedure. There is significant contro- hemoglobin target was significantly higher
Initially, this was felt to be the answer to versy regarding its risks and benefits, but its at 10 to 12 g/dL. The restrictive strategy
avoiding transmissible infection in any implementation has been limited due to a showed a 54% reduction in number of units
case where there was a likelihood of blood number of factors including need for main- of red cells given and decreased mortality at
loss. However, as the programs expanded, tenance and storage of the blood as well as 2 months. This effect seems to be more pro-
problems came to light including the fact increased anesthesia oversight. nounced in patients younger than 55 and in
that the patient may be subclinically in- Cell savage systems involve retrieval and those without cardiac disease. It is impor-
fected at the time of donation. In addition, processing of blood that is shed either dur- tant to understand that with ongoing blood
problems with improper storage as well as ing surgery or from a traumatic injury. It is loss, the minute-to-minute measurement
simple clerical errors may still occur in a preferred method for some surgeons due of hemoglobin will be misleading, and in
which the mislabeled blood product is then to the fact that it is unique in the sense that active bleeding one cannot make decisions

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 106 10/28/11 10:15:45 PM

 Chapter 6: Hemorrhagic Risk and Blood Components 107

based on data that is ⬎30 minutes old. leading to military clinical practice guide- own institution, an audit showed that more
However, it is clear from this study and oth- lines of 1:1 PRBC to Plasma. Others feel that than one-fourth of the patients in which

Perioperative Care of the Surgical Patient

ers that the surgeon should not give blood this algorithm is inappropriate and harm- cryoprecipitate was ordered and transfused
just to correct an abnormal lab value and ful. In fact, the use of FFP was recently had inappropriate indications. Some of the
needs to individualize blood product use. shown to be an independent risk factor for accepted indications are hypofibrinogenemia
the development of multisystem organ fail- ( fibrinogen ⬍100 mg/dL), life-threatening
Platelets ure in critically ill patients and it is well es- hemorrhage related to TPA, massive trans-
tablished that the risk of TRALI is increased fusion consisting of ⬎10 packed cells with
One of the major difficulties in deciding significantly with its use. continued bleeding, uremia with bleeding,
when to give platelet transfusions is related It is important to understand that there and vWD. It is effective in restoring fibrino-
to the fact that it is difficult to compare pa- is a difference between giving a patient who gen levels, and also in providing Factor VIII
tient to patient in regards to their level of is exsanguinating blood and plasma and and vWF. Some of the inappropriate indica-
platelet count, since absolute platelet count giving a large number of units of FFP to a pa- tions commonly seen include patients
does not always correlate to actual function tient who is bleeding, albeit steadily, during who are bleeding with elevated INRs due to
and subsequently bleeding manifestations. an aneurysm repair and/or a liver transplant. excess Coumadin, as a general aid to surgi-
For example, a patient with a count of 200, It is not always simply a problem of dilution— cal hemostasis even when the fibrinogen
who has been on clopidogrel and aspirin, after injury a number of acute processes oc- levels are not low and in patients who are
may require intraoperative transfusion of cur including activation of protein C and bleeding due to hepatic coagulopathy.
platelets with massive bleeding where an release of vasoactive cytokines. These pro- Cryoprecipitate initially was the product
otherwise healthy patient with a count of cesses cannot be simply countermanded of choice to treat hemophilia A, but now
100 may not need any transfusion. One unit but just giving “factors.” In addition, FFP due to commercially available Factor VIII
of platelets from whole blood contains contains antithrombin as well as plasmino- concentrations, it is not used in the United
5.5–10 × 1010 and one unit from pheresis gen, which would clearly not help with clot- States for this indication. It is very effective
contains 40 × 1010, which is equivalent to ting. To the contrary, FFP is very successful in patients with congenital or acquired low
approximately six units from whole blood. along with vitamin K in successfully treat- fibrinogen levels or patients in which the
In general, patients who are not undergoing ing elevated INRs seen in Warfarin overdose fibrinogen is not working properly. Its use
surgery are not likely to bleed until a plate- or dilutional situations. One caveat of so- in patients who have DIC and thus active
let count drops below 20 ⫻ 109/L. In pa- called reversal is the fact that administra- uncontrolled consumption of fibrinogen is
tients having significant surgical proce- tion of FFP can actually increase bleeding somewhat controversial. It is clearly not the
dures, the threshold is closer to 50 × 109/L. when large doses of heparin are being ad- only replacement factor to be given in these
This threshold is changed if patients are ac- ministered. This is mostly seen in post- patients who are actively bleeding. There is
tively bleeding, and have had transfusion of CABG patients or those with genetically also some concern that fibrinogen will acti-
other red cell products. The caveat, which is determined antithrombin deficiency. Once vate or enhance the thrombotic compo-
described in detail elsewhere in the chapter, FFP is given with its large component of an- nents of DIC and some authors recommend
is related to the use of platelets in heparin- tithrombin, so-called paradoxical antico- administering heparin in these patients be-
induced thrombocytopenia. Of note, plate- agulation can occur. fore replacing the fibrinogen.
lets have only been screened since 2004 for In regard to the bleeding that occurs in
bacterial contamination based on the find- uremic patients, it is often gastrointestinal in
ing that 1/3,000 random donor platelet con-
Cryoprecipitate nature and a significant cause of morbidity
centrates were found to be contaminated Cryoprecipitate is a concentrate of high- and mortality in these patients. The underly-
with gram-negative or gram-positive bacte- molecular-weight plasma proteins that ing hemostatic defect is multifactorial and
ria. This extended screening program has precipitate in the cold. It contains Factor the benefit of cryoprecipitate, likely, is re-
decreased the annual death rate due to VIII, vWF, fibrinogen, Factor XIII, fibronec- lated to increasing circulating vWF enhanc-
transfusion-related sepsis by about 40% in tin, IgG, IgM, and albumin. It is prepared by ing platelet function. In this setting, Desmo-
just the first year of its implementation. slowly thawing FFP at 4 ⬚C to 6 ⬚C, resulting pressin may be more direct and successful.
in the formation of an insoluble precipitate It is important to remember that cryo-
that is then resuspended in about 15 mL. of precipitate is a poor source of vitamin K-
Fresh Frozen Plasma plasma. It can then be stored at −18 ⬚C for dependent factors and is not used for this
In critically injured patients of all types, co- up to 1 year. Each concentrate is prepared setting. In contradistinction, FFP contains
agulopathy will be of major concern in up from a single donor unit of plasma and gen- all the coagulation factors and is the opti-
to 35%. Although there has been an overall erally contains 100 u of Factor VIII, up to mal product for rapid reversal of Warfarin-
trend to decrease the previously wrote and 300 mg of fibrinogen and 60 u of Factor XIII. induced “over”—anticoagulation. With
somewhat frankly indiscriminant use of The dose is typically one unit for 10 kg body bleeding abnormalities related to liver dis-
PRBC, the proper use/dose of FFP is still weight. Although the fibrinogen content of ease, the major defect is decreased synthe-
unclear. Traditionally, FFP is given to re- each unit is variable, in general, transfusion sis of coagulation factors. In addition, low
duce the INR to a level of 1.5 or is given in of one bag will raise the fibrinogen level by fibrinogen and platelet counts are accentu-
institutionally determined and specific ra- a minimum of 30 mg/dL and has a half-life ated with splenomegaly. Thus, as above,
tios with red cells. However, use of that par- of ⬎3 days. In general, with postoperative cryoprecipitate is not the first-line therapy
ticular INR as preventive of bleeding prob- bleeding fibrinogen levels of ⬍100 mg/dL in these patients.
lems has never been properly adjudicated. will trigger the use of this product. Complications of cryoprecipitate include
The increased use of FFP was further inten- The use of cryoprecipitate is often mis- increased risk of transfusion-transmitted
sified from retrospective reviews of massive understood by physicians caring for pa- disease when compared to “pure” prepara-
transfusion patients in the Iraqi theater, tients with bleeding issues. In fact, at our tions containing one factor alone. Even

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 107 10/28/11 10:15:45 PM

 108 Part I: Perioperative Care of the Surgical Patient

though cryoprecipitate concentrate is gen- tion appeared to significantly decrease transfusion and should be discussed with the
erated from one unit of plasma, the typical blood loss as well as need for transfusions patient prior to transfusion. Complications
infusion consists of a pool of multiple prod- in prostatectomy led to its evaluation in of blood component transfusion may be clas-
ucts. Red cell antibodies also may be present other procedures with incumbent blood sified as immune-mediated reactions, in-
leading to hemolytic anemia. Finally, due to loss. There was initial excitement about its cluding transfusion-related acute lung injury
the multiple proteins present, anaphylaxis use preoperatively in patients undergoing (TRALI) and immunosuppression, transmis-
and pulmonary reactions have occurred. liver transplantation, but some early posi- sion of infectious diseases, and physical,
tive results in a small group of patients was metabolic, and chemical complications.
Desmopressin not borne out in a larger data base. One of
the potential issues with understanding the Immune-Mediated
Desmopressin or DDAVP is a synthetic ana- proper role of this recombinant factor is
log of vasopressin that stimulates a one- that a number of different doses have been
Transfusion Reactions
time release from the endothelium of Fac- used in various studies, making the results Adverse events may occur during or shortly
tor VIII and vWF. Factor VIII is bound to very difficult to compare. In addition, higher after transfusion or may present in a de-
vWF while inactive in circulation; Factor doses, which seem to be very effective in layed manner. As many of these reactions
VIII degrades rapidly when not bound to controlling or limiting bleeding, often have start with the same symptoms, it may be
vWF. Use of the product is intended to ac- significant deleterious effects such as renal difficult to determine which type is occur-
celerate platelet aggregation. It has been dysfunction. There have been conflicting re- ring. For this reason, any untoward reaction
studied mostly in patients with congenital ports in its benefit in patients with blunt or occurring during transfusion should
platelet disorders, whereas its value in sur- penetrating trauma. prompt cessation of the transfusion and in-
gical hemostasis is unproven. Its mecha- Frankly, a significant amount of the in- vestigation into the event. Acute hemolytic
nism of action, via slow intravenous infu- terest in use of this factor has been related reactions, delayed hemolytic reactions,
sion, results in release of vWF from to case reports in patients with excessive non-hemolytic febrile reactions, and aller-
endothelial cells. This affects the plasma and/or uncontrollable life-threatening blood gic reactions are immune-mediated trans-
levels of vWF and associated Factor VIII loss. The claims have been related to a very fusion reactions that occur in up to 5% of
with improvement in hemostasis. Unfortu- rapid reduction in blood loss when all other transfusions with febrile reactions reported
nately, a number of trials investigating its measures have failed; however, no clinical in up to 1 in 100 transfusions. TRALI, a more
use in patients undergoing cardiac surgery trials have been performed specifically on recently described complication of transfu-
have at best showed minimal effect on peri- that topic. A very important point, well sion, is also mediated by immune mecha-
operative transfusion. Desmopressin was made by Lohrman and Becker in their excel- nisms and represents the leading cause of
traditionally felt to be especially effective in lent review article, was that in the majority transfusion-related mortality.
those patients with uremia and platelet of trials of this medication the patients had
dysfunction; however, its usefulness has es- very low risk of an incidence of thrombotic Acute Hemolytic Reactions
sentially been abolished by the effective- complications. Thus, its use cannot be ex-
ness of erythropoietin, which both increases trapolated to all comers. In those patients Acute hemolytic transfusion reactions oc-
red cell mass and leads to a more active in- who are at a high risk of thrombosis, there cur due to the destruction of donor red cells
teraction between platelets and vessel may be a significant increase in complica- via complement activation after binding
walls. This medication is now relegated to tions when given recombinant Factor VIIa. with preformed recipient antibodies. Anti-
use in hemophilia A and vWD and special The clotting appears to occur in both arte- bodies against the ABO antigens are most
off-label circumstances in which bleeding rial and venous systems and has been re- commonly implicated, although antibodies
continues even after exhaustion of standard ported in a number of off-label uses. In the to minor antigens such as anti-Rh, anti-Jka,
replacement therapies especially in pa- vast majority of the approximately 50 or so or anti-Kell have also been reported. Cleri-
tients on hemodialysis. reported deaths, thromboembolism was re- cal or procedural errors resulting in the
corded as the probable cause. Further modi- transfusion of the blood to the wrong pa-
fications of the drug with additional DNA tient as well as errors during the cross-
Recombinant Activated Factor VIIa match process may contribute to the oc-
technology engineering are underway. It is
Recombinant activated Factor VII (VIIa) probably best thought of currently as a last currence of acute hemolytic transfusion
acts locally at the site of tissue injury and hope in patients who are still bleeding when reactions. An acute hemolytic transfusion
vessel disruption, binds directly to exposed aggressive and appropriate traditional clot- reaction should be suspected in patients re-
tissue factor leading to thrombin genera- ting factor replacement has failed. In addi- porting fever, flank pain, chest pain, short-
tion and activation of platelets. The now tion the clinical scenarios in which it may be ness of breath, or a sense of impending
activated platelet surface forms a template, of benefit in general do not lend themselves doom or dread. Hypotension, hemoglobin-
in which factor VIIa further propels coagu- to large randomized clinical trials so more uria, and coagulopathy are often present
lation, generating a significant amount detailed data may not be forthcoming. and may progress to shock, acute renal fail-
of thrombin and converting fibrinogen to fi- ure, and DIC. Anesthetized or unconscious
brin. Another potential benefit of this medi- COMPLICATIONS OF patients may manifest with diffuse oozing
cation is stabilization of clot formation via BLOOD COMPONENT as their only sign of hemolysis.
inhibition of fibrinolysis. The medication Suspicion of an acute hemolytic transfu-
was initially developed for use in those with
TRANSFUSION sion reaction requires cessation of the
hemophilia. Then, its effectiveness was The use of blood components in the care of transfusion, supportive care of the patient,
evaluated in patients with major hemor- patients can result in significant morbidity and immediate investigation into the cause
rhage from surgery or trauma. An early re- and mortality. The risk of complications must of the reaction. It is important to note that
port in which one single preoperative injec- be weighed against the anticipated benefit of if a switch of units intended for different

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 108 10/28/11 10:15:45 PM

 Chapter 6: Hemorrhagic Risk and Blood Components 109

recipients has occurred, another patient re- be notified to prevent future hemolytic epi- Transfusion-Related Acute
mains at risk for transfusion of an inappro- sodes. Lung Injury

Perioperative Care of the Surgical Patient

priate blood product.
The blood unit and attached tubing TRALI is the onset of acute lung injury dur-
should be returned to the blood bank for
Non-hemolytic Febrile Reactions ing or within 6 hours of transfusion. The
further testing and culture, while blood Increase in temperature ⬎1 ⬚C during pathogenesis of TRALI is not entirely eluci-
samples from the recipient should be col- transfusion of blood components is com- dated. The interactions between transfused
lected for culture, direct Coombs testing, mon, occurring in up to 1% of transfu- anti-leukoctye antibodies and recipient leu-
plasma-free hemoglobin, and repeat cross- sions. While non-hemolytic febrile reac- kocytes, or activation of recipient leukocytes
matching. Urine should be analyzed for tions are the most common transfusion by other agents in the blood product such as
hemoglobinuria, which may be evident on reaction, fever may also represent the first cytokines or lipids are thought to contrib-
examination due to pink or brown discol- presentation of a hemolytic reaction, and ute to inflammation and increased permea-
oration of the urine. Supportive care thus requires cessation of the transfusion bility of the pulmonary microvasculature
may include intubation for airway protec- and the investigation outlined above. Non- and the clinical picture of TRALI. TRALI has
tion and respiratory support, and intrave- hemolytic febrile reactions may occur be- been reported after transfusion of all types
nous fluids and vasopressors for cardio- tween 1 and 6 hours of the transfusion and of blood product, but is most commonly
vascular support of shock. Intravenous may be accompanied by chills or mild dys- seen after packed red blood cells, FFP, and
fluids should be administered at a rate to pnea. Antipyretics may be administered platelets. Risk factors associated with the
support urine output at ⬎100 mL/h to for symptomatic relief of fever while sig- development of TRALI include prolonged
prevent damage to the renal tubules from nificant rigors or chills may respond to storage of products, hematologic malig-
free hemoglobin. After adequate volume meperidine. nancy, cardiopulmonary bypass, massive
resuscitation, loop or osmotic diuretics Cytokines are generated and accumu- transfusion, sepsis, and high Acute Physiol-
may be given to assist in diuresis. Urinary late in blood components during storage ogy and Chronic Health Evaluation II
alkalinization with bicarbonate has been including interleukin (IL)-1, IL-6, IL-8, and (APACHE II) score. The incidence of TRALI
advocated for further renal protection, al- tumor necrosis factor-alpha. In addition, is estimated at 0.04% to 0.1% of transfusions,
though the effectiveness of this approach interactions between donor leukocytes and while the mortality rate is reported at 5% to
has been questioned. The severity of the recipient antibody in the recipient drive 8% making TRALI the leading cause of
reaction depends, in part, on the volume the febrile reaction by the production of transfusion-related mortality.
of blood transfused. Metabolic complica- IL-1. Leukocyte reduction has been dem- Patients with TRALI may present with fe-
tions including hyperkalemia, renal fail- onstrated to decrease the incidence of fe- ver, tachycardia, tachypnea, dyspnea, and
ure, and DIC may require specific inter- brile reactions. Premedication with acet- hypoxemia with a PaO2/FIO2 ratio of ⬍300.
ventions including hemodialysis and aminophen and antihistamines has been Pink, frothy secretions may be noted and
correction of coagulopathy or careful advocated to prevent these reactions. A chest radiography demonstrates bilateral
heparinization. randomized, double-blind, placebo-con- patchy infiltrates. Central venous and pulmo-
trolled trial, however, failed to demonstrate nary artery pressures are normal, in contrast
Delayed Hemolytic Reactions a difference in the incidence of transfusion to transfusion-associated circulatory over-
reactions between those patients who re- load (TACO) or other causes of cardiogenic
Delayed hemolytic transfusion reactions ceived pretreatment and those who did pulmonary edema. Exclusion of other condi-
occur days to weeks after transfusion as a not. tions such as hemolytic transfusion reactions
result of an anamnestic antibody response and anaphylaxis is also required. Treatment
to donor red cell antigens from a prior sen- of TRALI is supportive with intubation and
sitizing event (transfusion, pregnancy, or
Allergic or Anaphylactic Reactions mechanical ventilation as needed. Protocols
transplant). Initial cross-match is negative Occurrence of hypotension, angioedema, employing lung-protective measures includ-
as the antibody is present at very low titers and respiratory distress shortly after initia- ing low tidal volumes and pressures are often
with subsequent amplification after trans- tion of transfusion marks the onset of an used. Resolution of TRALI typically occurs
fusion. The antibodies implicated are often anaphylactic reaction. Anaphylaxis compli- within a week of onset of symptoms. Use of
against minor, non-ABO antigens including cates 1:20,000 to 1:50,000 transfusions, most corticosteroids to modulate leukocyte acti-
the D antigen of the Rh system. Clinical pre- commonly occurring in patients who are vation has been reported with mixed results
sentations of delayed hemolytic transfusion IgA deficient. Presence of anti-IgA antibod- and is not currently recommended.
reactions is usually less evident than acute ies in a small proportion of these patients As anti-leukocyte antibodies have been
reactions due to slower rates of hemolysis. triggers the anaphylactic reaction. Similar implicated in the development of TRALI,
Patients may present with jaundice and reactions have been described in patients identification of donors with these antibod-
fever, while anemia, elevated bilirubin, and with anhaptoglobinemia. ies has been attempted. Multiparous women
evidence of hemolysis will be seen on labo- Management of transfusion-related ana- have been found to have the highest con-
ratory evaluation and peripheral smear. A phylaxis requires cessation of the transfu- centrations of anti-leukocyte antibodies.
newly positive Coombs test is often found sion, airway support with intubation if indi- Efforts to reduce the incidence of TRALI in-
and repeat cross-match with the original cated, and hemodynamic support with clude use of plasma from male donors or
transfused unit should be performed, if epinephrine, volume resuscitation, and va- never-pregnant women only or screening of
possible. Specific treatment is not indicated sopressors as needed. Prevention of ana- donors for anti-leukocyte antibodies.
unless significant, rapid hemolysis occurs. phylaxis requires identification of patient
Identification of the responsible antigen with IgA deficiency and provision of IgA- Immunosuppression
should be performed with notification to deficient products or extra washing of units The immunosuppressive effects of transfu-
both the patient and the blood bank should to remove IgA antibodies. sion on postoperative and nosocomial

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 109 10/28/11 10:15:46 PM

 110 Part I: Perioperative Care of the Surgical Patient

infection and tumor recurrence have been with continuous monitoring of urine out- As cells age in storage, they release potas-
termed transfusion-mediated immuno- put and daily weights may be required to sium into extracellular solution. Significant
modulation (TRIM). These effects are at- guide diuretic management and prevent hyperkalemia, however, is uncommon in
tributed to passenger leukocytes in the pulmonary edema. Limiting the total trans- the absence of hemolysis. The citrate in
transfused product. Multiple reports sug- fusion volume and extending the time of some products may counter hyperkalemia
gest increased rates of infection in patients product administration may also decrease as citrate is converted to bicarbonate lead-
receiving transfusion with lower rates in the likelihood of TACO. ing to alkalemia that may drive potassium
patients receiving autologous units or into cells in exchange for hydrogen ions. In
leukocyte-depleted products. These differ- Physical/Mechanical Complications fact, transfusion of large volumes of citrated
ences have not always persisted on multi- products may cause hypokalemia and the
variate analysis or in meta-analyses. Simi- Blood products are susceptible to thermal need for potassium supplementation.
larly, data on tumor recurrence after injury during acquisition, storage, or ad- Iron overload may occur in the setting of
transfusion are mixed with some studies ministration due to conditions that are ei- chronic red cell transfusion in the absence
suggesting a negative effect of transfusion ther too warm or too cold. In addition, of blood loss in such conditions as hemo-
while others do not support these conclu- freezing and thawing must occur at proper lytic anemias, aplastic anemia, and myelo-
sions. It is clear, however, that judicious use rates and in the presence of appropriate dysplastic disorders. Once iron-binding ca-
of blood products, especially in nonemer- cryoprotectant to prevent thermal lysis. pacity is exceeded, iron may be deposited in
gent situations, is the best general policy. Blood bank protocols are established for other organs and lead to cirrhosis, cardio-
Graft-versus-host disease (GVHD) has each type of blood component to prevent myopathy, and endocrine and pancreatic
been reported following transfusion into destruction of the product. Administration insufficiency. Therapeutic phlebotomy (in
immunocompromised recipients or recipi- of blood products through blood warmers nonanemic patients) or iron chelation may
ents who have partial HLA matching with must be carefully monitored to prevent slow end-organ damage in these settings.
the donor. The occurrence of posttransfu- warming above 40⬚C to avoid hemolysis.
sion GVHD requires the presence of viable Blood components should be adminis- Coagulation Defects in
donor lymphocytes thus leukoreduction or tered with isotonic saline solutions, ABO- Massive Transfusion
irradiation of donor products can decrease compatible plasma, or 5% albumin to avoid
the occurrence of this complication. osmotic damage that can lead to cell lysis. Massive transfusion is variably defined as
Products should never be administered replacement of ⬎50% of a patient’s blood
Non-immune-Mediated with other medications or infusions as volume in 24 hours or transfusion of ⬎10
hemolysis can occur. Red blood cells should units of red blood cells. Coagulation can be
Complications not be administered with lactated Ringers deranged in the setting of massive transfu-
In addition to the multiple potential immu- or other calcium-containing solutions to sion due to underlying tissue trauma, hypo-
nologic reactions to transfusion, numerous prevent clotting. Other mechanical compli- thermia, or DIC, or may be a result of dilu-
mechanical/physical, metabolic, and infec- cations can occur if blood products are tion of plasma proteins and platelets by
tious complications may occur. The collec- forced through small gauge needles, kinked crystalloid and transfused red blood cells.
tion, processing, and administration of intravenous lines, cardiopulmonary or ven- Acidosis and hypothermia, in combination
blood products, recipient factors, and vol- ovenous-bypass circuits, or hemodialysis or with deficiencies of clotting factors and
ume of transfused products may all con- pheresis units. Air embolism may occur in platelets, may lead to ongoing hemorrhage.
tribute to these complications, and modifi- pressurized infusions systems if care is not For most surgical patients, careful monitor-
cation of the treatment plan may limit the taken to keep the system closed. ing of platelet counts, prothrombin time
incidence or severity of poor outcomes. (PT), aPTT, and fibrinogen are sufficient to
guide further transfusion. In the setting of
Metabolic Complications massive trauma, recent retrospective re-
Volume Overload Blood collection systems often use citrate views suggest that improved survival was
Patients susceptible to pulmonary edema to chelate calcium and prevent clotting dur- seen in patients who received red cells,
due to compromised cardiac function may ing collection and processing. Citrate may plasma, and platelets in ratios approaching
develop TACO. Presenting symptoms and also be used as a preservative for red cells. 1:1:1.
signs include dyspnea, tachycardia, hypox- Transfusion of large quantities of citrate-
emia, and pulmonary edema on chest radi- containing products may lead to citrate
ography. Patients at risk for TACO include toxicity and symptomatic hypocalcemia
Transmission of Infectious Disease
the elderly, those with known congestive with circumoral paresthesias, carpopedal Transmission of infectious diseases through
heart failure, and small patients. Distin- spasm, tetany, anxiety, or arrhythmias. Pa- blood transfusion remains a major concern
guishing TACO from TRALI may be difficult tients at increased risk of citrate toxicity cited by patients. Bacterial contamination
in patients at risk for both complications include those with significant liver disease of blood products is relatively rare with rates
and both may occur in the same patient. El- or those receiving large-volume exchange of sepsis after red cell transfusion reported
evated central venous pressure and beta- transfusions. Symptomatic citrate toxicity at 1 in 5 million units. The most common
naturetic protein may help clarify the diag- can be avoided by slowing infusion rates or organisms recovered are the Gram-negative
nosis. Careful attention to cardiac function, administering oral calcium. Intravenous bacteria in the Yersinia, Pseudomonas, and
volume status including other fluids ad- calcium is given only in extreme circum- Enterobacter genera. As platelets are stored
ministered, and renal function with modifi- stances as administration can cause ar- at room temperature, the rate of bacterial
cation of the transfusion plan may abrogate rhythmias or clotting of blood products. contamination was previously reported as 1
this complication. Central venous pressure Hyperkalemia may occur during trans- in 25,000 units. Most centers now test plate-
or pulmonary artery pressure monitoring fusion, especially if older products are used. lets for contamination and have increasing

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 110 10/28/11 10:15:46 PM

 Chapter 6: Hemorrhagic Risk and Blood Components 111

use of pheresis-collected platelets, thus prevention or prophylaxis of venous throm- the initiation or propagation of coagulation
avoiding pooling of platelets from multiple boembolism (VTE), the efficacious treat- or attenuate fibrin formation by directly tar-

Perioperative Care of the Surgical Patient

donors. These changes have decreased the ment of VTE, without development of geting thrombin. Drugs that target the tis-
risk of transfusion-associated sepsis (TAS) heparin-induced thrombocytopenia, and sue factor/Factor VIIa complex typically
from platelet transfusion to now roughly 1 an oral replacement for Warfarin that block initiation, while those that inhibit IXa
in 75,000 units. would not require monitoring. Also, drugs, or Xa or their cofactors work by blocking
Potential blood donors are screened for which can be reversed or have an antidote propagation of coagulation. DTIs will atten-
risk factors for viral illnesses including HIV, may be more beneficial than others. In gen- uate fibrin generation. In addition, since
hepatitis B virus (HBV), and hepatitis C vi- eral, across various classes of very effective thrombin is the most potent physiological
rus (HCV). Donated products are tested for new anticoagulants, attempts to advance agonist of platelet activation and aggrega-
these viruses as well as for human T-lym- these new medications into widespread tion, drugs that inhibit thrombin will have
photropic virus (HTLV)-I/II, West Nile vi- clinical use have been problematic due to varying effects on platelet activity. Antico-
rus, and cytomegalovirus (CMV). Reported either increased bleeding at doses required agulants can also be thought as direct or
rates of transmission of HBV are 1 unit in for equipoise with standard preparations indirect inhibitors based on whether they
205,000; HCV, 1 unit in 2 million; and HIV, 1 such as LMWH or by serious side effects directly bind the target enzyme and block
unit in 2 million. Screening for risk factors such as hepatotoxicity. substrate interactions, or they bind naturally
and testing for nonviral agents including The proper choice of drug depends on a occurring plasma cofactors and accelerate
babesiosis, Lyme disease, malaria, Chagas number of factors including the substrate their activities with the critical enzymes.
disease, and variant Creutzfeldt–Jakob dis- in which the thrombus develops as well as Before describing the new classes and
ease are also common. whether the medication is used for prophy- specific drugs, it is important to review
Two methods are described to reduce laxis or therapeutic means. For example, some of the key information regarding the
the risk of viral transmission via blood there are important differences in the way standard drugs: Coumadin, UFH, and
products. Viral inactivation of plasma and arterial and venous thrombus typically de- LMWH. Based on some of the known prob-
plasma-derivatives has been described us- velop. Arterial thrombus often develops in lems with these medications, one can see
ing three techniques. Solvent-detergent injured vessels (trauma, plaque rupture) why the whole field of new anticoagulants
(S/D) treatment is the only method ap- and generally consists of mostly platelet ag- was created.
proved in the United States. S/D treatments gregates held together with just small Coumadin is a vitamin K antagonist that
disrupt the membranes of enveloped vi- amounts of fibrin. Thus, arterial strategies blocks the gamma carboxylation of gluta-
ruses including HIV, HBV, HCV, HTLV, Ep- often focus on drugs that lead to platelet mate groups of inactive coagulation factors
stein-Barr virus (EBV), and CMV. Of note, inhibition and block platelet aggregation produced by the liver. It mainly defunction-
S/D treatments will not inactivate hepatitis and activation, and not on the use of true alizes the prothrombotic factors—VII, IX,
A virus (HAV), parvoviruses, or non-viral anticoagulants. In fact, this was recently and X—but can have a short-lived procoag-
pathogens such as prions. Unfortunately, evaluated in over 2,000 patients with PAD ulant period based on its effect on Protein C
S/D treatments are not currently available who were given antiplatelets alone versus and S (discussed elsewhere). Although ef-
in the United States. Leukoreduction via antiplatelets plus oral anticoagulant with fective, oral, and reversible with an antidote
filtration at the time of component prepa- goal INR of 2 to 3. The composite end point (vitamin K), it requires frequent monitor-
ration or product administration may also of MI, stroke, or death from cardiovascular ing, has a prolonged loading period, dietary
reduce the transmission of many viral disease was the same in both groups— interactions, a narrow therapeutic window,
pathogens (HTLV, EBV, and CMV) as well as approximately 13% over mean f/u of 35 is associated with bleeding risk, and is
reduce the immunologic complications as- months. However, this was seen with a teratogenic. Due to nutritional vitamin K,
sociated with transfusion of passenger leu- greater than threefold risk in life-threaten- the inhibition of cytochrome P 450 by con-
kocytes in blood components. Most prod- ing bleeding complications in those receiv- comitant drugs and other drug/food inter-
ucts available in the United States today are ing combination therapy. This does not actions, the pharmacodynamics of Couma-
leukoreduced. mean that “arterial” patients will not bene- din are variable. In addition, mutations in
fit from the use of medications from differ- the gene, which encodes the target enzyme,
New Anticoagulants ent classes in certain situations, but does that is, vitamin K epoxide reductase, can
illustrate the concept explained above. Ve- actually produce Warfarin resistance and
Even with significant progress in the devel- nous thrombi in contradistinction are typi- may represent why interindividual variabil-
opment and study of new and improved an- cally composed mostly of fibrin, red cells, ity is so high. Due to increasing concern
ticoagulant drugs, surgeons have to remem- and actually have a paucity of platelets. over complications and risks of prolonged
ber that for over 50 years our armamentarium Thus, anticoagulants, and not antiplatelet Warfarin therapy, the Food and Drug Ad-
has been essentially limited to two medica- drugs, are the agent of choice for treatment ministration issued a black box warning in
tions: IV UFH for rapid anticoagulation and of VTE. In general, this explains the lack of October 2006. Even in well-controlled con-
oral Coumadin for more long-term treat- benefit in ASA preventing DVT, as well as temporary studies of Coumadin, the high-
ment. These two drugs were heralded by the lack of benefit of Coumadin in prevent- est rate of consistent and effective use (pa-
William Howell when he presented tech- ing MI. For the purpose of this chapter, we tients who continue drug at proper doses
niques on heparin isolation in 1922, and will focus mostly on true anticoagulants based on INR) is approximately 70%.
Karl Link and Wilhelm Schoeffel who iden- and will not discuss antiplatelet medica- UFH is a heterogeneous ionic polysac-
tified dicoumarol, a bacterial antagonist of tions specifically. charide. It is composed of multiple mole-
vitamin K in spoiled sweet clover, as the Although anticoagulants are generally cules ranging from 5 to 30 kDa. UFH’s pen-
cause of a fatal bleeding disorder in live- thought to be of one general class or scheme, tasaccharide sequence (the key moiety)
stock. The major reasons for development they can actually work at completely differ- binds antithrombin, which then in turn can
of new classes of anticoagulants is for the ent pathways. In general, they either inhibit inhibit activated Factor X as well as bind

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 111 10/28/11 10:15:46 PM

 112 Part I: Perioperative Care of the Surgical Patient

thrombin. It has a rapid onset, is very effec- Oral Acting Heparin Mimetic and bivalirudin. The first two are generally
tive, and is reversible (protamine), but has used for patients with heparin-induced
significant interaction with plasma pro- Oral acting heparin mimetic (SR 12781 A), a thrombocytopenia. Bivalirudin is approved as
teins, requires frequent monitoring and synthetic oligosaccharide with a combina- an alternative to heparin in patients undergo-
dosing adjustments due to somewhat un- tion of Factor Xa and IIa activities that ing coronary interventions, with or without
predictable response, and can lead to hepa- are antithrombin-dependent, was recently HIT. It is important to note that the efficacy of
rin-induced thrombocytopenia, osteoporosis, evaluated in patients undergoing total hip these non-heparin anticoagulants, except in
and bleeding. replacement. It shows a significant dose re- the case of bivalirudin in PCI, has not been
LMWH is a purified heparin product. It sponse effect in regards to prevention of based on randomized controlled trials and is
still contains a number of different mole- VTE although the exact dose has not been more based on the fact that their anticoagu-
cules, but in a smaller weight range, 2 to clearly identified. Unfortunately, the doses, lant action does not involve PF4.
10 kDa. It can be produced by a number which were most effective in actually show-
of enzymatic reactions or degradations ing a reduction in VTE compared to stan-
accounting for the different preparations dard Enoxaparin resulted in escalating Hirudin
including Dalteparin, Tinzaparin, and bleeding risk. It is a 65 amino acid polypeptide isolated
Enoxaparin. It promotes and mediates di- from the salivary glands of the medicinal
rect inhibition of Factor Xa, but has limited Ultra-Low-Molecular-Weight leech that binds to thrombin with very high
inhibition of thrombin directly, unlike Heparin affinity and an extremely low dissociative
UFH. Administration is typically subcuta- constant. Hirudin can inhibit both free and
neous once or twice a day depending on AVE5026 is a hemi synthetic ultra-low- clot-bound thrombin. After IV administra-
the preparation. Monitoring is more lim- molecular-weight heparin (ULMWH). It has tion it has a plasma half-life of 40 minutes
ited than UFH, but is recommended in ex- a novel antithrombotic profile with both and 2 hours after subcutaneous adminis-
tremes of weight, renal insufficiency, and very strong anti-factor Xa activity and re- tration. It is associated with production of
pediatric patients. Anti-factor Xa activity sidual anti-factor II activity. It shows a sig- anti-hirudin antibodies in up to 80% of pa-
is the gold standard. In addition to gener- nificant dose response in preventing VTE tients, which peak at day 8 but typically
ally being more effective overall than UFH that unfortunately has a negative correla- these antibodies are not associated with
(at the expense of increased cost), it also tion with risk of major bleeding. Although it adverse outcomes with efficacy or safety,
has a much lower incidence of HIT because may be very effective, it is not likely to have but with prolonged aPTT.
of the smaller molecules and decreased in- significant benefit over the oral inhibitors
teraction with PF4. One of the potential that are being studied currently. In addition,
major problems, especially in the periop- it needs to be given before the surgery as Lepirudin
erative period, unlike UFH is the inability typically is done in heparin preparations. The widespread use of Lepirudin (obtained
to reverse, although treatment with by recombinant technology from medicinal
protamine may have some limited benefi- Thrombin Inhibitors leaches) is limited mainly by two factors.
cial effect. First, generation of anti-hirudin antibodies
Thrombin can be inhibited directly or indi- is not uncommon and anaphylaxis has been
New Drugs (Heparin Related) rectly. In general, the indirect inhibitors act noted to occur. Secondly, its elimination is
by catalyzing heparin co-factor II, while di- mostly renal and is of concern in patients
Danaparoid rect inhibitors bind to thrombin itself and with decreased GFR. Lepirudin is dosed
Danaparoid is a preparation derived from block its interaction with substrate. Syn- with a bolus and then a constant infusion,
porcine gut mucosa that is a mixture of thetic, small-molecule DTIs are a new ther- and has a half-life of 80 minutes. It is the
number of anticoagulant sulfates (hepa- apeutic class that interact directly and ex- only DTI that requires an initial bolus be-
ran, chondroitin, and dermatan) and has a clusively with the active site of thrombin. By fore initiation of constant infusion.
half-life of approximately 28 hours. It is employing reversible inhibition, this allows
given subcutaneously and is renally ex- a certain amount of free enzymatically ac-
creted. The anticoagulant effect is medi- tive thrombin to be available in the blood Argatroban
ated by thrombin inhibition due to a com- stream to control hemostasis. It is thought Argatroban is also approved in the United
bination of antithrombin and heparin that the reversible binding contributes to States for both prevention and treatment of
co-factor II, in addition to an incompletely safer and more predictable anticoagulant HIT-associated thrombosis. It is dosed with-
categorized endothelial-based cellular treatment and one of the problems with out a bolus and started at an initial infusion
mechanism. It leads to a more selective Hirudin (the first DTI) was the fact that it rate. It is important to recognize that Arga-
Factor Xa inhibition than LMWH with a formed noncovalent irreversible binding. troban will significantly increase the INR well
sevenfold increased potency. It can be Since the direct inhibitors do not bind to out of the therapeutic range and when Arga-
monitored by an anti-factor Xa assay, plasma proteins, they should be more predict- troban/Coumadin overlap is attempted, the
which is particularly important in patients able. They do not require binding to PF4, and infusion needs to be stopped for 4 hours be-
with renal insufficiency. Although in vitro, thus, cannot produce immune complex- fore checking a PT/INR. Even though the INR
it does have some interaction with HIT- related thrombocytopenia and would be un- will be falsely elevated, this typically does not
type antibodies; this has not been seen affected by large quantities of PF4, which are pose any increased risk of bleeding. Thus, the
clinically and in other countries it is actu- released in the vicinity of platelet-rich thrombi, PTT is used to assess efficacy and toxicity. A
ally employed in the treatment of HIT. It is especially those that are seen in arterial clots. typical dosing guideline is as follows:
expensive, and does not have a reversing They would also be equally efficacious in the
agent and is currently not used in the treatment of venous clots. Currently, there are If PTT ⬍ 40 seconds, increase by
United States. three parenteral DTIs: lepirudin, argatroban, 0.5 mcg/kg/min

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 112 10/28/11 10:15:46 PM

 Chapter 6: Hemorrhagic Risk and Blood Components 113

If PTT 40 to 59 seconds, increase by It is an orally administered pro-drug, rap- be efficacious in VTE prophylaxis in ortho-
0.25 mcg/kg/min idly absorbed and converted to its active pedic patients. Fondaparinux is also felt to be

Perioperative Care of the Surgical Patient

If PTT 60 to 80 seconds, no change form, Dabigatran. Hydrophobic interac- as safe as LMWH in the general surgical pop-
If PTT 80 to 100 seconds, hold for tions are formed with the “distal pocket” of ulation. It enhances antithrombin-mediated
1 hour and decrease by 0.25 mcg/kg/min the active site of thrombin. It also inhibits inhibition of Factor Xa. It has no intrinsic an-
If PTT ⬎ 100 seconds, hold for 1 hour platelet aggregation and is highly selective tithrombin activity and thus, is clearly af-
and decrease by 0.5 mcg/kg/min and rapid, but reversible. Dabigatran’s fected/limited by endogenous antithrombin
plasma concentration is achieved in 2 hours levels/activity. It is completely bioavailable
Argatroban is eliminated via the hepato-
after oral administration and there is no ac- after subcutaneous injection, very predict-
biliary system and has a half-life of approxi-
cumulation upon multiple dosing. Factors able, has a peak plasma level in 2 hours, and
mately 40 minutes. It is the first approved
such as body weight, gender, smoking, and a half-life of 17 hours allowing for once a day
DTI, synthetically derived from Arginine. It
alcohol consumption do not influence its dosage. An important distinction, critical
is a small molecule and binds directly to the
kinetics. Another possible benefit of the with any heparin-like drug, is that there is no
catalytic site of thrombin, forming a revers-
drug is that it is not metabolized by the cy- interaction with PF4. No monitoring is rec-
ible complex that inhibits both free and
tochrome system and does inhibit or induce ommended but there is no reversal agent
fibrin-bound thrombin. It does not induce
cytochrome activity making drug–drug in- available. Potential issues with this medica-
antibody formation and is unaffected by
teractions less of an issue. Excretion is pre- tion are due to the fact that it is cleared via
patients’ age or renal function. In the United
dominantly via the renal route as un- the kidneys, so can be problematic in pa-
States, it is becoming first-line therapy in
changed drug, and thus, any differences in tients with renal dysfunction or in the elderly
treatment of HIT as well as an alternative
pharmacodynamics are associated with who typically have decreased GFR.
anticoagulant in specific circumstances
variations in renal function. Dabigatran has
(i.e., currently unproven but scenario highly
an elimination half-life of 12 to 17 hours, Idraparinux/Idrabiotaparinux
suggestive of HIT).
thus twice daily dosing reduces the vari- Idraparinux is more negatively charged
ability of anticoagulation effects. A general than Fondaparinux, basically a methylated
Bivalirudin recommendation is that currently it should derivative, and due to its higher affinity for
not be used in patients with a GFR ⬍30. binding antithrombin it has a plasma half-
Bivalirudin is a synthetic polypeptide that Although this is partly outside the scope life of 80 hours. It binds antithrombin with
binds both the active catalytic site of throm- of this chapter since this is likely the most such avidity that its own plasma half-life is
bin and its substrate recognition site. Its te- important new anticoagulant available, in- similar to that of antithrombin itself. It can
nacity of thrombin binding is less than Lep- formation from a recent cardiology trial is be given subcutaneously on a once weekly
irudin and greater than Argatroban. After important. Recently, Dabigatran was com- basis. Although it showed some promising
intravenous administration, peak plasma pared to Warfarin in patients with atrial fi- results when compared to Coumadin in
concentrations occur in 2 minutes. It is brillation (RE-LY trial). Over 18,000 patients DVT trials, there was a very tight dose re-
cleared both enzymatically and via the kid- were randomly assigned to Dabigatran at sponse curve in which higher doses, as
neys, has a half-life of approximately 25 min- two dose levels or to adjusted dose Warfa- would be expected, were more efficacious
utes, and doses may need to be decreased in rin. The primary outcome was stroke or sys- than Warfarin, but at an unacceptably high
the presence of renal dysfunction. It has a temic embolization and occurred in 1.69% bleeding rate especially intracranial.
separate indication in the United States and per year on Warfarin, 1.53% in 110-mg Due to the concerns related to inability to
other countries for anticoagulation during group of Dabigatran, and 1.11% in the neutralize or treat overdose of Idraparinux
percutaneous transluminal coronary angio- 150-mg group. The overall rate of bleeding and increased major bleeding events, espe-
plasty and does not require a diagnosis of was significantly higher in the Warfarin cially when treatment was extended more
HIT. In a large trial of Bivalirudin versus UFH group compared to the low-dose Dabiga- than 6 months, a new preparation, Idrabiota-
during PCI, Bivalirudin did not reduce the tran, but equal to that in the higher-dose parinux was created. Its benefit is the at-
incidence of death, MI, or target vessel revas- Dabigatran. Another key finding is that the tached biotin moiety at the nonreducing
cularization, but did significantly reduce the risk intracranial hemorrhage, which is a end, which allows its neutralization with
incidence of major bleeding. There have significant concern in this patient popula- Avidin. It is being evaluated in VTE but in-
been studies proving its efficacy in patients tion, was decreased to one-third the rate of vestigators will also have to take into account
undergoing cardiac surgery and is, in fact, Warfarin in both doses of the new drug. the potential negative effects of Avidin itself.
approved for that indication in Canada. Mortality rates were identical and no evi-
It is important to understand that the dence of hepatotoxicity was seen. One un-
indications for Lepirudin and Argatroban explained but potentially substantive find-
Oral Factor Xa Inhibitors
are for therapeutic treatment for HIT-asso- ing was a slightly higher rate of MI with The strategic positioning of oral Factor Xa
ciated thrombosis, and although they may Dabigatran compared to Warfarin, but this inhibitors between the intrinsic and extrin-
be given off-label as alternative anticoagu- has to be further investigated. It is currently sic pathways and proximal to thrombin of-
lants in patients with suspected HIT with- only approved for use in AF, not treatment fers a potential major advance. In addition,
out a current thrombotic event, they are of VTE. they are highly specific, fixed-dose drugs
currently not used or indicated as a primary that do not require routine monitoring.
anticoagulant. Drug elimination of oral Factor Xa in-
Parenteral Factor Xa Inhibitors hibitors involves multiple metabolic
Dabigatran Etexilate Fondaparinux pathways in addition to renal clearance
Fondaparinux is a synthetically modified (66% with Rivaroxaban, 25% with Apixa-
Dabigatran is a synthesized derivative of a analog of the active heparin pentasaccha- ban). The degree of metabolization by cyto-
peptide-like benzamidine-based inhibitor. ride sequence that has been clearly shown to chrome P-450 will affect use of drugs such

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 113 10/28/11 10:15:46 PM

 114 Part I: Perioperative Care of the Surgical Patient

as antifungals and protease inhibitors. The in only 0.2% of patients in the Rivaroxaban shown promise in early studies with a very
half-life of the Factor Xa agents are typically group versus 2% in the Enoxaparin group. rapid anticoagulant effect and also has the
7 to 10 hours as opposed to 20 to 60 hours This was seen without an increase in bleed- potential benefit of being acutely neutralized
for Coumadin. In addition, due to the in- ing rates. However, a more extensive meta- by a complimentary oligonucleotide.
credibly rapid anticoagulation seen with analysis of the effect of these drugs has raised
these oral drugs in the procedures most concerns about increase in bleeding risk and Factor Va Inhibitors
widely studied—hip and knee replace- will be discussed more below.
ment—the drug is actually given after the As of yet, no successful drug is in produc-
procedure when the wound already has un- tion. This target is promising due to the fact
dergone primary surgical hemostasis.
Apixaban that activated protein C degrades and in-
Apixaban is an orally bioavailable, highly se- hibits Factor Va, a key to thrombin genera-
lective direct-acting, but reversible Factor tion. The two best known drugs are Drotrec-
Ximelagatran Xa inhibitor that undergoes renal excretion ogin and ART 1,2,3, which have not been
Initially felt to be the answer in replace- as well as metabolism under multiple path- pursued due to lack of efficacy and exces-
ment of Warfarin and was the first oral ways including hydroxylation and demethy- sive bleeding risk.
agent in this new class. It is a small mole- lation. Apixaban has also been shown
cule given orally that directly inhibits Fac- in vitro to prevent tissue factor-induced SUMMARY
tor Xa and thrombin, is absorbed from the platelet aggregation. In fact, Apixaban was
GI tract, and undergoes rapid transforma- shown to be so effective compared to aspi- An excellent meta-analysis was performed at
tion to Melagatran. Ximelagatran incom- rin in preventing stroke in atrial fibrillation the Leiden University in the Netherlands by
pletely neutralizes the physiologic func- that a recent study was stopped early. How- Huisman et al., which pooled data from six,
tions of thrombin via its competitive and ever, the exact additive risks of combination phase III randomized trials, encompassing
reversible binding, and is active in both free of Factor Xa inhibitors with antiplatelet over 18,000 participants comparing Enox-
and fibrin-bound thrombin. It is a synthetic therapy is unknown, and a recent study us- aparin with either DTIs or oral Factor Xa in-
dipeptide that mimics fibrinogen and is ing Apixaban with aspirin for prevention of hibitors in patients undergoing hip or knee
converted to an active metabolite by mi- acute ischemic coronary events was termi- replacements. Dabigatran and Enoxaparin
crosomes and mitochondria of the liver and nated because of increased bleeding risk. compared favorably for both prevention of
the kidney. The half-life is 5 hours; the drug Apixaban has been most thoroughly VTE and all-cause mortality with no change
does not interact with food and has a very compared to LMWH essentially the gold in bleeding rates. However, although Rivar-
predictable anticoagulant response. Ini- standard for prevention of VTE in Europe. oxaban showed better prevention of VTE
tially approved in Europe for thrombopro- Two studies merit mention. Approximately and all-cause mortality this was at the ex-
phylaxis, but eventually due to idiosyncratic 4,000 patients undergoing hip replacement pense of significantly higher risk of bleeding.
hepatic toxicity it was withdrawn from the were either given Apixaban 12 hours after All Factor Xa inhibitors including Rivar-
market. closure or Enoxaparin 12 hours before sur- oxaban and Apixaban have been shown to
gery. Prophylaxis was continued for ap- be very effective in both treatment and pro-
proximately 1 month after surgery and all phylaxis of DVT. One of the strong potential
Rivaroxaban benefits of Factor Xa inhibitors is that they
patients had venograms for follow-up. A
It is an oxazolidone derivative with a bio- composite end point of any DVT, pulmo- can be given up to 12 hours after the surgi-
availability of 80% and a half-life of 9 hours, nary embolism, or death in the treatment cal procedure where wound hemostasis can
cleared by the kidneys and intestines. Initial period was evaluated. The end point oc- occur and still be effective in preventing
Phase II trials mainly in patients undergoing curred in only 1.4% in the Apixaban arm DVT. Even with this fact there are concerns
joint replacements proved difficult since ef- and in 3.9% of the Enoxaparin group. Major about Rivaroxaban and Apixaban that may
ficacy as far as dose response was not clear and clinical relevant bleeding occurred in have a safer profile in regards to bleeding.
and with dose escalation there were signifi- 4.8% Apixaban and 5.0% Enoxaparin. A sim- When comparing the most promising
cant bleeding complications. However, with ilar study performed in over 3,000 patients DTI-Dabigatran to the oral Factor Xa inhib-
refinements in exact dosing regimen (QD10 undergoing knee replacement resulted in itors one must take into account alterations
mg oral dose appears to be the most effec- Apixaban reducing the relative risk by of Rivaroxaban and Apixaban pharmacoki-
tive) Rivaroxaban was compared to LMWH 0.62%, with similar bleeding risk. Although netics upon interactions with inhibitors
in thromboprophylaxis after total knee sur- these studies show great efficacy it is im- and inducers of CYP3A4 or p-glycoprotein.
gery. The oral Rivaroxaban was given 8 hours portant to note that the prophylaxis was This may complicate the use of these com-
after surgery versus Enoxaparin beginning actually continued for a significant period pounds in daily practice, whereas Dabiga-
12 hours before surgery. It showed signifi- of time after surgery. However, the results tran elimination largely depends on renal
cant superiority in this trial involving over are actually more impressive than at first function.
2,000 patients with an absolute risk reduc- glance since the end point is very strict (in Ultimately, pharmacotherapy involving
tion of over 9% in the primary efficacy out- the United States venograms would not be anticoagulant use will be based on a num-
come including DVT and PE. It is important performed routinely and small asymptom- ber of factors including whether the therapy
to remember that even though this was a atic DVTs would be missed). is preventive or therapeutic, whether the
preventive trial the dose was given after sur- bed is arterial or venous, and whether the
gery and not preoperatively. In a complimen- treatment is used perioperatively or in non-
tary trial published at the same time, a simi-
Factor IXa Inhibitors surgical patients. The future also holds treat-
lar protocol was used in patients undergoing Currently under development is an intrave- ment paradigms that are based on patient
total hip arthroplasty. The trial encompassed nous preparation, which is an RNA aptimir genomics and biomarkers that may tailor
over 3,000 patients, and major VTE occurred that binds Factor IXa with high infinity. It has the type of therapy or dosing regimen.

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 114 10/28/11 10:15:46 PM

 Chapter 6: Hemorrhagic Risk and Blood Components 115

Anticoagulants Still in Development or not in Active Use in US SUGGESTED READINGS

Perioperative Care of the Surgical Patient

Borgman MA, Spinella PC, et al. The ratio of
B
Danaparoid Treatment for HIT, expensive, no reversal agent blood products transfused affects mortality
Heparin Mimetic Bleeding risk in patients receiving massive transfusions at
a combat support hospital. J Trauma 2007;63:
Ultra LMWH Bleeding risk-dosed before surgery 805–13.
Hirudin Early generation N
Napolitano LM, Kurek S, et al. Clinical practice guide-
Antibody production line: red blood cell transfusion in adult trauma
and critical care. J Trauma 2009;67:1439–42.
Idraparinux/Idrabiotaparinux Bleeding risk V
Vamvaka EC and Blajchman MA. Transfusion-re-
Longer ½ life than fondaparinux lated mortality: the ongoing risks of allogeneic
Ximelagatran Replacement for Coumadin stopped due to hepatotoxicity blood transfusion and the available strategies
for their prevention. Blood 2009;113:3406–17.
Rivaroxaban Bleeding risk
Apixaban Oral drug- may replace fondaparinux

Agents used in US (Indications/Issues)

Lepirudin Confirmed HIT
Anaphylaxis/Renal Elimination
Argatroban Currently First Choice for HIT
Bivalirudin Indicated for use in PCI not HIT
Broader indications outside US
Dabigatran Indicated for AF
“Likely will replace Warfarin for VTE”
Fondaparinux VTE prophylaxis
Renal elimination

EDITOR’S COMMENT bodies in a patient who requires anticoagula- We are preventing a stroke from an embolic
tion needs to be taken care of in a way that situation that likely will result in ⬍5% of these
we cannot overlook and so some knowledge, patients. You look at the data and decide for
The coagulation pathway was, and probably still at the very least a rudimentary knowledge, of yourself, but if you say that patients older than
is, the nemesis of all medical students. It certainly HIT antibodies and the various tests is essen- 70, or certainly older than 75, should not be
was mine, and the only pathway that was worse tial for every surgeon. In a way, it is not sur- anticoagulated with Coumadin, you will have
was the complement pathway. Yet, unfortunately, prising that HIT antibodies are so prevalent. an uphill task at your hands.
especially now, there is a need for surgeons and Although data clearly show that flushes with 4. Most of all, there are a large number of new
particularly surgical residents to learn the coagu- saline, as opposed to diluted heparin, of vari- agents, many of which are first-class drugs,
lation pathway and be able to make intelligent ous catheters, central venous catheters, and but their exact place and where they fit into
decisions, usually with consultants, on what catheters to administer intravenous antibi- the armamentarium is not clear. At least
kind of anticoagulant to be given under certain otics are perfectly satisfactory, it seems that some rudimentary knowledge of these an-
circumstances. This is an excellent chapter and diluted heparin flushing must be done. Thus, ticoagulants and when they should be used
comes at a very good time. why are we surprised that HIT antibodies are and when they should not be used is essen-
so prevalent? tial, if you are to take care of your patients
1. First, there are a host of new agents with 3. The obsession with anticoagulation in atrial and not rely entirely on individuals who are
strengths and weaknesses, which to my knowl- fibrillation, in my view and I realize that I am consultants but have little vested interest in
edge have not been put forth in a textbook of in a minority, is a public health hazard. The the long-term care of this patient. This latter
surgery. Drs. Hamdan and Evenson have done clot that originates in the left atrial append- point is particularly true in a neighborhood
a wonderful job listing these anticoagulants age for the most part is endothelialized over such as the one I live, which is Beacon Hill
and what they are useful for and what the dan- 2 years. Why patients persist with getting in Boston. Although one might think that a
gers are. anticoagulated with Coumadin (warfarin), or neighborhood that is a touriste trappe (no-
2. Heparin-induced thrombocytopenia (HIT), rather why physicians insist their patients get tice the Old English spelling), nonetheless,
or heparin-induced antibodies, is epidemic. anticoagulated with Coumadin, even after 2 it is a fairly tight-knit community and I serve
It is estimated that about 5% of patients who years is beyond me. There is total ignorance as someone with whom many patients and
come into hospital have some form of HIT of the data on trauma, even trivial trauma, to physicians consult as sort of a check on what
antibodies in their bloodstream to be reacti- the head in 70- and 75-year-old patients, and they are told. One need not go into detail
vated when they require care. It is also said when in various meetings I bring this up, I am about some of the things that they are told,
that once HIT antibodies are extant and the challenged, I tell the staff to look it up, and which may very well be injurious. My stance
patient needs anticoagulant medication that they come back at the next meeting and say, on anticoagulation, however, remains stead-
the HIT antibodies will persist for at least 1 “Dr. Fischer was right.” A trivial bump on the fast, as many of my neighbors and friends are
month. These are not just antibodies. HIT an- head in a 75-year-old who is anticoagulated older than 70, and so I get into difficulty. It is
tibodies actually cause clumping of platelets with Coumadin (and may be out of range, therefore important that you, the reader, if
and result in thrombosis, some of which are which many of them are) results in a 40% you serve in a similar capacity wherever you
life threatening. So the presence of HIT anti- mortality rate. And what are we preventing? are, have a knowledge base as well.

(continued)

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 115 10/28/11 10:15:46 PM

 116 Part I: Perioperative Care of the Surgical Patient

The world is a much smaller place and we withhold or delay necessarily invasive interven- tives and branches in the workout of what might
come in contact with many different people from tions, reduce the intensive anticoagulation, or be HIT.
many different societies, some of which are less prophylactic platelet transfusions (which I see The treatment of HIT often begins with the
well developed than the one in which we inhabit. a lot of), or change anticoagulants due to fear screening assay of a positive platelet factor 4
Chimutengwendi-Gordon M, et al. (Clinic Fea- of HIT. The threat of being misled by thrombo- (PF4) ⬎0.4 optical density (OD). The Warkentin
ture, J Perioperative Pract 2010;20:283–287) have cytopenia leads them to believe that relative 4-T scoring system, which is mentioned in the Lo
written an interesting review on perioperative decreases in platelet counts with the first 3 or article, is based on four features: thrombocytope-
blood transfusions. This article originates from 4 days after major surgery are more informative nia; its timing; thrombosis; and an alternative
the Institute of Orthopaedics and Musculoskele- on the magnitude of trauma and blood loss and cause for thrombocytopenia. Each feature is al-
tal Science, Royal National Orthopaedic Hospital, the dynamic of the platelet count course actu- lotted 0 to 2 points; subsequently, a score of 0 to 8
Stanmore, Middlesex, London, and was commis- ally is a good indication of whether or not the points is evaluated. The previous reports suggest
sioned by the journal editor. There is an attempt true physiologic compensatory mechanisms are that if the score is 0 to 3, HIT is unlikely; a score of
at a somewhat superficial article concerning working. They conclude that a slow and gradual 4 to 5 indicates an intermediate suspicion; and a
transfusion practices, reviewing cellular compo- decline in platelet counts developing over 5 to 7 score above 6 makes HIT highly likely. A PF4 test
nents, complications of blood transfusions, fresh days is more likely to be caused by consumptive is considered positive for HIT for values >0.4 OD.
frozen plasma, autologous transfusions, and im- coagulopathy and bone marrow failure whereas Confirmation is made with a C14 serotonin re-
munologic complications. Interestingly, some of the one that most surgeons fear is an abrupt leasing assay (SRA).
the data that referred to in this article, such as decrease in platelet counts within 1 or 2 days, In this study based on a clinical suspicion
autologous blood transfusions, are referred to fa- which may also be associated with an initial in- of HIT, PF4 ELISA tests were requested for 643
vorably, which in this country has proven to be crease in platelet counts, approximately 1 to 2 surgical ICU patients. One hundred thirty-seven
more expensive and not safer. And as a matter of weeks after surgery, and which strongly suggests of these patients were positive for PF4 (PF4
fact, an open letter from Tony Davies, transfusion immunologic causes including drug-induced ⱖ 0.4 OD). They exclude 506 PF4-negative pa-
liaison practitioner, and Kate Pendry, consultant immune thrombocytopenia, posttransfusion tients; nonetheless, 97 SRAs were ordered, and
hematologist, at the Manchester Blood Center purpura (whatever that is), and most important all were negative for HIT. On the other hand, of
in J Perioperative Pract 2011;21:46–48 take issue HIT. We do seem to spend a lot of time looking the 137 patients with positive PF4 tests, 104 had
with many of the practices that are put forth by over our shoulder nowadays at HIT. an available SRA test; 20 patients (19%) were
the authors. The authors’ response is appropri- Which brings us to the next paper by Berry true-positive HIT, and 84 patients (81%) were
ate and basically states that the readership of C, et al. (J Am Coll Surg 2011, published online). false-positive HIT. Thus, this is a somewhat com-
the journal is vast in both developed and lesser They start with stating the obvious that in pa- plicated situation, particularly when there was
well-developed countries and therefore what tients with modest general surgery without a fourth patient who had an initial SRA value of
they may take for granted as the standard in a prophylaxis, deep vein thrombosis and fatal 17% (negative); however, when the same speci-
well-developed Western institution does not re- pulmonary embolism range from 15% to 30% men was sent to a different laboratory, the SRA
ally apply in other situations such as lesser well- for thrombosis and 0.2% to 0.9% for fatal em- value was 97%, so the patient was reclassified as
developed countries and basically the article, bolism. They further state that prophylaxis with a true positive. Clearly, this is an area in which
they imply, is intended for lesser well-developed either low-dose unfractionated heparin or low- surgeons need to be more expert and it does
countries. I agree with that and probably the good molecular-weight heparin will reduce the rate bother me that the guidelines for anticoagula-
that they do is probably better in the lesser well- of these feared complications by at least 60%. tion for surgical patients were established by
developed countries than in the well-developed The American College of Chest Physicians 2008 the American College of Chest Physicians and
countries such as the United Kingdom and the guidelines (Lo GK, et al., J Thrombosis Haemo- not surgeons. However, we can’t seem to get our-
United States where there are ample numbers of statis 2006;4;759–765) state that for a major selves together in a lot of areas, so I’m not sure
well-qualified physicians and surgeons who can procedure for benign disease, thromboprophy- why this is any different.
give good advice. laxis with low-molecular-weight heparin or I am certain that as time goes on and sur-
Greinacher A and Selleng K, from the Insti- low-dose unfractionated heparin twice daily, geons become much more facile with the vari-
tute for of Immunology and Transfusion Medi- or in very heavy patients or high-risk patients 3 ous tests for HIT and what the substitutes are,
cine in Greifswald, Germany, in Hematology times daily, or fondaparinux, which seems to be it may finally be that some of the guidelines that
(2010;2010:135–142) discuss the thrombocy- equally efficacious, is recommended. are associated with surgical patients will be writ-
topenia in the intensive care unit (ICU) patient. The use of heparin, even low-dose unfraction- ten by surgeons. However, it does remain some-
They start with the premise that thrombocy- ated heparin, puts the patient at risk once the di- what disappointing for me that we have to rely
topenia is very common in various ICUs, with agnosis of HIT is suspected. Once it is suspected, on guidelines that are established by a nonsurgi-
approximately 40% manifesting it. Thus, mild the American Society of Hematology (Cuke A and cal group. This is not to say that the guidelines
to moderately low platelet counts when ad- Crowther A, Am Soc Hematol 2009;1–8) recom- are imperfect; they are quite good, but we need
ditional factors are present can interfere with mends the discontinuation of heparin and the to learn to make our own guidelines; we can’t be
normal homeostatic mechanisms. They go on administration of a nonheparin anticoagulant, that busy. We may be that fragmented so that we
to say that even when mild to moderate throm- such as argatroban, bivalirudin, or lepirudin, and can’t decide anything, but we really need to work
bocytopenia is not associated with bleeding, HIT confirmation with a serologic assay. There is, out getting along and bringing forth the guide-
low platelet counts often influence platelet as usual, if anything associated with coagulation lines that we need.
management and may prompt physicians to is a complicated chart showing various alterna- J.E.F.

www.medicalebookpdf.com

LWBK892_c06_p100-116.indd 116 10/28/11 10:15:47 PM

 Chapter 7: Perioperative Antimicrobial Prophylaxis and Treatment of Surgical Infection 117

7 Perioperative Antimicrobial Prophylaxis and

Perioperative Care of the Surgical Patient

Treatment of Surgical Infection
Joseph Solomkin

INTRODUCTION geons believe that such infections are more from this organism is becoming a focus
often a nuisance than a real problem, and point.
The prevention of surgical site infection believe that such infections should not be USA300, the primary strain of CA-MRSA
(SSI)1 remains a focus of attention because given equal weight with complex infections. in the United States, is now the predomi-
wound infections continue to be a major Because of the preceding issues, some have nant hospital-acquired MRSA strain in
source of expense, morbidity, and even recommended that external (public) re- particular hospitals in the United States
mortality. Surgical site infections compli- porting of rates of SSI exclude superficial (Deurenberg and Stobberingh: Infect Genet
cate an estimated 780,000 operations in the incisional SSIs and include only complex Evol 2008, 8:747). This attests to the abilities
United States each year, and are the second SSIs. (Modified From Kaye: Infect Control of this organism to colonize patients. In
most common hospital-associated infec- Hosp Epidemiol 2008, 29:941–6). parallel findings, an analysis of SSIs caused
tion. A patient who develops a wound infec- The public reporting of hospital-acquired by S. aureus showed that most of the SSIs
tion while still hospitalized has an approxi- infections, including SSIs, is obviously a occurring in hospitalized patients were due
mately 60% greater risk of being admitted subject of great discussion. The interested to CA-MRSA, but not those following out-
to the intensive care unit, and an attribut- reader is referred to a statement by the So- patient procedures.
able extra hospital stay of 6.5 days, at an ex- ciety for Healthcare Epidemiology of Amer- It is important to note that administra-
tra direct cost of $3,000. Risk of readmission ica (http://www.shea-online.org/Assets/ tion of systemic anti-infectives is only part
within 30 days is five times more likely for files/Essentials_of_Public_Reporting_ of a broad program of infection control in-
infected patients, at a cost of more than Tool_Kit.pdf, accessed August 29, 2010). volving adequate operating room ventila-
$5,000. Three quarters of deaths of surgical This is a view that I share, and the CDC is tion, sterilization, barrier usage, and deli-
patients with SSIs are attributed to nosoco- considering this reporting change. How- cate surgical technique. Furthermore, the
mial infection, nearly all of which are organ/ ever, much of the trials looking at benefits importance of the process used to provide
space infections. from various interventions to prevent in- therapies that reduce SSIs is now recog-
Since these definitions of SSIs were first fection have primarily focused on superfi- nized, and much of the discussion on pro-
developed, however, things have changed, cial incisional infections, since deeper SSIs phylaxis centers on process. One of the key
but not for the better. These frightening are only a third of the total and statistical conclusions of the Institute of Medicine’s
numbers come primarily from infections significance is more difficult to identify. In- “Crossing the Quality Chasm” is that poorly
presenting while patients are still in hospi- deed, many interventions may be highly ef- designed delivery systems, rather than cog-
tal. And therein lies the rub for putting this fective at preventing superficial infection nitive deficits or negligence on the part of
information in perspective. and of little value for organ space infection individuals, account for many of infections
The CDC definition for SSI encompasses (e.g., skin preparation where the major risk seen.
three specific subtypes of infection: superfi- for organ space infection is from enteric We have now moved into an era with
cial incisional, deep incisional, and organ flora). zero tolerance for hospital-acquired infec-
space. Collectively, deep incisional and or- Considerable effort has been expended tion. This philosophical stance may be
gan space infections can be termed “com- to identify potentially controllable variables argued with but is the direction of Center
plex” SSIs, and in most series represent that influence infection rates. A major re- for Medicare and Medicaid Services (CMS)
about a third of infections seen, the others view of this subject and an extensive list of in regards pay for hospital-acquired infec-
being superficial. Complex SSIs are serious recommendations for preoperative patient tions. This, in addition to public reporting
infections that typically require rehospital- preparation and operating room environ- of individual hospital compliance, has reca-
ization, return to the operating room, and ment have recently been published by the librated the equation of a risk/benefit in fa-
intravenous antibiotic therapy. Such infec- Hospital Infection Control Practices Advi- vor of providing antimicrobial prophylaxis
tions are difficult to ignore or miss when sory Committee of the CDC. to nearly all patients undergoing clean or
they do occur, and they are of undoubted Recently, new organisms have appeared clean contaminated surgical procedures.
significance to patients and their surgeons. as pathogens in SSIs in the United States. Given the move to wider application of
These are the infections with cost and mor- Perhaps, most important is community- antibiotic prophylaxis, it is important to ask
bidity information, as stated above. acquired methicillin-resistant Staphylococ- at the outset whether surgical prophylaxis
In contrast, superficial incisional SSIs cus aureus (CA-MRSA). This organism is has any substantial impact on bacterial re-
often do not require rehospitalization and genetically different than the staphylococci sistance patterns. The answer is that it is
are inconsistently diagnosed in outpatients previously seen in surgical infections. In unknown but unlikely. In comparison to the
by postdischarge surveillance. Many sur- particular, it carries an array of virulence raw tonnage of antibiotics prescribed in the
factors that allow it to more easily colonize community for upper respiratory infections,
1
The Centers for Disease Control and Prevention (CDC) and invade cutaneous wounds—including the amount provided to surgical patients
refers to postoperative wound infections as “surgical surgical incisions. It has become the most for prophylaxis is quite small, particularly if
site infection” and divides these into superficial (involv-
ing skin and subcutaneous tissue) and deep (involving
common form of S. aureus found in SSIs, guidelines for restricting antimicrobial pro-
the fascia and muscle) incisional infections, and organ/ and may be responsible for a recent increase phylaxis to ⬍24 hours (or 48 h for cardiac
space infections. in SSIs. How to reduce the risk of infection procedures) are adhered to. Indeed, it is

www.medicalebookpdf.com

LWBK892_c07_p117-126.indd 117 10/28/11 3:41:41 PM

 118 Part I: Perioperative Care of the Surgical Patient

extraordinary that for the millions of doses elements of the procedure; and those that various surgical sites and subsequent in-
of cefazolin resistance to streptococci and serve as markers for host susceptibility. fecting pathogens was established. This
community gram-negatives are uncommon. In 1964, the National Research Council microbiologic correlation included recog-
For vancomycin, there are now a total of 12 sponsored an examination of the efficacy nition of the role of anaerobes in postop-
isolates identified in the United States as of ultraviolet irradiation, and provided the erative wound infection and abscess for-
resistant. There has been considerable dis- data to validate a wound classification mation.
cussion about increases in MICs for S. au- scheme describing risk of infection in rela- Subsequent CDC efforts, the SENIC proj-
reus, but the data for this are from highly tion to the extent of wound contamination. ect (Study of the Efficacy of Nosocomial
selected observational studies that have That document is a landmark in this area, Infection Control) and NNIS (National
important problems in design. and the classification scheme has remained Nosocomial Infection Surveillance, since
Furthermore, within the hospital, anti- useful to the present day. This classifica- renamed NHSN, the National Hospital Sur-
microbial resistance is principally engen- tion is presented in Table 1. A clear connec- veillance Network) sought to examine these
dered in the intensive care units. The inten- tion between the contaminating flora at other variables as predictors of infection.
sive care unit is a home to patients at great
risk for infection by virtue of acute and
chronic disease and by the insertion of a
range of transepithelial drainage, monitor-
ing, and infusion catheters. These elements Table 1 Wound Classification
lower the inoculum needed to initiate in-
Classification Description Procedure type
fection and provide portals of entry. Fur-
thermore, the intensive care unit is more Clean Uninfected surgical wounds in Exploratory laparotomy
likely to be contaminated with highly trans- which no inflammation is Mastectomy
missible and antibiotic-resistant organisms encountered and the respiratory, Neck dissection
alimentary, genital, or uninfected Nonpenetrating blunt trauma
than other units. urinary tracts are not entered. In Thyroidectomy
This chapter will describe current no- addition, clean wounds are Total hip replacement
tions of risk factors for SSIs and discuss closed primarily and, if necessary, Vascular surgeries
problems relating to knowing what infec- drained with closed drainage.
tion rates really are. The chapter will then Surgical incisional wounds that
provide recommendations for practices occur with nonpenetrating
and describe the data supporting those (i.e., blunt) trauma should be
practices. Guidelines published by several included in this category if they
expert groups have created a near uniform meet the criteria.
approach to antibiotic usage for prophy- Clean/ A surgical wound in which the Bronchoscopy
laxis. contaminated respiratory alimentary, genital, Cholecystectomy (i.e., any approach)
or urinary tracts are entered Laryngectomy
under controlled conditions and Routine appendectomy
HISTORICAL ASPECTS without unusual contamination. Small bowel resection
Administration of antibiotics to decrease Specifically, procedures involving Transurethral resection of prostate
the incidence of postoperative wound infec- the biliary tract, appendix, Whipple pancreaticoduodenectomy
vagina, and oropharynx are
tion is a surprisingly recent strategy. In fact, included in this category,
early studies of anti-infective prophylaxis, provided no evidence of infection
performed in the 1950s, reported either no or major breaks in technique are
decrease in infection rates or even higher encountered.
rates than control. These results are ex-
Contaminated Open fresh, accidental wounds. Appendectomy for inflamed
plained by the fact that anti-infectives were In addition, procedures that have appendicitis
begun only in the postoperative period. major breaks in sterile technique Bile spillage during cholecystectomy
During the late 1950s and 1960s, important (e.g., open cardiac massage) or Diverticulitis
developments were made to rationalize an- gross spillage from the gastrointes-
timicrobial prophylaxis. The most funda- tinal tract and incisions in
mental was definition of the decisive period, which acute, nonpurulent
the time following wound contamination inflammation is encountered are
that antibiotics would still reduce the inci- included in this category.
dence infection. Dirty/infected Old traumatic wounds that have Excision and drainage of abscess
retained devitalized tissue Myringotomy for otitis media
and those that involve existing Perforated bowel
IDENTIFYING RISK OF SURGICAL clinical infection or perforated Peritonitis
SITE INFECTION viscera. This definition suggests
that the organisms causing
It is assumed that at least three categories postoperative infection were
of variables serve as predictors of SSI risk: present in the surgical field
Those that estimate the intrinsic degree of before the procedure.
microbial contamination of the surgical
site; those that measure the duration of the Centers for Disease Control and Prevention. Guideline for Prevention of Surgical Wound Infections, 1985. Atlanta:
operation and other less easily quantifiable Centers for Disease Control; 1955:1–10.

www.medicalebookpdf.com

LWBK892_c07_p117-126.indd 118 10/28/11 3:41:41 PM

 Chapter 7: Perioperative Antimicrobial Prophylaxis and Treatment of Surgical Infection 119

d
depends on the operative procedure being
Table 2 Elements in the American Society of Anesthesia Scoring System pperformed. This is typically the 75th percen-

Perioperative Care of the Surgical Patient

Preoperative health status ttile. Definitions for wound classes are pro-
ASA PS category comments Examples vvided in Table 1. Elements in an American
SSociety of Anesthesiologists preoperative
ASA PS 1 Normal healthy patient
aassessment score are in Table 2.
ASA PS 2 Patients with mild systemic disease No functional limitations; has a The surgical wound infection rates for
well-controlled disease of one ppatients with scores of 0, 1, 2, and 3 were
body system 11.5, 2.9, 6.8, and 13.0, respectively. The risk
ASA PS 3 Patients with severe systemic Some functional limitation; has a iindex is a significantly better predictor of
disease controlled disease of more than ssurgical wound infection risk than the tra-
one body system or one major dditional wound classification system and
system pperforms well across a broad range of op-
ASA PS 4 Patients with severe systemic Has at least one severe disease that eerative procedures.
disease that is a constant is poorly controlled or at end It is important to note that this system
threat to life stage pprovides little insight into risk of infection in
ASA PS 5 Moribund patients who are not cclean or clean-contaminated wounds, other
expected to survive without tthan identifying a correlation with length of
operation ooperation. It is specifically worth noting that
morbid obesity places a patient into Ameri-
m
http://en.wikipedia.org/wiki/ASA_physical_status_classification_system, accessed July 25, 2010.
ccan Society of Anesthesiologists 3 but the
rrelative weight of this and other variables is
not more precisely addressed by this short-
A risk index was developed to predict a with an American Society of Anesthesiolo- hand. The problem is that a morbidly obese
surgical patient’s risk of acquiring a surgical gists preoperative assessment score of 3, 4, patient undergoing a procedure, such as a
wound infection. The risk index score, rang- or 5 (see Table 2); (b) an operation classified caesarean section, is at a higher intrinsic
ing from 0 to 3, is the number of risk factors as contaminated or dirty/infected; and (c) risk of SSI than predicted by the risk system
present among the following: (a) a patient an operation lasting over T hours, where T described. A hospital with a large number of
such patients will therefore fall out in public
rreporting as a hospital with problems.
Table 3 Recommended Antibiotics
Penicillin or cephalosporin A
ACCEPTED INDICATIONS FOR
Surgical service Routine antibiotic allergy
AANTI-INFECTIVE PROPHYLAXIS
Burns Cefazolin Clindamycin AAND RECOMMENDED AGENTS
Cardiac Cefazolin plus Vancomycin Vancomycin
There is a wide consensus on specific proce-
Thoracic Cefuroxime Vancomycin or Clindamycin ddures that warrant antimicrobial prophylaxis.
Colorectal Cefazolin plus Metronidazole Gentamicin plus Clindamycin Consensus statements by the Surgical Infec-
C
Or ttion Society of North America, the Infectious
Ertapenem Diseases Society of America, the American
D
General surgery/endocrine Cefazolin Clindamycin SSociety of Hospital Pharmacists, the Canadian
Hepatobiliary (complicated) Piperacillin Gentamicin plus Vancomycin IInfectious Diseases Society, and the French
SSociety of Anesthesia and Intensive Care all
Obstetrical and gynecologic Cefazolin Gentamicin plus clindamycin aagree on a number of indications. The areas of
Urologic Cefazolin Gentamicin cconsensus and recommendations for antimi-
Plastics, reconstructive and Cefazolin Clindamycin or Vancomycin ccrobial therapy are provided in Table 3.
hand surgery These guidelines have needed updating,
aand this task was undertaken by the Ameri-
Vascular, orthopedic, and Cefazolin (add Vancomycin if Vancomycin
neurosurgical synthetic graft is being ccan Society of Health System Pharmacists,
placed) iin collaboration with the Surgical Infection
SSociety, the Infectious Diseases Society of
These recommendations are derived from recommendations in place at the University of Cincinnati Hospital, America, and the Society of Health Care
A
and encompass recommendations made from the Surgical Care Improvement Project. These also include com- Epidemiology. These guidelines are avail-
E
ments made by the American Society of Health System Pharmacists (referenced by URL in text).
Bratzler DW, Houck PM; Surgical Infection Prevention Guidelines Writers Workgroup; American Academy of aable in draft form (http://www.ashp.org/
Orthopedic Surgeons; American Association of Critical Care Nurses; American Association of Nurse Anesthe- pprophylaxis, accessed August 29, 2010).
tists; American College of Surgeons; American College of Osteopathic Surgeons; American Geriatrics Society; Controlled trials of antimicrobial pro-
American Society of Anesthesiologists; American Society of Colon and Rectal Surgeons; American Society of pphylaxis in minimally invasive procedures
Health-System Pharmacists; American Society of PeriAnesthesia Nurses; Ascension Health; Association of
periOperative Registered Nurses; Association for Professionals in Infection Control and Epidemiology; Infec-
have recently been reported. In low-risk lap-
h
tious Diseases Society of America; Medical Letter; Premier; Society for Healthcare Epidemiology of America; aaroscopic cholecystectomy and arthroscopic
Society of Thoracic Surgeons; Surgical Infection Society. Antimicrobial prophylaxis for surgery: an advisory ssurgery, routine prophylaxis is not indi-
statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004;38(12):1706–15. Epub ccated. In contaminated laparoscopic proce-
26 May 2004. ddures, such as high-risk cholecystectomy

www.medicalebookpdf.com

LWBK892_c07_p117-126.indd 119 10/28/11 3:41:41 PM

 120 Part I: Perioperative Care of the Surgical Patient

and bowel surgery, it is best to apply the The use of oral, nonabsorbable agents of infection is low for uncomplicated appen-
standards for similar open procedures. is no longer recommended. Antibiotics se- dicitis, the preoperative status of the pa-
lected for prophylaxis in colorectal surgery tient’s appendix may not be known. Metron-
Gastroduodenal should be active against both aerobic and idazole combined with a first-generation
anaerobic bacteria. Certain regimens were cephalosporin is an acceptable regimen. For
Prophylaxis is recommended for most gas- found to be inadequate. Inadequate regi- uncomplicated appendicitis, coverage need
trointestinal procedures. The density of mens included metronidazole alone (which not be extended to the postoperative period.
organisms and proportion of anaerobic lacks activity against facultative and aerobic Complicated appendicitis (e.g., with accom-
organisms progressively increase along the gram-negative organisms), doxycycline alone, panying perforation or abscess) is an indi-
gastrointestinal tract, so the recommenda- piperacillin alone (which lacks activity cation for antibiotic therapy, thereby ren-
tion depends on the segment of gastrointes- against anaerobes), and oral neomycin plus dering any consideration of prophylaxis
tinal tract entered during the procedure. The erythromycin on the day before operation. irrelevant.
density of microorganisms contaminating The addition of an effective parenteral agent
the surgical wound with procedures entering reduced infection rates seen with neomycin/
the stomach, duodenum, and proximal erythromycin to the same level as that seen
Biliary Tract Procedures
small bowel is quite low and consists pri- with the parenteral agent alone. Antimicrobial prophylaxis is not recom-
marily of gram-positive organisms. However, This study also found no evidence to mended in low-risk patients undergoing
any disease or therapeutic intervention that suggest that the new-generation cepha- laparoscopic cholecystectomy. The recom-
decreases gastric acidity causes a marked losporins are more effective than the first- mendations for antibiotic prophylaxis for
increase in the number of bacteria and the generation cephalosporins combined with procedures of the biliary tract depend on
risk of wound infection. Therefore, previous metronidazole. Surveys of resistance among the presence of specific risk factors. In gen-
use of antacids, histamine blockers, or a anaerobic organisms, specifically the rec- eral, prophylaxis for open cholecystectomy
proton pump inhibitor qualifies the patient ognized pathogen Bacteroides fragilis, have is considered beneficial. Antimicrobial pro-
for prophylaxis. Prophylaxis is also indicated documented a substantial increase in resis- phylaxis should be considered in patients
for procedures treating upper gastrointesti- tance to cefotetan and, to a lesser extent, undergoing laparoscopic cholecystectomy
nal bleeding. Stasis also leads to an increase cefoxitin. For this reason, cefotetan can no who are at high risk of infectious complica-
in bacterial counts, so prophylaxis is war- longer be recommended for prophylactic tions including emergency procedures, dia-
ranted in procedures to correct obstruction. usage. Ampicillin-sulbactam should not be betes, longer procedure duration, intraop-
In addition, the intrinsic risk of infection in used routinely for prophylaxis because erative gallbladder rupture, age (⬎70 years),
patients with morbid obesity and malig- many, if not most, Escherichia coli have be- conversion of laparoscopic to open chole-
nancy is sufficiently high to warrant prophy- come resistant to it. cystectomy, higher American Society of
laxis in these cases. Although the local flora A major study was recently completed Anesthesiologists score, acute cholecystitis,
is altered in these patients, cefazolin pro- comparing ertapenem, a carbapenem class bile spillage, jaundice, disease of the common
vides adequate prophylaxis and is the rec- of antibiotic typically reserved for cepha- duct, diagnosis of cholecystitis, previous
ommended agent. losporin-resistant gram-negatives, to cefo- history of biliary tract surgery, or immuno-
Generally, elective surgery on the stom- tetan. Cefotetan is no longer available for suppression.
ach or duodenum for ulcer disease is now use in the United States and has only mod-
included in those procedures requiring est B. fragilis activity. Predictably, ertap-
prophylaxis. enem, with excellent activity against E. coli
Neurosurgical Procedures
and B. fragilis, was superior to cefotetan. Studies evaluating the efficacy of antibiotic
Small Bowel and Colorectal The American Society of Health System prophylaxis in neurosurgical procedures
Procedures Pharmacists, in draft guidelines, recom- have shown variable results. Nonetheless,
mends against use of ertapenem because of prophylaxis is currently recommended for
The flora of the small bowel changes from concerns for the effects of additional car- craniotomy, laminectomy, and shunt pro-
small numbers of gram-positive organisms bapenem usage on resistance to these cedures. Coverage targets S. aureus or
proximally to heavier growth of gram- critical agents. I agree with this and, S. epidermidis. This is an area deserving
negatives more distally. In the distal ileum, despite FDA labeling that ertapenem is close local attention. We and others have
anaerobes emerge and become important effective in preventing SSIs following seen increased infection rates due to MRSA,
in SSIs. Therefore, the recommendation is colorectal surgery, I find no reason to particularly in bone flaps raised for cran-
that proximal small bowel procedures re- recommend it against cefazolin/metron- iotomies, and we have moved to a decoloni-
ceive prophylaxis with a first-generation idazole. zation strategy and added vancomycin to
cephalosporin; more distally, prophylaxis as Topical application of antibiotics in ad- routine prophylaxis for these agents.
for colorectal procedures is recommended. dition to the parenteral administration of
Colorectal procedures have a very high appropriate anti-infectives has not been
intrinsic risk of infection and warrant a found effective in controlled trials. No ad-
Head and Neck Procedures
strong recommendation for prophylaxis. In ditional benefit was observed in six trials For procedures entailing entry into the
patients undergoing colorectal surgery, the that compared parenteral anti-infectives oropharynx or esophagus, coverage of aero-
incidence of wound infection ranges from alone with parenteral plus topical antibiot- bic cocci is indicated. Prophylaxis has been
9% to 27%. Several studies have demon- ics. There is certainly anecdotal testimony shown to reduce the incidence of severe
strated efficacy with rates of infection de- to their efficacy and I doubt this “contro- wound infection by ∼50%. Either penicillin-
creasing from ⬎50% to ⬍9%. Antibiotics versy” will ever go away. or cephalosporin-based prophylaxis is ef-
are directed at gram-negative aerobes and Prophylaxis is also recommended for fective. Cefazolin is commonly used. Pro-
anaerobic bacteria. appendectomy. Although the intrinsic risk phylaxis is not indicated for dentoalveolar

www.medicalebookpdf.com

LWBK892_c07_p117-126.indd 120 10/28/11 3:41:42 PM

 Chapter 7: Perioperative Antimicrobial Prophylaxis and Treatment of Surgical Infection 121

procedures, although prophylaxis is war- ectomy. Numerous clinical trials have ANTI-INFECTIVE PROPHYLAXIS
ranted in immunocompromised patients demonstrated a reduction in risk of wound FOR CLEAN PROCEDURES

Perioperative Care of the Surgical Patient

undergoing these procedures. infection or endometritis by as much as
70% in patients undergoing cesarean sec- The biggest controversy regarding antibiotic
tion. For cesarean section, the American prophylaxis centers around prophylaxis for
General Thoracic Procedures College of Obstetrics and Gynecology is clean surgery. Prophylaxis has prevented
Prophylaxis is routinely used for nearly all now recommending that antibiotics should postoperative wound infection after clean
pulmonary resections, because of the like- be administered 1 hour prior to the proce- surgery in a majority of clinical trials with
lihood of contaminating the operative dure. Despite the theoretic need to cover sufficient power to identify a 50% reduction
field during airway transection. Likewise, gram-negative and anaerobic organisms, in risk. The low control rates of infection
prophylaxis is strongly recommended for studies have not demonstrated a superior mean that very large studies must be done
procedures entailing entry into the esoph- result with broad-spectrum antibiotics to see a significant effect; studies of more
agus. Although the range of microorgan- compared with cefazolin. Therefore, cefazo- than 1,000 procedures are needed to detect
isms encountered in thoracic procedures lin is the recommended agent. such reductions reliably.
is extensive, most are sensitive to cefazo- The major study on this subject was a
lin, which is the recommended agent. randomized, double-blind trial of 1,218 pa-
UROLOGIC PROCEDURES tients undergoing herniorrhaphy or surgery
involving the breast, including excision of a
Cardiac Procedures The range of potential urologic procedures
breast mass, mastectomy, reduction mam-
and intrinsic risk of infection varies widely.
Prophylaxis against S. aureus and S. epider- In general, it is recommended to achieve moplasty, and axillary-node dissection. The
midis is indicated for patients undergoing preoperative sterilization of the urine, if prophylactic regimen was a single dose of
cardiac procedures. Although the risk of in- clinically feasible. For procedures entailing cefonicid (1 g intravenously) administered
fection is low, the morbidity of mediastinitis the creation of urinary conduits, recom- approximately half an hour before surgery.
or a sternal wound infection is great. Numer- mendations are similar to those for proce- The patients were followed up for 4 to
ous studies have evaluated antibiotic regi- dures pertaining to the specific segment of 6 weeks after surgery.
mens based on penicillin, first-generation the intestinal tract being used for the con- The patients who received prophylaxis
cephalosporins, second-generation cepha- duit. Procedures not requiring entry into had 48% fewer probable or definite infec-
losporins, or vancomycin. Cardiopulmonary the intestinal tract and performed in the tions than those who did not. For patients
bypass reduces the elimination of drugs, so context of sterile urine are regarded as dean undergoing a procedure involving the breast,
additional intraoperative doses typically are procedures. It should be recognized, how- infection occurred in 6.6% of the cefonicid
not necessary. ever, that prophylaxis for specific urologic recipients (20 of 303) and 12.2% of the pla-
Antistaphylococcal penicillins and first- procedures has not been fully evaluated. cebo recipients (37 of 303); for those under-
generation cephalosporins have tradition- going herniorrhaphy, infection occurred in
ally been the prophylactic antibiotics of 2.3% of the cefonicid recipients (7 of 301)
choice for patients undergoing cardiotho- Orthopedic Procedures and 4.2% of the placebo recipients (13 of
racic operations. Recently published stud- 311). There were comparable reductions in
Antibiotic prophylaxis is clearly recom- the numbers of definite wound infections,
ies have claimed improved outcomes with
mended for certain orthopedic procedures. wounds that drained pus, and S. aureus
respect to postoperative wound infection
These include the insertion of a prosthetic wounds. There were comparable reductions
when second-generation cephalosporins
joint, ankle fusion and revision of a pros- in the need for postoperative antibiotic ther-
were used for prophylaxis.
thetic joint, reduction of hip fractures, re- apy, nonroutine visits to a physician for
Finally, the Society of Thoracic Surgeons
duction of high-energy closed fractures, problems involving, wound healing, incision
recently published a practice guideline for
and reduction of open fractures. Such pro- and drainage procedures, and readmission
duration of antibiotic therapy for patients
cedures are associated with a risk of infec- because of problems with wound healing.
receiving cardiac surgery [39]. The authors
tion of 5% to 15%, reduced to ⬍3% by the An observational study was then done
concluded that, although there is some
use of prophylactic antibiotics. S. aureus on the effects of antibiotic prophylaxis on
evidence that single-dose prophylaxis or
and S. epidermidis predominate in wound definite wound infections. Identified preop-
24-hour prophylaxis may be as effective as
or joint infections. Cefazolin provides ade- eratively were 3,202 patients undergoing
48-hour prophylaxis, few studies have di-
quate coverage. The additional use of amin- herniorrhaphy or selected breast surgery
rectly compared 24 hours of prophylaxis
oglycosides and extension of coverage be- procedures; these patients were monitored
with 48 hours of prophylaxis. Because pro-
yond the operative period is common but for 4 or more weeks. Thirty-four percent of
longed prophylaxis in cardiac surgery has
lacks supportive evidence. patients received prophylaxis at the discre-
been associated with an increased risk of
infection with drug-resistant organisms, tion of the surgeon; 86 definite wound in-
they concluded that prophylaxis should not fections (2.7%) were identified. Prophylaxis
be administered for ⬍48 hours [40].
Noncardiac Vascular Procedures recipients were at higher risk for infection,
In many centers, vancomycin is now Available data support the recommendation with a higher proportion of mastectomies,
routinely added for prophylaxis. for coverage of procedures using synthetic longer procedures, and other factors. Pa-
material, those requiring groin incisions, and tients who received prophylaxis experi-
OBSTETRIC AND GYNECOLOGIC those affecting the aorta. Cefazolin is the enced 41% fewer definite wound infections
recommended agent, since most infections and 65% fewer definite wound infections
PROCEDURES are caused by S. aureus or S. epidermidis. Pro- requiring parenteral antibiotic therapy af-
Prophylaxis is indicated for cesarean phylaxis is not recommended for patients ter adjustment for duration of surgery and
section and abdominal and vaginal hyster- undergoing carotid endarterectomy. type of procedure. Additional adjustment

www.medicalebookpdf.com

LWBK892_c07_p117-126.indd 121 10/28/11 3:41:42 PM

 122 Part I: Perioperative Care of the Surgical Patient

for age, body mass index, the presence of Screening for ␤-Lactam Allergy crobial resistance patterns and institutional
drains, diabetes, and exposure to corticos- Although many patients have drug allergies incidence of infections caused by organisms
teroids did not change the magnitude of documented in their medical records, the such as Clostridium difficile and S. epider-
this effect. The effect of prophylaxis was symptoms or circumstances associated midis. On the basis of antimicrobial spec-
similar for all procedures studied. with the allergies are rarely documented. trum data, vancomycin and clindamycin are
Dosing recommendations are provided Several studies have demonstrated that the appropriate alternatives to ␤-lactams, al-
in Table 4, along with adjustments for incidence of true drug “allergy” is lower though there are few data supporting the
weight. It is recommended that dosages than that recorded in medical records. Be- use of either for routine prophylaxis.
should be calculated based on actual body cause ␤-lactam antimicrobials often repre- Timing of administration of prophylaxis
weight, even for morbidly obese patients. sent agents of choice for prophylaxis, the and the duration of antimicrobial prophy-
Obesity is a well-known risk factor for SSI. medical history should be adequate to de- laxis will be detailed under the Surgical Care
Possible biological explanations for this as- termine if the patient likely had a true al- Improvement Project (SCIP) mandates.
sociation include the relative avascularity lergy (e.g., urticaria, pruritus, angioedema,
of adipose tissue, the increase in wound bronchospasm, hypotension, or arrhyth-
area, and the poor penetration of prophy- mia) or a serious adverse drug reaction (e.g., SCIP: THE SURGICAL CARE
lactic antibiotics in adipose tissue. drug-induced hypersensitivity syndrome, IMPROVEMENT PROJECT
On the basis of pharmacokinetic consid- drug fever, or toxic epidermal necrolysis).
erations, most published guidelines recom- In operations for which cephalosporins In 2002, the CMS, in collaboration with the
mend intraoperative redosing of the pro- represent appropriate prophylaxis, alterna- CDC, implemented the National SIP (Surgi-
phylactic antibiotic for procedures of tive antimicrobials should be provided to cal Improvement Project). The goal of the
prolonged duration to maintain effective those with a high likelihood of serious ad- project was to decrease the morbidity and
antibiotic concentrations. Support for in- verse reaction or allergy on the basis of pa- mortality associated with postoperative SSI
traoperative redosing of antibiotics has tient history or diagnostic tests such as skin by, among other items, promoting appro-
been inferred from observational studies in testing. However, the incidence of adverse priate selection and timing of prophylactic
which increased duration of surgery was as- reactions to cephalosporins among patients antimicrobials.
sociated with increased risk for SSI, as well with reported penicillin allergy is rare, and This rapidly transitioned into a larger
as loss of the protective effect of prophy- penicillin skin tests do not predict the likeli- program, SCIP. In 2003, representatives of
laxis over time. hood of allergic reactions to cephalosporins the CMS and the CDC, together with repre-
Dose adjustments for actual body in patients reporting penicillin allergy. Prac- sentatives of the VA, the American College
weight are important, and are provided in tical approaches to patients with a history of Surgeons, the American Society of Anes-
Table 3. of antibiotic allergy have been previously thesiologists, the Agency for Healthcare
An additional often neglected aspect of published. Research and Quality, the American Hospi-
prophylaxis concerns the need to maintain tal Association, and the Institute for Health-
effective antibiotic levels throughout the Antimicrobial Choice for care Improvement aligned efforts aimed at
procedure. This is typically accomplished ␤-Lactam Allergy reducing surgical complications and mor-
by providing repetitive dosing for lengthy Recommendations for patients with con- tality. The SCIP is a national quality
procedures. This is in part a function of the firmed ␤-lactam allergy are provided in partnership of organizations committed to
half-life of the agent selected, and is an ad- Table 3. In operations where prophylaxis is improving the safety of surgical care
ditional argument in favor of agents such as directed primarily at gram-positive cocci, through the reduction of postoperative
cefazolin that have half-lives approaching such as orthopedic operations with joint re- complications. In addition to the 10 organi-
2 hours. A current recommendation is to placement, cardiothoracic operations, or zations that constitute the steering com-
redose the patient at intervals of twice the general, vascular, and neurosurgical opera- mittee, 130 other organizations have com-
half-life of the agent provided. It is impor- tions with implants, alternatives to cepha- mitted to be supporting partners for the
tant to note that increasing the dose of an losporins for patients with ␤-lactam allergy project.
agent provides less benefit than shortening are vancomycin and clindamycin. The deci- Three performance measures were de-
the dosing interval, because drug clearance sion to use vancomycin or clindamycin veloped for national surveillance and qual-
is logarithmic. should involve examination of local antimi- ity improvement as regards SSIs.
These measures included:
11. the proportion of patients who have
Table 4 Weight-Based Dosing Recommendations parenteral antimicrobial prophylaxis
initiated within 1 hour before incision
ⱕ80 kg (ⱕ175 lb) 81–160 kg (175–350 lb) ⬎160 kg (⬎350 lb) (within 2 h for vancomycin or fluoroqui-
Cefazolin 1g 2g 3g nolones),
Metronidazole 500 mg 1,000 mg 1,500 mg 22. the proportion of patients who are given a
prophylactic antimicrobial regimen con-
Vancomycin# 20 mg/kg 20 mg/kg (max 2,500 mg) 3,000 mg
sistent with published guidelines, and
Gentamicin* 4 mg/kg 4 mg/kg (max 420 mg) 540 mg 33. the proportion of patients whose pro-
Clindamycin 600 mg 900 mg 1,200 mg phylactic antimicrobial is discontinued
Ampicillin-sulbactam 3g 4.5 g 6g
within 24 hours after surgery end time
(48 h for cardiac surgery patients).
Cefuroxime 1.5 g 3g 3g
Timing and selection of antimicrobial
Ciprofloxacin 400 mg 600 mg 800 mg
pprophylaxis were chosen as measures

www.medicalebookpdf.com

LWBK892_c07_p117-126.indd 122 10/28/11 3:41:42 PM

 Chapter 7: Perioperative Antimicrobial Prophylaxis and Treatment of Surgical Infection 123

ated policies regarding use of vancomycin”

(Bratzler and Hunt, Clin Infect Dis 2006).

Perioperative Care of the Surgical Patient

This guidance states that local recommen-
dations should be based on surveillance of
organisms specifically causing SSIs.
Vancomycin is a glycopeptide antibiotic
that has been in clinical use for nearly
50 years as a penicillin alternative for peni-
cillin-resistant strains of S. aureus. The
agent is highly effective and there have been
no blinded and randomized trials that sug-
gest anything is better. While early on in the
drug’s history, infusion-related toxicities
Fig. 1. Adherence rates and postoperative infection rates of Surgical Care Improvement Project (SCIP) and nephrotoxicity were commonly seen,
Infection-Prevention Measures. (From Stulberg JJ, Delaney CP, Neuhauser DV, et al. Adherence to surgical more recent studies with the agent pro-
care improvement project measures and the association with postoperative infections. JAMA 2010; duced by greatly improved isolation tech-
303(24):2479–85.) niques show that vancomycin has little po-
tential for nephrotoxicity or ototoxicity
when used at conventional dosages (15 mg/
kg every 12 h), unless it is used concomi-
because of an association with reduced SSI sence of a statistically significant associa- tantly with known nephrotoxic drugs or at
incidence. Duration of prophylaxis was se- tion between individual process-of-care very high dosages.
lected, because excessive use of antimicro- measures and clinical outcomes at the indi- In humans, nephrotoxicity due to van-
bials may promote bacterial resistance. vidual patient level suggests that the publi- comycin monotherapy with typical dosage
The focus areas for SCIP are cardiac sur- cized rates, as reported on the Hospital regimens is uncommon, is usually revers-
gery, vascular surgery, general abdominal Compare Web site, do not infer quality dif- ible, and occurs with an incidence only
colorectal surgery, hip and knee total joint ferences between hospitals. The lack of an slightly above what is reported with other
arthroplasty, and abdominal and vaginal associated quality difference further im- antimicrobials not considered to be neph-
hysterectomy. plies that implementing incentive-based rotoxic. There is a consensus statement of
Hospital participation in these data col- reimbursement schemes on these individ- the American Society of Health-System
lection efforts is voluntary. However, the ual items would do little to further improve Pharmacists, the Infectious Diseases Soci-
CMS reduce hospital reimbursement by hospital quality. ety of America, and the Society of Infectious
2% if they fail to report their performance Nonetheless, these data do not suggest Diseases Pharmacists regarding vancomy-
on these measures. After validation and that this initiative must be abandoned, or that cin usage.
cleanup of the data, the results are reported hospitals and surgeons practice less than Dosing recommendations from these
on the Hospital Compare Web site (http:// the recognized standards for best practices. guidelines are based on efficacy in estab-
www.hospitalcompare.hhs.gov). In fact, we believe that the institution of the lished infection, and include a series of as-
Recently, there has been a report of the SCIP measures is a key-organizing concept sumptions regarding the minimum inhibi-
effectiveness of the SCIP. The result of this for patient management through perioper- tory concentrations that are desirable and
study of ⬃250,000 patients was encourag- ative care. also assume that various methods for mea-
ing in that there were improvements in the suring extravascular drug levels have any
process measures listed above. However, VANCOMYCIN value as predictors of clinical success.
when taken in aggregate, improved perfor- As noted, most patients who are candi-
mance on our global all-or-none composite The use of vancomycin as a prophylactic dates for anti-MRSA prophylaxis are at risk
measure is associated with improved out- agent is the most controversial issue in the of infection from CA-MRSA. This organism
comes at the discharge level. Therefore, area of SSI prophylaxis. There are few pro- is highly susceptible to vancomycin, with
while the individual items may not imply spective and randomized clinical trials in MIC90 values ⬍1 ␮g/mL.
quality differences, the overall ability to this area, and those that have been done At dosing levels of 10 to 20 mg/kg, this
demonstrate adherence to multiple SCIP suffer from having been conducted in the level is easily achieved. The problem is that
processes of care may. Improved methods near past when MRSA was a substantially the effectiveness of vancomycin in animal
for identification of quality of care are nec- lesser problem. Given the rapid rise of and human studies does not depend di-
essary to be able to define improvements in MRSA in cultures from SSIs, the clinical rectly on the plasma level. Rather, microbial
patient outcomes, and to justify the mas- pressure to begin using this agent has been killing by vancomycin is slow, and depends
sive investment of time and money in track- considerable. In view of this, vancomycin on maintaining high levels of the drug over
ing these processes of care. However, there has been added to various guidelines, in- a considerable period of time.
was a small but significant increase in the cluding those for cardiac surgery, but the The antibiotics that have been previ-
incidence of SSIs during the study period. indications for its use was left vague (“high ously studied for prophylaxis kill S. aureus
This is demonstrated in Fig. 1. institutional prevalence”). Indeed, this has very quickly, and all that is needed is to
These individual measures are a compo- been indirectly sanctioned by the CMS, with maintain the concentration of the drug
nent of Medicare’s value-based purchasing the caveat that, “. . . (CMS) may explore tar- above the inhibitory concentration through-
initiatives directed toward improving the geted assessments of hospitals with high out the period of operation—thus, the im-
quality of care in the United States through rates of vancomycin use to determine if portance of repetitive intraoperative dosing
incentive-based reimbursement. The ab- they have documented the rationale or cre- for antibiotics that are cleared quickly.

www.medicalebookpdf.com

LWBK892_c07_p117-126.indd 123 10/28/11 3:41:42 PM

 124 Part I: Perioperative Care of the Surgical Patient

These observations are the reasons why, with chlorhexidine for patients shown to be Burke JF. The effective period of preventive antibi-
then, regulatory bodies and academic soci- colonized with S. aureus would lower SSIs. otic action in experimental incisions and der-
eties are not willing at this point to provide They found that patients randomized to re- mal lesions. Surgery 1961;50:161.
Craig WA. Basic pharmacodynamics of antibac-
guidelines for use. There is no evidence, but ceive mupirocin/chlorhexidine indeed had a terials with clinical applications to the use of
only “expert opinion,” and this is simply nei- significantly lower infection than controls beta-lactams, glycopeptides, and linezolid.
ther sufficient nor appropriate as the basis receiving appropriate anti-staphylococcal Infect Dis Clin North Am 2003;17:479–501.
for national guidelines. systemic antibiotic prophylaxis with a ce- Dellinger EP, Hausmann SM, Bratzler DW, et al.
Our approach to use of vancomycin for phalosporin. Most of the infections prevented Hospitals collaborate to decrease surgical site
prophylaxis at the University of Cincinnati were superficial incisional infections, but infections. Am J Surg 2005;190(1):9.
Ferraz EM, Ferraz AA, Coelho HS, et al. Postdis-
is heavily conditioned by our finding that there was a reduction in complex SSI as well charge surveillance for nosocomial wound in-
most of the pathogens identified in complex (significance not tested). fection: does judicious monitoring find cases?
SSIs are methicillin-resistant staphylococci, For patients undergoing cardiac, total Am J Infect Control 1995;23(5):290.
either S. aureus or other, coagulase-negative, joint replacement, neurosurgical, or vascu- Fields CL. Outcomes of a postdischarge surveil-
staphylococcal species. This is particularly lar procedures with graft insertion, we be- lance system for surgical site infections at a
true for complex infections seen in patients lieve that screening should be done with Midwestern regional referral center hospital.
admitted to the hospital rather than treated polymerase chain reaction and positive pa- Am J Infect Control 1999;27(2):158.
Finkelstein R, Rabino G, Mashiah T, et al. Vanco-
in ambulatory surgical practice. tients be decolonized as described herein. mycin versus cefazolin prophylaxis for cardiac
We have, therefore, changed our hospital Many such patients undergo urgent opera- surgery in the setting of a high prevalence of
policy to provide cefazolin/vancomycin pro- tion, particularly for coronary artery disease, methicillin-resistant staphylococcal infec-
phylaxis to all patients undergoing sterno- and in these patients, it is recommended tions. J Thorac Cardiovasc Surg 2002;123(2):
tomy, total joint replacement, operative that all must be treated with mupirocin and 326.
placement of synthetic vascular grafts, and chlorhexidine at the earliest opportunity. Garver JS, Jarvis WR, Emori TG, et al. CDC defi-
nitions for nosocomial infections, 1988. Am J
craniotomy with bone flap. We have decided The mupirocin should then be continued Infect Control 1988;16(3):128–40.
to use high-dose prophylaxis, 20 mg/kg, as for a total of 5 days. Harbarth S, Samore MH, Lichtenberg D, et al.
detailed in the previous table. The reasons Prolonged antibiotic prophylaxis after cardio-
for this higher dose (as opposed to 15 mg/kg) SUGGESTED READINGS vascular surgery and its effect on surgical site
are because of concerns for penetration of infections and antimicrobial resistance. Circu-
this molecule into extravascular sites. In ad- ACOG Committee on Practice Bulletins. Antibiotic lation 2000;101(25):2916.
prophylaxis for gynecologic procedures, 23rd ed. Horan TC, Culver DH, Gaynes RP, et al. Noso-
dition, particularly in obese patients, deliv- comial infections in surgical patients in the
Washington, DC: American College of Obstetri-
ery into subcutaneous tissue is of concern. cians and Gynecologists; 2001. United States, January 1986–June 1992. Na-
The process for this and other decisions Ad Hoc Committee of the Committee on Trauma tional Nosocomial Infections Surveillance
regarding SSI prevention must come from DoMSNAoS-NRC. Postoperative wound infec- (NNIS) System. Infect Control Hosp Epidemiol
an appropriately constituted hospital body tions: the influence of ultraviolet irradiation of 1993;14(2):73.
that involves all stakeholders. These stake- the operating room and of various other fac- Institute of Medicine Committee on Quality of
holders include involved surgeons, infectious tors. Ann Surg 2000;160(Suppl 2):1. Health Care in America. Crossing the quality
Alexander JK, Dennis EW, Smith WG, et al. Blood chasm: a new health system for the 21st century.
disease consultants, pharmacists, infection volume, cardiac output, and distribution of sys- Washington, DC: National Academy Press; 2001.
control personnel, nursing, administration, temic blood flow in extreme obesity. Cardiovasc Kirkland KB, Briggs JP, Trivette SL, et al. The impact
and operating room leadership. Recommen- Res Cent Bull 1962;1:39–44. of surgical-site infections in the 1990s: attribut-
dations should be then approved by an OR Altemeier WA. Control of wound infection. J R Coll able mortality, excess length of hospitalization,
committee or other body representing the Surg Edinb 1966;11(4):271. and extra costs. Infect Control Hosp Epidemiol
various surgical services. Because use of van- Anderson DJ, Kaye KS, Classen D, et al. Strate- 1999;20(11):725.
gies to prevent surgical site infections in acute Kirton OC, O’Neill PA, Kestner M, et al. Periopera-
comycin for prophylaxis is not based on care hospitals. Infect Control Hosp Epidemiol tive antibiotic use in high-risk penetrating hol-
high-quality evidence, this body must have 2008;29(Suppl 1):S51–S61. low viscus injury: a prospective randomized,
accurate information on rates of complex in- Anonymous. Antimicrobial prophylaxis in surgery. double-blind, placebo-control trial of 24 hours
fection and the infecting isolate. Med Lett Drugs Ther 2001;43:92. versus 5 days. J Trauma 2000;49(5):822.
Blouin RA, Bauer LA, Miller DD, et al. Vancomy- Lodise TP, Lomaestro B, Graves J, et al. Larger
cin pharmacokinetics in normal and morbidly vancomycin doses (ε4 grams/day) are as-
MRSA SURVEILLANCE obese subjects. Antimicrob Agents Chemother sociated with an increased incidence of
1982;21:575–80. nephrotoxicity. Antimicrob Agents Chemother
At first glance, the notion of screening for Bode LG, Kluytmans JA, Wertheim HF, et al. 2008;52:1330–6.
carriers of S. aureus and then decolonizing Preventing surgical-site infections in nasal Manian FA, Meyer L. Comprehensive surveillance
them appears attractive as an alternative to carriers of staphylococcus aureus. N Engl J Med of surgical wound infections in outpatient and
vancomycin prophylaxis. Further reflection 2010;362(1):9–17. inpatient surgery. Infect Control Hosp Epidemiol
suggests that these approaches are inde- Bratzler DW, Houck PM. Antimicrobial prophylax- 1990;11:515–20.
is for surgery: an advisory statement from the Manian FA, Meyer PL, Setzer J, et al. Surgical site
pendent and may actually target different National Surgical Infection Prevention Project. infections associated with methicillin-resistant
elements in the pathogenesis of SSI by CA- Clin Infect Dis 2004;38(12):1706. Staphylococcus aureus: do postoperative fac-
MRSA. Bratzler DW, Hunt DR. The surgical infection pre- tors play a role? Clin Infect Dis 2003;36(7):
The starting point for this discussion is vention and surgical care improvement proj- 863.
the finding in an outstanding study recently ects: national initiatives to improve outcomes Popovich K, Hota B, Rice T, et al. Phenotypic
reported from the Netherlands, where MRSA for patients having surgery. Clin Infect Dis 2006; prediction rule for community-associated
43:322–30. methicillin-resistant Staphylococcus aureus.
is not a major problem but methicillin- Brennan TA, Leape LL, Laird NM, et al. Incidence J Clin Microbiol 2007;45:2293–5.
sensitive S. aureus is. These investigators of adverse events and negligence in hospitalized Popovich KJ, Weinstein RA, Hota B. Are community-
tested the notion that a combination of in- patients: results of the Harvard Medical Practice associated methicillin-resistant Staphylococcus
tranasal mupirocin and preoperative bathing Study I. 1991. Qual Saf Health Care 2004;13(2):145. aureus (MRSA) strains replacing traditional

www.medicalebookpdf.com

LWBK892_c07_p117-126.indd 124 10/28/11 3:41:42 PM

 Chapter 7: Perioperative Antimicrobial Prophylaxis and Treatment of Surgical Infection 125

nosocomial MRSA strains? Clin Infect Dis evaluation of the effect of an aminoglycoside dosing of cefazolin and risk for surgical site
2008;46:787–94. dosing regimen on rates of observed neph- infection in cardiac surgery. Emerg Infect Dis

Perioperative Care of the Surgical Patient

Reimer K, Gleed C, Nicolle LE. The impact of post- rotoxicity and ototoxicity. Antimicrob Agents 2001;7(5):828.
discharge infection on surgical wound infection Chemother 1999;43:1549–55. Zelenitsky SA, Ariano RE, Harding GK, et al.
rates. Infect Control 1987;8(6):237. Stulberg JJ, Delaney CP, Neuhauser DV, et al. Ad- Antibiotic pharmacodynamics in surgical
Robinson JL, Hameed T, Carr S. Practical aspects herence to surgical care improvement project prophylaxis: an association between intra-
of choosing an antibiotic for patients with a measures and the association with postop- operative antibiotic concentrations and ef-
reported allergy to an antibiotic. Clin Infect Dis erative infections. JAMA 2010;303(24):2479– ficacy. Antimicrob Agents Chemother 2002;
2002;35(1):26. 85. 46(9):3026.
Rybak MJ, Abate BJ, Kang SL, et al. Prospective Zanetti G, Giardina R, Platt R. Intraoperative re-

EDITOR’S COMMENT that the wound is open.” However, in clean con- or in the particular play of surgery, to the nasal
taminated cases such as bowel resection, the cavity, and eradicate colonization if one can,
risk jumps significantly “at the time the bowel is for example if either patient or surgeon or a
It is generally agreed that surgical antimicrobial transected, something that takes place at a vari- member of the operative team is colonized by
prophylaxis is a useful thing. The CDC and the able time in the operation, but usually at least MRSA (Butterly, A, et al., Anesthesiology, 2010,
federal government Medicare and everybody else a third to a halfway through the procedure.” He 6:1453–1459).
has moved us into an era of zero tolerance of hos- does say that there does not appear to be any Another aspect of prophylaxis and SSI pre-
pital acquired infection. Although there are many systematic study of the timing of risk during the vention is the role of topical antibiotics. McHugh,
other components to hospital acquired infection, operation, it is not clear how such a study would SM, et al., Journal of Antimicrobial Chemotherapy,
one of the principal targets is surgical site infec- be done. I would remind Dr. Dellinger, however, 2011, 66:693–701 review the effects of topical an-
tion (SSI). There have been enumerable papers because he was probably there, when a paper tibiotics on the incidence of SSI. They come to the
written about this. Everybody agrees that SSI is a from Nashville of Dr. John Sawyer’s and other conclusion that a number of surgical procedures
bad thing and most people agree that SSI can be members of the department showed pretty con- have been definitively shown to benefit from topi-
affected by surgical prophylaxis. Unfortunately, vincingly that although the initial dose may be cal prophylaxis perioperatively. The operations
that is one of the only things that people agree on on time, if the cases, which were mostly colec- that they have mentioned include joint arthro-
and papers are still appearing on that. However, tomies lasted longer than three and a half hours plasty, cataract surgery, possibly breast augmen-
the prophylaxis against SSI is minimally in the and there was no redosing, the incidence of in- tation, obese patients undergoing abdominal
whole picture although it plays a major role; in fection went up dramatically. Thus, Dr. Dellinger surgery, and topical surgical prophylaxis. Since
prophylaxing against SSI there is a lot more that has a good point. We have concentrated so much topical prophylaxis has been deemed to be of
can be done. I will comment on this and give my on the initial dosing that we have completely dis- benefit in a series of surgical operations, why
views on the “maximum deterrent” as far as SSI at regarded some of the other aspects. not utilize it? They end with a whimper by saying
the end of this commentary. Perhaps a much better way of approaching that there was no randomized prospective trial. I
There are mandates as far as when antibiot- this is given in Bowater, RJ, et al. (Annals of Sur- would get back to the argument that was made in
ics must be given. In our institution, it is within gery, 2009, 249:551–556) entitled “Is Antibiotic a previous paper by Bowater, RJ, et al., that since
a half an hour of making the skin incision. Is this Prophylaxis in Surgery a Generally Effective In- we know that prophylaxis is of value, why not as-
correct? Weber, WP, et al., “The Timing of Surgi- tervention?”. In this well argued text, the authors sume that everybody should be prophylaxed in
cal Antimicrobial Prophylaxis”, Annals of Sur- argue that antibiotic prophylaxis is generally be- whichever way they can until proven otherwise,
gery, 2008, 247:918–926, reviewed the practices lieved to be effective in preventing postoperative and to wait for a randomized prospective trial to
at Basel University Hospital and analyzed the wound infection, and on that we can all agree. stop doing it if it is shown to be ineffective. How-
incidence of SSI by the timing of antimicrobial However, people continue to study low risk pa- ever, others have argued that a rise in clostridial
prophylaxis. They analyzed 3836 consecutive sur- tients as to whether or not they should receive any difficile may result—but I don’t believe it—with
gical procedures. The antibiotic that was chosen, prophylaxis at all. The authors argue that instead topical antibiotics.
which makes a difference, was 1.5 grams of cefu- of trying to get a clinical trial in each and every Finally, in Kato, Y, et al., dealing with infec-
roxime (plus 500 mg of metronidazole in colorec- situation where one needs prophylaxis, why not tious outcomes in pediatric cardiac surgery,
tal surgery). There is no mention of whether or accept that prophylaxis is a good thing, and only (Critical Care Medicine, 2007, 35:1763–1768)
not the dose was repeated in longer cases. That not give prophylaxis in certain types of surgery, carried out what was unfortunately a sequential
is interesting because it certainly is clear that if it can be proven to the contrary. Indeed, some case control study in two groups of pediatric
redosing must take place depending on the an- argue that patients who are very low risk, such as patients under the age of 18 undergoing cardiac
tibiotic; if an operative procedure, for example, laparoscopic cholecystectomy patients, need not surgery at a university hospital. They used pro-
in some of the colectomies, for example, are be given antibiotic prophylaxis. These are clean phylactic antimicrobials up to 48 hours after op-
more than four hours, the redosing should take cases, theoretically, and the infection rate should eration and patients at high risk of methicillin
place at three hours. However, this dealt only be less than two percent. But in taking laparo- resistant staphylococcus aureus were strongly
with the initial dose. The authors concluded that scopic cholecystectomy, what happens if there encouraged to use glycopeptides. In the first
when the dose was hung between 30 minutes is bile spillage during the operation and the bile 21 months of the study, there were 185 patients
and the start of the operation, the incidence of happens to be infected, which has been shown a who underwent cardiac surgery with no prophy-
SSI was increased. 4.7 percent (180 of 3836) was long time ago that with a duration of acute chole- laxis. In the next part of the study, 185 were ad-
what was achieved. It does appear as if the SSI cystitis by Frank Glenn of the New York Hospital, ministered antimicrobials for a median of four
is increased when it is given between 30 minutes that with each passing day the percentage of bile days in the intervention group. There was a sig-
prior to operation as compared to the reference becoming infected increases as if bacteria crawl nificantly lower SSI of MRSA at 0 percent vs. 18
interval of 59 to 30 minutes. Patchen Dellinger along the lymphatics to infect the gallbladder. At percent in the previous group and the frequency
from the University of Washington wrote an edi- that point, this is not a clean case, but it becomes of all infections was lowered from 39 percent to
torial on this publication and made the observa- a potentially contaminated case. 11 percent in the intervention group. They also
tion, which I agree with entirely, that the point Why not prophylax everybody so that the believe that the use of glycopeptides in prop-
is not when you give it but that there be a good risk of SSI goes down from two percent to per- erly selected patients who were at high risk for
level of antibiotics when the incision is made. haps one percent? We also have certainly not MRSA can also lower the rate of postoperative
He also goes into some discussion concerning made the jump that if we do prophylaxis for infections even more. It does seem as if there
clean cases in which it doesn’t particularly mat- surgery, have we taken care of all of the circum- is a very significant feeling that SSI should and
ter because there is a low risk of contamination stances that may contribute to SSI? An example could be prophylaxed and that the evidence is
to the wound “that extends throughout the time of this is colonization on the part of oral cavity, there that this is reasonable.

(continued)

www.medicalebookpdf.com

LWBK892_c07_p117-126.indd 125 10/28/11 3:41:42 PM

 126 Part I: Perioperative Care of the Surgical Patient

I would prefer to take my cue from another perior to any other method of hair removal. a SSI. Indeed, there is a great deal of evi-
really well written paper by Dr. J. Wesley Alexan- This should be carried out effectively with a dence that this is the case. It does not mat-
der, a noted infectious disease surgeon, Dr. Jo- new head for the clipper; shaving should not ter whether or not one uses lap pads that are
seph S. Solomkin, the author of this chapter, and be carried out, and the hair removal should soaked in antibiotic and placed at the edge
Dr. Michael J. Edwards the Chair of Surgery from be limited to the least amount which is nec- of the wound, or as I do, taking a blue towel,
the University of Cincinnati, who wrote a really essary. b.) Skin contamination at the time dipping the edges in antibiotic solution, and
spectacular review entitled “Updated Recom- of operation. Povidone-iodine scrubs and sewing them in place on the peritoneum.
mendations for Control of Surgical Site Infec- subsequent two to three minute scrubs are This is widely quoted. In addition, prior to
tions”, Annals of Surgery, 2011, published online. more effective. Alcohol and iodophor have closure, antibiotic irrigation should be used
They take the argument, and I agree entirely, been formulated to paint the area of inci- on the wound edges, especially on the subcu-
that as long as one is prophylaxing SSIs, why not sion, leading to a longer lasting barrier than taneous tissue and left in place and sucked
try and go all out and really try and control SSIs, prepping with aqueous materials. Also, the out two hours after they are left in place.
since they are so devastating and expensive. In use of an incised drape found a 40 percent 10. Systemic prophylactic antibiotics have been
the introduction to the paper, they state that mi- reduction in total SSI. covered elsewhere.
nor superficial infections are about 400 dollars 5. Incise drapes. The use of adhesive antimi- 11. The influence of body temperature in the
per case, complex infections are 63,000 dollars crobacterial incise drapes may or may not operating room. The warm operating room,
after joint prosthesis, 300,000 dollars after medi- increase the incidence of wound infection, reversing the effects of mild hypothermia
astinitis after cardiac surgery and home health depending on the composition of the drape. have been known to reduce the incidence of
expenses, which can be as high as 6200 dollars With the proper application of the incise infection from 14 percent to a wound infec-
per patient after infections for colon resection. drape, without lifting from the skin edge, tion rate of five percent when patients are
In the 1990s, the medical direct cost of hospi- contamination of the wound with skin or- warm.
talization was double that of a non-infected pa- ganisms is not possible. This is not yet set in 12. Effect of oxygen therapy. In patients receiv-
tient, 7500 dollars vs. 3800 dollars. The increase stone, as there is further development ongo- ing 80 percent oxygen during colorectal op-
in cost for SSI ranged from 2600 dollars in co- ing with skin barrier drapes. eration, 5.2 percent of the patients developed
lon surgery to 11,000 dollars for spinal surgery. 6. Anticontamination (Antisepsis) sutures. In wound infections compared to 11.2 percent
In Massachusetts, the cost of such infections in a prospective randomized clinical trial, re- of patients receiving 30 percent oxygen, as is
2006 was 223,000,000 to 275,000,000 dollars. A cently demonstrated that using the antimi- customary. This has been repeated in other
one percent incidence of SSI was projected to crobial sutures compared to standard sutures studies.
generate national costs of over 900,000,000 per reduced the incidence rate in cerebrospinal 13. Glucose control. This is well worked out.
year for in-hospital costs and a total of 1.6 bil- shunt surgery from 21 percent to 4.3 percent. Mediastinitis has been reduced to almost
lion in excess costs. So if we are serious about Other PDS loops that are coated with antibi- zero with a glucose control to less than 120.
eliminating SSI, why don’t we get serious? The otics reduced the incidence of wound closure However, most investigators believe that the
following are their suggestions, and I must say infection to 4.9 percent with antibacterial su- incidence of hypoglycemia under these cir-
that I agree entirely. They are, in no particular tures to 10.8 percent with standard sutures. cumstances is too high, and therefore they
order but have some logic to it, as to how one In addition, braided sutures with silk can will accept 150 as the maximum.
would go about getting as close to completely cause as much as a 10,000-fold decrease in 14. Avoid perioperative blood transfusions,
eliminating SSI. the number of bacteria necessary to cause an which is an independent predictor of infec-
infection. Monofilament sutures have been tion. In 13 studies of which six were prospec-
1. Reduction in contamination in the operat- amply demonstrated for decades and are tive, perioperative blood transfusion was an
ing room environment. These include ster- much less prone to potentiating infection. independent predictor of infection. Of course,
ilization techniques, activities of the surgi- 7. Opening the skin with electrocautery. Open- if patients need blood, they should receive it.
cal team members, and surgical gloves—in ing the skin is thought to increase the inci- 15. Smoking. Avoidance of smoking is essential,
which there is a high likelihood of perforated dence of SSI. If electrocautery is to be used, it but this is difficult. If you can get the patient
surgical gloves as opposed to double gloving. should be used primarily for pinpoint treat- to stop smoking for eight weeks before op-
2. Patients: preoperative bathing with antisep- ment of bleeders. eration, that will decrease the incidence of
tic agents. My own policy is to have patients 8. Drains. Drains should not exit through the wound infection. Of course, it is difficult to
shower with chlorhexidine three days before working incision. Closed suction drains are do so.
the operation with a thorough bathing. It re- preferable to open drains in preventing infec-
duces pathogenetic organisms in the skin but tion. In a meta-analysis involving 36 studies What I have tried to do is give an incidence of
has a nonsignificant reduction in wound in- with 5464 patients, there was no significant prophylaxis of wound infection, which will in 15
fections. Cleansing with a cloth impregnated difference in the incidence of wound infec- different areas really bring down the incidence of
with chlorhexidine before the operation will tion in orthopedic patients with a closed suc- wound infection. Whether or not this is possible
provide additional removal of dirt and skin tion drain. In addition, there is a way of using I do not know, and it will take a commitment to
bacteria. closed suction drainage in which a topical do so. However, given the expense and the misery
3. Reduction of colonization. Culture of the na- antibiotic is inserted into the wound during that SSI costs, I am surprised that there has not
res both for the patient and for the operative closure, left in place for two hours, and then been a more concentrated effort to do this.
team, any positivity of the nares is treated placed on suction, and left connected to a Those are my thoughts on this issue. For
with bacitracin for at least three days or until suction reservoir. those who are more interested in following up, a
the colonization has disappeared. 9. Prophylactic topical antimicrobials. I per- wonderfully documented series of references are
4. In the operating room. a) Hair removal. sonally believe, and there is good evidence listed in Alexander, Solomkin, and Edwards’ pa-
There is no question that clipping with a me- for this, that bathing the edges of the wound per in the Annals of Surgery.
chanical clipper in the operating room is su- with a topical antibiotic solution reduces J.E.F.

www.medicalebookpdf.com

LWBK892_c07_p117-126.indd 126 10/28/11 3:41:42 PM

 Chapter 8: The Multiple Organ Dysfunction Syndrome: Prevention and Clinical Management 127

8 The Multiple Organ Dysfunction Syndrome:

Perioperative Care of the Surgical Patient

Prevention and Clinical Management
John C. Marshall

The multiple organ dysfunction syndrome ironically, during the conduct of war. At With the widespread establishment of
(MODS) is the final common pathway to the time of the World War I, for example, ICUs in large hospitals during the 1960s,
death for most critically ill patients who die abdominal wounds carried such a high a spectrum of new clinical disorders
within the contemporary health care sys- mortality rate that surgical intervention emerged—stress-induced upper gastroin-
tem. It is a process that is all too familiar to was deemed futile and inappropriate. Pio- testinal bleeding, disseminated intravascu-
the surgeon, often arising as a complication neering studies by Blalock and others less lar coagulation, gram-negative septicemia,
of treatment, and heralding an inexorable than 100 years ago inform our current un- ICU jaundice, and ARDS to list the more
trajectory toward major morbidity or death. derstanding of the role that reduced intra- prominent. The concept that these were
It is, moreover, an intimidatingly complex vascular volume plays in the pathogenesis varied manifestations of a common process
process that integrates a rapidly expanding of shock. The very word “shock” reflects the was first articulated by Arthur Baue, who,
and unfamiliar biology with some of the mistaken belief prevalent at the time that in 1975, suggested that each was a manifes-
most sophisticated supportive technologies the syndrome was a psychological state re- tation of a process that was better under-
in health care, and that evolves at the inter- flecting fear of impending death, rather stood as multiple systems failure. Epidemi-
face between heroic care and inappropriate than a readily correctible circulating fluid ologic studies of this new and common ICU
meddling in the process of dying. MODS is deficit. Recognition of the importance of syndrome revealed a number of discrete
both a complication to be prevented and a intravascular fluid loss enabled crystalloid risk factors, all of which reflect the activa-
reflection of the successes and limitations resuscitation and blood transfusion, and tion of an innate immune response to a po-
of contemporary critical care. salvaged patients who in an earlier era tentially life-threatening insult (Table 1).
Critical illness is fundamentally differ- would have died.
ent from other conditions that the surgeon Dialytic techniques to support the fail-
manages. Unlike diseases such as acute ap- ing kidney were developed in the aftermath
TERMINOLOGY AND
pendicitis or subarachnoid hemorrhage, it of World War II, while positive pressure me- DEFINITIONS
lacks a discrete and definable locus for in- chanical ventilation was an innovation of The clinical syndrome of organ failure in the
tervention, through a broad spectrum of polio epidemics of the early 1950s. Tech- critically ill patient has many synonyms—
diseases may be its antecedents. Unlike niques for accessing and monitoring the multiple organ failure, multiple systems or-
cancer or localized inflammatory condi- central venous system were also developed gan failure, and remote organ failure, to
tions, it lacks defining histological features in the 1950s, and enabled more precise name a few. A consensus conference held in
that permit the definition of a discrete characterization of the hemodynamic al- 1991 proposed the terminology “the Multiple
pathologic state, though disseminated pro- terations of shock. These innovations set
cesses such as inflammation, thrombosis, the stage for the development of the inten-
or ischemia are commonly present. Most sive care unit (ICU) as a geographic locale
importantly, however, the unique feature of where life support technologies could be Table 1 Risk Factors for the
critical illness that defines it, and makes its administered; they fundamentally altered Development of MODS
management so challenging, is the depen- the processes through which the multiply Insult Examples
dence of the phenotype and course on the traumatized or critically ill patient pro-
Infection Peritonitis
very clinical interventions used to sustain ceeded toward recovery or death.
life in a patient who would otherwise have The development of novel life support Soft tissue infection
died a rapid death. technologies also spawned the emergence Pneumonia
The construct of MODS embodies these of new clinical syndromes. Acute renal fail- Injury Multiple trauma
features, and is at once a description of the ure following crush injuries or multiple
Burns
clinical course of a patient over time, a con- traumas was first described in the 1940s
sequence of tissue injury and the host re- and 1950s; its description only became pos- Ischemia Ruptured aneurysm
sponse to that injury, and a metaphor for sible as techniques of renal dialysis enabled Intestinal infarction
the changing processes of ICU care. patients with acute renal failure to live more Inflammation Pancreatitis
than several days. Similarly, the acute respi-
Immune disease Autoimmune
MULTIPLE ORGAN DYSFUNCTION ratory distress syndrome (ARDS) only be-
disorders
SYNDROME AND THE EVOLUTION came a relevant concept when it was pos-
Transplant rejection
OF INTENSIVE CARE sible to survive acute respiratory failure
through the intervention of mechanical Intoxication Endotoxin overdose
The capacity to resuscitate the mortally ventilation, while septic shock is a disorder Iatrogenic Mechanical
injured or ill patient, and to sustain life that arose with the capacity of medical ventilation
through the provision of exogenous life sup- technology to support the profound cardio- Blood transfusion
port measures, is a product of insights gar- vascular derangements of systemic inflam-
nered during the twentieth century, often, mation. Idiopathic

www.medicalebookpdf.com

LWBK892_c08_p127-139.indd 127 10/28/11 3:37:22 PM

 128 Part I: Perioperative Care of the Surgical Patient

Organ Dysfunction Syndrome (MODS)” to

emphasize several key aspects of the pro-
cess. First, organ system insufficiency in Viremia
Trauma
MODS is appropriately seen as dysfunction
rather than failure, for it is variable in sever- Infection
ity and potentially reversible. Second, the
process is a systemic one, reflected in the Bacteremia SIRS
Burns
involvement of more than one organ system, Sepsis
hence the terminology “multiple organ.” Fi-
nally, although the mechanisms of the pro- Fungemia
cess are incompletely understood, it arises
Pancreatitis
through the activation of a systemic inflam-
matory response, and so can be considered a
syndrome—a descriptive term for a disorder Fig. 1. The relationship between sepsis and infection. Infection denotes the microbial process—invasion
that is defined on the basis of clinical mani- of normally sterile tissues by microorganisms, while sepsis describes the systemic host response that
results from infection. The response can occur following noninfectious insults, and so the term systemic
festations that are believed to have common inflammatory response syndrome (SIRS) describes that response independent of its cause. (From Bone
underlying pathologic mechanisms. RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. ACCP/SCCM CONSENSUS CONFER-
The same consensus conference also ENCE. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.
sought to clarify terminology related to the Chest 1992;101:1644–55.)
complex interplay of host and microbial
factors that shapes the clinical syndrome of
sepsis in the critically ill patient. Infection is
the invasion of normally sterile host tissues teristic of systemic inflammation, but ex- chloroplasts of plants, and that enabled cells
by viable microorganisms. This process may pansion of the definition only serves to re- to generate energy and to develop special-
or may not evoke an inflammatory response duce its specificity. We currently lack a ized functions as part of a larger organism.
that can occur in the local environment of well-characterized clinical syndrome of But microorganisms in the environment also
the infectious challenge (e.g., a surgical systemic inflammation, though the classic pose a potential threat, and the emergence
wound infection) or may be a disseminated cardinal signs of inflammation defined by of multicellularity occurred in parallel with
systemic process; the latter defines sepsis— Galen and Celsus two millennia in the past the evolution of elegant mechanisms that
the systemic host inflammatory response provide a framework for thinking of the serve to recognize danger and to respond ef-
to invasive infection. Because the response clinical syndrome, and incorporate MODS fectively in such a way that host homeostasis
may be variable in its expression and in- as the systemic counterpart of the local loss is restored. These mechanisms are varied
flammation is a normal adaptive response of function that is characteristic of acute and intricate, and include specialized im-
to infection, sepsis was further character- inflammation (Table 2). mune cells, the coagulation cascade, and lit-
ized as severe sepsis (sepsis in association erally hundreds of host-derived molecules
with organ dysfunction) and septic shock that modify cellular physiology and support
(sepsis resulting in hemodynamic compro-
THE PATHOGENESIS a coordinated response to danger. One of the
mise). But it is also evident that a systemic OF MULTIPLE ORGAN most important of these systems—based on
host response that is clinically indistin- DYSFUNCTION SYNDROME a family of genetically encoded receptors
guishable from sepsis can also be evoked called toll-like receptors (TLRs)—is de-
by noninfectious stimuli; the terminology The Cellular Biology of Inflammation scribed in greater detail (Fig. 2).
systemic inflammatory response syndrome Multicellular organisms have lived in inti- TLRs represent a family of 11 proteins
(SIRS) was proposed to describe the clinical mate proximity with the microbial world for expressed on the surface of cells of the in-
response independent of its cause. more than a billion years. The very existence nate immune system as well as on nonim-
The consensus conference terminology of complex organisms is a consequence of mune tissues such as epithelial cells. The
has been widely adopted, and the relation- the fact that primitive unicellular species ligands for TLRs are molecules, whose pres-
ship between these differing entities illus- were parasitized by proteobacteria that be- ence in the microenvironment of the cell
trated schematically (Fig. 1). While the came the mitochondria of animals and the signifies the possibility of danger; as a class,
concepts are useful, they have inherent limi- these ligands have been termed pathogen-
tations. Most importantly, the classic SIRS aassociated molecular patterns (PAMPs), or
criteria—tachycardia, tachypnea, hyper- or Table 2 Cardinal Manifestations m
more accurately damage-associated molec-
hypothermia, and leukocytosis or leukope- of Local and Systemic uular patterns (DAMPs). For example, endo-
nia—are nonspecific, and readily evoked by Inflammation ttoxin—a lipopolysaccharide that is the
noninflammatory stimuli such as vigorous Local Systemic
m
major constituent of the cell wall of gram-
exercise. They were proposed not on the ba- n
negative bacteria—binds to and activates
sis of epidemiologic data but on the basis of Rubor (redness) Vasodilatation T
TLR4, while TLR2 is activated by molecules
an arbitrary consensus process. Subsequent Calor (warmth) Fever ssuch as peptidoglycan and lipoteichoic
studies have shown that they are present in Dolor (pain) Altered mentation aacid that are found in the cell wall of
the majority of patients in an ICU, and ggram-positive bacteria. Viral RNA or DNA
Tumor (swelling) Edema and capillary
equally, that serious infection may be pres- leak iis recognized by TLR3, TLR7, and TLR8,
ent when SIRS criteria are not met. A more w
while characteristic motifs in bacterial
recent consensus conference has proposed Functio laesa (loss Organ dysfunction D
DNA activate TLR9. Flagellin, a protein
of function)
additional clinical criteria that are charac- ffound in the flagellae of bacteria, activates

www.medicalebookpdf.com

LWBK892_c08_p127-139.indd 128 10/28/11 3:37:22 PM

 Chapter 8: The Multiple Organ Dysfunction Syndrome: Prevention and Clinical Management 129

cell, where it results in the expression of

some genes and in the inhibition of others.

Perioperative Care of the Surgical Patient

The process called signaling involves multi-
Endotoxin ple cellular proteins but common biochemi-
cal principles. When the extracellular region
TLR4 of a TLR is engaged by its ligand, the confor-
CD14 mation of the intracellular portion of the
receptor is altered. This change results in
clustering of proteins associated with the
receptor, and in secondary changes to
the structure of the intracellular portion of
MyD88 IRAK the receptor. A particularly important ex-
ample of the latter is phosphorylation—the
addition of a phosphate group derived from
TRAF2 ATP to specific amino acids (in particular
tyrosine, serine, and threonine) in the intra-
MAP Kinases: Erk, cellular tail of the receptor. The addition of a
p38 phosphate group occurs through the action
NFkB of enzymes called kinases, while the removal
PI3 Kinase
of a phosphate group is effected by phos-
phatases. By changing the shape and charge
Pro-inflammatory genes: of the receptor tail, phosphorylation or de-
Il-1, TNF phosphorylation enables the receptor to re-
cruit additional signaling molecules from
the cytoplasm, and so to begin the process
of transmitting the environmental signal to
PAF, Nitric oxide, the nucleus to induce changed patterns of
Coagulation gene expression.
Transduction of a signal from the cell
surface to the nucleus results from the se-
rial activation of intracellular enzymatic
cascades, for example, the mitogen-
Tissue ischemia, activated protein (MAP) kinase cascades
Cell necrosis, and the phosphatidyl inositol-3 (PI3) kinase
cascade. Cytoplasmic proteins called tran-
Apoptosis
scription factors are activated, and translo-
cate to the nucleus where they bind to the
Vascular occulusion promoter region of target genes, and initi-
ate or inhibit the process of gene expression
Fig. 2. A schematic representation of the cellular events that occur in response to infection or tissue or transcription. A transcription factor called
injury. Engagement of a pattern recognition receptor on the surface of cells such as neutrophils and NF␬B plays a particularly important role in
monocytes (e.g., engagement of TLR4 by endotoxin) results in the recruitment of signaling molecules to initiating the transcription of a number of
the intracellular tail of the receptor, and activates intracellular pathways that result in the expression of inflammatory genes.
early proinflammatory genes such as interleukin-1␤ and tumor necrosis factor (TNF). These proteins, in The early response to TLR activation is
turn, act on cells through their own specific receptors, inducing the expression of a broad variety of the synthesis and release of early proin-
mediators that have been implicated in the pathogenesis of inflammation. flammatory cytokines. Cytokines are pro-
teins whose expression is induced in re-
sponse to an immunologic stimulus, and
TLR5. In contrast to the recognition mole- the cell signals injury, and so danger. In ad- which can, in turn, bind specific receptors
cules of the adaptive immune system—the dition to endotoxin, for example, TLR4 can and evoke a response in their target cells.
T-cell receptor and specific antibody—TLRs be activated by heparan sulfate, heat shock Interleukin-1 (IL-1) and tumor necrosis fac-
are encoded in the genome, and constitu- proteins, oxidized phospholipids, and other tor (TNF) are particularly important exam-
tively expressed on cells; thus they are rap- substances released by injured host tissues. ples of cytokines that are released early, fol-
idly activated when their ligand is present. Reflecting their ancient bacterial origins, lowing cellular exposure to an inflammatory
A degree of specificity results from the spe- mitochondrial products released as a result stimulus. Cytokines induce a further cas-
cific TLR that is engaged, but because the of cellular injury can activate innate im- cade of signal transduction and new gene
cellular mechanisms downstream of the re- mune cells through interactions with TLR9. expression including the expression of
ceptor are similar, the response is not spe- Thus, at both a clinical and a molecular key genes that shape the clinical pheno-
cific for the cause, at the level of either the level, the host response is not specific to in- type of systemic inflammation. For exam-
cell or the whole organism. fection, but rather is more appropriately ple, cytokine-mediated upregulation of
TLRs are activated by both microbial understood as a response to danger. the enzyme inducible nitric oxide syn-
molecular patterns and by certain host- The engagement of a TLR initiates a sig- thase (iNOS) in endothelial cells results
based molecules whose presence outside nal that is transmitted to the nucleus of the in increased enzymatic activity and the

www.medicalebookpdf.com

LWBK892_c08_p127-139.indd 129 10/28/11 3:37:23 PM

 130 Part I: Perioperative Care of the Surgical Patient

conversion of the amino acid arginine to The Response

citrulline, a process that generates a mole-
cule of the short-lived gas, nitric oxide. Ni-
tric oxide is a potent vasodilator, and in-
creased local production results in vascular The Insult
smooth muscle relaxation and the charac- The Host
teristic vasodilatation of inflammation. In- The Doctor
creased expression of tissue factor on en-
dothelial cells induces local activation of
the coagulation cascade, and microvascu- Injury
lar thrombosis. Cytokine-mediated injury Infection
to the tight junctions between endothelial Ischemia
cells permits fluid extravasation into the Mechanical ventilator
interstitium, producing edema. Transfusion
The forgoing description is necessarily Nosocomial infection
simplified. Innate immune cells can be acti-
vated through receptors other than those of
the TLR family. Endotoxin exposure in the
healthy human volunteer leads to differen- Secondary Insults
tial expression of more than 3,700 genes,
and for many of these, little is known about Fig. 3. The evolution of multiple organ dysfunction syndrome (MODS) occurs through the interactions
of the initial insult with the inflammatory response of the host and the clinical response of the doctor,
their pathogenic role in systemic inflam-
modified by subsequent insults or “second hits” that include ICU-acquired infection or the adverse con-
mation. The subsequent activation of genes sequences of interventions such as transfusion, ventilation, or drugs.
that amplify, suppress, or modulate those
genes expressed in response to TLR stimu-
lation results in a bewilderingly complex
cascade of cascades whose key features defy Tissue Injury Induced by Ischemia across a greater distance to reach adjacent
simple characterization. Nonetheless, in and Inflammation capillaries. Cytokine-mediated expression
aggregate they support integrated re- Activation of the innate immune system of tissue factor on pulmonary endothelial
sponses that generate key features of sys- provides a rapid and effective defense cells activates the coagulation cascade,
temic inflammation, and so are intimately against invading microorganisms, but at a producing focal areas of microvascular
implicated in the pathogenesis of MODS. cost of local tissue injury. Neutrophils re- thrombosis. The generation of fibrin as the
lease reactive oxygen intermediates and a end product of the coagulation cascade ini-
number of proteases that kill bacteria but tiates the process of tissue repair, but this
From Inflammation to also injure host cells, while monocytes and fibrosis also creates an additional barrier to
Organ Dysfunction macrophages release an extensive reper- gas exchange in the lung, a characteristic
toire of proinflammatory mediators follow- feature of the late stages of ARDS.
Activation of a systemic inflammatory re-
ing the recognition of bacterial DAMPS; Multiple factors contribute to cellular
sponse evokes a diverse series of alterations
these agents alter cellular metabolism and hypoxia during an inflammatory response
in homeostasis at the cellular level. How
blood flow locally, and induce activation of (Fig. 5). The unloading of oxygen from the
these changes result in physiologic dysfunc-
the coagulation cascade. This sequence of red blood cell to the tissue occurs by passive
tion at the level of the organ or entire organ-
cellular responses is responsible for the diffusion down a gradient dependent on
ism remains speculative, although a number
characteristic changes seen in the organs of the difference in oxygen tension between
of models have been proposed. These are by
the patient with MODS. the red cell and the tissues. This process oc-
no means mutually exclusive, and probably
The early stages of the ARDS, for exam- curs in the microvasculature, where transit
better conceptualized as differing perspec-
ple, are characterized by interstitial edema, is slowest, and the distance between blood
tives on a very complex process. Moreover,
vascular thrombosis, and massive neutro- cells and cells of the adjacent tissues is
the histologic changes in failing organs are
philic infiltration (Fig. 4). This response can minimal. Interstitial edema increases this
variable and surprisingly bland, and in the
be precipitated by a local insult in the lung, distance, with the result that the diffusion
absence of characteristic pathologic changes,
but can also result from a remote insult gradient is less steep, and less oxygen is un-
a single pathogenic mechanism is difficult to
such as intestinal ischemia and reperfusion loaded. Reduced vascular resistance results
discern. The mechanisms of MODS at the
that triggers neutrophil activation, cytokine in both a faster rate of flow through the mi-
organ level can be thought of as arising from
release from macrophages, and the expres- crovasculature and shunting of oxygenated
three overlapping processes (Fig. 3).
sion of adhesion molecules on the pulmo- blood, both of which limit the offloading of
1. Direct tissue injury from ischemia and nary vascular endothelium. Activated neu- oxygen. The formation of anatomic shunts
inflammation trophils bind to adhesion molecules on is further exacerbated as individual capil-
2. Remote cellular responses to circulating endothelial cells in the lung, and then ex- laries become occluded by adherent white
factors released in response to tissue in- travasate into the pulmonary interstitium. cells, red cells, and platelet thrombi result-
jury Damage to the epithelial tight junctions re- ing from activation of the coagulation cas-
3. “Second hits”—further injury resulting, sults in increased extravasation of protein- cade. The net result is that although blood
for example, from products from the gut, rich fluid into the interstitial space, produc- entering the capillary bed is adequately oxy-
the environment, or the adverse effects ing permeability edema; oxygenation is genated, it unloads much less of its carried
of ICU supportive care. impaired since alveolar oxygen must diffuse oxygen, and so oxygenation of tissues is

www.medicalebookpdf.com

LWBK892_c08_p127-139.indd 130 10/28/11 3:37:23 PM

 Chapter 8: The Multiple Organ Dysfunction Syndrome: Prevention and Clinical Management 131

Perioperative Care of the Surgical Patient

A B

Fig. 4. A: The histologic features of acute respiratory distress syndrome (ARDS) reflect several concomitant pathologic pro-
cesses including the infiltration of neutrophils (double-lined arrow), intravascular thrombosis (solid arrows) and fibrin deposi-
tion (dashed arrow). B: Although ARDS appears as diffuse fluffy infiltrates on a chest x-ray, a CT scan reveals the process to be
inhomogeneous, and reflects the role of clinical factors in its development—atelectasis in dependent lung zones resulting
from nursing the patient in a supine position and cystic changes in the antidependent regions reflecting injury caused by
overdistention of the lung by the mechanical ventilator.

impaired. At the same time, venous blood is impaired in sepsis, a state that has been vascular resistance combine to render tis-
returning to the heart carries more than the termed “cytopathic hypoxia.” sues ischemic. With resuscitation, products
normal content of oxygen (normal values In summary, tissue oxygenation in the from ischemic tissues activate the inflam-
are about 70% saturation), and the mixed patient with MODS is impaired for multiple matory response, with the result that en-
venous oxygen saturation is characteristi- reasons, and the function of the hypoxic cell dothelial adhesion molecule expression is
cally increased. Finally, there is some evi- is altered. Prior to resuscitation, intravas- increased, and activated neutrophils mi-
dence that oxygen utilization by the tissues cular volume loss and reduced systemic grate into tissues where their products in-
duce further injury. The local inflammatory
response results in increased capillary per-
meability and tissue edema, as well as en-
dovascular activation of coagulation, fur-
80% ther compromising oxygen uptake at the
tissue level, and creating a vicious cycle of
local tissue injury.

• Reduced resistance Remote Cellular Responses to

• Increased permeability Circulating Inflammatory Products
• Tissue edema Cellular dysfunction can be a direct conse-
• Capillary plugging quence of cellular hypoxia as discussed
• Cytopathic hypoxia above. It can also result from cellular injury
or death, either by necrosis or by the pro-
grammed cell death or apoptosis of the cell.
Profound cellular hypoxia or the prod-
ucts of activated neutrophils can induce
100% structural damage to the cell with the result
that membrane integrity is lost, and intracel-
lular constituents leak into the extracellular
Fig. 5. Under normal circumstances, blood leaving the lungs is 100% saturated with oxygen; as it passes environment. This process is known as ne-
through the capillary bed, about 30% of that carried oxygen diffuses into the adjacent tissues, so that
crosis; as discussed above, constituents of
the blood returning to the heart is only 70% saturated. In sepsis, the amount of oxygen unloaded is less,
so that the returning venous blood has an oxygen saturation of 80% or even higher. Factors contributing the cell, which are normally intracellular,
to the failure of off-loading of oxygen include reduced vascular resistance resulting in faster transit of function as DAMPs in the extracellular space,
blood, with less time for release of oxygen, increased endothelial permeability and tissue edema resulting and activate local inflammation by engaging
in a reduced gradient for oxygen diffusion, capillary plugging leading to shunting, and impaired oxygen TLRs. Necrosis evokes inflammation, and
uptake at the cell membrane. the resulting inflammatory response results

www.medicalebookpdf.com

LWBK892_c08_p127-139.indd 131 10/28/11 3:37:23 PM

 132 Part I: Perioperative Care of the Surgical Patient

in further cellular necrosis, amplifying the infections in the critically ill patient. They that the systems defining MODS should not
injury. grow in biofilms on synthetic surfaces such include the endocrine system, the immune
Apoptosis is a noninflammatory mode of as endotracheal tubes and intravascular and system, or the musculoskeletal system.
physiologic cell death that plays a funda- urinary catheters, and established colonies The most commonly used systems to de-
mental role in normal homeostasis during on these devices are difficult to eradicate. scribe organ dysfunction in the critically ill
embryogenesis, cell turnover, and immune They also are the predominant species that include the Multiple Organ Dysfunction
surveillance for infected or transformed colonize the proximal gastrointestinal tract (MOD) score, the Sequential Organ Failure
cells. For example, in health, neutrophils are of the critically ill patient, and each is capable Assessment (SOFA) score, the Multiple Or-
the shortest-lived cell of the human body, of translocating in an intact and viable form gan Failure (MOF) score, and the Logistic
constitutively dying by apoptosis within across an intact gut mucosa. Finally, they are Organ Dysfunction (LOD) score; the MOD
hours of their release from bone marrow. resistant to common first-line antibiotics score is shown in Table 3. Each of these scores
Each day, in excess of ten billion neutrophils used in an ICU, and are capable of increasing quantifies organ dysfunction on a continu-
are released from bone marrow stores and a their intrinsic virulence in an acutely ill host. ous scale, and sums the values of these to
comparable number die by apoptosis. Apop- Other common organisms causing nosoco- produce a score that reflects the degree of
tosis not only removes aged, transformed, mial ICU-acquired infection emerge as patho- organ dysfunction at or over a discrete time
or infected cells, but the uptake of apoptotic gens under a combination of antibiotic resis- interval.
cell remnants by the reticuloendothelial tance and person-to-person transmission Dysfunction may be measured as the
system induces the expression of genes that (methicillin-resistant Staphylococcus aureus dysfunction of an isolated organ system, or
support the resolution of inflammation and or Clostridium difficile) or because they persist as the aggregate dysfunction of all systems
the processes of tissue repair. Apoptosis can and thrive in the hospital water supply (Acine- that comprise the score. Organ dysfunction
be initiated by proteins that engage death tobacter). may be described at a single point in time
receptors on the surface of the target cell. Noninfectious insults also serve as sec- (e.g., the day of admission to the ICU) by
The receptor for TNF is such a receptor, and ond hits within the ICU. Lung distention by summing the values for each variable at a
the tumor-killing properties of this cytokine positive pressure mechanical ventilation common time point; such a measure pro-
derive from its ability to evoke apoptosis in can cause pulmonary injury and activate a vides a point estimate of the severity of ill-
the transformed cell. local inflammatory response that can, in ness at the time the measurement was
Cellular apoptosis during MODS may be turn, induce remote tissue damage (Fig. 4). taken. Alternatively, the worst value for
either excessive or inadequate. Increased The use of vasopressor agents to increase each system over a defined time period—
rates of apoptosis are evident in lympho- blood pressure can cause regional isch- the first 7 days, following an experimental
cyte populations (accounting for the char- emia—particularly within the splanchnic intervention, or the duration of the ICU
acteristic lymphopenia of critical illness) circulation—and so evoke further tissue in- stay—may be recorded to produce an ag-
and in epithelial cells, particularly those of jury. Bed rest results in pressure necrosis in gregate score. Subtracting the initial score
the gut and kidney. In contrast, the apopto- dependent areas, and in atelectasis in de- from the aggregate score over a defined
sis of neutrophils is inhibited, with the re- pendent portions of the lung, both of which time interval yields a delta score that mea-
sult that activated and potentially injurious can evoke an inflammatory response. sures new onset organ dysfunction that has
neutrophils persist in the circulation, and Finally, multiple factors present in the occurred following ICU admission, and so
the normal stimulus to tissue repair that acutely ill patient, including lack of enteral is potentially preventable. The total burden
results from the phagocytosis of apoptotic feeding, use of broad-spectrum antibiotics, of organ dysfunction over a period of time
cells is dampened. use of opioid analgesics, and other factors can be measured by summing the scores, or
that reduce splanchnic perfusion can pro- by calculating the area under the curve of a
“Second Hits” Inducing Further mote proximal intestinal overgrowth with series of scores over time. Finally, the effects
Tissue Injury potentially pathogenic organisms, and both of mortality can be incorporated by calcu-
The initial disease process leading to life- the translocation of viable bacteria and the lating a mortality-adjusted score as the
threatening critical illness is usually the absorption of bacterial endotoxin into the maximal score plus one additional point.
dominant insult experienced by the patient; host. The value of measuring MODS within the
however, the process of resuscitation and ICU lies not in its capacity to predict survival
support in the ICU creates a series of sec- Organ Dysfunction as a or death, although any severity measure
ondary insults that can modify or perpetu- Clinical Syndrome will, by definition, correlate with an in-
ate the response to the initial problem. This creased risk of death. Rather, the utility of
notion is embodied in the concept of a “sec- MODS is a systemic process, and its mani- quantifying organ dysfunction arises from
ond hit.” Its sources are many. festations are ubiquitous, involving all as- the ability to measure potentially modifiable
Nosocomial infection is an important pects of normal physiologic homeostasis. It morbidity, and to ascertain within which
second hit in the critically ill patient. ICU- is, therefore, somewhat arbitrary that exist- physiologic domains that morbidity arises.
acquired infections differ in important ing systems try to describe and quantify the
respects from the infections that charact- syndrome focus on the same six organ sys- Organ Dysfunction in the Critically
eristically lead to ICU admission. The in- tems—the lung, the cardiovascular system, Ill: Prevention and Management
fecting flora includes organisms such as the renal system, the coagulation system,
coagulase-negative Staphylococci, Entero- the hematologic system, and the central Although the parsing of organ system dys-
cocci, Pseudomonas, and Candida—species nervous system. These systems are amena- function into the dysfunction of discrete
that have low intrinsic virulence, and that are ble to support by the intensivist; more im- organ systems is an arbitrary, and poten-
uncommon in community-acquired infec- portantly, their function is readily monitored tially misleading exercise, it is informative
tions. These organisms, however, share fea- using data that are routinely collected within to consider dysfunction within each system
tures that account for their predominance in the ICU. There is, however, no a priori reason to delineate modifiable causes.

www.medicalebookpdf.com

LWBK892_c08_p127-139.indd 132 10/28/11 3:37:25 PM

 Chapter 8: The Multiple Organ Dysfunction Syndrome: Prevention and Clinical Management 133

Table 3 The Multiple Organ Dysfunction (MOD) Score

P ti t
S gi l Patient
Organ system 0 1 2 3 4
Respiratorya

th Surgical
(PO2/FIO2 ratio) ⬎300 226–300 151–225 76–150 ≤75
Renalb

C off the
(Serum creatinine) ≤100 101–200 201–350 351–500 ⬎500
Hepaticc

ti Care
(serum bilirubin) ⱕ20 21–60 61–120 121–240 ⬎240

PPerioperative
Cardiovascular d
(PAR) ⱕ10.0 10.1–15.0 15.1–20.0 20.1–30.0 ⬎30.0
Hematologic e

i
(platelet count) ⬎120 81–120 51–80 21–50 ≤20
Neurologic f
(Glasgow Coma Score) 15 13–14 10–12 7–9 ≤6
a
The PO2/FIO2 ratio is calculated without reference to the use or mode of mechanical ventilation, and without reference to the use or level of PEEP.
b
The serum creatinine level is measured in μmol/L, without reference to the use of dialysis.
c
The serum bilirubin level is measured in μmol/L.
d
The pressure-adjusted heart rate (PAR) is calculated as the product of the heart rate and right atrial (central venous) pressure, divided by the mean arterial pressure:
PAR, heart rate X RAP
Mean BP
e
The platelet count is measured in platelets/mL.
f
The Glasgow Coma Score is preferably calculated by the patient’s nurse, and is scored conservatively ( for the patient receiving sedation or muscle relaxants, normal function
is assumed unless there is evidence of intrinsically altered mentation) (From Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL, Sibbald WJ. Multiple organ dysfunction
score: a reliable descriptor of a complex clinical outcome. Crit Care Med 1995;23:1638–52.)

Pulmonary Dysfunction The pathologic features of lung injury in ated lung is overdistended by the mechani-
The sine qua non of pulmonary function in the critically ill patient are nonspecific find- cal ventilator; ARDS is revealed less as a
the critically ill patient is impaired gas ex- ings of inflammation and tissue repair pathologic disease of the lung than as an
change in the lung, reflected in reduced oxy- (Fig. 4). Early in its clinical evolution, lung iatrogenic disorder resulting from modifi-
gen content in arterial blood. Since this injury is characterized by extensive neutro- able processes of ICU care.
value is influenced by the fraction of inspired philic infiltration into the alveolar septa, The goal of physiologic support within
oxygen delivered by the mechanical ventila- increased interstitial edema, and patchy the ICU is to sustain vital organ function
tor, it is better measured as the ratio of the thrombosis of adjacent small blood vessels. while preventing or minimizing further in-
partial pressure of oxygen in the blood to the With time, the acute inflammatory process jury. De novo lung injury arises through the
percentage of oxygen in the inspired gas, the gives way to evidence of destruction of al- interaction of a lung whose physiology has
PO2/FIO2 ratio—a measure of physiologic veolar architecture, with areas of atelecta- been modified by systemic inflammation
pulmonary dysfunction. However, pulmo- sis and cyst formation, in association with with a variety of new insults from the envi-
nary dysfunction can also be described as interstitial fibrosis. ronment. A systemic inflammatory re-
the clinical intervention used to support the The clinical antecedents of acute lung sponse results in the characteristic vascular
failing lung—the FIO2, or even the mode of injury are many, and include direct insults alterations of inflammation including vaso-
ventilatory support. Finally, lung dysfunc- such as pneumonia or pulmonary contu- dilatation, increased capillary permeability,
tion can be described as a constellation of sion, as well as indirect insults such as pan- and neutrophil sequestration with local
manifestations that comprise a clinical syn- creatitis or ischemia reperfusion injury that neutrophil-mediated cellular injury and
drome. The ARDS is defined as a PO2/FIO2 result in neutrophil influx into the lung. death. Excessive fluid administration re-
ratio of ⬍200, in association with diffuse However, the characteristic pathology is sults in interstitial edema, and impairs the
pulmonary infiltrates, and absence of vol- also a consequence of mechanical injury to diffusion of oxygen across the alveolar-
ume overload, reflected in a pulmonary cap- the lung resulting from overdistention by capillary membrane, thus judicious admin-
illary wedge pressure of ⬍18 mm Hg. A the mechanical ventilator. While plain istration of intravenous fluids is a compo-
milder degree of pulmonary insufficiency is chest radiographs show ARDS as diffuse bi- nent of the prevention of further injury.
described as acute lung injury, for which the lateral pulmonary infiltrates, computerized Multiple exogenous stimuli can further in-
defining degree of hypoxemia is set at a PO2/ tomography shows a strikingly different jure the vulnerable lung, including mi-
FIO2 ratio of ⬍300. None of these represents picture (Fig. 4). Dependent regions of the croaspiration of gastric contents, superim-
a distinct disease process that is either pres- lung show extensive atelectasis, whereas posed infection, and atelectasis resulting
ent or absent, but rather a continuum of se- cystic changes are evident in the antide- from supine positioning and oversedation.
verity that is, moreover, not specific for any pendent lung zones. These changes reflect Perhaps, the most readily modifiable risk
particular insult or outcome. Moreover, the the prevailing mode of support of the criti- factor for exacerbated lung injury is the
terms describe a readily measurable clinical cally ill patient, who is nursed sedated and mechanical ventilator itself. Overdistention
phenomenon, rather than a unique patho- supine in an ICU bed, and so is vulnerable of the lung can cause further regional lung
logic state—a syndrome, and not a disease. to dependent atelectasis, and whose aer- injury, and so minimization of distending

www.medicalebookpdf.com

LWBK892_c08_p127-139.indd 133 10/28/11 3:37:25 PM

 134 Part I: Perioperative Care of the Surgical Patient

pressures, with maintenance of alveolar past hypoxic tissues, and so the oxygen sat- peripheral resistance is reduced. Indeed, it
opening is the objective of lung support. uration of blood returning to the heart is has been shown that, independent of the
This can be accomplished by limiting tidal actually increased, compared to a normal blood pressure target that triggered their
volumes, while maximizing the opening of state of health. Under these circumstances, initiation, vasopressors actually increase
lung units using positive end-expiratory a reduced, or even normal central venous the rate of anastomotic leak in critically ill
pressure (PEEP), augmented, as needed, by oxygen saturation is indicative of markedly surgical patients who have undergone an
the use of a recruitment maneuver to open inadequate tissue perfusion. intestinal anastomosis.
collapsed lung units. Multiple host-derived cytokines, as well Prevention of cardiovascular dysfunc-
The mechanical ventilator is the main- as products from activated leukocytes, con- tion in the patient at risk for MODS neces-
stay of the support of the failing lung, al- tribute to enhanced capillary permeability sitates early and vigorous fluid resuscita-
though it can also be the cause of further in MODS. Vasodilatation is a result of in- tion. There is no compelling evidence for
lung injury. In more severe cases of pulmo- creased activity of iNOS—an enzyme that is the superiority of any specific fluid. Albu-
nary dysfunction, in which adequate oxy- present in vascular endothelial cells and min may have benefits over crystalloids in
genation (reflected in an oxygen saturation that catalyzes the conversion of arginine to patients with septic shock, though this con-
of 88% to 90%) cannot be maintained, even citrulline, releasing a single molecule of ni- clusion derives from a subgroup analysis of
when the FIO2 is 1.00, a variety of salvage tric oxide (NO) in the process. Nitric oxide a clinical trial enrolling a heterogeneous
supportive therapies are available. Nursing is a potent vasodilator, a property that population of patients, and is the subject of
the patient in the prone position can aid in underlies the clinical utility of nitric oxide ongoing active clinical research. Conversely,
counteracting the positional abnormalities donors such as nitroglycerine or sodium ni- synthetic starch-based colloids appear to
that result from supine positioning (see troprusside. be associated with worse clinical outcomes
above), and so ameliorate the ventilation- Just as injudicious ventilatory strategies because of an increased risk for the devel-
perfusion mismatch. High-frequency oscil- can actually enhance pulmonary injury, so opment of renal failure. Rapid correction of
lation (HFO) can also be highly effective in attempts to support cardiovascular dys- intravascular volume deficit is associated
directing gas flow to perfused areas of the function may also exacerbate organ injury. with improved survival, and the early goal-
lung, while minimizing further trauma re- As discussed above, overly vigorous fluid directed therapy approach popularized by
sulting from overdistention. Inhaled nitric administration results in increased intersti- Rivers (Fig. 6), remains the best resuscita-
oxide will transiently improve oxygenation tial edema, and so increases cellular hy- tion strategy for the septic patient. Individ-
by delivering a potent vasodilator to those poxia. Vasopressor agents such as norepi- ual elements of this approach are currently
lung regions that are being ventilated. Ex- nephrine or epinephrine increase mean undergoing evaluation.
tracorporeal membrane oxygenation—the arterial pressure, but do so by increasing
provision of oxygen through the use of an peripheral resistance, which results in re- Renal Dysfunction
extracorporeal perfusion circuit—bypasses duced flow to peripheral tissues. An opti- Renal dysfunction in the critically ill patient
the injured lung, but commits the patient mal target for the titration of vasopressor is reflected in a reduced urine output and in
and the ICU to an extraordinary use of re- agents has never been established, nor has an inability to clear solutes such as creati-
sources, with complications such as major it been shown that vasopressors confer any nine. The term “acute kidney injury” or AKI
hemorrhage; its use is generally restricted beneficial effects on tissue perfusion when has replaced the phrase acute renal failure
to patients in whom lung dysfunction is the
dominant or only manifestation of MODS.
Pharmacologic prophylaxis or treat-
ment of pulmonary dysfunction has been
studied, but to date, no effective strategies CVP
<8
have been identified.
≥8
Fluids
Cardiovascular Dysfunction
While derangements of intrinsic cardiac
dysfunction, including myocardial depres- Mean arterial pressure
sion and right ventricular dysfunction have <65
been described in critically ill patients with ≥65
MODS, the most striking abnormalities in- Pressors
volve the peripheral vasculature. Indeed, it is
notable how rarely the critically ill patient ScvO2
with organ dysfunction develops congestive
heart failure or sustains an acute myocardial
infarction, even though cardiac work is sig- ≥70
Transfusion,
nificantly increased during critical illness. inotropes
The vascular derangements of MODS are
described above (Fig. 5), and include pe- Goals achieved
ripheral vasodilatation, increased capillary Fig. 6. Early goal-directed resuscitation. Fluids are administered initially to raise the central venous
permeability, microvascular occlusion by pressure. If the mean arterial pressure remains low following this, then a vasopressor such as norepi-
aggregates of platelets, red cells, and leuko- nephrine is added. The central venous oxygen saturation is measured, and if it remains below 70%, trans-
cytes, and selective derangements of re- fusions and/or dobutamine are administered. (From Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A,
gional vascular perfusion. Together, these Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J
result in the shunting of oxygenated blood Med 2001;345(19):1368–77.)

www.medicalebookpdf.com

LWBK892_c08_p127-139.indd 134 10/28/11 3:37:26 PM

 Chapter 8: The Multiple Organ Dysfunction Syndrome: Prevention and Clinical Management 135

to reflect the fact that renal dysfunction in sociation with elevated levels of intermedi- tory vasopressor-dependent septic shock is
the critically ill patient reflects a continuum ates of the coagulation cascade. currently in progress.

Perioperative Care of the Surgical Patient

of severity, with differing preventive and As is the case in other organ systems, the The development of mild microcytic
therapeutic strategies for its management. causes of hematologic dysfunction in MODS anemia is another manifestation of hema-
Even in its more advanced stages, the are multifactorial. Infection and trauma ac- tologic dysfunction in the critically ill. The
histologic features of AKI are relatively mild tivate innate immune mechanisms and shift anemia is usually well-tolerated, and trans-
and nonspecific. Sustained hypovolemia the coagulation cascade to a procoagulant fusion to increase hemoglobin levels to an
with renal hypoperfusion is a common an- state, for example, inducing microvascular arbitrary target of 10 g/dL has been associ-
tecedent, although renal dysfunction com- thrombosis, and suppressing hepatic syn- ated with exacerbation of organ dysfunc-
monly becomes manifest later during the thesis of endogenous anticoagulants. Cer- tion, underlining an important concept in
course of critical illness. Other factors con- tain medications, notably heparin, can in- the support of the critically ill patient with
tributing to the development of AKI include duce thrombocytopenia. Following multiple organ dysfunction—normal physiology is
exposure to nephrotoxic drugs and intra- trauma, ongoing hemorrhage results in de- not necessarily optimal physiology.
parenchymal thrombosis. pletion of coagulation factors, while acido-
Early and adequate volume resuscitation sis and hypothermia impair the function of Neurologic Dysfunction
is central to the prevention of acute kidney components of the coagulation cascade. Dysfunction of the central nervous system
injury; the optimal selection of resuscitative The treatment of hematologic dysfunc- is evidenced as confusion or alterations in
fluid is unclear, although there is evidence tion in critical illness involves the reversal the level of consciousness; focal neurologic
that the use of synthetic starches may in- of underlying causes, and the replacement deficit should suggest the possibility of di-
crease the risk of renal dysfunction. The risk of depleted factors. Since the coagulation rect cerebral injury. Weakness is the domi-
of further renal injury associated with expo- cascade is activated, the risks and benefits nant manifestation of peripheral nerve dys-
sure to intravenous contrast agents used for of replacement therapy must be carefully function.
computerized tomography can be reduced considered. In general, and in the absence Factors contributing to neurologic dys-
by the use of N-acetyl cysteine prior to con- of active bleeding, platelet transfusion can function in the critically ill include interstitial
trast exposure. be safely withheld unless the platelet count edema in the brain because of altered vascu-
Diuretic agents such as furosemide may drops below 5 to 10,000. lar permeability, and the effects of medica-
have some utility in accelerating the mobi- Supplementation of endogenous antico- tions, in particular, analgesics, anxiolytics,
lization of interstitial fluid following ag- agulants is a conceptually appealing ap- and sedatives. Preventive strategies focus on
gressive volume resuscitation, although proach to the management of coagulopathy minimizing exogenous sedation and exercis-
there is no evidence that they prevent the in the critically ill. Three key anticoagulant ing the patient—strategies that are notori-
development of renal failure. Dialysis re- proteins have been evaluated. Antithrombin ously challenging to implement. The desire to
mains the mainstay of support of the pa- binds thrombin, and so inhibits fibrin gen- alleviate pain and suffering in the critically ill
tient with established acute renal failure, eration. Small, poorly controlled studies have patient commonly leads to the liberal use of
and several modalities are available. Con- suggested that antithrombin supplementa- analgesics and sedatives, and ironically in-
ventional intermittent hemodialysis can tion may be beneficial in critical illness; how- creases the risk of ICU morbidity and mortal-
remove large amounts of solute and fluid, ever, efficacy was not shown in a large multi- ity. Indeed, several clinical trials have shown
but may cause hemodynamic instability in center clinical trial, possibly because of an that the conscious intermittent withholding
the critically ill patient. Thus, techniques interaction with heparin. Tissue factor path- of sedation to provide a “sedation holiday”
such as continuous venovenous hemofiltra- way inhibitor (TFPI) is an endogenous anti- results in improved clinical outcomes.
tion, with or without dialysis, have gained coagulant that inhibits the activity of Factor
popularity in the ICU. Fluid removal, rather Xa and thrombin. The clinical promise of
Gastrointestinal Dysfunction
than correction of hyperkalemia or acido- TFPI supplementation seen in animal mod-
The classical manifestation of gastrointesti-
sis, is the most common indication for their els, however, has not been replicated in large
nal dysfunction in the critically ill patient—
use. It has been suggested that dialysis may human clinical trials. Finally, protein C is an
the development of stress-related upper gas-
remove circulating inflammatory media- anticoagulant protein that is synthesized in
trointestinal bleeding—is uncommon in the
tors, though the clinical importance of such the liver, and activated through its interac-
contemporary ICU. This changing epidemi-
activity is uncertain. tion with thrombomodulin on endothelial
ology can be ascribed both to the widespread
cells. Activated protein C exerts multiple bio-
use of stress ulcer prophylaxis, but even
Hematologic Dysfunction logic activities. It inhibits Factors V and VIII,
more importantly to the earlier diagnosis
Critical illness is characterized by a shift in and so inhibits progression of the coagula-
and treatment of intra-abdominal infection,
coagulation function toward a prothrom- tion cascade. It also exerts independent anti-
and to improved hemodynamic manage-
botic state. Inflammatory mediators induce inflammatory and antiapoptotic activity
ment of the critically ill patient. Similarly,
the expression of thrombotic triggers such through its binding to the endothelial cell
ICU-acquired jaundice has become a rarity,
as tissue factor on endothelial cells, while protein C receptor. Recombinant activated
likely because of a reduced dependence on
the synthesis and activation of endogenous protein C (drotrecogin alpha activated) was
total parenteral nutrition, and increased
anticoagulants such as protein C is im- shown to improve survival in sepsis in a large
use of the enteral route for nutritional
paired. In its most severe form, hematologic clinical trial, and has been licensed for the
support.
dysfunction is expressed as consumptive treatment of severe sepsis and septic shock
coagulopathy and the syndrome of dissemi- in patients with organ failure. Its introduc-
nated intravascular coagulation, as wide- tion has been controversial, and follow-up Other Forms of Organ Dysfunction
spread intravascular thrombosis occurs, studies in low risk populations have not The description of MODS as the aggregate
consuming platelets and clotting factors, shown the efficacy seen in the original study. dysfunction of six key organ systems is
and resulting in increased bleeding in as- A confirmatory trial in patients with refrac- an arbitrary one, driven by the ease of

www.medicalebookpdf.com

LWBK892_c08_p127-139.indd 135 10/28/11 3:37:26 PM

 136 Part I: Perioperative Care of the Surgical Patient

measurement and the supportive strategies care is limited to the support of deranged thy can be minimized by the concomitant
available for clinical care. However, physio- physiology and the prevention of de novo replacement of platelets and clotting fac-
logic dysfunction of many other organ sys- complications during that process. Ex- tors as guided by serial laboratory tests.
tems is a prominent feature of severe criti- pressed differently, the most important Moreover, the prevention of organ dysfunc-
cal illness. thing the intensivist can do for the criti- tion is a dynamic process, and once physi-
Immunologic dysfunction is manifested cally ill patient is to liberate him or her ologic stability has been accomplished, the
by evidence of impaired cell-mediated im- from ICU technology as rapidly and safely focus must shift to reversing the inadver-
munity seen, for example, as anergy to skin as possible. tent sequelae of resuscitation and liberat-
testing with common recall antigens. It is ing the patient from the need for ICU
clinically apparent as increased susceptibil- Prevention of Organ Dysfunction support technology.
ity to nosocomial infection with relatively The support of cardiorespiratory function Active infection is a potent stimulus for
avirulent endogenous organisms such as and the control of the process that has the release of the host-based mediator mol-
coagulase-negative Staphylococci, Entero- caused this function to become deranged is ecules that result in a septic response and
cocci, gram-negative bacteria such as the fundamental principle of early resusci- accompanying organ dysfunction. Thus, a
Pseudomonas and Enterobacter, and Can- tation and the key to minimizing the subse- broad and nonspecific group of physiologic
dida. Multiple factors contribute to in- quent development of organ dysfunction. alterations (e.g., fluid retention, fever, confu-
creased infectious susceptibility including Studies show that rapid restoration of oxy- sion, new onset atrial arrhythmia, tachyp-
the use of invasive devices such as central gen delivery to tissues can reduce organ nea, tachycardia, and thrombocytopenia)
lines and endotracheal tubes, and the ad- dysfunction and mortality, although the op- may be the earliest clinical evidence of infec-
verse effects of broad spectrum antibiotic timal approach to accomplishing this goal tion. When such abnormalities are present
therapy on the endogenous flora of the gas- remains to be determined. A landmark in a patient who has recently undergone sur-
trointestinal tract. study showed that resuscitation of septic gery, the possibility of a complication such
The most common manifestation of en- patients to explicit physiologic (Fig. 6) goals as an anastomotic leak should be enter-
docrine dysfunction is relative insulin resis- could minimize new organ dysfunction tained and sought using the appropriate di-
tance, with a need to provide exogenous evolving within the ICU, and increase ulti- agnostic investigations. Cultures should be
insulin to maintain glucose levels in a near mate survival. Aggressive fluid resuscitation obtained, and antibiotics initiated empiri-
normal range. Recent evidence suggests remains the cornerstone of hemodynamic cally with a spectrum that is broad enough
that the optimal glucose target is not a nor- resuscitation. There is no compelling evi- to target the potential infecting pathogens.
mal level, but rather one that is up to one dence to favor crystalloids over colloids or Conversely, and consistent with the princi-
and a half times the normal level. Adrenal vice versa and no evidence for the superior- ple of minimizing the harms of intervention
insufficiency is also common in the critically ity of one formulation over another, though articulated above, if investigations fail to
ill patient, and presents as vasopressor- the selection of resuscitative fluid is an ac- show infection then antibiotics should be
dependent hypotension. The administra- tive area of ongoing research. Instead, the stopped, and once a specific pathogen has
tion of pharmacologic doses of glucocorti- guiding principle is that intravascular vol- been isolated, the agents should be changed
coids can improve hemodynamic stability, ume needs to be restored and maintained to specifically target the infecting organism.
though the impact on long term survival is as rapidly as possible, recognizing that, in Other strategies to prevent organ dys-
less clear. Derangements in thyroid func- the face of increased vascular permeability, function in the critically ill target common
tion, calcium homeostasis, and sex hor- an inevitable consequence will be increased complications or seek to minimize the
mones have also been described, though tissue edema, which may be sufficiently se- harms of ICU support. The risks of stress-
their clinical importance is largely un- vere as to limit gas exchange in the lung, induced gastrointestinal bleeding can be
known. and necessitate intubation and mechanical reduced through the use of prophylactic
ventilation. Patients with active bleeding histamine H2 blockers, of deep venous
pose a challenge to the general application thrombosis with pharmacologic or me-
Prevention and Management of this principle, for increasing the intravas- chanical prophylaxis, and of ventilator-
of Organ Dysfunction in the cular volume will increase the bleeding; associated pneumonia with the elevation of
Critically Ill Surgical Patient thus, the concept of more conservative fluid the head of the bed. Techniques to selec-
resuscitation and early definitive control of tively decontaminate the oropharynx and
MODS is a complication to be prevented, bleeding has gained popularity in the man- upper GI tract, and to provide enteral nutri-
more than it is a disease to be treated. agement of traumatic bleeding. Although tion can reduce the risk of infectious com-
Implicit in that statement is a philosophy they are widely used to raise blood pressure, plications. Increasingly, these prophylactic
of ICU care that focuses on minimizing the the benefits of vasopressor agents are un- strategies are being considered as an inte-
adverse consequences of that care, while certain. grated bundle of interventions. The mne-
recognizing the subtle and nonspecific na- Early resuscitation of the hypotensive monic FAST HUG, for example, emphasizes
ture of clinical manifestations that some- patient can reduce the risk of later organ the importance of feeding, analgesia, seda-
thing is awry during the course of recovery failure or death, but in doing so, underlines tion, thromboprophylaxis, head of bed ele-
from a life-threatening insult. Indeed, for the important concept that the prevention vation, stress ulcer prophylaxis, and glucose
all the complexities of the technologies and management of the patient with organ control in minimizing new onset organ dys-
that are available in a contemporary ICU, failure requires a careful consideration of function.
the reality is that once the initial problem both the benefits and the risks of interven-
has been treated (e.g., the bleeding con- tion. Adequate hemodynamic resuscitation Management of Organ Dysfunction
trolled and the fracture stabilized, or the reduces the subsequent risk of renal dys- in the Critically Ill
focus of infection controlled with source function, but does so at the cost of increased The management of organ dysfunction in a
control and antibiotics), the focus of ICU early pulmonary dysfunction. Coagulopa- critically ill patient encompasses the entire

www.medicalebookpdf.com

LWBK892_c08_p127-139.indd 136 10/28/11 3:37:26 PM

 Chapter 8: The Multiple Organ Dysfunction Syndrome: Prevention and Clinical Management 137

n
namic changes that may be associated with leave the hospital—a statistic that reflects
Table 4 Iatrogenic Factors in the h
higher volume intermittent dialysis, while the intrinsic uncertainty inherent in dying
Etiology of MODS

Perioperative Care of the Surgical Patient

jjudicious use of transfusion or antibiotics more than the shortcomings of the critical
Positive pressure ventilation rreduces the attendant risks of these inter- care team.
Blood transfusion vventions.
Sedatives and analgesics Effective pharmacologic therapy for pa-
Antibiotics
ttients with MODS remains an elusive goal. CONCLUSIONS
R
Recent evidence suggests that activated
Bed rest MODS is not a disease, but a syndrome
pprotein C (drotrecogin alpha activated) can whose roots lie in the processes of ICU care.
Loss of day/night cycle iimprove survival for patients with organ Its phenotype changes as those processes
Parenteral nutrition ddysfunction as a consequence of severe sep- change—manifestations such as stress
ssis, and that moderate doses of corticoster-
Vasopressor agents bleeding or ICU jaundice have become much
ooids can benefit patients with vasopressor- less common, and advances in the ventila-
ddependent septic shock, however, the role tory support of the critically ill are changing
of each is controversial. patterns of acute respiratory insufficiency.
scope of the practice of intensive care, and Even with the best of contemporary Ironically, we are less able to see the new
so only the most generic of principles can technological support, however, and de- and potentially preventable dimensions of
be articulated here. By definition, the de- pending largely on the case mix of the par- the disease, although the adverse sequelae
velopment of organ dysfunction implies the ticular ICU, some 10% to 20% of patients of hemodynamic resuscitation and pain
need for supportive ICU intervention to who are admitted to the ICU will not sur- control and sedation within the ICU are
sustain life. This intervention both sup- vive their stay, and in this challenging credible foci. While MODS arises as a con-
ports life, and modifies the phenotype of minority of patients, the question arises sequence of the activation of a systemic in-
organ dysfunction, both by minimizing the whether heroic supportive measures are flammatory response, it is best seen as a
physiologic abnormality and inducing in- providing a realistic chance of independent dynamic process that reflects the interac-
advertent iatrogenic harm that can con- survival or simply prolonging the process of tion of a life-threatening insult, the host re-
tribute to further dysfunction (Table 4). The dying. sponse that the insult evokes, and the inter-
concept is complex, but of fundamental ventions that the physician uses to sustain
importance in the care of the critically ill. Organ Dysfunction and the Limits vital organ function.
Once the disease that precipitated ICU ad-
mission has been treated, the perforated
of Intensive Care Technology Ultimately, the optimal management of
MODS entails three discrete elements:
colon removed, the bleeding controlled, MODS is the leading cause of death in the
the necrotic tissue debrided, or the com- contemporary ICU because it is the em- 1. An appreciation that the development
plex elective procedure concluded, the pri- bodiment of both the possibilities and lim- of MODS suggests that classical surgical
mary objective of critical care is to liberate its of medical technology. complications such as an anastomotic
the patient from the need for ICU support. Approximately 80% of those who die in leak or missed injury are present.
Critical illness is a quintessentially iatro- the ICU do so as a consequence of an active 2. An understanding of the underlying
genic process. It only arises because medi- decision to limit further escalation of care, pathophysiology that can, in turn, in-
cal intervention has been successful in or to withdraw existing supportive mea- form new therapeutic strategies to cor-
averting lethal organ system insufficiency, sures. The decision to accept that contin- rect these abnormalities.
at least transiently. But having accom- ued organ system support is unlikely to re- 3. An awareness that the process of ICU
plished this immediate objective, the state turn the patient to an independent care contributes to the development
of critical illness evolves as a direct conse- existence is challenging, shaped by multi- of MODS, and the humility to recog-
quence of the intentional, and even more ple factors including family and patient nize when the clinician’s extraordinary
importantly, inadvertent, consequences of wishes, the reversibility of the underlying measures to sustain life have become
ICU supportive care. disease process, the local philosophy of part of the problem, rather than its
Intensive care support of the patient care, and a host of other ethical, religious, resolution.
with organ dysfunction, therefore, focuses and social values. The extent to which limi-
on minimizing the harms of intervention tation of life support is performed explicitly
while maximizing the benefits. Overdisten- or implicitly varies and objective guidelines SUGGESTED READINGS
tion of the lung by positive pressure ventila- to inform the decision are probably not Abraham E, Singer M. Mechanisms of sepsis-
tion evokes further lung injury, and, at least possible. It is, however, apparent that the induced organ dysfunction. Crit Care Med 2007;
in experimental models, can induce remote process of limiting or withdrawing life sup- 35(10):2408–16.
organ injury. Minimizing the distending port and orchestrating the process of death Barie PS, Hydo LJ, Pieracci FM, Shou J, Eachempati
SR. Multiple organ dysfunction syndrome in
pressure by limiting tidal volumes or through is a core component of critical care prac- critical surgical illness. Surg Infect (Larchmt)
the use of novel ventilatory modalities such tice, and one that is usually accomplished 2009;10(5):369–77.
as HFO can limit this inadvertent injury. Se- by limiting respiratory, hemodynamic, or Baue AE. Multiple, progressive, or sequential sys-
dation and analgesia reduce pain and anxi- renal support and focusing instead on com- tems failure. A syndrome of the 1970s. Arch
ety, but at the cost of muscle weakness and fort measures. It is important to realize Surg 1975;110:779–81.
an increased risk of complications such as that the decision to withdraw or withhold Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein
AM, Knaus WA, et al. ACCP/SCCM CONSEN-
aspiration or pressure sores; sedation holi- support does not necessarily imply that the SUS CONFERENCE. Definitions for sepsis and
days and planned activities such as ambu- patient will die. Almost 4% of patients in organ failure and guidelines for the use of in-
lation can minimize this risk. Continuous whom mechanical ventilation is withdrawn novative therapies in sepsis. Chest 1992;101:
dialytic techniques can reduce the hemody- in anticipation of death will ultimately 1644–55.

www.medicalebookpdf.com

LWBK892_c08_p127-139.indd 137 10/28/11 3:37:27 PM

 138 Part I: Perioperative Care of the Surgical Patient

Brower RG, Matthay MA, Morris A, Schoenfeld randomized controlled clinical trial of transfu- clinical outcome. Crit Care Med 1995;23:1638–
D, Thompson BT, Wheeler A, et al. Ventilation sion requirements in critical care. N Engl J Med 52.
with lower tidal volumes as compared with tra- 1999;340:409–17. Marshall JC, Charbonney E, Gonzalez PD. The im-
ditional tidal volumes for acute lung injury and Hotchkiss RS, Karl IE. The pathophysiology and mune system in critical illness. Clin Chest Med
the acute respiratory distress syndrome. N Engl treatment of sepsis. N Engl J Med 2003;348(2): 2008;29(4):605–16.
J Med 2000;342(18):1301–8. 238–50. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A,
Dellinger RP, Levy MM, Carlet JM, Bion J, Parker Marshall JC. Inflammation, coagulopathy, and the Knoblich B, et al. Early goal-directed therapy in
MM, Jaeschke R, et al. Surviving Sepsis Cam- pathogenesis of the multiple organ dysfunc- the treatment of severe sepsis and septic shock.
paign: international guidelines for manage- tion syndrome. Crit Care Med 2001;29(Suppl) N Engl J Med 2001;345(19):1368–77.
ment of severe sepsis and septic shock: 2008. S99–S106. Slutsky AS, Tremblay LN. Multiple system organ
Crit Care Med 2008;36(1):296–327. Marshall JC, Cook DJ, Christou NV, Bernard GR, failure. Is mechanical ventilation a contributing
Hebert PC, Wells G, Blajchman MA, Marshall J, Sprung CL, Sibbald WJ. Multiple organ dysfunc- factor? Am J Respir Crit Care Med 1998;157(6 Pt 1):
Martin C, Pagliarello G, et al. A multicentre tion score: a reliable descriptor of a complex 1721–5.

EDITOR’S COMMENT scription of “high output respiratory failure,” that row stores, and to keep the number within rela-
is rapid breathing, an attempt at oxygenation tively normal limits, 10 billion die. The cells that
with failure of oxygenation, should be accredited die are aged, transformed, or infected and the
This chapter could almost be called an “anti-ICU to Dr. John Burke’s writing in 1963 that he recog- uptake of these cells by the reticuloendothelial
care” chapter. As someone whose experience in nized the syndrome that we now call ARDS. How- system supports the resolution of inflammation
surgery dates back to the origins of the intensive ever, since he did not call it that, and Ashbaugh and the processes of tissue repair. As he points
care unit (ICU), I must confess that I have person- and Petty’s article is much more available, they out, the receptor for TNF is such a receptor, and
ally had a healthy suspicion of what we do in the get the credit. the tumor-killing properties of this cytokine
ICU. This is not the reason why I chose Dr. Mar- Endotoxin is ubiquitous in the MODS and is “derive from its ability to evoke apoptosis in the
shall to do this chapter, but I must say that I am of interest as Dr. Marshall mentions that endo- transformed cell.” The bottom line is apopto-
greatly in sympathy with Dr. Marshall’s stance on toxin exposure in the healthy human volunteer sis, which leads to healing. Dr. Marshall argues,
ICU care. He begins the chapter appropriately in leads to a differential expression in more than I think successfully, for the value of measuring
the first paragraph saying that the multiple or- 3,700 genes. Furthermore, we do not know much MODS within the ICU, not because of its capac-
gan dysfunction syndrome (MODS) “is the final about each one of these genes nor do we know ity to predict survival or death, but correlate with
common pathway to death for most critically how many of these genes in the sick patients such the increased risk of death. If the modifiable mor-
ill patients who die within the contemporary as our ICU model patient is poorly affected. It ’is bidity is mentioned, one also can ascertain which
healthcare system.” He also states that it is an probably not a good thing. When we make the physiological domain will be the wisest.
intimidatingly complex process that “integrates transition from the healthy patient or the patient One such morbidity is ARDS. ARDS is partially
a rapidly expanding and unfamiliar biology with who previously had an intact vascular system in- a function of nursing patients and ventilation on
some … supportive technologies in health care” cluding endothelial tight junctions and damage the supine position. It is a pathologic disease
and warns us that “the interface between heroic these tight junctions increasing vascular per- that we have created. It probably can be changed
care and inappropriate meddling in the process meability and edema, we then activate all sorts somewhat by changing the way we nurse patients
of dying.” According to Dr. Marshall, we some- of things including the coagulation cascade and and nursing them prone. Do we do that? The an-
times intervene in a process, which is going to this initiates the process of tissue repair. We do swer is no, we do not, because it is too difficult,
inevitably end in death and prolong it or make it not help the matter by giving large amounts of too expensive, and we do not have the nursing
worse. For example, although Dr. Marshall agrees crystalloid, which then results in ARDS. I must manpower to do this. But the fact is that between
that both crystalloid resuscitation and especially say that I got into many fights or arguments with the way we treat patients and what we do to them
blood transfusion salvaged patients who would my ICU crew in Cincinnati when we started dis- (“the beached whale syndrome”) we actually con-
have earlier died, in my view, the crystalloid re- cussing ARDS at mortality and morbidity confer- tribute to the ARDS and respiratory failure. We
suscitation or “beached whale technique” actu- ence in the early 1980s. It did not seem that we can, for example, limit total volumes, and we
ally contributes to a poorer outcome and we, I needed a great deal of imagination to remember can maximize the opening of units of pulmonary
believe, overdo a crystalloid resuscitation. Of late, that we had never really seen this entity and it co- function by judicious use of PEEP. This will work
there have been those who have said that in the incided with the administration of large amounts much better in a prone nursing patient, except
absence of blood or plasma or colloid, we should of crystalloid in resuscitation from trauma before we do not seem able to do this. After spelling out
minimize our crystalloid resuscitation so that we we had blood and blood products and plasma what we can do for acute lung injury, cardiac in-
do not render the patient edematous and it is dif- and protein-containing solutions. This of course jury, excessive fluid administration that contrib-
ficult to ventilate and contribute to multiple or- led to the opening of the epithelial tight junctions utes to pulmonary interstitial edema, to various
gan failure syndrome. and fluid resuscitation and lung damage. Oxygen other exogenous insults and injuries, including
Indeed, with the concept of the widespread utilization is impaired and mixed-venous oxygen microaspiration of gastric contents, and so on, it
establishment of ICUs, we were inflicting the saturation is increased thereby indicating that al- does seem as if we can do a lot more in the ICU as
spectrum of new clinical disorders on patients, though we are delivering the oxygen, there is little we currently constitute it by thinking about what
including stress-induced upper gastrointestinal utilization. In addition, the process of opening we are doing. When we give vasopressors, for ex-
bleeding, disseminated intravascular coagula- tight junctions leads to migration of products of ample, what do we want to achieve? If we adopt
tion, gram-negative septicemia, ICU jaundice, ischemic injury. In the section entitled “Remote the corollary that vasopressors increase the cap-
and ARDS. Dr. Arthur Baue, who happened to be Cellular Responses to Circulating Inflammatory illary leak, then if we go to Figure 6, what do we
my chief resident when I was an intern has been Products,” Dr. Marshall raises the issue of apop- want to achieve? We want to achieve reasonable
interested in this phenomenon for some time. tosis and that apoptosis is a good thing, although tissue perfusion. How do we do that? We do that
In 1975, Dr. Baue stated that all of this and each many of us have initially had a problem under- by getting a reasonable central aortic pressure.
is a manifestation of a process that was better standing whether this was a good or a bad thing. How do we recognize central aortic pressure?
understood as a single entity, which is multiple It is, as he points out, a non-inflammatory mode We do that by measuring a mean central blood
systems failure (Baue, AE. Multiple, progressive, of physiologic cell death, which seems to be pro- pressure. How do we achieve the volume status
or sequential systems failure. A syndrome of the grammed and plays a fundamental role in normal of supporting a mean arterial pressure of greater
1970s. Arch Surg 1975;110:779–81). Dr. Baue is not homeostasis during cell turnover. The neutrophil, than 65 mm Hg? We limit the CVP to approxi-
generally given credit for this enumeration of this as he points out, is a good example because they mately 8. We also try and limit tidal volume. We
synthesis, and high output respiratory failure or do die by apoptosis within hours of release from also attempt to maintain normal glycemia, and I
ARDS is generally credited to Ashbaugh and Petty their bone marrow, and on each day, 10 billion am not talking about TPN as yet, although that
of the University of Colorado. However, the de- neutrophils or more are released from bone mar- enters into the situation. We try and normalize

www.medicalebookpdf.com

LWBK892_c08_p127-139.indd 138 10/28/11 3:37:27 PM

 Chapter 8: The Multiple Organ Dysfunction Syndrome: Prevention and Clinical Management 139

glucose in the blood stream. We have normal gly- organ dysfunction syndrome. Free Radic Biol Med tain that this trial would qualify as a reasonable

Perioperative Care of the Surgical Patient

cemia, which we try and maintain with insulin, 2009;47:1517–25). In this paper, they make the trial in healthy people because patients with a
but we do not try and get glucose normality of jump from gross attempts to influence sepsis- heart rate of 90 bpm are associated with a two- or
120, because hypoglycemia is too prominent, but related MODS by analyzing 51 studies and cat- threefold higher mortality. I think that if you have
we limit insulin to 150 mU/l in which the hypogly- egorizing them according to various mitochon- a resting heart rate of 90 bpm, there is probably
cemia is not likely to happen. There are any num- drial therapies: something wrong with your heart, and so I am
ber of wise sayings in this chapter, but the best not surprised that there is a higher rate of mor-
one as far as I am concerned is under the heading 1. Substrate provision tality rate. However, there are other trials that
late in the chapter where it says Prevention and 2. Cofactor provision took patients with coronary artery disease and a
Management of Organ Dysfunction in the Criti- 3. Mitochondrial antioxidants left ventricular ejection fraction of ⬍40% and a
cally Ill Surgical Patient is “expressed differently, 4. Mitochondrial reactive oxygen species scav- heart rate of ⬎60 bpm and carried out a random-
the most important thing the intensivist can do engers ized, double-blinded, placebo-controlled parallel
for the critically ill patient is to liberate him or 5. Membrane stabilizers group using ivabradine, which had a significant
her from ICU technology as rapidly and safely as According to the authors, mitochondrial effect on secondary endpoints. Ivabradine is a
possible.” This, I think, is the essence of this really therapies during sepsis were associated with beta blocker, which does not have the deleteri-
commonsense chapter. The author is a common- improvement in electron transport function, ous effects of a beta blocker. In a multicenter trial
sense intensivist who is anti-intensive care. oxidative phosphorylation, and ATP production, conducted from 2004 to 2006, heart rate reduc-
A reasonable discussion of ICU care should as well as decrease in the negative factors such tion with ivabradine had a significant effect on
probably start with cytokine production because as markers of oxidative stress. A variety of other secondary but not on primary endpoints includ-
that is what brings most patients there. Some in- improvements were reported in these various pa- ing a relative reduction in admissions to the hos-
vestigators discuss this as the cytokine storm, as pers including amelioration of proinflammatory pital for fatal and nonfatal myocardial infarction
do Wang and Ma (Am J Emerg Med 2008;26:711–5). cytokines, caspase activation, and membrane by 36%, and as a secondary tertiary endpoint to
The two authors argue that they believe that MODS permeability and stabilization. Thus, the authors relative reduction and coronary revasculariza-
is a result of inappropriate generalized inflamma- predict that as these mitochondrial therapies be- tion. The question then is what happens if one
tory response of the host to a variety of acute in- come better known, the management in sepsis uses ivabradine as a heart rate lowering drug-
sults. I think numerous authors have said this, but will become better, and that they believe that the medicine in patients in the ICU, which does not
the sequence and severity of organ dysfunction in time has come for randomized prospective trials have the deleterious effects of a beta blocker, and
the early phase of MODS is, according to the au- in the treatment of patients with MODS. will it result in a decrease in mortality of MODS
thors, because of circulating cytokines that cause One of the possible sources of MODS is the (Nuding S et al., Clin Res Cardiol, published on-
universal endothelium injury in various organs. I gut and although this is now not been as popu- line, 2011, 3 June). The trial should be completed
think most of us agree that capillary leak is very lar as it has been in the past, Silvestri studied in 2012 and give us some idea of whether or not
important, and is decisive in actually resulting in the impact of selective decontamination of the this is a reasonable way to decrease mortality in
widespread activation of intrinsic inflammatory digestive tract on MODS (Silvestri L et al., Crit MODS patients.
cells and inflammatory mediators. They predict Care Med 2010;38:1370–6) in which they included Finally, some experimental evidence about
that antagonists directed at adhesion molecules all randomized trials, which included not only gene deletion in Zymosan-related MOF. This
may alleviate the severity of endothelial damage. oropharyngeal and intestinal administration of research carried out in mice utilized the Zymo-
Indeed, as one reviews what is happening in the antibiotics in an effort to selectively decontami- san-induced MODS, which is a systemic inflam-
field of ICU care when we see a progression from nate the digestive tract. They included all such matory event resulting in organ damage failure
various antagonists, from anti-cytokines, to anti- studies regardless of whether there was a paren- and higher risk of mortality. They used this to
adhesion molecules, to a whole series of mito- teral component utilized with placebo or stan- evaluate the possible role of GITR and TNFR-
chondrial inhibitors of mitochondrial damage. dard therapy used in the controls. Two blinded related glucocorticoid-induced gene in Zymo-
Jastrow et al. (J Am Coll Surg 2009;209:320–31) reviewers applied selection criteria. They found san-induced MODS. All the mice were treated
talk about early cytokine production and the fact seven randomized trials including 1,270 patients with Zymosan (500 mg/kg, suspended in saline)
that this risk stratifies trauma patients for early and there were MOF or dysfunction syndrome, and one of the animals received a blocking agent
organ failure. This is the result of a prospective ob- and 132 of 637 patients (21%) in the selective de- GITR-Fc by mini-osmotic pump. There were three
servational pilot study at a Level I trauma center contamination trial and in 219 of 633 patients in control groups, of which one was administered
in which serum cytokine levels were determined the control group (35%). The mortality was less in of saline instead of Zymosan and treating one
within a 24-hour period using multiple immuno- the control patients, showing 23% or 145 of 633, of the GITR-WT with GITR-Fc by mini-osmotic
assays in which they measured cytokines in those and in the SDD or the selective decontamination pumps. A number of inflammatory parameters,
patients with non-brain injuries and major torso patients 19% or 119 of 637. However, the reduc- which are unusual but we see in MODS include
trauma who met criteria for standardized shock tion was not significant and the authors argue edema, adhesion molecules expression, histologi-
resuscitation. Multiple organ failure (MOF) was that the study groups were too small. Well, I am cal damage to epithelium, and neutrophil infiltra-
the endpoint that they attempted to predict and not sure. It may be that they have something but tion of pro-inflammatory cytokines. The authors
MOF was assessed with the Denver score. There as one compares various meta analyses, the num- conclude that GITR may play a role in Zymosan-
were 48 young patients (mean age of 39 years), ber of patients is pretty significant and makes one induced inflammation and multiple organ func-
67% male—which is surprisingly low, 88% with think that perhaps this is not the whole story or tion. I have no idea whether or not this substance
a blunt mechanism, and a mean Injury Severity at least it is not a very significant story. It is hard is toxic to humans, or whether or not any of these
Score of 25. Eleven (almost 25%) developed MOF. to tell, but it would have been much better if the experiments will be tested in patients.
Not surprisingly, the patients had a high mortal- results were statistically significant and if the au- In short, MODS is a disease, which occurred
ity of 64% versus 3%. The traditional predictors of thors did not have to argue that the results were in about 1970s or 1980s; it is aided and embedded
MOF including age, Injury Severity Score, admis- insignificant because of the fact that there were by us; we do not do things which we know will im-
sion hemoglobin, and base deficit were not sig- not enough patients in the study. prove the lot of the patient, which is particularly
nificant. Macrophage inflammatory protein-1β, Another simpler approach was to try and unfortunate, and probably one of the nice things
interleukin-10, interleukin-6, interleukin-1Ra, reduce the elevated heart rate with a new drug, we could do would be to carry out prone nursing
and eotaxin, which were statistically different be- ivabradine, which is a “funny channel current” in- and decrease the amount of PEEP as well as fluid
tween those who developed MOF and those who hibitor. There is a meta-analysis of various trials resuscitation, really relying on a mean arterial
did not. These authors suggest that if one follows using either taking patients with a slower heart blood pressure and not pushing the CVP much
the development of these cytokines, one can pre- rate as in the US Army trial in 1945 in which they above 8 mm Hg. I think if we did that, we would
dict which patients will develop MOF. used the resting heart rate as a prognostic factor probably stop making the ARDS that we have
A much more mechanistic approach to MODS in a retrospective analysis with members of the treated worse, whether or not it would result in
is contained in a systemic review by Dare et al. (A US army who had a resting heart rate of more a better outcome I do not know, but it is entirely
systemic review of experimental treatments for than 100 beats per minute (bpm) in a routine ex- possible that it might.
mitochondrial dysfunction in sepsis and multiple amination versus a heart rate of 60. I am not cer- J.E.F.

www.medicalebookpdf.com

LWBK892_c08_p127-139.indd 139 10/28/11 3:37:27 PM

 140 Part I: Perioperative Care of the Surgical Patient

9 Immunosuppression in Organ Transplantation

Pierre-Alain Clavien and Philipp Dutkowski

HISTORICAL EVOLUTION inevitably lead to graft rejection. The allograft The tentative development of kidney
becomes infiltrated with T-lymphocytes, transplantation was carried out in a few
Since the classical studies of Medawar et al. plasma cells, and macrophages; alloantibod- centers in the United States and Europe,
in the early 1950s, it became clear that ies may develop; and small blood vessels tend but it took more than 20 years to see the
transplanted grafts between individuals to bear the brunt of rejection damage in the implementation of such programs in many
from the same species are liable to be de- acute phase and also in patients who un- centers. The routine application of solid or-
stroyed by an immune reaction, which in- dergo so-called chronic rejection, in which gan transplantation had to wait for the
volves both cellular and humoral elements. there is damage to the endothelium of the landmark discovery by J.F. Borel and H.
In the subsequent 50 years, solid organ graft vessels with reduplication of the intima Stähelin, working in the Sandoz laborato-
transplantation has evolved as an extraor- leading to thickening and eventual obstruc- ries, who described the immunosuppres-
dinarily successful form of treatment for tion of graft arterioles and small arteries. The sive effects, both in vitro and in vivo of the
patients who previously would have died. story of immunosuppression can be summa- cyclic peptide cyclosporine (CsA). Use of
In the early history of transplantation, rized in terms of major agents that have been this agent in animals with organ grafts, first
there were two approaches to prevent rejec- shown to prevent graft rejection, or at least with heart grafts in rats, and then in dogs
tion of allogeneic tissue. One was acquired attenuate the process. with kidney grafts, and subsequently in pigs
immunologic tolerance discovered natu- The early attempts at clinical kidney with orthotopic heart grafts, showed that
rally in dizygotic twins, and then, demon- transplantation utilized total body irradia- CsA was far more powerful than any other
strated experimentally between inbred strains tion, but this tool was too nonspecific and products that had been investigated; in ad-
of mice by Medawar’s group. The other ap- ineffective to be of value, except in the dition, the early use of cyclosporine with
proach was to destroy the immune system closely related sibling–sibling transplants. and without steroids resulted in a better
of the recipient completely by total body There were two famous cases, one in Boston outcome, and life-supporting graft survival
irradiation and then rescue the patient by and the other in Paris, of transplants be- of 80% per year was reported. The unex-
transplanting bone marrow from a putative tween nonidentical twins, who were in fact, pected observation of nephrotoxicity in
donor. disclosed identical matches for the six ma- patients treated with cyclosporine was a se-
Although these two ideas did not seem jor HLA antigens. The success of these cases rious setback, so that although early graft
to have a direct bearing on organ grafting, led to disastrous trials using similar immu- survival was much improved with the use of
much has been learned of the basic immu- nosuppressive protocol in recipients, who cyclosporine, by 10 years results were little
nology of tolerance and from the develop- received an organ from a donor not so different from those in patients treated with
ment of bone marrow transplantation. In closely related. These failures demonstrated azathioprine and steroids. It was suspected
the clinic, every successful bone marrow the need for a different approach. In 1959, that the nephrotoxicity of CsA was mainly
transplant is an example of “immunologic Schwartz and Dameshek reported that the responsible for the late failures. A strategy
tolerance” since the patient accepts the antileukemia drug 6-mercaptopurine im- was developed for combining the three
graft without the need for any continuing paired the ability of rabbits to respond im- drugs—cyclosporine, azathioprine, and corti-
immunosuppressive treatment, and if a kid- munologically to foreign antigens. Follow- costeroids—in lower dose each.
ney or a liver from the same donor is trans- ing this report, 6-mercaptopurine was In the mid-1990s, mycophenolate mofetil
planted to the recipient of the marrow, no investigated in dogs with renal allografts (MMF) replaced azathioprine in many
further immunosuppression is needed and and was shown to prolong survival. After- centers in view of trials demonstrating its
the graft is accepted. The mechanisms of wards, the imidazole derivative of 6-mer- superiority. The rationale of this strategy
graft rejection have been studied intensively captopurine, azathioprine, was shown to be combining several drugs was to benefit
in many laboratories. The characteristics of somewhat superior to 6-mercaptopurine in from the additional immunosuppressive ef-
each individual, as defined by red blood cell a dog model of allograft renal transplanta- fects of each of the drugs, while avoiding
groups and histocompatibility or human tion, and this drug was used in the first the serious side effects associated with high
leukocyte antigens (HLA), provide a unique clinical trials of immunosuppression in re- doses of each of the agents. Protocols based
mosaic for each human being. Identity of all nal transplantation. Initial results were on this theme were used worldwide and the
factors can only be expected between iden- again disappointing and, could be improved number of centers engaged in organ trans-
tical twins, but matching for the major red only when anti-inflammatory corticoster- plantation increased from a handful to
blood cell groups and avoiding mismatches oids were combined with azathioprine. more than a thousand in a few years. Confi-
of the six major HLA antigens provide a set- These two drugs then constituted the initial dence developed in clinical transplantation
ting in which relatively mild immunosup- phase of clinical immunosuppression for of the liver and the heart, and to a lesser ex-
pression is likely to get very good long-term kidney grafting with the expectation of rea- tent the lung and the pancreas. In some
results. The minor incompatibilities can be sonable results (e.g., graft survival and func- centers polyclonal antilymphocyte antibod-
controlled with low-dose standard immu- tion at 1 year around 50%), compared with ies were added to the protocol or used for
nosuppression. any other previous strategies including the treatment of acute rejection. The principle
There is no doubt, however, that immu- disastrous experience with total body irra- extensively investigated by Woodruff et al.
nologic engagement between donor and re- diation. In fact, some of the earliest patients was to inject human lymphocytes into
cipient occurs in all organ allografts and this treated with this regimen are still alive. animals and use the animal serum as an

www.medicalebookpdf.com

LWBK892_c09_p140-146.indd 140 10/28/11 3:37:58 PM

 Chapter 9: Immunosuppression in Organ Transplantation 141

immunosuppressive agent. Unfortunately, of transplant; further, exacerbation by the activity, dependent on IL-2 receptor activa-
batches tended to vary. Some were effective use of calcineurin inhibitors appears at tion. When their population is expanded,

Perioperative Care of the Surgical Patient

without toxicity, while others were ineffec- present as one of the major problems, post- these T-cells exhibit the same regulatory and
tive and/or toxic. operatively. cytotoxic functions as would be predicted by
Kohler and Milstein’s discovery of how Another goal is the induction of a sus- the immune response to infection. The dam-
to make monoclonal antibodies has been a tained specific tolerance to donor alloanti- age occurs through a number of different
major step forward. The advantage of gens in the absence of any immunosuppres- routes, including the release of destructive
monoclonal antibodies is that each one is sive therapy. However, the pathways of enzymes, vasoactive and toxic proteins, and
directed against a single molecular target, allograft recognition leading to rejection are direct cell-mediated cytotoxicity. The result-
and it has been possible to modify the anti- extremely complex and far away of complete ing injury is clinically apparent as acute re-
bodies to remove most of the animal origin discovery. Current knowledge is shortly sum- jection; for example, manifested histologi-
components, so that such “humanized” or marized as follows. cally in the liver as endotheliitis and bile
chimeric antibodies are unlikely to elicit Immune reactions are systematically duct damage.
xenoantibody responses. divided into: (a) alloantigen recognition, Based on these pathways, modern im-
Nowadays, clinicians are more experi- (b) lymphocyte activation, (c) clonal expan- munosuppressive agents can be separated
enced in recognizing early acute rejections sion, and (d) graft inflammation. Progres- into four effector classes (Fig. 1):
at the stage when corticosteroid bolus sion from alloantigen recognition to cellu-
Class 1: Depletion of T-cells by poly-
treatment for a few days is usually success- lar activation depends on the presence of
clonal or monoclonal antibodies against
ful in reversing the process. One attack of several stimulatory signals presented
lymphocytes (e.g., anti-thymocyte glob-
acute rejection managed efficaciously does mostly to T-cell lymphocytes. Immune re-
ulin, OKT3)
not seem to have a serious long-term dele- sponses can either be induced by recogni-
Class 2: Inhibition of T-cell activa-
terious effect on the graft, but repeated tion of allogenic molecules of the major
tion by blockage of the T-cell receptor-
acute rejections, particularly when they do histocompatability complex (MHC) at the
dependent activation pathway (e.g.,
not fully respond to corticosteroids or anti- surface of donor cells (direct pathway) or by
calcineurin inhibitors: cyclosporine,
bodies, are a harbinger for chronic rejection peptides derived from MHC molecules pre-
tacrolimus)
and graft failure later. sented on recipient cells (indirect pathway).
Class 3: Inhibition of the IL-2 recep-
Over the years, many new agents have Direct alloresponse is currently believed to
tor by specific antibodies or biochemi-
been investigated; some have reached the occur more in the early posttransplant pe-
cal interference (e.g., basiliximab, dacli-
clinic and unfortunately there has been a riod, while indirect pathways may contrib-
zumab)
tendency for clinicians to add new agents ute to chronic rejection. In the early stages
Class 4: Inhibition of T-cell prolifera-
to the standard protocol, often with the re- after transplantation, tissue-resident im-
tion downstream the IL-2 receptor, such
sult of overimmunosuppression and cer- mature dendritic cells migrate out of the
as cell cycle blockade (e.g., azathioprine,
tainly interfering with any natural biologic graft toward lymphoid organs where they
MMF or enteric-coated mycophenolic
switch-off mechanisms that are part of ev- mature and involve memory T-cells. It is
acid, and mammalian target of rapamy-
ery immune response. conceivable, on the other hand, that graft
cin (mTOR) inhibitors (sirolimus and
dendritic cells may also present antigens
everolimus).
REJECTION MECHANISMS AND without migration. However, the trafficking
and maturation of dendritic cells is trig- Over the last 10 years, many additional
IMMUNOSUPPRESSIVE AGENTS gered by inflammatory signals produced agents were identified as promising candi-
The majority of the commonly used immu- as a result of tissue injury during organ dates for clinical investigation, but several
nosuppressive drugs control rejection procurement or transplant surgery, and of those failed the rigors of clinical develop-
mechanisms by targeting the immune re- appears as cornerstone for the initiation ment (e.g., FTY720, FK778). Consequently,
sponse in a nonspecific manner. Despite of effective adaptive immune response. there has been no new approval for trans-
this shortcoming, acute allograft rejection Whether the first meeting point between plant therapeutics within this period in
can currently be prevented or treated with host T-cells and foreign transplant antigens contrast to the 1990s. The reasons for this
modern immunosuppressive agents, lead- occurs in the secondary lymphoid organs or are: (1) a continuous reduction of acute re-
ing to an 85% to 90% 1-year survival for in the graft itself remains controversial. jection after liver, lung, and kidney trans-
most organs. Besides, there remains a cer- Full T-cell activation requires two dis- plantation and (2) toxicities associated
tain loss of transplanted grafts with an an- tinct signals. The first signal (signal 1) is de- with current regimens. Besides the search
nual rate of 3% to 5% due to chronic al- livered through the T-cell receptor by recog- for new immune targets, the dominant goal
lograft rejection through a still incompletely nition of peptide antigens presented in the of the transplant drug development is
understood process. In addition, most of context of allograft MHC molecules on the therefore the reduction of long-term side
the currently used drugs lead to significant antigen-presenting cells. Additional costim- effects associated with current regimes.
side effects, including nephrotoxicity, in- ulatory signals (signal 2) are delivered via Yet, seven drugs are in phase II/III clini-
creased infection rates, and a risk of tumor inducible receptors on the T-cell surface. cal trials, including ISA247, AEB071,
development, as well as increased incidence These activating signals are balanced by in- CP690550, belatacept, efalizumab, and ale-
of cardiovascular diseases. Minimizing hibitory signals allowing a downregulation facept. They can also be attributed to the
these side effects is one dominant task for of the response after initial T-cell activation. above-mentioned classes (Fig. 1):
future research. For example, within the era Activated T-cells mediate through intra-
of liver allocation through the model for cellular calcium and several promoters and
end-stage liver disease (MELD) system, increased transcription of interleukin-2
ISA247
most candidates for liver transplantation (IL-2) gene. Once IL-2 expression started, ISA247 is a semisynthetic structural ana-
have renal dysfunction already at the time T-cells undergo a burst of proliferative logue of cyclosporine with modification at

www.medicalebookpdf.com

LWBK892_c09_p140-146.indd 141 10/28/11 3:37:58 PM

 142 Part I: Perioperative Care of the Surgical Patient

Antigen presenting cell

Efalizumab
MHCI MHC II Efalizumab is a soluble, leukocyte-associ-
Costimulation IL-2 ated antigen-1 immunoglobulin molecule
Betalacept
that blocks T-cell responses through inhibi-
signal 2
Alefacept Basiliximab tion of T-cell antigen-presenting cell inter-
signal 1 signal 3
Efalizmab Daclizumab actions and can be applied on a weekly basis
T cell receptor IL-2 receptor (Class 2). Efalizumab may act synergistically
CP690550 with agents like belatacept.
JAK3
CD28 TOR
Sirolimus
CD3-complex
Everolimus Alefacept
AEB071 PKC Alefacept is a human LFA-3-IgG1 fusion
Azathioprine protein. The LFA-3 portion binds to CD2 on
Calcineurin NFAT Cell cyle MMF
T-lymphocytes interfering with T-cell acti-
Cyclosporine
Tacrolimus
vation. Alefacept has been shown to delay
ISA247 IL-2 transcription rejection in cardiac transplantation. A
phase II in kidney transplant recipients is
CD4/CD8 T cell currently ongoing.
Anti-thymocyte globuline (ATG) In summary, despite many achievements
Muromonab-CD3 (OKT3) and research efforts during the past de-
Alemtuzumab cades, immunosuppression therapy after
Fig. 1. Mechanisms of immune response and current immunosuppressive agents. Four effector classes transplantation remains poorly standard-
are shown, including depletion of T-cells by antibodies (anti-thymocyte globulin, OKT3, Alemtuzumab), ized. Even the most fundamental issues,
inhibition of T-cell activation by either inference with signal 2 (belatacept, alefacept, efalizumab) or such as the optimal timing, dose, and dura-
downstream signal 2 (AEB071) and signal 1 (cyclosporine, tacrolimus, ISA247), inhibition of the IL-2 tion of calcineurin inhibition, are unclear.
receptor by antibodies (daclizumab, basiliximab) or by interference with Janus kinase (CP690550), and In the absence of reliable data from clinical
inhibition of T-cell proliferation downstream the IL-2 receptor (azathioprine, mycophenolate mofetil trials, transplant physicians are, therefore,
(MMF), sirolimus, everolimus). NFAT, nuclear factor of activated T-cells; PKC, protein kinase C; JAK3, compelled to draw their own conclusions
Janus kinase 3; MHC, major histocompatibility complex; IL2, interleukin-2; MMF, mycophenolate mofetil; and develop their own practices. This is
TOR, target of rapamycin.
particularly true for most approaches taken
for immunosuppression. On the other hand,
only a minor percentage of long-term mor-
the first amino acid of the molecule (Class 2). the T-cell receptor (signal 1) and CD28 tality appears nowadays, related to chronic
Studies in rats, rabbits, dogs, and monkeys (signal 2), and thereby block early T-cell rejection. Having tamed rejection after
suggest that ISA3247 has no nephrotoxicity, activation independent of calcineurin transplantation, the major challenge be-
despite its even higher immunosuppressive (Class 2). One trial is currently ongoing in longs currently to nephrotoxicity, cardio-
effect compared to cyclosporine. A phase II Europe comparing AEB071 combined with vascular diseases, tumor development, and
trial in renal transplant recipients showed everolimus and steroids and tacrolimus recurrent hepatitis C. Antibody-based ther-
promising results in terms of low incidence combined with mycophenolic sodium and apies, with their lack of renal effects, point
of rejection and preserved renal function. A steroids. to a future direction.
phase III trial is therefore awaited.
Alemtuzumab TARGETING REPERFUSION
Janus Kinase Inhibitors/CP-690550 Alemtuzumab is an anti-CD52 monoclo-
INJURY
Janus kinases (JAKs) are cytoplasmatic ty- nal antibody that depletes T-cells, mono- The relationship between reperfusion injury
rosine kinases, mainly present in blood cytes, macrophages, and natural killer and early immune response is of growing in-
cells, which are involved in downstream cells (Class 1), and provides the opportu- terest. The release of reactive oxygen species
IL-2 receptor activation. Compared to other nity for resetting the immune response (ROS) during organ procurement, preserva-
members of the JAK family, JAK3 has special before exposure to the transplanted graft. tion, and reperfusion results in oxidative
features that make it a potentially attractive At present, clinical trials are under way, damage in the graft, and leads to the genera-
target for immunosuppression. For exam- testing whether the combination of alem- tion of several heat shock proteins. These
ple, genetic absence of JAK3 results in se- tuzumab and calcineurin inhibitors can proteins activate the dendritic Toll-like re-
vere combined immunodeficiency syn- lead to tolerance. ceptor 4, which triggers maturation of den-
drome. CP-690550 is the only JAK3 inhibitor dritic cells. Thus, prevention of oxidative
currently in clinical trials (Class 3). A phase stress during reperfusion may lead also to
II trial showed comparable immunosup-
Belatacept reduced activation of dendritic cells and
pressive effects to tacrolimus. Belatacept is a soluble cytotoxic T-lympho- consequently only partial activation of
cyte antigen-4 immunoglobulin that inter- T-cells resulting in apoptotic death of T-cells.
feres with T-cell costimulation and can be Prevention of the initial inflammatory re-
Protein Kinase Inhibition/AEB071 applied on a monthly basis (Class 2). Trials sponse evoked by ischemia and reperfusion
AEB-071 targets protein kinase C, which in liver transplant recipients have been ini- injury may, therefore, not only decrease rep-
plays a key role in signaling downstream of tiated. erfusion injury, but also attenuate immune

www.medicalebookpdf.com

LWBK892_c09_p140-146.indd 142 10/28/11 3:37:58 PM

 Chapter 9: Immunosuppression in Organ Transplantation 143

response. However, despite a huge amount plantation for hematological indications peutic avenue toward transplant tolerance.
of agents targeting reperfusion injury in ani- and later sold organ transplantation, al- Experimental ex vivo manipulation of den-

Perioperative Care of the Surgical Patient

mals, only few have been investigated in hu- lografts were accepted across MHC barriers dritic cells has enabled increased toleroge-
man transplantation. One promising candi- without immunosuppression. However, in nicity in small animal transplant models.
date molecule is recombinant PSGL-Ig, a the absence of hematologic disease, the re-
novel fusion protein, which inhibits all se- quired conditioning to achieve mixed chi- Costimulation-Based Therapies
lectin molecule interactions. It has, there- merism includes peripheral lymphocyte
fore, the potential to disrupt many pro- deletion followed by central tolerance in- A costimulatory-based therapy is derived
inflammatory events related to pathologic duction with donor hematopoietic stem from the premise that naive T-cells require
cell adhesion and is currently investigated in cell infusion. Such conditioning is achieved more than one signal for their full activa-
a phase I–II clinical trial. Other approaches by myeloablative total body irradiation, cy- tion. The second, or costimulatory signal, is
include steroid treatment in deceased do- totoxic drugs and T-cell depletion by anti- provided by the interactions between spe-
nors before transplantation and no inhala- bodies, and is thus associated with signifi- cific receptors on the T-cell and their li-
tion of recipients during implantation. Vola- cant morbidity. Reduction of the toxicity of gands on the dendritic cell. Several key co-
tile anesthetics like sevoflurane may also the conditioning regimen is therefore the stimulatory molecules have been identified,
have beneficial effects during transplanta- most important task for future clinical tri- the most important being the CD154:CD40
tion surgery by inducing increased iNOS als. Costimulatory blockade has emerged as and the CD28:B7 pathways. Initial preclini-
levels. In addition, machine perfusion of grafts a potentially viable alternative to cytotoxic cal trials with blockade of the CD154:CD40
appears as a strategy, which would allow mul- lymphocyte depletion for experimental costimulatory pathway showed operational
tiple pharmacological interventions during mixed chimerism induction. tolerance in a nonhuman primate kidney
preservation without potential negative sys- transplantation model. Belatacept, a modi-
temic effects. But long-term data regarding Depleting Protocols fied CTLA-4 Ig with higher affinity for B7
immune response after decreasing reperfu- molecules, has now been used in phase II
sion injury are not available yet. The advent of antibodies against the T-cell clinical trials in renal and islet transplanta-
receptor has allowed the development of tion. Importantly, memory T-cells appear
various cell depleting protocols, in order to less dependent on costimulatory signals for
TOLERANCE prevent acute rejection or to promote trans- their activation, and may therefore be more
Although the initial episode of acute rejec- plantation tolerance. For example, lympho- resistant to tolerance induction strategies.
tion typically occurs within the first 3 cyte depletion with alemtuzumab, a hu- In summary, preexisting memory T-cells
months of transplantation, particularly manized anti-CD52 antibody (CAMPATH-1 and heterologous immunity are considered
within the first 2 weeks, further episodes of H), was used to minimize immunosuppres- the major barrier in the induction of toler-
rejection can occur anytime after grafting. sion. Other agents such as anti-CD45RB ance in humans. Strategies are needed that
The ultimate objective is, therefore, to de- and anti-CD4 mAbs have been tested in target more efficiently this population with-
velop a protocol in which chronic mainte- nonhuman primates. out compromising normal host defenses to
nance immunosuppression is not needed, i.e., The combined use of rapamycin may add environmental pathogens. Based on this,
“operational tolerance”. This occurs every a beneficial effect, as this drug is thought to limitation of immunosuppressive therapy
time there is a successful bone marrow trans- facilitate the peripheral deletion of effector to only one target appears less promising
plant with a requirement of close donor/ T-cells while inducing T-regulatory cells than combined strategies.
recipient HLA matching, and also occurs in (Tregs) in the periphery. By inhibiting T-cell
a significant number of patients after liver activation rather than eliminating all T- CONCLUSIONS
grafting, but only very rarely in recipients of cells, this type of strategy might more selec-
kidney/pancreas and heart grafts. tively target effector T-cells and spare ben- The major challenge ahead in immunosup-
Immunological tolerance involves central eficial Tregs. Recent studies, however, have pressive treatment is the prevention of
and peripheral mechanisms. Central toler- shown that depleting regimes are less effec- long-term toxicities associated with the
ance results from intrathymic deletion of T- tive at elimination memory T-cells. current highly effective regimens. There are
cells, which provides tolerance through the a high number of new agents available for
mechanism of intrathymic clonal deletion of studies and several immune targets remain
Adoptive Cellular Transfer to be investigated.
donor reactive cells. This process begins with
donor stem cell engraftment in the recipient Infusion of various regulatory cell popula- The trend toward trying to produce im-
bone marrow and thymus, characterized by tions can prevent transplant rejection. In munologic tolerance or at least minimal
the coexistence of donor and recipient he- particular, both Tregs and tolerogenic den- maintenance immunosuppression is a logi-
matopoietic cells (mixed chimerism). Pe- dritic cells have demonstrated promising cal development in the next few years. Pa-
ripheral tolerance to non-self-molecules can results in animal models. For example, tients will be monitored closely but given
be achieved by various methods including FoxP3⫹ Tregs can suppress the differentia- less severe doses of immunosuppressive
deletion of activated T-cells, active regula- tion and function of effector T-cells. In this agents to avoid the risks of infection, malig-
tion of effector T-cells (adoptive cellular context, adoptive transfer of Tregs in pre- nancy, and the side effects of each of the
transfer), or manipulation of dendritic cells clinical transplantation trials has demon- individual drugs. The shortage of organ do-
(costimulation-based pathways). strated striking results. Phase I trials are nors will remain and be of considerable
currently ongoing for grafts-versus-host worry to doctors who are trying to give
disease in bone marrow transplantation. their patients the best treatment, but are
Mixed Chimerism Dendritic cells are strategically positioned anxious not to put pressure on potential do-
In several cases, series of patients who un- at the interface between innate and adaptive nors or to accept grafts of minor quality.
derwent allogeneic bone marrow trans- immunity and represent an additional thera- Therefore, optimizing strategies before or

www.medicalebookpdf.com

LWBK892_c09_p140-146.indd 143 10/28/11 3:37:58 PM

 144 Part I: Perioperative Care of the Surgical Patient

during preservation deserve future research Golshahyan D, Buhler L, Lechler RI, Pascual M. From Pascual M, Theruvath T, Kawai T, Tolkoff-Rubin
activity to minimize not only reperfusion current immunosuppressive strategies to clini- N, Cosimi AB. Strategies to improve long-term
injury, but also immune response. cal tolerance of allografts. Transplant Int 2007; outcomes after renal transplantation. N Engl
20:12–24. Med 2002;346:580.
Kaczorowski D, Nakao A, Vallabhaneni R, et al. Rogers NJ, Lechler RI. Alloregognition. Am J Trans-
SUGGESTED READINGS Mechanisms of Toll-like receptor 4 (TLR4)- plant 2001;2:97.
mediated inflammation after cold ischemia/ Sayeh MH, Turka LA. The role of T-cell costimu-
Buhler LH, Spitzer TR, Sykes M, et al. Induction of reperfusion in the heart. Transplantation 2009; latory activation pathways in transplant rejec-
kidney allograft tolerance after transient lym- 87:1455–63. tion. N Engl J Med 1998;338:1813–21.
phohematopoietic chimerism in patients with Martinez-Llordella M, Lozano JJ, Puig-Pey I, Starzl TE, Murase N, Abu-Eimagd K, et al. Tolero-
multiple myeloma and end-stage renal disease. et al. Using transcriptional profiling to develop genic immunosuppression for organ transplan-
Transplantation 2002;74:1405. a diagnostic test of operational tolerance in tation. Lancet 2003;361:1502.
Geissler EH, Schlitt HJ. Immunosuppression for liver transplant recipients. J Clin Invest 2008; Vincenti F, Kirk AD. What’s next in the pipeline.
liver transplantation. Gut 2009;58:452–63. 118:2845–57. Am J Transplant 2008;8:1972–81.

EDITOR’S COMMENT can lead to tolerance. This is interesting although those such as myself, who do not walk around
I am not terribly familiar with the history of this thinking about the complex rejection system,
area, as far as I am aware, this is the first direct include natural killer cells (NK), mast cells and
Professor Clavien gives us a nice history of the statement that the clinical trials are headed in dendritic cells (DCs) exert a variety of immuno-
development of immunosuppression. Initially the direction of trying to establish tolerance. regulatory mechanisms which are important for
the goal was to suppress rejection totally; and the Thus, in summary, according to Professor Clavien the induction of tolerance such as regulating
number of drugs that were available was minimal where the field is, is not frantic, but a measured T cell activations and differentiation through
and therefore corticosteroids were required. The search for tolerance with low-dose immunosup- cytokine production and inhibiting or killing ef-
number of medications has increased, and the pression to improve tolerance and minimalize fector T cells. For those who are interested there
drugs have improved. Although there have not toxicity. As I stated earlier this is more likely in are excellent reviews on the function of various
been any new immunosuppression medications large volume transplants. In addition, promoting cells in both rejection and tolerance. While their
confirmed since the 1990s, the theme has been tolerance goes hand in hand with decreasing the conclusion “while T cells were once thought to
fewer toxicities and low-dose immunosuppres- hyperfusion injury and weakening the immune be of primary, perhaps exclusive, importance for
sion particularly in the first month after trans- response. transplant rejection and tolerance, the ability of
plant so that some type of tolerance develops. McShane, P J and Garrity Jr., E R, Transplant In- innate immune cells (previously mentioned) to
However, as the author knows too well, the ternational 2009; 22: 90-95, speak, as the title says, shape both processes is now increasingly appre-
ability to suppress rejection also comes with a on the Minimization of immunosuppression after ciated.” Strategies which are aimed at targeting
price; long-term immunosuppression leads to lung transplantation. They believe that as time T cells are attempts to induce consistent clinical
damage to the transplanted organ so that ulti- has gone on, the survival in adult long transplant transplant tolerance and they conclude “have of-
mately after 15 or 20 years the survival may be recipients from 1994 - June 2005, survival rates at ten led to improvements in graft survival but have
anywhere from 35-50% not from chronic rejec- one-, three-, and five- years were 78%, 62% and rarely achieved the goal of tolerance.” As I stated
tion, although that occurs, but perhaps from the 50% respectively. Although in chronic rejection earlier, it does appear that the goal of the trans-
drugs that suppress rejection. He gives us a nice the basic mechanism appears to be a bronchioli- plant community and the immunological trans-
brief history of 6-mercaptopurine, to the develop- tis obliterans syndrome (BOS) which they take as plant physicians and surgeons is the achievement
ment of azathioprine to the addition of steroids being a marker for chronic rejection which is, in of tolerance.
so that the need for azathioprine would be atten- fact, the most significant long-term complication Jain A, et al. Transplantation 2011; 91 1025-
uated, and then the breakthrough of cyclosporine and simultaneously the major cause of late death 1030, review the role of tacrolimus in immuno-
finally mycophenolate mofetil (MMF). after lung transplant. The prevalence of BOS is suppression in primary liver transplantation with
The evolution of immunosuppression has apparently 50% at 5- and 6-years. While the im- a 17-20 year longitudinal follow-up from a single
now arrived at the point where although there munosuppressive medications have reduced the center, this being Temple University Hospital and
are a large number of agents available each agent incidence of acute rejection within the first year the Thomas Starzl Transplantation Institute. This
is given lower dosage to decrease toxicity. Still, of transplantation the long-term outcomes have is a mixed group of 630 adults, 204 seniors and
in back of the background of desiring to avoid not been affected. Thus lung transplant physi- 166 children. The suppression was tacrolimus
rejection, is the hope that ultimately, particularly cians have turned their attention to minimiz- based until 2009 and the beginning point of the
in the large organs such as liver, lung and heart, ing immunosuppression and trying to achieve review was August 1989 between August 1989 and
there may be the development of tolerance. An- donor-specific immuno-tolerance so that the im- December 1992. The 20-year actuarial patient and
tilymphocytic globulin also made its appearance munosuppressive medications can be stopped all graft survivals 36% and 33% respectively, although
although the batches that are raised are of vari- together and that chronic rejection can be inhib- children seemed to do somewhat better. 183 re-
able efficacy and not entirely dependable. ited by the appearance of tolerance. cipients underwent retransplant and the primary
The hypothesis towards the development of Murphy, S P, Porrett, P M, and Tuka, L A, Im- causes for this were primary nonfunction, hepatic
tolerance is a rather straightforward concept of munological Reviews 2011; 241: 39-48 have fo- artery thrombosis and recurrent primary disease.
cell killing based on the conventional concept cused on the passenger leukocytes as other have 180 of these patients required dialysis probably
of T cell interactions. More about this later in the in order to try and treat patients so that rejection because of the toxicity of rejection and 45 under-
commentary, but this seems to differ markedly is a thing of the past. The passenger leukocytes went kidney transplant. Of the survivors almost
from Starzl’s concept of microchimerism (Chap- are those lymphocytic type cells which come 100% remained on tacrolimus and 26% were also
ter 124). Professor Clavien tells us that there 7 along, as it were, as a passenger in the transplant receiving adjunctive immunosuppressions. They
new drugs that are intended in various forms of due to the fact that they have been in the host at compared their results with those of Busuttil et
second order trials. One of them is very interest- the time of transplant. While the cells of the in- al. Annals of Surgery 2005; 241: 905-912 whose 1-,
ing, alemtuzumab which is an anti-CD52 mono- nate immune system are, according to most in- 5-, 10- and 15-year patient and graft survival were
clonal antibody that depletes T cells, monocyctes, vestigators thought to serve as the initiators of respectively 81%, 72%, 68% and 64% for patient
macrophages and natural killer cells, and “pro- the immune response and thus graft rejection, survival and graft survival of 73%, 64%, 59% and
vides the opportunity for resetting the immune there is also emerging an actually intense inter- 55% respectively. These seem clearly better then
response before exposure to the transplanted est for the innate immune system and its role in that Temple University - Starzl Institute survival
graft. The clinical trials that are currently ongo- the induction of tolerance. This will be more obvi- and the disclaimer in the discussion that this is a
ing apparently are testing whether the combina- ous from Dr. Starzl’s chapter who has been most slightly shorter follow-up period which may con-
tion of alemtuzumab and calcineurin inhibitors active in this area. The innate immune cells, for tribute somewhat, in other words 15 years in the

www.medicalebookpdf.com

LWBK892_c09_p140-146.indd 144 10/28/11 3:37:58 PM

 Chapter 9: Immunosuppression in Organ Transplantation 145

Busuttil study and 17-20 years in the Jain study, plants has come in for a lot of experimentation does appear as if attempts have intensified in the

Perioperative Care of the Surgical Patient

had a higher percentage of pediatric patients, probably largely because the bronchiolitis oblit- group of lung transplants since this represents
22% vs. 17%, is disingenuous because I doubt that erans syndrome has been so troublesome (BOS.) the most apparent cause of mortality, and this is
those differences explain the superior outcome in Because of this the long term survival among continual chronic rejection resulting in bronchi-
the Busuttil study. Obviously, as 77% of the pediat- lung transplants has not been as great as it has alitis obstructive respiratory failure. The review
ric patients were compared in the Jain study, 35% been with other solid organs. The history of lung ends with the hope that new agents, refinements
of adults and 16% of seniors, the slightly greater transplants is that Dr. James Hardy attempted in techniques to monitor immunosuppression,
prevalence of pediatric patients may actually the first human lung transplant but that patient and of course, the greater understanding of trans-
contribute to the superior results but I doubt that died several weeks post-operatively. Two decades plant immunobiology will result in improved out-
they explain the whole thing. later there had been approximately 40 lung trans- comes.
Another large volume study by Campsen, J plant procedures and most patients died within Apparently the transplant population has
et al. Journal of Transplantation 2011; published weeks to infectious complications, graft rejection seen an early emergence of tolerance in allogeneic
online, utilized a review of patients receiving ra- and bronchial anastomotic dehiscence. Dr. Joel hematopoietic stem cell transplantation (HSCT).
pamycin or sirolimus (SRL) which suppresses the Cooper performed a unilateral lung transplant Roncarolo M-G, et al. Immunological Reviews
T cell response to interleukin-2 by binding and in 1983 in a patient with idopathic pulmonary 2011; 241: 145-163 have made greater progress
inhibiting the mammalian target of rapamycin fibrosis who ultimately survived 6 years, omit- with tolerance in solid organ transplants. The pe-
(m-TOR). Both benefits and risks have been re- ting corticosteroids which were thought to be ripheral tolerance induction after allogeneic he-
ported for the use of sirolimus in liver transplan- related to a major cause of mortality in bron- matopoietic stem cell transplantation apparently
tation as there are apparently increased reports chial anastomosis dehiscence. His immunosup- involves peripheral clonal deletion or at least ac-
of liver failure, hepatic artery thrombosis, and pression regiment was cyclosporine based and tive suppression mediated by various regulatory
over all post transplant mortality compared with initially did not include corticosteroids. Induc- cells which include natural killer (NK) and mes-
the use of the calcineurin inhibitors (CNIs). Other tion therapy utilized potent immunosuppressive enchimal cells as well as T and D natural killer
studies apparently report good outcomes and a agents in the perioperative and early postopera- cells. In Table 1 the hallmark of IL-10/TR1 medi-
renal-sparing effect of sirolimus (Montalbano, tive periods to reduce the risk of acute rejection ated peripheral tolerance in humans is listed with
M, et al. Transplantation 2004; 78: 126-129.) The and permit more gradual initial of maintenance the confirmed studies in vivo which involves per-
Colorado center from which Campsen writes immunosuppression. Several types of induction sistent mix/split chimerism and a whole series of
has routinely used SRL or sirolimus for immuno- agents specifically targeted T-lymphocytes which other changes which are thought to contribute
suppression although with the CNIs in the early were thought to be the primary effector cells of to the long term survival of allogeneic stem cells
post operative period. They have changed their the cell-mediated immune system (Floreth T, et on the basis of tolerance. It would seem that this
practice lately and apparently find no increase al. Clinical Chest Medicine 2011; 32: 265-267.) Ap- situation is a better model and a better outcome
in morbidity or mortality in the SRL compared parently the use of alemtuzumab (Campath-1H), for allogeneic hematopoietic stem cells and gives
to standard therapy of CNIs and enteric-coated which is a human monoclonal antibody to CD52 us an understanding that in fact tolerance as as-
mycophenolate sodium. Their preliminary stud- which is a cell surface market found on all mono- sociated with microchimerism is a good model
ies state that it can reduce donor graft rejection nuclear lymphocytes, but it is not use extensively for patients with transplants.
and could ameliorate renal injury secondary to in many transplant centers. The administration of In summary based on the available data it
the increased use of the calcineurin inhibitors. alemtuzumab results in profound and prolonged seems that the transplant community is now
Their conclusion following a series of very com- T cell depletion with various effects on various convinced that long term tolerance perhaps on
plex calculations is that they are justified in the natural killer cells, monocyte populations and on the basis of microchimerism as well as minimal
use of sirolimus and perhaps the newer immuno- B-lymphocyte populations. In a review of more multiple repressive agents from a variety of types
suppression combinations including everolimus than 4000 lung transplant recipients between thus decreasing long term toxicity and improving
will prove superior to spare kidney damage and January 2000 and March 2004 induction therapy survival with long term suppression albeit with
increase survival. with either an IL_2R antagonist or polyclonal smaller doses of multiple agents than previously
Lung transplantation perhaps because the ATG resulted in or at least was associated with had been followed seem to give a hope of tolerance
immunosuppression thereof is perhaps slightly improved survival at 4 years, that is 64% and 60% which is the Holy Grail of transplant biology.
more difficult than in other solid organ trans- as compared with 57% with no induction. Thus it J.E.F.

www.medicalebookpdf.com

LWBK892_c09_p140-146.indd 145 10/28/11 3:37:58 PM

 www.medicalebookpdf.com

LWBK892_c09_p140-146.indd 146 10/28/11 3:37:59 PM

 Basic Surgical Skills: New and Emerging Technology II

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 147 10/28/11 3:38:47 PM

 10 Abdominal Wall Incisions and Repair
Including Release
Stephen R.T. Evans and Parag Bhanot

INTRODUCTION is the innervation of the abdominal mus- 1. Vertical. These incisions may be midline,
culature should be minimally interfered paramedian, or even pararectus. They
The success of any open abdominal opera- with to preserve its functionality. This is can be supraumbilical or infraumbilical
tion requires adequate exposure via the a limitation with oblique and transverse and, if necessary (e.g. for extensive intra-
appropriate selection of the incision as incisions. Ideally, it is best to sacrifice less abdominal trauma) can be extended in
well as proper closure of the abdominal than one segmental nerve trunk ipsilater- the midline upward to the xiphoid pro-
wall to limit unnecessary morbidity. In the ally, regardless of the length of the incision. cess and/or downward to the symphysis
current era of laparo-endoscopic surgery, An incision should be so placed that it does pubis.
the general surgeon must still be well not interfere with future stages of planned 2. Transverse or oblique. The best examples
versed with the anatomic principles of the surgery. of these incisions are Kocher’s sub-
abdominal wall. In the past several de- 3. A reliable closure must be obtained, unless costal incision for cholecystectomy, a
cades, there has been a broadening of the postoperative intra-abdominal hyperten- supraumbilical or infraumbilical trans-
options available in selecting an incision sion (IAH) is a concern. The integrity of verse incision for intestinal surgery, Mc-
for an abdominal operation. The primary the abdominal wall must be maintained Burney’s or the Rockey-Davis’ incision
factors that should be considered are the with adequate fascial closure. In cases for appendectomy, Pfannenstiel incision
diagnosed intra-abdominal disease and involving contamination, such as a per- for gynecologic surgery, and a transverse
the organ(s) that must be modified or re- forated viscus, we advocate delayed clo- or oblique central and lateral incision
moved to treat that disease process. Never- sure of the skin to minimize postopera- for exposure of the colon.
theless, even among experienced surgeons, tive soft tissue infections. 3. Retroperitoneal and extraperitoneal ap-
there are frequently differences of opinion proaches. These incisions are ideal for
about the best incision for treating a given The morbidity from abdominal incisions
surgery of the kidney or adrenal gland,
disease in a particular patient. is poorly reported and probably underesti-
renal transplantation, and aortoiliac
There are three primary requirements for mated. Any error, such as a poorly placed
surgery.
an incision to be used for any given operation. incision and/or unsatisfactory method of
4. Thoracoabdominal. This incision gives
The incision must provide optimal exposure, closure can lead to complications including
excellent exposure of the upper abdomi-
be flexible, and allow for a reliable closure. hematoma, stitch abscess, infection, wound
nal organs by connecting the mediasti-
dehiscence or evisceration, incisional her-
1. Exposure must be optimal. The incision num, pleural, and peritoneal cavities
nia, or an unsightly scar. Rarely, a misdiag-
must provide direct access to the peri- into a single operative field.
nosis may necessitate making a different
toneal cavity without significant limita- 5. Separate thoracic and abdominal inci-
incision altogether.
tions if additional exposure is needed at sions. These incisions spare the costal
a later point. There must be adequate TYPES OF INCISIONS margin and cause less postoperative pain
visualization of the diseased organ or in- and disability than does the thoracoab-
jured area, and provide sufficient work- Figure 1 illustrates some common types of dominal incision, as in an Ivor-Lewis
ing space so that the procedure can be abdominal incisions. esophagectomy.
performed directly and rapidly without
limiting the intra-abdominal manipu-
lation or excision, especially important
in the trauma setting. Appropriate po-
sitioning of the patient (e.g. lithotomy
for pelvic surgery) and application of
abdominal wall retractors are ancillary
measures. Inadequate lighting can make
even a simple procedure very difficult;
thus, headlights and lighted retractors
P O
should be readily available.
2. Flexibility is a requirement of any operative
F
incision. The popularity of the vertical mid-
line incision is partly based on its ability to
be extended if the scope of the operation
dictates a larger incision. The limitations A B
of the vertical incision are the xiphoid pro- Fig. 1. Common types of incisions. A: Clockwise from the upper right quadrant are subcostal (Kocher),
cess and the pubis symphysis. To some ex- thoracoabdominal, left lower quadrant (extraperitoneal), vertical midline, and Rockey-Davis (trans-
tent, transverse incisions are also amena- verse)/McBurney (oblique). B: From superior to inferior are bilateral subcostal with vertical T extension,
ble to a curvilinear extension. Of concern, supraumbilical transverse, infraumbilical transverse, left paramedian, and Pfannenstiel incision.

148

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 148 10/28/11 3:38:49 PM

 Chapter 10: Abdominal Wall Incisions and Repair Including Release 149

SELECTION OF THE INCISION VERTICAL INCISIONS bladder should always be decompressed by

a Foley catheter. The anterior fascia can be
The choice of incision varies with the sur- incised to the pubic symphysis if needed, but
geon’s experience and preferences. Integral
Midline Incision
the posterior incision involving the perito-
to the decision is the organ(s) or site that The midline incision provides the fastest neum should be angled away from the blad-
needs to be exposed, whether rapid access and simplest approach making it a popular der. Blunt dissection in the space of Retzius
is needed as for severe hemorrhage or incision. It offers adequate exposure to any can also be used to safely sweep the dome of
trauma, the certainty of the diagnosis, body part of the abdominal cavity including the the bladder away from the incision.
habitus, the presence of previous abdomi- retroperitoneum. When speed is essential,
nal incisions, and cosmesis. it is clearly the incision of choice because it
Many surgeons prefer oblique or trans- can be made and closed rapidly. It is almost
Paramedian Incision
verse incisions when adequate exposure avascular, allows for preservation of muscle A paramedian incision is a vertical incision
can be obtained because the direction of fibers, and avoids nerve injury. It can be ex- made 2.5 to 4.0 cm from the midline (Fig.
pull of the lateral abdominal muscles is par- tended upward and downward the full 3A). It is deepened through the subcutane-
allel to the incision, and much less distract- length of the abdomen by curving the skin ous fat onto the anterior rectus sheath,
ing tension occurs on the wound edges than incision around the umbilicus (Fig. 2A). The which is opened for the whole length of
with vertical incisions. The wounds are incision is deepened through skin, subcuta- the wound no more than 2 to 3 cm from the
stronger and less liable to dehiscence or neous fat, linea alba, properitoneal fat, and midline (Fig. 3B). The medial portion of the
herniation; in general, they seldom dehisce peritoneum. Properitoneal fat is abundant anterior rectus fascia is then dissected off

Basic Surgical Skills: New and

unless infection is present. However, these in obese individuals, and medium-sized the muscle to the medial edge of the muscle.

Emerging Technology
are somewhat more time-consuming to vessels may be encountered. If the falciform This dissection is more difficult in the upper
make than a midline incision. Also note- ligament is encountered or is found inter- abdomen because of the tendinous attach-
worthy is that they cause somewhat less fering with exposure in the upper abdomen, ments (inscriptions) of the rectus muscle to
postoperative pain than does an upper mid- it should be clamped, divided, and ligated. the anterior fascia. These are located just
line incision. Upper midline incisions provide adequate below the xiphoid, at the umbilicus, and oc-
In emergency operations for major intra- exposure for most operations on the esoph- casionally midway between these two points.
abdominal hemorrhage, the midline ap- ageal hiatus, abdominal esophagus (and Segmental blood vessels are encountered
proach gives the most rapid access and, if vagus nerves), stomach, duodenum, gall- when the tendinous inscriptions are freed
necessary, can be quickly extended from the bladder, pancreas, and spleen. Lower mid- and must be electrocoagulated or clamped
xiphoid to the symphysis pubis. In general, line incisions provide good exposure for and ligated. Once the muscle is free anteri-
an upper midline incision may be preferable operations for the sigmoid colon and rec- orly and medially, it can be retracted later-
in a thin patient with a very narrow costal tum, as well as all the pelvic organs. ally by a ribbon retractor because it is not
angle, but in a patient with a wide costal When making vertical abdominal inci- adherent to the posterior fascia. The poste-
angle, a unilateral or bilateral subcostal or sions, one should enter the peritoneum rior sheath and the peritoneum are then in-
transverse incision gives excellent exposure near the umbilicus to avoid injury to the cised vertically for the length of and in line
of upper abdominal viscera, especially the bladder. Care must be exercised in opening with the skin incision. The lower rectus
pancreas, liver, biliary tract, or spleen. the peritoneum to avoid injury to an under- sheath differs from the upper in two re-
The McBurney or Rockey-Davis muscle- lying bowel loop, particularly when the spects: the posterior fascial layer is largely
splitting incision for appendectomy is bowel is distended in the setting of a bowel absent below the semicircular line of Doug-
ideal and can be easily extended medially obstruction. A safe method is to pick up a las, and the deep inferior epigastric vessels
or obliquely laterally (Weir extension) if fold of peritoneum with a pair of forceps, need to be divided and ligated as they run
greater exposure is required. If an ileos- palpate it to ensure that no other structure across the lower part of the incision.
tomy or colostomy is to be part of an op- has been caught up with it, and then care- The paramedian incision avoids injury to
erative procedure, the main incision fully incise the raised fold with a scalpel or nerves, limits trauma to the rectus muscle,
should be kept as far from the stoma as scissors (Fig. 2B). The small opening is en- allows an anatomical and secure closure,
possible, with use of either a midline inci- larged to admit two fingers, which are used and permits good restoration of abdominal
sion or even a paramedian approach on to protect viscera while the peritoneum is wall function. If necessary, it can be ex-
the opposite side from the planned stoma. being opened throughout the length of the tended from the pubis to the xiphoid by
Transverse incisions above the umbilicus incision (Fig. 2C). When operating through slanting the upper end of the incision medi-
provide ample room for an infraumbilical a previous incision, one must be extra care- ally toward the xiphoid. When placed on the
stoma, or vice versa. ful to avoid underlying adhesions involving appropriate side, it can be used satisfacto-
When reoperating on the abdomen, the bowel. If possible, the incision should begin rily for any intra-abdominal surgery, al-
surgeon should, if possible, enter through 2 to 3 cm beyond the previous scar so that though it is more time-consuming to make
the previous incision, particularly if the sur- the peritoneum can be opened where it is than a vertical midline incision. The theo-
gery entails excision of a disfiguring scar or relatively free of adhesions. Once the perito- retical advantage of this incision is that the
repair of an incisional hernia. When operat- neum has been opened, the fascia and peri- rectus muscle resumes its original place and
ing through a previous scar, one must be toneum are held up with Kocher’s clamps splints the incisions in the anterior and pos-
wary of adhesions from bowel or omentum. so that the attachments of adhesions can be terior sheath, and thus should diminish the
The surgeon should never make a new inci- seen and carefully divided sharply to pre- risk of wound dehiscence and incisional
sion closely parallel to a previous one be- vent thermal injury to the bowel. hernia. However, despite the known hernia
cause it may cause ischemia of the tissue When making the incision in the lower incidence with midline incisions, the para-
between the incisions and lead to necrosis anterior abdominal wall, the surgeon must median incision is less commonly employed
of the intervening skin and fascia. be careful to avoid a bladder injury. The because it is more time-consuming.

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 149 10/28/11 3:38:49 PM

 150 Part II: Basic Surgical Skills: New and Emerging Technology

Fig. 2. Vertical midline incision with gentle curve around the umbilicus, which is preferred over the keyhole. A: The peritone-
um is opened with a knife, which requires that the surgeon’s fingers or a malleable retractor protect the underlying intestine
and omentum. B: The peritoneum and posterior fascia are grasped with two forceps so as not to crush the intestinal wall if
it should happen to be trapped in the jaws of an instrument. The incision should not be made at the apex of the tented-up
peritoneum, but 1 cm or so below the instruments, again to avoid cutting into a trapped loop of intestine. When air enters
the small opening made with a scalpel, the intestine and omentum will fall away from the peritoneum, unless held there
by adhesions. C: The peritoneum while the underlying structures are protected with two fingers of the other hand. D: The
midline fascia and peritoneum can be closed with one layer of continuous suture, either with nonabsorbable or absorbable
suture. E: Closure of fascia in one layer with the peritoneum is the technique most surgeons use. For the average abdominal
wall, the bites should be at least 1 cm from the cut edge.

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 150 10/28/11 3:38:49 PM

 Chapter 10: Abdominal Wall Incisions and Repair Including Release 151

except possibly in a short individual with a

wide abdomen and a wide costal margin. In
such a patient a long, transverse supraumbili-
cal incision gives very satisfactory exposure
for most intra-abdominal surgery with the ex-
ception of the deep pelvis. An infraumbilical
incision, properly placed, is satisfactory for
operation in the pelvis, for example, the sig-
moid colon or rectum. However, the same
transverse incision may not provide adequate
exposure if mobilization of the splenic flexure
is also required as in a left hemicolectomy.
The transverse tendinous inscriptions
attach the rectus muscle to the anterior rec-
tus sheath, thereby keeping it from retract-
ing significantly when it is incised. Tendi-
nous inscriptions do not occur below the
umbilicus, however, some retraction of the
incised rectus muscle may occur in that

Basic Surgical Skills: New and

area. One should avoid making a transverse

Emerging Technology
Fig. 3. Upper abdominal paramedian incision. A: The superior end of the incision curves toward the incision at or very close to the symphysis
midline to leave sufficient fascia lateral to the incision to allow ample bites to be taken without impinging pubis because, if a hernia develops, suffi-
on the costal margin. B: The anterior rectus sheath is opened 2 to 3 cm lateral to the midline; the rectus cient fascia may not be available along the
muscle is then dissected free of the fascia until the medial margin of the muscle is exposed. The posterior lower margin of the incision to permit satis-
fascia and peritoneum are opened directly below the anterior fascial opening with the muscle retracted factory repair without bony fixation.
laterally. One should emphasize that transverse
or oblique incisions have substantially more
intrinsic strength than vertical incisions
Vertical Muscle-Splitting Incision considerably in angle. The incision may be because fascial fibers are transversely ori-
limited to the oblique muscles, may involve ented. When the incision is made, the fas-
The vertical muscle-splitting incision is division of all or part of one rectus muscle, or cia is incised parallel to the fibers. Closure
performed in much the same way as the may even encompass the entire width of both of the incision places the sutures perpen-
paramedian incision except that the rectus recti as in the bilateral subcostal incision. dicular to the fascial fibers making it more
muscle is split longitudinally in its medial Transverse or oblique incisions mostly fol- secure than in a vertical incision in which
third, after which the posterior rectus low Langer lines and give better cosmetic re- the sutures are parallel to the fiber orienta-
sheath and peritoneum are opened in the sults than vertical incisions. Any nerve injury tion and can tear or cut through the fascia
same line. If the incision is short, it can be that occurs is usually limited to one or, rarely, (Figs. 4 and 5). This is the reason that dehis-
quickly made and repaired. It is very satis- two nerves. In general, transverse or oblique cence or incisional hernia is three to five
factory when a limited incision is needed, incisions give limited exposure if disease is times as common with vertical incisions
for example, for placement of a Tenckhoff found in both the upper and lower abdomen, compared with transverse incisions.
peritoneal dialysis catheter. An extensive
incision should be avoided, however, be-
cause it results in more injury to nerves and
muscle, and in substantially more bleeding
than the midline or even the paramedian
incision. If more than two nerves are sacri-
ficed, the corresponding area of the abdom-
inal wall may become dysfunctional post-
operatively. The main value of this incision
is in reopening the scar of a previous para-
median incision, when dissecting the rectus
muscle from scar tissue in its sheath is very
difficult and splitting the muscle may there-
fore be preferable.

TRANSVERSE OR
OBLIQUE INCISIONS Fig. 4. A: When a vertical incision is made, the closure has the intrinsic disadvantage that sutures are
placed parallel to the direction of the fascial fibers, which are essentially transversely oriented. When
There are several variations of transverse or these are tied, tension is with the grain, which is not as strong a configuration as would be obtained
oblique incisions (Fig. 1). Transverse inci- with a transverse incision. B: When intra-abdominal pressure (IAP) increases as the abdominal muscles
sions may be truly horizontal or may curve contract, the sutures tend to tear through the fascia, which allows the fascial edges to separate. (From
to varying degrees. Similarly, oblique inci- Baker RJ. Incisional hernia. In: Nyhus LM, Condon RE, eds. Hernia, 3rd ed. Philadelphia: JB Lippincott;
sions may be straight or curved and may vary 1989, with permission.)

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 151 10/28/11 3:38:49 PM

 152 Part II: Basic Surgical Skills: New and Emerging Technology

muscles can be divided for a variable dis-

tance. Although the eighth intercostal nerve
is almost invariably divided, care must be
taken to preserve the ninth nerve to prevent
weakening of the abdominal musculature.
The incision is then deepened to open the
peritoneum (Fig. 6B). Although the rectus
muscle is divided, this results in no weaken-
ing of the abdominal muscles, provided that
the anterior and posterior sheaths are re-
paired because the incision generally cuts
only one intercostal nerve. The rectus mus-
cles have a segmental nerve supply, allow-
ing a transverse or slightly oblique division
without significant risk to its innervation.
Healing of the incision simply results in an
iatrogenically produced additional fibrous
inscription in the muscle.

Transverse Incision
Fig. 5. The subcostal or transverse incision obviates the disadvantages of the closure of the vertical inci- Transverse incisions are ideally suited for
sion. A: This incision is essentially parallel to the fascial fibers, and the sutures are placed and tied against open operations on the small intestine and
the grain of the fascia. B: The second advantage of the transverse incision is that muscle tension on con- are usually performed through an infraumbil-
traction is parallel to the incision and does not tend to distract the edges. (From Baker RJ. Incisional hernia. ical transverse incision, located approxi-
In: Nyhus LM, Condon RE, eds. Hernia, 3rd ed. Philadelphia: JB Lippincott; 1989, with permission.) mately 2 to 3 cm below the umbilicus. For

Kocher’s Subcostal Incision

Frequently, a right subcostal incision is used
for open operations in the gallbladder, liver,
and biliary system, particularly in obese or
muscular individuals with wide costal an-
gles (Figs. 1 and 6). A left-sided subcostal
incision is used mainly for elective splenec-
tomy. A bilateral subcostal incision provides
excellent exposure in the upper abdomen. It
is useful for performing total gastrectomy
in an obese individual, for anterior expo-
sure of both adrenal glands, for major liver
resections, for pancreatic operations, and
for hepatic transplantation.
The standard subcostal incision starts in
the midline 2.5 to 5.0 cm below the xiphoid
and extends laterally approximately 2.5 cm
below the costal margin for a variable dis-
tance, depending on the patient and the ex-
posure required (Fig. 6A). If the liver is en-
larged, the incision may have to be placed at
a lower level. The incision should not be
made too close to the costal margin be-
cause, if a hernia develops, enough abdomi-
nal wall fascia must be available at the up-
per margin to permit a satisfactory repair or
bony fixation would be required to the ribs. Fig. 6. Kocher’s incision. A: The subcostal incision should be placed at least two fingerbreadths below
the costal margin, which assures that ample fascia is available on the superior side below the costal
After the anterior rectus sheath is incised, margin to afford a secure closure. B: The rectus muscle is cut transversely or slightly obliquely, usually
the rectus muscle is divided along the with monopolar cautery; other muscles can be split laterally as far as necessary to achieve the desired
course of the wound; electrocautery is used incision length. C: The incision is repaired in two layers: posterior fascia and peritoneum, as shown, are
to control branches of the superior epigas- the deep layer, and the second layer is the anterior fascia and the aponeurosis of the external oblique.
tric artery and other blood vessels, or suture The subcutaneous tissue is irrigated copiously and the skin is reapproximated with either staples or a
ligatures can be used. The lateral abdominal continuous absorbable subdermal closure.

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 152 10/28/11 3:38:50 PM

 Chapter 10: Abdominal Wall Incisions and Repair Including Release 153

operations involving the proximal small in- early postoperative pulmonary complica- sis is opened in the direction of its fibers to
testine, the incision can be favored to the left tions. As would be expected, there are fewer expose the internal oblique muscle (Fig.
of the midline. Right-sided transverse inci- incisional hernias after transverse laparo- 7A). Its investing fascia is opened so that
sions provide excellent exposure for the dis- tomy compared with vertical laparotomy. the muscle can be split in the direction of its
tal small intestine, cecum, and the ascending As with any abdominal incision, postopera- fibers, from the lateral border of the rectus
colon to the midtransverse colon. For right tive wound infection adversely affects the sheath in a lateral direction (Fig. 7B). The
colon operations, the incision is placed 2 to occurrence of incisional hernia; however, underlying transversus abdominis muscle
3 cm above the umbilicus. If the left trans- there is some evidence that even in this cir- is similarly split in the direction of its fibers,
verse colon or splenic flexure is to be oper- cumstance, the results are better with a which exposes the transversalis fascia and
ated, the mirror-image incision on the left is transverse incision. peritoneum (Fig. 7C). The muscles are actu-
satisfactory. In either incision, it may be ex- Nevertheless, a midline vertical incision ally opened by inserting a closed Kelly he-
tended to the opposite side of the midline as is still the most expeditious and practical mostat into the center of the muscle and
far as is necessary to obtain adequate expo- incision for significant abdominal trauma, then opening it perpendicular to the direc-
sure in either right or left colon procedures. when the nature of the disease process in a tion of the fibers to split the muscle. A small
As previously noted, a transverse incision patient with an acute abdomen is not de- opening is then made in the peritoneum
may be suboptimal in an extended left hemi- termined, or in patients with gastrointesti- and is enlarged as much as necessary to ex-
colectomy when the splenic flexure requires nal hemorrhage in which the site of bleed- pose the appendix and adjacent portion of
mobilization with a pelvic anastomosis. ing is not known. The midline incision is the cecum (Fig. 7D). If further exposure is
The layers of the abdominal wall to be definitely opened more rapidly than the necessary, the wound can be enlarged by

Basic Surgical Skills: New and

incised are, for all practical purposes, the vertical, and extension of the midline verti- extending the skin and fascial incision me-

Emerging Technology
same as those described for the subcostal cal incision is a simple matter, affording ex- dially and opening the anterior rectus
incision. In patients who are thin, especially cellent exposure to any part of the abdomen sheath, retracting the muscle medially, and
those with a narrow costal margin, the or retroperitoneum. extending the peritoneal opening medially
straight transverse incision is frequently When making incisions, particularly into the posterior rectus sheath and under-
modified with the lateral end being placed oblique or transverse incisions in the lower lying peritoneum.
in the same plane as the umbilicus, and the abdomen, close to the inguinal ligaments, If the wound needs to be enlarged laterally
incision can be somewhat oblique superi- the surgeon should keep in mind that the il- (Weir extension), this can be accomplished
orly so that the midline end of the incision iohypogastric nerve (branch of first lumbar by a combination of splitting and dividing the
is several centimeters above the umbilicus. nerve) enters the abdominal wall approxi- three lateral abdominal muscles superiorly.
If the incision needs to be extended across mately 2 cm medial and 1 cm inferior to the The extended muscle-splitting incision can
the midline for some distance, it then be- anterior superior iliac spine, and then fol- occasionally be used to perform a right hemi-
comes a bilateral subcostal incision. In the lows a linear course, terminating 4 cm lat- colectomy in suitable individuals, although a
event that it is necessary to enter the supe- eral to the midline and 5 cm superior to the transverse infraumbilical or supraumbilical
rior portion of the abdomen, a vertical ex- pubic symphysis. This nerve is essentially incision is ideal for the procedure.
tension in the midline can be utilized as far sensory, but sectioning it may lead to areas
superiorly as the paraxiphoid area. The xi- of hypesthesia or anesthesia, which patients Pfannenstiel Incision
phoid process can be excised if additional find distressing. The ilioinguinal nerve is the
exposure is required. This extension gives inferior branch of the first lumbar nerve and The Pfannenstiel incision is frequently used
excellent exposure to the upper quadrants actually terminates in the scrotum, having for gynecologic procedures or in men for
as necessary for operations close to the hia- exited the abdominal wall through the ex- extraperitoneal retropubic prostatectomy.
tus or for hepatic resections, especially in ternal inguinal ring; it is less subject to in- A Foley catheter should always be placed
larger patients. jury than the iliohypogastric nerve. prior to making this incision to avoid injur-
As previously noted, the major advan- ing a distended bladder. The skin incision is
tage of either transverse or oblique inci- Rockey-Davis’ and placed in the curved interspinous crease
sions is that the incision splits the fascial McBurney’s Incision with its center located approximately 5 cm
fibers of the abdominal wall parallel to the above the symphysis pubis (Fig. 8A). Both
long axis of the fascia; when sutured, the These incisions are ordinarily used for per- anterior rectus sheaths are exposed and di-
sutures are placed at right angle to the fas- forming an open appendectomy or a cecos- vided transversely along the entire length of
cial fibers and make a substantially stron- tomy. The position and length of the inci- the wound. Hemostats are used to elevate
ger closure than with closure of the vertical sion depend on the suspected location of the divided upper and lower edges of the
incision. In addition, Langer’s skin lines are the appendix and the amount of fat in the sheaths, which are then dissected widely
essentially transversely oriented and the abdominal wall. A useful clue to locate the from the underlying rectus muscles upward,
cosmetic appearance of the healed trans- appendix is the palpation of the abdomen almost to the umbilicus, and downward to
verse incision is superior to that of the ver- once the patient is anesthetized as a mass the symphysis (Fig. 8B). The rectus muscles
tical incision in many patients. Any nerve may be felt and the incision should be made are then retracted laterally, and the perito-
damage that occurs is fairly limited. In ad- over it. If nothing is palpated, the incision is neum is opened vertically in the midline so
dition, most reports that compare vertical centered at McBurney’s point at the junc- as to protect the bladder at the lower end of
and transverse incisions in abdominal sur- tion of the middle and outer third of a line the wound. The exposure obtained is rather
gery emphasize that complications in the drawn between the umbilicus and antero- limited and the incision should not be used
early postoperative period are substantially superior iliac spine. The skin incision is now when a procedure outside the pelvis may be
less common with the transverse incision; placed transversely (Fig. 1). necessary. The incision, being in a skin
these include severity of pain in upper ab- After the skin and subcutaneous tissues crease, leaves a barely noticeable scar, which
dominal incisions, wound dehiscence, and are divided, the external oblique aponeuro- can be partially hidden by the pubic hair.

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 153 10/28/11 3:38:50 PM

 154 Part II: Basic Surgical Skills: New and Emerging Technology

Fig. 7. The Rockey-Davis (modified McBurney’s) muscle-splitting incision. A: The transverse skin incision is at McBurney’s
point, and the external oblique aponeurosis is incised for a short distance with a knife; the tips of Metzenbaum scissors are
slightly opened, and the fascia is split by pushing the scissors both medially and laterally to the edges of the incision. B: The
internal oblique muscle is scored with a knife or cautery, a blunt hemostat is used to penetrate the muscle, and the blades of
the hemostat are opened at right angles to the direction of the fibers. The surgeon’s index fingertips are then inserted into the
muscle, and gentle traction on the muscle perpendicular to the fibers enlarges the opening and dissects the underside of the
muscle so that the retractors can be placed to retract the muscle edges. C: The transversus abdominis muscle is split as in
B. D: The peritoneum is opened transversely, with an opening half the length of the incision, as retraction of the edges will
stretch the peritoneum quite sufficiently without enlarging the peritoneal opening too far and complicating the closure. E: The
peritoneum and transversalis fascia are closed with a running absorbable suture, and the transversus and internal oblique are
closed as a single layer by closing the investing fascia at the anterior surface of the internal oblique. The external oblique
aponeurosis is also closed with interrupted absorbable sutures. If pus or fecal material is present in the abdomen, the skin and
subcutaneous tissues are packed open.

RETROPERITONEAL and external iliac vessels. Three commonly with care taken not to injure the underlying
AND EXTRAPERITONEAL used retroperitoneal incisions include the pleura. The skin and subcutaneous tissues
retroperitoneal approach to the lumbar area, are mobilized to a limited extent from the
APPROACHES to the adrenal glands, and to the iliac fossa. underlying fascia; the external and internal
Retroperitoneal and extraperitoneal ap- abdominal oblique and transversus abdo-
proaches inherently decrease manipulation Retroperitoneal Approach minis muscles are opened in the direction of
of intra-abdominal viscera and limit postop- their fibers. Exposure is facilitated by un-
erative bleeding and infection. Bleeding is
to the Lumbar Area dermining each layer. When the retroperi-
much more likely to be tamponaded here The retroperitoneal approach to the lumbar toneal space is entered, the peritoneum and
than when it occurs in the peritoneal cavity. area is most frequently used for nephrec- retroperitoneal fat are moved forward (an-
Infections are more frequently localized here tomy, aortic surgery, lumbar sympathec- teriorly) by blunt dissection with fingers
than in the abdomen, and are more readily tomy, or ureterolithotomy. For operation on and sponge sticks. Care must be taken not to
drained. The limited retraction without dis- the left side, the patient is positioned in the dissect behind the psoas muscle. This com-
placement of viscera with retroperitoneal supine position with the left side elevated to mon mistake may make an otherwise easy
operations reduces postoperative ileus. 30 to 45 degrees and with the left knee and dissection confusing and bloody. By con-
These incisions can be used for opera- hip flexed. The incision begins at the level of tinuing this forward displacement, the sym-
tions on the kidney, ureter, adrenal glands, the umbilicus at the lateral margin of the pathetic nervous chain, ureter, and lower
bladder, splenic artery and vein, groin her- rectus sheath and is extended into the flank pole of the kidney are easily identified (Fig.
nia, lumbar sympathetic chain, vena cava, toward the 12th rib for 12 to 20 cm (Fig. 9A). 9B). On the right, the vena cava is exposed
abdominal aorta, and common, internal, If necessary, a portion of the rib is resected, and, on the left, the aorta. If the peritoneum

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 154 10/28/11 3:38:50 PM

 Chapter 10: Abdominal Wall Incisions and Repair Including Release 155

Fig. 8. Pfannenstiel incision, popular in gynecologic

surgery but seldom used by general surgeons. A: The
skin incision should be no more than 4 to 5 cm supe-
rior to the pubic symphysis, in the natural crease
that runs between the anterior superior iliac spines.
B: The rectus abdominis anterior fascia has been
opened transversely over both recti, and the anterior
fascia has been dissected free of the muscle both su-
periorly and inferiorly. The central small pyramidalis

Basic Surgical Skills: New and

muscles are split in the midline, and the thin trans-
versalis fascia and peritoneum are opened vertically

Emerging Technology
in the midline, which protects the bladder from in-
jury on the inferior side.

is inadvertently opened, it is closed imme- Retroperitoneal Approach be explored transabdominally) or in those

diately with a continuous absorbable suture. who have large adrenal tumors, especially if
At the conclusion of the operation, the ret- to the Adrenal Glands
carcinoma is suspected.
roperitoneal fat and viscera fall back into The open retroperitoneal approach to the With the posterior approach, little dan-
place, and the muscle layers are repaired adrenal glands can be chosen except in pa- ger exists of inadvertent injury to the vis-
with continuous sutures. tients with pheochromocytomas (who may cera or spleen because dissection is carried

Fig. 9. A: Left lumbar approach to the retro-

peritoneum, specifically for exposing the kidney,
adrenal, and infrarenal abdominal aorta. B: The
peritoneum has been bluntly dissected from the
retroperitoneal structures along with the properi-
toneal fat. Origins of the celiac, superior mesen-
teric, left renal, and inferior mesenteric arteries
are shown.

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 155 10/28/11 3:38:51 PM

 156 Part II: Basic Surgical Skills: New and Emerging Technology

Fig. 10. The posterior approach to the kidney and adrenal. A: J-shaped incision over the 10th to 12th ribs, extending inferiorly
6 to 10 cm below the 12th rib. B: Resection of the 12th rib facilitates exposure. C: The diaphragmatic attachment to the 12th
rib is taken down, with care taken not to enter the pleura. If the pleura is opened, the wound closure is made over a pleural
suction catheter, which is removed with simultaneous positive airway pressure by the anesthesiologist as the skin is being
closed.

out entirely in the retroperitoneal space. eral to the posterior midline) (Fig. 10A). It is sected subperiosteally, with care taken not
Isolation and ligation of the right adrenal deepened through subcutaneous fat, the to injure the underlying pleura (Fig. 10B).
vein at its junction with the vena cava, a posterior layer of the lumbodorsal fascia, The middle layer of the lumbodorsal fascia
maneuver that is the most critical step in and the fibers of the latissimus dorsi mus- is then incised longitudinally along the lat-
performing right adrenalectomy, is facili- cle, which take origin from it. This exposes eral margin of the quadratus lumborum
tated. Postoperative ileus is rare. Moreover, the erector spinae muscle, which is re- muscle to expose Gerota’s fascia, which in-
patients have less pain and fewer pulmo- tracted medially toward the spine to reveal vests the kidney and perirenal fat. The inter-
nary complications than those who have the glistening middle layer of the lumbodor- costal vessels are now visible directly below
undergone adrenalectomy via the transab- sal fascia and the 12th rib. The quadratus and parallel to the bed of the resected 12th
dominal approach, and their overall hospi- lumborum muscle, which is directly subja- rib. The intercostal nerve usually lies ap-
tal stay is shorter. cent, is visible through the lumbodorsal fas- proximately 1.5 cm below the vessels. The
The patient is placed in the prone jack- cia. Several vessels and nerves penetrate vessels are clamped, divided, and ligated,
knife position to eliminate the lumbar lor- the fascia to enter the erector spinae mus- while at the same time, the nerve is gently
dotic curve. The incision is made in a curvi- cle. These are secured between clamps, di- retracted downward.
linear fashion from the 10th rib (three vided, and ligated. Using electrocautery, the The insertion of posterior fibers of the di-
fingerbreadths lateral to the midline) to- attachments of the erector spinae to the aphragm into the periosteum of the 12th rib
ward the iliac crest ( four fingerbreadths lat- 12th rib are divided and the rib is then re- is identified. The glistening pleura is directly

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 156 10/28/11 3:38:51 PM

 Chapter 10: Abdominal Wall Incisions and Repair Including Release 157

above. With hyperinflation, the lower margin incision gives excellent exposure of the iliac The patient is placed in the “corkscrew”
of the lung comes into view. The diaphrag- fossa (Fig. 11B). Closure of the various layers position. The thorax is placed in the lateral
matic attachment is divided and the pleura is accomplished using either absorbable or position while the abdomen is tilted to ap-
is gently pushed out of the way (Fig. 10C). nonabsorbable, or continuous or interrupted proximately 45 degrees from horizontal
Should the pleural cavity be inadvertently sutures in each muscular and fascial layer. If (Fig. 12A). This position allows optimal ac-
entered, the resultant pneumothorax is eas- the peritoneum is opened during the expo- cess to both the abdomen and the thorax.
ily dealt with during closure with the use of a sure, it should be closed immediately with In patients with carcinoma of the lower
large-bore catheter. The catheter is placed in absorbable suture. esophagus or the stomach, completing the
the pleural space and with the combination abdominal part of the incision first is advis-
of catheter suction and hyperinflation of the THORACOABDOMINAL INCISION able to determine resectability before ex-
lungs, the air will be evacuated from the tending the incision into the chest. Prefer-
pleural cavity without any sequela. The thoracoabdominal incision provides ably, a right subcostal upper abdominal
excellent exposure by bringing the pleural incision is used, which continues directly
Retroperitoneal Approach and peritoneal cavities into a single space. into the left thoracic segment of the inci-
This incision appropriately placed on the sion. Alternatively, a midline incision is
to the Iliac Fossa right or left is indicated for a variety of op- used, and then its upper end is angled
The retroperitoneal approach to the iliac erations of the lower esophagus and/or car- obliquely into the right or left eighth inter-
fossa gives exposure to the distal ureter, dia of the stomach, right hepatic lobe resec- space. Resection of a rib is not necessary
bladder, and common iliac, hypogastric, and tions, construction of portacaval shunts, because the intercostal approach gives sat-

Basic Surgical Skills: New and

external iliac vessels. It is frequently used for massive splenomegaly, and for other large isfactory exposure and has less morbidity

Emerging Technology
transplantation of the kidney into the iliac upper abdominal masses involving the kid- than rib resection. The eighth intercostal
fossa and for surgery of the iliac arteries. The neys or adrenal glands. Aortic aneurysms space is easily identified as it lies immedi-
incision extends from 2 cm above the an- above the renal vessels can be exposed by a ately below the inferior angle of the scapula
terosuperior iliac spine to just lateral to the long, combined incision that extends into posteriorly.
symphysis pubis (Fig. 11A). It can be ex- the lower abdomen, but a retroperitoneal Once the abdomen is opened, the tho-
tended cephalad as far as the costal margin, approach is preferred if it can suffice. When racic incision is deepened through the latis-
if desired. The external oblique, internal an operation can be safely accomplished simus dorsi, serratus anterior, and external
oblique, and transversus abdominis muscles via an abdominal approach alone, this is oblique muscles. The intercostal muscles of
and transversalis fascia are divided in line preferable because it is associated with less the eighth interspace are incised to open
with the skin incision. The external and in- morbidity than the thoracoabdominal inci- the pleural cavity, after which the costal
ternal inguinal rings are not seen because sion. Some surgeons prefer an anterolateral margin is divided. Either a short segment of
they lie inferior to the lower edge of the inci- thoracic incision separate from the abdom- costal cartilage should be removed as this
sion. When the retroperitoneal area is en- inal incision. This choice maintains the in- facilitates later closure of the chest, or the
tered, the retroperitoneal fat and peritoneum tegrity of the costal margin and avoids po- costal margin can be cut with a scalpel in a
are bluntly dissected upward and medially, tential pain from division of the costal arch ⬍ shape. A self-retaining rib retractor is in-
and are maintained there by retractors. This or from an intercostals nerve injury. serted and slowly opened to enlarge the in-
tercostal space (Fig. 12B). The diaphragm is
split radially with ligation and division of
phrenic vessels. The diaphragmatic incision
is usually made toward the esophageal hia-
tus (Fig. 12C), but it can be directed further
posteriorly along the chest wall for opera-
tions on the kidney or adrenal gland. If the
contemplated operation does not require
an incision down to the esophageal hiatus,
the diaphragm should be divided in a curvi-
linear manner 2 to 3 cm from its attach-
ment to the chest wall (Fig. 12D). This leaves
only a small area of permanently paralyzed
diaphragm.
After completion of the operative proce-
dure, chest tubes to drain the pleural cavity
are brought out through separate stab inci-
sions. The diaphragm is repaired with two
layers of nonabsorbable, interrupted mat-
tress sutures. Pericostal sutures are passed
around the ribs and the costal arch is stabi-
lized by passing one or two heavy sutures
Fig. 11. Right lower quadrant extraperitoneal approach to the iliac vessels, ureter, and bladder, used through the divided cartilaginous ends of
for renal transplant but also very useful to expose the iliac artery and vein, drain psoas or retrocecal the ribs with a strong cutting-edged needle.
abscesses, or resect localized retroperitoneal tumors. A: Skin incision may be shorter than depicted in The ends of the ⬍ incision in the cartilagi-
thinner patients or if an abscess is to be drained. B: Peritoneum is retracted medially by blunt dissection, nous costochondral junction tend to lock
which exposes the psoas muscle and gonadal artery and vein, shown anterior to the ureter. when sutured together, which decreases

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 157 10/28/11 3:38:52 PM

 158 Part II: Basic Surgical Skills: New and Emerging Technology

Fig. 12. Anterolateral thoracoabdominal incision to expose the distal esophagus and stomach, to resect tumors of the upper
third of the stomach, to treat short esophagus with gastroesophageal reflux, or to expose suprarenal aortic aneurysms. A: The
“corkscrew” position, with the thorax in the lateral position and the abdomen at 45 degrees from the horizontal. Very careful
positioning on the operating table is essential to prevent injury to the brachial plexus or pressure on peripheral nerves. B: The
abdominal incision is ordinarily made first, to determine operability and be certain that the thoracic extension is needed. This
is usually done with a vertical midline incision that is extended into the chest through the eighth intercostal space. The abdo-
men has been opened and the pleural space is being entered. C: The diaphragm is usually opened in a radial fashion with an
incision directed toward the esophageal or aortic hiatus. D: The diaphragm can be opened with a hemi-elliptical incision 2 to
3 cm from the lateral chest wall; this incision is longer than a straight phrenicotomy but preserves phrenic nerve function, of
importance in patients with chronic pulmonary disease or less than optimal pulmonary function.

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 158 10/28/11 3:38:52 PM

 Chapter 10: Abdominal Wall Incisions and Repair Including Release 159

postoperative pain. This is followed by clo- dehiscence or hernia. For difficult abdomi- Components Separation Technique
sure of the chest muscles and abdominal nal closures, one can use several widely
wall in layers. spaced, buried, interrupted full-thickness In certain situations that involve large fas-
sutures to reinforce the closure; the closure cial defects in which the surgeon cannot
can be made with a continuous suture, but achieve midline approximation of the rectus
CLOSURE OF THE INCISION muscles, a components separation tech-
interrupted sutures may be better. In cases
Abdominal wall closure, irrespective of the of abdominal dehiscence, some surgeons nique is extremely effective and should be
incision, has changed significantly in the close the abdomen with deep bites of bur- in any general surgeon’s armamentarium
past two decades in regards to the type of ied figure-of-eight sutures, but the Gambee (Fig. 14). The neurovascular anatomy of the
suture (absorbable or nonabsorbable) and suture (Fig. 13) is far better. The skin and abdominal wall allows for a bilateral myo-
technique (interrupted or continuous) uti- subcutaneous tissues are left open in all fascial advancement of the rectus muscles
lized. For several reasons, most importantly cases in which sepsis is encountered and a while maintaining the dynamic functional-
the time consideration, continuous sutures VAC dressing may be employed. ity of the abdominal wall.
have gradually become far more common We prefer a two-layer closure of the ab- The procedure is begun with the eleva-
closures than interrupted sutures in initial dominal wall muscles in a Kocher’s or trans- tion of subcutaneous flaps from the under-
wound closure. In addition, slowly absorb- verse incision, closing the posterior rectus lying abdominal musculature to expose the
able continuous suture (polydioxanone) sheath and peritoneum with a continuous linea semilunaris. The external oblique fas-
has gradually begun to replace all perma- absorbable suture (Fig. 6C) and the anterior cia is then incised lateral to its insertion
nent sutures, primarily because the poly- rectus sheath with a separate, slowly ab- into the rectus sheath. This allows for the

Basic Surgical Skills: New and

propylene knots frequently the cause of sorbable or nonabsorbable suture. Rockey- development of an avascular plane between

Emerging Technology
draining suture sinuses. For most elective Davis’ or McBurney’s incisions are closed in the external oblique aponeurosis and inter-
operations, therefore, slowly absorbable layers, with the peritoneum and transversa- nal oblique muscle as far as the posterior
continuous sutures (PDS) are more com- lis fascia included in one layer using long- axillary line. The developed myofascial
monly used than other types of sutures. On acting absorbable sutures and subsequent complex allows for an 8- to 10-cm advance-
the other hand, when repairing a dehisced fascial layers closed separately, as previ- ment at the waist; 3- to 5-cm advancement
incision, closure is done with interrupted ously described. in the upper and lower abdomen. An addi-
permanent suture with consideration of re- tional 2-cm advancement can be achieved
tention sutures. if the rectus muscle is elevated off of the
Regardless of the type of suture used, at posterior sheath.
least 1-cm bites must be taken from the
wound edge, and must be placed at approx-
imately 1-cm intervals, incorporating all INTRAABDOMINAL
layers of the abdominal wall, except for skin HYPERTENSION AND
and subcutaneous fat. In the morbidly ABDOMINAL COMPARTMENT
obese patient, it is preferable to clear the SYNDROME
fascial edges for 2 cm to avoid loosening of
the suture with incorporation of the fat. In recent years, the importance of increased
Some surgeons prefer to close a midline in- intra-abdominal pressure (IAP) leading to
cision with two No. 1 continuous sutures, IAH and the ensuing abdominal compart-
starting at either end (Fig. 2D, E). Because ment syndrome (ACS) has been emphasized
of the bulky knot that occurs, an effort in patients with severe abdominal trauma
should be made to bury it. A reasonable al- and various surgical emergencies such as
ternative is to use simple interrupted su- peritonitis, necrotizing pancreatitis, and
tures placed at least 1 cm from the cut fas- intestinal obstruction. IAH is defined as
cial edges. The skin is then closed based on sustained IAP ⱖ12 mm Hg and be caused
individual preferences with staples or su- Fig. 13. When a single full-thickness closure of by intestinal edema or congestion, accumu-
tures. The peritoneum need not be closed as the abdominal wall is desired, either including lation of intraperitoneal or retroperitoneal
peritoneum and fascia or encompassing all layers,
numerous studies have shown that laparo- blood and clot, and extensive retroperito-
including skin as with retention suture closure,
tomy wounds heal just as well whether or excellent closure can be obtained with a modi- neal inflammation in acutely ill patients.
not the peritoneum is closed. Reperitoneal- fied Gambee stitch. The suture is first introduced ACS is a separate clinical entity and is de-
ization of the pelvis is worthwhile, however, at an adequate distance from the wound edge, fined as a sustained IAP ⬎20 mm Hg with
when that peritoneum has been opened for usually 2.5 to 3.0 cm with retention sutures and new organ dysfunction.
dissection. slightly less if the skin is not included, as shown. Indirect IAP measurement has become
One should never bring drains or osto- The needle is then passed through the perito- an important study in patients following
mies out through the main abdominal inci- neum–posterior fascia from the inside up; the major abdominal trauma or in patients in
sion as they tend to weaken it, predispose to needle is reversed, and the other side is sewn in the intensive care unit with progressive ab-
infection, and may precipitate wound sep- the same way. Finally, the needle is passed from dominal distention and allows for the defi-
peritoneal cavity to above fascia or through skin.
sis and/or wound dehiscence. nite diagnosis of ACS. IAP is most com-
The purpose of this suture technique is to prevent
Retention sutures through all the layers the “cheese cutter” effect of simple full-thickness monly measured indirectly using bladder
of the abdominal wall are seldom used for sutures, which may injure the underlying bowel. pressures and can be done intermittently or
routine closure because they are painful (From Baker RJ. Incisional hernia. In: Nyhus LM, continuously if the Foley catheter is con-
and may leave unsightly scars. Furthermore, Condon RE, eds. Hernia, 3rd ed. Philadelphia: JB nected to a pressure transducer with a re-
little evidence supports their use to prevent Lippincott; 1989, with permission.) cording device. The technique is simple and

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 159 10/28/11 3:38:53 PM

 160 Part II: Basic Surgical Skills: New and Emerging Technology

Plane of dissection between

external and internal obliques 3 to 5 cm

Plane of dissection between

rectus muscle and posterior sheath
8 to 10 cm

3 to 5 cm

Fig. 14. A: When a midline abdominal wall defect cannot be closed primarily, a components separation procedure can be
utilized. The dissection begins with the elevation of subcutaneous flaps to the anterior axillary line to expose the underlying
abdominal musculature. The linea semilunaris line is palpated and the external oblique fascia is then incised lateral to its
insertion in to the rectus sheath. An avascular plane is developed between the external oblique aponeurosis and internal
oblique muscle to allow the rectus muscle to be advanced to the midline. The posterior sheath can also be incised and elevat-
ed off of the rectus muscle to achieve additional 2 cm advancement. B: There is a variable degree of advancement dependent
upon location. The developed myofascial complex allows for an 8- to 10-cm advancement at the waist; 3- to 5-cm advance-
ment in the upper and lower abdomen. (Adapted from Nguyen VT, Shestak, KC. “Separation of anatomic components” method
of abdominal wall reconstruction. Oper Tech Gen Surg 2006;183–91.)

the first step is to instill up to 70 mL of ster- and medical illnesses that require massive The management of ACS consists of ven-
ile saline into the bladder through the Foley fluid resuscitation. tilator and hemodynamic support along with
catheter which is then clamped. An 18- The clinical presentation of patients surgical decompression through the original
gauge needle is inserted into the aspiration with ACS makes confirmation of the diag- incision in most cases. Burn patients may re-
port and attached to a pressure transducer. nosis difficult given that they are critically spond to escharotomy alone. High airway
It is critical in order to obtain accurate ill and may already have multiorgan dys- pressures may require a switch to a pressure-
measurements that the pressure is obtained function. Furthermore, imaging studies are limited mode, allowing for permissive hyper-
at end-expiration and the transducer is ze- not helpful. ACS can be exhibited in every capnia. The administration of volume may
roed at the midaxillary line. Bladder pres- organ system with a multitude of physiolog- temporarily improve hemodynamics, but if
sures may not provide an accurate mea- ical consequences (Table 1). too much crystalloid is given, IAP will be
surement in patients with morbid obesity,
massive ascites, pelvic hematomas, adhe-
sions, or in a neurogenic bladder. In these
situations, IAP can be measured using in- Table 1 Physiological and Clinical Consequences of IAH
tragastric, intracolonic, or inferior vena CNS Cardiac Pulmonary GI Renal
cava catheters.
There are several factors involved in the c ICP c CVP c Peak pressures T Blood flow c Venous
development of ACS in patients irregardless resistance
of the IAP such as abdominal wall compli- T CCP c PCWP T Compliance T Portal flow Vasoconstriction
ance, systemic blood pressure, and body T Cardiac output T PaO2 T Lactate T GFR
mass index. Thus, in a clinical setting, ACS clearance
can be defined as new organ dysfunction
T Venous return c PaCO2
with IAH without strict IAP criteria. In gen-
eral, patients with IAP ⬍10 mm Hg do not Cerebral Impaired cardiac Barotrauma Bowel edema Oliguria
have ACS while a value ⬎25 mm Hg pre- ischemia function
dicts ACS. The incidence of ACS is highest in DVT Pulmonary edema Bowel ischemia Anuria
the most critically ill patients and includes Peripheral edema Infection
trauma, severe burns, liver transplantation,

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 160 10/28/11 3:38:53 PM

 Chapter 10: Abdominal Wall Incisions and Repair Including Release 161

Basic Surgical Skills: New and

Emerging Technology
B

Fig. 15. A: A temporary closure of the abdomen allows

for expansion if necessary from ongoing resuscitation
and bowel edema and is particularly useful in patients
who require repeat explorations. Any sterile plastic sheet
can be used and is sewn to the edges of the fascia with
continuous sutures. This prevents excessive fluid loss
from an open abdomen and also prevents retraction of
the fascia. Suction drains are placed and covered with an
adhesive sheet to keep the wound from being saturated
with peritoneal fluid. B: An alternative method is the ap-
plication of an vacuum-assisted wound closure (VAWC)
using subatmospheric pressure.

adversely affected. It is critical that before with acute abdominal wall defects (Fig. surgery at some point after the patient has
the decision for surgery is finalized, periop- 15B). The application of a dressing that cov- recovered to repair the resultant hernia or
erative morbidity and mortality is considered ers the open wound under subatmospheric for placement of a split-thickness skin graft.
versus potential benefit for each patient. pressure accelerates the healing process Synthetic mesh is prone to additional risks
After decompression is performed, we and time for complete wound closure. In such as infection, fistulization, and adhe-
advocate maintaining an open abdomen the immediate postoperative period, it sion formation. There are several biological
using temporary abdominal wall closure. simplifies the wound management of these mesh products available, which are ideally
One technique is to suture a 3-L intrave- patients. The contraindication to its use is suited for this situation in which abdominal
nous fluid bag to the edges of the fascia a wound without complete debridement, wall reconstruction can be performed safely
loosely to allow for additional intra-ab- without hemostasis, or the presence of a in high-risk patients avoiding all of the pre-
dominal expansion. The open wound is fistula. viously mentioned problems. If a temporary
then covered with a towel, closed suction We do not advocate the use of absorb- closure was performed, we advocate clo-
drains, and an adhesive drape (Fig. 15A). able or permanent mesh for several reasons. sure of the fascial defect when the intestinal
An alternative is the utilization of the vacu- In some cases, reexploration may be neces- edema and distension have subsided and as
um-assisted wound closure (VAWC) dress- sary wasting the previously placed mesh. soon as the patient’s general status permits.
ing, which has become increasingly recog- The mesh also does not allow for expansion The surgeon should be prepared to sched-
nized as an effective adjunctive technique if needed. Absorbable mesh, such as poly- ule the patient for serial attempts at clo-
in managing the open wound associated galactic acid (Vicryl), will require additional sure, if necessary.

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 161 10/28/11 3:38:53 PM

 162 Part II: Basic Surgical Skills: New and Emerging Technology

SUGGESTED READINGS Miller PR, Meredith JW, Johnson JC, et al. Pro-
spective evaluation of vacuum-assisted fascial
analysis delineates the optimal technique. Am
Surg 2001;67(5):421–6.
Barker DE, Kaufman HJ, Smith LA, et al. Vacuum closure after open abdomen: planned ventral Seiler CM, Deckert A, Deiner MK, et al. Midline ver-
pack technique of temporary abdominal closure: hernia rate is substantially reduced. Ann Surg sus transverse incision in major abdominal sur-
a 7-year experience with 112 patients. J Trauma 2004;239:608. gery: a randomized, double-blind equivalence
2000;48:201. Poole GV Jr. Mechanical factors in abdominal trial. Ann Surg 2009;249:913.
Hultman CS, Pratt B, Cairns BA, et al. Multidisci- wound closure: prevention of fascial dehiscence. Smart P, Mann GB. Meta-analysis of techniques
plinary approach to abdominal wall reconstruc- Surgery 1985;97:631–40. for closure of midline abdominal incisions. Br
tion after decompressive laparotomy for ab- Ramirez OM, Ruas E, Dellon AL. “Component J Surg 2003;90:370.
dominal compartment syndrome. Ann Plast Surg Separation” method closure of abdominal-wall Vargo D. Component separation in the manage-
2005;54:269–75. defects: an anatomic and clinical study. Plast ment of the difficult abdominal wall. Am J Surg
Ivatury RR, Diebel L, Porter JM, et al. Intra-abdom- Reconstr Surg 1990;86:519–26. 2004;188:633.
inal hypertension and the abdominal compart- Rucinski J, Margolis M, Panagopoulos G, Wise L.
ment syndrome. Surg Clin N Am 1997;77:783. Closure of the abdominal midline fascia: meta-

EDITOR’S COMMENT tion, as it were, is locally in the wound. The Blake ture that is snugged up fairly tight but not overly
drains are left in place for at least 10 days after tight and placed approximately 1 cm back from
which time the suppuration has occurred and it the fascial edge and with 1 cm between sutures
This is a complete chapter by the authors and is drained out. It is then possible to remove the is the best type of closure with the lowest inci-
surgeons who supervise an abdominal incision Blake drains. It is rare that one gets late suppu- dence of herniation. Another aspect of Sir John
course annually which is highly regarded. How- ration of the wound after this treatment and it Goligher’s studies was that a monofilament type
ever, there are a number of statements in the saves the painful process of a delayed primary of suture, in his case English wire, was the best
chapter, which require comment. closure even with sutures that have been placed type of closure. We do not have access to English
First, let us consider the concept of a con- at the time of surgery. It is important to remem- wire in this country. Further, it has an entirely
taminated wound. This is a common misconcep- ber that when closing the subcutaneous tissue different characteristic from the wire we get, the
tion and is an issue I believe for all surgical prac- one should use either a monofilament or a syn- important thing is that the suture be monofila-
tices. In the first place, despite years of evidence thetic monofilament suture which is much more ment and thus not harbor bacteria that may in-
that wound protectors—which are either plastic resistant than, for example, a braided suture. vite possible contamination. It is thought that the
wound protectors that encase the wound from the Another point that needs to be emphasized braided suture such as silk is 10,000 times more
skin which is usually draped in iodophor or simi- is a thoracoabdominal incision while a standard likely to carry bacteria than a monofilament su-
lar drape to within the peritoneum to help pro- incision is a tremendously morbidity produc- ture. As Wesley Alexander and Joseph Solomkin
tect the wound from possible contamination—or ing incision. It is much better to use a separate state in the recent excellent review of preventing
in my own practice, seems to give adequate pro- thoracotomy incision and a midline or parame- surgical site infection (Ann Surg 2011), there are
tection, but I get very few cases of wound infec- dian incision in doing an operation that requires a number of sutures which are being developed
tions, wherein I would use blue towels whose a thoracoabdominal approach. Where possible, which are impregnated with antibiotics or silver
edges are soaked in antibiotics then sewn to the of course nowadays, and if the surgeon is skilled or other types of sutures which will help prevent
peritoneum and put over the iodophor drape. enough a thorascopic incision should be the pre- infection. My daughter, a veterinarian, tells me
A contaminated wound or a wound in which ferred choice. that she always uses antibiotic impregnated su-
contamination has occurred may be treated or A transverse incision heals to a considerably tures when she closes an animal’s abdomen, so
dealt with a delayed primary closure as per the greater extent than the vertical incision. The it seems unreasonable that these sutures are not
authors’ statement. However, one should remem- transverse incision rarely has an incisional hernia available to us.
ber that a delayed primary closure does not have and then only usually when there is a wound in- In discussing a flank or transverse incision in
a wound infection rate which is zero; a delayed fection or when infection is already in a contami- the repair of an inguinal hernia, especially in the
primary closure by which one usually means that nated wound. The paramedian incision, which is male, the authors state that the ilioinguinal and
the wound is dressed at the time of surgery with the incision that many of us grew up with, has a iliohypogastric nerves actually and especially the
moist sponges generally soaked in antibiotics but bad reputation and is thought to induce hernia- ilioinguinal terminates in the scrotum having ex-
not 100% of the time has a wound infection rate tion. The reason for this, I believe, is because it is ited the abdominal wall through the external in-
of 5% which is not significantly different than a imperfectly carried out, as most individuals who guinal ring. I do not believe that this is anatomi-
wound infection rate in which the wound would carry out what they think is a paramedian inci- cally correct. The main source of inguinodynia in
be closed with drainage. My own practice with a sion, in fact, is a midline incision. This is because the scrotum is genitofemoral nerve or the genital
contaminated wound, especially the one which in the paramedian incision one wants the rectus branch of the genitofemoral nerve that splits from
has been protected with the antibiotic soaked sheath incised fairly laterally so that there is a the lateral femoral anterior cutaneous nerve in
drapes is as follows: After thorough cleaning with rectus muscle that falls back into place between the retroperitoneum and injury to the genitofem-
antibiotic solution, Kantrex or Kanamycin if I can the peritoneal incision and the rectus and then oral nerve as it transverses alongside the cord
get it and Kefzol if I cannot, the wound is closed the fascial incision. If one carries out the para- often results in scrotal pain in addition to occa-
in the usual fashion, the subcutaneous tissue is median incision in that fashion, there is a much sions when the ilioinguinal nerve, when injured,
dosed with antibiotic irrigation, and then aspi- lower incidence of herniation. also results in some time of scrotal pain. However,
rated. Two #19 Blake drains are placed along the When one opens the abdomen, it is essential the pain in Scarpa’s triangle, which is the junction
length of the wound and the wound is closed over that the bowel not be injured. It is possible to do of the anterior abdominal wall and the leg far me-
them. Antibiotic irrigation is instilled in the Blake this and completely avoid an inadvertent incision dial and close to the scrotum, but not actually the
drains and it is not hooked to suction for 2 hours in the bowel by picking up the peritoneum with scrotum, is the result of the crural branch of the
after which it is connected to suction. By this two forceps, dropping it, and repeating the pro- genitofemoral nerve which separates from the
time, the wound has been thoroughly bathed in cedure between the surgeon and his or her assis- genitofemoral at the inferior end of the internal
the antibiotic irrigating solution. The drains are tant with two forceps three times at which point a inguinal canal. It is small and difficult to find but
not removed early. The reason for this is that the small nick in the peritoneum generally reveals that is a genuine source of real problems with patients
suppuration does not occur until comparatively the peritoneum is free and one can then divide the with inguinodynia.
late in the course perhaps five to seven days after peritoneum while preparing for the operation. One of the aspects of surgical research is that
wound closure. One could use IV antibiotics dur- It has been well established that since Sir John for every 20 years the surgical research needs to
ing this period but it is probably not necessary Goligher and his classic randomized prospective be repeated because what was previously seen,
for more than 24 hours because most of the ac- trial in types of closures that a continuous su- and in the case of Goligher’s classic study, needs

(continued)

www.medicalebookpdf.com

LWBK892_c10_p147-162.indd 162 10/28/11 3:38:54 PM

 Chapter 11: Laparoscopic Suturing and Stapling 163

to be repeated because what was previously seen, incision, and incision-related blood loss. Post- ous fashion using a slowly absorbing suture. All
and in the case of Goligher’s classic study, needs to operative wound infection was comparable in residents stated that the sutures should be placed
be repeated because everybody has forgotten it. In both techniques (P = 0.147) although other data, 1 cm from the incision with 1 cm advances. Only
the nicely carried out randomized prospective trial as mentioned in the previous paper by Alexan- one resident knew the correct suture-to-wound
conducted from the Study Center of the German der, suggests that the use of cautery is subject to length ratio for closure and only four residents
Surgical Society, a randomized prospective trial greater incidence of wound infection. Diathermy were familiar with the literature about abdominal
(Seiler CM et al. Ann Surg 2009;249:576–782) com- gave significantly less pain (P = 0.031) and the wall closure. With increasing closure experience,
pared closures in 625 properly randomized patients time needed to complete the incision and inci- there was significant improvement.
with 210 receiving interrupted Vicryl closures, 205 sion-related blood loss was significantly less with The conclusion was that it was disappointing
continuous polydioxanone suture (PDS), and 210 diathermy opening. It does seem that except with that residents did not know some of the basics of
with continuous Monoplus. There were 28 incisional the incidence of wound infection which other suture closures, but in fact, they learned. It is not
hernias in the interrupted Vicryl group (15.9%) ver- claim in their meta-analysis was greater in the clear that the residents were not taught closure
sus 15 (8.4%) in the group with continuous slowly diathermy incision, but not in the 11 studies sub- or they just were not listening. Obviously, this
absorbable sutures and in this case PDS versus 22 jected to meta-analysis in this study, diathermy is a serious problem because wound disruption
(12.5%) for the continuous Monoplus suture. There has an advantage. The cold scalpel group infec- is a serious problem and if residents are not be-
was no significant difference between the three tion rate ranged from 0% in two studies to 15.2%, ing taught the basics of closure then something
groups in regard to burst abdomen, wound infec- whereas the incisions with diathermy showed needs to happen to improve this.
tions, or pulmonary infections, or other serious wound infection rates 0% to 12.39%. Finally, let me state that the reoperative sur-
adverse events. One year mortality was not signifi- Finally, let us consider the question of resi- gery is difficult and one can get into great dif-
cant, ranging between 5.5% and 7.9%. The authors dent education and their ability to do closures. ficulty by operating too close to the previous
comment that the incidence of incisional hernias Hope et al. (Hernia 2010;14:463–66) carried out operation. In my experience, even without sep-
and the frequency of wound infection which range studies on various residents and their ability to sis, operations create an obliterative peritonitis

Basic Surgical Skills: New and

between 4% and 19.4% were much higher than ex- close a 10 cm incision in a felt piece which was which is maximal at 6 to 8 weeks. Enterotomies

Emerging Technology
pected in all groups and called for a renewed effort tacked to a board. As many as 10 surgical resi- are much more common if the operation takes
to attempt closure which gave a lower incidence of dents participated and the average time for clo- place too soon after the last laparotomy. My rule
wound infection. sure was 4 minutes, 23 seconds. They measured of thumb is that obliterative peritonitis largely
Another randomized, prospective trial was the average distance between the bite and the subsides by four months. It is best if one can do
carried at the Waterford Regional Hospital in the incision and it was 0.9 cm and between bites it the fifth month, but sometimes one is under pres-
Republic of Ireland by Ahmad, NZ and Ahmed, A, was 0.8 cm. They found that all knots were satis- sure and the fourth month is reasonable. Waiting
on opening wounds with surgical scalpels versus factory and intact following closure. Participant’s for the appropriate time can prevent a disaster
cautery. The end points compared were postop- experience showed that it is the range of 0 to 233 in the reoperation with numerous enterotomies
erative wound infection, pain in the first 24 hours for previously treated abdominal closures. All and one should pay careful attention to this.
after surgery, time taken to completely open the residents chose to perform closure in a continu- J.E.F.

11 Laparoscopic Suturing and Stapling

Daniel B. Jones and Henry Lin

BRIEF HISTORY shorten the loop to appropriate length be- Suturing Instrumentation
fore the suture is placed into the body. for the Extracorporeal and
Minimally invasive surgery evolved from
loop ligatures to extracorporeal suturing, 1. The loop ligature is placed through an
Intracorporeal Suturing
then to intracorporeal suturing, and finally ipsilateral trocar with the grasping for- There are several types of laparoscopic nee-
to mechanical suturing devices. Each tech- ceps on the contralateral side. dle drivers. Spring-loaded needle drivers
nique has particular advantages and disad- 2. The loop is swept over the target (Fig. 1D (see Fig. 2A) include both straight tip and
vantages depending on tissue and the type and E). spur tip (Fig. 2B and C). The handles of the
of setting. 3. The grasper is inserted through the loop needle drivers may be “pistol-grip” style
and to grasp the pedicle and retract it (Fig. 2D) or “in-line” handles available today
toward the anterior aspect of the body (Fig. 2A). Rod-like handles optimize full ro-
Loop Ligature cavity, utilizing gravity as countertrac- tation of the needle driver without compro-
Loop ligatures are used for a variety of pur- tion (Fig. 1F–G). mising the positions of the hand.
poses, including ligating vascular pedicles 4. Then the loop is tightened. Placing the
or other structures such as an appendix. pre-formed slip knot on the target tis-
The loop ligature (see Fig. 1A and B) con- sue and then tightening the loop toward
Extracorporeal/Hand Tie
sists of a slip knot pre-tied, the standing the knot (Fig. 1H and I). Conceptualizing The extracorporeal knot was developed as a
end of the suture material that is swaged to the tip of the rod as the surgeon’s finger technique to allow laparoscopic suturing
the end of the rod through which the suture tip in this knot-tying effort is a means to without the perceived frustration of intrac-
material passes through, and the pusher expedite the learning process for newer orporeal knot-tying. Extracorporeal sutur-
rod. Several manufacturers offer loop liga- learners. ing involves placing the needle and long
tures pre-packaged. 5. The traction of the suture should not ex- suture into the abdomen, passing the nee-
Optimal technique: The surgeon may ert undue pressure on the tissue to pre- dle and suture through the targeted tissue,
break the swage ahead of time (Fig. 1C) and vent avulsion. and then pulling the needle and a portion of

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 163 11/16/11 2:19:02 AM

 164 Part II: Basic Surgical Skills: New and Emerging Technology

A B

C D

E F

Fig. 1. A. Ligating loop. B. Endoloop. C. Break the swage. D. Sweeping over the target. E. Sweeping over the target completely.
F. Grasping the target. (continued)

the suture back through the port. Once both have at least one 10-mm port to place 2. Insertion of Needle and Suture:
the ends of the suture are available, a stan- a curved needle (SH) through. Most a. The suture is grasped behind the
dard hand knot is created and a suture of the current commercially available swage and carried into the body cavi-
passer is used to push the knot down trocar sleeves have trapdoor type ty through the trocar of the dominant
through the trocar back onto the tissue. valves that minimize desufflation hand (see Fig. 3C).
when the suture “stents” the valve b. The nonprimary or empty needle
open during suturing. driver is used to grasp the needle and
OPTIMAL TECHNIQUE b. A “ski needle” (see Fig. 3B) is frequent- the first or primary needle driver is
1. Choice of Needles: ly used by many surgeons through a then used to push more slack of the
a. Most curved needles still cannot fit 5-mm port as an alternative to the braided suture into the body cavity
through a 5-mm port. Most surgeons, standard curved needle. (see Fig. 3D and E) to prevent acci-
therefore, have planned their ports c. Sutures should be at least 30 cm long dental suture movement during pas-
in particular operations so that they for optimal extracorporeal knot-tying. sage of the needle through the tissue.

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 164 10/28/11 3:57:11 PM

 Chapter 11: Laparoscopic Suturing and Stapling 165

G H

Basic Surgical Skills: New and

Emerging Technology
I J

K L

Fig. 1. (Continued ) G. Retracting the target and using gravity for counter traction. H. Start tightening the slip knot. I. Tighten-
ing the slip knot. J. Tightening the slip knot further. K. Tightening the slip knot completely. L. Loop ligature appendix.

c. The dominant needle driver is then dle changes its position in the domi- b. Then the primary needle driver is
used to grasp the needle in the usual nant needle driver (see Fig. 3H–J). used to pull the suture and the needle
fashion as the open technique (see Fig. 3. Tissue Passage: back out of the body cavity and out of
3F and G). (With the advent of reliable a. The needle is passed through the tis- the primary trocar.
needle drivers, grasping the needle at sue (see Fig. 3K–M). 5. Knot-Tying:
90 degrees to the needle driver is no b. The primary needle driver grasps the a. The needle side of the suture is
longer a compromise in the technique suture about 1.5 cm behind the swage brought out of the body cavity at least
that is required.) To optimize the nee- (see Fig. 3N). 3 cm, preferably 6 cm, and tagged
dle angle in the needle driver, while 4. Withdrawal of the Needle: with clamp and the needle removed.
gently grasping the needle three-fifths a. The secondary needle driver is used b. Two half-hitches followed by a squar-
from the tip with one needle driver, use as a “pulley” to protect the suture ing knot can be thrown (see Fig. 3Q).
the assisting needle driver to gently from “sawing” into the tissue (see Fig. i. Each half-hitch is pushed down
manipulate the suture so that the nee- 3O and P). onto the targeted tissue with a knot

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 165 10/28/11 3:57:15 PM

 166 Part II: Basic Surgical Skills: New and Emerging Technology

Fig. 2. A. Needle driver handles. B. Needle holder

straight tip. C. Needle holder curved tip. D. Nee-
D dle driver pistol grip.

pusher with carefully handling the is not as gentle on tissue. Thus, on delicate dles with their needle drivers. Zoltan Szabo
tissue (see Fig. 3R–V). tissue, such as the common bile duct, intra- broke down the technique to component
ii. The squaring knot must be corporeal suturing is the preferred method. steps and quantified efficient knot-tying to
watched carefully while placing to 30 seconds for the square knot and 1 min-
optimize snugness. ute for the complete stitch (ii). Donald Mur-
6. The suture is then cut with a laparoscop- INTRACORPOREAL/ phy defined several methods for creating
ic nontissue, suture-cutting scissors. INSTRUMENT TIE this intracorporeal surgeon’s knot.2 Yassine
Nouira described a pre-looped intracorpo-
Types of tissue: This extracorporeal tech- The intracorporeal “instrument” tie is one
real knot that takes only 2 minutes after
nique is very useful in the crural closure of the most advance techniques in laparo-
practice. Finally, James C. Rosser promul-
during hiatal hernia repair. However, the scopic surgery. Early laparoscopic surgeons
gates his “Top Gun” method of intracorporeal
long suture length with extracorporeal tying like Kurt Semm utilized large straight nee-

A B

Fig. 3. A. “Ski’d” needle allows for easier passage through 5 mm trocar. B. Inserting extracorporeal suture via trocar. (continued)

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 166 10/28/11 3:57:20 PM

 Chapter 11: Laparoscopic Suturing and Stapling 167

C D

Basic Surgical Skills: New and

Emerging Technology
E F

G H

I J

Fig. 3. (Continued ) C. Pushing slack in. D. Pushing more slack in. E. Positioning the needle. F. Acquiring the needle. G. Ma-
nipulating the needle. H. Manipulating the needle: repositioning to optimal length of the needle. I. Manipulating the needle at
3/5ths along shaft. J. Passage through the tissue initially. (continued)

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 167 10/28/11 3:57:30 PM

 168 Part II: Basic Surgical Skills: New and Emerging Technology

K L

M N

O P

Q R

Fig. 3. A. (Continued ) K. Passage through the tissue halfway. L. Passage through the tissue near completion. M. Grasping
suture and needle for extracorporeal tie. N, O. Using needle driver as a pulley to avoid “sawing” through tissue. P. Three half-
hitches for extra corporeal knot. Q. Knot pusher: acquiring the knot. R, S. Knot pusher: pushing to the target. (continued)

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 168 10/28/11 3:57:36 PM

 Chapter 11: Laparoscopic Suturing and Stapling 169

S T

Basic Surgical Skills: New and

Emerging Technology
Fig. 3. (Continued) T. Knot pusher: pushing onto the target.
U U. Knot pusher: seated the knot.

anastomosis in his “Top Gun Laparoscopic grasps the needle in the ready position directions to set the suture memory in
Skill and Suturing program that readily that is usually almost three-fifths from optimal position for knot-tying. While
achieves intracorporeal complete knots in the needle tip (see Fig. 4B–D). Adjust- keeping the axis of the needle perpen-
less than 30 seconds.ii ment of the needle position can be per- dicular to the axis of the needle driver,
Moreover, these techniques have been formed by maintaining a gentle grasp loop the suture medially and clockwise
incorporated into the skills portion of Fun- of the needle with the dominant needle around the dominant needle driver and
damentals of Laparoscopic Surgery (FLS) driver and then moving the suture with then grasp the tip of the tail of the suture
course that is now a prerequisite before the assisting grasper to move the needle (see Fig. 4P–S). While avoiding the addi-
graduating surgical residents are permitted into the optimal or ready position (see tion of significant length to the tail of the
to enroll for the qualifying computer-based Fig. 4E–L). suture, push the grasper toward 1 o’clock
examination for the American Board of Sur- 2. Tissue Passage: position and the tail toward the 7 o’clock
gery.3 At the verified target or entrance point, position to prevent locking the suture in
the needle tip is pushed gently through the closing mechanism of the dominant
and then rotated quickly as in the open needle driver (see Fig. 4T–V).
TECHNIQUE suturing technique (see Fig. 4M and O). 4. Subsequent Knots:
The rotational arc should be the focus Return both instruments to the middle
Position: Visualize with the laparoscope
and avoidance of any other movement of the field and ensure that the needle
from the same side of the surgeon. Suture
is key to following the needle to the is in ready position. Then position the
length of 8 to 12 cm should be chosen for
target exit point. When the tip of the suture on lateral aspect of needle driver
optimal looping and knot-tying.4 In addi-
needle has adequately cleared the tis- and wrap counterclockwise once and
tion, avoid grasping the suture with the
sue by greater than 0.5 cm, the tip of the grab the tail with the needle driver (see
needle drivers tightly since doing so will
needle is grasped. Toward the end of the Fig. 4X–Z). Again, without lengthening
fray the suture and cause loss of tensile
rotational arc, a gentle nudge away from the tail, tighten the knot by moving the
strength.
the trocar will prevent excessive tissue grasper with the needle to the 11 o’clock
1. Needle Preparation: trauma and thus avoid pesky bleeding at position and the needle driver in the op-
Gently grasp the suture less than 1 cm the exit site. posite direction to the 5 o’clock position
behind the swage with the assisting 3. First Knot: (see Fig. 4ZA–ZB). As with the open tech-
grasper and then insert the needle into Pull the needle away from the camera nique, the change in direction allows for
the body cavity via the nonsuturing tro- to shorten the tail to 1 to 2 cm and keep a square knot to be achieved. Repeat the
car. The needle can be rested against an the needle in the ready position. Move single throws as necessary for the suture
organ and the dominant needle driver the instruments in equal and opposite material and surgeon preference.

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 169 10/28/11 3:57:44 PM

 170 Part II: Basic Surgical Skills: New and Emerging Technology

A
B

C
D

E F

G H

Fig. 4. A. Manipulating the needle. B. Acquiring the Needle: for intracorporeal knot. C. Acquiring the needle. D. Acquiring
the needle. E. Resting the needle against organ. F. Resting against “organ.” G. Grasping the needle. H. Resting against organ.
(continued)

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 170 10/28/11 3:57:47 PM

 Chapter 11: Laparoscopic Suturing and Stapling 171

I J

Basic Surgical Skills: New and

Emerging Technology
K L

M N

O P

Fig. 4. (Continued ) I, J. Manipulating the needle. K. Optimizing the needle. L. Manipulating the needle. M. Tissue passage.
N, O. Tissue passage. P. 1st knot: starting the 1st loop. (continued )

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 171 10/28/11 3:57:58 PM

 Q R

S T

U V

X Y

Fig. 4. (Continued ) Q. 1st loop completed. R. 2nd loop com-

pleted for surgeon’s knot. S. Grab tip of suture tail. T. 1 and
7 o’clock positions. U. Taut 1 and 7 o’clock positions. V. Snug
Z
1 and 7 o’clock. X. 2nd hitch start. Y. 2nd hitch looped. Z. Tip
grasp 2nd hitch. (continued)

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 172 11/15/11 3:07:45 PM

 Chapter 11: Laparoscopic Suturing and Stapling 173

Za Zb

Zc

Basic Surgical Skills: New and

Emerging Technology
Ze
Zd

Zf ZgA

ZgB Zh

Fig. 4. (Continued ) Za. 11 and 4 o’clock position. Zb. 2nd hitch complete. Zc. EndoStitch. Zd. EndoStitch. Ze. EndoStitch
tissue passage. Zf. EndoStitch creating the loop. Zg. EndoStitch toggling the needle (parts a and b). Zh. EndoStitch cinching
the knot.

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 173 11/15/11 3:08:00 PM

 174 Part II: Basic Surgical Skills: New and Emerging Technology

Mechanical Assist Devices e. Repeat as many times as necessary STAPLING

for the suture material and surgeon
Commercially available mechanical sutur- preference. Surgical stapling devices have evolved since
ing devices have been manufactured to fa- the 1800s. The modern era of mechanical
cilitate and expedite the creation of the in- Running sutures is possible by utilizing staplers was launched when American sur-
tracorporeal knot. The Endo-Stitch device a specialized clip applier (Lapra-Ty: Covid- geon Mark Ravitch observed a Russian sur-
(Covidien, New Haven, CT) (see Fig. 4ZC) ien, New Haven, CT) that quickly anchors geon in Kiev operating with a stapler on the
has been demonstrated to decrease times and secures each end of a single strand of lung.7,8
and possibly greater knot strengths. The Su- suture material or utilizing a square knot to There are a few types of laparoscopic
ture Assist device also showed this advan- start and a modified fisherman’s knot to staplers currently in use today, including
tage but had a misfire rate of 9.7%.i finish. the laparoscopic linear stapler (see Fig. 6A).
The gastrointestinal anastomosis with the
laparoscopic technique is made similar to
OPTIMAL TECHNIQUEi Simulators the open technique, but the location of the
The Endo-Stitch allows for the needle to be The laparoscopic evolution occurred with ports dictates the difficulty level of creating
toggled between each jaw through a toggle many surgeons already comfortable with these anastomoses.
switch on the handle (Fig. 4ZD). This me- the open technique. The laparoscopic tech- The circular or end-to-end anastomosis
chanical assist passage of the needle de- nique, however, is viewed as more techni- (EEA) stapler traditionally used for anorec-
creases the learning curve for intracorpo- cally demanding and clearly, a need to train tal or colorectal anastomosis can also be
real suturing. surgeons systematically outside of the live used via a 15-cm laparoscopic incision to
patient became quite evident. Practicing create an EEA for bowel such as in the Roux-
1. Tissue Penetration: the suturing technique inside of a training en-Y gastric bypass (see Fig. 6B–D). To allow
a. Open Jaws of Endo-Stitch device box is now a critical part of the FLS course5,6 for passage of the stapler, a gastrostomy is
b. Place jaws around tissue to be su- (see Fig. 5A). created to pass the anvil to the optimal po-
tured and squeeze handles to close Furthermore, computers or camera-as- sition of the pouch and that gastrostomy is
jaws on the tissue (Fig. 4ZE). sist devices that measure the motion deriv- subsequently closed with another linear
c. Toggle switch to move needle to oth- atives of FLS tasks have become available stapler. The Roux limb is opened at the
er jaw and open jaws to gently pull such as in the Haptica system (see Fig. 5B). proximal end to allow for passage of the
needle through tissue and the suture Due to the intense labor such as the EEA stapler and then the two ends are
follows through. proctor and staffing for immediate feed- mated to create the gastrojejunal anasto-
2. Knot-Tying back to the learner with the training box mosis. Subsequently, the open Roux limb is
a. Rotate the jaws greater than 90 de- simulator of FLS as well as the appeal of stapled off with a linear stapler.
grees until a c-loop is formed. video-gaming to many members of the Alternatively, instead of creating a sec-
b. The suture tail is grasped with the younger generation, there has been much ond gastrostomy to pass the anvil, one can
nondominant hand instrument (Fig. development in virtual reality versions of pass the anvil transorally by tying that anvil
4ZF). FLS (see Fig. 5C). The explosion of virtual through a nasogastric tube that is then
c. The needle is passed through the loop reality simulators has been somewhat pulled out the targeted gastrostomy of the
and toggled to the other jaw (Fig. dampened by the lack of haptics, which has pouch (see Fig. 6E).
4ZG). subsequently resulted in a second genera- One company also produces an auto-
d. The knot is cinched with jaws closed tion of virtual reality simulators with hap- matic purse-string applier that is designed
(Fig. 4ZH). tics (see Fig. 5D). to save time in securing the anvil (see Fig. 8)

A B

Fig. 5. A. Fundamentals of laparoscopic surgery (FLS) equipment. B. Virtual reality simulator w/ laptop adapter. (continued)

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 174 10/28/11 3:58:17 PM

 Chapter 11: Laparoscopic Suturing and Stapling 175

Basic Surgical Skills: New and

Emerging Technology
C D

Fig. 5. (Continued) C. Virtual basic laparoscopic skills trainer (VBLaST). D. Haptic laparoscopy simulator.

A B

Fig. 6. A. Stapler: linear. B. EEA anvil insertion. C. EEA Pouch prepara-

C tion. (continued)

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 175 10/28/11 3:58:23 PM

 176 Part II: Basic Surgical Skills: New and Emerging Technology

D1 D2

Fig. 6. (Continued ) D. EEA anvil stapler mating. (continued)

D3

but is designed to be applied extracorpore- Randal Baker’s group has popularized Authors of many studies do not define
ally. the “science of stapling” to promote aware- the types of leaks that they were reporting,
The endo-TA (thoracoabdominal) stapler ness on how gastrointestinal leaks from for example, whether the leak was anasto-
provides multiple rows of staples similar to staple lines can occur. From his conclu- motic or what type of stapler was used.
the open TA stapler (see Fig. 6H and I). sions, we can understand how leaks may The causes of the leaks fall into two key
The thicknesses of the staplers are listed occur when surgeons who did not know the categories: mechanical/tissue causes that
in Figure 6F and are color-coded between technology of the brand of stapler that they occur postoperative days 0 to 2 and make
companies, for example, as listed in the fig- were using and inadvertently transferred one up the vast majority of the leaks; ischemic
ure with Covidien. The green load com- technique from one type of stapler to another. causes that occur postoperative days 5 to 7,
presses to 2.00 from 4.8 mm for thick tissue Certainly, leaks may occur regardless of but are very rare.
such as colon, antrum of the stomach, and how perfect the surgical technique is exe- Principles of avoiding mechanical/tissue
lung. There is a gold load from one of the cuted, but a surgeon should be familiar with causes of leaks include the following: Opti-
stapling companies that compresses down the packet insert, that is, the instructions for mal stapling allows adequate time for tissue
to 1.80 mm for moderately thick tissue such use (IFU), for the particular brand of stapler compression and creep (elongation when
as the body of the stomach. The next com- being used. A critical difference is that the crushing force applied); stress relaxation is
mon load is the blue load that compresses Ethicon staplers require perpendicular reduction in the amount of force required
to 1.50 from 3.5 mm for less tensile areas of tissue compression for 15 seconds before fir- to maintain applied displacement and is
the colon and fundus of the stomach. The ing the stapler to optimize the staple forma- important to avoid tearing of tissues from
white load compresses to 1.00 from 2.5 mm tion, whereas the competing brand, the excess tissue shear or tensile stress. The opti-
for the small bowel. Then the gray load is Covidien or AutoSuture stapler, requires mal pressure used to measure tissue thick-
used for compression to 0.75 from 1.0 mm longitudinal tissue compression in the form ness for stapling for the stomach in which
for mesenteric vessels and the pulmonary of countertraction during the firing of the there was no surgical bleeding, there was
artery or other thoracic vessels. stapler. good apposition, and there was no long-term

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 176 10/28/11 3:58:26 PM

 Chapter 11: Laparoscopic Suturing and Stapling 177

Basic Surgical Skills: New and

Emerging Technology
E

Staple Size Before Firing Lengths and Color Staple Size After Firing (typical) Tissue Compression Range

2.0mm 30mm, 45mm 0.75mm 0.75mm - 1.0mm

2.5mm 30mm, 45mm, 60mm 1.0mm 1.0mm - 1.5mm

3.5mm 30mm, 45mm, 60mm 1.5mm 1.5mm - 2.0mm

4.8mm 45mm, 60mm 2.0mm 2.0mm

Formed staple dimensions may vary depending on tissue type, thickness, and density.
F IMPORTANT: Please refer to package insert for complete instructions, warnings, precautions and contraindications.

Fig. 6. (Continued ) E. EEA anvil trans-oral placement. F. Stapler heights. (continued)

tissue disruption or aggravation was 8 g/m2. bunching of tissue at crotch of stapler, for equate tissue compression with the appro-
Thus, gastric tissue is less elastic and more example, at a thick fundus and (b) remov- priate type stapler, a surgeon should then
prone to tissue stress if too high pressure is ing the occasional migratory crotch staple vary the choice of the stapler with the part
applied. The optimal pressure for the esoph- that is caught on the next staple load that of the stomach that is being worked on. The
agus and intestines was 6 g/m2. would otherwise cause the stapler to lock thicker part of the stomach is near the pylo-
Undersizing the stapler to the expected when firing attempted (see Fig. 6G). rus and consists of the antrum and is less
compressed size of the tissue increases risk Recently, multiple row staples have been likely to leak with a green (2.0 mm) load
of inadequate staple formation and excess progressed from two to three rows of sta- than with a blue (1.5 mm) load. Further-
tissue compression causes tearing of the ples, but the bench data demonstrated no more, a surgeon must avoid migration of sta-
tissue and perforation. Knowing the in- difference in pressure leak testing. Other pler with incorporation of esophagus when
tended tissue thickness is a key factor in surgeons have oversewn staple lines in at- performing a sleeve gastrectomy.
preventing staple-line leaks, but we cannot tempts to minimize leak, but bench data Buttress material increases strength of the
declare with confidence that we know demonstrates that full-thickness oversew- staple line in bench testing. When using but-
thickness of tissue that we are working on ing of staple lines significantly weakened all tress material, one should choose a stapler
as surgeons rely on subjective estimates. the staple lines. that compresses tissue so that total thickness
Other key technical recommendations Stomach thickness varies significantly in falls within the recommended range for sta-
to avoid leaks include: (a) the avoidance of the same stomach. From the principle of ad- pler (see Fig. 7A and B). Ironically, however,

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 177 10/28/11 3:58:28 PM

 H

Fig. 6. (Continued ) G. Migratory staple. H. Stapler endo-TA

I I. Stapler TA. (Parts A–E reprinted with permission from Jones
et al., Atlas of Minimally Invasive Surgery. Cine-Med, 2006.)

A1 A2

Fig. 7. A. (A1 and A2) Buttress material seam guard. B. Buttress

D material duet C. Articulating stapler D. Articulating stapler.
(Image courtesy of W. L. Gore & Associates, Inc.)

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 178 11/15/11 3:08:09 PM

 Chapter 11: Laparoscopic Suturing and Stapling 179

the thicker green load is stronger than shorter SUGGESTED READINGS

blue staple lines with reinforcement.vi
But there is no level I data yet on clinical Baker RS et al. The science of stapling and leaks.
Obes Surg 2004;14:1290–8.
significance of this stronger and more he- Buriev IM, Knazev MV, Josef E. Ch. 11 Stapling
mostatic staple line reinforced with but- techniques in operations on the gastrointesti-
tress material. Chen et al. reviewed the cur- nal tract. In: Baker RJ, Fischer JE, eds. Mastery
rent literature in 2008 and found no data of surgery, 5th ed. Philadelphia: Lippincott
that buttress material decreased clinical Williams & Wilkins, 2007. In web edition.
leak rates.9 Chen B et al. Reinforcement does not necessarily
reduce the rate of staple line leaks after sleeve
But with careful attention to tissue thick- gastrectomy. A review of the literature and clin-
ness and stapler selection, leak rates were ical experiences. Obes Surg 2009;19(2):166–72.
decreased from 1% down to less than 0.3%.vi Derossis AM et al. Evaluation of laparoscopic
The endoscopic staplers are also avail- skills: a 2-year follow-up during residency train-
able with not only articulating heads but ing. Can J Surg 1999;42(4):293–6.
also articulating to optimize the angle for Fraser et al. Evaluating laparoscopic skills: setting
stapling (see Fig. 7C and D). the pass fail score for the MISTELS system. Surg
Endosc 2003;17(6):964–7. Epub 2003 Mar 28.
Jones DB, Soper NJ. Suturing and knot tying, laparo-
CONCLUSIONS scopic surgery: principles and procedures. St. Lou-
is: Quality Medical Publishing Inc; 1997:50–65.

Basic Surgical Skills: New and

The stapling devices are valued assets to the Murphy D. Endoscopic suturing and knot tying:

Emerging Technology
surgeon. Tissue can be quickly resected and theory into practice. Snn Duth 2001;234(5):607.
anastomosed, but stapler devices must be Rosser JC, Josef E. Ch. 11A Intracorporeal suturing:
the top gun experience. In: Mastery of surgery, 5th
used with care and with thorough under- ed. Lippincott Williams & Wilkins; 2007:150–66.
standing of how they optimally work to Tsuda S et al. Surgical skills training and simula-
minimize risk of leak at staple lines. tion. Curr Probl Surg 2009;46(4):328:261–372.
Fig. 8 Auto suture purse string.

EDITOR’S COMMENT through the staple line was a function of staple the interior mesenteric side of a side-to-side
tightness that led to the development of the gray laparoscopic anastomosis for bleeding that re-
load, which is suggested for large-vessel closure. sulted in a small but fixed incidence of bleed-
The earliest laparoscopic procedures such as Immediate bleeding from the staple line is often ing when laparoscopic gastric bypass become
cholecystectomy became popular in part because self-limited or can be controlled with a clip, ligat- popular initially. To some degree, the evolution
neither suturing nor stapling was required. How- ing loop, or a suture ligature. Bleeding from the of staple technology with the most up-to-date
ever, after mastering these procedures, the lap- gastrointestinal track such as the appendiceal designs has lessened this as well as anastomotic
aroscopists of the 1990s were not to be deterred stump can also be a late occurrence after the leaks. Despite these advances, staple line leaks
and procedures requiring suturing or stapling completion of the procedure when vessel spasm and bleeding do occur. For instance, most bar-
emerged. The first operative case to gain com- is diminished. Staple formation failure of any iatric surgeons reinforce the staple line on the
mon acceptance with a laparoscopic stapling de- type is fortunately uncommon but is disastrous if relatively forgiving stomach during sleeve gas-
vice was laparoscopic appendectomy where the the cutting blade performs as expected resulting trectomy for the treatment of morbid obesity
mesoappendix and/or the base of the appendix in an open vessel. Surgeons who are controlling to reduce the extremely morbid complications
was stapled closed. For simplicity, device manu- these major vessels should always be prepared or bleeding or leak (Stamou et al., Surg Endosc
facturers created the same staple sizes and color for worst-case scenarios and have laparoscopic 2011 Jun 3. [Epub ahead of print]). This can be
schemes found in the open version of staplers. noncrushing clamps, proximal control where accomplished with either oversewing the staple
Solid organ resection became the second class of possible, laparoscopic suction, and an open sur- line or using prosthetic reinforcements on the
procedures where staplers were commonly ap- gery set at the very least. The odds of safe control staple cartridge load. Reinforcement is a simpler
plied. Control of the splenic, adrenal, or renal vein with blind clip application in such a staple failure but a more expensive choice (Salgado et al., Adv
in particular with the aid of a white load (2.5-mm scenario are poor and potentially dangerous. Surg Tech A 2011;21(7):579–582). While laparo-
staple height) or gray load (2.0-mm staple height) As laparoscopic procedures continued to de- scopic linear staplers have enjoyed a number of
in the staplers has become commonplace since velop, endoscopic stapling became necessary to iterations over the last several years, the circular
the mid-1990s. The advent of stapler head articu- perform intestinal anastomosis for laparoscopic staplers have been used in laparoscopy compris-
lation became one of the key enabling advances colectomy, small bowel resection, and gastric by- ing the open format staplers and placing them
allowing the surgeon to achieve true perpendicu- pass. Although there have always been stapling through large ports or extended skin incisions.
lar alignment across these large vessels. Reliable ìpuristsî who never augment a stapled anasto- The most common intra-abdominal use of the
(though not absolutely so) control of these major mosis with acceptable results, many surgeons open circular stapler is in the creation of the
vessels by laparoscopic stapling was considered have felt comfortable during open surgery sutur- gastrojejunostomy in the laparoscopic Roux-en-y
a safety improvement since neither clip applica- ing various aspects of the anastomosis such as gastric bypass procedure. Laparoscopic low
tion nor ligation with intra/extracorporeal ties the ìcrotch ìof the staple lines to prevent undue rectal anastomosis is accomplished is a fashion
was felt to be sufficiently secure to control large tension on the staples, turning in the cut ends, similar to the open counterpart, although align-
veins at that time. Complications of staplers used or hand sewing the enterotomies. Laparoscopic ing and connecting the anvil to the receptacle on
for these early purposes were mostly in three cat- intestinal stapling brought many surgeons out the stapler can be challenging. The development
egories: bleeding, staple non/malformation, and of their comfort zones, at least initially, to em- of stapling devices on flexible platforms provides
vessel shredding by the cutting knife. Bleeding ploy these techniques. It is difficult to inspect some intriguing possibilities. Transoral passage

(continued)

www.medicalebookpdf.com

LWBK892_c11_p163-179.indd 179 10/28/11 3:58:36 PM

 180 Part II: Basic Surgical Skills: New and Emerging Technology

of the circular stapler on this platform may be years. These devices have been met with varying surgery even for the uninitiated. Even without
useful for esophagojejunostomy or gastrojejunos- degrees of enthusiasm. Although more costly than the robot, these skills can be taught and learned
tomy. The cutting blade and staple formation is simple suturing, the characteristics of the more well. James ìButchî Rosser and Zoltan Szabo were
powered by a mechanical drive system that deliv- successful devices are (a) ease of needle loading, amongst the most prominent early educators of
ers adequate force to the stapler head. (b) predictable needle path through the tissue, (c) laparoscopic suturing and knot tying techniques.
Laparoscopic suturing is the most demanding one-handed operation, and (d) able to function They deconstructed the steps of laparoscopic su-
of the basic skills for the laparoscopist. The two through a single trocar. These devices enabled turing into a series of steps allowing step-by-step
components, needle placement and knot tying, many surgeons to perform laparoscopic Nissen methodology, teaching thousands of surgeons
can be considered separately. The challenge for fundoplication in the 1990s by simplifying the in the process. Surgeons can effectively tie knots
most neophyte suturers is needle control. The needle management issue, leaving the surgeon to using incorporeal or extracorporeal techniques,
authors describe the appropriate method for de- learn only knot tying in order to perform the re- although tension can be more effectively main-
livering the needle to the abdomen, but achiev- construction. As a matter of fact, some surgeons tained extracorporeally. The learning curve of lap-
ing optimal needle alignment is more difficult. have employed crushable customized suture clips aroscopic suturing has been studied extensively
The relative orientation of the needle in relation to secure the suture, avoiding the need for knot by our laboratory as well as others (Surg Endosc
to the needle driver can be confusing when it is tying altogether, but I find it hard to recommend 2008;22(7):1614–1619). The inclusion of suturing
perpendicular to the axis of the camera. Suturing this as optimal technique. Although the overall into the Fundamentals of Laparoscopic Surgery
in the axis parallel to the camera can be equally economic value of the surgical robot is hard to skill set signifies the recognition that surgeons
difficult, especially when the needle driver is par- discern, it is indisputable that learning to use the performing laparoscopy need the same basic skills
allel with the camera since needle rotation in this robot to perform laparoscopic suturing is simple. employed in open surgery representing one of the
circumstance is difficult to achieve. A number of Needle management, knot tying, as well as on or final evolutions of the laparoscopic revolution.
suturing devices have been developed over the off axis suturing is no more difficult than open J.E.F.

12 Ultrasonography by Surgeons
Junji Machi

INTRODUCTION rior of organs and deep structures. This for conventional operative radiography,
imaging capability of LUS can remarkably (c) confirmation of completion of operation,
Ultrasound is the only imaging modality compensate for the inherent limitation of and (d) guidance of surgical procedures.
that can be used by surgeons widely during laparoscopic examination. Acquisition of new information that is
various types of operations. It provides It is 30 years since high-resolution real- not obtained by preoperative studies or in-
valuable intraoperative information once time B-mode ultrasound was first intro- traoperative exploration includes new diag-
appropriately performed by surgeons. In duced in the operating theater as IOUS. The nosis of diseases, localization, or exclusion
spite of advances of various imaging tech- value of this imaging tool has since been of previously suspected lesions, and acqui-
niques employed preoperatively, surgeons demonstrated in a variety of surgical fields sition of other anatomic information. IOUS
often need to make final decisions on surgi- including general surgery, neurosurgery, helps to assess the extent of malignant dis-
cal indications or type of operations to be cardiovascular surgery, urology, and gyne- ease (tumor staging). For example, vascular
performed during surgery based on intra- cology. With increasing number of laparo- invasion and lymph node and liver metasta-
operative findings. Meticulous exploration scopic operations being performed, the sis of hepatobiliary, pancreatic, and gast-
by inspection and palpation may not always application of LUS has also been expanding. rointestinal carcinoma can be diagnosed
be accurate or possible; this is particularly I have performed IOUS/LUS in ⬎5,000 op- more accurately than by preoperative meth-
true in evaluation of solid organs or deep erations, and have identified indications, ods. IOUS has changed previously planned
structures. Intraoperative imaging methods benefits, and limitations. My recent major surgical procedures for hepatic tumors in
can provide useful and, at times, critical application of IOUS/LUS has been in hepa- 30% to 50% of operations. When used as a
information. Intraoperative ultrasound tobiliary pancreatic surgery. In this chapter, screening procedure, IOUS has detected oc-
(IOUS) is a valuable and widely applicable I review the indications, advantages, and cult liver metastases from colorectal carci-
modality because it provides high-resolution limitations of IOUS and LUS, in addition to noma in 5% to 10% of operations. Precise
images of the operative field in real time, technical issues. Endoscopic and endorec- localization of nonpalpable lesions such as
which cannot be obtained by other intraop- tal ultrasound, advances, and perspective hepatic tumors, liver cysts and abscesses,
erative studies. of surgeon’s ultrasound are also discussed. intrahepatic calculi, pancreatic cysts, and
While a laparoscopic approach has a dilated pancreatic ducts is possible. For ex-
number of advantages, it has certain limita- INDICATIONS FOR ample, as many as 40% of hepatocellular
tions, in particular, the lack of sufficient carcinomas in cirrhotic liver are not palpa-
tactile feedback from the tissues and little INTRAOPERATIVE ble during operation, but can be readily
or no capability of palpation. Laparoscopic ULTRASOUND localized by IOUS. IOUS is now regarded as
ultrasound (LUS) is a form of IOUS, which There are four general indications of IOUS one of the best means to localize islet cell
represents a recent merger in the laparo- during open surgery: (a) acquisition of new tumors. In addition to diagnosing focal
scopic and IOUS technologies, and allows diagnostic information not otherwise avail- lesions, important anatomic structures
surgeons to visualize and evaluate the inte- able, (b) complement to or replacement (e.g., vascular structures, bile ducts) can be

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 180 10/28/11 3:55:57 PM

 Chapter 12: Ultrasonography by Surgeons 181

identified prior to extensive dissection. By More than 10 prospective studies have ance of uncertain liver lesions or liver tu-
providing new imaging information early compared LUS and operative cholangiogra- mors of unknown pathology, guidance of
during operation, IOUS facilitates intraop- phy during laparoscopic cholecystectomy laparoscopic ablation of liver tumors, assis-
erative decision making and the selection of during 1990s. The time required to com- tance during laparoscopic surgery of liver
the most appropriate surgical operation. plete LUS ranged from 4 to 10 minutes, with cysts, guidance of laparoscopic liver resec-
IOUS is useful as a complement to or re- an average of ⬃7 minutes, about half of the tion, evaluation of gallbladder polyps, de-
placement for operative radiographic stud- time needed for operative cholangiography. tection and drainage assistance of pancre-
ies. In comparison to operative cholangiog- The success rate in completing the exami- atic pseudocysts, localization of pancreatic
raphy during open cholecystectomy (studies nation was comparable for LUS and opera- islet cell tumors, guidance of pancreatic
in 1980s to 1990s), IOUS has demonstrated tive cholangiography. The results of LUS resection (particularly distal pancreatec-
equal or superior accuracy in diagnosing and operative cholangiography in diagnos- tomy), assistance during laparoscopic
bile duct calculi. We believe that IOUS can ing bile duct calculi were comparable ex- adrenalectomy, evaluation of splenic le-
replace traditional operative cholangiogra- cept for better LUS in terms of the positive sions and localization of accessory spleens,
phy as a routine screening test. Currently, predictive value and specificity. More recent evaluation and biopsy guidance of other in-
while most of the cholecystectomies are studies have shown that LUS can delineate traperitoneal and retroperitoneal tumors
performed by laparoscope, open biliary biliary anatomy clearly, and the routine use or lymph nodes, assistance of drainage of
surgery is used for more complicated biliary of LUS might help to significantly reduce abscesses or fluid collections, and so forth.
problems. IOUS can be valuable not only for the need for cholangiography and moreover Particularly during laparoscopic colorectal
diagnosing bile duct calculi, but also for to decrease bile duct injuries. LUS cannot surgery, which is becoming a standard

Basic Surgical Skills: New and

clarification of biliary anatomy. entirely replace operative cholangiography, treatment, LUS will be a valuable tool to

Emerging Technology
Confirmation of completion of operation and both should be used in a complemen- evaluate the liver and lymph nodes for me-
includes both the assessment of adequate tary fashion. However, LUS can become the tastases. As laparoscopic surgery continues
tissue resection or calculus and foreign first-choice procedure during laparoscopic to apply to the larger numbers and various
body extraction and discovery of technical biliary surgery because of its safety, speed, types of abdominal diseases, the applica-
problems. For confirmation of completion and cost-effectiveness. tion and utility of LUS during laparoscopic
of operation, IOUS can be used after re- LUS is indicated whenever laparoscopic surgery are expected to increase.
moval of biliary or renal calculi, extraction exploration is performed for abdominal
of foreign bodies and extirpation of tumors malignant tumors. Laparoscopy has been
in solid organs (e.g., liver, pancreas). During shown to more correctly predict the resect- ADVANTAGES AND LIMITATIONS
peripheral vascular surgery, IOUS has shown ability of abdominal tumors than preopera- OF INTRAOPERATIVE
equal accuracy to operative arteriography tive studies. Laparoscopic inspection is ef-
in detecting vascular defects, such as inti- fective to detect peritoneal dissemination
ULTRASOUND
mal flaps, strictures, and thrombi. Therefore, and metastasis to the liver surface, but not Compared to preoperative studies and op-
IOUS can be used as a completion examina- to evaluate structures or organs under the erative radiography, IOUS has a number of
tion immediately after vascular reconstruc- surface. LUS delineates tumors deep in the advantages including safety, repeatability,
tions. More recently, completion IOUS has parenchyma of organs, especially solid or- speed, high accuracy, more imaging infor-
become important during organ transplan- gans such as the liver. The retroperitoneal mation, wider applicability, and procedure
tation. After liver, pancreas, or kidney trans- structures are visualized without tissue dis- guidance capability. IOUS is inherently
plantation, color/power Doppler imaging section. First, local tumor invasion to other safer, and therefore can be used repeatedly
can be used to evaluate the vascular anasto- structures, particularly blood vessels can be as necessary during the course of opera-
mosis and to assess adequate blood flow to evaluated by LUS. Second, liver and lymph tion. IOUS can be performed in a short pe-
organs intraoperatively. node metastases are assessed in a manner riod of time. For example, biliary and liver
Ultrasound is an ideal modality to guide similar to IOUS at open surgery. Studies of IOUS for the purpose of screening can be
surgical procedures in the operating room. malignant liver tumors showed that LUS completed within 5 minutes. Even detailed
Ultrasound guidance of various manipula- demonstrated liver tumors that had been evaluation of hepatobiliary or pancreatic
tions during operation has the advantage of imperceptible to laparoscopic inspection in cancer requires about 10 minutes. IOUS-
real-time imaging without using ionizing ra- 20% to 40% of patients. Further information guided procedures are usually much faster
diation. The detail of IOUS-/LUS-guided pro- regarding the resectability, such as major and safer than “blind” procedures without
cedures is discussed in the following section. vascular invasion or lymph node metasta- IOUS.
sis, was obtained by LUS in 10% to 30%. IOUS is highly accurate compared to
INDICATIONS FOR Similar results were reported by studies of preoperative imaging studies or even to sur-
LAPAROSCOPIC laparoscopy with LUS on pancreatic cancer, gical exploration of deeper lesions or struc-
biliary cancer, and gastroesophageal can- tures. Hepatic, endocrine, and other small
ULTRASOUND cer. Laparoscopic exploration prior to tumors are often more accurately detected
In general, the indications of LUS are essen- planned laparotomy will be increasingly with IOUS. Vascular tumor invasion (e.g.,
tially similar to those of IOUS during lapa- utilized for various abdominal malignan- portal vein invasion by pancreatic cancer)
rotomy. Among various indications, there cies, and LUS is capable of improving the and the size of the lymph nodes are more
are two major situations in which LUS is staging accuracy, thereby decreasing un- precisely assessed. IOUS provides multi-
frequently performed: (a) examination of necessary or nontherapeutic laparotomies. planar images from multiple angles in real
the bile duct during laparoscopic cholecys- A number of other applications have time, thus offering more imaging views and
tectomy and (b) staging and determination been suggested by recent reports on LUS three-dimensional information than opera-
of resectability during laparoscopic explo- during laparoscopic surgery or exploration. tive radiography. The unique capability of
ration for abdominal malignancies. These include evaluation and biopsy guid- IOUS in guiding various procedures cannot

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 181 10/28/11 3:55:57 PM

 182 Part II: Basic Surgical Skills: New and Emerging Technology

be substituted by intraoperative radiogra- ultrasound equipment, including that used plane parallel to the shaft). A side-viewing
phy. The appropriate use of IOUS can have a for IOUS and LUS. Although potential com- linear-array or convex probe can be used for
marked impact on intraoperative manage- plications include organ injuries due to LUS scanning of almost all organs of the
ment, including improved decision making, probe manipulation and contamination abdomen, and is essential for scanning of
reduction in surgical tissue dissection, op- due to disruption of a sterile cover, such the liver. A front-viewing probe is suitable
erating time and complications, and devel- complications are very rare during diagnos- for scanning of the extrahepatic bile duct. A
opment of new procedures. tic IOUS or LUS. rigid-shaft probe and a flexible-tip probe
IOUS has limitations or disadvantages. are available. A flexible tip is mobile in two
Limitations in imaging capabilities relate to INSTRUMENTATION or four directions (bi- or quad-directional).
detectability of small lesions and delinea- A flexible tip facilitates scanning of areas
tion of ductal or tubular structures. IOUS The equipment of choice for IOUS and LUS is that are difficult to delineate with a rigid
displays smaller fields of view than opera- a so-called small parts scanner, which is a probe (e.g., behind the dome of the liver),
tive radiography. Diagnosis and localization high-frequency high-resolution real-time and may reduce the number of trocar inser-
of fistulas is limited. Special transducers ultrasound system, using transducers with tion sites. LUS-guided needle placement
that are small and easily maneuverable in frequencies of 5 to 10 MHz. While ultrasound may be more difficult with a side-viewing
the operative field are required for IOUS at higher frequency does not penetrate probe; this can be done much easier with a
scanning. Currently, each high-frequency deeply, it provides greater resolution of im- rigid front-viewing probe.
IOUS probe costs in the range of $6,000 to ages; this is an ideal trade-off for IOUS/LUS
$10,000. One disadvantage of IOUS is opera- because penetrating the body wall is not an SCANNING TECHNIQUES
tor dependency. There is a learning curve issue. With a 7.5 MHz transducer, the sound
for mastering IOUS; this will be solved by penetration depth is about 8 to 10 cm, and Preparations and Timing
surgeon’s recognition of the benefits of small lesions such as 1-mm calculi and 3- to
IOUS, which should provide sufficient moti- 5-mm tumors can be delineated. To meet of Scanning
vation to acquire the needed skills. We be- special requirements of IOUS and LUS appli- In the operating room, usually, the person
lieve that these limitations or disadvantages cations, several manufacturers have devel- performing the scan should be in the sur-
are outweighed by the multiple advantages oped high-frequency probes specifically de- geon’s position. The monitor should be
of IOUS. signed for use within the operative field. placed to permit easy viewing of the screen
Two basic shapes of IOUS probes are and the operative field with minimal
ADVANTAGES AND LIMITATIONS flat and cylindrical. Flat probes consist of change-of-gaze movement. Probe sterility
linear-array or curvilinear-array (convex) for intraoperative use is achieved by cold
OF LAPAROSCOPIC ULTRASOUND transducers, and are usually configured into gas sterilization or use of a sterile cover. A
The main advantage of LUS during laparo- “T” or “I” shape (Fig. 1). T-shaped probes newer sterilization method such as a low-
scopic exploration is the capability of com- have either side- or end ( front)- viewing. temperature chemical sterilization, which
pensating for the disadvantage of laparos- Cylindrical probes consist of curvilinear- can sterilize instruments in 30 to 60 min-
copy per se, particularly the loss of tactile array (convex) or phased-array transducers. utes is available, and some probes are ame-
sensation and the inability to examine deeply They are pencil-like, often with flattened nable to this method.
located structures or lesions. Overall, advan- sides to achieve greater slimness. Flat IOUS or LUS can be performed at any
tages of LUS over preoperative imaging stud- probes are suitable for examination of rela- time and repeatable during the operation.
ies and operative radiography are basically tively large, flat organs such as the liver, Early in the course of operation, IOUS/LUS
the same as those of IOUS. Likewise, limita- pancreas, and kidney. Flat side-viewing is used to obtain new information, which
tions or disadvantages are similar. probes are particularly important for the may help early operative decision making
Because of the same high-frequency in- scanning of the liver because the probe and determine the approach or the type of
strument, the resolutions of LUS should be must be placed between the anterior sur- procedure to be performed. For example,
the same as that of IOUS. However, LUS face of the liver and the diaphragm. On the immediately after laparotomy or laparos-
scanning techniques are more difficult than other hand, cylindrical probes are useful for copy for abdominal malignancy, IOUS/LUS
IOUS scanning performed during laparo- examination of small target organs such as can be conducted to evaluate the liver and
tomy because of limited access to organs by the extrahepatic biliary duct, especially lymph nodes as well as the primary lesion.
LUS. For example, the complete LUS screen- when areas of interest are situated deeply in IOUS/LUS can be used during surgical pro-
ing of the entire liver is not as easy as IOUS the operative field where manipulation of cedure for guidance. After finishing a pro-
screening. Therefore, information and diag- the probe is limited. It is ideal to have both cedure but prior to closure, completion
nostic accuracy provided by LUS should be types of probes; however, a side-viewing flat IOUS/LUS examination can be performed
close to, but may not be as accurate as those T-shaped probe can be used for examina- to look for problems that still may be cor-
provided by open IOUS. The time needed to tion of abdominal organs in almost all ab- rected. It is therefore, recommended to
scan the same organ or lesions is longer dominal operations. keep the IOUS/LUS equipment available
with LUS. The learning curve for LUS is also LUS probes consist of transducers and the probe sterile until closure so that
longer. LUS probes are more costly and mounted on or near the tip of a slender shaft IOUS/LUS scanning can be repeated when-
availability is still limited. LUS equipment (Fig. 1). The shaft is usually 10 mm in diam- ever indicated.
needs some refinements, particularly in the eter and 50 to 70 cm in length. Several types
development of an appropriate needle- of LUS probes are presently available, pro- Probe Placement
guidance system, which currently is not viding linear-array, convex, or sector trans-
widely available. ducers. A probe can be either side viewing Ultrasound scanning is a two-step process:
There are no confirmed biological effects (scanning plane at the right angle with the probe placement and probe movement.
on patients or examiners caused by present probe shaft) or front viewing (scanning Various techniques can be performed to

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 182 10/28/11 3:55:57 PM

 Chapter 12: Ultrasonography by Surgeons 183

Basic Surgical Skills: New and

Emerging Technology
Fig. 1. Upper left picture: curvilinear array (convex) flat, T-, or I-shaped, side-viewing or front-viewing intraoperative ultra-
sound (IOUS) probes. Upper right picture: I-shaped convex side-viewing IOUS probe for easier needle guidance. Lower left
picture: (top two probes) LUS side-viewing flexible and rigid probes, and (bottom two probes) IOUS side-viewing I- and T-shaped
probes. Lower right picture: LUS end-viewing probe, front-viewing, rigid-shaft with transducers located at the tip of the shaft.
End-viewing probes are useful for the scanning of extrahepatic biliary system, pancreas, or other organs, but also useful to
guide needles for biopsy or ablation.

facilitate IOUS/LUS scanning and to obtain

the best imaging information. Two basic
transducer placement techniques of IOUS/
LUS are contact scanning and probe-stand-
off scanning. In contact scanning the probe
is placed in direct contact with the tissue or
organ, whereas in probe-standoff scanning
the probe is positioned 1 to 2 cm away from
the surface of structure (Fig. 2).
The size of the target organ and the dis-
tance from the probe to the area of interest
in the organ determines which scanning
technique should be used. Usually, contact
scanning is used for examination of the inte- A B C
rior of the liver, kidney, or pancreas (Fig. 3). Fig. 2. Intraoperative ultrasound probe placement, including contact scanning (A), probe-standoff
However, when the surface or the superficial scanning (B), and compression scanning (C).

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 183 10/28/11 3:55:57 PM

 184 Part II: Basic Surgical Skills: New and Emerging Technology

Fig. 3. For intraoperative ultrasound scanning of

the liver, a probe is placed on the liver surface and
usually contact scanning is performed. “Sliding,”
“rotating,” and “angulating” maneuvers should be
appropriately used.

area of the organs needs to be examined,

probe-standoff scanning should be em-
ployed. For examination of relatively small
superficial structures such as the extrahe-
patic bile ducts, probe-standoff technique is
particularly important (Fig. 4). In probe- Fig. 4. Intraoperative ultrasound scanning of the extrahepatic bile duct using a probe-standoff tech-
standoff scanning, acoustic coupling is ob- nique. The probe-standoff is particularly important when the bile duct is exposed or located superfi-
tained between the tissue and the probe by cially in the hepatoduodenal ligament.
filling the operative field with saline until
the transducer surface of the probe is im-
mersed beneath the solution. The probe-
standoff with saline immersion technique is usually important to obtain longitudinal, Scanning maneuvers are the ways by
a unique IOUS/LUS method that is not com- transverse, and at times, oblique views of a le- which the probe is manipulated during its
monly used in percutaneous ultrasound. sion or organ (Fig. 5). A longitudinal view is movement. There are three basic scanning
This permits placement of the target at the the ultrasound image parallel to the long axis maneuvers of the probe: sliding, rotating, and
appropriate focal distance and also prevents of the structure or organ being examined, angulating (rocking or tilting). In “sliding,” the
inadvertent compression of structures by whereas a transverse view is the image at the probe slides across the surface of a tissue or
the probe. One additional useful technique right angle to the long axis. Oblique views are organ while the probe-to-surface geometry is
is compression scanning, in which the tis- intermediate in position between longitudi- maintained. In “rotating,” the probe is turned
sue is compressed intentionally by the probe nal and transverse views. along the direction of the sound beam, either
(Fig. 2). This technique helps to eliminate air
between the transducer and the tissue. Also,
air in the gastrointestinal tract lumen that
overlies a region of interest can be displaced
by compression. This is especially effective C
when air in the duodenum obscures the dis-
tal common bile duct. Compression is also B
used to distinguish arteries from veins,
which are more easily compressed. A

Probe Movement
(Scanning Maneuvers)
The second step in ultrasound scanning is
probe movement. A target or suspected lesion
should be scanned from various positions and
directions, and an organ should be scanned in
a systematic fashion for a thorough IOUS/LUS
examination. Although the scanning method Fig. 5. Transverse (A), longitudinal (B), and oblique (C) scanning of the liver. One probe can be used to
varies depending on the organ examined, it is perform scanning of these planes by “rotating” maneuver.

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 184 10/28/11 3:55:59 PM

 Chapter 12: Ultrasonography by Surgeons 185

A
B

MHV

IVC

RHV

Basic Surgical Skills: New and

Fig. 6. During intraoperative ultrasound scanning, “angulating” maneuver is very useful. As shown in the left illustration,
“angulating” maneuver facilitates the visualization of the target in the liver from one location, in different directions. It also

Emerging Technology
helps to understand the three-dimensional (3D) information of the target lesions. As shown in the right illustration, “angulat-
ing” maneuver is particularly valuable to scan the superior area of the segments 7 or 8. Often it is not easy to bring the trans-
ducer high up in the dome of the liver. However, by “angulating” maneuver, these superior areas of the liver can be visualized.
In this circumstance, saline immersion technique needs to be used frequently. This is because partial probe-standoff tech-
nique is necessary (B) to visualize the superior area, as compared to the contact scanning (A). MHV, middle hepatic vein;
RHV, right hepatic vein; IVC, inferior vena cava.

clockwise or anticlockwise. With this tech- over the liver surface under the abdominal of invasion to the middle hepatic vein and
nique, lesions or structures are delineated wall or the diaphragm. In the majority of the vena cava.
continually from longitudinal to oblique to operations, the entire liver is visualized by The extrahepatic bile duct is best
transverse views or vice versa, and thus three- scanning from the anterior and diaphrag- scanned with the end-viewing cylindrical
dimensional (3D) information of lesions can matic surfaces of the liver (Figs. 3,5,6). probe, although a flat probe may be used
be acquired. In “angulating,” the probe’s head Scanning from the inferior surface may be when the operative field is wide and suffi-
(transducer surface side) remains relatively needed at times for examination of the pos- cient space is available. Probe-standoff
stationary while the shaft of the probe is terior segment of the right lobe and cau- scanning is critical for the exposed or su-
moved or swung to different angles (Fig. 6). date lobe. Intrahepatic vessels are scanned perficially situated bile ducts. The supradu-
This technique is especially useful in a deep using sliding, rotating, and at times mini- odenal portion of the bile duct is first visu-
and restricted operative field where “sliding” mal angulating maneuvers (Fig. 6). The alized longitudinally, as the probe is moved
of the probe is limited or impossible. These right and left portal veins are followed from from the hepatic hilum to the duodenum
basic maneuvers can be combined simulta- the hilum to the peripheral branches (Fig. (Fig. 4). The retroduodenal and intrapan-
neously, and in reality, combination maneu- 7). Intrahepatic bile ducts and hepatic ar- creatic portions are then scanned through
vers are commonly performed during IOUS. teries are followed in a similar manner. The the duodenum, occasionally with the gentle
Probe movement of LUS is somewhat three main hepatic veins are then identi- compression. The extrahepatic bile duct is
limited as compared to IOUS. “Sliding” and fied and followed from their confluence also examined transversely, which also dis-
“rotation” movements are two major ma- with the vena cava and tracked back into plays the portal vein and hepatic artery in
neuvers of the LUS probe. Mastering IOUS is the liver (Fig. 7). Hepatic veins are easily transverse sections (the appearance of the
technically much easier for the surgeon and distinguished from the portal vein branches portal triad is described as “Mickey Mouse”
greatly facilitates the performance of LUS. that show a hyperechoic thickened wall. head and ears). Figure 9 shows an extrahe-
Therefore, surgeons who intend to perform Identification of each of the intrahepatic patic cholangiocarcinoma, which was eval-
LUS should learn IOUS prior to or at the portal and hepatic veins is essential to de- uated and determined to be resectable by
same time as learning LUS. Surgeons who termine the segmental or subsegmental IOUS.
intend to use LUS should be able to perform location of lesions (i.e., eight segments of The pancreas is best scanned with a flat
open IOUS just as surgeons who perform the liver). Following visualization of the probe after the exposure of the anterior sur-
laparoscopic cholecystectomy should know blood vessels of the liver, scanning of the face of the pancreas following entrance into
open cholecystectomy. right and left lobes is performed to system- the lesser sac. However, the pancreas can
atically examine the entire liver. This is ac- also be visualized through the stomach or
INTRAOPERATIVE ULTRASOUND complished by sliding scan maneuvers that omentum. In this situation, if the operative
SCANNING OF THE SPECIFIC encompasses the entire liver. The system- field is limited, the cylindrical probe is use-
atic examination of the entire liver should ful. Viewing the pancreas through other
ORGANS be thorough to discover occult lesions. Fig- structures is often needed in the presence
The liver is best scanned with the side-view- ure 8 shows a liver tumor, which was con- of adhesions or peritonitis. Both contact
ing flat T-shaped probe. The probe is passed firmed to be unresectable by IOUS because and probe-standoff techniques should be

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 185 10/28/11 3:55:59 PM

 186 Part II: Basic Surgical Skills: New and Emerging Technology

Fig. 7. Left: intraoperative ultrasound (IOUS) showing the left portal vein and the caudate lobe (segment 1, S1) in transverse
views. S1 is located posterior to the right and left portal veins and the ligament venosum (small arrow), anterior and lateral to
the vena cava (VC). PV-A, ascending portion of left portal vein, PV3, segment 3 branch of portal vein; S3, segment 3; S4, segment
4. Right: IOUS of three hepatic veins. The right (RHV), middle (MHV), and left (LHV) veins are coming into the vena cava (VC).
The relation of the hepatic veins to segments (S2, S4, S8, S7) is shown.

used to completely examine the superficial LAPAROSCOPIC ULTRASOUND differ depending on the target organ, intra-
and deep portions of the pancreas. The en- SCANNING OF THE SPECIFIC peritoneal conditions, the type of LUS
tire pancreas is imaged using longitudinal probes, and also investigator’s preference.
and transverse scanning. The pancreatic ORGANS During laparoscopic cholecystectomy,
head and the uncinate process can be The scanning techniques of LUS for each or- 10-mm umbilical and subxiphoid trocars
scanned together with the examination of gan depend strongly on the type of LUS can be usually used for LUS evaluation of the
the intrapancreatic bile duct. The main probes (i.e., side viewing vs. front viewing, bile ducts. The LUS probe is introduced into
pancreatic duct, even when normal size, rigid vs. flexible probes) and the location of the peritoneal cavity through the subxiphoid
can be visualized by scanning from the head trocar insertion sites. The location and port under laparoscopic observation, and is
to the tail of the pancreas. number of trocars for LUS probe insertion positioned perpendicular and lateral to the
edge of hepatoduodenal ligament when a
side-viewing probe is used (Fig. 10). This
produces a transverse section of the bile
duct, portal vein, and hepatic artery: an ap-
pearance resembling the silhouette of a
“Mickey Mouse” head and ears in which the
larger tubular cross section of the portal
vein corresponds to the “head” and the cross
sections of the bile duct and hepatic artery
to the “ears.” The probe is then moved (“slid-
ing”) along a longitudinal path parallel to
the long axis of the bile duct between the
cystic duct and the duodenum. At the same
time, the probe is rotated (“rotating”) to
sweep-scan the ductal system. To examine
the intrahepatic bile ducts, the probe is po-
sitioned atop the liver surface above the hi-
lum. When an end-viewing probe is used, it
Fig. 8. Intraoperative ultrasound (IOUS) is particularly important to determine the final resectability of is placed over the hepatoduodenal ligament
liver tumors, in terms of major vascular invasion and intrahepatic metastases. This was a metastatic liver (Fig. 11); by rotating the probe, longitudinal
tumor from a left colon cancer. The tumor (T) was located in segment 4 to segment 8, and it was invading and transverse views of the bile duct can be
the middle hepatic vein (MHV) and the vena cava (VC), as indicated by white arrows. These IOUS find- visualized quickly. During LUS of the biliary
ings suggested that surgical resection was impossible with negative margin. system, the cystic duct can be visualized as

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 186 10/28/11 3:55:59 PM

 Chapter 12: Ultrasonography by Surgeons 187

Fig. 9. Intraoperative ultrasound (IOUS) showing a resectable bile duct cancer (cholangiocarcinoma). Left: a longitudinal view
of the bile duct (BD) at the level of the junction with the cystic duct (CD). The proximal bile duct was dilated. The tumor (T)

Basic Surgical Skills: New and

(bile duct cancer) was located at that area. It appeared to be a localized tumor. P, ⫽ head of the pancreas. Right: in a transverse

Emerging Technology
view of this cancer, there was no invasion of the tumor (T) to the portal vein (PV) and hepatic artery (HA). An arrow indicates
a biliary catheter (associated with shadowing). VC, inferior vena cava. From these IOUS findings, this bile duct cancer was
judged to be resectable.

well as the bile duct, which may help subse- for LUS probe insertion. The basic steps of tail, and scanning from the right side for im-
quent tissue dissection, avoiding injury to LUS scanning of the liver are the same as aging the pancreatic head. The pancreas is
the bile duct. Figure 12 shows clear identifi- those of open IOUS: delineation of vascular visualized through organs or tissues, and usu-
cation of a cystic duct and a bile duct before structures and systematic scanning of the en- ally exposure of the anterior surface of the
and after clipping of cystic duct during lap- tire liver, usually using a side-viewing probe. pancreas is not required.
aroscopic cholecystectomy. An end-viewing probe can be used for LUS
For LUS examination of the liver, pancreas, scanning of the liver mainly for focused evalu- INTRAOPERATIVE AND
other organs, and abdominal vascular struc- ation of liver lesions (rather than screening) LAPAROSCOPIC ULTRASOUND-
tures, first the umbilical port can be made for and for subsequent LUS-guided liver aspira-
laparoscopic exploration, and the second tro- tion, biopsy, or ablation. The basic steps of
GUIDED PROCEDURES
car site for LUS can be selected depending on LUS screening of the pancreas are also similar IOUS/LUS can guide various operative pro-
the intraperitoneal condition determined by to those of open IOUS: longitudinal and trans- cedures. This indication for IOUS/LUS is
laparoscopy. Umbilical, subxiphoid, right, verse scanning from the anterior surface par- unique because the assistance it provides is
and left subcostal ports are frequently used ticularly for imaging the pancreatic body and more than simply supplying diagnostic

GB GB

Fig. 10. Laparoscopic ultrasound (LUS) scanning of the bile duct using a flexible-tip probe. The scanning is performed via the
subxiphoid port. With the flexible-tip probe, it is not necessary to change the port for introduction of the probe. The left picture
shows transverse scanning of the bile ducts, and the right picture shows longitudinal scanning after upward-flexion of the probe
tip. The gallbladder (GB) is retracted up over the liver. Arrows indicate the location of transducers at the tip of LUS probe.

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 187 10/28/11 3:56:00 PM

 188 Part II: Basic Surgical Skills: New and Emerging Technology

BD

BD

Fig. 11. Laparoscopic ultrasound (LUS) scanning of the extrahepatic bile duct using a rigid end-
viewing LUS probe. It is much easy and quick to visualize both transverse and longitudinal
sections of the bile duct (BD) by rotating this probe (as seen in two right sonograms). Note that
the tip of the probe is under water (saline solution).

information and the use of ultrasound in this Ultrasound-Guided Needle, Cannula, catheter introduction into the ducts or le-
context may directly affect the therapeutic or Ablation Probe Placement sions. Following needle placement under
outcome of surgery. Surgical procedures or IOUS/LUS guidance, biopsy is performed
manipulations guided by IOUS/LUS are clas- IOUS/LUS-guided needle placement aids for hepatobiliary pancreatic and other ab-
sified into two categories: (a) intraoperative biopsy of tumors (especially nonpalpable dominal tumors. Needle biopsy of suspi-
needle, cannula, or ablation probe place- tumors), fluid aspiration of cystic lesions, cious lymph nodes can be performed. IOUS/
ment and (b) surgical tissue dissection. injection of contrast or other agents, and LUS-guided needle biopsy is particularly

CD
BD BD

Fig. 12. Laparoscopic ultrasound (LUS) identification and evaluation of the biliary system. Left: visualization of the bile duct
(BD) and cystic duct (CD) before tissue dissection and application of clips during cholecystectomy. Right: after clipping of the
CD, a clip is visualized (red arrow) away from the BD, which is intact.

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 188 10/28/11 3:56:03 PM

 Chapter 12: Ultrasonography by Surgeons 189

indispensable for deeply located, invisible, IOUS-guided tissue dissection for resec- The parenchyma of organs (most fre-
nonpalpable tumors, or lymph nodes. IOUS/ tion is performed in various organs; how- quently the liver) or tissue can be dissected
LUS-guided fluid aspiration is mainly per- ever, it is used most frequently during he- for incision or resection under IOUS/LUS
formed for cystic lesions, such as liver and patic resection. Resection procedures of the guidance. Unlike needle placement, the dis-
pancreatic cysts, and abdominal abscesses. liver that are guided by IOUS include lobec- section itself is not visualized in real time.
Aspiration is also used to confirm the loca- tomy, segmentectomy, subsegmentectomy, Rather, IOUS/LUS is performed repeatedly,
tion of the bile duct or pancreatic duct. and other non-anatomical resections. These and the dissection plane is intermittently
IOUS/LUS-guided agent injection is per- operations are performed in most instances visualized in relation to surrounding struc-
formed during operations on the liver, bil- for the treatment of primary and metastatic tures. The dissection or transection plane,
iary tract, and pancreas. Various agents can malignant tumors, and in a fewer instances which contains air bubbles, is delineated as
be injected: alcohol is injected directly into for the treatment of benign tumors, intrahe- a hyperechoic glittering line on IOUS/LUS.
malignant tumors such as small hepatomas patic calculi, or other benign diseases. Dur- The plane can be recognized also by insert-
or for celiac ganglion block, and contrast ing hepatectomy, the transecting plane of ing a surgeon’s finger into it.
materials are injected for intraoperative ra- the liver is clearly delineated on IOUS im-
diographic examination (e.g., intraoperative ages, and thus, IOUS can direct appropriate ENDOSCOPIC AND ENDORECTAL
cholangiography). Under IOUS/LUS guid- hepatic resection. Tumors of the pancreas or ULTRASOUND
ance, catheters can be introduced and biliary system can also be resected with the
placed for drainage of the intrahepatic bil- assistance of IOUS guidance. Furthermore, Endoscopic ultrasound (EUS) has been per-
iary ducts for bile, into cysts for fluid, and new surgical operative techniques, such as formed mostly by gastroenterologists, and

Basic Surgical Skills: New and

into abdominal abscesses for pus. IOUS-guided systematic subsegmentectomy is a technically demanding procedure.

Emerging Technology
With IOUS/LUS guidance, ablation can- of the liver, have been developed as a result However, it is expected that surgeons will
nula or probe placement is performed for of the introduction of IOUS. When laparo- be involved in endoscopic procedures in
nonresectional tumor treatment such as ther- scopic surgery is performed for these opera- near future more than before, partly be-
mal ablation (radiofrequency or microwave) tions (e.g., hepatectomy, pancreatectomy, cause of recent introduction of “natural
or cryoablation. Recently, radiofrequency and cystogastrostomy), LUS guidance can be orifice transluminal endoscopic surgery
thermal ablation has been used increasingly used in a manner similar to open IOUS guid- (NOTES).”
because of excellent local control of tumors ance for incision or resection. The major advantage of EUS is that the
and fewer associated complications. Depend- probe is directly on or very close to the or-
ing on the tumor and the patient condition, gan of interest. This proximity allows the
Ultrasound-Guided Techniques use of higher frequencies with better reso-
radiofrequency thermal ablation can be per-
formed percutaneously, laparoscopically, For IOUS-guided needle, cannula, or abla- lution and very detailed examinations, sim-
open surgically, or hand-assisted laparoscopi- tion probe placement, the freehand tech- ilar to IOUS-LUS. A radial probe (transducer
cally. These ablation therapies are currently nique or the technique using a needle-guid- rotates 360 degrees; perpendicular to the
performed mainly for unresectable malignant ance system (an adapter attachable to an axis of scope) or a curvilinear probe (180
liver tumors; however, their indications may IOUS probe for needle guidance) (Fig. 13) is degrees; parallel to the axis of scope; biopsy
expand to include tumors of other abdominal selected, based on the size, location, and capability) is located on the tip of flexible
and extra-abdominal organs. The ablation depth of the target lesion and the condition endoscope. Scanning can be performed
process can be precisely planned and moni- of the operative field (accessibility of the le- with an interchangeable 7 to 12 MHz trans-
tored with IOUS/LUS. sion). A needle is inserted from the lateral ducer. A catheter-type miniprobe that can
aspect of the probe into tissue so that the be inserted through the scope is also avail-
Ultrasound-Guided needle shaft is visualized while the needle able with a frequency as high as 30 MHz.
is advanced (Fig. 13). Motion of a needle fa- Although mostly used for diagnosis, EUS is
Tissue Dissection cilitates the localization of the tip in the im- also a therapeutic tool.
IOUS-guided tissue dissection can assist in- age. In general, needle or cannula place- There are various diagnostic and thera-
cision or resection of solid organs such as ment in superficially situated, larger lesions peutic indications for EUS for the foregut,
the liver, pancreas, or other intraperitoneal- can be performed by the freehand tech- including the pancreas, gastrointestinal
retroperitoneal tissues. During operations nique, whereas deeply situated, smaller le- tract, biliary tract, and others. Presently,
for chronic pancreatitis, dilated pancreatic sions require use of a needle-guidance sys- EUS is probably used most frequently for
ducts and small pancreatic pseudocysts of- tem. Figure 14 shows IOUS-guided liver pancreatic diseases. For pancreatic cancers,
ten are not palpable. In such instances, inci- tumor biopsy, and Figure 15 shows IOUS- evaluation of the portal vein, hepatic artery,
sion of the pancreatic parenchyma (pancre- guided radiofrequency ablation of a liver tu- or superior mesenteric artery encroach-
atotomy) or incision of the cyst wall is guided mor. With more experience, the surgeon can ment can help determine resectability. A
by IOUS for internal drainage (e.g., Puestow use the freehand technique more often. LUS- tissue diagnosis can be obtained with the
operation or cystogastrostomy). For enucle- guided needle placement is technically more use of EUS-guided needle biopsies. EUS can
ation of islet cell tumors of the pancreas, es- demanding because of greater distance to localize islet cell tumors, allow aspiration of
pecially those which are nonpalpable, IOUS- target lesions (owing to peritoneal insuffla- cystic lesions or neoplasms for diagnosis
guided pancreatotomy is carried out until tion), and limited access for LUS probe (Fig. 18), evaluate the extent of intraductal
the tumor is visualized. The abdominal placement (Fig. 16). At times, it is difficult papillary mucinous neoplasm (IPMN), and,
abscess cavity wall is incised under IOUS to visualize the entire needle shaft and tip in the case of pancreatic pseudocysts, help
guidance to achieve wide surgical drainage. during needle insertion especially under a guide endoscopic drainage. EUS-guided
Foreign bodies in various organs or tissues side-viewing LUS guidance. An end-viewing celiac ganglion block is used to palliate pain
can be extracted using IOUS-guided needle LUS probe with a needle-guidance system from pancreatic cancer or chronic pancrea-
localization and tissue incision. is preferable (Fig. 17). titis.

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 189 10/28/11 3:56:05 PM

 190 Part II: Basic Surgical Skills: New and Emerging Technology

Fig. 13. Intraoperative ultrasound (IOUS) needle-guidance

system. Needle guidance is attached to an IOUS T-shaped cur-
vilinear array probe (upper pictures). This system maintains
the needle in the scanning plane. Lower sonogram shows pre-
cise guidance of a needle into a small cystic lesion (arrow).

On high-resolution ultrasound images, of the normal five-layer configuration as a cancer or pancreatic invasion of gastric
the wall of the gastrointestinal tract exhib- result of cancer invasion. Thus, the depth of cancer can be assessed. Therefore, for both
its a five-layer (or seven-layer) appearance, tumor invasion and intramural lateral tu- esophagus and gastric cancers, T-staging
which corresponds to the layered structures mor extension can be determined by EUS. can be determined preoperatively (accu-
obtained on histological examination. EUS For locally advanced cancer, vascular inva- racy of T-stage is 80% to 90%). N-staging of
can demonstrate distortion or destruction sion such as aortic invasion of esophageal gastroesophageal cancers can also be per-
formed by EUS (accuracy of N-stage is 75%
to 85%). Newer indications include staging
of lung cancers with mediastinal node eval-
uation and biopsy. Other indications for
EUS include evaluation of submucosal tu-
mors or lesions such as gastrointestinal
stromal tumor (GIST), evaluation of biliary
obstruction, staging of bile duct cancer and
ampullary cancer, and identification of
choledocholithiasis. Esophagogastric va-
rices can be evaluated and therapeutic in-
jection can be performed.
Endorectal/anorectal ultrasound has
also an advantage of the use of high fre-
quency (7 to 12 MHz) probe directly on the
pathology in the rectum or anus. It has been
performed by many colorectal surgeons, as
an inexpensive office-based procedure, and
has a significant impact on the management
Fig. 14. Intraoperative liver tumor biopsy. A metastatic tumor (T) was located adjacent to the middle of malignant and benign conditions of the
hepatic vein (MHV). After biopsy, a needle (arrow) was withdrawn slightly, and an air which was left rectum and anus. For endorectal ultrasound,
behind in the needle track caused hyperechogenicity (arrowhead). a rigid straight probe is more frequently

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 190 10/28/11 3:56:05 PM

 Chapter 12: Ultrasonography by Surgeons 191

Basic Surgical Skills: New and

Emerging Technology
Fig. 15. Intraoperative ultrasound-guided radiofrequency ablation process.
A metastatic tumor (T) was in segment 8 (left upper). RFA needles (arrows)
were deployed (right upper), and ablation was started (left lower). Ablated
areas (A) became hyperechoic due to outgassing. RHV, right hepatic vein.

used. Similar to the upper gastrointestinal

tract, anorectal wall and surrounding struc-
tures can be assessed. Endorectal ultrasound
can determine depth of tumor penetration
in and outside the rectal wall and the pres-
ence of metastatic lymph nodes, and thereby,
T- and N-staging can be obtained. With this
information, the surgeon can individualize
treatment, which may consist of transanal
excision, transabdominal resection, or pre-
operative neoadjuvant radiation-chemo-
therapy followed by surgery. In addition,
surveillance of the anastomosis and opera-
tive site can be performed with endorectal
ultrasound, and is especially indicated for
patients who have undergone transanal ex-
cision of a tumor. Anal ultrasound provides
Fig. 16. Laparoscopic ultrasound (LUS)-guided needle placement for laparoscopic radiofrequency ther- precise images of the sphincter muscles, and
mal ablation. The tumor was located in segment 3. The needle (arrow) was inserted from one lateral side helps determine whether fecal incontinence
of the LUS probe and advanced under LUS guidance by freehand method. is surgically correctable. Ultrasound can also

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 191 10/28/11 3:56:06 PM

 192 Part II: Basic Surgical Skills: New and Emerging Technology

Fig. 17. End-viewing laparoscopic ultrasound (LUS) probe is useful to guide

a needle because of easier freehand guidance capability. Upper left picture:
an end-viewing LUS probe with a guide grove, where a needle can be placed.
Bottom picture: insertion of a needle using end-viewing LUS probe (inserted
via the subxiphoid port, adjacent to the falciform ligament) into a tumor
at the caudate lobe. Upper right sonogram: an LUS sector image showing a
needle (arrows) into a tumor (T) in the deep location at the caudate lobe of
the liver.

Fig. 18. Left: transgastric endoscopic ultrasound (EUS) localized a small insulinoma (markers, I) at the pancreatic neck adja-
cent to the pancreatic duct (PD). The lesion was 3.6 ⫻ 2.8 mm. PV, portal vein. Right: a pancreatic cyst in the tail of pancreas
undergoing EUS-guided cyst aspiration. A needle (arrow) was inserted in the center of a cyst.

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 192 10/28/11 3:56:07 PM

 Chapter 12: Ultrasonography by Surgeons 193

be used to evaluate complex anal fistula, scanning a freshly excised surgical speci- helpful for surgeons, especially for the ul-
anal pain without an identifiable source, men such as a gallbladder. With such prac- trasound neophyte, who are interested in
and perianal sepsis or abscess. tice, image orientation of a target in rela- getting started in IOUS and LUS. For gen-
tion to the position of the probe will be eral surgeons, particularly hepatobiliary,
TRAINING OF INTRAOPERATIVE observed and interpretation of images will pancreatic, and endocrine surgeons, surgi-
AND LAPAROSCOPIC be facilitated. Eventually, a surgeon be- cal oncologists and laparoscopic surgeons,
comes capable of creating 3D images in his it will become critically important to mas-
ULTRASOUND or her brain from 2D images in real time. ter IOUS and LUS. Collaboration with radi-
Interpretation of a two-dimensional (2D) Ultrasound phantoms are available for ologists may be important initially; how-
real-time ultrasound image requires famil- practicing IOUS and LUS scanning tech- ever, I believe it is imperative that surgeons
iarity with how the position of probe (trans- niques (Fig. 19). Ultrasound simulation sys- eventually perform surgical ultrasound
ducer) relates to the image on the monitor tems can be used to learn EUS as well as such as IOUS and LUS by themselves.
screen. This probe-image orientation re- IOUS. Practice with percutaneous ultra-
quires hand-eye coordination by the opera- sound examination, for example, scanning
tor in order to understand where a particu- of the liver and gallbladder, also helps to de- ADVANCES AND FUTURE
lar anatomic region is represented on the velop basic scanning skills. Surgical ultra- PERSPECTIVE OF SURGEONS’
screen. To acquire this type of orientation, sound courses including hands-on sessions INTRA-PROCEDURAL
the surgeon who is not familiar with the ul- have been provided by societies such as the
trasound probe and scan display on the American College of Surgeons and Society
ULTRASOUND

Basic Surgical Skills: New and

monitor is well advised to practice with the of American Gastrointestinal and Endo- Although intraoperative radiography such

Emerging Technology
probe in a small basin of water; for example, scopic Surgeons. Taking such courses is as intraoperative cholangiography was used

PV

VC
AO

Fig. 19. Intraoperative ultrasound (IOUS)/laparoscopic ultrasound (LUS) phantom is valuable prior to actual IOUS/LUS scan-
ning on patients. Upper left: an ultrasound phantom specifically made for IOUS/LUS. Upper right: IOUS scanning training using
a phantom. Lower left: LUS scanning training using a phantom placed in a trainer box. Lower right: a sonogram of the phantom,
showing the pancreas and vascular structures. Note a stone (arrow) in the pancreatic portion of the bile duct. PV, portal vein;
VC, vena cava; AO, aorta.

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 193 10/28/11 3:56:09 PM

 194 Part II: Basic Surgical Skills: New and Emerging Technology

as early as the 1930s or 1940s, the develop-

ment of IOUS/LUS did not start until the
1960s. There have been three remarkable
periods in the history of IOUS/LUS: the first
period in the 1960s was the beginning of A
BD
IOUS/LUS utilizing A-mode or static B- PV
mode ultrasound; the second period in the PV
late 1970s and the 1980s was due to the ex-
pansion of IOUS with real-time B-mode ul-
trasound; and the third period occurred in VC
the 1990s with the application of intraop-
erative color Doppler imaging and the ex-
pansion of LUS. Now 2010s will become the
fourth period in the history of IOUS/LUS.
Color or power Doppler imaging, which
displays blood flow in real-time color on B- A
mode gray scale images, has been used dur-
BD
ing operation. This modality enhances the PV
efficacy of IOUS and LUS during general and
cardiovascular surgery by offering blood
flow information in addition to anatomical VC VC
information. Intraoperative color or power
Doppler imaging can detect and localize
smaller vessels, can more promptly distin-
guish them from ductal structures and tis-
sue spaces than conventional B-mode ultra- Fig. 20. Three-dimensional (3D) intraoperative ultrasound (IOUS) images of the portal triad (portal vein,
sound, and can confirm blood flow to hepatic artery, and bile duct; “Mickey Mouse” head and ears). Three perpendicular planes (two upper
organs after surgical operations such as images and lower left image) are visualized in (near) real time, and 3D reconstruction can be performed
major organ resection or transplantation. subsequently (lower right image). PV, portal vein; BD, bile duct; A, hepatic artery; VC, vena cava.
The future uses of ultrasound during
various procedures (intra-procedural ultra-
sound) will be brought about by a combina-
tion of surgeons’ interest and experience of color or power Doppler imaging. The re- which EUS will play a role. There are current
with ultrasound and technological ad- finement of 3D images will simplify IOUS reports of EUS-guided radiofrequency abla-
vances. Some predictable issues include ex- and LUS for planning and guiding tumor ab- tion of unresectable pancreatic tumors. As
pansion of its applications, improvement in lation or organ resections, such as hepatec- technology evolves, many of the surgical
instrumentation, and incorporation of new tomy. Anatomical and pathological informa- procedures that have been done with open,
ultrasound technology. tion provided by 3D IOUS/LUS will enable a laparoscopic, or percutaneous approaches
The use of IOUS/LUS by surgeons will be quicker and more assured IOUS/LUS-guided will be performed by endoscopic approaches,
steadily increasing, along with more formal surgical procedures (Fig. 20). Three-dimen- which in many cases may be guided by EUS.
training in ultrasound for residents and sional images may increase the diagnostic Virtual reality technology will continu-
surgeons. Having competent surgeons per- confidence of the surgeons, which is often ally advance so that more realistic simula-
forming IOUS/LUS and having IOUS/LUS an obstacle for the broader applications of tion of IOUS/LUS examinations, as well as
instruments always available in the operat- IOUS/LUS. Ultrasonic tissue characteriza- surgical procedures, will be available. Com-
ing room will permit IOUS/LUS to become tion and high-intensity focused ultrasound puter-based ultrasound simulators will
an everyday tool for acquiring intraopera- are innovative diagnostic and therapeutic greatly help future education and training
tive information; it will allow surgeons to ultrasound currently under investigation, in IOUS/LUS. As technology is evolving,
“see” in new dimension. This is particularly which can be applicable during IOUS/LUS new advances in procedures and imaging
true in the use of LUS because of ongoing as well as percutaneous ultrasound. methods including IOUS, LUS, and EUS
broader applications of laparoscopic or Advances in various other medical or must be carefully assessed to define its
minimally invasive operations. nonmedical technologies will continuously emerging role and cost-effectiveness for
The introduction of new ultrasound tech- influence or alter surgical procedures and improving surgical practice of the future.
nologies will lead to further improvement in imaging methods including IOUS. Less and
resolution and deeper sound penetration of less invasive surgery with smaller access CONCLUSIONS
IOUS/LUS. New probes and more user- sites will keep surgeons’ hands further away
friendly scanners for surgeons are being de- from organs, thus requiring more image IOUS and LUS can provide various diagnos-
veloped. New ultrasound technological de- guidance as seen in minimally invasive and tic information, which are otherwise not
velopments, such as harmonic imaging with percutaneous image-guided procedure. available, and can guide or assist various
contrast agents (intravenous ultrasound Therefore, there will be a less distinctive bor- surgical procedures in real time. IOUS/LUS
contrast is not available yet for abdominal der between IOUS and percutaneous inter- is commonly performed during hepatobil-
organs in the United States as of August ventional ultrasound; all can be categorized iary, pancreatic, endocrine, cardiovascular,
2011), will improve the diagnostic accuracy as “intra-procedural ultrasound.” NOTES is and neurological surgery; however, its ap-
of IOUS/LUS, particularly intraoperative use another newer surgical-endoscopic field, in plications are expanding to other surgical

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 194 10/28/11 3:56:11 PM

 Chapter 12: Ultrasonography by Surgeons 195

fields. Advantages of IOUS/LUS, including able technique, which is recommended to Kane RA. Intraoperative, laparoscopic and en-
safety, speed, high accuracy, comprehensive master for surgeons in various fields to im- doluminal ultrasound. Philadelphia: Churchill
anatomical information, and real-time prove intraoperative decision making and Livingstone; 1999.
Machi J. Intraoperative and laparoscopic ultra-
guidance capability, outweigh its disadvan- surgical procedures. sound. Surg Oncol Clin N Am 1999;8:205–26.
tages such as specific equipment require- Machi J, Staren ED. Ultrasound for surgeons,
ment and slow learning curve. The use of 2nd ed. Philadelphia: Lippincott Williams &
IOUS/LUS by surgeons is expected to in-
SUGGESTED READINGS Wilkins; 2005.
crease along with more formal training and Ganguli S, Kruskal JB, Brennan DD, et al. Intraop- Machi J, Oishi AJ, Furumoto NL, et al. Intraopera-
experience in ultrasound for surgeons. New erative laparoscopic ultrasound. Radiol Clin N tive ultrasound. Surg Clin N Am 2004;84:1085–
Am 2006;44:925–35. 111.
ultrasound technologies such as ultrasound Machi J, Johnson JO, Deziel DJ, et al. The routine
Garden OJ. Intraoperative/laparoscopic ultra-
contrast enhancement, 3D ultrasound, and sound. Cambridge: Blackwell Science; 1995. use of laparoscopic ultrasound decreases bile
high-intensity focused ultrasound will be Harness JK, Wisher DB. Ultrasound in surgical duct injury: a multi-center study. Surg Endosc
utilized more during future IOUS and LUS, practice. New York: Wiley; 2001. 2009;23:384–8.
and may potentially improve surgical out- Jakimowicz JJ. Intraoperative ultrasonography in Staren ED, Arregui ME. Ultrasound for the sur-
come. Being safe, quick, accurate, and ver- open and laparoscopic abdominal surgery: an geon. Philadelphia: Lippincott-Raven; 1997.
satile intraoperatively, IOUS/LUS is a valu- overview. Surg Endosc 2006;20:S425–35.

Basic Surgical Skills: New and

EDITOR’S COMMENT Dr. Machi is an enthusiast of LUS and ultra- management in the cohort of 24 colorectal cancer

Emerging Technology
sound in general. Despite the fact that the intra- patients is noticeably much lower compared with
operative ultrasound first became of interest with the change in surgical management in this study.
Ultrasound has been a form of bodily examination, the advent of laparoscopic cholecystectomy, this They argued that the higher impact in their study
which has been around for some time. Its intro- was introduced in 1991. It is my belief that this may be accounted for by the superiority of dedi-
duction into human use started in the early 1960s. technique can be extremely valuable and is not cated high-frequency probe and the software that
Considering what the possibilities are, I think it is particularly harmful and is not used as frequently they used, which may be possible.
fair to say that ultrasound is underutilized for ab- as it should. The author of this chapter, Machi et al., with a
domen, whether used for the diagnosis of chole- In a recent review, Jakimowicz, from the Catha- number of others (Surg Endosc 2009;23:384–8) re-
cystitis, in which it is used to a considerable extent rina hospital in Eindhoven, the Netherlands, reviews ported on LUS as it had been used for 15 years to
and in use of laparoscopy as we have seen in other the current state of intraoperative ultrasonography screen the common duct for stones and delineated
situations, can make laparoscopy more valuable as of 2006 (Surg Endosc 2006;20:s425–35). However, anatomy during laparoscopic cholecystectomy.
than those currently being used. On the other the technique is spreading. Piccolboni et al. (Surg They claim that out of 1,381 patients who under-
hand, one has the feeling that ultrasound is not Endosc 2008;22:112–7) recently reviewed the intro- went laparoscopic cholecystectomy with LUS, LUS
being utilized as well as it might. It is not clear why duction of LUS to the Monaldi Hospital in Naples, was successful in delineating the anatomy and
this is the case. It appears that for some reason sur- Italy, and showed that without a water bath the presence of the bile duct in 1,352 patients (92%), al-
geons think that ultrasound is not something that extent of attempting to get as much information as though it was considered unsuccessful and incom-
they should be doing. In other situations, they may possible in 4 years between 2001 and 2005, 36 liver plete and not very helpful in 29 patients (2%). They
feel that they are not secure enough in its use. resections, 40 pancreas procedures, 203 procedures believe that LUS was safe and avoided conversion to
Laparoscopic ultrasound (LUS) in laparo- for suspected common duct stones, 541 colecto- open in 81 patients (5.9%). Intraoperative cholang-
scopic cholecystectomy is considerably faster mies, 82 stomach resections, and 82 renal surgery iography was performed in 504 patients, which was
than intraoperative cholangiography. Surgeons procedures were performed. Thus, intraoperative (36.5%) much higher than I suspect it is used in the
are not utilizing ultrasound to the level they ultrasound was brought to use, automatically with United States. There were a few false-negative and
should. It is basically harmless once one learns all liver, biliary, and pancreatic operations to decide false-positive results, but no injuries at the time
how to put in the instrument and can give a great the extent of the tumor while pancreatic, biliary, of this series, in which there should have been at
deal more information than we take advantage colonic, gastric, and adrenal pathologies were se- least several in this number of patients. There were
of. For example, the use of LUS gives much more lectively studied when there were questions about three minor bile leaks from liver bed in three pa-
information, for example, in screening tumors, the extent of disease. They found that the identifi- tients (0.2%), but no other bile duct injuries. Thus,
which are deep in the parenchyma of organs, es- cation of the hepatic lesions were the median size the routine use of LUS may actually speed along the
pecially solid organs such as the liver. In addition, of 8 mm with a minimum of 4 mm provided fur- case, but certainly will make it safer.
endoscopic ultrasound is much more valuable for ther information in 50% of the cases and actually Finally, not discussed to a great extent in any
the purpose of visualizing local tumor invasion changed the intended operation in 30%. In many of of these papers is the use of endoscopic ultra-
or invasion of all the structures and particularly the cases, lesions that were thought to have been sound. Endoscopic ultrasound has recently been
blood vessels. Liver metastases and lymph node totally resectable revealed information on ultra- shown to be of great value in looking at various
metastases of liver disease can be assessed in the sound that a complete resection and particularly a parts of the common bile duct when used in the
matter similar to intraoperative ultrasound in dangerous resection might not have been possible. duodenum and in the stomach. Under these cir-
open surgery and various series show that LUS We have not heard much about contrast- cumstances, it is entirely possible that a screen-
demonstrates liver tumors that have been im- enhanced intraoperative ultrasonography. In a let- ing endoscopic ultrasound may be of great value
perceptible to laparoscopic inspection in 20% to ter to the editor, Torzilli et al., from the Third De- for the examination of the lower end of the bile
40% of patients. Furthermore, information such partment of Surgery in the Faculty of Medicine in duct, particularly the sphincter of oddi and show-
as resectability is also available for laparoscopic the University of Milan, wrote for the use of a con- ing neoplastic disease.
inspection in 20% to 40% of patients that are trast-enhanced intraoperative ultrasonography, I end this discussion as I begun that LUS,
deemed unresectable. Further matters such as which is a technique that has not been used very endoscopic ultrasound, and intraoperative ul-
resectability, major vascular invasion, or lymph often, at least in our country. They quote Leen et al. trasound are probably not utilized as widely as it
node metastases are also obtained by LUS in the (Ann Surg 2006;243:236–40), in which Leen asked should be, and the patient and the surgeon are the
range of 10% to 30% when such patients were the question whether contrast-enhanced intraop- losers. For some reason, we think that this is not
thought to be resectable. Similar studies of lap- erative ultrasonography should be used routinely a technique that surgeons should use. This is par-
aroscopy in dealing with pancreatic cancer, bil- before all partial hepatectomies to try and indicate ticularly unfortunate, since I believe that this can
iary cancer, and gastroesophageal cancer give to the surgeon that the lesion is totally resectable. be of great help and great value once one becomes
valuable information as to the fact that such tu- In a gracious response to this letter, Leen and his facile with this technique of examination.
mors may not be as resectable as one thinks. coworkers reported that 21% alteration in surgical J.E.F.

www.medicalebookpdf.com

LWBK892_c12_p180-195.indd 195 10/28/11 3:56:11 PM

 196 Part II: Basic Surgical Skills: New and Emerging Technology

13 Cancer Ablation: Understanding the

Technologies and Their Applications
Salomao Faintuch, Muneeb Ahmed, and S. Nahum Goldberg

INTRODUCTION taneous ablative therapies over conven- leads to necrosis of the vascular endothe-
tional standard surgical resection is the po- lium, subsequent vascular thrombosis, and
Thermal (radiofrequency [RF], microwave, tential to remove or destroy only a minimal ultimately ischemic tissue necrosis. The
laser, and cryoablation) and nonthermal amount of normal tissue. For example, in treatment of primary hepatocellular carci-
(chemical and irreversible electroporation primary liver tumors, where functional he- noma with ethanol injection has been con-
[IRE]) ablative therapies have gained in- patic reserve is a primary predictive factor siderably more successful than the treat-
creasing clinical acceptance as methods for in long-term patient survival outcomes, ab- ment of liver metastases because of tumor
treating focal primary and secondary ma- lation therapies can minimize iatrogenic characteristics, including softer tissue com-
lignancies of the liver, kidney, lung, and damage to surrounding cirrhotic paren- position compared to the heterogeneous
bone. chyma. This is also useful when nephron- and dense fibrous nature of metastases, and
This chapter presents the general prin- sparing treatments are needed in patients a capsule or pseudo-capsule surrounded by
ciples and underlying rationale for com- with von Hippel-Lindau, who are prone to cirrhotic liver, which limits diffusion and in-
monly used ablative tumor therapies. Re- the development of multiple renal cell carci- creases concentration within the target
cent technological advances and future nomas, and in patients with primary lung (Fig. 1).
directions will also be discussed. malignancies in the setting of extensive un- Intratumoral administration of chemi-
derlying emphysema and limited lung func- cally ablative substances such as ethanol
APPROACHES TO TUMOR tion. Other clinical circumstances in which and acetic acid is the ablation modality that
ABLATION high specificity and accuracy of targeting has the longest experience and clinical
have proven useful include providing symp- follow-up, particularly in the treatment of
The use of percutaneous image guidance fa- tomatic relief for patients with symptomatic hepatocellular carcinoma. Chemical abla-
cilitates the least invasive approach for osseous metastases or hormonally active tion is an attractive option in many devel-
needle-based tumor therapies. By using im- neuroendocrine tumors, and in using per- oping regions because it is inexpensive and
aging such as ultrasound, computed tomog- cutaneous therapies to improve focal inter- simple. However, success of chemical abla-
raphy (CT), or magnetic resonance imaging stitial drug delivery. Percutaneous thermal tion therapies in more solid adenocarcino-
(MRI), tumors can be precisely targeted and therapies are limited, however, by the qual- mas has been limited by reported difficulty
treated by advancing a percutaneous nee- ity of imaging guidance, and in some cases, in achieving uniform diffusion of percuta-
dle applicator. Only a few needle insertions by complex anatomy and difficult access. neously injected drugs over larger tumor
are necessary, and no skin incision is cre- Another important factor is that the amount volumes, due to poor diffusion of chemical
ated. Most of these procedures can be safely of tumor destruction is determined by the agents throughout the tumor. As a result,
performed under local anesthesia and in- pattern of temperature, energy, or chemical focal thermal ablation has replaced chemi-
travenous moderate sedation, on an outpa- distribution within treated tissues. This cal ablation in many cases. Chemical abla-
tient basis. means that for larger tumors (usually de- tion is now more typically used for tumors
Tumor ablations have also been success- fined to be larger than 3 cm in diameter), a difficult to treat with thermal therapies
fully performed using laparoscopic and single ablation treatment may not be suffi- (mostly due to tumor proximity to heat sen-
open surgical approaches, under general cient to entirely encompass the desired ab- sitive adjacent structures), and for small
anesthesia, with varying degrees of inva- lative margins. In these instances, multiple tumors such as locally recurrent thyroid
siveness. overlapping ablations or simultaneous use cancer or benign lesions such as broncho-
of multiple applicators may be required to genic cysts, thyroglossal duct cysts, or en-
successfully treat the entire tumor and abla- dometriomas.
Objectives of Tumor Ablation tive margin, though accurate targeting and
The primary goal of most ablation proce- applicator placement can often be techni- Thermal Ablation Therapies
dures is to eradicate all viable malignant cally challenging in this scenario.
cells within a designated target volume. Thermal ablation strategies attempt to de-
Similar to the surgical approach of metasta- TECHNIQUES FOR stroy tumor tissue by increasing or decreas-
sectomy, tumor ablation therapies attempt ing temperatures sufficiently to induce ir-
to include at least a 0.5 to 1.0 cm ablative
TUMOR ABLATION reversible cellular injury. These strategies
margin of seemingly normal tissue for the can be broadly divided into cryoablation or
liver and the lung, though less may be
Chemical Ablation hyperthermic ablation, where heat may be
needed for some tumors in the kidney. Ethanol instillation has been used mainly generated by ultrasound or electromag-
While complete tumor eradication is of pri- for treating hepatocellular carcinoma in pa- netic (RF, microwave, and laser) energy.
mary importance, sparing normal sur- tients with cirrhosis. Ethanol destroys tis- Other techniques to generate heat or other-
rounding tissues and accuracy of therapy sue by causing dehydration of the cytoplasm wise induce cellular necrosis have been
are also important clinical considerations. and protein denaturation. Furthermore, al- reported; however, none have found wide-
As such, one significant advantage of percu- cohol entering the local tumor circulation spread utility to date.

www.medicalebookpdf.com

LWBK892_c13_p196-204.indd 196 10/28/11 3:55:02 PM

 Chapter 13: Cancer Ablation: Understanding the Technologies and Their Applications 197

Basic Surgical Skills: New and

B

Emerging Technology
C

Fig. 1. Ethanol Ablation. (A) A 21-gauge needle is used to inject ethanol into
the tumor after placement with US- or CT-guidance. (B) Gross pathologic
cross-section demonstrating gross effects of ethanol instillation in a primary
hepatic tumor. (C and D) Pretreatment contrast-enhanced axial CT image
demonstrates a focal hepatocellular carcinoma within the right lobe of the
liver. Follow-up imaging 3 months after ethanol instillation (D) demonstrates
D focal tumor necrosis with minimal peripheral enhancement.

Radiofrequency Ablation known as the Joule effect. Heating occurs injections of saline can be used to augment
most rapidly in areas of high current density; RF current flow.
By far, the most well-studied and clinically tissues nearest to an electrode are heated Irreversible cellular injury occurs when
relevant percutaneous ablation source to most effectively while more peripheral areas cells are heated to 46⬚C for 60 minutes, and
date has been RF energy. During RF ablation, receive heat by thermal conduction. occurs more rapidly as the temperature
electrical current from the generator oscil- Ablative heating leads to tissue dehydra- rises. Immediate cellular damage centers on
lates between electrodes through ion chan- tion and water vaporization, which cause protein coagulation of cytosolic and mito-
nels present in most biological tissues. In this dramatic increases in circuit impedance. chondrial enzymes and nucleic acid–
way, the RF ablation setup can be thought of These rapid and often sudden increases in histone protein complexes. The exact tem-
as a simple electrical circuit, where the cur- impedance can be used as a feedback signal perature at which cell death occurs is
rent loop comprises a generator, cabling, in RF generators, which will be covered in multifactorial and tissue specific. Based
electrodes, and tissues as the resistive ele- more detail later. When these effects begin upon prior studies demonstrating that tis-
ment. Tissues are imperfect conductors of to inhibit current flow from a generator, al- sue coagulation can be induced by focal tis-
electricity (i.e., they have electrical imped- ternative methods to decrease circuit im- sue heating to ⬃50⬚C for ⬍5 minutes, this
ance), so current flow leads to frictional agi- pedance such as expanding the electrode has become the standard surrogate endpoint
tation at the ionic level and heat generation, surface area, pulsing the input power, and for thermal ablation therapies (Fig. 2).

www.medicalebookpdf.com

LWBK892_c13_p196-204.indd 197 10/28/11 3:55:02 PM

 198 Part II: Basic Surgical Skills: New and Emerging Technology

A B

Fig. 2. Schematic (A) and pictorial (B) representation of focal thermal ablation therapy. Electrode applicators are positioned
either with image guidance or direct visualization within the target tumor, and thermal energy is applied via the electrode.
This creates a central zone of high temperatures in the tissue immediately around the electrode (they can exceed 100°C), and
surrounded by more peripheral zones of sublethal tissue heating (⬍50⬚C) and background liver parenchyma.

Electrodes In contrast, electrodes with multiple properties. Deployable electrodes are capa-
Although any conductor and power source tines emanating from a single electrode ble of creating zones of ablation approxi-
can create a thermal ablation, the power sheath or handle assembly aim to distribute mately 5 to 7 cm in diameter, though care
output and control algorithms of each gen- energy spatially. The use of multiple tines should be taken when evaluating device per-
erator have been tailored to suit their asso- improves heating efficiency in the target formance since deployable designs have also
ciated electrode(s). Most RF ablation sys- volume and also increases total electrode been associated with irregular heating pat-
tems today operate in a monopolar mode surface area, thereby reducing circuit im- terns. In general, multi-tined electrodes are
using two different types of electrodes: in- pedance and promoting greater energy de- more invasive and may increase complica-
terstitial and dispersive electrodes (ground position. As a result, larger zones of abla- tion rates, especially in percutaneous set-
pads) on the skin surface. The interstitial tion and potentially faster heating can be tings, though relevant comparisons between
electrode delivers energy to the tumor, cre- obtained. One type of multi-tined electrode devices are lacking. Introduction or retrac-
ating a volume of high current density and utilizes three single 17-gauge electrodes, tion complications with deployable elec-
localized heating. The ground pad closes spaced 5 mm apart in a triangular configu- trodes have been reported, but are relatively
the electrical current path, but is designed ration and driven in parallel by the same rare. Examples of multi-tined deployable de-
to disperse energy over a large surface generator source. This configuration effec- signs include the StarburstTM (RITA Medical
area to reduce the likelihood of thermal in- tively behaves as a single, larger electrode Systems, Mountain View, CA) and LeVeenTM
jury to the skin. but with a limited puncture area, and can (Boston Scientific Corporation, Natick, MA)
Monopolar electrode designs include create zones of ablation over 3 cm in diam- electrodes (Fig. 3).
both straight insulated needles with an ex- eter in normal liver in 12 minutes with a Alternatively, in bipolar systems, current
posed metallic tip and multi-tined elec- 200 W generator. The ClusterTM electrode oscillates between two interstitial electrodes
trodes. Internally cooled electrodes use a (Covidien) is an example of a nondeploy- without the need for a ground pad. The elec-
single needle, in which fluid is circulated able multi-tined electrode. trodes may lie on separate applicators, or be
inside the electrode’s active tip, and tem- Other multi-tined electrode designs de- situated longitudinally along the same ap-
peratures at the electrode–tissue interface ploy several smaller electrodes from a single plicator. The bipolar setup restricts current
are reduced. Lower temperatures inhibit needle shaft. Two such designs are clinically flow primarily to the area between the elec-
charring, which in turn allows increased available today that create either star-shaped trodes and protects this area from perfusion-
power deposition. In effect, internal cooling or umbrella-shaped arrays. Star-shaped mediated cooling, resulting in faster and
drives RF heating from the electrode–tissue electrodes are deployable from a 14-gauge more focal heating between the electrodes.
interface deeper into the tissue to create (2.1-mm diameter) needle using arrays of 4, Bipolar operation may require more precise
more clinically relevant ablations (⬃2 cm 9, or 12 tines. Many such electrodes also uti- placement of the electrodes to create a con-
in diameter in normal liver). When using lize hollow tines capable of injecting saline fluent zone of necrosis and can be limited by
water as a cooling fluid, the initial tempera- into the surrounding tissue to reduce imped- local changes in conductivity resulting from
ture of the water does not seem to impact ance and increase energy delivery. Umbrella- the ablation. For this reason, bipolar systems
device performance. The cooled needle de- shaped electrodes, on the other hand, con- often use saline infusion to increase energy
sign also uses a smaller caliber applicator tain 10 tines and are deployed from a delivery between the electrodes. More recently,
(17-gauge, 1.5-mm diameter), compared to 13-gauge needle. These tines are electrically “multipolar” operation has become avail-
expandable electrodes. Internally cooled connected and operated in parallel, which able, which involves switching between pairs
needles are now employed by the Cool-tipTM means that current flowing through each of bipolar electrodes situated on individual
system (Covidien, Boulder, CO). tine can vary depending upon local tissue needles. The ProSurgeTM system (Celon AG;

www.medicalebookpdf.com

LWBK892_c13_p196-204.indd 198 10/28/11 3:55:03 PM

 Chapter 13: Cancer Ablation: Understanding the Technologies and Their Applications 199

A B

Basic Surgical Skills: New and

Emerging Technology
C D

Fig. 3. Various RF electrode designs. Commonly used and commercially available electrode designs, including (A) a single
internally cooled electrode with a 3 cm active tip (Cool-tipTM system, Valleylab, Boulder, CO), (B) a cluster internally cooled
electrode system with three 2.5 cm active tips (ClusterTM electrode system, Valleylab, Boulder, CO), and two variations of
an expandable electrode system (C: StarburstTM, RITA Medical Systems, Mountain View, CA; D: LeVeenTM, Boston Scientific
Corporation, Natick, MA).

Teltow, Germany) is an example of a multi- underpowered for some clinical scenarios switches back on. This power pulsing algo-
polar device. (e.g., in lung). Higher-power designs are rithm has been shown to increase ablation
currently under development to address zone size and decrease treatment time.
Generator and Ground Pads these problems. Switching between multiple electrodes
The RF ablation generator provides three The most important distinguishing fac- based on impedance spikes uses the inher-
essential functions: power generation, con- tor between commercially available genera- ent off-time of the power pulsing algorithm
trol, and user interface. Power output is tors is in the feedback and control system. to deliver energy through another electri-
controlled by the output voltage and circuit Both impedance-based and electrode tem- cally independent electrode. Up to three
impedance, which includes all possible fac- perature-based controls are available. In equivalent ablations can be created inde-
tors such as electrode design, target tissue the Boston Scientific system, power is set pendently in the same time as a single-
environment, background tissue proper- initially at a relatively low level (typically 20 electrode ablation, or a closely spaced array
ties, and ground pad connectivity. Since to 50 W) and gradually increased until im- can be used to create large, conglomerate
power depends on impedance, RF ablation pedance elevates to near-infinite levels. In ablations with substantial time savings over
may be limited in areas of high background the Covidien system, initial power is usually the technique of overlapping single-
impedance, such as the lung, even if the tu- set to the maximum level. When the circuit electrode ablations.
mor exhibits a relatively high conductivity. impedance spikes rapidly, the generator Electrode tip temperatures are also moni-
As tissue impedance rises, power output turns off RF power for a short period to fa- tored in some systems; however, only the An-
tends to decrease. Generators are now cilitate tissue cooling, which allows more gioDynamics/RITA system uses that infor-
available from 150 to 250 W, which may be power to be used when the generator mation to control power output. In that

www.medicalebookpdf.com

LWBK892_c13_p196-204.indd 199 10/28/11 3:55:05 PM

 200 Part II: Basic Surgical Skills: New and Emerging Technology

system, generator output is ramped until waves also heat tissue more efficiently than tion as well. Laser sources—including
electrode temperatures reach a predeter- RF energy in tissue; microwaves do not re- pumped, neodymium-doped, yttrium alumi-
mined value, usually around 95⬚C, and main- quire ground pads, and multiple antennas num garnet (Nd:YAG), and semiconductor
tained at this temperature for typically 20 can be operated simultaneously. diodes that emit ⬃600 to 1,000 nm wave-
to 30 minutes. This power delivery strategy On the other hand, microwave energy is length light energy—can be found in most
works effectively with multiple-tine electrode inherently more difficult to distribute than clinical centers but rarely are they employed
designs because of the dispersion in current RF energy. Microwaves must be carried in for thermal tumor ablation. Adoption outside
density and large electrode surface area. waveguides, such as coaxial cable, which of a few centers in Europe has been relatively
The ground pad used with monopolar are typically more cumbersome than the weak compared to RF and cryoablation, in
electrodes is intended to provide a large small wires used to feed energy to RF elec- part due to a lack of FDA-approved systems,
dissipative surface for electrical current trodes and prone to heating when carrying sparse availability of applicators, and few per-
flow through the skin. However, most of the large amounts of power. It is well known formance advantages over existing RF, mi-
current tends to congregate around the that higher microwave powers increase ab- crowave, and cryoablation systems.
edge of the pad nearest to the interstitial lation zone size, but excessive power in the Like RF and microwave energy, lasers in-
electrode and skin burns can result from antenna shaft can lead to unintended inju- duce electromagnetic heating to elevate tis-
uneven placement or insufficient number ries to traversed tissues, such as the skin. sue temperatures to lethal levels. The pri-
of pads. In practice, given substantial atten- Recent investigations have shown that add- mary advantage of using laser energy is that
tion to this problem, ground pad burns are ing a cooling jacket around the antenna can it may be coupled through optical fibers,
rarely a problem. Nevertheless, as more RF reduce cable heating and eliminate skin which are inherently MRI-compatible. In
energy is being applied per procedure with burns while effectively increasing the addition, the lack of metal in the power dis-
higher power and multiple-electrode sys- amount of power that can safely be deliv- tribution chain and relatively small diame-
tems, ground pad loads are also increasing. ered to the tumor. ter of most applicators effectively elimi-
Strategies to prevent ground pad burns in- The purpose of the antenna is to couple nates image artifacts on CT and MRI. Thus,
clude monitoring temperature and imped- energy from the feeding cable into the tis- it is more reasonable to perform MR tem-
ance through each pad, cooling the pad, sue. Antenna designs vary, and trade-offs perature mapping during laser ablation.
optimized pad designs, and switching be- between antenna efficiency, size, and heat- Laser light is a very efficient and precise
tween pads to reduce heating. ing pattern are often required. Antenna energy source for tissue heating. However,
In summary, notable advantages of RF properties such as efficiency and heating because light is scattered and absorbed rap-
ablation include the largest worldwide clin- pattern are primarily controlled by the sur- idly by most body tissues, lasers have lim-
ical and experimental published experience rounding tissue properties and antenna ge- ited energy penetration and create smaller
among thermal ablation technologies, and ometry. Common designs include mono- ablation zones than many other devices
the small caliber of its electrodes. Disad- pole, dipole, triaxial, choked, and slotted currently in use (1 to 2 cm diameter). Light
vantages include its susceptibility to heat- antennas. Most antennas utilize a straight does not penetrate through charred or des-
sink effect (insufficient heat deposition needle-like design, though deployable loops iccated tissues. Diffuser tips are used to im-
close to blood vessels or airways) and the have also been reported. prove applicator heating profiles and higher
small risk of skin burns at the grounding Microwave ablation has been utilized powers can offset the reduced penetration
pad sites. the most in Japan and China, where several depth by increasing local temperatures, but
systems have been described. Most of these when high powers are used, fibers must be
Microwave Ablation systems operate at 2.45 GHz and use mono- cooled to avoid skin burns or probe failure.
pole, dipole, or slotted coaxial antennas to Cooling increases the diameter of each ap-
The term “microwave” describes electromag- deliver up to 60 W. Recently, 915 MHz and plicator. Larger ablation volumes are typi-
netic energy in the range of 300 MHz to 300 water-cooled systems have been described cally realized using multiple applicators,
GHz though, for practical and regulatory rea- that appear to deliver up to 80 W and create which can be operated independently and
sons, microwave ablation devices are typi- larger ablations than previous-generation simultaneously.
cally operated at either 915 MHz or 2.45 GHz. systems. At the present time, only one sys-
When electromagnetic energy is applied to tem is FDA-approved and actively marketed
tissue, some of the energy is used to force
Cryoablation
for percutaneous microwave tumor abla-
molecules with an intrinsic dipole moment tion in the United States (Covidien). The While early generation cryotherapy systems
(i.e., water) to continuously realign with the EvidentTM system comprises a water-cooled were bulky and limited to open surgical use,
applied field. This rotation of molecules rep- 13-gauge dipole antenna coupled to a 915 modern systems use more advanced cooling
resents an increase in kinetic energy and, MHz generator with a maximum output techniques that allow laparoscopic and per-
hence, an elevation in local tissue tempera- power of 45 W. Other systems are currently cutaneous approaches in combination with
tures. As such, microwave energy has dem- in development worldwide and will likely imaging guidance. However, it is important
onstrated several advantages for tissue abla- see clinical launch in the United States to note that the size of the ablation zone cor-
tion. Microwaves readily penetrate through within the next few years. relates to probe diameter in these systems;
biological materials, including those with that is, smaller-diameter cryoprobes typically
low electrical conductivity such as the lung create smaller zones of complete ablation.
and the bone, and dehydrated or charred tis-
Laser Ablation For example, 13-gauge (2.4 mm diameter)
sue. Consequently, microwave power can be Laser ablation is familiar to many for treating cryoprobes from one manufacturer (Endo-
continually applied to produce very high skin disorders or corrective procedures in the care, Irvine, CA) can be expected to produce
temperatures (over 150⬚C), which improves eye, but similar generator technologies and zones of ablation ⬃2.5 cm in diameter in nor-
ablation efficacy by increasing thermal con- specially designed applicators have allowed mal liver and lung tissues, while 15-gauge
duction into the surrounding tissue. Micro- lasers to be used for interstitial tumor abla- (1.7 mm diameter) probes will create 1.5 to

www.medicalebookpdf.com

LWBK892_c13_p196-204.indd 200 10/28/11 3:55:09 PM

 Chapter 13: Cancer Ablation: Understanding the Technologies and Their Applications 201

A B

Basic Surgical Skills: New and

Emerging Technology
Fig. 4. Cryoablation. (A) Schematic illustration of the tip of a cryoprobe with surrounding iceball formation. (B) An axial
contrast-enhanced CT image demonstrates multiple cryoprobes placed and iceball formation during cryoablation of a tumor
in the right lobe of the liver.

2.0 cm zones of ablation in these same or- trasound a unique ability to concentrate an attractive option for thermally sensitive
gans. For this reason, many users choose to maximal heating in one sector to increase areas (e.g., in the prostate, near large blood
employ two or more cryoprobes in proximity local heating with relatively high precision, vessels, bile ducts, or the renal cortex).
to ensure complete coverage of the tumor by and larger ablations may be realized by IRE electrodes consist of insulated 19-
the lethal isotherm. Thermal synergy between sweeping the active heating region through gauge (1.1 mm diameter) or larger needles
cryoprobes has been shown to improve effi- the target volume. The directivity of the ap- with an exposed active portion of 1 to 4 cm.
cacy in both numerical and experimental tis- plicator may also be used to protect critical For most applications, multiple electrodes
sue models, though inappropriate spacing in structures while heating nearby tissues. are required and spaced 1 to 3 cm apart to
a given tissue type may lead to clefts between To date, the diameters of many of these provide sufficient electric field strengths for
zones of ablation. Lethal target temperatures devices have been larger than 13-gauge, irreversible cell damage. A single-needle bi-
achieved with cryoablation therapy range be- falling outside the boundaries of what is polar electrode is also available for more
tween −20°C to −40°C. normally considered acceptable for percu- localized treatments. While initial studies
Common clinically treated tumors in- taneous tumor ablation; however, percuta- required very high-voltage pulses, recent
clude focal primary renal tumors and palli- neous devices have been investigated. Re- reports have shown that lower-voltage
ative treatment of osseous metastases. cent reports in animal prostate models pulses can be used when repeated several
A key advantage of cryoablation when have demonstrated the potential of percu- hundred times.
compared to other technologies is the easy taneous interstitial ultrasound heating for Current IRE devices do have notable
visualization of the treatment zone (ice ball), interventional oncology, but almost no drawbacks, including generation of poten-
using imaging methods during the treat- clinical experience exists. tially dangerous electrical harmonics that
ment. This allows for reliable monitoring of can stimulate muscle contraction or car-
ablation coverage of the lesion and appar- diac arrhythmias. Therefore, these tech-
ently healthy margins. Relative disadvan-
Irreversible Electroporation niques require general anesthesia and para-
tages of cryoablation include the relatively Percutaneous IRE is a relative newcomer to lytic induction. There is also a requirement
large size and number of probes necessary the field of tumor ablation, and is most no- for accurate placement of several needles
for adequate tumor coverage and the in- table because it is inherently nonthermal, to achieve moderately sized ablations (⬃3
creased length of time for a complete treat- that is, no heat is produced to cause cell to 4 cm); and a lack of coagulation around
ment cycle ( freeze-thaw-freeze), when com- death. Rather, cells are eradicated using the needle insertion sites, which theoreti-
pared to most heat-based systems (Fig. 4). several microsecond- to millisecond-long cally could elevate bleeding complication
pulses of electrical current. The pulses gen- risks. Ongoing research aims to minimize
erate electric fields up to 3 kV/cm, which these complications.
EMERGING TECHNOLOGIES cause irreversible damage to the cell mem-
brane, thereby inducing apoptosis. Since
Ultrasonic Ablation IRE is nonthermal, heat sinks such as large
Comparison of Technologies
In addition to the well-known transcutane- vessels should have a much smaller influ- While each thermal ablation energy source
ous uses of ultrasound, it is also possible to ence on the ablation zone as with thermal is unique, the goal of each is to change tis-
elevate tissue temperatures using intersti- treatments. IRE also appears to limit dam- sue temperatures enough to create zones of
tial ultrasound applicators. Highly direc- age to more collagenous tissues and nerves, irreversible cellular damage. RF energy is
tional power delivery gives interstitial ul- which if verified in larger trials will make it relatively inexpensive and easy to generate,

www.medicalebookpdf.com

LWBK892_c13_p196-204.indd 201 10/28/11 3:55:09 PM

 202 Part II: Basic Surgical Skills: New and Emerging Technology

but is limited by the need for electrical cur- Regarding kidney tumors, data on both sublethal hyperthermia, and (c) surround-
rent flow. For this reason, RF suffers in areas RF and cryoablation, and on both percuta- ing tumor or normal tissue that is unaf-
of high blood flow or high tissue impedance neous and laparoscopic approaches, seem to fected by focal ablation, though still exposed
(e.g., lung), and requires electrical switching indicate midterm oncologic efficacy similar to adjuvant systemic therapies.
for effective multiple-applicator use. Micro- to what is encountered with partial nephre- Several studies have demonstrated that
wave heating is fast and efficient and, thus, ctomy. The laparoscopic approach to abla- tumor death can be enhanced when com-
appears better-equipped to overcome heat tion seems to have higher rates of complete bining RF thermal therapy with adjuvant
sinks and treat large tumor volumes. Micro- tumor ablation achieved in a single treat- chemotherapy or radiosensitizers. The goal
waves are also relatively tissue-insensitive ment session, while the percutaneous ap- of this combined approach is to increase tu-
and offer improved multiple-applicator sup- proach seems to have less periprocedural mor destruction occurring within the siz-
port, but can be more difficult to distribute morbidity and complications. The highest ef- able peripheral zone of sublethal tempera-
than other energy sources. Laser energy is ficacy and lowest complication rates are tures (i.e., largely reversible cell damage
also fast, relatively tissue insensitive, and seen for smaller and exophytic renal masses. induced by mildly elevated tissue tempera-
generators are already available worldwide, tures from 41 to 45°C) surrounding the
but ablation applicators are not as common CURRENT RESEARCH AND heat-induced coagulation. Additional ad-
and perform about the same as established FUTURE DIRECTIONS vantages of combined therapy also may in-
RF electrodes of similar size. Interstitial ul- clude creating a more complete area of tu-
trasound devices offer better control of the Combining Ablation with mor destruction by filling in untreated gaps
applicator heating pattern, but are typically Other Therapies within the ablation zone, and reducing the
too large for percutaneous use and are, so duration or course of therapy (a process
far, clinically unproven. Finally, operator While substantial efforts have been made in which currently takes hours to treat larger
technique may have as much influence on modifying ablation systems and the bio- tumors, with many protocols requiring re-
performance as device technology; for ex- logic environment to improve the clinical peat sessions).
ample, multiple applicators can be used to utility of percutaneous ablation, limitations
increase heating rather than switching to a in clinical efficacy persist. For example,
different energy source. Although some en- with further long-term follow-up of patients Thermal Ablation Combined
ergy sources may be better suited to certain undergoing ablation therapy, there has been with Chemotherapy
applications, none has proven itself a clear an increased incidence of detection of pro- Combining thermal ablation (predominantly
favorite for all applications. gressive local tumor growth for all tumor using RF-based systems) with chemotherapy
types and sizes despite initial indications of (either free or contained within liposomes),
CLINICAL OUTCOMES OF adequate therapy, suggesting that there are through direct injection, intravenous, or
residual foci of viable, untreated disease in
TUMOR ABLATION a substantial number of cases. The ability to
intra-arterial administration, increases the
overall volume of tumor necrosis, as well as
Two recent prospective randomized trials achieve complete and uniform eradication intratumoral drug accumulation. These ef-
have shown overall survival and disease- of all malignant cells remains a key barrier fects occur preferentially in the peripheral
free survival up to 4 years to be equivalent to clinical success, and therefore, strategies zone of hyperemia surrounding the central
between RF ablation (95.8%, 82.1%, 71.4%, that can increase the completeness of RF zone of ablation, and have been confirmed
67.9% at 1, 2, 3, and 4 years, respectively) tumor destruction, even for small tumors, in larger animal tumor models, in different
and surgical resection for hepatocellular are needed. tumor and tissue types, for different chemo-
carcinomas ≤5 cm. Periprocedural morbid- Investigators have sought to improve re- therapeutic agents, and in a pilot clinical
ity and complications were less frequent in sults by combining thermal ablation with study in primary and secondary hepatic ma-
patients who underwent ablation. adjuvant therapies such as radiation and lignancies. In clinical cases, the treatment
For colorectal metastases to the liver, sur- chemotherapy. Currently, thermal ablation effect extended in most cases to encompass
vival data for ablation is not as good as what only takes advantage of temperatures that peritumoral liver, and enabled the destruc-
is seen with surgical resection. For percuta- are sufficient by themselves to induce co- tion of the difficult to treat 0.5 to 1 cm “abla-
neous RF ablation, the 1-, 3-, and 5-year sur- agulation necrosis (⬎50°C). Yet, based upon tive margin.” The cytotoxic effects of the che-
vival rates range from 91% to 93%, from 28% the exponential decrease in RF tissue heat- motherapy agent combines with the heat-
to 69%, and from 25% to 46%, respectively. ing, there is a steep thermal gradient in tis- induced reduction in cellular reparative
Tumor ablation has emerged as a prom- sues surrounding an RF electrode. Hence, mechanisms to increase apoptosis as well as
ising treatment alternative for patients there is substantial flattening of the curve other cytotoxic mechanisms.
with primary and secondary lung tumors, below 50°C, with a much larger tissue vol-
who are not considered surgical candi- ume encompassed by the 45°C isotherm. Thermal Ablation with
dates. The best survival results have been Modeling studies demonstrate that were
demonstrated for tumors smaller than the threshold for cell death to be decreased
Radiation Therapy
3 cm. Survival data is not as strong as that by as few as 5°C, tumor coagulation could Investigators have begun exploring combi-
seen in the surgical resection literature. be increased up to 1.5 cm (up to a 59% in- nation RF ablation and radiation therapy
While this may be due to limited efficacy of crease in spherical volume of the ablation with promising results. Previous data in
ablation in this particular organ, it may zone). Therefore, target tumors can be con- the literature has demonstrated increased
also be a result of patient selection (all pa- ceptually divided into three zones: (a) a cen- tumor destruction with external-beam ra-
tients referred for ablation have severe co- tral area, predominantly treated by thermal diation therapy and low-temperature hy-
morbidities—most commonly advanced ablation, which undergoes heat-induced perthermia. More recent experimental ani-
COPD—which deemed them unfit for sur- coagulation necrosis, (b) a peripheral rim, mal studies have demonstrated increased
gical resection). which undergoes reversible changes from tumor necrosis, reduced tumor growth, and

www.medicalebookpdf.com

LWBK892_c13_p196-204.indd 202 10/28/11 3:55:09 PM

 Chapter 13: Cancer Ablation: Understanding the Technologies and Their Applications 203

improved animal survival with combined that includes an understanding of the goals Gervais DA, Goldberg SN, Brown DB, et al. Soci-
therapy when compared to either therapy of tumor ablation and the mechanisms of ety of Interventional Radiology position state-
alone. Preliminary clinical studies in pri- tissue destruction that occur with ablation ment on percutaneous radiofrequency ablation
for the treatment of liver tumors. J Vasc Interv
mary lung malignancies confirm the syner- are a necessary prerequisite to its success- Radiol 2009;20:S342–7.
gistic effects of these therapies. Potential ful clinical application. Several successful McWilliams JP, Yamamoto S, Raman SS, et al. Percu-
causes for the synergy include the sensitiza- strategies have been used to improve ther- taneous ablation of hepatocellular carcinoma: cur-
tion of the tumor to subsequent radiation mal ablation efficacy including technologi- rent status. J Vasc Interv Radiol 2010;21:S204–13.
due to the increased oxygenation resulting cal advancements in ablation devices, ap- Mendiratta-Lala M, Brook OR, Midkiff BD, et al.
from hyperthermia-induced increased blood plicator developments, and modifications Quality initiatives: strategies for anticipating
and reducing complications and treatment fail-
flow to the area surrounding the tumor. An- of tissue and tumor environment. Finally, ures in hepatic radiofrequency ablation. Radio-
other possible mechanism, which has been thermal ablation has been successfully graphics 2010;30:1107–22.
seen in animal tumor models, is an inhibi- combined with adjuvant chemotherapy and Mostafa EM, Ganguli S, Faintuch S, et al. Optimal
tion of radiation-induced repair and recov- radiation, and future investigation will ex- strategies for combining transcatheter arterial
ery and increased free radical formation. plore tailoring-specific adjuvant therapies chemoembolization and radiofrequency abla-
for specific tumors and organs. tion in rabbit VX2 hepatic tumors. J Vasc Interv
Radiol 2008;19:1740–8.
CONCLUSION Pua BB, Thornton RH, Solomon SB, et al. Abla-
Thermal ablation is being more widely ac- SUGGESTED READINGS tion of pulmonary malignancy: current status.
J Vasc Interv Radiol 2010;21:S223–32.
cepted in clinical practice for treatment of a Flanders VL, Gervais DA. Ablation of liver me- Thumar AB, Trabulsi EJ, Lallas CD, et al. Thermal abla-

Basic Surgical Skills: New and

range of tumor types in various organ sites. tastases: Current status. J Vasc Interv Radiol tion of renal cell carcinoma: triage, treatment and

Emerging Technology
However, a good conceptual framework 2010;21:S214–22. follow-up. J Vasc Interv Radiol 2010;21:S204–13.

EDITOR’S COMMENT nonetheless, survival in 5 years did not necessar- between 2.8 and 9 months, the long-term survival
ily mean that the patient lives forever. I had one is followed and does seem to be approximately in
patient who had a clear bill of health at 5 years, some as long as 6 years and others 5 years. One
The concept of radiofrequency (RF) ablation, and stopped returning for a follow-up because he patient died post procedure from a bowel per-
which has changed a lot since the last edition, misunderstood what that meant and showed up foration, which took place 10 weeks later. This
now includes many other forms of energy as 8 years following the original primary with a cau- patient actually had the unrecognized bowel per-
compared with the last edition. However, the date lobe recurrence after a right hepatectomy, foration after RF ablation of four retroperitoneal
concerns about RF ablation are the same and al- which was unresectable, and of course died not too metastases at the crus of the diaphragm. I believe
though different forms of energy could be utilized, much later. The problem with the advertisements, that this is an inadvertent leakage of RF along the
the questions about it remain. Dr. Faintuc and his as it were, for RF ablation remains the same—that electrode. He died in an outside hospital 10 weeks
coworkers have written a very reasonable and the RF ablation is carried out percutaneously and after the ablation procedure but was hospitalized
modest approach to RF ablation, and included usually under ultrasound or occasionally under at that hospital 4 days post procedure. Another
not only RF ablation, with which they spend most MR, and then followed up a week later to see for patient was admitted to the medical service with
of the time since that is the form of energy, which its completeness. However, those who do RF abla- wide swings in blood pressure, indicating that the
is most current, but also a number of other forms tion always quote the paper of Dr. Pfister and his pheochromocytoma had not been controlled. We
of energy in development and different types of group from M.D. Anderson, which has the highest are left, as are the authors, with a question about
transfers. They also have talked about cryoabla- survival and that is because the RF ablation was whether or not this was a useful or something
tion, which of course was in use at the time of done openly so that the outcomes from that type that should approach larger use. They themselves
the last edition, but cryoablation seems to have of approach have always been better than those suggest that they need to do follow-ups with the
dropped as a means of energy transfer for the that have been done percutaneously. However, quality of life.
very simple reason that the bleeding rate has at least at this point in time, there is beginning to Another approach to other areas is non–
been significantly higher than the other forms of be a realization from hard data that the outcome small-cell lung cancer and RF ablation (Beland
radio ablation. The types of lesions, which have in colorectal disease, which is the most frequent MD et al., Radiology 2010;254:301–7) in which 79
now been ablated or destroyed or attempted to reason to do RF ablation, is not as good as open patients who were said to be nonsurgical candi-
be destroyed have been enlarged. The basic issue surgery as the authors state in the chapter. dates underwent RF ablation from January 1998
remains the same. There needs to be a 0.5 to 1 cm Other groups (McBride JF et al., J Vasc Interv to January 2008. Ten patients had no posttreat-
ablated margin around the tumor that is being Radiol 2011;22:1263–70) evaluated a minimally ment imaging and two patients were excluded
dealt with. In the past, the question of viable cells invasive treatment for metastatic pheochromo- with multiple treated lung cancer. Tumor size
remains, and although there may be but a few, cytoma and paraganglioma in 10 patients treated was between 2.5 cm as a mean, but up to 5.5 cm.
since there is ample detritus debris from the cells from May 2001 to November 2009 (mean age 45 Fifteen (19%) of the tumors were central, and
that have died, one assumes that the cells have an years) with metastatic pheochromocytoma and 64 (81%) were peripheral. Twenty-four percent
ample source of protein and energy that then can paraganglioma and treated with percutaneous of patients underwent adjuvant external beam
lead to recurrence and the outcomes that have ablation. These patients apparently were not radiation and therefore probably should be ex-
been reported basically show the same pattern as considered surgical candidates, although it is not cluded from the results. Another 11% underwent
many neoplastic diseases, a high rate of survival entirely clear as to why that is the case. Of the ab- concomitant brachiotherapy. Follow-up was
for the first year, and then a steady drop off until lation procedures, 16 of the 18 sessions were per- from 1 to 92 months, with a mean of 17 months;
the fifth year. Initially, the chapter was to contain formed in a hospital CT suite using CT guidance 45 patients (57%) had no evidence at time of
a section on outcomes, and in fact it did, but Dr. for bone tumors, CT and ultrasound guidance follow-up of recurrence ; recurrence was seen in
Faintuch decided to withdraw it. for superficial tumors, or CT and ultrasound for 34 (43%) of patients with a range of 2—which is
One of the issues that is disappointing is that selective hepatic tumors. Two ablation sessions probably persistence—and 48 months, with a
the principal views for RF ablation in metastatic were performed intraoperatively in conjunction mean of 14 months. Only local recurrence was
disease of colorectal tumors to the liver is clearly with a general surgery team or an orthopedic seen in 38%, that is, at the area which had been
seen as not being as good as open resection, which surgery team. Although the follow-up that is ablated of which intrapulmonary recurrence was
has at least a 30% 5-year survival. I would say that mentioned in the paper is relatively short, that is six (18%), nodal was six (18%), mixed in two (6%),

(continued)

www.medicalebookpdf.com

LWBK892_c13_p196-204.indd 203 10/28/11 3:55:09 PM

 204 Part II: Basic Surgical Skills: New and Emerging Technology

and distant in seven cases (21%). Mean survival compression and rarefaction of the tissue; in di- me most uncomfortable. The one saving grace of
was 23%. Given the fact that mean survival was agnostic ultrasound, the waves are reflected back the studies that are proposed is that the patients
23% and the patients were nonoperative candi- to the probe, resulting in information that can will then be followed by an MRI tumor viabil-
dates for whatever reason, and given the fact that be used to create an image of the tissue. FUSA ity assessment at 10 to 14 days; all patients will
the department of thoracic surgery was allegedly uses a higher-power ultrasound waves at lower then undergo excision and standard therapy. The
consulted, this may be a reasonable way to go in frequency, between 0.8 and 3.5 MHz. The beam study is in its final stages of preparation for FDA
certain recurrent tumors. is focused on a selected point, passing through approval. Apparently in China, another group is
Another way of considering types of ablation the skin seemingly without damage to the focal using this technique in 22 patients as primary
was the synergistic administration of photother- point, where the rarefaction and compression treatment of breast cancer without excision. They
mal therapy and chemotherapy utilizing various rapidly heat and physically disrupt the target tis- had tumors ranging from 2 to 4.8 cm; all patients
plasmonic matrices. This is from the journal of sue. Apparently, the energy is delivered to a small, received a combination of chemotherapy, radia-
Nanomedicine, 2011;6:459–73 by Huang et al. cigar-shaped target volume, measuring up to 3 by tion therapy, and tamoxifen following USgFUSA.
from a combination of the chemical engineering 15 mm. If a larger volume of treatment is desired, To make a long story short, despite ultrasound-
department at Arizona State University in Tempe, multiple cigar-shaped sonification zones are ar- guided biopsies, at 2 weeks, 3 months, 6 months,
as well as the Center for Engineering in Medi- rayed side by side. The lethal force is thermal en- and 1 year, no viable tumor was identified within
cine at the Mass General Hospital and Harvard ergy and mechanical stress. The FUSA can raise the first year. However, 2 of 22 patients devel-
Medical School. In this paper, which is clearly the temperature to about 80°C; maintenance of oped local recurrence in the treated area—one at
experimental, the combination of gold particles tissue temperature at greater than 56°C for more 18 months and the other at 22 months after abla-
in nanorod elastin-like polypeptide matrices, than 1 second is generally accepted to result in tion. This is a very complicated protocol, which
which were generated and also loaded with the cell death. It apparently does not leave a scar and seems initially to have a local recurrence at the
heat-shock protein in vitro; cells cultured over Figure 1 shows four patients with T1, N0 breast site of treatment in ⬃10%. I am not certain what
the plasmonic matrices resulted in the viability cancer treated without excision. They were pa- advantages it offers, because it is very complex
of such cells. The combination of hyperthermic tients treated with courtesy of Dr. Furusawa at and it requires very careful follow-up with mul-
temperatures and the release of 17-AAG, a heat- Breastopia, Namba Hospital, Miyazaki, Japan. tiple percutaneous biopsies. I am surprised that
shock inhibitor, seemed to result in a ⬎90% death They treated 12 patients with invasive breast the FDA would approve this if they knew the data
of cancer cells while hyperthermia alone and cancers ⬍3.5 cm who underwent MRgFUSA in a given the difficulties that the FDA has given to a
17-AAG alone demonstrated minimal loss of can- volume of breast tissue with an estimated normal variety of studies that actually do not have this
cer cell viability. This is an interesting approach volume margin of 0.5 cm. Twenty-four days after kind of recurrence.
and it is one of the early applications of nanomed- this treatment, all patients underwent routine Finally, speaking of therapies which one
icine that I have seen. It will undoubtedly signal segmental resection and they had a minimum wonders about, Goers et al., in a paper entitled
the interest in greater use of nanomedicine, for distance of 1 cm between the tumor and the “Concomitant Endoscopic Radiofrequency Abla-
example, as that seen in the next paper, which is skin on the ribs. The resected specimen under- tion and Laparoscopic Reflux Operative Results
by Walter et al. (J Nanobiotechnol 2010;8:21–32). went an exhausted series of examinations using in More Effective and Efficient Treatment of Bar-
In this paper, the laser ablation is based on in situ three-dimensional macroscopic and microscopic rett Esophagus,” report on 10 patients selected
conjugation of nanoparticles with biomolecules histopathologic measurements combined with for combination treatment of Barrett esophagus
in an aqueous medium. The DNA aptamer, which standard hematoxylin-eosin staining. In the first using endoscopic RF ablation, which apparently
was directed against streptavidin conjugation three patients, the treatment only necrosed 43% they believe is better than what we have, which to
resulted in nanoparticles with diameters of 9 nm of the tumors. In the last nine patients, 88% of my way of thinking is the excision of the Barrett
with a high surface density and a conjugation mean tumor volume was necrosed. Two of the esophagus endoscopically. Five of the patients
efficiency of 40.3%. They believed that the general last nine patients had no residual viable tumor. had 100% resolution of their Barrett esophagus
applicability of the in situ conjugation of gold Two patients suffered from second-degree skin at their first postoperative endoscopy, but the
nanoparticles may be a successful way of treating burns, both under 2.3 cm in size. “Based on their remaining three had a ⬎50% resolution and un-
human prostate cancer. initial feasibility study, Gianfelice and coworkers derwent additional endoscopic ablation. Four
Other energy transfer in an effort to induce concluded that MRgFUSA held significant prom- patients had substantial dysphagia to solids and
ablation in a more controlled fashion and hope- ise in terms of patient tolerability but that the other symptoms were minimal. Two patients
fully safer fashion was presented by Brenin (Ann observation of residual tumor at the margins of were noted to have complications related to the
Surg Oncol 2011, published online, 23 August the treatment zone suggested that refinements ablative treatments, which included one stricture
2011) using focused ultrasound ablation (FUSA) in tumor imaging and targeting were required.” I and one perforation. I am surprised that they
in breast cancer. This would seem to be a reason- would have to agree. can be optimistic about this study in which there
able approach to an accessible organ since ultra- Furusawa reported on 30 additional women were two highly significant complications (J Am
sound is already used in the diagnosis of breast with invasive breast cancer ⬍3.5 cm and wanted Coll Surg, 2011, published online). The patient
cancer; a nonabrasive ablative therapy is a natu- at least a 5 mm safety margin of normal tissue. with a perforation apparently had this discov-
ral continuation of the trend. The paper that is They were followed 5 to 23 days later by rou- ered 6 weeks postoperatively within the proximal
quoted discusses the concepts under ultrasound tine breast conserving surgery or mastectomy. RF ablation field. I could not discover what the
ablation therapy for the treatment of breast can- There were apparently five protocol violations, outcome of this patient was. Twenty percent had
cer and reviews the investigative experience to whatever they were, resulting in 25 evaluable pa- significant complications, including life in dan-
date. tients. Mean tumor necrosis was 98% by volume ger, related to the ablative treatments. To me,
Standard diagnostic ultrasound typically uti- and 100% necrosis was observed in 15 patients. this is not something that I would care to have
lizes frequencies between 1 and 20 MHz. They I must say that the subsequent discussion in publicized.
use alternating waves of pressure resulting in which a Phase II study is being planned leaves J.E.F.

www.medicalebookpdf.com

LWBK892_c13_p196-204.indd 204 10/28/11 3:55:09 PM

 Chapter 14: Upper and Lower Gastrointestinal Endoscopy 205

14 Upper and Lower Gastrointestinal Endoscopy

Jeffrey L. Ponsky and Jonathan P. Pearl

INTRODUCTION Other common indications for colonoscopy Hemostasis may be achieved by contact-
include diagnosis of infectious or inflamma- ing the source of bleeding with a probe and
Since the introduction of flexible endoscopy tory colitis, surveillance for dysplasia or car- applying tamponade and bipolar coagula-
five decades ago, surgeons have played a cinoma in patients with ulcerative colitis, tion at once or by supplying energy without
major role in its practice. Many of the and lower gastrointestinal bleeding. Colonos- contacting the source, such as argon plasma
advances in endoscopy were developed by copy may be used to decompress dilated coagulation. Nonthermal hemostasis can
surgeons, and endoscopy continues to be bowel in colonic pseudo-obstruction and be achieved with hemostatic clips, loops, or
the mainstay of diagnosis and treatment of untwist the sigmoid colon in volvulus. bands.
common gastrointestinal disorders. There are few absolute contraindications
We have entered a new era in endoscopic for endoscopy. Severe comorbidities and
therapy. The prospect of natural orifice sur- inability to tolerate conscious sedation pre-
ADVANCED IMAGING
gery using flexible endoscopes has led to a clude safe endoscopy. Endoscopic examina- IN ENDOSCOPY
renaissance in the practice of surgical en- tions should be performed with caution in White light is used for most endoscopic ex-

Basic Surgical Skills: New and

doscopy. Advanced imaging, instrumenta- patients with recent gastrointestinal anas- aminations and therapies. Most recent ad-
tion, and techniques facilitate complex en-

Emerging Technology
tomoses or inflammation of the gastroin- vances in endoscopic imaging enable the
doscopic therapies, which in many cases, testinal tract, such as diverticulitis. Endos- early detection of mucosal abnormalities in
supplant traditional surgical management. copy is not without complications and each either the upper or lower gastrointestinal
In order to practice modern gastrointestinal case should be carefully considered prior to tract. Performing this “optical biopsy” using
surgery, surgeons must become proficient performance of the examination. advanced imaging may direct biopsies and
in standard endoscopy and gain familiarity resections to areas of premalignant and
with the advanced endoscopic options. malignant change.
INSTRUMENTATION In chromoendoscopy, a liquid dye such
INDICATIONS AND Modern endoscopy is performed with a as methylene blue or Lugol’s solution is
CONTRAINDICATIONS FOR light source and a video processor attached applied to the gastrointestinal mucosa.
DIGESTIVE ENDOSCOPY to a flexible video endoscope. Develop- Diseases such as Barrett’s esophagus and
ments in digital camera technology have squamous cell carcinoma demonstrate dif-
Upper endoscopy may be prompted by com- allowed the integration of the two modali- ferential staining by normal cells and cells
plaints of dysphagia, odynophagia, or pyrosis. ties so that modern video endoscopes de- with metaplasia or dysplasia.
Suspected foreign body impaction, an abnor- liver light by a fiberoptic bundle, but trans- Narrow band imaging is available on
mal barium radiograph, and gastrointestinal mit the endoscopic image by digital signal most contemporary endoscopes. By chang-
bleeding will also indicate a need for endo- to a processor and video screen. The latter ing the bandwidth of projected light from the
scopic examination. Additional indications allows for a larger, brighter image, which endoscope, metaplasia and flat adenomas
for esophagogastroduodenoscopy include the can be easily recorded and electronically can be differentiated from normal mucosa.
need for tube gastrostomy for feeding or enhanced, if necessary. Optical coherence tomography (OCT) uses
drainage, persistent vomiting, unremitting A large variety of endoscopes are avail- reflection of near-infrared light to produce
epigastric pain, gastric polyposis, and surveil- able for diagnostic and specialized thera- real-time two-dimensional cross-sectional
lance for neoplasia in patients with condi- peutic purposes in adults and children. images of the gastrointestinal tract. A small
tions predisposing to malignancy such as These include small caliber (9 mm) gastro- probe, similar to an endoscopic ultrasound
Barrett’s esophagus, gastric ulcer, pernicious scopes and pediatric colonoscopes, large probe, is passed through the scope. OCT pro-
anemia, and previous gastrectomy. In most caliber (13 mm) and large working channel duces a high-resolution image of the layers of
cases, the modern endoscopist is prepared to (6 mm) scopes for complex interventions, the gastrointestinal tract and might be used
deliver therapy during the same procedure mother–daughter scope combinations for for early detection of dysplasia or metaplasia.
during which the diagnosis is established. biliary and pancreatic ductoscopy, and
Therapy may include removal of foreign bod- long slender enteroscopes for small bowel Technique of
ies, dilation of strictures, ablation or stenting examination. A double-balloon endoscope,
of tumors, sclerotherapy or ligation of varices, which includes an overtube and a scope
Esophagogastroduodenoscopy
control of hemorrhage, placement of feeding with a balloon at its tip, enables a large pro- Patients are prepared for upper endoscopy
tubes, and polypectomy. portion of small bowel to be examined. by assuring that their stomach is empty. This
Colonoscopy is most commonly per- There has been a recent expansion of the usually involves a 4- to 6-hour fast or, in ur-
formed as a screening tool for colorectal tools available for therapeutic endoscopy. gent cases, gastric lavage. The patient is po-
cancer. Screening colonoscopy should begin Biopsy forceps, cytology brushes, and snares sitioned on his side with the left side down
at age 50 in average risk patients. The rec- are most commonly used for tissue sam- and sedation is administered intravenously
ommended age for screening is lowered in pling. Rotatable snares and snares of vari- while vital signs and oxygen saturation are
patients with a family history of colorectal ous shapes facilitate difficult polypectomies. monitored. Topical posterior pharyngeal
cancer, conditions that predispose to col- Nets may be passed through the working anesthesia may also be used. The endoscope
orectal cancer, and high-risk ethnic groups. channel for retrieval of large specimens. handle is held in the left hand regardless of

www.medicalebookpdf.com

LWBK892_c14_p205-213.indd 205 11/16/11 4:42:48 AM

 206 Part II: Basic Surgical Skills: New and Emerging Technology

Fig. 1. A: The gastroscope may be introduced under direct vision. This method is best for observing the uppermost esophagus.
B: The scope may be introduced by digital guidance, using the endoscopist’s fingers to depress the tongue and center the in-
strument.

the surgeon’s hand dominance. The up and esophageal introitus, and the patient is The stomach should be fully inflated with
down deflection knob is controlled by the asked to swallow again. air. Any redundancy in the scope should be
left thumb, while the air, water, and suction The esophageal lumen appears as a long, reduced and the mucosa carefully observed.
buttons are manipulated by the left index straight tube. Once it is entered, air is insuf- The scope should be oriented in the gastric
and middle fingers. The smaller left–right flated. A long view of the esophagus should body so that the stomach’s posterior wall
deflection knob is usually managed by the be obtained and its mucosa inspected. Peri- is at the 3 o’clock position, the lesser curva-
right hand. The surgeon’s right hand con- stalsis should be noted, and evidence of in- ture at the 12 o’clock position, the anterior
trols the shaft of the endoscope for advanc- flammation or Barrett’s epithelium sought. wall at the 9 o’clock position, and the greater
ing and torquing the instrument. The endoscope is advanced carefully and curvature at the 6 o’clock position (Fig. 3).
The endoscope may be introduced by only while visualizing the lumen rather than Small movements of the control knobs will
digital palpation, the endoscopist’s finger(s) sliding along the mucosa. Interruptions in direct the tip of the scope in any desired di-
being used to guide the scope, but the safest the normal mucosa by inflammation or sus- rection. Abnormalities noted may include
method of introducing the endoscope into pected neoplasm should be assessed by cy- ulcerations, gastritis, vascular lesions, neo-
the esophagus is under direct vision (Fig. 1). tologic brushing and biopsy. A hiatal hernia plasia, or extrinsic impressions upon the
The endoscope is slowly advanced over the will appear as a saccular portion of gastric gastric wall. The location of such extrinsic
tongue until the epiglottis and vocal cords mucosa above the pinching action of the di- impression may indicate the probable
are visualized. The tip is then angled poste- aphragm. Normally, the esophagus turns source. For example, a large impression on
riorly between the arytenoids while the pa- slightly to the left as it traverses the dia- the posterior wall of the stomach, noted at
tient is asked to swallow. Gentle pressure is phragm and enters the abdomen. The esoph- the 3 o’clock position, may indicate a pan-
then applied to advance the scope into the agogastric junction is noted by the “z” line, creatic mass such as a pseudocyst or tumor.
esophageal introitus. If the tip of the scope an irregular junction of the orange columnar The endoscope is advanced toward the
slips into the piriform sinus, it is withdrawn gastric mucosa with the pale pink squamous gastric antrum by following the lesser cur-
and positioned in the midline above the mucosa of the esophagus (Fig. 2). vature, and the incisura angularis will be

www.medicalebookpdf.com

LWBK892_c14_p205-213.indd 206 10/28/11 3:54:05 PM

 Chapter 14: Upper and Lower Gastrointestinal Endoscopy 207

12 retroflexed scope is rotated to allow careful

assessment of the cardia, fundus, and the
lesser curvature.
The large rugal folds noted on the greater
curvature of the stomach’s body disappear as
9 3 the antrum is entered. The tip of the scope is
elevated to permit its advancement toward
the pylorus. Small circular motions of the
scope’s tip will permit visualization of the
entire antrum. The pylorus is normally round
and may be observed to open and close
6 (Fig. 5). Irregularities of the pyloric shape
may suggest past or present ulceration.
12 While keeping the pyloric orifice directly in
6 the center of view, the scope is advanced
with gentle pressure and slight insufflation of
air, into the duodenal bulb. The bulb has no
folds, and is a frequent site of inflammation
and ulceration. Small motions of the instru-

Basic Surgical Skills: New and

ment’s tip will help reveal the more obscure

Emerging Technology
corners of the bulb where ulcers may hide
(Fig. 6). Once inspection of the anterior and
posterior bulb is complete, the scope is ad-
vanced into the descending duodenum. This
Fig. 2. The “z” line appears at the esophagogastric junction. It represents the change from the squamous usually requires a maneuver, which is not un-
esophageal mucosa to the columnar epithelium of the stomach. der direct vision. The scope’s tip is turned to
the right as the shaft of the instrument is also
rotated to the right. The tip is first moved up-
ward and then down. This turns the instru-
observed at the 12 o’clock position. It is a gastric angle will usually permit a “retro- ment posteriorly and then downward into
smooth curved arch dividing the gastric flexed” view of the gastric cardia and fun- the second portion of the duodenum. Once
body from the antrum. Marked elevation of dus (Fig. 4). The shaft of the scope is then the lumen of the descending duodenum is in
the instrument’s tip and a small turn to the withdrawn to bring the tip of the scope to- view, slight pressure may be applied to the
left while the scope is positioned at the ward the gastric cardia. The shaft of the shaft of the scope to introduce it farther. If
resistance is encountered, the scope should
12
be pulled back and straightened. This will
usually result in the endoscope advancing
further in the duodenum as the redundant
gastric loop is straightened. The scope is
then withdrawn while close attention is paid
9 3
to the mucosal detail. The small bowel is
noted by the semicircular folds, which are
the hallmark of its architecture. The ampulla
of Vater may be seen in profile at the 9 o’clock
position in the descending duodenum (Fig. 7).
Its orifice is usually difficult to observe with
6
the end-viewing panendoscope used for
standard upper endoscopy. The accessory
papilla, orifice of the duct of Santorini, may
sometimes be observed slightly proximal to
the ampulla of Vater in the 1 o’clock position.
The instrument is pulled back, with the en-
12
doscopist slowly manipulating the controls
6
to again survey the walls of the duodenum,
stomach, and esophagus.

Therapeutic Interventions During

Upper Endoscopy
Fig. 3. In the body of the stomach, with the patient in the left lateral decubitus position, the lesser cur- The ability to deliver endoscopic therapy
vature is at the 12 o’clock position, the posterior gastric wall at 3 o’clock, the anterior wall at 9 o’clock, has increased greatly in recent years as
and the greater curvature at the 6 o’clock position. The gastric angle, separating the gastric body from the technologies have been developed to per-
antrum, is seen as a smooth arch along the lesser curvature. mit treatment through the working channel

www.medicalebookpdf.com

LWBK892_c14_p205-213.indd 207 10/28/11 3:54:06 PM

 208 Part II: Basic Surgical Skills: New and Emerging Technology

12 dysplasia, and early carcinoma. The most

common resection technique uses saline in-
jected beneath the lesion to elevate the mu-
cosal lesion off the underlying submucosa.
The area is then resected with a snare. Other
9 3 EMR techniques include the suck-and-cut
and suck-and-ligate techniques. Both of
these use specially designed systems to re-
sect lesions in the submucosal plane.
Endoscopic submucosal dissection is
often used to resect larger, diffuse lesions.
6 This technique uses a combination of needle
cautery and blunt endoscope cap dissection
to achieve an en bloc resection, rather than
the piecemeal resection in EMR. The onco-
logic benefits of endoscopic submucosal
dissection are accompanied by a substantial
risk of bleeding, perforation, and stricture.
Barrett’s esophagus with or without dys-
6 plasia may be treated with radiofrequency
12 ablation. Specially designed balloons de-
liver controlled doses of energy to the entire
circumference of the distal esophagus in
Fig. 4. A retroflexed view can be easily accomplished and permits inspection of the cardia and fundus. long-segment Barrett’s. A cap can be affixed
to the tip of the endoscope to deliver radiof-
requency energy to isolated areas of intesti-
nal metaplasia. Salutary results have been
of the endoscope. These applications have through the working channel to dilate reported in low-grade dysplasia, and some
included the ability to coagulate bleeding esophageal, anastomotic, and pyloric stric- endoscopists are ablating Barrett’s esopha-
lesions with monopolar or bipolar probes, tures, and laser energy can be directed gus with high-grade dysplasia.
or to inject them with long needle injection through the scope to debulk obstructing Covered, removable stents may be used
catheters. Esophageal varices can be treated esophageal tumors or to treat vascular le- to divert enteric flow away from a perfora-
with injection sclerotherapy or rubber band sions of the stomach. tion or fistula. Permanent, expandable
ligation, controlling hemorrhage and even- Endoscopic mucosal resection (EMR) stents can be used to alleviate esophageal or
tually obliterating the large venous trunks. may be used to excise esophageal and gas- duodenal obstruction due to malignancy.
Hydrostatic balloons can be introduced tric lesions including Barrett’s esophagus,
Technique of Colonoscopy
12
For effective examination of the colon, proper
cleansing must be accomplished prior to the
procedure. This may involve a mechanical
preparation including up to 48 hours of a
9 3 clear liquid diet prior to the procedure, ac-
companied by cathartics such as citrate of
magnesia and enemas just before beginning.
Alternatively, hypertonic lavage prepara-
tions, usually containing polyethylene glycol,
can be used to purge the colonic contents in
6
approximately 4 hours. The latter approach
is highly effective and widely employed,
albeit somewhat distasteful to the patient.
The left lateral decubitus position is used
to begin the procedure, although it is com-
mon to turn the patient occasionally during
the course of the procedure to facilitate pas-
sage of the instrument through tortuous ar-
eas. A careful digital rectal examination
should precede introduction of the scope, in
order to dilate the rectum as well as to assure
that no low-lying lesions are overlooked.
The colonoscope is positioned in the
Fig. 5. The antrum has few rugal folds. The pylorus is typically round and may be observed to open and rectal vault and inserted proximally by a
close. combination of maneuvers, which include:

www.medicalebookpdf.com

LWBK892_c14_p205-213.indd 208 10/28/11 3:54:07 PM

 Chapter 14: Upper and Lower Gastrointestinal Endoscopy 209

12 the shaft back slightly, inflate a bit, and reas-

sess the position of the lumen. These re-
peated pullbacks and advancements can be
accomplished quite rapidly and serve to tele-
scope the colon on the endoscope (Fig. 9).
9 3 The optimal colonoscopy is performed
without any looping of the scope. This can
be gauged by the length of scope inserted. A
straight scope usually reaches the splenic
flexure in 50 to 55 cm, and the cecum can
normally be reached in 100 cm or less. Dur-
6 ing negotiation of the sigmoid colon, a loop
often forms. This should be reduced in the
12 descending colon prior to traversing the
6
sigmoid flexure. At times, in spite of the en-
doscopist’s best efforts, insertion of the
scope’s shaft does not result in advance-
ment of the tip because of looping. Further
introduction of the scope will usually exac-

Basic Surgical Skills: New and

erbate the looping, cause the patient dis-

Emerging Technology
comfort, and risk of perforation. In such
situations, it may be useful to have an as-
sistant apply some pressure to, or lift, the
left side of the abdomen. This will act to
Fig. 6. Inspection of the duodenal bulb is often best accomplished through the pylorus or with the stiffen the sigmoid loop and allow advance-
scope’s tip in the pyloric channel. The superior duodenal fold marks the downward turn of the second ment of the scope. Alternatively, the pa-
portion of the duodenum. tient’s position may be changed to alter the
position of the colonic loops. Placing the
patient in the supine position, while trying
manipulation of the endoscope tip with the Blind insertion of the scope in hopes that it to proceed through a difficult sigmoid co-
control knobs, advancement and torsion of will “slide by” may cause perforation. While lonic segment is often rewarding.
the instrument shaft, repeated hooking of the latter method may occasionally be em- Even when direct pressure continues to
the scope’s tip around colonic folds and ployed by experts in difficult circumstances, result in advancement of the scope’s tip, it is
withdrawal to remove redundant coils in it remains risky and should be used spar- useful to remove redundant loops by stop-
the shaft, and repeated suctioning (Fig. 8). ingly. When the lumen is visible ahead, the ping, hooking the tip, and pulling back, in an
The colonoscope should be advanced scope may be inserted further. Should the effort to telescope the colon onto the scope’s
only when the lumen ahead is clearly visible. lumen disappear, it is most effective to pull shaft (Fig. 10). This is easily accomplished
after entering the transverse colon, and after
12
turning downward into the right colon. In
fact, pulling back on the shaft may actually
produce significant paradoxical advance-
ment of the scope’s tip. Finally, the applica-
tion of suction, while the instrument is posi-
9 3 tioned in the center of the colonic lumen,
will often draw colon up onto the scope and
shorten the colon. The latter technique may
be particularly useful in intubating the final
several centimeters of the cecum.
After insertion to the cecum, the instru-
6 ment is slowly withdrawn while slight ad-
12
justments to the tip position are made to
6
ensure complete visualization to the colonic
mucosa. Withdrawal times of at least 6 min-
utes have been shown to increase the rate of
adenoma detection. The varying appearance
of the interior colon aid the endoscopist in
defining the location of the endoscope’s tip
and the location of any pathology encoun-
tered. The cecum demonstrates an arching
convergence of the colonic tenia, often de-
scribed as the “Mercedes sign,” and the ap-
Fig. 7. Once in the descending duodenum, the scope is pulled back and straightened. The ampulla of pendiceal orifice can usually be defined.
Vater may be seen in profile at the 9 o’clock position on the medical duodenal wall. Just slightly above (distal) to this area is the

www.medicalebookpdf.com

LWBK892_c14_p205-213.indd 209 10/28/11 3:54:07 PM

 210 Part II: Basic Surgical Skills: New and Emerging Technology

Fig. 8. After insertion into the rectal vault, the colonoscope is inserted under direct vision.

Fig. 10. Multiple sequences of hooking and

pulling back should result of straightening of the
ileocecal valve, appearing as a slightly thick- As the scope is withdrawn from the colonic loops and telescoping of the colonic
ened fold, occasionally yellow in hue due to transverse colon past the splenic flexure, segments onto the scope.
some lipomatous infiltration (Fig. 11). The he- the sharp turns may hinder complete ex-
patic flexure transmits the bluish cast of the amination of the lumen, and reinsertion
liver adjacent to it. Triangular folds are the past this point several times may be neces- become eccentric. Finally, the rectum will
distinguishing anatomic feature of the trans- sary to accomplish satisfactory examina- be noted to display prominent vasculature
verse colon, and long segments of the lumen tion of the area. The descending colon usu- and a widened lumen. Once the colono-
may be viewed at one time. Care should be ally appears as a long straight tube with scope has been withdrawn to the level of
taken to look behind large folds for lesions, little haustration, and the endoscopist will the rectal columns, a retroflexed view of the
such as small neoplasms, which may be hid- recognize entry into the sigmoid colon rectal vault is usually performed to assure
den behind them. when the lumen turns frequently and folds that lesions just adjacent to the anal open-
ing are not overlooked. The retroflexion is
accomplished by directing the tip of the in-
strument severely upward while rotating
the shaft of the scope to the left and insert-
ing it further. Should the patient experience
pain with the maneuver, the scope should
A be withdrawn and the procedure started
again. Satisfactory retroflexion will be rec-
ognized by visualization of the scope enter-
ing the rectum, and the dentate line will be
clearly visible. In this position, the scope is
brought closer to the dentate line by with-
drawing the shaft. Rotation of the shaft per-
mits full examination of the rectal vault. Fi-
nally, the scope is straightened, air suctioned
from the colonic lumen, and removed.

Therapy During Colonoscopy

The most frequent interventions performed
at colonoscopy are biopsy and polypectomy.
Biopsy forceps may be passed through the
working channel of the colonoscope to
B
sample tissue. Areas of suspected neopla-
sia, dysplasia, or inflammation are sampled.
Insulated forceps with large jaws permit
Fig. 9. Hooking the tip of the scope around folds and pulling back often permits advancement through simultaneous biopsy and thermal destruc-
tortuous colonic turns. tion of small lesions (Fig. 12). Coagulation

www.medicalebookpdf.com

LWBK892_c14_p205-213.indd 210 10/28/11 3:54:08 PM

 Chapter 14: Upper and Lower Gastrointestinal Endoscopy 211

current is used in small bursts to accom-

plish this, while care is taken that excessive
energy, which might cause a transmural
burn, is not applied.
Polypectomy is the most common thera-
peutic application of colonoscopy. These
techniques have been well described, and
involve the encirclement of polypoid tissue
with a wire loop, subsequent tightening of
the loop, and application of coagulation
current to effect separation of the tissue
(Fig. 13). Small or pedunculated polyps are
removed with one application of the snare
loop, while larger or sessile lesions usually
require piecemeal excision. Once again,
with large or sessile lesions, EMR may be
accomplished by first injecting saline to el-
evate the lesion, and then using the snare
and cautery to resect it. Samples are re-

Basic Surgical Skills: New and

trieved with suction, snare, or baskets and

Emerging Technology
sent for pathological examination (Fig. 14).
Stenting of near-obstructing colon neo-
plasms has been shown to be an effective
bridge to definitive surgery and may avoid a
colostomy in many cases. Descending and
sigmoid colon lesions are most amenable to
stenting. The endoscope is advanced to the
Fig. 11. The cecum can be recognized by the confluence of the colonic tenia, the “Mercedes sign,” and near-obstructing lesion. A wire is advanced
the profile of the ileocecal valve. through the residual lumen and the stent is
placed over the wire across the lesion. Its
proper placement is confirmed endoscopi-
cally. Additional therapeutic interventions
through the colonoscope include thermal
ablation of tumors and vascular malforma-
tions, colonic decompression, and detor-
sion of volvulus.

New and Evolving

Endoscopic Techniques
Endoscopic treatment of gastroesophageal
reflux disease has been attempted using
Fig. 12. A hot biopsy forceps permits sampling of small lesions with their simultaneous destruction. injected polymers, suturing devices, and
Care must be taken to avoid excessive application of current with subsequent transmural injury. radiofrequency energy. More recent endo-
scopic therapies for reflux try to mimic a

A B C D

Fig. 13. A: Pedunculated polyps are surrounded by a polypectomy snare. B: The snare is tightened at the junction of the stalk
and the polyp head. C: Coagulation current is then used to transect the stalk. D: The head is then retrieved for pathological
examination.

www.medicalebookpdf.com

LWBK892_c14_p205-213.indd 211 10/28/11 3:54:09 PM

 212 Part II: Basic Surgical Skills: New and Emerging Technology

the esophagogastric junction to the an- disease. Techniques and technology con-
trum. This functions much like a vertical tinue to proliferate, expanding the opportu-
gastroplasty or sleeve gastrectomy. Long nities for minimally invasive therapy and
plastic sleeves may be placed from the duo- benefiting patients. Surgeons must be intro-
denum into the middle to distal jejunum. duced to these methods early in their train-
The material prevents absorption of nutri- ing, become proficient in basic diagnostic
ents by the small bowel mucosa. and therapeutic endoscopy, and should be-
Many years of research have been de- come familiar with advanced endoscopic im-
voted to natural orifice transluminal endo- aging and therapies. The lines of traditional
scopic surgery (NOTES). In NOTES, an endo- surgery and minimally invasive therapy have
scope is advanced into the mouth, rectum, become increasingly blurred, and surgeons
or vagina. A viscus is punctured to enter the will incorporate the techniques of digestive
abdominal cavity and an operation is per- endoscopy into their delivery of patient care.
formed. Both pure and hybrid (using some New endoscopic therapies for gastroesopha-
laparoscopic instrumentation) NOTES pro- geal reflux, morbid obesity, and cancer ther-
cedures have been performed in humans. apy are being developed, and NOTES re-
NOTES peritoneoscopy, cholecystectomy, search has generated advanced endoscopic
Fig. 14. Sessile or large pedunculated polyps may
and appendectomy have all been shown to instrumentation. Surgeons must be skilled in
require piecemeal excision. All fragments should
then be retrieved for pathological examination. be feasible and safe, albeit challenging, time- the techniques of gastrointestinal endoscopy
consuming, and with few tangible benefits. if they have to perform and lead in the devel-
While routine transgastric cholecystec- opment of these new techniques.
tomy may not be performed for many years,
surgical fundoplication. A device using a the instrumentation developed during
specialized retractor and T-fasteners can NOTES research is applicable to today’s ad- SUGGESTED READINGS
create a 270-degree posterior-to-anterior vanced endoscopic procedures. Endoscopic
Barclay RL, Vicari JJ, Doughty AS, et al. Colono-
fundoplication. This is contraindicated in staplers can be used to perform full-thick-
scopic withdrawal times and adenoma detec-
patients with large hiatal hernias and is ness resection of gastric neoplasms. Endo- tion during screening colonoscopy. N Engl J
often performed under general anesthesia. scopic suturing devices are currently being Med 2006;355(24):2533–41.
As the technology advances, endoscopy will used to narrow enlarged stomas after gas- Guillem J, Forde K, Treat M, et al. The Impact of
most certainly be the primary means for tric bypass. Both staplers and suturing de- colonoscopy on the early detection of colonic
treating gastroesophageal reflux. vices might be used to close inadvertent neoplasms in patients with rectal bleeding. Ann
perforations by approximating the full Surg 1987;206:606–11.
The obesity epidemic has spawned nu- Ponsky JL. Atlas of surgical endoscopy. St. Louis:
merous endoscopic weight-loss therapies. thickness of the visceral wall. Multichannel Mosby Year Book; 1992.
Most are still being trialed in the United endoscopes with position-stabilizing plat- Schuman BM, Sugawa C: Diagnostic endoscopy of
States, but European and South American forms facilitate complex EMRs. upper gastrointestinal bleeding. In: Sugawa C,
results have been favorable. A balloon can Schuman BM, Lucas CE, eds. Gastrointestinal
be placed through the endoscope and into bleeding. New York: Igaku Schoin; 1992:222–9.
the gastric body. It can be inflated to occupy
CONCLUSION Shaheen NJ, Sharma P, Overholt BF, et al. Radiof-
requency ablation in Barrett’s esophagus with
space in the stomach and provide a sensa- Digestive endoscopy has evolved from a di- dysplasia. N Engl J Med 2009;360(22):2277–88.
tion of early satiety. Another restrictive agnostic curiosity to a major therapeutic Shinya H. Colonoscopy: diagnosis and treatment of
treatment option uses a tube placed from modality in the approach to gastrointestinal colonic diseases. Tokyo: Igaku-Shoin; 1982.

EDITOR’S COMMENT host of different techniques which are currently it up again when there is another promising tech-
available for stopping upper gastrointestinal nique.
bleeding. However it is interesting that despite One of the problems of bulking (which is in-
Dr. Ponsky continues his leadership in surgery in all the technical expertise, the mortality and out- jecting various types of materials into the gas-
the area of endoscopy and raises a whole series comes of gastrointestinal bleeding remain the troesophageal junction) was explored by Kamler
of questions which will require answering, not same. Thus one must be careful before buying JP, et al. (Gastrointest Endosc 2010;72:337–42) in
only by the authors but also by other laborato- into new technology and keep one’s eye forever which experimental animals were injected with
ries such as IRCAD in Strasburg. Suffice it to say on what the ultimate goal is, which is not a new polymethylmethacrylate (PMMA) microspheres
that the original presentation of the PEG, which way of doing something but a new way of helping in miniature swine. This was a Phase I study and
is covered elsewhere in this volume by a triad of patients through a difficult situation. they initially started with 40-μm PPMA micro-
authors of which Dr. Ponsky was one, and in pe- Along these lines, upper endoscopy has en- spheres which are biocompatible and resistant
diatric patients, has led to enormous numbers of joyed (if that is the correct word) a whole series to degradation when “injected submucosally into
the PEGS being done. of attempts to carry out antireflux procedures the wall of the esophagus. However, the 40-μm
Endoscopy has been a moving target with a with suturing, “bulking”, and a variety of other PPMA microspheres were transported away from
number of very technically gifted and bright in- maneuvers. I may be somewhat of a curmudgeon the injection site into local lymph nodes, liver and
dividuals seeking to extend the range of what can but it seems to me that the group of superb in- lungs of some animals in the Phase I study. Thus
be accomplished with the endoscope. While en- terventional gastroenterologists that I deal with attention was turned to increasing the size of the
doscopy itself and colonoscopy has changed the have basically given it up at this point in time. microspheres to 125-μm, which apparently were
ground so that there are, for example, a whole This is not to say that in the future they may take not transported. It is the authors’ hope that in

www.medicalebookpdf.com

LWBK892_c14_p205-213.indd 212 10/28/11 3:54:09 PM

 Chapter 14: Upper and Lower Gastrointestinal Endoscopy 213

the absence of transport that perhaps these can as if it is. The problem is if this is not sufficient knowledge, to carcinomas of the esophagus
be used clinically. In an effort to obtain a reading to keep these patients from becoming diabetic, growing under the healing mucosa. Radiofre-
of where bulking currently is I availed myself of a what one has is that in 24% of the patients there quency ablation of Barrett’s esophagus dysplasia
number of highly qualified and superb gastroen- is a statistically significant weight loss but it is seems to be coming more popular. One worry is
terologists. Suffice it to day in the present state not a biologically significant weight loss. And an esophageal stricture rate of up to 6%. If this
of technology it does not seem to enjoy a great more patients have undergone bariatric surgery increases, my guess would be that this would kill
following, nor does endoscopic suturing for an- in the past several years than have actually held the RFA procedure.
tireflux procedures, etc. Perhaps there will come their weight loss. I cannot be enthusiastic at this By far the most exciting eventuality is NOTES.
a day when there are better techniques which are point in time unless there are better results than A very nice review is provided by Dallemagne B,
available and laparoscopic Nissens or other anti- are present in this paper. et al. (World J Gastrointest Surg 2010 27;2:187–92).
reflux procedures may not be necessary. Another outgrowth of endoscopy is capsule en- This group is from the Department of Diges-
Another application of endoscopy that is ex- doscopy. An enthusiastic and futuristic paper was tive and Endocrine Surgery in Strasburg and of
tending what can be accomplished therapeutically contributed by Zvi Fireman (World J Gastrointest course IRCAD. Dallemagne, while optimistic, is
is the intragastric balloon. There have been a num- Endosc 2010; 16:305–307). In this paper, Fireman realistic. He does point to this as a hybrid tech-
ber of reports of intragastric balloons and quite a attempts to give us a picture of what may be nique in which a transumbilical port is neces-
nice and extensive paper was written by Dastis SN, technically possible in the future. Certainly cap- sary. He also points out that since Kalloo et al.
et al. (Endoscopy 2009; 41:575–580). The protocol in sule endoscopy is popular and he estimates that (Gastrointest Endosc 2004;60:114–7) that there
this study was taking 100 patients whose average probably more than a million capsules have been have been a number of attempts to bring this to
BMI was 35 ⫾ 5.6 kg and prospectively followed swallowed worldwide, and there have been nearly a clinical usage and indeed, it has been done. He
for 6 months after endoscopic implantation of a a thousand peer-reviewed publications. The is dismissive of transvaginal cholecystectomy
saline-filled intragastric balloon. These patients problem is that while one can see and sometimes and concerned about transgastric cholecystec-
were followed for near 5 years. According to the is helped by a diagnosis, there is a limitation on tomy not only because of the possibility of con-

Basic Surgical Skills: New and

authors, successful intragastric balloon therapy what can be accomplished. What Fireman would tamination in which there has been very little in

Emerging Technology
was arbitrarily set at a loss of 10% of weight at the like (and I suspect everybody else) is to have a studies that had already been done but because
end of 6 months and that this weight loss remain technique which surpasses the results that cur- of the closure and the difficulties of the closure
at ⫾ 10% after 2 years without bariatric surgery. rently can only be read unlike “conventional en- as documented in a nice paper by Sohn DK, et al.
Unfortunately no attempt was made to instill a nu- doscopic procedures” which enable concomitant (Surg Endosc 2010;24:277–282). Closures require
tritional program with follow up at weekly inter- biopsy when indicated. He goes on to say that the additional instruments placed through an um-
vals but patients were encouraged to visit with a ideal capsule endoscopy should improve the qual- bilical port. This of course is the Achilles heel of
dietician once a week for 6 months. After 6 months ity of the image which is currently available and many endoscopic procedures including vascular
the mean weight loss was 12.6 ⫾ 8.3 kg. 63 individ- have a faster frame rate than the one currently procedures and it does appear as in the vascular
uals had a 10% or greater baseline weight loss and available; it should be therapeutic in the sense area that much damage can be done, including
“no severe morbidity was detected”, whatever that that it is capable of performing a biopsy, aspirat- obstruction of vessels and this keeps the vas-
means. The balloon was removed and the patients ing fluids, culturing lesions, delivering drugs, and cular surgeons fairly busy. While one can argue
were followed for the first and second year. Body measuring the motility of the small bowel wall. that one is decreasing the number of holes in the
mass increased by 4.2 and 2.3 kg, respectively. At He believes that the technology for doing this is abdominal wall, it does appear that in several
the end of 2.5 years, only 24% had maintained their almost within grasp and with the work that goes cases as reported in this paper that additional
initial weight loss. However the remainder did not on, it should be possible. For example if one could ports had to be used because of either techni-
have a successful outcome and 35 had bariatric have a capsule that stops bleeding by an adrena- cal malfunctions or inability to see the anatomy
surgery at the end of 4.8 years. lin injection, a heat probe, argon plasma coagula- clearly.
Now let us consider what the possible uses of tion, perhaps include special detectors for white I think the jury is still out on this one and I, like
a 10% weight loss are. One of the problems that blood cells and oncological markers such as CEA the authors, am concerned about closure. It will
patients with a BMI of 35 are is that no insurance and CA 19-9, etc, this would be a great advance. be closure which is the Achilles heel. In addition,
company, at least at the present time, will pay for Apparently there is a lot of work going on around while the pain seems to be less, the patients stay
bariatric procedures. This is unfortunate in my the world including some in South Korea with in the hospital for 2 days, something which the
view although it is being closely followed I know a MiroCam by Intromedic (Seoul, South Korea). author does not emphasize but since many lap-
by several large insurance corporations. Between This particular technology uses the human body aroscopic cholecystectomies are essentially be-
30–35 BMI there are a number of patients who instead of radiofrequency to transmit data and ing done as outpatients; (this is a practice which
will become diabetic within 10 years if nothing is reduces power consumption. He notes that in I do not approve of since there have been several
done in the way of intervention. The intervention the first clinical trial with 45 patients, MiroCam deaths on the night following laparoscopic chole-
need not be severe; it can be a gastric band. The captured images from the whole small intestine cystectomy) but there is an additional length of
failure to pay for this is penny wise and pound as far as the cecum, and the bowel mucosa was stay which of course is expensive.
foolish, in my opinion, because although not all viewed without blurring or distortion in 90% of Taken as a whole, using endoscopy as a base,
of these patients will be diabetic after 10 years the patients. There are a number of research proj- there do seem to be a large number of products
if there is no intervention, a significant number ects including those financed by the European and techniques which utilize endoscopy particu-
will and the cost of following diabetic patients Union and perhaps there will be some progress larly upper gastrointestinal endoscopy as a take
who probably have a life expectancy of at least in this area. off. The future will undoubtedly see other at-
30 years is substantial. Is intragastric balloon a One area which does appear to be thriving tempts to utilize these techniques so that there
way of dealing with these patients? I do not be- is upper endoscopic treatment of low or inter- are not abdominal incisions, but it does not ap-
lieve it is because I do not think weight loss of mediate grade dysphasia in Barrett’s esophagus pear as if the patients are currently spared ab-
10% will result in ameliorization of future type by excision. While there is some concern about dominal incisions.
2 diabetes. I may be wrong but it does not seem buried epithelium, this has not resulted, in my J.E.F.

www.medicalebookpdf.com

LWBK892_c14_p205-213.indd 213 10/28/11 3:54:10 PM

 214 Part II: Basic Surgical Skills: New and Emerging Technology

15 Soft Tissue Reconstruction with Flap Techniques

Luis O. Vasconez, Salman Ashruf, and Franziska Huettner

INTRODUCTION use of a free flap should be considered. The the disadvantage of an additional operation
essential principle for reconstructive soft and the concomitant swelling and edema
Sound understanding of reconstructive sur- tissue wounds is the application of the most that ensue, making it more difficult to trans-
gery is imperative to all practicing general effective flap that will succeed in covering fer such a flap. A microvascular free flap,
surgeons. The integumentary system is the the defect, regardless of the complexity of first reported in 1973, allows the transfer of
largest organ system of the body. It is subject the procedure. Sufficient experience has de- tissues to distant sites with the reestablish-
to systemic disease as well as the extremes termined what is more likely to succeed. ment of blood flow to the flap by anastomo-
of the environment. The ability to surgically One should forego the trial and error of us- sis of the artery and the vein to appropriate
manipulate and reconstruct acquired de- ing a simpler procedure that may not work recipient vessels in the vicinity of the defect.
fects in an efficacious fashion is the learning and eventually end up with the appropriate The free flaps are most effective in providing
objective of this chapter. but more complex flap reconstruction. coverage of areas with insufficient local, ad-
In today’s medical environment the re- Skin grafts can include the entire epider- jacent soft tissue. Performed by experienced
constructive ladder is no longer practical. mis and dermis, or the epidermis with a microsurgeons with an appropriate team,
Reconstructive surgeons must have a solid portion of the dermis. The former, known as the free flap is one of the safest of all flaps,
understanding of the surgical options avail- a full-thickness graft, resists contraction, with a success rate exceeding 95%.
able and those procedures that provide the needs a well-vascularized recipient bed,
best outcome, even though it may be the maintains the adnexal structures, and has
most complex solution. pigmentation similar to normal skin. Split- GENERAL PRINCIPLES
In the management of large wounds cre- thickness skin grafts are more likely to con- FOR COVERAGE OF SOFT
ated by extirpation of benign or malignant tract or shrink, hyperpigment, and survive TISSUE WOUNDS
tumors, postradiation ulcerations, or post- under less favorable conditions, and they
traumatic defects, the cooperative efforts leave less donor site morbidity. Factors that Difficult wounds usually fall into three cat-
between the general surgeon and the plastic lead to skin grafts not “taking” include shear, egories: (a) superficially infected wounds,
surgeon will most likely result in satisfactory hematoma, infection, and an avascular bed. (b) wounds over bone devoid of periosteum,
coverage of the wound and a shorter recov- For a skin graft to take requires a vascular- and (c) postradiation wounds. We will de-
ery and hospitalization for the patient. In the ized bed. These recipient sites can be mus- scribe principles for their management in-
occasions when the wound cannot be closed cle, fascia, paratenon, or periosteum. When dividually.
primarily or in cases where a skin graft will such a bed is absent, a well-vascularized flap
not suffice, the use of flaps is the most ap- is necessary to provide durable coverage. Superficially Infected Wounds
propriate option. Different approaches are A flap is a unit of moveable tissue that re-
required in different clinical settings such as mains attached to its original blood supply. Chronic wounds in which granulation tissue
congenital defects, infected wounds, postra- Flaps can contain skin, muscle, bone, fascia, has been allowed to develop and to persist
diation ulcers, as well as tumor excision. or any combination of these. When the flap for a prolonged time are often difficult to
The coverage needed may be skin alone, or contains a named septocutaneous or mus- treat. Pathophysiologically, one should note
skin and fat, such as for reconstruction of culocutaneous blood vessel, it is known as that granulation tissue is a combination of
the breast; muscle or omentum for the cov- an axial flap. It can therefore be transferred capillaries, fibroblasts, and bacteria. Of these
erage of postradiation wounds or composite reliably to different sites to reconstruct soft three elements, only one is helpful to the sur-
tissue such as skin and muscle; and, often, tissue defects that may also require special- geon, the capillaries. Consequently, if a
muscle and bone or any combination. ized tissue, such as fascia to restore abdomi- wound is filled with granulation tissue, it is
During the initial evaluation, it is essen- nal wall integrity. Vascular anatomy of any essential that one resect surgically in a tan-
tial to recognize the type of soft tissue de- particular flap is well known at this time gential way until all of the granulation tissue
fect with which one is dealing. For example, and makes it reliable as long as one includes is removed and one gets down to a clean fas-
if it is a loss of the skin such as a large exci- the vascular pedicle within the flap. We also cial level. Following such tangential resec-
sion of a melanoma of the face, the defect know the safety of the length for that par- tion, a simple meshed split-thickness skin
can be covered by an adjacent skin flap. If ticular flap. The so-called random flaps (ex- graft may suffice, but in cases in which the
one is dealing with a surgical loss of the cept for the face), where the distinct vascu- wound cannot be completely cleansed or ex-
breast, one needs to reconstruct by replac- lar anatomy is unclear, should be avoided cised because that would entail the removal
ing the skin and the breast mound with ei- because of the uncertainty of success. These of essential structures, or in such patients
ther adipose tissue or, occasionally, the use flaps are perfused exclusively through the with pressure sores, those infected wounds
of an implant. If, on the other hand, one is subdermal, or more accurately, the subcuta- demand coverage with an adjacent muscle.
dealing with a postradiation persistent or neous plexus and have no named blood ves- Muscle has an antibacterial effect on the
recurrent tumor that requires a large extir- sel that supplies them. Similarly, so-called coverage of infected wounds, most likely be-
pation, the defect needs to be covered with delayed procedures, which have the objec- cause it brings in additional blood supply,
muscle or a musculocutaneous flap or by tive to improve the vascularity of a flap, are which helps in the amelioration of the infec-
the use of omentum. In the case of postra- rarely if ever indicated because there is no tion. The use of an adjacent fasciocutaneous
diation wounds, although adjacent muscu- assurance that the safety of the flap will be flap is a second choice, although this is not
locutaneous flaps are given first priority, the increased. The “delay” procedure also has as effective as muscle.

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 214 10/28/11 8:48:36 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 215

Basic Surgical Skills: New and

A B

Emerging Technology
Fig. 1. A, B: Knowledge of septocutaneous flaps allow us to move the fasciocutaneous flap in the leg for coverage of defects
even in the lower third of the leg. The lowest septocutaneous perforator is located 5 to 6 cm above the medial malleolus.

Wounds with Exposed Bone an adequate debridement of the wound, it is Postradiation Wounds
Devoid of Periosteum essential that one cover that defect immedi-
ately with an adjacent muscle to fill in the The sophistication in the delivery of radio-
In these types of wounds, it is essential that cavity and to cover the exposed bone. If the therapy for the management of malignant
one try to maintain the exposed bone moist skull is exposed, as may occur following an tumors has resulted in the markedly de-
with frequent dressing changes or a slow sa- electrical burn, it is not essential to remove creased injury to the soft tissues, specifi-
line drip. In a recently traumatized extremity the exposed skull but to cleanse it and to cally the skin. We see much less ulceration
with exposed tibia, one could use an adjacent cover it with a free muscle flap, such as the or deformity following an appropriately de-
fasciocutaneous flap. However, when dealing latissimus dorsi. One has often rejoiced to livered cancerocidal dose of 60 rads (radia-
with cases in which there is active or chronic see what appears to be dead bone revascu- tion). However, we often see postradiation
infection, such as in chronic osteomyelitis, larized or replenished once it is covered with persistent and/or recurrent malignant tu-
the treatment is much different. Following well-vascularized muscle (Fig. 1). mors that must be salvaged with surgical

A B

Fig. 2. A–E: Patient who underwent bilateral mastectomies with radiation 24 years ago presented with large area of radiation
necrosis over the sternum. TRAM flap reconstruction was not an option because radiation usually obliterates the arterial
walls and in this particular patient, the resection entailed removal of both internal mammary arteries. The chest wall was
stabilized with a polypropylene mesh. The omentum was transposed over the mesh, with immediate application of a mesh
split thickness skin graft. The omentum is passed through an opening in the upper abdominal incision at the subcutaneous
tissue level. This is preferable to passage of the omentum through the diaphragm. (continued)

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 215 10/28/11 8:48:37 PM

 216 Part II: Basic Surgical Skills: New and Emerging Technology

E Fig. 2. (Continued)

excision. If one is dealing with a persistent slight hyperpigmentation of the skin, the to the wound. Over the muscle or the
or recurrent tumor, the amount of excision lack of the skin appendages, as well as omentum, one can immediately place a
should be left to the oncology surgeon. On the leathery appearance and feeling of the meshed split-thickness skin graft. A trans-
the other hand, if one is dealing with a skin. verse rectus abdominis muscle (TRAM)
postradiation ulceration, a previous biopsy Following wide excision of the entire flap, either conventional or microvascular,
is not essential because the treatment is field that has been irradiated, one should is often successful if the skin edges to be
going to be the same, and the pathologist is immediately cover the defect with muscle approximated are beyond the field of radia-
likely to report: “Chronic ulceration with or a musculocutaneous flap, and if that is tion (Fig. 2).
postradiation effects but tumor cannot be not available, with omentum. A skin graft
ruled out.” In either case, the surgical treat- for postradiation wounds is not effective
ment of these postradiation problems con- and is likely to fail. Adjacent skin flaps sim-
SOFT TISSUE FLAP TECHNIQUES
sists of the extirpation not only of the tu- ilarly may not adhere to the underlying We will describe specific soft tissue recon-
mor or the ulceration, but also of the entire postradiation bed or to the skin edges. struction with flap techniques throughout
portal of radiation. One determines the en- Muscle or omentum is successful because the body that are likely to be encountered in
tire portal of radiation by noticing the of the increase in blood supply they bring a busy general surgical practice.

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 216 10/28/11 8:48:38 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 217

Fig. 3. Diagrammatic representation of double chondrocutaneous advancement flaps for reconstruction of a large (3 to 4 cm)
helical defect. (From Antia NH, Buch VI. Chondrocutaneous advancement flap for the marginal defect of the ear. Plast Reconstr
Surg 1967;39:472, with permission.)

Basic Surgical Skills: New and

Emerging Technology
Facial Defects lower portion of the ear is incised along both ears at the same time. A smaller, well-
the helix through the skin and underlying contoured ear is accepted by most casual
Facial defects often result from excision of cartilage to the ear lobe. If necessary, the observers.
malignant tumors, whether simple basal cell upper portion similarly below the helix is
carcinoma or more complex squamous cell also incised through the skin and the carti- Defects of the Nose
lesions, and melanoma, which is increas- lage. This leaves the two ends of the helix Basal cell carcinomas that occur along the
ingly seen today. We will describe specifically able to be moved toward each other and dorsum or the tip of the nose often require
defects on the ear, nose, and cheek. to be approximated, thus restoring the flap coverage for a satisfactory result. The
normal helical contour of the ear. The infe- flap coverage should be from adjacent nasal
Defects of the Ear rior cartilage and overlying skin are also skin because it provides the same color and
Removal of large basal or squamous cell car- approximated. texture as well as thickness, and in elderly
cinomas of the ear requires immediate re- This method of reconstruction has the patients, the scar is almost imperceptible.
construction. If a wedge resection is so advantage of restoring the normal shape of On the other hand, skin grafts may leave a
large that it may result in deformity of the the ear and is relatively straightforward and visible concavity and a patch appearance be-
ear, a local technique described by Antia is effective. One does end up with a slightly cause of the different color of the surround-
the more desirable method of reconstruc- smaller ear in comparison with the contral- ing skin. We do not favor the routine use of
tion (Fig. 3). Following the excision of the ateral normal one, but this is not really a the nasolabial flap for defects of the nose be-
large defect along the helix of the ear, the problem because we are seldom able to see cause it is a different skin from the nose, and

A B C
Fig. 4. A: The typical defect is in a paramedian position on the nasal tip. The nasalis musculocutaneous flap is designed with
its caudal line right at the alar groove and the cephalad line determined by the width of the defect. B: The flap is elevated down
to the muscular attachments at the base of the piriform fossa. C: The flap is advanced. Any small dog ears resulting from the
concave flap merging against a convex recipient area can by excised. (From Rybka FJ. Reconstruction of the nasal tip using
nasalis myocutaneous sliding flaps. Plast Reconstr Surg 1983;71:40, with permission.)

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 217 10/28/11 8:48:39 PM

 218 Part II: Basic Surgical Skills: New and Emerging Technology

often leaves a “biscuit” type of appearance. outlines a transposition flap, which is ele-
For smaller defects, we advocate the use of vated and transposed to cover the primary
the VY advancement flap or the banner flap. defect while the secondary defect is covered
For total reconstruction of the nose, the mid- in the form of a Z plasty from the adjacent
line forehead flap is safe and appropriate. tissue along the ala. There may be a slight
elevation of the involved ala, but this is usu-
VY Advancement Flap ally minimally noticeable.
The VY advancement flaps rely on the mo- For larger defects along the tip of the
bility of the subcutaneous layer (Fig. 4). For nose where the banner flap will not suffice,
smaller defects on the dorsum or the lateral it is advisable to use the entire remaining
aspect of the nose, once the lesion has been skin on the dorsum of the nose by outlining
excised with appropriate margins, if it is a flap that extends beyond the defect and
malignant, one could design an adjacent VY along the lateral aspect of the nose to the
flap that is incised and advanced to cover glabella. By cutting it toward the opposite
the defect. It is a simple and effective method side by maintaining the angular vessel and
for coverage of smaller defects. freeing up the skin flap to cover the entire
defect and the secondary defect along the
Fig. 6. The axial flap is based on vessels emerging at
Banner Flap glabella, it is closed in a VY type of fashion the level of the inner canthus. This allows increased
For larger defects, usually along the tip of (Figs. 6 and 7). The dog ear that occurs can mobility and precise adjustment. (From Marchac D,
the nose, a banner flap is indicated (Fig. 5). be handled at the same time by resection, Toth B. The axial frontonasal flap revisited. Plast
Again, the created defect is noted, and one thus making it a single-stage procedure. Reconstr Surg 1985;76:686, with permission.)

Total Reconstruction of the Nose with a

Midline Forehead Flap
For patients with large basal or squamous
cell carcinoma of the nose or postradiation
persistent tumors, total excision of the
overlying skin is indicated, and reconstruc-
tion, after appropriate margins have been
obtained, is best done with a midline fore-
head flap (Fig. 8).
The techniques of the procedure are
straightforward. A pattern is obtained of
the area to be excised in the nose through
transparent x-ray film and is transferred to
the midline of the forehead. Following the
excision of the tumor, the defect is con-
firmed again, and the dimensions of the
flap are similarly drawn. The forehead flap
A B is then incised and elevated at the subcuta-
neous tissue level to ∼2 cm above the gla-
bella. At that point, the flap is deepened to
include the galea to ensure that the blood
supply, which comes from the angular ves-
sels of the nose, is included. The flap is then

C D
Fig. 5. Principles of the banner flap procedure. A: Triangular flap is outlined by points a, b, and c. Fig. 7. The axis of rotation should be considered
B: Larger flap x and smaller flap y. Each may be transposed as a modified Z-plasty. C: Flap y is inset, and and the incision taken rather low on the lateral
the tip of flap x is trimmed to fit the residual defect. D: The resultant dog ear at point a, if excessive, may side of the nose. (From Marchac D, Toth B. The
be reduced by a triangular excision (leaving the base untouched). (From Masson JK, Mendelson BC. The axial frontonasal flap revisited. Plast Reconstr Surg
banner flap. Am J Surg 1977;134:419, with permission.) 1985;76:686, with permission.)

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 218 10/28/11 8:48:45 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 219

tient chooses mastectomy, immediate re- cause, even if one uses a TRAM flap, it is
construction is often suggested. likely to shrink and to become fibrotic. If
one were to use an implant or an expander,
Immediate Versus Delayed failure as indicated by the exposure of the
Breast Reconstruction implant, infection, or inability to expand
It is our experience that patients who are and to obtain symmetry with the other
offered immediate reconstruction follow- breast are very likely possibilities. For such
ing skin-sparing mastectomy accept it and cases, delayed reconstruction is necessary.
are pleased with the eventual results. A con- In patients with large tumors who receive
siderable amount of literature has been preoperative chemotherapy to shrink the
published indicating the positive and favor- tumor, immediate reconstruction is appro-
able psychological effects of immediate priate, although it is done with caution
breast reconstruction, particularly when it and with the expectation of problems with
is done with relative simplicity, safety, and delayed healing, not only of the flap used
obtains symmetry with the opposite side. for reconstruction, but also for the second-
Questions that oncologists as well as pa- ary defect, most likely in the abdominal
tients ask and have been answered include: wall, if the TRAM flap was used. The reason
“Will reconstruction hide or delay the de- for this is that the deleterious effect of che-
tection of recurrent cancer?” The answer is motherapy on wound healing persists for

Basic Surgical Skills: New and

Fig. 8. Forehead flap, based on supratrochlear ves- “No” because most of the recurrent cancers 6 to 12 weeks following the cessation of

Emerging Technology
sels. It easily reaches the entire notes. The forehead occur at the subcutaneous tissue level and chemotherapy.
defect is closed primarily as much as possible and alongside the mastectomy scar. This is eas- In patients with persistent or recurrent
the remaining is left open to heal. (Modified from ily detectable by palpation. Concerning the tumors following lumpectomy and radia-
Mathes S, Nahai F. Reconstructive Surgery: Princi- development of fat necrosis if a TRAM flap tion, immediate reconstruction is essential,
ples, Anatomy, and Technique. New York: Churchill has been used, and which presents as a either with a latissimus dorsi muscle or the
Livingstone, 1997:262, with permission.) hardened mass, one can determine its exact TRAM flap because delayed wound healing
nature by the rapidity of its appearance fol- or wound breakdown of the postradiation
lowing the reconstruction (within weeks) wound is likely to occur.
and confirmation by fine-needle aspiration, Nonetheless, a decreasing number of
turned on either the left or the right axis, which is read as fat necrosis. Will adjuvant patients present months or even years
whichever is easiest to reach the distal por- therapy be delayed? No. Adjuvant chemo- later for delayed reconstruction. The aes-
tion of the defect. Although it is advisable to therapy is usually started 6 weeks following thetic result is as satisfactory as with im-
save at least one of the supratrochlear and the mastectomy and reconstruction. In mediate reconstruction, although it has
supraorbital vessels, it is not essential be- most cases, this is an appropriate schedule. the disadvantage of requiring a second op-
cause the midline forehead flap is supplied In fact, studies have demonstrated that if erative procedure and a second hospital-
from the angular vessels of the nose that are there is no immediate breast reconstruc- ization.
located along the lower border of the nasal tion, the possibility of flap necrosis or
bones as it meets with the maxilla. The seroma formation along the axilla often de- Objectives and Principles of
midline forehead flap does require a second lays the initiation of chemotherapy beyond Breast Reconstruction
stage, which is the division and insetting of the 6-week interval. The objective of breast reconstruction is to
the pedicle. Finally, patients ask whether they need perform a safe operative procedure that will
blood transfusions. The answer is, most obtain symmetry with the opposite breast.
likely, no. Blood transfusions, although not This often requires modifying the contralat-
Breast Reconstruction proven deleterious for carcinoma of the eral normal breast by either reduction
breast as has been shown for carcinoma of mammoplasty or a mastopexy, which we
What was initially an imperfect product the colon, are often not necessary even advocate being done at the same time as
consisting only of the creation of a mound when one performs unilateral or bilateral the breast reconstruction.
with an implant has now developed into a TRAM flaps. This is because of the judi- The principles of breast reconstruction,
most satisfactory and acceptable method cious use of lidocaine with epinephrine to which apply to any method used, include:
in which, following the extirpation of a elevate the flap, the judicious use of elec- (a) the preservation or restoration of the in-
breast, one is able to restore the removed trocautery for the undermining of the ab- framammary fold, (b) obtaining satisfac-
structure and obtain symmetry with the dominal flap, and the realization that one tory projection, (c) obtaining satisfactory
opposite side. This is possible because of does not need to transfuse unless the he- and matching ptosis with the contralateral
the introduction of the latissimus dorsi matocrit falls below 20 or the patient is breast, and (d) closing the axillary defect in
myocutaneous flap method of breast recon- symptomatic. immediate reconstructions (Fig. 9).
struction in 1977, as well as the more so- Patients in whom immediate recon-
phisticated TRAM flap that was introduced struction would not be indicated include The Inframammary Fold
in the early 1980s. Both methods have un- those with systemic diseases, which may The inframammary fold is nothing more
dergone considerable development and make reconstruction more hazardous, such than the lower pole of the breast. Conse-
sophistication to increase their safety and as patients on steroids or with uncontrolled quently, the oncology surgeon does not
versatility. diabetes. Similarly, if one knows preopera- need to extend the dissection any further
Most breast centers at the present time tively that the oncology surgeon plans to than the inframammary fold in completing
offer the patient different alternatives for irradiate postoperatively, one would not the mastectomy. It is not unusual for some
treatment of breast cancer, and if the pa- perform an immediate reconstruction be- plastic surgeons to preoperatively place

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 219 10/28/11 8:48:52 PM

 220 Part II: Basic Surgical Skills: New and Emerging Technology

A B C

Fig. 9. Diagrammatic demonstration of projection or ptosis of the breast. A: Projection is determined by the transverse diam-
eter over the convex surface of the breast from the sternum to the anterior axillary line. B: Ptosis is determined by the vertical
distance over the breast to the inframammary fold. C: Inframammary line is determined by the lower edge of the breast, or in
the case of a reconstructed breast, by the lower edge of the TRAM flap. (Modified from Vasconez LO, Lejeur M, Gamboa-
Bobadilla M. Atlas of Breast Reconstruction. Philadelphia: JB Lippincott, 1991:12, with permission.)

some percutaneous sutures prior to the cle over the breast and down to the infra- Bilateral Mastectomies
mastectomy. In a reconstructed breast with mammary fold. If one has fixed the Presently, patients are electing to undergo
a TRAM flap, the inframammary fold is the inframammary fold, either with sutures or bilateral mastectomies and immediate re-
lower end of the flap. However, if one has preservation, one can place the flap in such construction. This usually entails doing the
reconstructed the breast with the use of an a way that it will hang down below the in- mastectomy and sentinel node biopsy on
implant or an expander, the inframammary framammary fold to obtain ptosis. Usually the side of the cancer, and usually a prophy-
fold represents the lower edge of the cap- this is done for a minimal amount of ptosis lactic skin sparing mastectomy on the con-
sule around the implant. Because implants because it is preferable to modify the con- tralateral side.
are likely to develop capsular contractures tralateral breast with a mastopexy or reduc- Patient who request bilateral mastecto-
that raise the inframammary fold, most re- tion mammoplasty. Ptosis is rarely possible mies include not only those done for prophy-
constructive surgeons place the expanders with the use of an implant or an expander, laxis due to BRCA 1–2 gene, but also young
or the implants 2 to 3 cm below the infra- except in the experienced hands of plastic patients who do not want to live with the
mammary fold so that the folds will be surgeons who use oval or anatomic type of burden of frequent checkups for recurrence
matched with the ensuing capsular con- implants. of the cancer or the possibility of develop-
tracture. ment cancer in the opposite breast. Other
Closing the Axillary Defect group who ask for bilateral mastectomies are
Projection The fourth principle of breast reconstruc- those who have undergone previous lumpec-
Projection is defined as the transverse di- tion that should be addressed is closing the tomy, irradiation, and chemotherapy, and are
ameter from the sternum to the anterior axillary defect. The breast extends only to seriously afraid of going through the suffer-
axillary line. If one is to obtain more projec- the anterior axillary line. The oncology sur- ing of possible radiation or chemotherapy in
tion, if a transverse incision has been used geon, even with a skin-sparing mastectomy, the future for cancer in the opposite breast
for the mastectomy, the upper end of the dissects the skin flaps to the anterior bor- (Fig. 10). A recent study by Boughey et al. in-
incision needs to be zigzagged so that the der of the latissimus dorsi muscle, which is dicates that contralateral prophylactic mas-
transverse diameter will be larger. This is in the posterior axillary line; the surgeon tectomy in high-risk women with a personal
avoided with the use of the skin-sparing also will perform a sentinel node biopsy of history of breast cancer is associated with a
mastectomy because the entire envelope of the axilla. Consequently, it is essential that survival advantage, reflecting an improved
skin is present except for the nipple and the reconstructive surgeon closes and oblit- overall and disease-free survival. This might
areola, and one need to fill only the skin en- erates the axillary defect by approximating represent an additional reason for woman
velope with tissue, usually the TRAM flap, the lateral skin flap to the anterior axillary to decide for contralateral prophylactic mas-
to obtain a satisfactory projection. line with sutures and placing a drain along tectomy at the time of the cancer resection.
the axilla, particularly in immediate breast
Ptosis reconstructions. In delayed breast recon- Options for Breast Reconstruction
Ptosis refers to a vertical dimension mea- structions, the dissection of the flaps is There are several methods for breast recon-
sured over a curved surface from the clavi- done only to the anterior axillary line. struction, and each one must be discussed

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 220 10/28/11 8:48:52 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 221

A B

Basic Surgical Skills: New and

Fig. 10. A, B: Patient status post lumpectomy and radiation. Above patient presented with post lumpectomy radiation with
persistent and or recurrent carcinoma of the breast. Note the shrinking of the irradiated breast. Patient elected to have bilat-

Emerging Technology
eral mastectomies with immediate reconstruction. Skin sparing mastectomy was chosen on the left side, which left a larger
skin envelope and thus the slight discrepancy in size.

with the patient, addressing the advantages quired and how much the patient can toler- with vascularized tissue may ultimately
and disadvantages of each. The methods in- ate each time. After the expansion is com- be required.
clude the use of implants or expanders, the plete, the expander is left in place for ⬃3
use of flaps such as the latissimus myocuta- months in an effort to avoid the “recall phe- Additional Considerations
neous flap or the TRAM flap, and, in fewer nomena,” thus allowing the expander cap- Although the use of expanders indicate a
instances, other flaps, including microvas- sule to mature so that contraction of the two-stage procedure, large centers indicate
cular ones. These techniques vary consider- pocket does not occur once the expander is that there is, in fact, an average of 3.2 opera-
ably in their complexity. Symmetry may be removed. The expander is replaced with a tions per patient because of the problems
more difficult to achieve with implants than permanent prosthesis, and the port is then with exposure of the implant, capsular con-
with flaps. removed on an outpatient basis. tracture requiring reoperation, elevation of
the inframammary fold, as well as inadequate
Implants and Expanders Advantages symmetry with the contralateral breast.
Patients who have good skin tone, are non- 1. Short operating time A second and most important consider-
smokers, have small breasts, and will not 2. Short recovery time ation is the increasing use of skin-sparing
be receiving radiotherapy postoperatively 3. Lack of donor site scars mastectomy by oncology surgeons. This pro-
are good candidates for implants. Most pa- 4. Lack of donor site morbidity cedure develops thin skin flaps, which in
tients undergo placement of tissue expand- most large series have an incidence of 18%
ers because one does not want to add an Disadvantages for skin necrosis. Were one to put an implant
additional insult to the relatively thin over- 1. The breast is only partly reconstructed or an expander under this relatively thin skin,
lying skin from underlying pressure. In and requires an expansion. exposure of the implant would be unavoid-
addition, with mastectomies (except skin- 2. The reconstructed breast is round and able. To avoid exposure, total muscle cover-
sparing mastectomies), skin is removed and creates unnatural upper pole fullness; to age of the implant is essential. Although
skin expansion is required. obtain symmetry, it is not unusual that the serratus muscle does provide a certain
The tissue expander or implant can be one needs to put a smaller implant on amount of muscle coverage to the lower
used for immediate or delayed reconstruc- the contralateral normal breast. pole of the implant, if one depends only on
tion (Figs. 11 and 12). The prosthesis is 3. The reconstructed breast has an unnatu- the serratus muscle for such coverage, one is
placed submuscularly beneath the pectora- ral feel. likely to place the implant higher than one
lis major muscle and the serratus anterior 4. Potential complications are infection, would like, thus elevating the inframammary
muscle, if possible, to provide an extra layer capsular contracture, deflation, and fold. Because of this consideration, in our
of tissue in the event of a skin breakdown. extrusion. Capsular contracture may practice when a skin-sparing mastectomy
The port is placed at the lower axilla, al- cause variable amounts of pain and an has been performed and an implant recon-
though some expanders have a built-in port unnatural appearance of the breast. The struction is planned, we prefer to transpose
that is located anteriorly and identified incidence of capsular contracture has the latissimus dorsi myocutaneous flap. This
with a magnet. The hospitalization is short, been reduced with submuscular place- provides excellent muscle coverage for the
1 or 2 days, and the expansion is usually ment of the implant. Capsulotomy or lower portion of the implant and restores the
begun on the second week and proceeds at capsulectomy may be required for cap- skin island at the site of the nipple and
weekly intervals for a period of 4 to 6 weeks, sular contracture. Removal of the im- areola. If this is done, as demonstrated in
depending on the amount of expansion re- plant and autologous reconstruction our practice, one does not need to put an

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 221 10/28/11 8:48:52 PM

 222 Part II: Basic Surgical Skills: New and Emerging Technology

Scar
Incision over
pectoralis major
muscle

Area of
undermining

Expander

Injection
portal
A B
Tubing connection

C Saline-filled
Expansion with saline syringe D Tubing connection without portal

Fig. 11. A–D: As seen in the diagrams, it is easy to place the expander too high because the pectoralis major does not extend
to the inframammary fold. For proper and a lower positioning, the expander does not have muscle coverage in the distal third.
(Modified from Vasconez LO, Lejeur M, Gamboa-Bobadilla M. Atlas of Breast Reconstruction. Philadelphia: JB Lippincott,
1991:22, with permission.)

expander; instead, a permanent implant is Use of Acellular Dermis and Biologic Mesh lower coverage of the implant with the latis-
used, thus reducing the number of operative Following a skin sparing mastectomy, it is simus dorsi muscle, although this entails a
procedures. Even if the overlying skin flap not possible to cover the lower portion of bigger operation and turning of the patient.
were to necrose in a small portion, the im- an implant, if that is the method chosen To avoid that, one has the option of using
plant is covered with muscle and is salvaged. by the reconstructive surgeon. We advocate acellular dermis. These materials come in
two general classes: human collagen and
pig collagen (Alloderm and Strattice).
The materials although helpful to pro-
vide coverage of the implant or reinforce the
thin skin flaps are devoid of deleterious ef-
fects. These effects may include the follow-
ing: There is a low level of inflammation of
Permanent the wound, which may be mistaken for an
silicone gel
implant
infection. This is due to the fact that colla-
gen has a low level of antigenicity (perhaps
more with the xenographic mesh—pig).
There is invariable fluid collection or seroma,
which requires the use of drains for a pro-
longed period of time. In addition, one has
to be sure that the native skin flaps are well
vascularized to avoid exposure of the mesh.
Optimistic reports have been published, al-
Fig. 12. The permanent implant is placed 2 to 3 cm below the inframammary fold to allow for the capsu- though generalized experience is limited.
lar contracture which will invariably ensue. (Modified from Vasconez LO, Lejeur M, Gamboa-Bobadilla Nonetheless, it is an attractive and easy op-
M. Atlas of Breast Reconstruction. Philadelphia: JB Lippincott, 1991:22, with permission.) tion, although the materials are quite costly.

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 222 10/28/11 8:48:53 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 223

Superior border of orly above the tip of the scapula and inferi-
latissimus dorsi orly for at least 10 to 15 cm. The dissection
muscle of the muscle is begun superiorly, where the
upper border of the latissimus dorsi is eas-
ily identified, and extends posteriorly along
the paravertebral fascia down the inferior
border of the dissection while dividing the
muscular attachments with the cautery.
The anterior border of the latissimus dorsi
is identified, and one grasps the muscle
edges with an Allis clamp, and the elevation
is continued by dividing the posterior inter-
costal attachments.
Care must be exercised to avoid elevat-
ing the serratus muscle. This is avoided by
beginning the dissection superiorly where
Tip of one finds the appropriate plane within the
scapula
planned dissection. The muscle with the
overlying skin island is freed up all the way

Basic Surgical Skills: New and

Position of
skin island around. The thoracodorsal vessel is easily

Emerging Technology
identified in the axilla. Rarely, the serratus
Anterior border of branch needs to be divided to improve the
latissimus dorsi arc of rotation, but this is not routinely
muscle done. The thoracodorsal vessel does not
Caudad extent
need to be skeletonized, but the muscle
of flap should be freed up posteriorly, almost all
the way to the humerus. The latissimus
Fig. 13. External landmarks of the latissimus dorsi muscle. The skin island is preferentially outlined trans- myocutaneous flap is then tunneled to the
versely so that the scar will be covered by the brassiere. (Modified from Vasconez LO, Lejeur M, Gamboa-
Bobadilla M. Atlas of Breast Reconstruction. Philadelphia: JB Lippincott, 1991:39, with permission.)
anterior chest by making a very high tunnel
through the skin-sparing mastectomy dis-
section or by using the axillary incision that
may have been made for the sentinel node
Latissimus Dorsi Myocutaneous skin island taken transversely across the biopsy. Variations of the flap may be used
Flap and Implant back so that the scar will be covered with a instead (Fig. 14).
This procedure is the safest method of breast brassiere. A skin island should be limited to Once the myocutaneous unit is trans-
reconstruction; it is relatively straightfor- no more than 6 to 8 cm to allow primary posed anteriorly, one elevates the pectoralis
ward and very well tolerated by the patient. closure of the donor site. major muscle, partially divides its origin
This technique is particularly applicable to along the sternum, and the latissimus dorsi
immediate reconstruction following skin- Technique muscle is sutured to the undersurface of the
sparing mastectomy. The latissimus pro- The patient is marked in the standing posi- pectoralis major muscle and to the subcu-
vides additional muscle coverage to the im- tion preoperatively. The anterior border of taneous tissue of the skin in the inferior
plant, particularly on the inferior pole. the latissimus dorsi muscle should be flap, in preference of suturing to the chest
The latissimus dorsi is a rhomboid- marked on the ipsilateral side, and the infra- wall. An immediate implant is inserted and
shaped muscle that originates along the mammary fold should also be marked. The inflated to the proper volume, but it is ad-
paravertebral fascia in the back and inserts skin paddle is oriented transversely to cor- visable that the implant be placed at least 2
in the upper portion of the humerus. The respond to the brassiere line. If necessary, to 3 cm below the contralateral inframam-
upper border of the muscle is just above the an extension along the anterior border of mary fold (Fig. 15). The reason for suturing
tip of the scapula, extending obliquely pos- the latissimus dorsi muscle is done to gain the lower portion of the latissimus dorsi
teriorly, and inferiorly it then reaches the access to the upper portion of the muscle. muscle to the subcutaneous tissue is to
iliac crest (Fig. 13). It is a “tree-climbing” Working in concert with the oncology avoid restricting the implant pocket. A suc-
muscle, but its function can be taken over surgeon, the flap can be elevated before the tion catheter is placed along the axilla.
by other adjacent muscles. The blood sup- mastectomy or following it. If it is elevated The patient is then returned to the re-
ply is from the thoracodorsal artery, which before the mastectomy, the patient is placed cumbent position, is sat up on the operat-
is a branch of the subscapular artery (third on a bean bag in the lateral recumbent po- ing table, and appropriate adjustments are
portion of the axillary artery). The pivot sition, the flap, which is elevated and ready made if necessary by putting another
point should be as high as possible, limited to be transposed, is placed on a sterile plas- smaller implant on the contralateral side.
only by the thoracodorsal pedicle. The in- tic bag, and the wound is closed with the
sertion need not be transected, but the insertion of drains. If the mastectomy is Advantages
muscle should be freed up as high as possi- done first, the patient is placed in the lat- 1. The implant is totally covered by muscle,
ble to make it transpose as a pendulum eral decubitus position with the shoulder and thus protected of the overlying soft
rather than rotating it to avoid the bulge and arm resting at 90 degrees over a Mayo tissue.
along the axilla. The flap is usually har- tray. The skin island is incised right down to 2. Although it requires repositioning of
vested as a musculocutaneous flap with a the muscle. The skin flap is elevated superi- the patient, thus increasing the operating

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 223 10/28/11 8:48:54 PM

 224 Part II: Basic Surgical Skills: New and Emerging Technology

Transverse Oblique Midoblique

A B C

Fig. 14. A–C: Outline the skin island to fit the different scars from the mastectomy. Transverse outline (A) is the most used.
(Modified from Vasconez LO, Lejeur M, Gamboa-Bobadilla M. Atlas of Breast Reconstruction. Philadelphia: JB Lippincott,
1991:3.9, with permission.)

time, the recovery time and hospitaliza-

tion are shorter.

Disadvantages
1. Because an implant is used, capsular
contracture remains a possibility even
though there is total muscle coverage.
Deflation is also possible, although ex-
trusion is rare.
2. There is a donor site scar on the back,
which usually is covered by the bras-
siere.
3. Seroma is very common at the donor
site and is usually treated by a second-
ary stab wound percutaneous needle as-
piration in the most dependent portion
of the seroma.

Transverse Rectus Abdominus

Myocutaneous Flap
The TRAM flap is the most commonly used
method of autogenous reconstruction of
the breast. This is a most innovative proce-
dure that results in the best and most
natural method of breast reconstruction,
obtaining symmetry with the contralateral
breast in the majority of cases. It supplies
Fig. 15. Most often the distal third of the implant is not covered by muscle, although occasionally the ser- an abundant amount of soft tissue; how-
ratus muscle does help achieve lower coverage of the implant. (Modified from Vasconez LO, Lejeur M, Gam- ever, the recovery time is longer and the
boa-Bobadilla M. Atlas of Breast Reconstruction. Philadelphia: JB Lippincott, 1991:3.9, with permission.) hospitalization may be 4 to 6 days. The

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 224 10/28/11 8:48:54 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 225

side so as to preserve at least the lateral half

of the inframammary fold. The contralat-
eral rectus may also be used, depending on
previous abdominal incisions.

Technique
Xiphoid The procedure is begun by circumscribing
suture the umbilicus and leaving it in place. The
upper abdominal incision is then made to
the anterior rectus sheath, and the superior
abdominal flap is undermined to the costal
Midline margin bilaterally and then to the xiphoid
in the midline. At this point, working from
the chest by either the mastectomy defect
or reopening the mastectomy scar in a de-
layed reconstruction, a midline tunnel is
created of sufficient size to allow the pas-
sage of the flap. Again, the tunnel must be
midline and extend to the contralateral side

Basic Surgical Skills: New and

to preserve the inframammary fold. Having

Emerging Technology
elevated the upper abdominal flap, the an-
terior rectus sheath is exposed and one can
see the location of the perforating vessels,
which have either been controlled with
Pubic
hemoclips or electrocautery. A 5-cm wide
suture
anterior rectus sheath is preserved with the
perforating vessels in the midline, and this
Fig. 16. Two sutures: one placed on the xiphoid and the second on the mid-pubis allow us to obtain bi- anterior rectus sheath is incised on each
lateral symmetry by triangulation. (Modified from Vasconez LO, Lejeur M, Gamboa-Bobadilla M. Atlas of side, preserving the midline fascia as well as
Breast Reconstruction. Philadelphia: JB Lippincott, 1991:4.31, with permission.) the lateral fascia and freeing up the entire
muscle from the posterior rectus sheath.
The lower incision is then made as far
blood supply is the deep inferior epigastric particularly in patients less than 50 years down toward the pubis to allow for direct
artery, from the external iliac artery and the and without any systemic illnesses, but in closure. The contralateral side is first ele-
superior epigastric artery from the internal all cases, zone 4 should be discarded be- vated rapidly, just past the midline to cor-
thoracic artery (Fig. 16). They communicate cause it is likely to necrose. respond to the medial incision of the ante-
through a series of vascular interconnec- The standard design for breast recon- rior rectus sheath superiorly, and then the
tions just above the umbilicus, thus form- struction is an elliptical lower abdominal fascia along the midline is also divided to-
ing the epigastric arcade. In addition, the transverse skin island at the level of the um- ward the pubis, preserving the linea alba.
segmental and intercostal vessels join the bilicus to above the pubis to allow for the The lateral flap is then elevated rapidly,
arcade at the deep portion of the muscle. direct closure with acceptable tension. De- again to the lateral edge of the muscle, and
The inferior epigastric artery is the dom- pending on the volume of tissue necessary using the incision along the anterior rectus
inant blood supply and enters the muscle for the reconstruction, the flap is harvested sheath superiorly as a guide, the dissection
laterally at the semilunar line. The pedicle as a unipedicle, bipedicle, free TRAM flap, extends to that level where the fascia is di-
length is 8 to 10 cm. The blood supply to the or perforator flap. The entire skin paddle vided again toward the pubis, communicat-
overlying skin is through musculocutane- can be transferred with a bipedicle flap, and ing through a transverse incision with the
ous perforators thought to be arranged in a 75% can be transferred as a free tissue trans- midline dissection.
medial row and a lateral row. The perfora- fer. We do not favor bipedicle TRAM flaps The rectus muscle is then freed up from
tors are primarily periumbilical, with few, for unilateral breast reconstructions except the lateral aspect as well as from the medial
if any, perforators below this semicircular in postradiation cases in which a large aspect; the deep inferior epigastric vessels,
line. As determined by the so-called perfo- amount of skin has been resected from the which are located below the semicircular
rator flap, the entire flap is probably nour- chest wall. line, and surrounded by fat, are identified
ished by a large periumbilical perforator. and then divided between hemoclips. The
This is important to know because the flap Unipedicle Transverse Rectus rectus abdominus muscle is then also di-
should never be outlined with the upper in- Abdominus Flap vided just below this semicircular line, pre-
cision below the umbilicus to ensure the The unipedicle TRAM flap is based on the serving the divided inferior epigastric pedi-
inclusion of this perforator. Four zones are superior epigastric artery and vein (Figs. 17 cle. The flap unit is elevated by dividing the
designed on a transverse elliptical skin is- and 18). We advise the use of the ipsilateral segmental intercostal vessels and freed up
land to describe the availability of the blood TRAM flap because of the shorter arc of ro- from the posterior rectus sheath. Once ap-
supply based on the superior epigastric ves- tation and the avoidance of the epigastric propriate hemostasis has been obtained,
sels. The hemiflap is totally reliable, and lat- fullness. However, when the ipsilateral flap the flap is passed through the midline tun-
eral extension into the flank is also reliable. is used, the tunnel must be in the midline nel toward the chest. The flap is turned with
A portion of it is viable past the midline, and, preferably, extends to the contralateral the skin side out and the distal portion of

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 225 10/28/11 8:48:55 PM

 226 Part II: Basic Surgical Skills: New and Emerging Technology

IV
III
I

II
I
II
IV

III

Fig. 17. Presently, the ipsilateral flap is the first choice. In either case, the tunnel is on the midline of the abdomen and chest.
(Modified from Vasconez LO, Lejeur M, Gamboa-Bobadilla M. Atlas of Breast Reconstruction. Philadelphia: JB Lippincott,
1991:4.10, with permission.)

the contralateral side (zone 4) is discarded, the internal oblique fascias below the um- obtained by suturing the umbilicus with in-
as are additional portions of so-called zone bilicus (Figs. 20 and 21). One should re- terrupted nylon sutures to the anterior rec-
2. The best way to evaluate the viability of member that the anterior rectus sheath tus sheath as it is pulled toward the center.
the flap is by observing bright red bleeding splits into the external and internal oblique The abdominal wound is then closed,
from the skin edges. This is observed even if fascia approximately halfway between the and the umbilicus is re-exteriorized at the
one has used lidocaine with epinephrine for umbilicus and the pubis. The internal appropriate level and sutured with fine ny-
the vasoconstricting effect. The presence of oblique fascia has a tendency to retract, lon. Suction catheters are placed. It should
dark blood is indicative of inadequate blood and if one does not identify this internal be noted that seromas in a TRAM flap pro-
supply and further resection should be layer and approximate it to the midline, cedure are relatively rare. This is in contrast
performed. either together or separately with the exter- to the almost universal seromas that are
The orientation of the flap is relatively nal oblique, a lower abdominal bulge or seen in abdominoplasties. The reason for
simple as the tip of the flap is placed to sim- pseudohernia will appear. this is not clear, but a possible explanation
ulate the axillary tail of the breast. The re- In unilateral breast reconstructions, di- may be that fluid is suctioned intra-
maining flap is allowed to hang down rect closure is almost always possible. To abdominally through small openings in the
obliquely or vertically, or very simply to fill accomplish this, we place three retention abdominal sheaths, particularly below the
the envelope of skin-sparing mastectomy sutures of 0 Prolene, one at the level of the semicircular line.
(Fig. 19). In a case of a delayed reconstruc- umbilicus and one above and one below the
tion in which the mastectomy has been umbilicus. Once these sutures are approxi- Advantages
done with a transverse incision, the upper mated to the midline, we run a loop suture 1. Large volume of tissue sufficient to pro-
edge of the skin flap may be zigzagged to from just below the turn of the muscle in vide excellent shape and symmetry with
obtain more projection and the lower skin the epigastrium down to the pubis. To cen- the contralateral breast.
may actually be resected close to the infra- tralize the umbilicus, which has been moved 2. Abdominoplasty results with donor site
mammary fold to allow for satisfactory pro- to the side of the flap, the contralateral in- closure.
jection and ptosis of the flap. The closure of tact anterior rectus sheath is also plicated
the abdominal defect is essential, and the with interrupted or continuous sutures of Disadvantages
most important admonition is to close ei- Prolene for ⬃4 cm. If the umbilicus is on a 1. Fat necrosis is 14% in conventional flaps
ther separately or together the external and large stalk, additional centralization can be and 4% to 5% in free flaps.

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 226 10/28/11 8:48:55 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 227

Internal oblique
muscle sutured to
anterior rectus sheath External
oblique
muscle
External oblique
Internal
muscle (reflected)
oblique
muscle

Basic Surgical Skills: New and

Emerging Technology
Fig. 20. The external oblique muscles are freed up to the flanks. The internal oblique muscles are ap-
Fig. 18. In molding the breast, attention is paid proximated as close to the midline as possible. It is not possible to make them reach the midline. (Mod-
to projection, ptosis, and the equal placement of ified from Vasconez LO, Lejeur M, Gamboa-Bobadilla M. Atlas of Breast Reconstruction. Philadelphia: JB
the inframammary fold bilaterally. It is essential Lippincott, 1991:4.22, with permission.)
to be able to sit the patient intraoperatively, to
determine symmetry. (Modified from Vasconez
LO, Lejeur M, Gamboa-Bobadilla M. Atlas of
Breast Reconstruction. Philadelphia: JB Lippincott, 2. Pseudohernia is 4%.
1991:4.10, with permission.) 3. Possibility of partial or total loss of the
flap, particularly in smokers and very
obese patients.

Bipedicle Transverse Rectus Abdominus

Myocutaneous Flap
In cases in which a bilateral mastectomy is
performed, bilateral TRAM flaps are per-
formed, again on the ipsilateral side but al-
Superior
epigastric
ways with the midline tunnel preserving
arteries the inframammary fold in each side. Rarely,
a bipedicle TRAM flap is needed for postra-
Bilateral diation defects in which large amounts of
transposed skin are resected. In such cases, the skin
rectus paddle is reliably from the ipsilateral ante-
muscles rior axillary line fold to the contralateral
anterior axillary line fold. The flap is har-
vested in the same manner as the pedicle
Posterior
level of
flap except that both rectus abdominus
rectus muscles are harvested along with the trans-
sheath verse skin paddle, preserving both superior
epigastric vessels. Although one preserves
the linea alba or midline fascia for at least
2 cm as well as the lateral portion of the an-
terior rectus sheath bilaterally, and primary
closure can be done in a good number of
patients, mesh is sometimes necessary as
an inlay to approximate the remaining fas-
cias. Again, we emphasize that attention
Linea arcuata Inferior epigastric arteries must be paid to approximate the internal
Fig. 19. For bilateral reconstruction, it is important to design ipsilateral flaps. Rotation of the flap ei- oblique fascia. If mesh is used, we prefer the
ther in clockwise or in anticlockwise direction is safe. (Modified from Vasconez LO, Lejeur M, Gamboa- use of folded polypropylene mesh, usually
Bobadilla M. Atlas of Breast Reconstruction. Philadelphia: JB Lippincott, 1991:4.10, with permission.) four thicknesses, and approximate it with

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 227 10/28/11 8:48:55 PM

 228 Part II: Basic Surgical Skills: New and Emerging Technology

traced down to its origin at the external il-

iac vessels, and ligated at this point. The re-
cipient vessel often used for the anastomo-
sis is the internal mammary artery and its
accompanying vein. The thoracodorsal ves-
sel is a second choice at present. The reason
for this change is the popularity of the sen-
tinel node dissection. By using the sentinel
node, the thoracodorsal vessel is not skele-
tonized as it was with an axillary dissection,
and there is the rare possibility that an ini-
tial negative sentinel node may turn out to
External be positive in the permanent sections, re-
oblique quiring the return to the axilla, where the
muscle anastomosis may be compromised. In addi-
advanced tion, the internal mammary artery provides
over
internal
a very satisfactory way of molding the breast
oblique to match the opposite side.
Advantages
1. Preferred in smokers, obese patients,
and patients with mediastinal irradia-
tion for lymphomas
2. Larger volume of tissue
3. Greater freedom of rotation
4. Less incidence of fat necrosis
Fig. 21. Once the internal oblique muscles are plicated, the leaves of the external obliques easily reach
the midline. It is imperative that the closure be performed simultaneously on both sides. Otherwise, Disadvantages
closure of the second side is nearly impossible due to fascial tears. (Modified from Vasconez LO, Lejeur 1. Longer operating time
M, Gamboa-Bobadilla M. Atlas of Breast Reconstruction. Philadelphia: JB Lippincott, 1991:4.22, with per- 2. Requires microsurgical expertise and
mission.) well-trained team for small artery anas-
tomosis

Prolene suture on each side. The use of an preserved along with a small segment of Perforator Flap
onlay mesh is less satisfactory. rectus abdominus muscle (Fig. 22). It is not A modification of the free TRAM flap is the
necessary to take the entire width of the free perforator flap. This entails the preser-
Advantages muscle. The vessel is identified entering the vation of the periumbilical perforator with
1. Larger volume of tissue. rectus muscle near the semicircular line, its accompanying veins dissected along
2. Makes for bilateral symmetric recon-
structions of the breasts. Preferred also
in patients who are markedly obese and
have had previous chest wall radiation
(patients who have had previous medi-
astinal irradiation such as for Hodgkin
disease, in which internal mammary
damage is possible) are best treated
with a free TRAM flap anastomosed to
the thoracodorsal or other appropriate
vessel.
Disadvantages
1. Often requires the placement of mesh
2. Longer operating time
3. Greater risk of abdominal wall compli-
cations

Free Transverse Rectus Abdominus

Myocutaneous Flap
The dominant blood supply of the free
TRAM flap is the deep inferior epigastric Fig. 22. For a free TRAM flap, the anastomosis is made to the thoracodorsal vessels as shown above.
vessels. The flap is harvested in the same Presently, most microsurgeons prefer to do the anastomosis to the internal thoracic artery and vein
way as the previously described flaps except or veins. (Modified from Vasconez LO, Lejeur M, Gamboa-Bobadilla M. Atlas of Breast Reconstruction.
that the deep inferior epigastric vessel is Philadelphia: JB Lippincott, 1991:13.6, with permission.)

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 228 10/28/11 8:48:56 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 229

superior option taken by well-qualified teams.

The vessels can nourish the same amount of
abdominal tissue.

Other Autologous Options

The TRAM flap may not be indicated in pa-
tients who have had previous abdominal
Rectus operations that have transected the rectus
muscle muscle, patients who have had previous ab-
dominoplasty, or in patients in whom there
is inadequate abdominal fat to make a
Perforators breast mound. These following additional
free flaps can be offered. (a) The gluteal free
flap, based on either the inferior or more
recently the superior gluteal artery, which
Anterior provides an abundant amount of tissue to
rectus sheath be transferred. The pedicle is of good length,
8 to 10 cm, but the patient must be prone
during the harvest of the flap and needs to

Basic Surgical Skills: New and

be turned over for the reconstruction.

Emerging Technology
(b) The “Rubens flap,” which uses the fat in
the flank over the iliac crest region. It is
Lateral branch based on the deep circumflex iliac artery
of deep inferior and offers adequate volume for breast re-
epigastric artery
Medial branch construction. The vessels offer good caliber
and length, 6 to 7 cm, and the donor site scar
is hidden underneath pants. During surgery,
Fig. 23. Diagrammatic demonstration of the perforators from the deep inferior epigastric vessels. The
the patient is supine with the hip lifted by a
main perforator is near the umbilicus. (From Spear SL, Little JW, Wood WC, eds. Surgery of the Breast:
Principles and Art, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006:814.)

with the deep inferior epigastric vessel, but

preserving almost the entire integrity of the
rectus abdominus muscle (Figs. 23 and 24).
The proponents of this flap indicate the ad-
vantages, such as increasing integrity of the
abdominal wall, but it does take a more me- Internal
ticulous and lengthier dissection, at least in mammary
less-experienced hands. artery
One can usually predetermine if a perfo-
Inferior
rator flap type of reconstruction is possible,
epigastric
by performing a CT angiogram. It accu- artery
rately indicates if the perforators are appro-
priate for the anastomosis, avoiding the
need to visually dissect those vessels. The
perforator flap is gaining popularity be-
cause it preserves the integrity of the rectus
muscle and of the abdominal wall.

Superficial Inferior Epigastric

Breast Reconstruction
This option is a possibility in a minority of
the patients who elect microvascular breast
reconstruction.
The CT angiogram visualizes the superfi-
cial inferior epigastric vessels and one can
determine if those vessels are large and long
enough to perform the breast reconstruc-
tion. It does require additional expertise and
does not offer the safety of the deep inferior Fig. 24. The preferred method of anastomosis. It has the advantage of leaving the axillary region free for
epigastric vessels. Reconstruction with the a possible additional axillary dissection. (From Spear SL, Little JW, Wood WC, eds. Surgery of the Breast:
superficial inferior epigastric vessels is a Principles and Art, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006:815.)

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 229 10/28/11 8:48:57 PM

 230 Part II: Basic Surgical Skills: New and Emerging Technology

bean bag during the harvest. (c) The tro-

chanteric free flap, which is applicable to
patients who have trochanteric lipodystro-
phy with a relatively narrow torso. In such
patients, the fat from the trochanter can be
harvested based on the vessel of the tensor
fascia lata, leaving an acceptable defect
with a linear incision on the lateral aspect
of the leg. If a unilateral reconstruction is
performed, a subsequent procedure, such
as liposuction, will be needed to match the
opposite side. Presently, it is rarely used, al-
though its proper application is clear.
The gracilis free flap is a potential option A B
for thin patients who have small breasts. It is
harvested with a transverse orientation, leav-
ing a most acceptable scar. The limiting fac-
tor is the relatively small volume of tissue.

Nipple and Areola Reconstruction

With the sophistication and increasing
excellence of breast reconstruction, most
patients want completion of the recon-
struction by having the nipple and areola
reconstructed. This is usually performed 3
to 6 months after breast reconstruction, or
later if the patient has undergone chemo-
therapy or radiotherapy. One should wait C D
for the breast to be stable and symmetry Fig. 25. A: Diagram of modified skate flap on the breast. Flaps extend to the neoareola margin. B: Flap
has been achieved. In reconstructions us- elevation is complete, with care taken near the flap base to avoid vascular compromise. C: Neoareola is
ing the TRAM flap in which the contralat- de-epithelialized and grafted. Donor sites may be closed primarily. D: Tip of the dermal-fat flap may be de-
eral flap is modified at the same time, usu- epithelialized and buried if needed. Closure is complete. Optional areolar grafting is shown. (From Strauch
ally by a reduction mammoplasty, the nipple B, Vasconez LO, Hall-Findlay E. Grabb’s Encyclopedia of Flaps. Philadelphia: JB Lippincott, 1998:1365.)
reconstruction is performed on the second
operative procedure along with whatever
modifications are needed on the recon-
structed or the contralateral breast to ob-
tain symmetry, as well as liposuction of the
bulging of the epigastrium and the persis-
tent dog ears along the flanks.
The position of the nipple is determined
preoperatively with the patient sitting up.
No measurements are performed because
the nipple sits in relation to the breast itself.
The most accurate and effective way to
determine the location of the nipple is by
A B
visual marking and confirming it with a
digital photograph. Slight asymmetries are
easily seen in the picture.
The nipple itself is reconstructed in a
TRAM flap by using the adjacent tissue in
the form of a flap, the so-called skate flap,
which entails elevating a portion of the un-
derlying fat on a superiorly based flap and
using the wings from the lateral aspects to
wrap the base of the flap (Figs. 25 and 26).
For the areola, tattooing is the method of
choice. Occasionally, we tattoo the contral- C D
ateral areola to obtain satisfactory skin Fig. 26. A: Diagram of modified fish-tail flap on the breast. The angle between flaps a and b may vary ac-
color match. The reconstructed nipple must cording to local conditions. B: Flaps are elevated, with care taken at the flap base to avoid vascular com-
be planned and made larger than the de- promise. Flap a is rotated into position and secured. C: Flap b is de-epithelialized and passed beneath
sired final size because it contracts in the flap a. Flap b is secured and donor defects are closed. D: Completed nipple construct. (From Strauch B,
first few months postoperatively. Rarely, if Vasconez LO, Hall-Findlay E. Grabb’s Encyclopedia of Flaps. Philadelphia: JB Lippincott, 1998:1365.)

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 230 10/28/11 8:48:59 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 231

the patient has a very large contralateral

nipple, part of the nipple can be used as a
free graft to provide adequate size and pro-
jection. The use of skin grafts from the me-
dial thigh or any other area of the body to
reconstruct the areola has been supplanted
with tattooing.

Management of Post Lumpectomy;

Post Radiation-Persistent or
Recurrent Breast Cancer
Presently, the Multi Center Fisher Study has
surpassed 25 years of follow up. Patients
who elected to be treated by lumpectomy
and irradiation are now seeking help be-
cause of an increasing number of breast
cancer recurrences. The treatment for those
patients is completion mastectomy. Often Fig. 27. Division of the left gastroepiploic artery and detachment of the gastroepiploic arch from the
those patients elect bilateral mastectomies curvature of the stomach. The right gastroepiploic artery is preserved. (From Strauch B, Vasconez LO,

Basic Surgical Skills: New and

Hall-Findlay E. Grabb’s Encyclopedia of Flaps. Philadelphia: JB Lippincott, 1998:1427.)
and immediate reconstruction with autolo-

Emerging Technology
gous tissue. Less often, the reconstruction
is done with the latissimus dorsi musculo
cutaneous flap and an implant. The use of a radiation ulcer, the ulceration as well as it through the subcostal region based on the
expanders or implants, even with the added the entire surrounding portal of irradiation right gastroepiploic vessels. The omentum
attribute of acellular dermis is fraught with should be excised, including the underlying is used to fill in the cavity, the skin edges
complications and is not recommended. ribs if they are affected, leaving only essen- can be approximated directly (Figs. 27 and
tial or nonirradiated tissue. Infected tissue, 28). The use of the omentum alone is usu-
Oncoplastic Surgery whether from empyema, mediastinitis, or ally unsatisfactory because it can be blown
The popularity of lumpectomy and irradia- necrotic tissue, requires debridement above away with the persistent fistula. It is better
tion even in the case of larger tumors (over all, drainage, and appropriate intravenous to plug it with muscle first, and then addi-
4 cm) often leaves a significant and unat- antibiotics. (b) Obliteration of the intratho- tional omentum will provide a second line
tractive defect in the breast. The so-called racic dead space. The reconstruction should of defense. Methods for omental transposi-
oncoplastic techniques have been devel- be performed from the inside to outside. tion will be described later.
oped to correct the depression and the The pleural cavity should first be filled and
asymmetry left by the large removal of the intrathoracic organs must be protected. Postradiation Ulcerations in the
breast tissue with the tumor. These maneu- (c) Skeletal stabilization. Paradoxical respi- Anterior Chest
vers entail moving the remaining breast ratory motion of the inflated chest must be Commonly seen in the past with the meth-
tissue around. It requires considerable prevented. Skeletal stabilization is usually ods of external irradiation, postradiation
knowledge of the anatomy and particularly required for rib resections of more than four ulcerations are much rarer now. Nonethe-
the blood supply to the breast, to avoid cre- ribs or a defect larger than 5 cm. (d) Soft less, when they occur, the approach follows
ating worse defects. It is usually accompa- tissue coverage that is well vascularized, the principles previously outlined for post-
nied by a reduction of the opposite breast. tension-free, and leak-free must be provided. radiation ulcers. One should resect not only
Although such surgical manipulations the ulceration, but also all the surrounding
are possible, and symmetry may be ob- Bronchopleural Fistulas tissues that have been irradiated; that is, the
tained, it does not replace the skin sparing Bronchopleural fistulas usually occur fol- entire portal of irradiation. Most often, this
mastectomy and immediate reconstruction lowing empyema and occasionally follow- also requires the resection of the underlying
in the quality of the appearance of the new ing treatment for malignant tumors with ribs, which will appear chalky, friable, and
breasts, and particularly in diminishing the irradiation. In most patients with these fis- devascularized. A formidable defect is thus
fear of the patient for a possible cancer re- tulas, a thoracotomy has been performed; produced.
currence. It should be noted that the recur- consequently, the use of available muscle For the reconstruction, one must first
rence rate following skin sparing mastec- flaps such as the latissimus is limited. stabilize the chest wall. To do this, we prefer
tomy is ∼4%. Proper treatment requires removal of the use of polypropylene mesh sutured to
the fistulous tract, approaching the leaking the ribs, or whatever firm and healthy tis-
Chest Wall Reconstruction bronchus in as safe a fashion as possible. sue is found all the way around. We have
The bronchus should be plugged with the not found any significant advantage of
The reconstructive surgeon is presented use of adjacent muscle. The latissimus dorsi the newer composite meshes to advocate
with thoracic wounds that result from muscle is probably divided from the thora- its use. This mesh is sufficient to provide
trauma, tumor resection, infection, radia- cotomy, but there may be portions of the stabilization of the chest wall and allow for
tion, and congenital defects. The following serratus or even the upper portion of the extubation at an early time. Following the
principles must be considered: (a) Complete latissimus muscle that can be used to plug placement of the mesh, the omentum is
surgical resection and/or debridement. The the fistula. This still leaves a large cavity or transposed through a midline upper epigas-
tumor is completely excised with tumor- tract. This cavity can be obliterated with the tric incision, through the subcutaneous tis-
free frozen section margins. If dealing with use of the omentum transposed by passing sue, and over the chest wall. It is preferable

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 231 10/28/11 8:48:59 PM

 232 Part II: Basic Surgical Skills: New and Emerging Technology

Fig. 28. Division of the omental arcade along the dotted line converts the omentum into a long vascularized pedicle. (From
Strauch B, Vasconez LO, Hall-Findlay E. Grabb’s Encyclopedia of Flaps. Philadelphia: JB Lippincott, 1998:1427.)

not to tunnel the omentum, and to make an Prosthetic Options supine position. An axial incision is made in
incision on the remaining bridge of skin to Prosthetic materials can be used in unin- the lateral thigh beginning approximately
avoid any undue pressure. The omentum is fected and clearly cleansed wounds. (a) 12 to 14 cm below the anterior superior iliac
then spread over the entire wound defect, Prolene mesh: polypropylene is a fine-grade spine. The length of the incision varies, de-
particularly over the mesh, and stabilized mesh that is rigid in two directions and al- pending on the size of the graft needed. The
with sutures all the way around; immedi- lows fibrovascular ingrowth. This mesh is dissection is carried down to the fascia lata,
ately, the meshed split-thickness skin graft easily handled, cheap, and readily available. and skin flaps are elevated medially and lat-
is placed over the omentum. By bringing (b) Marlex mesh is presently also being erally. The fascia lata graft can be taken up
out the omentum in the epigastrium, one made of polypropylene, and is similar to to 25 to 28 cm in length and 14 to 16 cm in
would think that a possible hernial site is Prolene. (c) GoreTex is a polytetrafluoroeth- width. The posterior part of the fascia lata
produced, but this has not occurred be- ylene mesh requiring port sizes of 10 to 30 is preserved to prevent lateral instability.
cause the omentum fills in the defect nicely. μm. Mini mono initial adherence allows it The graft can be used to cover chest wall de-
We prefer this method to bring the omen- not to adhere to the underlying lung. It is fects for skeletal stability. The donor site is
tum through an opening across the dia- moldable and flexible, and adapts well to then closed with drains.
phragm and the chest wall. the chest wall movements. It has superior
The advantages of the use of the omen- durability and strength, but unfortunately Advantages
tum include the following: (a) A large it is easily infected, in which case it has to 1. Large portion of the fascia lata can be
amount of well-vascularized tissue is avail- be removed. We do not favor the use of used.
able, (b) dissection is straightforward and GoreTex for most chest wall reconstruc- 2. Ease of dissection.
reliable, and (c) early extubation is possible tions. 3. Minimal functional morbidity.
with the mesh stabilization of the chest
wall. The disadvantages are: (a) the need for Autogenous Options Disadvantages
laparotomy, (b) improper handling may re- Split-rib grafts can be used to bridge skele- 1. Graft stretches and becomes flaccid
sult in hematomas of the omentum, and tal defects, but it is not necessary to per- with time.
(c) herniation of intra-abdominal organs is form this involved and difficult procedure 2. Prosthetic materials are just as effec-
possible, although unlikely. when simpler procedures are available that tive.
are just as effective. If they are used, ribs
Skeletal Stabilization may resorb with time. They leave a fibrous
Skeletal stabilization is required in chest capsule and are subject to fractures.
Sternal Wound Reconstruction
wall resections of more than four ribs and It should also be noted that if a latissi- Sternal wounds complicating cardiac pro-
on an area of resection larger than 5 cm to mus dorsi flap is used occasionally for chest cedures most often occur in patients who
prevent paradoxical motion and inflated wall coverage and the chest wall defect is have diabetes, pulmonary disease, and who
chest. Location of the skeletal defect also relatively small, the muscle itself will be sat- use steroids. Mediastinitis occurs in 1% to
determines whether skeletal stabilization isfactory to provide skeletal stabilization in 2.5% of patients who undergo median ster-
is necessary. Posterior and superior defects a relatively short time, requiring no addi- notomy. Risk factors during cardiac surgery
near the scapula do not require skeletal sta- tional chest wall stabilization. include the duration of surgery; excessive
bilization because of the shielding effect of bleeding, necessitating reentry; the use of
the scapula. Prosthetic and autogenous Fascia Lata Graft internal mammary arteries, particularly
materials can be used to replace the rigid The tensor fascia lata muscle has a long fas- bilaterally; and, most importantly, the length
chest wall. cial extension that can be harvested in the of postoperative intubation. A sudden,

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 232 10/28/11 8:49:04 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 233

otherwise unexplained rise in the blood

glucose levels of the patient can be the
only sign of a developing septic picture
due to sternal wound infection and im-
pending mediastinitis. Sternal wound
infections must be treated with adequate
debridement of the necrotic tissue, foreign
material, blood clots, granulation tissue,
and devascularized bone, and exposed car-
tilage must be removed. Judicious use of
antibiotics for infected organisms is neces- Pectoralis
sary. Sometimes, if one is not certain of the myocutaneous
debridement or there is a considerable (advancement) flap
amount of purulency, the wound must be
left open, with dressing changes and topical
antibacterials prior to a second debride-
ment and definitive coverage. Once the
wound is clean, coverage is usually possible Anterior rectus
with the use of the pectoralis advancement sheath fascia

Basic Surgical Skills: New and

musculocutaneous flaps and, rarely, the use

Emerging Technology
of the omentum. The rectus abdominus
muscle is used less often, particularly if the Rectus muscle
internal mammary artery has been used for
Fig. 29. The pectoralis muscle and the overlying skin are elevated as a unit. Often, the insertion of the
revascularization of the heart. pectoralis muscle over the humerus is left intact. (Modified from Ascherman JA, Patel SM, Malhotra SM,
It should be noted that we used to be- et al. Management of sternal wounds with bilateral pectoralis major myocutaneous advancement flaps
lieve that obliteration of the dead space was in 114 consecutively treated patients: refinements in technique and outcomes analysis. Plast Reconstr
essential for the management of mediasti- Surg 2004;114:678, with permission.)
nal wounds, but this is no longer true be-
cause the potential dead space is rapidly
obliterated with pectoralis myocutaneous
flaps and the use of suction. muscle based superiorly. We do not favor apron based on the left gastroepiploic ves-
the use of turnover pectoralis major flaps sels, but occasionally, if additional length is
based on the perforating vessels of the in- needed, it can be based on either one of the
Flap Options ternal mammary artery. gastroepiploic vessels. Selective omental di-
Pectoralis Major Muscle Flap The blood supply to the pectoralis myo- vision can be performed to lengthen the
When using a pectoralis major muscle flap cutaneous flap is from the thoracoacromial omentum. The right gastroepiploic vessel is
the mediastinal wound is débrided, resect- blood vessels. The pectoral or the thora- usually the dominant blood supply. Omen-
ing the remnants of the sternum on both coacromial branch follows a path marked tum can be harvested as a pedicle flap by
sides. If the costal cartilages are exposed, from the tip of the acromion to the xiphoid tunneling through the upper end of the
they must be removed, particularly if they and is left undisturbed as one frees it from midline incision, which is used to dissect
are devoid of perichondrium; otherwise, the chest wall. The pectoralis minor muscle the omentum.
they are likely to result in draining fistulous is left in place and undisturbed.
tracts. Following debridement, a myocuta- The advantage is the ease of dissection Technique
neous flap of pectoralis major muscle is el- and effectiveness, particularly for the upper The omentum is exposed through a midline
evated (Fig. 29). One divides the origin of two-thirds of the mediastinal wounds. The laparotomy incision, placed on traction,
the pectoralis major muscle from the lateral disadvantages are that it will not cover the and separated from its vascular attach-
aspect of the sternum on both sides and lower-third of the mediastinum, and hema- ments to the transverse colon. The short
bluntly undermines toward the anterior ax- toma is possible, particularly in patients vessels between the gastroepiploic system
illary line and the clavicle. It is not neces- who have been anticoagulated. and the stomach may be individually
sary to divide the insertion of the pectoralis clamped and ligated as far as the antrum
major muscle from the clavicle or acromion. Omentum and duodenum. The right and left gastro-
Once this mobilization has been obtained, In patients who have large mediastinal de- epiploic vessels are alternately uprooted to
the muscles are sutured with permanent fects in which both internal mammary ar- determine the competency of the blood
sutures in the midline and over drains, and teries have been used and the sternum is supply. The right gastroepiploic vessel is
the overlying subcutaneous tissue and skin chalky and necrotic, and particularly in pa- usually the more pulsatile and larger of the
are also closed. If the mediastinal wound tients with heart transplants, the omentum two, and thus the left gastroepiploic vessels
extends inferiorly, where the pectoralis ma- is an ideal and most satisfactory method may be sacrificed. Depending on the loca-
jor muscle cannot cover it, it is possible to for reconstruction. tion of the defect, the omental flap can be
free up the origin of the rectus abdominus The omentum is a large flap, providing lengthened by selective omental division. A
muscle from the costal cartilages bilaterally 25 ⫻ 35 cm of vascularized tissue. It can be tunnel is created in the subcutaneous space
and advance it superiorly and suture it to used as a pedicle or even as a free flap to fill for passage of the omental flap through the
each other. This is preferable to making the pleural defects, chest wall wounds, and upper midline laparotomy incision. Care
formal transposition of the rectus abdominus sternal wounds. It is usually folded as an should be taken not to twist the pedicle.

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 233 10/28/11 8:49:11 PM

 234 Part II: Basic Surgical Skills: New and Emerging Technology

Tacking sutures can be placed from the in most patients. A myocutaneous paddle- The muscles of the anterior abdomen are
omentum to the exit wound to help secure like flap is outlined at the border of the de- the external oblique, internal oblique, trans-
the flap, although this is usually unneces- fect and extends beyond it. It is elevated versus abdominus, rectus abdominus, and
sary. We prefer exiting the omentum through with the underlying muscle and extends it pyramidalis.
the upper laparotomy midline incision superiorly by dividing the muscle at the Abdominal wall defects may involve a
rather than through the diaphragm or a sep- posterior neck, but preserving the trans- deficiency of skin, fascia, or both. The most
arate incision, which may create more prob- verse cervical artery. The flap is then trans- frequent causes of defects include trauma,
lems. The advantage is that a large flap is posed to cover the defect or rotated to cover tumor resection, infection, incisional her-
created. The disadvantage is that it requires the occiput and the upper cervical spine. nia, congenital anomalies, and radiation
an intra-abdominal operation with subse- Care must be used to elevate the skin and/ therapy. Acute traumatic wounds require
quent abdominal pain, which may compro- or muscle flap, preserving the underlying multiple stages for abdominal wound clo-
mise respiratory function. latissimus dorsi and rhomboid muscles but sure. These injuries require extensive debri-
dividing the fibers of insertion to the scap- dement as abdominal organs are frequently
ula as needed. injured. It is best to avoid closure of acute
Postradiation Posterior Neck and injuries by elevation of local soft tissue
Upper Dorsal Wound Reconstruction flaps. This will open new tissue planes that
Neurosurgical wounds in the lower cervical
Abdomen Reconstruction may spread infection; it also increases op-
or upper dorsal spinal cord may have been The abdominal wall plays multiple func- erative times. Therefore, in the acute setting
treated by surgery followed by irradiation. tional roles. Its various muscles are ar- of loss of abdominal wall the best operative
The wounds do not heal because of the ra- ranged in a complex fashion. The muscle fi- choice is the use of mesh or a split-thickness
diation, and present a challenging problem bers are arranged vertically, obliquely, and skin graft.
to the reconstructive surgeon. For wounds transversely. These muscles are important Infectious processes involving the abdo-
in the occiput, down to the level of the mid- in maintaining posture, standing, ambula- men are of special note. Necrotizing fascii-
scapula, the trapezius myocutaneous flap is tion, bending, and lifting objects. The ab- tis requires wide surgical debridement of all
useful and effective. dominal wall also protects the internal or- involved fascia and overlying skin and sub-
gans and regulates the intraabdominal cutaneous tissue. Clostridial myonecrosis
Flap Options—Trapezius pressure to assist in defecation, urination, involves all layers of the abdominal wall,
The trapezius myocutaneous flap is nour- coughing, and vomiting. and therefore requires full-thickness resec-
ished from the transverse cervical artery, There are multiple layers of the abdomi- tion. This is a mixed anaerobic and aerobic
and its minor blood supply comes from nal wall; these include skin, Camper’s and infection involving at least one Clostridium
branches of the occipital vessels, dorsal scap- Scarpa’s fascia, oblique and transverses species. These organisms produce a num-
ular vessels, and posterior intercostal vessels muscles and their aponeuroses, two recti ber of exotoxins including lecithinase, col-
(Fig. 30). The muscle measures 34 ⫻ 18 cm muscles, preperitoneal fat, and peritoneum. lagenase, and hyaluronidase, which allow
the infective process to penetrate all layers
of the abdominal wall. These infections re-
quire prompt diagnosis, intravenous antibi-
otics, and wide surgical debridement.
The reconstructive options for abdomi-
nal wall reconstruction are varied. Pros-
thetic materials are used for abdominal
Transverse
wall support. When massive abdominal
cervical artery trauma is present, skin grafts may be re-
quired. These are then removed when the
Descending
pedicle
wound is stable and the hernia is to be re-
constructed. Local flaps such as the exter-
Ascending
nal oblique and rectus abdominus muscle
pedicle
may be used with care to avoid creating a
larger defect. Regional flaps such as the ten-
sor fascia lata and rectus femoris are also
options. Distant flaps include the omen-
tum, latissimus dorsi, and free flaps.
Direct approximation of fascial defects
is possible in a good number of cases. In
1990, Ramirez described the components
separation technique to allow for closure of
large defects (Fig. 31). This technique sepa-
rates the rectus abdominus from the poste-
rior sheath and the external oblique muscle
from the internal oblique muscle. Therefore,
a composite flap of rectus muscle, anterior
Fig. 30. Diagrammatic demonstration of the trapezius muscle and its vascular supply from the transverse sheath, and attached internal oblique and
cervical artery. (Modified from Cohen M. Mastery of Plastic and Reconstructive Surgery, Vol. 1. Boston: transversus abdominis muscle is advanced
Little Brown, 1994:83, with permission.) toward the midline. A simpler technique

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 234 10/28/11 8:49:11 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 235

1 2 3 4 lateral circumflex femoral artery that enters

RA at its proximal third and has a perforator
branch that emerges through the muscle at
approximately the same level to supply the
overlying skin and fascial unit. As long as
one preserves this vascular supply, it is pos-
sible to use the two components separately
for reconstructive purposes. The rectus fem-
1 2 4 oris muscle can be harvested alone for lower
3 abdominal defects or for coverage for de-
fects along the groin. If additional skin and
fascial coverage is needed, the overlying fas-
ciocutaneous unit can also be elevated,
sometimes with a wider extension at the
fascial level. The fasciocutaneous unit can
also be used to cover defects in the groin,
whether because of trauma or following
1 3 large excisions of carcinomas of the vulva or
for postradiation ulcerations in the groin

Basic Surgical Skills: New and

following groin dissections. The use of both

Emerging Technology
rectus femoris musculocutaneous flaps as
four separate units allows reconstruction of
the entire abdominal wall, and although re-
sults are arguably satisfactory, these units
have been used to reconstruct the prune
2 belly type of defect of the abdomen. There is
Fig. 31. Components separation for closure of abdominal wall defects. (Modified from Ramirez OM, an increasing popularity in the use of acel-
Ruas E, Dellon AL. “Components separation” method for closure of abdominal wall defects: an anatomic lular or biologic meshes for reconstruction
and clinical study. Plast Reconstr Surg 1990;86:519, with permission.) of the abdominal wall or in the repair of
large incisional herniae. The mesh is used

would be to perform an external oblique

flap. To accomplish this, the external
oblique fascia is incised along its lateral as-
pect. The linea alba is then approximated.

Flap Options—Rectus Femoris

Fasciocutaneous and
Musculocutaneous Flap m1
Although the tensor fascia lata flap was ad-
vocated for autologous reconstruction of
abdominal wall defects because of its versa-
tility and distal fascial extension, it now has D
been supplanted by the rectus femoris fas-
ciocutaneous or musculocutaneous flap
(Figs. 32 and 33). This is because of the lat-
ter flap’s shorter arc of rotation, higher
reach, and the increasing versatility in that
one can move the fasciocutaneous unit
separately from the rectus femoris muscle. m2
The tensor fascia lata, on the other hand,
has to pivot on a wider arc of rotation to
reach the abdomen. In addition, the distal
third of the tensor lata flap is somewhat un-
reliable, making it impossible to reach de-
fects past the midline (Fig. 34).
The rectus femoris muscle originates
from the anterior iliac spine and inserts into
the complex of the quadriceps extensor ten-
don. Dividing its insertion does not interfere
with full extension of the knee if the remain- Fig. 32. The rectus femoris fasciocutaneous and musculocutaneous flaps for abdominal reconstruction.
ing quadriceps tendon is reapproximated (Modified from Mathes S, Nahai F. Reconstructive Surgery: Principles, Anatomy, and Technique. New York:
with sutures. Its blood supply is from the Churchill Livingstone, 1997:1234, with permission.)

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 235 10/28/11 8:49:11 PM

 236 Part II: Basic Surgical Skills: New and Emerging Technology

A B

Fig. 33. A, B: Post radiation defect in the suprapubic region. It is best covered with the rectus femoris myocutaneous flap.

either as an inlay or an overlay type of cover- 3. Wide arc of rotation, shorter to cover Perineal Wound Reconstruction
age. No clear advantages have been demon- the groin and the abdominal wall.
strated, and the disadvantages include fluid 4. May be used for full-thickness abdomi- Abdominal perineal resections for rectal
collection, low antigenicity, stretching of the nal wall defects in the lower abdomen. carcinoma or inflammatory bowel disease
mesh, as well as the possibility for the bio- were initially treated openly, producing large
logical mesh to serve as culture medium. Disadvantages defects requiring open packing and long-
1. Potential for functional weakness dur- term dressing changes. Fortunately, they
Advantages ing knee extension and hip flexion have been supplanted by the reintroduction
1. Predictable vascular pedicle. 2. Visible and unsightly donor site when a of primary closure with closed suction
2. A large cutaneous component can be large cutaneous component is required drainage, resulting in an improved quality
elevated separately from the underlying 3. Generally limited to lower abdominal of life, shorter hospital stay, and decreased
muscle. wall reconstruction perineal pain.
Nonetheless, the present treatment of
persistent and/or recurrent carcinoma of
the anus, which requires chemotherapy and
radiation, does present challenging prob-
lems for reconstruction following excision
of these perineal cancers.
The treatment of choice for these large
perineal wounds is the use of the bilateral
gluteus maximus myocutaneous flaps. Pre-
vious experience with the use of gracilis
flaps was only partly successful. The use of
the rectus abdominus muscle is effective in
reaching the perineum and closing those
wounds, but requires that the muscle be
introduced intra-abdominally through an
opening in the intra-abdominal cavity.
Flap Options
Bilateral Gluteus Maximus
Musculocutaneous Flap
The lithotomy position is often used for the
resection of postradiation persistent and/
or recurrent carcinoma of the anus and the
rectum. The large defect that is thus created
necessitates the advancement of the mus-
culocutaneous units from the gluteus maxi-
mus region to obliterate the dead space ap-
proximating the muscles and the skin in the
midline (Figs. 35–37).
Fig. 34. The tensor fascia lata flap. (Modified from Mathes S, Nahai F. Reconstructive Surgery: Principles, The patient must be changed to the
Anatomy, and Technique. New York: Churchill Livingstone, 1997:1272, with permission.) prone position with the legs abducted. The

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 236 10/28/11 8:49:12 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 237

Superior posterior iliac spine as well as the greater

Area of origin of gluteal artery trochanters is noted. Bilateral skin islands
gluteus maximus muscle in the form of triangles are outlined below
the iliac crest and with the apex toward the
Skin
trochanter and the base, along the medial
Fat defect on each side of the perineum. The
Piriformis skin island is incised and skin flaps are ele-
muscle vated superiorly and inferiorly to expose
Muscle
the upper and lower portion of the gluteus
maximus on each side. The gluteus maxi-
Sciatic mus is then freed up by careful dissection
nerve from the sacrum. This is a bloody dissection
because one has to divide a number of the
sacral vessels, but once this is accom-
Sacrotuberous
plished, a blunt dissection is continued
ligament with the finger to identify the superior and
the inferior gluteal arteries. The inferior
gluteal artery is a key, in that the sciatic
nerve is inferior and lateral to it and should

Basic Surgical Skills: New and

be protected. With the gluteus maximus

Emerging Technology
Inferior
gluteal artery
freed up medially, one can then incise the
and nerve upper portion of the gluteus maximus down
to the medius superiorly and inferiorly, as
much as is necessary to advance it to the mid-
Fig. 35. The dissection is difficult and bloody, as one needs to disinsert (divide) the origin of the muscle line. This is done bilaterally. Once the mobili-
from the sacrum. Once it is disinserted on both sides, it can be approximated to each other to cover defects zation has been accomplished, the muscles
over the perineum. (Modified from Ramirez OM, Orlando JC, Hurwitz DJ. The sliding gluteus maximus
myocutaneous flap: its relevance in ambulatory patients. Plast Reconstr Surg 1984;74:68, with permission.)
are sutured in the midline to each other over
drains (Fig. 38). The overlying skin is also ap-
proximated by a VY maneuver, which is
straightforward and easy.
Advantages
Area of 1. Healthy muscle and overlying skin is suf-
subcutaneous
dissection ficient to obliterate the perineal defect.
2. Different from what was previously be-
Skin island lieved, the procedure can be done in
ambulatory patients without any dys-
function.
Disadvantages
1. The patient needs to be repositioned on
the operating table.
2. The dissection is bloody and somewhat
difficult, particularly as the gluteus max-
imus is freed up from the sacrum.
3. There is a possibility of injury to the
bladder as well as to the sciatic nerve,
although both are rare.

Gluteus Maximus to Reconstruct

Anal Sphincter
Particularly in children with Hirschsprung
disease, who have weak or absent anal
sphincters, a local procedure using portions
of the gluteus maximus are effective and
synergistic (Fig. 39). The anus is circum-
scribed and a linear incision is extended
over the gluteus maximus on each side. A
segment of the gluteus maximus, ⬃2 cm
Fig. 36. Ambulatory patients are also good candidates for the procedure. They will need help, temporar- wide and 10 cm long, is removed and freed
ily, in ambulation and particularly climbing stairs. (Modified from Ramirez OM, Orlando JC, Hurwitz DJ. from the gluteus medius. Each segment of
The sliding gluteus maximus myocutaneous flap: its relevance in ambulatory patients. Plast Reconstr muscle is then turned around and extends
Surg 1984;74:68, with permission.) circles ∼270 degrees, with the anus on each

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 237 10/28/11 8:49:14 PM

 238 Part II: Basic Surgical Skills: New and Emerging Technology

Gluteus medius

Superior
gluteal artery

Inferior
gluteal artery

Fig. 39. Portions of the gluteus maximus are taken

from both sides. They are crossed in a figure-eight
fashion to allow them to simulate a sphincter as
they contract.

Medial
circumflex
side forming a figure-of-eight type of ar-
artery rangement. Each end is sutured with suffi-
cient tension so that when the muscle con-
First tracts, the anus is obliterated. The secondary
perforating defects are closed directly. This is the most
artery effective and synergistic muscle for anal
sphincter control.
Advantages
1. The gluteus maximus is synergistic, and
the patient can learn a voluntary control
of the anal sphincter.
Fig. 37. Diagrammatic demonstration of the vascular supply to the gluteus maximus. (Modified from 2. The muscle is located in the same opera-
Ramirez OM, Orlando JC, Hurwitz DJ. The sliding gluteus maximus myocutaneous flap: its relevance in tive field.
ambulatory patients. Plast Reconstr Surg 1984;4:68, with permission.)
Disadvantages
1. Proper tension must be obtained for an
effective sphincter control.
2. The dissection is bloody at times.

Rectus Abdominus Musculocutaneous Flap

If skin and soft tissue are required for
perineal coverage to supplement the filling
of dead space by the rectus muscle, the rec-
tus muscle with the overlying skin and soft
tissues can be mobilized as a unit. A large
skin paddle can be used when designed to
include multiple musculocutaneous perfo-
rators (Fig. 40). The greatest density of perfo-
rators exists in the periumbilical region and,
therefore, it is often included during the flap
design. The skin paddle can be oriented on
the vertical, oblique, or transverse fashion,
depending on the reconstructive necessity.
The skin paddle, whether vertically or trans-
versely oriented, is incised right down to the
anterior rectus sheath. The musculocutane-
ous perforators should be maintained intact
to supply the overlying skin. A portion of an-
terior rectus sheath is included with the flap
for ∼4 cm, which will facilitate the removal
of the entire rectus muscle with its superior
Fig. 38. Freed up bilaterally, the muscle units can be approximated in the midline, and the skin islands and inferior extensions. The medial and lat-
can be moved in a V-Y manner. (Modified from Ramirez OM, Orlando JC, Hurwitz DJ. The sliding gluteus eral borders of the rectus muscles are freed
maximus myocutaneous flap: its relevance in ambulatory patients. Plast Reconstr Surg 1984;4:68, with up, and then the muscle is also freed up from
permission.) the posterior rectus sheath. The superior

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 238 10/28/11 8:49:14 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 239

of entrance of the muscle intra-abdominally

(Figs. 41 and 42).
Advantages
1. No change in position of the patient is
needed if the abdominal perineal resec-
tion was done in the lithotomy position.
2. Large amounts of muscle and skin are
easily obtained.

Disadvantages
1. A site of intra-abdominal entrance is nec-
essary for the musculocutaneous unit.
2. A bulge remains in the suprapubic region.

Gracilis Muscle and

Musculocutaneous Flaps
The gracilis muscle and musculocutaneous
flaps are presently used for reconstruction

Basic Surgical Skills: New and

of the vagina following the rare pelvic exen-

Emerging Technology
terations and also for coverage of defects
along the ischium. Its use is disappointing
in obliterating defects following abdominal
A B
perineal resections or following large exci-
sions for Crohn’s disease.
Fig. 40. Cutaneous paddle design of rectus abdominis flaps for reconstruction showing the relationship of the The gracilis is the most superficial mus-
paddle to the muscle, vascular pedicle, laparotomy incision, and surface landmarks. A: Diagram of the most cle of the adductor group of the medial side
frequently used design, with a vertical paddle axis aligned with the muscle. B: Diagram of the transverse
paddle, which can be used to lessen tissue bulk in the deep pelvis. (From Tobin GR, Persell SH, Day TG. Refine-
of the thigh. It is a long strap-like muscle
ments in vaginal reconstruction using rectus abdominis flaps. Clin Plast Surg 1990;17:705, with permission.) with motor innervation arising from the an-
terior branch of the obturator nerve. It
serves to adduct the thigh and to flex and
end of the muscle toward the insertion in the skin or muscle is used to obliterate the medially rotate the leg. It has an aponeu-
the costal margin is divided, and the whole perineal cavity. The secondary defect is rotic origin from the body and inferior ra-
unit is introduced intra-abdominally, usu- closed by approximating the remaining an- mus of the pubis, and inserts into the medial
ally just above the semicircular line. The unit terior rectus sheath, making sure that one surface of the tibia between the sartorius
is then grasped through the perineum, and does not leave too large a defect at the point and the semitendinosus muscles. It lies

Fig. 41. Demonstrating steps of the operative pro-

cedure. Schema of a vertical flap transposition from A B
the abdominal field to the groin region for formation
of the vaginal pouch, which allows simultaneous Fig. 42. Closure of the donor defect after inset of neovagina and stomas. A: Diagram illustrating direct
construction of the urinary conduit and colostomy. closure of the anterior rectus fascia donor site above the umbilicus (arrows) and abdominal wall closure
(From Tobin GR, Persell SH, Day TG. Refinements below the umbilicus by suture of the anterior rectus fascia to the linea alba. B: Direct closure of the cuta-
in vaginal reconstruction using rectus abdominis neous donor site in continuity with the laparotomy. (From Tobin GR, Persell SH, Day TG. Refinements in
flaps. Clin Plast Surg 1990;17:705, with permission.) vaginal reconstruction using rectus abdominis flaps. Clin Plast Surg 1990;17:705, with permission.)

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 239 10/28/11 8:49:15 PM

 240 Part II: Basic Surgical Skills: New and Emerging Technology

A B

E F

Fig. 43. Diagrammatic representation of vaginal reconstruction using the modified Singapore flap. A: Exenteration defect
prior to reconstruction. B: Partial suturing of defect with 6 ⫻ 15 cm flaps straddling the inguinal crease. C: Flaps elevated at
the subfascial level, with division of the labia posteriorly, to allow easy insetting of the neovagina without incision of the skin
at the base of the flaps. D: Initial suturing of the flaps is carried out to even the flap edges into the neovagina, avoiding burial
of the dermis. E: The completed pouch prior to insetting. Note preliminary closure of the donor defects. F: Nearly completed
suturing of neovagina after insetting. (From Woods JE, Alter G, Meland B, et al. Experience with vaginal reconstruction utiliz-
ing the modified Singapore flap. Plast Reconstr Surg 1992;90:280, with permission. Modified from Strauch B, Vasconez LO,
Hall-Findlay E. Grabb’s Encyclopedia of Flaps. Philadelphia: JB Lippincott, 1998:1477.)

posterior to the adductor longus and ante- from the superficial femoral vessels, and Disadvantages
rior to the semimembranosus muscles and typically penetrate the muscle at the junc- 1. Unreliable distal cutaneous territory
superficial to the adductor magnus muscle. tion of the middle and the distal third of the 2. Most limited arc of rotation of the pedi-
Its superficial surface is covered by the deep gracilis. The skin island over the gracilis is cle, which does not reach the depth of a
fascia of the thigh. safe over the proximal half of the entire perineal wound
The gracilis has a dominant neurovascu- length of the muscle. 3. Relatively narrow muscle belly
lar pedicle and two more minor pedicles.
The dominant vascular pedicle is derived Advantages Puborectalis Fasciocutaneous Flap for
from the medial femoral circumflex vessels. 1. Relative proximity to the perineum Vaginal Reconstruction (Wei Flap)
It traverses medially between the adductor 2. An expendable muscle providing a mini- For vaginal reconstruction in patients who
longus and adductor magnus muscles and mal donor deformity with minimal func- have not undergone radiation, a simple and
enters the deep aspect of the muscle ap- tional loss effective method has been described by Wei.
proximately 5 to 2 cm inferior to the pubic 3. Relative inconspicuous incision on the Two fasciocutaneous flaps inferiorly based
tubercle. The minor pedicles are branches inner thigh on the pudendal arteries are elevated on

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 240 10/28/11 8:49:17 PM

 Chapter 15: Soft Tissue Reconstruction with Flap Techniques 241

A B

Fig. 44. A: The internal oblique muscle is exposed and then retracted to visualize the origin of the rectus abdominis muscle

Basic Surgical Skills: New and

from the pubis. The Penrose drain is retracting the cord structures. B: The mesh is placed in the properitoneal space and deep

Emerging Technology
to the origin of the rectus muscle, prior to advancing the internal oblique to cover the mesh.

each side of the labia majora. The flaps are The approach for its correction is simple Fansa H, Schirmer S, Frerichs O, et al. Significance
made into an island, if necessary, as long as and effective. Access is gained through an of abdominal wall CT-angiography in planning
one maintains its proximal blood supply. incision similar to that used in an inguinal DIEA perforator flaps, TRAM flaps and SIEA
flaps. Handchir Mikrochir Plast Chir 2010. Epub
They are sutured to each other to form a hernia repair. In a male patient, the sper- ahead of print.
tube and introduced into the vagina in a matic cord is isolated and efforts are made Fitoussi AD, Berry MG, Famà F, et al. Oncoplastic
relatively straightforward fashion. The sec- to check for an indirect inguinal hernia breast surgery for cancer: analysis of 540 con-
ondary defect is closed primarily (Fig. 43). even if it was not present clinically. As one secutive cases (outcomes article). Plast Recon-
dissects the floor of the inguinal region, one str Surg 2010;125(2):454–62.
Advantages notices a weakness in that area but no di- Lee EI, Chike-Obi CJ, Gonzalez P, et al. Abdominal
wall repair using human acellular dermal matrix:
1. Adjacent, well-vascularized flaps that rect hernia. The repair consists in placing a a follow-up study. Am J Surg 2009;198(5):650–7.
allow an easy dissection piece of mesh to strengthen the pelvic floor Losken A, Schaefer TG, Newell M, et al. The impact
2. Allows for a one-stage procedure and, over the polypropylene mesh, the con- of partial breast reconstruction using reduction
joined tendon, which is a junction of the techniques on postoperative cancer surveil-
Disadvantages internal and transverse abdominus muscle, lance. Plast Reconstr Surg 2009;124(1):9–17.
Not applicable to patients who have under- is approximated to the inguinal ligament. Mathes DW, Neligan PC. Preoperative imaging tech-
gone radiation to the vulva or perineum. niques for perforator selection in abdomen-based
The wound is then closed similar to a her- microsurgical breast reconstruction. Clin Plast
nia repair (Fig. 44). Surg 2010;37(4):581–91, xi. Epub July 21, 2010.
Internal Oblique Muscle Flap Shortly after the repair, the patient is Mathes S, Nahai F. Reconstructive surgery: prin-
for Athletic Pubalgia free of pain except for the incisional surgi- ciples, anatomy, and technique. New York:
A clinical entity that is probably more com- cal pain. The rehabilitation is done during a Churchill Livingstone; 1997:262.
mon than previously diagnosed is the so-called period of 3 months, and most patients are Meyers WC, McKechnie A, Philippon MJ, et al.
athletic pubalgia, more commonly known as able to return to their athletic endeavors. Experience with “sports hernia” spanning two
“sports hernia.” Although the pathophysiology decades. Ann Surg 2008:248(4):656–65.
Spear SL, Little JW, Wood WC, eds. Surgery of the
is not clear, it appears that this represents a breast: principles and art, 2nd ed. Philadelphia:
partial rupture of portions of the rectus ab- SUGGESTED READINGS Lippincott Williams & Wilkins; 2006.
dominus muscle as they insert into the pubic Ahumada LA, Ashruf S, Espinosa-de-los-Monteros Strauch B, Vasconez LO, Hall-Findlay E. Grabb’s
tubercle. The patient presents with pain over A, et al. Athletic pubalgia: definition and surgi- encyclopedia of flaps, 3rd ed. Philadelphia: JB
the pubis and this is exacerbated by forced ab- cal treatment. Ann Plast Surg 2005;55(4):393–6. Lippincott; 2009.
duction of the involved thigh. More often than Aquilina D, Darmanin FX, Briffa J, et al. Chest wall re- Stucky CC, Gray RJ, Wasif N, et al. Increase in con-
not, radiographs and magnetic resonance im- construction using an omental flap and Integra. tralateral prophylactic mastectomy: echoes of a
J Plast Reconstr Aesthet Surg 2009;62(7):e200–2. bygone era? Surgical trends for unilateral breast
ages are interpreted as normal, and are not Epub March 31, 2009. cancer. Ann Surg Oncol 2010;17(Suppl 3):330–7.
diagnostic. Boughey JC, Hoskin TL, Degnim AC, et al. Contral- Epub September 19, 2010.
Its treatment is straightforward once the ateral prophylactic mastectomy is associated Topol BM, Dalton EF, Ponn T, et al. Immediate
proper diagnosis has been made. General with a survival advantage in high-risk women single-stage breast reconstruction using im-
surgeons often see patients with this entity with a personal history of breast cancer. Ann plants and human acellular dermal tissue ma-
because they are referred for the possibility of Surg Oncol 2010;17(10):2702–9. Epub Septem- trix with adjustment of the lower pole of the
ber 19, 2010. breast to reduce unwanted lift. Ann Plast Surg
an inguinal hernia, but when none is found, Chun YS, Verma K, Rosen H, et al. Implant-based 2008;61(5):494–9.
they are rejected for surgery, even though the breast reconstruction using acellular dermal Vasconez LO, Lejeur M, Gamboa-Bobadilla M.
patient continues with incapacitating pain, matrix and the risk of postoperative complica- Atlas of breast reconstruction. Philadelphia: JB
particularly if the patient is an athlete. tions. Plast Reconstr Surg 2010;125(2):429–36. Lippincott; 1991.

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 241 10/28/11 8:49:17 PM

 242 Part II: Basic Surgical Skills: New and Emerging Technology

EDITOR’S COMMENT limitations of such flaps, Kleintjes ( J Plast Recon- was a requirement for protection of the large cir-
str Aesthet Surg 2007;60:593–606) reviews the fore- cumferential wound, to protect the underlying
head anatomy and most importantly the arterial structures, obliterating the dead space between
Plastic surgery and its ability to restore individu- and venous variations. This chapter is the largest the tendons and the exposed plates and a gliding
als not only to function, but also to psychologi- prospective cadaver study, which was done over a surface for the skeletonized tendons. A dorsal tho-
cally function is one of the marvels of surgery over 3-year period to investigate the arterial variations racic fascial flap was selected. The authors then go
the past 30 or 40 years. We are indeed privileged of the forehead as presented. The primary goal into some detail as to how to do the flap, how they
to have Dr. Luis Vasconez as the author of this was, not surprisingly, to find anatomical support did the flap, and the various stages in the flap as
important chapter. In the introduction, Profes- for various forehead flaps previously designed. they finally covered the arm. All wounds healed
sor Vasconez points out the types of wounds that In order to do this, the author dissected 30 ca- without incident; they placed the arm in a long-
need coverage because of the destruction of tis- daver foreheads or 60 cadaver hemi-foreheads from arm splint, which permitted limited, gentle pas-
sues around the wounds. These difficult wounds deep to superficial to identify arterial variations; sive and active range-of-motion of the digits. After
include the following: the arteries were filled with a latex solution prior to 4 months, the skeletal fixation was revised and
dissection. The author goes into detail concerning the flap was able to be transected longitudinally
1. Superficially infected wounds regarding the the supratrochlear and dorsal nasal arteries have a without compromising its blood supply. Figure 8
obvious coverage and the inability to cut out relatively constant origin and the various branches shows a rather good-looking arm and reasonable
the infection. of supraorbital artery were identified. Besides, the range-of-motion of the fingers at 6 months appar-
2. Wounds over bone that do not have perios- frontal branch of the superficial temporal artery ently. The authors said that a positive Tinel’s sign
teum, thereby inhibiting the ability of bone to is found to continue in the direction of the scalp was appreciated 12 cm distal to the proximal re-
heal. at the lateral orbital rim vertical line and gives off pair of the ulnar nerve. Intrinsic muscle atrophy
3. Postradiation wounds, in which all the tissues a transverse branch, the transverse frontal artery, was noted in the palm of the injured extremity,
around the wounds are dead and need trans- to supply the forehead. The author also states that which is not surprising. This is a heroic attempt to
plantation as these were swinging over a flap a central artery is consistently found originating provide reasonable function for a left hand, which
in order to provide blood supply, muscle, and from the dorsal nasal artery usually 5 mm from its likely is at least halfway there. The authors should
skin which will survive. origin and it had a constant anastomosis with the be congratulated for seeing it through.
In addition, importantly, there is a quote opposite central artery in the inferior transverse The third area which is critical is sterno-
which should be part of every operative adven- third from the forehead. The central artery was tomy following deep sternal wound infections
ture as follows: “There is an increasing popular- not easily identifiable in the superior third of the after cardiac surgery. Without stabilization of
ity in the use of acellular of biological measures forehead. The conclusion is that “The significance this area, the function of the chest, both arms,
for reconstruction of the abdominal wall or the of the central artery and vein favors the median and perhaps coverage of the heart and various
repair of large incision hernia. The mesh is used forehead flap as anatomically superior and the mediastinal structures lead to high morbidity
either as an onlay, as an inlay or an overlay type of prominent central vein is a constant landmark on and mortality. Kobayashi et al. ( J Cardiac Thorac
coverage.” Most importantly, “No clear advantages which to select the side of the pedicle.” The authors Surg 211–656, published online) show the strat-
have been demonstrated and the disadvantages provide clear landmarks for identifying the pedicle egy for deep-scale wound infection, which in-
include, fluid collection, low antigenicity, stretch- base of the median forehead flap. I am certain that cludes aggressive sternal debridement followed
ing of the mesh as well as the possibility for the this is helpful for individuals who do not have as by vacuum-assisted closure and omental-muscle
biological mesh to serve as a culture medium” much experience with forehead flaps as the au- flap reconstruction.
(Fischer JE, American Journal of Surgery, 2008). In thor, but these are extremely valuable. Unfortunately, they had 16 patients that they
a recent editorial, I pointed out that the use of bi- A second area where flaps are difficult is treated for deep sternal wound infection between
ological mesh in trying to close the wound of the when periosteum is denuded from bone; some- 2001 and 2007. Of these, the most recent nine pa-
infective gastrointestinal fistula often resulted in times with respect to the arm, especially when tients were treated with total sternal resection fol-
an increased incidence of refistulization, abscess, there is forearm denudation in association with lowed by VAC therapy and secondary closure with
and large, difficult-to-control infections. crush injuries, mostly in vehicular collisions. an omental-muscle flap reconstruction. This is
This chapter will demonstrate how far re- The case report by Hazani et. al. (Microsurgery called the recent group. The former seven patients
construction has continued to come with the 2009;29:128–32) comes from the well-known Di- were treated with sternal preservation, without
essence of being the restoration of function. It is vision of Plastic Surgery, University of Louisville VAC therapy and four of these patients underwent
not a panacea, but it certainly does help individu- School of Medicine as well as the Division of Mi- primary closure. They assessed long-term qual-
als return to function, both psychologically and crosurgical Transplantation and Replantation, ity of life after by using the Short Form 36 index
physically. The Buncke Clinic, San Francisco, California. It is a health survey Version 2. One patient died and four
In reviewing the literature that was available, case report of a right-handed dominant male who required further surgery for deep sternal wound
I will use the function of the types of restoration, sustained a crush injury in an all-terrain vehicle infection in the first group. That is an unsuccessful
but I believe are most important to those that are rollover collision, not surprising and fairly com- result in five out of the seven deep sternal wound
in need. mon. On the initial survey, he had open fractures infections. In the recent group, nine patients had
The first and most important area that I be- of the radius and the ulna, significant bone loss, a shorter course: 63 ⫾ 54 days versus 120 ⫾ 31
lieve is the face, and in the face both the area which will ultimately require metal fixation and days, respectively, P ⫽ 0.09. Despite the aggressive
around the eyes, which of course are important transection of the ulnar artery and the nerve. A sternal resection, the authors state that the qual-
because one looks at people in the eyes, and also challenging situation, happily not the dominant ity of life of the nine more recent patients was only
the mouth, which includes loss of large segments forearm, but bad enough. The initial repair con- minimally compromised compared with surgical
of the upper and lower lip. As previously pointed sisted of external fixation of the transected ulnar procedures without the sternal wound infection.
out, in Chapter 23 on mouth and restoration of artery, fasciotomy of the forearm compartments The authors conclude that an aggressive sternal
lips, while the upper lip actually is very impor- as a first step. The patient was then transferred debridement followed by VAC therapy and the sec-
tant because that is the first thing that people to the tertiary care center for management of his ondary closure not with bone, but with an omen-
look at and it also is important in making the soft tissue injuries. There were muscle and tendon tal muscle flap is effective and results in a better
oral entrance continent so that the patient does avulsions and the extensor tendons were skele- outcome short of the lower incidence of current
not drool and one looks straight at the upper lip. tonized as shown in a photograph, which does not infection and shorter hospitalization, and “it did
Nonetheless, the lower lip has the function of both reproduce particularly well (Fig. 1). Radiographs not compromise long-term quality of life greatly.”
becoming continent and also in verbalization. revealed a comminuted shortening of the long Figure 1 shows the quality of life of patients treated
A major source of flaps for both the upper and bones. Fortunately, there was good flow through with total sternectomy. It is not up to standard of
the lower lip is the midline for a flap. This comes the palmar arch, a patent radial artery, and a what would be reasonable quality of life, but one
in very handy, especially when there are losses of compromised ulnar artery anastomosis. After se- must point out that sternal osteomyelitis carries
the lip of more than one-half because it may be rial debridements, plate fixation of the radius and with it a mortality rate of ∼30%. Some compro-
helpful not only in the white line, but also in re- ulna, an internal skeletal fixation, which included mised quality of life is expected in order to achieve
storing the vermillion. In effort to determine the the free-floating bony segment of the radius, there survival. This may be one way to achieve it.

www.medicalebookpdf.com

LWBK892_c15_p214-242.indd 242 10/28/11 8:49:20 PM

 Chapter 16: Hand Surgery: Traumatic Injuries of the Hand 243

The next two areas deal with reconstruction Various portions of the abdominal wall had ap- TRAM flaps (n ⫽ 162). The average of the women
of both breasts under normal circumstances and propriate decreased muscle strength and the free was 47 and hospital stay was 5.1 days. There were
immediate reconstruction of breast following ad- TRAM/SIEA data were not significant, whereas 15 major complications (8.8%), but the postopera-
vanced disease. Selber et al. (Plast Reconstr Surg the others showed increase in muscle strength. tive chemotherapy was delayed in only eight pa-
2010;126:438–441) demonstrates the impact of Psychometric testing showed trends, but there tients (4.7%), the maximum delay lasted 3 weeks
bilateral free flap breast reconstruction on the were no significant differences between the three in one patient. In advanced breast cancer, 30%
abdominal wall. This is part of a two part series groups. The authors concluded that decreases in of the patients required postoperative radiation
and presented here are the muscle-sparing free muscle strength were closely adherent to the the- therapy, which in most cases, most surgeons have
transverse rectus abdominis myocutaneous oretical prediction based on the amount of surgi- shied away from, but only 10% of the patients ex-
(TRAM) flap, the deep inferior epigastric perfo- cal muscle sacrifice. Again, this is not surprising. perienced severe breast distortion. The authors
rator flap (DIEP), and the superficial epigastric Finally, a major problem is the immediate concluded that the overall cosmetic outcome in
artery (SIEA). As many as 234 patients were in- free flap reconstruction of advanced-stage breast patients who received postoperative radiation
volved in a blinded prospective cohort study. Pa- cancer. Crisera et al. (Plast Reconstr Surg, advance was comparable to those who did not. The au-
tients were evaluated preoperatively and 1 year online article, published online) examine the thors asked the question at the beginning as to
postoperatively. Instead of simple observation, problems that plastic surgeons have with women whether or not women with 2B or greater carci-
patients underwent objective abdominal strength who undergo post-mastectomy immediate breast noma of the breast would benefit from immediate
testing using a manual muscle function test and reconstruction. There is no argument that imme- breast reconstruction, given the advantages that
a short form 36 questionnaire in addition to psy- diate breast reconstruction results in improve- are now firmly established. Their findings over
chometric testing. Complicated analyses were ment in quality of life and body image. The prob- 10 years make a strong argument for not with-
carried out. lem comes in advanced breast reconstruction for holding immediate breast reconstruction. They
Of the 234 patients enrolled, 157 went recon- advanced-stage breast cancer, which remains have sacrificed some breasts, but not too many,
struction, 82 of which were bilateral. There was controversial. They studied the outcomes in pa- and there has been very little in the way of delay

Basic Surgical Skills: New and

no unexpected significant decline of upper and tients over 10 years, patients that were diagnosed in postoperative radiochemotherapy. Ten percent

Emerging Technology
lower abdominal strength from abdominal flaps with stage 2B or greater breast cancer treated of the patients experienced late distortion in the
as compared with the bilateral DIEP flaps, P ⫽ with mastectomy followed by immediate breast breast mound and this is a price to pay, but each
0.02, and lower P ⫽ 0.05. Not surprisingly, there reconstruction. They tracked breast and compli- woman should be capable of deciding whether
was a significant decline in upper, P ⫽0.055, and cation rates and the reconstructive aesthetics. they wanted a delayed reconstruction or would go
lower, P ⫽ 0.04, abdominal strength from bilat- Totally, 170 patients were identified who un- for an immediate reconstruction. I suspect that
eral free TRAM flaps as compared with the bilat- derwent 157 unilateral and 13 bilateral recon- most of them will take immediate reconstruction.
eral SIEA flaps. struction with 183 flaps, predominantly the free J.E.F.

16 Hand Surgery: Traumatic Injuries of the Hand

Kevin C. Chung

INTRODUCTION the elbow, and even sometimes as far as don’ts of assessing a patient with hand in-
the shoulder. In this chapter, we will define jury. Many of these caveats are violated dur-
Traumatic injuries of the hand are common hand surgery territory as injuries below the ing the initial assessments and frequently
in emergency departments and account for elbow. lead to inefficient care and consequent con-
approximately one-fifth of total patient vis- Traumatic injuries of the hand often sternation for everyone involved. But with
its each year. Because of the complexity of occur from laceration or crush accidents. some fundamental understanding of hand
hand anatomy, treating hand injuries can The distinct structures of the hand include surgery principles, the hand can be less
be daunting for all involved and injudicious the bone, tendon, nerve, blood vessel, joint, mystifying. The care of the hand-injured
treatment often leads to unsatisfactory out- and skin. Combined injuries of the hand, patient starts with the hand examination.
comes and potential litigations. Because of with involvement of multiple structures,
the ubiquity of hand and upper limb trauma, can be challenging because of the uncer-
this chapter will present a systematic ap-
HAND EXAMINATION
tainty of what structures should be treated
proach to evaluate the injured hand by first. However, understanding the anatomy A comprehensive hand examination does
presenting the anatomy of the structures of the hand will assist in rendering a treat- not need to be a tedious exercise, but rather
involved as well as the relevant examina- ment plan based on a sequential and struc- a rapid, sequential examination of the hand
tion and treatment concepts. tured physical examination, rather than and upper limb to understand the extent of
haphazard probing of the injured limb. The injury. For example, a person with a fore-
ANATOMY hand-injured patient is already quite dis- arm laceration may sustain tendon and
tressed, and the chaos in the typical emer- nerve injuries. Therefore, based on the func-
The precise territory encompassed by “hand gency room does not provide sufficient tional anatomy concept, the lack of exten-
surgery” is not clearly defined. In the tradi- tranquility to assuage the anxious patient. sion of the index and middle fingers may
tional sense, hand surgery may involve It is critical that the hand-injured patient is suggest tendon or muscle injuries to these
only the hand distal to the wrist joint. How- moved into a quiet room where a system- respective structures. Furthermore, lack of
ever, the current concept of hand surgery atic evaluation of the hand can be under- sensation over the radial dorsal hand may
territory may extend from the fingertip to taken. Table 1 lists some of the do’s and suggest an injury to the superficial radial

www.medicalebookpdf.com

LWBK892_c16_p243-255.indd 243 10/28/11 10:15:59 PM

 244 Part II: Basic Surgical Skills: New and Emerging Technology

n
nerve, which supplies the radial dorsal half
Table 1 Do’s and Don’ts of Assessing a Patient with Hand Injury oof the hand.
Do’s Don’ts My examination sequence is to evaluate
tthe nerve, tendon, vessel, and the joints,
1. Put the patient in a quiet room for hand 1. Probe the wound. aand then obtain plain radiographs of the in-
examination. 2. Give pain medicine until after a full jjured regions of the upper limb to detect
2. Examine the patient expediently. examination. ppotential fractures.
3. Give pain medicine and local anesthesia 3. Give local anesthesia until after the
after full sensory examination. sensory examination is done.
4. Irrigate the wound copiously with saline 4. Close a contaminated traumatic wound. Nerve
N
and suture close the wound, for nonurgent
injuries. The hand is innervated by three major nerves:
5. Get x-rays to evaluate potential bone tthe median, ulnar, and radial nerves (Fig.
injuries. 11A-C). Each nerve provides sensory and mo-
6. Consult a hand surgeon expediently if an ttor input to the hand. For example, the radial
operation is required immediately, such as nerve supplies sensation to the dorsum of
n
a devascularized limb or severe infection tthe thumb, index, and middle finger, and
that requires urgent drainage. aalso gives motor input to all the finger and
wrist extensor tendons. There are specific
w

B C
Fig. 1. A: Diagram of the anatomical nerve territory in the hand from the dorsal aspect. B: Illustration of median nerve ter-
ritory, which has been shaded in purple to indicate coverage. C: Illustration of ulnar nerve territory, which has been shaded
in grey to indicate coverage..

www.medicalebookpdf.com

LWBK892_c16_p243-255.indd 244 10/28/11 10:15:59 PM

 Chapter 16: Hand Surgery: Traumatic Injuries of the Hand 245

addition, injury to the ulnar nerve also para-

lyzes the thumb adductor muscle, making it
difficult for the patient to grip objects.
In ulnar nerve examinations, the pre-
dictable sensory distribution is over the
volar little finger (Fig. 7A). The notable mo-
tor exam is the ability to cross the index and
middle fingers, which illustrates the func-
tion of the ulnar nerve innervating the in-
terosseous muscles (Fig. 7B).
The median nerve provides sensation to
the radial hand by sending nerve fibers
into the thumb, index, middle, and radial
side of the ring finger. It also controls the
thenar muscles of the hand as well as most
of the finger and wrist flexors. Injury to the
median nerve proximal to the wrist not only
Fig. 2. Examination of integrity of radial sensory nerve by testing sensation of the dorsum thumb/ will result in loss of sensation to the radial
index webspace. hand, but the patient will experience weak-

Basic Surgical Skills: New and

ness of the thumb because of paralysis of

Emerging Technology
the thenar muscles that powers thumb ab-
examination findings of nerve territories include the interosseous muscles that flex duction and opposition. In median nerve
that indicate the conditions of the nerve in- the finger metacarpophalangeal joints and examination, the intact sensation over the
volved. For the radial nerve, intact sensation extend the finger interphalangeal joints (Fig. pulp of the thumb is predictable for sensory
over the dorsum thumb/index webspace in- 4). In contrast, extrinsic muscles are muscles nerve function and the ability to abduct the
dicates the integrity of the radial nerve, or that have their origins outside the hand. For thumb marked by thenar muscle contrac-
more specifically, the radial sensory nerve example, extrinsic finger flexors such as the tion confirms the median motor nerve func-
(Fig. 2). The ability to extend the thumb when superficialis and profundus tendons have tion proximal to the wrist (Figs. 8A and B).
the hand lies flat on a table is powered by the their origins over the medial epicondyle at
extensor pollicis longus, which is supplied by the elbow to produce flexion of the fingers.
the terminal branch of the radial nerve, or In the forearm, the ulnar nerve’s motor in-
Tendon
more specifically, the posterior interosseous nervations are only limited to the flexor carpi In each finger, there are two tendons that
branch of the radial nerve (Fig. 3A-C). ulnaris, which flexes the ulnar wrist and the move the fingers, the superficialis and the
Laceration of the ulnar nerve can pro- profundus tendons to the ring and little fin- profundus tendons, and each attaches to the
duce discrete areas of functional loss that gers (Fig. 5). The coordination of the ulnar distal aspects of a joint in order to move it.
can be predicted based on the location of the nerve is particularly important because in- The creases in the fingers and the wrist cor-
laceration. The ulnar nerve is a highly spe- jury to the ulnar nerve paralyzes the in- respond to joints in which the tendons are
cialized nerve that innervates most of the terosseous muscles, which balance the flexor attached. For example, the wrist creases are
intrinsic muscles of the hand. Intrinsic mus- and extensor muscle tone, to result in a hand made by wrist flexor and extensor tendons
cles are muscles that have their origins and posture known as claw deformity. This de- that insert at the base of the metacarpals. In
insertions in the hand that function to or- formity is a result of the overpowering of the some patients in whom the joints are not de-
chestrate the fine movements of the fingers. extensor tendons by the flexor tendons to veloped, finger creases are not present, which
These intricate, fine muscles of the hand cause this nonfunctional posture (Fig. 6). In reveal that the joint is nonfunctional. The
thumb has only one flexor tendon ( flexor pol-
licis longus) that attaches at the interphalan-
geal joint. However, the thumb is supported
by a group of intrinsic muscles at the thenar
area, which includes muscles that provide
abduction (abductor pollicis) and opposition
(opponens pollicis) of the thumb.
A complex arrangement of the extensor
tendons of the fingers and wrist lies over the
dorsum of the hand. For example, the thumb
is controlled by the extensor pollicis longus
tendon, whereas the index and the little
fingers are controlled by two tendons, the
communis tendon (all attached to a single
muscle to power all the fingers) and the
proprius tendon that gives independent mo-
tion of the index and little fingers. The exten-
sor tendons to the hand are interconnected
Fig. 3. Ability to extend thumb indicates integrity of the posterior interosseous branch of the radial by junctura tendinae that serve to coordi-
nerve. nate motion for each finger during finger

www.medicalebookpdf.com

LWBK892_c16_p243-255.indd 245 10/28/11 10:16:02 PM

 246 Part II: Basic Surgical Skills: New and Emerging Technology

Adductor
pollicis

Opponens
digiti minimi
Flexor Flexor digiti
Opponens
pollicis brevis minimi
pollicis
Abductor Abductor digiti
pollicis brevis minimi

Fig. 4. Anatomical sketch of the intrinsic muscles of the hand.

Sheaths of terminal
paris of Flexores
digitorum

Extensor indicis
Abductor
pollicis
Extensor digiti minimi

Extensor digitorum
communis
Extensor pollicis
longus
Abductor pollicis
longus

Transverse Common sheath of

carpal Flexorus digitorum
ligament sublimis and
Sheats of Flexor profundus
Extensor digiti minimi pollicis longus
Extensor digitorum
communis
Extensor
Extensor pollicis brevis indicis

Abductor pollicis longus

Fig. 5. Anatomical sketch of the extrinsic muscles of the hand.

www.medicalebookpdf.com

LWBK892_c16_p243-255.indd 246 10/28/11 10:16:05 PM

 Basic Surgical Skills: New and
Emerging Technology
Fig. 6. Picture of a hand with claw deformity.

A B

Fig. 7. A: Examination of integrity of ulnar nerve by testing sensation of the volar aspect of the little finger. B: Ability to
cross the index and middle fingers indicates ulnar nerve function innervating the interosseous muscles.

A B

Fig. 8. A: Examination of integrity of the median nerve by testing sensation of the pulp of the thumb. B: Ability to abduct
the thumb (against pressure) indicates median motor nerve function proximal to the wrist.
247

www.medicalebookpdf.com

LWBK892_c16_p243-255.indd 247 10/28/11 10:16:11 PM

 248 Part II: Basic Surgical Skills: New and Emerging Technology

extension. The wrist is controlled by three arteries are occluded. Because of this net- (dorsal-palmar) and are analogous to the
extensor tendons: the extensor carpi radialis work of blood vessels, a hand that is perfused hinges of a door. The taut collateral liga-
longus, brevis, and the extensor carpi ulnaris. may still present with a laceration of either ment that supports the interphalangeal
The examination of the tendons is rather the ulnar or the radial artery. In most cases, joint limits lateral mobility, but allows for 0
straightforward. The examiner will ask the it is not necessary in a healthy individual to to 110 degrees of motion in the dorsal-
patient to flex each joint distal to the injury reconstruct or repair an injured radial or ul- palmar plane. The thumb carpometacarpal
site in order to determine whether a tendon nar artery. However, because repairing these joint is a highly mobile saddle joint, which
or tendons are cut. For example, an inability large caliber arteries is technically not too permits the thumb to oppose the fingers in
to flex the distal interphalangeal joint after challenging, it is recommended by the exam- multiple planes (Fig. 10). The saddle shape
a volar finger laceration is a clear indication iner in order to avoid ischemic problems for of this joint is enveloped by a number of in-
of a flexor digitorum profundus tendon lac- patients working in cold environments. To trinsic muscles that arise from the hand to
eration. assess the adequacy of blood supply to the provide a symphony of movements.
hand, the examiner should perform the Al- Finger joint injuries are common and
len test by alternating occlusion of the radial often result from sports injuries or high-
Blood Vessels and ulnar arteries and observing the finger speed accidents. If the injury is severe, the
The hand is richly endowed by a generous turgor. In finger lacerations, cool and pallor dislocation of the joint will be easily notice-
vascular supply mainly through the radial fingers indicate laceration to both digital able upon physical examination and can be
and ulnar arteries, which form the superfi- nerves and immediate revascularization of confirmed by x-rays (Fig. 11). Many disloca-
cial and deep palmar arches. In addition, the the digital arteries is required (Fig. 9). tions can be reduced by traction, after ade-
contributions of the anterior and posterior quate digital anesthesia. In some cases,
interosseous arteries that are cross volar and when the volar plate or tendon is interposed
dorsal to the interosseous membrane can
Joints within the joint, closed reduction is not pos-
sometimes provide collateral circulation to The interphalangeal joints are considered sible and the patient will require operative
the hand when both the radial and ulnar condylar joints. They move in one direction reduction. When a finger joint is swollen

Radial artery
Ulnar artery

Radial artery Ulnar artery

Fig. 9. Anatomical sketch of blood vessels in the hand.

www.medicalebookpdf.com

LWBK892_c16_p243-255.indd 248 10/28/11 10:16:19 PM

 Chapter 16: Hand Surgery: Traumatic Injuries of the Hand 249

incorrectly by prolonged splinting (over 3

weeks). Prolonged splinting can cause joint
stiffness that can be difficult to overcome
once a contracture is established. Most
cases of ligament tears or sprain injuries can
be treated by buddy taping and early motion
to enhance joint movement and to decrease
swelling. Buddy taping entails the taping of
the injured finger to an adjacent finger in
order to provide stability to the injured fin-
ger while maintaining joint motion during
ligament healing. Early mobility and judi-
cious protection of the joint under the care
of a hand therapist can often prevent pro-
longed impairment from joint stiffness.

Bone
The bones form the foundation of the upper

Basic Surgical Skills: New and

limb. It is analogous to the frame of a house
under the support of beams. Therefore, in

Emerging Technology
combined injuries, restoring the skeletal sup-
port of the hand is the key initial step in order
to restore a framework for repairing other
structures such as tendons and nerves. The
Fig. 10. Anatomical sketch of thumb carpometacarpal joint.
fingers consist of three phalanges: the distal,
middle, and proximal phalanges. On the other
hand, the thumb only has two phalanges: the
and tender after an injury, x-rays should be distal and proximal phalanx (Fig. 12).
obtained first to be sure there are no associ-
ated fractures before manipulation. If the
x-rays reveal no fracture, then the lateral
stability of the injured joint can be com-
pared with an uninjured joint to assess po-
tential ligament tear. In most cases, liga-
ment injuries in the fingers are being treated Distal
interphalangeal
joint
Proximal
interphalangeal Distal phalanx
joint
Middle phalanx

Metacarpophalangeal
joint Proximal phalanx

Metacarpals

Thumb
carpometacarpal Carpal
joint bones

Distal
radioulnar
joint

Radius Ulna
Fig. 11. X-ray of hand with dislocated joint. Fig. 12. Anatomical sketch of hand bones.

www.medicalebookpdf.com

LWBK892_c16_p243-255.indd 249 10/28/11 10:16:19 PM

 250 Part II: Basic Surgical Skills: New and Emerging Technology

deal of pain and anxiety to the patient and

family. The injury should not be probed, in
most cases, when the patient is conscious,
but one can perform the systematic exami-
nation based on the specific anatomic struc-
tures of the hand. For example, I will often do
the Ten-Point Pain Test, in which I touch a
patient’s face to indicate a normal sensation
and then have the patient assign a number
when I touch individual fingers or distinct
Capitate sensory territories of the hand. A patient
Trapezoid
Hamate who is conscious, alert, and can cooperate
Trapezium Triquetrum should be able to give a fairly accurate as-
Pisiform signment of how much they can feel based
Scaphoid
on 10 being normal and 0 being absolutely no
Lunate
sensation. The Ten-Point Pain Test can give a
Lister’s tubercle rapid assessment of the sensory territories of
Styloid process the hand without hurting the patient.
Head of ulna Similarly, after a sensory examination,
one can proceed to a motor examination by
systematically asking the patient to flex
each joint, which will correspond to the
tendon that moves the joint. For example,
the patient with a laceration at the base of
the thumb may not be able to flex the thumb
interphalangeal joint because of a lacera-
Radius
tion of the flexor pollicis longus tendon. For
complex injuries, it is critical to systemati-
Ulna cally assess all of the relevant joints in the
Fig. 13. Anatomical sketch of carpal bones. hand so that no injury is missed. One can
quickly assess the vascularity of the fingers
by observing capillary refill, which should
These phalanges are supported by the quires x-rays to detect fractures and dis- be brisk. A finger that is cool and dusky re-
metacarpal bones, which are linked to the placement of the bones that may suggest quires immediate attention by a hand sur-
forearm bones by the eight carpal bones in ligament injuries. Obtaining plain x-rays is geon to revascularize the finger using mi-
the wrist. The carpal bones are arranged in indispensable in the overall hand and up- crovascular techniques. Unless the injury is
two rows of four bones, each of which is per limb evaluation. limited only to soft tissue, x-rays are always
named for their unique shape. For example, taken in order to assess the joint and skele-
the scaphoid, which comes from the Greek MANAGEMENT OF HAND tal integrity.
words skaphe (meaning “boat”) and eidos
(meaning “like”), is shaped like a boat and TRAUMA PATIENTS
functions as the anchor of the proximal and
PRACTICAL CASE EXAMPLES
distal carpal rows. The lunate, which is Clinical Presentation
shaped like a moon, sits in the proximal
Dislocation
When a patient presents to the emergency
carpal row (Fig. 13). All the carpal bones room with a hand trauma, sometimes the The patient is a 59-year-old man who sus-
have shapes that determine their structural hand injury is so severe that the treating tained a dorsal dislocation of the left index
role in assisting with motion, but at the physician may overlook other more life- finger proximal interphalangeal joint (PIPJ)
same time provide remarkable stability to threatening injuries. The basic concept of during a basketball game (Fig. 14A–C). This
the wrist during motion. The impressive ar- treating hand injuries is “Life over Limb.” is a common injury that is often not treated
chitectural design is in full display as a Even though the treating physician or sur- adequately. In order for the dorsal disloca-
gymnast tumbles across the floor and stops geon may be faced with a severely mangled tion to occur, the patient must have torn
to support the entire weight of the body on hand, there may be other injuries that two of the three supporting structures of
the wrist during a handstand. The wrist should take precedence such as abdominal the PIPJ, which include the radial and ulnar
joint sits on the distal radius and the ulna, injuries. collateral ligaments, as well as the volar
which are connected by a complex liga- plate. However, the PIPJ is a hinge joint that
mentous structure called the triangular fi- How I Do It can maintain relative stability after the
brocartilage complex (TFCC). The triangu- joint is adequately reduced. In this particu-
lar fibrocartilage complex allows for The trauma evaluation must be systematic lar case, in order to reduce this fracture, the
rotational motion of the distal radius over and the patient should be fully unclothed in wrist is flexed to take tension off the flexor
the fixed distal ulna. The interosseous order to be certain that no injuries are tendons. Manual traction is performed by
membrane between the radius and the ulna missed. Another caveat to remember is that pulling the distal finger to engage the con-
links the two bones and provides additional a patient can be extremely anxious and inju- dyles into the reduced position. This is done
stability. Examination of these bones re- dicious probing of the hand can cause a great under sedation and digital block. Once the

www.medicalebookpdf.com

LWBK892_c16_p243-255.indd 250 10/28/11 10:16:20 PM

 Chapter 16: Hand Surgery: Traumatic Injuries of the Hand 251

Basic Surgical Skills: New and

Emerging Technology
A B C

Fig. 14. A, B, and C. Anteroposterior, oblique, and lateral x-ray view of a left index finger proximal interphalangeal joint
(PIPJ) dorsal dislocation.

joint appears to be reduced, x-rays are taken head of the proximal phalanx is caught be- required the abscess to be drained (Fig. 18).
to assure that the joint is congruent, which tween the flexor tendons and the lumbrical The abscess on the dorsum of the finger can
is shown in Figure 15A–C. muscle, which creates a noose effect and be drained with an open incision, whereas
PIPJ dislocations are not uncommon, prevent reduction. These situations require the flexor tendon sheath infection should
but the treatment has not been well formu- the patient going to the operating room for be evacuated using closed catheter irriga-
lated in the emergency department settings. open reduction either with a volar or with a tion as shown in Figure 19. The much more
These patients are often placed into pro- dorsal approach to place the PIPJ structures aggressive open approach in which the en-
longed splinting in order to allow the liga- into anatomic alignment. tire flexor tendon sheath is exposed is not
ment tears to heal. But prolonged splinting advisable because desiccation of the flexor
for greater than 3 weeks will create a tendons can occur.
stiff PIPJ that will be very difficult to regain
Infection In the closed technique, two incisions
full active flexion once scar tissue has The patient is a 44-year-old woman, who can be made, one V incision over the A1
formed around the PIPJ. In this injury, early presented with progressive erythema and pulley and a separate mid-axial incision is
control active motion exercises should be swelling 2 days after a small insect bite to made over the noncontact ulnar surface of
instituted to prevent joint contracture. her right ring finger (Fig. 17). On examina- the DIP joint to provide egress of fluid that
After adequate reduction, the patient is tion, the patient had obvious, diffused in- is irrigated into the flexor tendon sheath
placed in a dorsal blocking splint to keep fection of the finger. There was an abscess proximally. A small opening is made at the
the reduced PIPJ at 30 degrees of flexion in on the dorsum of the finger, but what was A1 pulley and the 18-gauge catheter is then
an effort to avoid dislocation again. The pa- more concerning was the exquisite pain carefully threaded into the flexor tendon
tient will initiate active range of motion in with passive extension of the finger, which sheath and gently irrigates the tendon
order to maintain the mobility of the joint indicated potential suppurative flexor teno- sheath to evacuate all pus contents. After
and prevent contracture. After about 3 synovitis. the fluid becomes clear, the incisions can
weeks of active exercises, the ligament The classic signs of flexor sheath infec- be left open to contract and heal second-
structures should have healed sufficiently tion include fusiform swelling, redness arily. If there is concern for residual infec-
for the patient to initiate full finger motion along the finger, tenderness with palpation tion, the catheter can be left into the ten-
(Fig. 16A and B). over the flexor tendons, and pain with pas- don sheath by suturing it to the skin and
There are occasional situations when sive extension of the finger. All these signs the tendon sheath may be irrigated every
the PIPJ cannot be reduced. The reason for pointed to an infection of the flexor tendon 8 hours for the next 48 hours in order to
this difficulty is that the volar plate may be sheath that sometimes may propagate evacuate additional pus. One must be ex-
torn and is interposed in the joint to pre- along the tendon sheath into the wrist. tremely careful not to irrigate the fluid ag-
vent reduction. Other situations may be the Hand infection is a surgical emergency that gressively because leakage of fluid around

www.medicalebookpdf.com

LWBK892_c16_p243-255.indd 251 10/28/11 10:16:21 PM

 252 Part II: Basic Surgical Skills: New and Emerging Technology

A B

Fig. 15. A, B, and C: Anteroposterior, oblique, and lateral

x-ray view after reduction, showing well-reduced, congru-
C ent finger proximal interphalangeal joint.

the tendon sheath can cause trapping of in a resting position, placed in an elevated thumb amputation, multiple finger ampu-
the irrigation fluid within the soft tissue posture, and broad-spectrum antibiotics tations, and any amputation in children. In
of the finger, resulting in compartment that are targeted toward the bacteria of this case, there was a crushing component
syndrome. The patient is placed on appro- concern. that rendered the thumb and index finger
priate broad-spectrum antibiotics until the not salvageable (Fig. 20). The patient had a
infection is cleared. The typical treatment revision amputation of the thumb and in-
for hand infection is antibiotics, elevation
Amputation dex finger after adequate debridement.
of the hand, and immobility in order to de- The patient is a 60-year-old male who sus- The middle finger underwent repairs of
crease the inflammation associated with tained a table saw injury to the left thumb, the flexor tendons, nerves, and digital ar-
the infection. The patient should be fabri- index finger, and middle finger. The indica- teries (Fig. 21A and B). The optimal man-
cated with a volar splint to keep the hand tions for finger replantation include any agement for this patient is to recover as

www.medicalebookpdf.com

LWBK892_c16_p243-255.indd 252 10/28/11 10:16:21 PM

 Chapter 16: Hand Surgery: Traumatic Injuries of the Hand 253

A B

Fig. 16. A and B: Full extension and flexion after adequate treatment.

Basic Surgical Skills: New and

Emerging Technology
much function as possible. Flexor tendon INDICATIONS FOR patient presenting to the emergency room;
injuries should be repaired at the earliest EMERGENCY HAND one is vascular problems that compromise
convenient time, if possible, within 1 week the viability of the digits or the hand, and
of injury in order to prevent tendons from SURGERY the other is infection. A patient with a se-
retracting proximally that would make re- A common concern is to determine when a vere crush injury or laceration of both digi-
pair much more difficult. This patient at- hand surgeon should be involved in the tal arteries to the fingers requires immedi-
tained good recovery of hand function, emergency care of a hand injury patient. ate revascularization by an experienced
given the severity of the injury (Fig. 22A There are two situations when the service of microsurgeon in order to establish blood
and B). a hand surgeon is absolutely necessary for a flow to the fingers or the hand. Infections of

Fig. 17. Diffused erythema over the right ring finger. Fig. 18. Evacuation of pus from the ring finger.

www.medicalebookpdf.com

LWBK892_c16_p243-255.indd 253 10/28/11 10:16:25 PM

 254 Part II: Basic Surgical Skills: New and Emerging Technology

Fig. 19. Closed catheter drainage of suppurative flexor tenosynovitis Fig. 20. Table saw injury of the left hand.
of the ring finger.

A B

Fig. 21. A and B: Amputations completed for the thumb and index finger with residual nerve and tendon injuries to the
middle finger.

A B

Fig. 22. A and B: Acceptable function after nerve and tendon reconstruction to the left middle finger.

www.medicalebookpdf.com

LWBK892_c16_p243-255.indd 254 10/28/11 10:16:30 PM

 Chapter 16: Hand Surgery: Traumatic Injuries of the Hand 255

the finger or hand that need to be drained, participate in the active testing of the flexor anxiety of facing the variety of injuries that
such as bacterial tenosynovitis, are often tendons. For this reason, children are often afflict the hand and the upper limb.
considered emergencies. It is important taken to the operating room for exploration
that abscesses be properly drained, particu- in order to determine the extent of injury SUGGESTED READINGS
larly for patients who are immunocompro- and repair the injured structures. In the sit-
Bindra RR, Dias JJ, Heras-Palau C, et al. Assessing
mised such as individuals with diabetes or uation when an unconscious patient can- outcome after hand surgery: the current state.
other immunodeficiency conditions. Short not participate in a hand examination be- J Hand Surg 2003;28B(4):289–4.
of those two conditions, most hand injuries cause of either drug or alcohol influence or Cable D, Mullany C, Schaff H. The Allen Test. Ann
can be referred to a hand surgeon for elec- head injuries, the patient may require Thorac Surg 1999;67:876–7.
tive treatment. Common hand problems another examination after their medical Chung K. Reconstructive surgery of the hand. In:
that present in the emergency room include conditions are stable and the patient is Greenfield LJ, ed. Surgery, scientific principles
and practice. Philadelphia: Lippincott Williams
digital nerve injuries, which can be repaired conscious enough to relay an accurate ex- & Wilkins; 2001:2294–302.
within 2 to 3 weeks or tendon injuries that amination. Chung K. Anatomy and biomechanics of the hand.
can be repaired within 10 days. Displaced This chapter gives a practical guide in In: Chung K, ed. Hand surgery, plastic surgery.
fractures can often be reduced in the emer- how to approach a hand injury patient in St Louis: Mosby; 2008:935–40.
gency department and definite fixation can the emergency setting. The examination of Chung K, DJ Smith, MC Robson. Management of
be performed within 1 or 2 weeks. an injured hand requires constant practice thermal, electrical radiation, and chemical in-
Treatment of the pediatric patient is of in order to develop expertise in determin- juries of the hand. In: Peimer CA, ed. Surgery
of the hand and upper extremity. New York:
unique concern. Children sometimes can- ing what findings are normal and what are McGraw-Hill; 1996:1797–818.

Basic Surgical Skills: New and

not articulate precisely the loss of sensation abnormal. Mastery of the hand examina- Dias J, Garcia-Elias M. Hand injury costs. Injury

Emerging Technology
to his/her fingers or may not be able to tion and hand anatomy will overcome the 2006;37:1071–7.

EDITOR’S COMMENT 1. Recognize and treat common hand infections. Ruijis et al. (Journal of Hand Surgery 2011;
I would add that the general surgeon treating published online) attempt to use a diagnostic test
hand infections should have a good idea of of cold-induced vasodilatation (CIVD) following
This is a well-written chapter that assumes that what the compartments are and how they can traumatic median or ulnar nerve injury. CIVD can
hand injuries will continue to be present and that be walled off by various fascia and bones. be detected by prolonged cooling at low tempera-
many of the hand injuries will have to be treated 2. Define the pathophysiology and appropri- tures. The authors tested 12 patients, 6 of whom
by a general surgeon because of the shortage of ately manage high-pressure injection injuries. had a median and the remaining 6 had an ulnar
hand surgeons. This is probably an accurate goal Personally, I had little knowledge of what a nerve injury, 4 to 76 months after nerve repair.
for this chapter because it is unlikely that there high-pressure injection injury is, but it does They used a cold plate at 5⬚C and measured the
will be enough hand surgeons to go around, so seem from some of the figures that there is skin temperature of the fingers using video ther-
what this is actually doing is performing a tri- an enormous destructive force depending on mography. They plotted the graph of the tempera-
age with less consequential injuries being taken what happened with the injection injury de- ture change of the nail bed. The presence of the
care of by general surgeons and then the more spite the innocuous appearance of the wound CIVD reaction was defined as a minimal increase
consequential and complicated injuries being (Fig. 2). of temperature of 2.5⬚C starting at the distal pha-
taken care of by hand surgeons after initial tri- 3. Define the operative indications for the treat- lanx. The authors used this as a test of success
age and perhaps emergency treatment by general ment of Dupuytren’s contracture. of the nerve repair but cautioned that although
surgeons. 4. Understand the role of operative treatment in this may be an indication of nerve recovery the
A very essential part of the chapter is the exam- rheumatoid arthritis and osteoarthritis. One positive CIVD reactions do not include subjective
ination of the hand; associated with that is a good certainly would not want anybody but a special- symptoms of posttraumatic cold intolerance.
review of muscles, tendons, and nerves, which ized hand surgeon to undertake the treatment Not to propose that general surgeons will
can easily be examined by a few simple maneu- of severe osteoarthritis and rearranging the be able to do this repair technique, Ho AM and
vers. In this way, an early triage can be obtained as joints and the tendons to get a functional hand. Chang J writing in The Journal of Hand Surgery
to the types of patients who will be taken care of (2010;35A:308–11) describe the surgery of a ra-
by a hand surgeon and those who can probably be The treatment of hand infections is prob- dial artery perforator flap which they believe the
taken care of by a general surgeon. ably the best and most rewarding aspect that a retrograde radial forearm fasciocutaneous flap is
The essential repairs that will need to be general surgeon can do in seeing a patient with the workhorse flap to cover many hand and wrist
taken care of in some situations by general sur- a hand infection. First and foremost, before the defects. They discuss the surgical anatomy indica-
geons include the following: cultures or drainage can be obtained, one must tions, operating technique, rehabilitation protocol,
be able to assume that most hand infections and potential complications of carrying this out. It
1. Repairs of tendons are caused by Staphylococcus and Streptococcus, does appear that this repair mechanism is beyond
2. Setting fractures and cephalosporin or some other first-line drug the capacity of most general surgeons but I would
3. Treatment of simple avulsions of tendons or might be useful. In patients with intravenous imagine that in a pinch, with nobody around, all
other intrinsic parts of the hand drug use or who are incarcerated or those who communication cut, and isolation, that there
4. Any other repair that might be initially re- are nondiabetic, methicillin-resistant Staphylo- might be a time when a general surgeon might
quired in the absence of access to a hand sur- coccus aureus may likely be to be the organism have to carry it out. Several pictures are given in
geon that has caused the infection. In this situation, this chapter indicating the benefits of a well-done
the infection should be treated empirically with radical perforator flap done either retrograde or
Obviously in the latter case, not all of these will be Bactrim, 850 mg, three times a day or vancomy- prograde to fit and repair a number of defects.
well done, or definitive. cin. They warn that coverage of Streptococcus is Looking at some of the pictures in some of
With this in mind, a review by Watt et al. poor with Bactrim and vancomycin is bacterio- these chapters, one is impressed at how complex
(published online in the PRSjournal, Plastic Re- static, not bactericidal. Thus, the importance of the mechanism is of these hand injuries and of
constructive Surgery 2010;126:288e–350a) sug- culture data and antibiotic regimens which are in what benefit somebody with advanced training
gests that what the participant in this review keeping with what the infections in a community might serve.
should be able to do is include the following: usually have. J.E.F.

www.medicalebookpdf.com

LWBK892_c16_p243-255.indd 255 10/28/11 10:16:38 PM

 256 Part II: Basic Surgical Skills: New and Emerging Technology

17 Robotic Surgery
Santiago Horgan and Michael F. Sedrak

INTRODUCTION tem for Optimal Positioning (AESOP)—a ro- Representative Uses: According to Intui-
botic arm system whose applications entered tive Surgical, Inc., the da Vinci System has
The human nature of the surgeon has been to the operating room allowing the surgeon to been successfully used in the following
gain the maximal access to the surgical area control the surgical camera controlled by the procedures, among others:
of interest while inflicting as minimal trauma robotic arm first with a foot-pedal interface,
to the patient as possible. As operative tech- 1. Urology
then later by voice commands as experience
niques and technologies have evolved, the ■ Radical prostatectomy, pyeloplasty,
showed that this was the preferred method
ability to achieve that goal has advanced tre- cystectomy, nephrectomy, ureteral
of controlling the arm.
mendously. Surgeons have gained the ability reimplantation.
Later, extending their technology, Com-
and technical expertise first to make smaller, 2. Gynecology
puter Motion Inc. developed the Zeus Ro-
more strategically located incisions for open ■ Hysterectomy, myomectomy, and
botic Surgical System which was a master-
surgical access, then to perform the same sacrocolpopexy.
slave robotic system that allowed the
operation utilizing surgical telescopes and 3. General Surgery
surgeon to control up to three surgical arms
minimal access tools, then to the current ■ Cholecystectomy, Nissen fundoplica-
in addition to the camera system from a
state-of-the-art use of computer-aided tech- tion, Heller myotomy, gastric bypass,
separate control console.
nologies and robotics to further gain full donor nephrectomy, adrenalectomy,
The Stanford Research Institute (SRI) de-
access to what otherwise would have been splenectomy, and bowel resection.
veloped a robotic surgical system with re-
difficult-to-approach surgical areas of inter- 4. Cardiac Surgery
search funded from the National Institutes
est while having nearly negligible secondary ■ Internal mammary artery mobiliza-
of Health and with interest from the Defense
surgical trauma to the patient. tion and cardiac tissue ablation.
Advanced Research Projects Administration
In truth of fact, as these technologies ■ Mitral valve repair, endoscopic atrial
(DARPA). Ultimately, becoming the da Vinci
continue to demonstrate their immense septal defect closure.
Robotic Surgical System by Intuitive Surgical
utility as tools to significantly improve the ■ Mammary to left anterior descending
of Mountain View, CA, the da Vinci is also a
surgeon’s ability to safely and superiorly coronary artery anastomosis for car-
master-slave robotic system, but with some
treat disease, their use will ultimately be- diac revascularization with adjunc-
very distinct advantages over its progeni-
come ubiquitous in the operating room tive mediastinotomy.
tors. The system includes a fully integrated
much as the surgical telescopic devices 5. Otolaryngology
three-dimensional (3-D), high-definition (HD)
have infiltrated surgical practice in recent ■ Oropharyngeal, laryngeal, and hypo-
visualization system that allows a spectacu-
years. pharyngeal resections; floor of mouth
lar visualization of the magnified surgical
Hurdles to overcome include developing and oral cavity resections.
topography. Further, the instruments have a
and improving the technologies and their fully articulating wrist that truly facilitates
limitations, improving physician training operating with such degree of freedom that
Equipment and Setup Fundamentals
and expertise to maximize their abilities to allows full, natural motions in the tightest of The da Vinci Surgical System has a surgeon
safely and effectively use these tools, incor- surgical fields. Finally, the system has a console where the operator receives a bin-
porating technologies training into the sur- fourth arm, thus mitigating the need for a ocular image from the surgical field and op-
gical education of trainees in the various trained assistant. erates the robotic arms through a comput-
disciplines, and of course managing the in- The U.S. Food and Drug Administration erized system using master controls. In this
creased cost in a manner that will ulti- (FDA) has cleared the da Vinci Surgical Sys- system, depending on the model, three or
mately allow patients’ increased access to tem for use in urological surgical proce- four robotic arms are assembled on a
the best care available. dures, general laparoscopic surgical proce- movable single unit, with the central arm
dures, gynecologic laparoscopic surgical supporting two parallel high-definition
ROBOTIC PLATFORMS procedures, transoral otolaryngology surgi- cameras and the lateral arms serving as
AND TECHNOLOGY cal procedures restricted to benign and ma- instrument arms. The image is acquired
lignant tumors classified as T1 and T2, gen- and delivered simultaneously to the con-
Telemanipulation systems developed from eral thoracoscopic surgical procedures, and sole’s two monitors and is observed in a
modest beginnings two decades ago with thoracoscopically assisted cardiotomy pro- parallel binocular fashion by the surgeon’s
two devices that used robotic technologies cedures. The system can also be employed eyes, allowing a magnified 3-D stereoscopic
to automate camera positioning during with adjunctive mediastinotomy to perform view with depth perception. Camera posi-
telescopic procedures. The EndoAssist coronary anastomosis during cardiac revas- tioning is controlled by the operator at the
(Armstrong Health Care, High Wycombe, cularization. The system is indicated for console.
UK) used infrared sensors to detect the adult and pediatric use, and is recently ap- The instrument tips have seven degrees of
movements of the surgeon’s head in order to proved for transoral otolaryngology surgi- freedom and wrist action controlled by the
maneuver the camera. Later, under a NASA cal procedures. It is intended for use by surgeon hand controls at the console that are
Small Business Innovation Research Con- trained physicians in an operating room greatly similar to the hand and wrist move-
tract from the Jet Propulsion Laboratory, environment in accordance with represen- ment mechanics of open surgery, allowing
Computer Motion Inc., Santa Barbara, CA, tative, specific procedures set forth in the more complex and delicate tasks than the
developed the Automated Endoscopic Sys- Professional Instructions for Use. standard laparoscopic instrumentation at

www.medicalebookpdf.com

LWBK892_c17_p256-263.indd 256 10/28/11 8:51:13 PM

 Chapter 17: Robotic Surgery 257

the tissue level. A clutching system allows re-

adjustment of the surgeon hand positions at
the console to maintain ergonomic control
of the instruments within the surgical field of
interest.
Principles of triangulation are generally
employed with robotic system setup. Com-
monly, the patient cart, camera arm, and
camera port are aligned in a straight line
with the field of interest. The two working
ports are placed on either side of the cam-
era, allowing triangulation to the target
field. A fourth port is placed in a manner
conducive to the operation being performed
and can be used for an assistant or for the
fourth robotic arm. In situations where ab-
dominal access is gained from a small area
at the skin level, as in single incision sur-
gery, the working ports can be reversed to

Basic Surgical Skills: New and

allow a wide degree of freedom within the

Emerging Technology
cavity, maintaining triangulation and mini-
mizing equipment conflict.
Additionally, the cannulas are marked
with a fulcrum point such that when the
ports are inserted into the cavity of interest
to the depth noted on the cannula, the full
range of motion is optimized by the pre-
measured fulcrum point into this remote
center of focus as designed in the transla-
tional software of the robotic system to
maximize the efficacy of the robotic arm
movements with minimal torque onto the
patient at the port entry site.
Finally, port and arm clutch maneuvers
are used to dock the camera and instru-
ment arms while maximizing the space be-
tween the instrument arms.

Robotic System Summary

1. Surgeon console: The surgeon operates Fig. 1. Operating room setup for robotic bariatric surgery.
while seated at a console using four ped-
als, a set of console switches, and two
master controls. The movements of the tion. It has been successfully performed lap- regarding abdominal wall girth as described
surgeon’s fingers are transmitted by the aroscopically for the past two decades, but is earlier. However, the success of adjustable
master controls to the instrument locat- technically demanding. In addition to deal- gastric banding in these patients compared
ed inside the patient. A 3-D image of the ing with equipment torque on the abdomi- to other operations such as sleeve gastrec-
surgical field is obtained using a 12-mm nal wall due to patient girth, the most tech- tomy or gastric bypass should be considered.
scope, which contains two cameras that nically challenging step in the operation is Robotic-assisted vertical sleeve gastrec-
integrate images. completion of the gastrojejunal anastomo- tomy will undoubtedly be demonstrated as
2. Control tower: This component con- sis. Multiple techniques have been described, an outstanding surgical option as long-term
tains a monitor, light sources, and cord including linear and circular stapling, as results of laparoscopic sleeve gastrectomy
attachments for the cameras. well as handsewn anastomosis (Fig. 1). begin to confirm the long-term success of
3. Surgical arm cart: This component pro- For the surgeon who prefers to handsew this surgical option to bariatric patients.
vides four robotic arms, three instrument the gastrojejunostomy, use of computer-en- Particularly useful is the stabilization of the
arms, and one endoscope arm, which ex- hanced robotic equipment facilitates this step camera and tools during handsewn staple
ecute the surgeon’s commands. as the robotic arms are able to stabilize the line reinforcement in addition to the in-
telescope and instruments from the torque creased capacity of the general dissection.
caused at the abdominal wall, thus maintain-
GENERAL SURGERY ing instrument position and stability. Robotically Assisted Roux-en-Y
Utility of robotic assistance in adjustable
Bariatric Surgery gastric banding has been demonstrated in
Gastric Bypass Surgical Technique
Roux-en-Y gastric bypass has been described very high morbidly obese patients with BMI The patient is placed in the low lithotomy
as being the gold-standard bariatric opera- greater than 60 kg/m2 for the same reasons position with the legs and arms open; a

www.medicalebookpdf.com

LWBK892_c17_p256-263.indd 257 10/28/11 8:51:13 PM

 258 Part II: Basic Surgical Skills: New and Emerging Technology

surgeon operates between the patient’s legs,

with the assistant at the patient’s left side.
Prophylactic antibiotics (first-generation
cephalosporin) as well as 5,000 U subcuta-
neous heparin are given to the patient dur-
ing the anesthesia induction.
Four trocars are used. The first is a 10- to
12-mm bladeless trocar that is inserted
under direct vision 15 to 20 cm from the
xiphoid process using a 10-mm, 0-degree
scope. Pneumoperitoneum is then achieved
to 20 mm Hg. The rest of the trocars are
placed under direct vision using a 30-degree
scope. An 8-mm trocar (robotic arm) is
placed immediately below the left rib cage
in the mid clavicular line. An 18-mm trocar
is then placed on the left flank at the same
level as the camera. At this point, the pa-
tient is placed in the reverse Trendelenburg
position, which allows for better visualiza-
tion of the gastroesophageal junction. A
5-mm incision is made below the xyphoid
Fig. 2. Trocar placement for robotically assisted Roux-en-Y gastric bypass. process to facilitate introduction of a Na-
thanson liver retractor. The last 8-mm tro-
car (robotic arm) is placed ⬃8 cm below
beanbag is placed under the patient to sup- this time, the surgical arm patient-side cart the right rib cage, depending on the posi-
port the steep reverse Trendelenburg posi- robotic surgical system is positioned. To per- tion of the liver edge.
tion during the operation. A single dose of form the gastrojejunal anastomosis, a Cadière The Cadière forceps are attached to the
preoperative prophylactic antibiotics ( first- forceps is attached to the right arm and a right arm and the harmonic scalpel to the
generation cephalosporin) is given. Thigh- needle holder to the left arm. The posterior left arm. The first step of the operation con-
length antiembolic stockings and a sequen- layer of the gastrojejunal anastomosis is per- sists of detaching the phrenogastric liga-
tial pneumatic compression device are formed with 3-0 silk. Then, using electrocau- ment in order to expose the left crura. Then,
placed on both lower extremities before in- tery, a 1.5-cm opening is created in both the the gastrohepatic ligament is opened. The
duction of anesthesia. A single dose of 5,000 jejunum and the gastric pouch; for the open- caudate lobe of the liver, the inferior vena
U subcutaneous heparin is given for pro- ing, the cautery is hooked to the left arm. cava, and the right crura are subsequently
phylaxis against venous thrombosis. After Once the bowel and the stomach are opened, exposed. Having identified these structures
general anesthesia is achieved, an NG tube the handmade anastomosis using the robot correctly, we create a retrogastric tunnel
is placed in the stomach and a Foley cathe- is started. A running suture is placed to the using blunt dissection. We start the dissec-
ter is put in position. right and left of the anastomosis using 3-0 tion between the edge of the right crura
The trocar placement for robotically as- absorbable suture. The anterior serosa–se- and the posterior wall of the stomach, and
sisted Roux-en-Y gastric bypass is shown in rosa layer of the gastrojejunal anastomosis is it is continued until the articulated tip of
Figure 2. The procedure starts by dividing closed using 3-0 silk. Once the anastomosis is the robotic instrument is visualized at the
the small bowel ⬃50 cm below the angle of finished, the robotic surgical cart is removed other side of the stomach, at the angle of
Treitz using a vascular stapler; the mesen- from the patient’s side. His. At this time, and using the 18-mm tro-
tery of the bowel is also divided using a vas- The NG tube is passed down into the car, the band is placed inside the abdomen.
cular stapler. After creating a 150-cm limb, gastric pouch. The distal limb of the ileum Following this, the tip of the tubing is
a jejunojejunal anastomosis is performed is clamped, and 60 mL of methylene blue is placed between the jaws of the Cadière for-
using 2 reloads of vascular staplers. The introduced to rule out the presence of leak. ceps, attached to the left arm, and the band
bowel opening is closed using an endo- Patients are encouraged to ambulate on the is threaded around the stomach (Fig. 3).
needle holder with interrupted stitches of same operative day. On postoperative day 1, Since the tip of the instrument is articu-
3-0 silk. The defect between the mesentery patients undergo a Gastrografin swallow to lated, there is no need to use the band
is closed using a 3-0 silk suture. evaluate the status of the gastrojejunal passer. Then the tip of the tubing is inserted
At this time, the patient is placed in a re- anastomosis. Following this, they start a into the band buckle and locked. With the
verse Trendelenburg position; the omentum clear liquid diet. On postoperative day 2, if band closed and in position, a wrap is fash-
is mobilized and sectioned using the har- no complications are experienced, they are ioned out of the stomach to secure the band
monic scalpel. Next, beginning at the lesser discharged home. in place. We place 3 (or 4 if necessary) non-
curve (⬃5 cm from the gastroesophageal absorbable seromuscular sutures during
junction), the retrogastric tunnel is created Robotically Assisted Adjustable the creation of this wrap (Fig. 4). The first is
using the harmonic scalpel. Several firings of Gastric Banding placed in the left lateral aspect of the gas-
the surgical stapler are performed to create a tric pouch, and two more are placed in the
⬃30-cm3 gastric pouch; following comple- Surgical Technique anterior aspect. Once the band is in posi-
tion, the distal portion of the ileum is brought The patient is placed in the low lithotomy tion, the port is then secured using four
up for creation of the gastrojejunostomy. At position with the legs and arms open. The polypropylene 2-0 sutures.

www.medicalebookpdf.com

LWBK892_c17_p256-263.indd 258 10/28/11 8:51:17 PM

 Chapter 17: Robotic Surgery 259

postoperative heartburn, and operative time The myotomy is started just above the
after the initial learning curve of the robotic- gastroesophageal junction at the 12 o’clock
assisted technique. This retrospective study position using the robotic articulated hook
clearly demonstrates the increased safety of electrocautery. The submucosal plane is
the advanced technology for this operation. reached in one step. This is followed by
extension of the myotomy a minimum of
Operative Technique 6 cm proximally and ⬃2 cm distally into the
After satisfactory induction of general en- stomach.
dotracheal anesthesia, the patient is placed The preferred antireflux operation is the
in the semilithotomy position on top of a Dor fundoplication, which is an anterior
“bean bag.” Regular use of the “bean bag” 180-degree fundoplication. Dor fundoplica-
permits the patient to be secured to the ta- tion involves two rows of sutures, each
ble when steep reverse Trendelenburg is composed of three stitches. The first row of
needed. Pneumatic compression stockings sutures includes the gastric fundus, the left
are placed on both legs routinely, and the crura, and the left side of the myotomy. The
legs are placed in stirrups. An orogastric second row of sutures is created by placing
tube is placed, which decompresses the stitches between the stomach and the right
esophagus and stomach. Trocar placement, edge of the myotomy.
Fig. 3. Robot-assisted adjustable gastric banding. similar to that for laparoscopic Heller myo-

Basic Surgical Skills: New and

tomy, is identical for every advanced esoph- Follow-up Assessment

Emerging Technology
ageal procedure. Two 8-mm trocars (the size The patients are seen for follow-up assess-
Achalasia of these trocars is specific for the robotic ment 1 week after surgery, then every 3
Lower esophageal sphincter myotomy, or system) and two 12-mm trocars are inserted. months for the first year. After this, the pa-
Heller myotomy, is the gold-standard treat- A 0.5-cm incision is made in the subxiphoid tients are seen at regular 6-month intervals,
ment for achalasia. Mucosal perforation is area, and the left lobe of the liver is then re- or as needed.
the most significant complication specific tracted anteriorly using the Nathanson liver During each follow-up visit, a detailed
to this operation and is described with an retractor. At this point, the robotic surgical symptomatic evaluation is performed for
incidence of 5% to 10% with the laparo- cart is brought into position, and the arms all patients. Postoperatively, barium swal-
scopic approach. With the precision instru- are attached to the three specific trocars. A low, upper endoscopy, and esophageal func-
mentation and magnified 3-D, HD visualiza- Cadière forceps is placed in the surgeon’s tion tests are ordered as needed.
tion afforded by the computer-enhanced left hand, and the articulated hook cautery
robotic-assisted technology, the myotomy is introduced with the right hand. The setup Gastric Fundoplication and
can be successfully and safely performed of the robot is usually performed by the as- Paraesophageal Hernia Repair
with significantly improved visualization of sistant at the bedside. The assistant surgeon Robotic-assisted gastric fundoplication has
the transition to mucosa. With this tech- is positioned on the patient’s left side. Dur- been demonstrated to be feasible with simi-
nique, a multi-institutional study involving ing the case, the assistant is in charge of cut- lar outcomes as the traditional laparoscopic
121 patients, who had similar preoperative ting, suction, and retraction. Also, if needed, approach. Increased utility of the technol-
data, demonstrated the ability to perform the assistant switches the robotic instru- ogy is noted with concurrent paraesopha-
this operation with 0% perforation in the ments for the operating surgeon. For this geal hernia repair, and is exponentially ap-
robotic-assisted myotomy group compared reason, basic training in laparoscopic sur- preciated when either of these operations
to 16% in the laparoscopic group. All other gery and robotics is essential. are undertaken in the setting of reoperation
measured operative and postoperative data The left crura approach is used routinely. as the improved visualization of the anat-
were similar in regards to relief of symptoms, The dissection is continued in the posterior omy with the magnified 3-D, HD stereo-
mediastinum laterally and anteriorly to ex- scopic telescopes facilitates fine dissection
pose the lower third of the esophagus. The with stable, articulating tools, thus allow-
short gastric vessels are then divided care- ing the surgeon to successfully and safely
fully. Full mobilization of the fundus is per- undertake this endeavor as they work to
formed by dividing posterior adhesions to identify vital anatomy such as the vagus
the anterior capsule of the pancreas in an nerve, aorta, vena cava, pleura, and pericar-
attempt to make the partial fundoplication dium in the often difficult reoperative field.
tension free. Only the anterior part of the
esophagus is dissected, respecting the pos- Colorectal Surgery
terior attachments. The gastrohepatic liga- Utilization of computer-enhanced robotic
ment and the phrenoesophageal membrane assistance enhances the ability of the sur-
are divided. The right crura is recognized geon to perform rectal resection during low
and separated from the esophagus by blunt anterior resection (LAR) and abdomino-
dissection. No posterior dissection is per- perineal resection (APR). The superior visu-
formed. After a 44-Fr bougie has been passed alization provided by the 3-D, HD stereotele-
through the mouth, the fat pad is removed scope facilitates a maximally distal dissection
for better exposure of the gastroesophageal with the articulating instruments in the con-
junction. The anterior branch of the vagus fines of the pelvis while also allowing an on-
Fig. 4. Robot-assisted adjustable gastric banding nerve is mobilized from the esophageal cologic lymphadenectomy to be performed
wrap suturing. wall. during total mesorectal excision (TME)

www.medicalebookpdf.com

LWBK892_c17_p256-263.indd 259 10/28/11 8:51:17 PM

 260 Part II: Basic Surgical Skills: New and Emerging Technology

while avoiding autonomic nerve injury dur- invasion of adjacent structures (e.g., recur- the greater curvature and also posterior to
ing the minimally invasive operation. Addi- rent laryngeal nerve, tracheobronchial tree, the stomach to allow for adequate mobili-
tionally, the dexterity of the tools allows for a aorta, or pericardium) are excluded from zation. The pylorus is carefully dissected. In
handsewn anastomosis based on the sur- resection. Instead, these patients are of- the current series, a Kocher maneuver and
geon’s preferences. Given the multiple ab- fered palliation therapy (e.g., self-expanding pyloroplasty were not performed in the last
dominal quadrants involved in the opera- stents and chemoradiation therapy). 15 cases.
tion, as the descending colon and splenic The robotic surgical cart is brought into
flexure are mobilized to provide a tension- Operative Technique position cephalad to the patient. The arms
free anastomosis, initial reports describe a After satisfactory induction of general of the robot are attached to the three spe-
hybrid laparoscopic approach. However, as endotracheal anesthesia, the patient is cific trocars (Fig. 5). A Cadière forceps is
the robotic technologies have improved, placed in the semilithotomy position over placed in the surgeon’s left hand. With the
fully robotic left colon and rectal cancer re- a “bean bag.” Regular use of the “bean bag” right hand, the surgeon introduces the ar-
sections have been described. Given the po- permits the patient to be secured to the ticulated hook cautery. The setup of the ro-
tential for maximal oncologic resection table when steep reverse Trendelenburg is bot is usually performed by the assistant at
while maintaining genitourinary autonomic needed. Pneumatic compression stockings the bedside. The assistant surgeon is posi-
function during LAR and APR, this tech- are placed on both legs routinely, and the tioned on the patient’s left side.
nique can certainly be considered as the legs are placed in stirrups. An orogastric Transhiatal dissection of the esophagus
preferable approach for these patients. tube is placed, which decompresses the is started and continued in a cephalad di-
esophagus and stomach. Preoperative an- rection. The articulated hook cautery and
THORACIC SURGERY tibiotics are given to the patient. the Cadière forceps are used for precise cir-
A 12-mm trocar is placed initially under cumferential dissection of the esophagus,
Non-Cardiac Thoracic Surgery direct vision in the left mid-abdomen two allowing easy access to the thoracic inlet.
fingerbreadths lateral to the umbilicus and Soft tissue attachments are divided bluntly,
Esophagectomy one palm width inferior to the left costal with extreme care taken to avoid opening
Robotic-assisted minimally invasive tran- margin. This port is used for the robotic the pleura.
shiatal esophagectomy is an operation that camera. Two 8-mm trocars are then placed Once it is proximal to the carina, the ro-
clearly exploits the benefits of the computer- for the robotic arms: one on the right sub- botic dissection is finalized, and the robotic
enhanced robotic platform. The ability of costal midclavicular line and one on the left cart is removed. The neck is prepped and
the equipment to allow the surgeon to suc- subcostal midclavicular line. A 5-mm subxi- draped, after which a cervical incision is
cessfully perform the operation decreases phoid incision is used for placement of the made along the anterior border of the left
morbidity to the patient by allowing trans- Nathanson liver retractor. An assistant port sternocleidomastoid muscle. Mobilization
abdominal, trans-hiatal approach, thereby (10 mm) is inserted in the left anterior axil- of the proximal esophagus along the medi-
avoiding thoracic incisions. The equipment lary line 2 cm below the costal margin. astinum is completed.
has sufficient articulation and reach, being The operation is started using conven- After completion of esophageal mobili-
7.5 cm longer than standard laparoscopic tional laparoscopic technique. The patient zation, the stomach is tubularized along
tools, allowing safe dissection and proximal is placed in steep reverse Trendelenburg the lesser curvature using a 3.5-mm linear
mobilization beyond the level of the carina. position, and the surgeon stands between cutting stapler. The gastric conduit then is
Further, the enhanced stereoscopic visual- the legs of the patient. The first assistant pulled up into the mediastinum and out
ization too facilitates the safe dissection and stands to the patient’s left. through the cervical incision. The specimen
oncologic lymphadenectomy throughout The left crus is first mobilized from the is removed through the neck incision.
the limited confines of the entire posterior phrenoesophageal membrane with the as- We use two different techniques to com-
mediastinum. Anastomosis in the neck is sistance of ultrasonic shears. Once this is plete the gastroesophageal anastomosis. A
preferred as the potential complication of accomplished, blunt dissection is performed total stapled anastomosis using a 3.5-mm
leak can be easily managed; however, medi- to separate the esophagus from the left crus, GIA stapler device for the posterior wall,
astinal anastomosis is technically feasible thus minimizing the risk of perforation. The and a TA 55 device for the closure of the an-
with the robotic assistance and still provides short gastric vessels are transected using ul- terior wall. Alternatively, a two-layer hand-
a minimally invasive approach that can mit- trasonic energy, starting from the inferior sewn anastomosis may be performed. A
igate the potential morbidities associated pole of the spleen. During transection of the single 7-mm drain was placed near the me-
with wide abdominal or chest incisions. vessels, special care is taken to avoid dam- diastinum immediately lateral and posterior
aging the right gastroepiploic artery be- to the anastomosis. A laparoscopic feeding
Preoperative Evaluation cause this vessel is responsible for nourish- jejunostomy may be placed at this time.
Preoperative evaluation consisted of evalu- ing the gastric conduit. The gastrohepatic
ating the patient’s functional status and ligament then is opened, and the hepatic Postoperative Management
ability to tolerate an esophagectomy (i.e., branch of the vagus nerve is transected. Patients are transferred to the ICU for post-
cardiac and respiratory function). It also Next, the right crus is freed from its at- operative observation. Early ambulation is
comprised staging of the tumor by barium tachments using electrocautery. A retroe- encouraged. Postoperative pain control is
esophagram, upper endoscopy with biopsy, sophageal window is created, and a Penrose provided by patient-controlled analgesia.
endoscopic ultrasound, and abdominal and drain passed and clipped anteriorly. The On postoperative day 1, J-tube feeding is
chest computed tomography (CT). During drain is used to encircle the esophagus for started. An upper GI contrast study with
the preoperative screening, patients with further manipulation as the dissection con- water-soluble contrast is performed on post-
metastatic disease to lymph nodes (i.e., tinues. The left gastric artery and vein are operative day 3 to rule out the presence of an
celiac, cervical, or supraclavicular) or solid then transected with a vascular linear sta- anastomotic leak. A clear liquid diet is initi-
organs (e.g., liver or lungs), and those with pling device. Dissection is continued along ated if no leak was present in the contrast

www.medicalebookpdf.com

LWBK892_c17_p256-263.indd 260 10/28/11 8:51:18 PM

 Chapter 17: Robotic Surgery 261

study. If a leak is present, the drain in the

neck was left in place until the leak closed
spontaneously, and nutrition was provided
entirely through the feeding jejunostomy.

Follow-up Evaluation
The patients were seen at a follow-up visit 1
week after surgery, then every 3 months for
the first year. After this, the patients were
seen at regular 1-year intervals.

Anterior Mediastinum
The confines of the anterior mediastinum
represent an anatomic area where the com-
puter-enhanced robotic platform can allow
the surgeon to safely perform a minimally
invasive operation. Visualization of this
treacherous anatomy requires the maximal
advantage gained by the 3-D, HD stereo-

Basic Surgical Skills: New and

scopic telescope to allow safe identification

Emerging Technology
of the structures during delicate dissection
with the articulating instruments, whose
value in this tight space is magnified in al-
lowing the procedure to be completed in a
minimally invasive fashion.

Pulmonary Resection
Pulmonary lobectomy using robotic assis-
tance has been demonstrated to be feasible
and has facilitated the thoracoscopic pro-
cedure as the technology allows an im-
proved minimally invasive dissection.

UROLOGIC SURGERY
Nephrectomy and Partial
Nephrectomy
Whether nephrectomy is performed for pri-
mary disease or for organ recovery in the in-
stance of living donor nephrectomy, the
morbidity associated with wide incisions in
the open operation was clearly mitigated
with the advent of laparoscopic techniques
in the early 1990s. However, technical limita-
tions made standard laparoscopic dissec-
tion of the renal hilum within the limited
space technically demanding, and visualiza-
tion and isolation of the ureter was also a
challenge. The advantage of improved visu-
alization of the surgical topography as well
as the wrist-like articulations of the surgical
tools in these instances clearly demonstrated
the benefit of the advanced technology in
performing the operation with as minimal
disruption to the patient as possible.
With such improvements in equipment
and technique, the added benefits to the
care of potential kidney donor can serve to
Fig. 5. Robotic setup for advanced esophageal surgery. reassure the patient that their decision to
offer the gift of their organ for transplanta-
tion would be performed with minimal dis-
ruption to their own quality of life.

www.medicalebookpdf.com

LWBK892_c17_p256-263.indd 261 10/28/11 8:51:18 PM

 262 Part II: Basic Surgical Skills: New and Emerging Technology

Nephron sparing partial nephrectomy is

particularly useful in that potential over-
treatment with complete nephrectomy can
be avoided as the renal mass can be well vi-
sualized both with the surgical telescopes
and intraoperative ultrasound, allowing a
complete excision of the lesion with clear
margins while preserving renal function.

Donor Nephrectomy
Operative Technique
After administration of general anesthesia,
the patient is placed in a right lateral decu-
bitus position with pressure points padded.
The abdomen then is prepped and draped
in a standard sterile fashion. Beginning at
the umbilicus, a 7-cm infraumbilical inci-
sion is made at the midline, then taken
down through the fascia and into the ab-
dominal cavity. A hand-assist port is in-
serted, and pneumoperitoneum is achieved
with 14 mm Hg of carbon dioxide (CO2) in-
sufflation. It is from this site that the donor
kidney will be later extracted. Under direct
visualization, a 12-mm trocar is placed in
the left lateral abdominal wall; 8-mm tro-
cars are placed in the subxiphoid and left
lower lateral abdomen; and another 12-mm
trocar is placed in the left inguinal region.
The robotic surgical patient-side cart is
then brought into position, and the arms
are connected to the trocars (Fig. 6).
The descending colon is freed from the
lateral peritoneal attachments using elec-
trocautery and reflected medially. The ure-
ter is identified during dissection along the
psoas, and is dissected free circumferen-
tially in a cephalad direction, beginning at Fig. 6. Operating room setup for donor nephrectomy.
the level of the left common iliac artery. The
posterior attachments of the kidney then
are taken down.
The gonadal vein is identified medially as it fires only one staple line, offering addi-
and followed superiorly up to its junction tional artery length.
Prostatectomy
with the left renal vein. The renal vein then After firing of the stapler, once the artery One of the first areas where the benefits of
is dissected free, and its tributaries (go- is divided and proper exposure of the renal computer-enhanced robotic telemanipula-
nadal, lumbar, and left adrenal veins) are vein is achieved, a laparoscopic linear cutting tion was clearly demonstrated was in the
divided between locking clips. At this point, stapler is used alone for the transection of the use of the technology for localized prostate
the kidney is retracted medially, and the renal vein. At this point, the left kidney is re- carcinoma. Maintaining the oncologic ben-
main renal artery together with any acces- moved through the lower midline incision efit while preserving the functional status
sory renal artery is identified and dissected and taken to the back table where it is flushed and quality of life are the main consider-
free up to the level of the aortic takeoff. with cold infusion of University of Wisconsin ations for this procedure. Most positive
The ureter is clipped twice distally at the solution. Inspection of the renal bed is then margins occur at the prostatic apex, which
level of the iliac artery and sharply performed with the robotic system to ensure is where the neurovascular bundle resides.
transected. At this point, intravenous (IV) hemostasis while IV protamine of appropri- With the magnified 3D, HD imaging, dissec-
heparin is administered at a dose of 80 U/kg. ate dosage is administered. tion along the prostate and maintaining the
The renal artery is transected by first firing After evacuation of the pneumoperito- prostatic fascia, while minimizing disrup-
and endo-TA stapler at the takeoff of the neum and removal of the trocars, the lower tion to the nerves, with the ability to use the
renal artery. Next, a locking clip is placed on midline fascia is closed with a running #1 ab- articulating tools in the confined space
top of the staple line. The artery is then sorbable monofilament. The skin incisions allow maximal opportunity to successfully
sharply divided with the robotic scissors are closed with subcuticular 4-0 absorbable perform the operation while achieving the
just distal to the staple line. We prefer this monofilament and routinely infiltrated us- goals of an oncologic success and maintain-
endo-TA technique over the cutting stapler ing 0.25% bupivacaine with epinephrine. ing the patient’s genitourinary function.

www.medicalebookpdf.com

LWBK892_c17_p256-263.indd 262 10/28/11 8:51:21 PM

 Chapter 17: Robotic Surgery 263

Other Urologic Surgery surgery, including but not limited to cardiac measurable outcomes are generally similar
resynchronization, cardiac tissue ablation, to standard laparoscopic surgeries, such as
Feasibility of computer-enhanced robotic atrial septal defect repair, aortic valve re- seen with Nissen gastric fundoplication,
surgery has been demonstrated in cystec- construction or replacement, and pulmo- cholecystectomy, and gastric bypass, the
tomy, pyeloplasty, and ureteropelvic ob- nary vein isolation or ablation. method of using robotics actually improves
struction. Long-term studies are still surgical quality. The benefits of performing
needed to demonstrate broad applicability the maximal surgery with minimal trauma
of these operations relative to the current GYNECOLOGIC SURGERY to the patient are invaluable. The confi-
standards. Use of computer-enhanced telemanipula- dence of the surgeons during the operation,
tion robotics has enhanced the success of knowing that their operation is safe, de-
CARDIAC SURGERY minimally invasive techniques in gyneco- creases perioperative and postoperative
logic surgery including performing hyster- morbidities, and results in patients who en-
Cardiac Revascularization ectomy, myomectomy, tubal anastomosis, joy the best we can offer, further reinforces
and pelvic reconstruction procedures. The surgeons’ motivation to modify, add to, and
Cardiac revascularization is traditionally
improved visualization and dexterity rela- otherwise improve their technical base so
performed via median sternotomy. While
tive to standard laparoscopic techniques they can offer each patient the best care
providing excellent results for coronary
allow for decreased conversion rates and within our abilities. As more physicians and
revascularization, the morbidities associ-
increased success in completing the opera- facilities embrace robotic surgery and its
ated with cardiopulmonary bypass and the
tion in a minimally invasive fashion. benefits to the delivery of care to their pa-
sternotomy are not insignificant. Tech-

Basic Surgical Skills: New and

Dissection around the ureters and blad- tients, and as younger surgeons gain experi-
niques later developed for these procedures

Emerging Technology
der is technically easier with the robotic ence earlier in their training, the ingenuity,
to be performed off-pump and via thoraco-
platform in complex hysterectomies, and creativity, and capabilities of operating sur-
tomies, thus mitigating those problems.
visualization of planes allows for safe enu- geons in developing operative techniques
As technologies advanced, use of
cleation of uterine myomas. applying the latest technologies will simply
computer-enhanced robotics demonstrated
Rectovaginal and presacral dissection is continue exponentially grow, taking us into
their tremendous utility for this applica-
facilitated with the robotic equipment, al- the future of surgery.
tion. First used for left internal thoracic
artery harvesting, then later for the actual lowing sacrocolpopexy to be successfully
completed with a minimally invasive ap-
anastomosis, the robotic system allows for
proach.
SUGGESTED READINGS
completely minimally invasive access tak-
D’Annibale A, Morpurgo E, Fiscon V, et al. Ro-
ing advantage of the enhanced visualization botic and laparoscopic surgery for treatment
and dexterity of the tools to allow the sur- PEDIATRIC SURGERY of colorectal diseases. Dis Colon Rectum 2004;
geon to successfully and safely perform 47(12):2162–8.
multi-vessel totally endoscopic coronary The tremendous benefit of computer- Darzi SA, Munz Y. The impact of minimally inva-
artery bypass (TECAB). enhanced robotic surgery is truly magnified sive surgical techniques. Annu Rev Med 2004;
With patency rates comparable to the in the pediatric patient. These patients’ 55:223–37.
traditional techniques, avoiding the mor- smaller size, confined operative fields, and Galvani CA, Gorodner MV, Moser F, et al.
demand for precision dissection are loga- Robotically assisted laparoscopic transhiatal
bidities associated with the traditional esophagectomy. Surg Endosc 2008;22(1):188–95.
techniques clearly demonstrate the benefit rithmically enhanced with the robotic tools Hanly EJ, Talamini MA. Robotic abdominal sur-
of the emerging technologies. and enhanced visualization. gery. Am J Surg 2004;188(4A):19S–26S.
The first report of a robotic-assisted lap- Horgan S, Galvani C, Gorodner MV, et al. Robotic-
aroscopic pediatric Heller’s cardiomyotomy assisted Heller myotomy versus laparoscopic
Mitral Valve Repair demonstrates this fact, and with the preci- Heller myotomy for the treatment of esopha-
sion instrumentation and magnified 3-D, geal achalasia: multicenter study. J Gastrointest
Complex mitral valve repair is an area Surg 2005;9(8):1020–9; discussion 1029–30.
where the visualization and dexterity of the HD visualization of the anatomy, the myo- Horgan S, Vanuno D, Sileri P, et al. Robotic-
computer-enhanced robotic system is tomy was successfully and safely performed assisted laparoscopic donor nephrectomy for
clearly demonstrated. Further demonstrat- with visualization of the transition to mu- kidney transplantation. Transplantation 2002;
ing the ability to avoid the morbidities of cosa, allowing near certainty that the safest 73(9):1474–9.
sternotomy, endoscopic robotic mitral valve minimally invasive approach was effectively Menon M, Shrivastava A, Kaul S, et al. Vattikuti
applied. Institute prostatectomy: contemporary tech-
repair has been shown to be safe, feasible, nique and analysis of results. Eur Urol 2007;
and with consistently acceptable postoper- Investigation into the used robotic-en-
51(3):648–57; discussion 657–8. Epub 2006 Nov 3.
ative results. hanced laparoscopic surgery in pediatric Modi P, Rodriguez E, Chitwood WR Jr. Robot-
urology and pediatric cardiothoracic sur- assisted cardiac surgery. Interact Cardiovasc
gery are very promising and exciting. Thorac Surg 2009;9(3):500–5. Epub 2009 Jun 19.
Other Cardiac Surgery Suematsu Y, del Nido PJ. Robotic pediatric cardiac
As the techniques and durability of the ro- surgery: present and future perspectives. Am J
botic telemanipulation devices are devel-
CONCLUSION Surg 2004;188(4A):98S–103S.
Talamini MA, Chapman S, Horgan S, et al. The aca-
oped and accepted, the success of utilizing Quality of care should be measured by demic robotics group. A prospective analysis of
minimally invasive robotic techniques are means and methods, in addition to out- 211 robotic-assisted surgical procedures. Surg
growing in the applications used in cardiac comes. Even though some may argue that Endosc 2003;17(10):1521–4. Epub 2003 Aug 15.

www.medicalebookpdf.com

LWBK892_c17_p256-263.indd 263 10/28/11 8:51:22 PM

 264 Part II: Basic Surgical Skills: New and Emerging Technology

EDITOR’S COMMENT Dr. Horgan emphasizes the importance of gastrojejunostomy easier. But for the well-skilled
improving physician training in robotic surgery. laparoscopic surgeon, will the added time re-
Expertise to maximize one’s abilities to safely and quired to set up the robot contraption really
Dr. Horgan has extensive experience with ro- effectively use robotic surgery requires that we achieve any time savings for a gastric fundoplica-
botic surgery and with the da Vinci system. He incorporate these technologies into the surgical tion or paraesophageal hernia? Using an expen-
was an early adaptor of robotics and can boast education of trainees in the various disciplines. sive robot to place an adjustable gastric band for
excellent results. In this comprehensive chapter, Surgeons in practice need structured learning morbid obesity seems silly and a very poor alloca-
Dr. Horgan reviews the numerous procedures opportunities like the one offered at the annual tion of healthcare resources.
that claim robotic superiority. Several operations meeting of the Society of American Gastrointes- However, if we look to automobile manufac-
are described in detail. He also drills down to the tinal and Endoscopic Surgeons (SAGES) in 2012 turing, aerospace, and almost any industry, ro-
details of ideal setup and instrument selection. at University of San Diego robotic training facility. botic technology is embraced as truly beneficial.
Dr. Horgan lists operations for which the Formal certification of robotic surgery expertise Imagine, if you will, that one’s mouse would tag
robot claims enthusiasts including: urological has been proposed, but lacks widespread support the beginning and end of an anastomosis and then
surgical procedures, general laparoscopic surgi- by credentialing bodies. the surgeon presses “enter” and the anastomosis
cal procedures, gynecologic laparoscopic surgi- Naysayers claim the robot is little more than is completed perfectly. The spacing and tension
cal procedures, transoral otolaryngology surgical wasteful marketing ploy to capture more patient on each suture pass would be programmed based
procedures restricted to benign and malignant referrals. Of the foregut operations to which I am on tissue type and thickness. Next generation
tumors classified as T1 and T2, general thoraco- most familiar, Horgan describes robotic gastric robots will surely help surgeons approach per-
scopic surgical procedures, and thoracoscopi- bypass, adjustable gastric banding, achalasia, fect surgery (better, cheaper, faster, and safer).
cally assisted cardiotomy procedures. To the fundoplication, and paraesophageal hernia. I can Dr. Horgan’s personal enthusiasm for today’s ro-
casual reader, it seems like almost any operation appreciate that the Heller myotomy may be eas- bot should not supercede rational decision mak-
is better suited to the use of robotic technology. ier with the 3-D visualization and extra degrees ing as hospitals weigh whether this multimillion
Though the randomized trials and cost data seem of instrument motion. For the bariatric surgeon dollar investment makes surgery cost-effective
to be sorely lacking, I cannot help thinking, “try it committed to a handsewn rather than a stapled for patients and society.
you might like it . . . don’t be left behind.” anastomosis, the robotic system will make the D.B.J

18 Diagnostic Laparoscopy
Kevin C. Conlon and Paul F. Ridgway

INTRODUCTION accessed body cavities by rudimentary rigid were almost universal gynecologists like
instrumentation. Laparoscopic examina- Dr Hasson (whose name is frequently used
Evolution of the Role of Laparoscopy tion of the abdominal cavity in humans synonymously with the open technique).
was first described in 1910 by Jacobaeus, a Many early techniques thus centered on
Laparoscopy represents a disruptive tech- Swedish physician. Two years later, he pub- the pelvic organs. At a time when cross-
nology, where the technology occasions lished a 97-patient series performed be- sectional imaging was significantly less so-
change in indications for treatment, not just tween 1910 and 1912 at Stockholm’s Com- phisticated than today, it seems a natural
the method of treatment. Its promise of re- munity Hospital. However, it was not until evolution that laparoscopy would have
duced pain scores following the laparoscopic the routine diagnostic use of laparoscopy benefit in evaluation in many general surgi-
resectional surgery, shorter postoperative was fostered by gynecology in the early cal benign and malignant pathologies.
ileus, and shorter hospital stay, as well as 1970s that laparoscopy became more com- Diagnostic laparoscopy is safe, available,
better cosmesis has promoted its usage in monplace. Endometriosis, infertility, and and may be applied in the contemporary
many general surgical and gynecologic pro- ovarian cystic disease seem eminently suit- management of a range of conditions in-
cedures. able for laparoscopic evaluation. General cluding the acute and elective abdomen and
Laparoscopy further represents a shift surgeons were rather late adopters with the pelvis. Its current role is as a replacement
in management attitudes toward rehabili- routine use of laparoscopy coming in the for exploratory laparotomy, particularly in
tation and discharge planning. Even in soci- 1990s. The benefits quickly became appar- oncological staging.
eties where length of stay includes a period ent in the treatment of conditions such as It is noteworthy that introduction of sur-
of convalescence, laparoscopy represents a cholecystectomy and appendectomy. Once gical technologies is not submitted to the
minimally invasive strategy that facilitates the initial learning curve issues (Sweeney rigorous study that new medicines require.
enhanced recovery programs and early dis- et al.) had been addressed, laparoscopy has This is particularly important where the use
charge. It is noteworthy, however, with inte- replaced laparotomy as a default pathway of minimal access techniques in the surgi-
grated clinical pathways, that hospital stay for the operative management of many gen- cal diagnosis of cancer should be beneficial
following open colonic resection can be re- eral surgical pathologies. in terms of the oncological effect on the tu-
duced to 2 days, indicating that the differ- mor compared with conventional surgery
ences shown in other studies may not be so Rationale for Diagnostic or simple imaging. Murthy et al. in 1989
clear-cut. demonstrated that surgical injury itself pro-
Much was written of endoscopic surgery
Laparoscopy motes tumor growth and others showed
about 100 years ago; many specialties have The early authors who described techniques that reducing peritoneal trauma resulted in
dabbled in various techniques that have for induction of the pneumoperitoneum a decrease in tumor cell implantation. There

www.medicalebookpdf.com

LWBK892_c18_p264-270.indd 264 10/28/11 3:50:58 PM

 Chapter 18: Diagnostic Laparoscopy 265

matory processes, albeit with different po-

sitions of the monitors.
The laparoscopic stack (with contralat-
eral slave monitor where possible) should
be placed across from the right anterior su-
perior iliac spine (ASIS). For upper abdomi-
nal conditions, the stack is best placed as
per laparoscopic cholecystectomy at the
right thorax. In addition, we routinely use
the slave monitor on the contralateral side
at the same level.
Frequently, the setup for these routine
procedures is compromised in order to
save time. The authors feel that this is a false
economy as in the more difficult case this
serves to severely increase the duration of
Fig. 1. Standard instrument tray. the procedure. Standardization of setup is,
in fact, the key to efficiency of setup. This is
greatly facilitated if there is a “universal”

Basic Surgical Skills: New and

setup for all different surgical teams within

Emerging Technology
are many theories, best summarized by graspers (including at least two atraumatic a department (Fig. 2).
Ziprin’s work in 2002, but the message is the bowel graspers), and a scissors (Fig. 1). The
same; conditions specific to the laparo- use angled lens (30/45 degree) is desirable Induction of the
scopic surgical environment promote im- where possible, especially if pelvic or upper
plantation and a more aggressive invasive gastrointestinal (GI) conditions are strongly
Pneumoperitoneum
capability for shed tumor cells. Thus, thera- suspected preoperatively. This has the ben- Induction of the pneumoperitoneum is
peutic use of laparoscopies in the resection efit of improved optical ability but relies achieved by a modified open approach. Much
of intra-abdominal malignancies deserves upon the camera assistance having greater has been written about the safety of the in-
separate analysis, and although its skill than with a straight scope. Ports should duction of the pneumoperitoneum by closed
introduction was fraught, it has lessons for be selected depending on individual com- (Veress) or optical ports. In interpreting these
us all. fort and practice. Obesity is the main rea- data, it should be considered that the pneu-
son we amend our diagnostic instruments, moperitoneum induction method should be
favoring longer bariatric ports where the comfortable for the surgeon. It is our opinion
GENERAL TECHNIQUE abdominal wall girth mandates. There is a that the open technique is the safest although
similar setup for upper abdominal inflam- our techniques differ slightly; neither of us
Patient Factors and Positioning
Patient preparation has been modified over
time. In the early days, nasogastric tube Monitor Monitor
and urinary catheter were mandatory for
diagnostic laparoscopy. In more recent times
we have abandoned these in all but selected
cases. We do request our patients to void
their bladder once the attendant arrived to
transport the patient to the operating room.
The operating theater setup depends on
considering both patient and pathology fac-
tors. Our basic setup remains similar for the Equipment
investigation of most emergency right iliac Surgeon rack
fossa (RIF) pains. The patient lies supine on a
suitable gel-foam mattress and is secured by
two table straps, one at the mid-thigh level
and the other at the mid-chest. If significant
pelvic pathology or a need for colonic resec-
tion is suspected, then the patient is placed Nurse Assistant
on a bean bag and secured by a mid-chest
strap (this allows more flexibility and access
to the cervix if mobility is required).

Equipment Selection Surgical

instruments
The basic laparoscopic set includes the lap-
aroscope (either 5 or 10 mm), a range of Fig. 2. Operating room setup.

www.medicalebookpdf.com

LWBK892_c18_p264-270.indd 265 10/28/11 3:50:58 PM

 266 Part II: Basic Surgical Skills: New and Emerging Technology

Umbilicus

Scalpel making
subumbilical skin
B
incision (longitudinal)
A
Fig. 3. Modified “Hasson” technique.

has experienced an injury caused by induc- tects the sharp edge of the trochar on enter- INDICATIONS (WITH
tion of the pneumoperitoneum in well over ing the peritoneal cavity and locks in posi- CONSIDERATION OF
4,000 laparoscopies. The technique involves tion to prevent organ injury. EVIDENCE FOR USAGE)
dissection of the infraumbilical fascia at the Once the peritoneum is breached the
base of the umbilical cicatrix using an artery port is secured and pressure is set to 12 to Acute Abdomen Inflammatory
forceps, placement of stay sutures (using 15 mm Hg. We generally feel the lower end
polyglactin on a J needle) through the ante- of the range adequate for purpose. The ad-
Conditions
rior fascia after vertical incision of the linea ditional ports are placed according to pa- This is the commonest general surgical in-
alba (Fig. 3). The posterior fascia is then in- thology. We generally start with a suprapu- dication for diagnostic laparoscopy in the
cised under direct vision by electrocautery or bic 5 mm with a 10 mm situated either in use of evaluation of RIF pain. It is most im-
bluntly using a finger depending on surgeon’s the midline (between the 5 mm and the op- portant that the operating surgeon exam-
preference. tical) or in the left lower quadrant 2 cm me- ines the patient preoperatively. Frequently,
The needle closed technique was ini- dial and above the ASIS to standardize the nowadays, due to working time directives
tially described by Veress in 1938. Although sequence of the diagnostic part of the lap- and new on-call rotas, the operating sur-
we do not routinely use it, it has had a re- aroscopy to aid completeness. In the case of geon may not be the same as the admitting
surgence of use in upper GI and bariatric RIF pain, the RIF is the first place to start surgeon. The temptation to accept the ad-
surgery. With the patient in the Trendelen- with an anticlockwise direction to survey mission note as verbatim must be resisted.
burg position, the Veress needle is inserted the other structures. The appendix is lo- Excellent information may be lost that will
in the midline, below the umbilicus, aiming cated following the teniae coli down to the guide the diagnostic laparoscopy. Similarly,
toward the pelvis at 45 degrees to the hori- base. It or its mesentery should not be all preoperative imaging and blood work
zontal. Others prefer the left upper quad- grasped until the decision to resect has should be reviewed.
rant over the stomach. During insertion the been reached. The ovaries, fallopian tubes, In our treatment algorithm we also uti-
abdominal wall should be grasped on either and uterus are then viewed, using a closed lize laparoscopy to perform therapy, that
side, with towel clips, if necessary, and lifted grasper to hook under the tubes to deliver is, appendectomy, Meckel’s diverticulec-
away from the viscera. As the needle passes the ovary. The left iliac fossa is then looked tomy, or perforated duodenal ulcer (DU)
through the fascia and into the peritoneal at to survey the colon. Then the small bowel patch, wherever indicated. With specific
cavity, the surgeon should feel a loss of re- is “run” from the cecum to the duodeno- regard to RIF pain, this is, despite the Co-
sistance to the needle. The saline drop test jejunal flexure. This is to rule out segmental chrane review, suggesting higher rates of
indicates lack of resistance to flow and enteritis (inflammatory or Yersina enteri- intrapelvic collections in laparoscopic ap-
probable correct placement as the saline is tis) as well as a Meckel’s diverticulitis. The pendectomy for perforated appendicitis.
sucked into the abdomen by the negative laparoscopy can be continued into the right We believe that the examined trials were
pressure occasioned by the lifted abdomi- upper quadrant to survey the duodenum, conducted in the early learning curve as
nal wall. The intra-abdominal pressures liver, and gallbladder, thus, completing the well as with inferior aspiration instrumen-
should be measured throughout; usually, standard diagnostic sequence. tation. Certainly in our practice we have
they remain below 5 mm Hg. Initial insuffla- The placement of additional ports is not witnessed the high rates of pelvic col-
tion should be set at a low flow rate until governed by the operative plan made fol- lection and the significant improvement in
peritoneal entry is confirmed. Once ade- lowing the diagnostic part of the laparos- wound infection rates, coupled with the
quate pneumoperitoneum is established a copy. Most disposable ports have excellent improved wound infection rates although
small skin incision is made in the midline ridged profiles, which prevents the slippage for most efficient and efficacious therapy.
below the umbilicus and a 10- to 12-mm associated with loosening cased by pro- The benefits of laparoscopic management
trochar is then inserted in the same man- longed procedures. This has caused a reduc- of perforated DU is that diverticular dis-
ner as the Veress needle. Trochars may have tion in the use of oversheaths in all but non- eases are being actively studied and it is not
a spring-loaded “safety shield,” which pro- disposable ports. surprising that the benefits relate to

www.medicalebookpdf.com

LWBK892_c18_p264-270.indd 266 10/28/11 3:50:59 PM

 Chapter 18: Diagnostic Laparoscopy 267

decreased pain, better cosmesis, and ear- sis may be undertaken. Setup is as per stan- this makes sense as the peritoneum is a site
lier return to function. dard diagnostic laparoscopy, but usually of recurrence in over 50% of resected cancer
the patient is placed in lithotomy position cases. Controversy remains whether it should
Trauma (Blunt, Penetrating) on a bean bag; sequence proceeds as per be used routinely. Its additive value (specific
The improvement of axial imaging has less- laparoscopy for RIF pain. management changes secondary to positive
ened the utility for routine use of laparos- Laparoscopy for chronic upper abdomi- cytology in isolation) ranges up to 8%. It is
copy in blunt abdominal trauma. Indeed, nal pain is unusual given the prevalence of noteworthy, however, that the majority of
there are a number of low-level evidence solid organs, which are best visualized by patients with positive peritoneal cytology
critics. Overall, the sensitivity is still above axial imaging or laparoscopic ultrasound have intercurrent overt metastases. Cytology
90% for detecting injury following blunt (LUS). has a positive predictive value and specificity
trauma although with improved tech- of over 90% for peritoneal disease.
niques therapy for the injuries may be af- Staging of Cancer Extended LS is defined at the outset by
fected in a minimally invasive fashion as Laparoscopic staging (LS) in cancer is not a good understanding of anterior, circum-
well. recent advance. Halstead had a patient who ferential, and posterior local invasion
Much of the trauma literature is com- was staged preoperatively by Bernheim. He properties of the primary. It may be used
prised of case series and mix of penetrating observed that the finding of “general metas- for pancreatic, cholangiocarcinoma, gas-
and blunt trauma. It is fair to summarize tases may render further procedures un- tric, and esophagogastric tumors, as well
that laparoscopy has a role in evaluating necessary, saving the patient a prolonged as lower GI cancers and lymphomas. The
the hemodynamically stable penetrating convalescence.” There was a hiatus after- role of laparoscopy is to define anterior/

Basic Surgical Skills: New and

trauma patient and the hemodynamically ward, however, and it was not until intraperitoneal extent while LUS and pre-

Emerging Technology
stable blunt trauma patient with a signifi- Drs Cuschieri’s and Warshaw’s work in the operative good quality CT allow the at-
cant CT finding. Furthermore, it may re- late 1970s and 1980s that minimally inva- tending physician to determine postero-
duce the cost of unnecessary laparotomies. sive operative staging once more became lateral/retroperitoneal relations wherever
The technique is similar to diagnostic lap- used. Proponents advocate LS as increas- appropriate.
aroscopy in the emergency setting although ingly relevant in recent times as minimally The laparoscopy commences after gen-
there is more importance placed on speed invasive strategies may be employed to fa- eral anesthesia has been introduced. It is
of pneumoperitoneum induction and the cilitate bypass. LS may be performed imme- helpful to mark the definitive incision on the
ability to convert to open procedure should diately before conversion to laparotomy or skin, allowing ports to be placed on the ulti-
injury or patient factors mandate. In the as an interval staging measure. In experi- mate laparotomy wound (Fig. 4). The patient
case of significant penetrating injuries, gas enced hands, it is safe and tolerated well as is then placed in 25 degree anti-Trendelen-
leaks maybe managed by simple suturing of a day-case procedure. burg and a general laparoscopy is performed.
the wounds intraoperatively. Situation of The two key aims of LS are to determine All four quadrants and pelvis are inspected
the laparoscopic stacks (at the ASIS or head resectability and to identify occult metasta- for any gross metastases. Any preexisting
of the table) depends on suspected injuries ses. Both of these aims seek to provide the adhesions are dissected at this time if they
and mechanism of injury. We still favor the relevant T and M staging data without the restrict adequate inspection. The perito-
open technique in establishing the pneu- need for significant access-related morbid- neum is examined in all quadrants; however,
moperitoneum and see no reason to devi- ity seen with laparotomy. Initial work in the special attention is placed in the upper half
ate from the standard practice. It is note- 1980s suggested over a quarter of his cohort of the abdomen. This is where the angled
worthy that there are reports of feasibly was upstaged based on occult small volume lens proves most useful. The liver is exam-
conducting laparoscopy under local anes- liver metastases alone. Despite improve- ined systematically by “palpation.” Usually,
thetic in the emergency department. As ments in imaging technology, the added all but posterior of segments 4 a, 7, and 8 can
technology continues to miniaturize and value of laparoscopy over state-of-the-art be viewed. The technique employs two dis-
allows for mobility, it is likely in coming dynamic multislice CT remains up to 38% sectors to flatten the convexity of the surface
years that natural orifice and image-guided in some cancers. In real terms, today you of the liver, one “chasing” after the other
diagnostic laparoscopies will come to the could expect an added value for most of (Fig. 5). The laparoscope is kept in close
fore. these cancers nearer to 10%, however. proximity and driven over the surface. This
Apart from determining low volume oc- allows appreciation of subtle subcapsular as
Elective Abdomen cult metastases, LS plays a role in identify- well as superficial substance lesions. This
ing locoregionally advanced tumors, allow- concludes the “M” staging.
Pain ing the patient to avoid the operating room Should there be no evidence of metas-
Chronic abdominal pain (⬎6 months) en- for bypass and make it to palliative chemo- tases, nodal basins are inspected. Th e
compasses a range of conditions, often as- therapy earlier. lesser sac is opened wherever appropriate
sociated with limited efficacy for treatment. Washings for cytology obtained at LS by incising the gastrocolic omentum. This
There is sparse good quality of data to guide may be examined for occult carcinomatosis. is easily achievable in approximately 80%,
the use of laparoscopy, largely owing to the (200 mL of warmed normal saline is instilled without the need for ultrasonic dissec-
wide variety of associated diagnoses. Gen- into the left and right upper quadrants and tion. Once the sac opens, it is inspected
erally, it forms the last of the investigations pelvis prior to dissection or biopsy; the pa- for tumor and biopsies of the primary
after exhaustive imaging. The highest effi- tient is rocked on the table to agitate the maybe performed, although this is not
cacy is in gynecological conditions such as fluid. The fluid is then suctioned into “traps” routine.
endometriosis. Often in these cases, it is not and sent for routine cytology.) This implies LUS has been introduced as an adjunct to
until the laparoscopy when the diagnosis is that tumor resection occurs at a planned in- LS predominately to detect small hepatic
reached. At the same time as diagnosis terval after LS. Peritoneal cytology is pro- metastases, to evaluate lymph node status,
therapy such as cryoablation or adhesioly- posed as a useful adjunct to LS. Intuitively, and to define vascular anatomy related to the

www.medicalebookpdf.com

LWBK892_c18_p264-270.indd 267 11/15/11 10:44:04 PM

 268 Part II: Basic Surgical Skills: New and Emerging Technology

primary tumor (Fig. 6). The latter is particu-

larly relevant when the CT imaging is unclear
regarding respectability. Indeed, prospective
analysis of LS with LUS is approximately 30%
more specific and accurate in predicting tu-
mor resectability than laparoscopy alone.
Laparoscopic ultrasonography was signifi-
cantly more specific for assessing unresect-
ability compared with CT previously. Meth-
ods of accurate N staging remain elusive,
although LUS is undoubtedly useful in evalu-
ating the primary tumor and peripancreatic
vascular anatomy. Some authors propose
that the addition of LUS may confer similar
ability to open surgery in determining re-
5-mm port
5-mm port spectability, without the additional access-
10–12 mm port related trauma. Implementation of such an
10/11-mm port
adjunctive LUS staging program is not with-
(camera) out resource implications. The technique and
interpretation requires adequate training.
In pancreatic cases, the patient is placed
in steep anti-Trendelenburg and the greater
omentum is placed into the left upper quad-
Fig. 4. Port placement for upper gastrointestinal (GI) cancer.
rant. This allows the ligament of Treitz as
well as the transverse mesocolon to be in-
spected. It is the author’s experience that
tumor bubbling through adjacent to the in-
Falciform ferior mesenteric vein usually denotes irre-
ligament
sectability. In thinner patients, the pulsation
of the superior mesenteric artery is visible.
LUS may clarify any ambiguous findings.

CONTRAINDICATIONS
In contemporary laparoscopy, there are few
absolute contraindications. Generally, they
Liver
are in a patient who is considered medically
unfit for general anesthesia or who has an
ongoing bleeding diathesis. Relative con-
Blunt 10-mm traindications also exist and feature in any
instrument decision to operate on case-by-case basis.
Stomach These are listed in Table 1. It is notable that
Fig. 5. Examination of the liver. earlier concern that the creation of the
pneumoperitoneum would result in dis-
semination of malignant disease within the
peritoneal cavity has not been borne out by
clinical experience. Large clinical series
have suggested that the incidence of port-
site or incisional recurrence are similar to
open surgery once the learning curve has
Liver
been taken into account.

SUMMARY OF EVIDENCE
Diagnostic laparoscopy has a significant
role to play in the management of a wide
variety of acute and subacute abdominal
conditions. It is feasible and safe in the he-
modynamically stable trauma patient. Most
contraindications are now relative. Lap-
aroscopy in the diagnosis and treatment of
malignancy is now well established with
Fig. 6. Examination of stomach using linear array laparoscopic ultrasound (LUS) probe. port-site metastases a rarity.

www.medicalebookpdf.com

LWBK892_c18_p264-270.indd 268 10/28/11 3:50:59 PM

 Chapter 18: Diagnostic Laparoscopy 269

MMinnard EA, Conlon KC, Hoos A, Dougherty EC,

Table 1 Contraindications (Relative) and Associated Risks Hann LE, Brennan MF. Laparoscopic ultra-
sound enhances standard laparoscopy in the
Relative contraindication Possible risk staging of pancreatic cancer. Ann Surg 1998;
Previous surgery Adhesions leading to unrecognized visceral injury 228(2):182–7.
Intra-abdominal sepsis Friable bowel prone to injury PParaskeva PA, Ridgway PF, Jones T, Smith A,
Bowel obstruction Friable-dependent bowel prone to injury Peck DH, Darzi AW. Laparoscopic environ-
Morbid obesity Difficult access, requirement for longer instruments mental changes during surgery enhance the
Increased intra-abdominal pressure invasive potential of tumours. Tumour Biol
Pregnancy Injury to gravid uterus 2005;26(2):94–102.
RRidgway PF, Smith A, Ziprin P, et al. Pneumo-
Fetal distress
peritoneum augmented tumor invasiveness is
Aortic or iliac aneurismal disease Vascular injury abolished by matrix metalloproteinase block-
Cardiopulmonary compromise ↑ Intra-abdominal pressure may significantly reduce ade. Surg Endosc 2002;16(3):533–6.
cardiac preload SSaenz NC, Conlon KC, Aronson DC, LaQuaglia MP.
CO2 insufflation may result in CO2 retention The application of minimal access procedures
in infants, children, and young adults with pe-
diatric malignancies. J Laparoendosc Adv Surg
Tech A 1997;7(5):289–94.
SUGGESTED READINGS Conlon KC, Rusch VW, Gillern S. Laparoscopy:
an important tool in the staging of malignant
Shoup M, Brennan MF, Karpeh MS, Gillern SM,
McMahon RL, Conlon KC. Port site metastasis
Bartlett DL, Conlon KC, Gerdes H, Karpeh MS Jr. pleural mesothelioma. Ann Surg Oncol 1996; after diagnostic laparoscopy for upper gastro-

Basic Surgical Skills: New and

Laparoscopic ultrasonography: the best pretreat- 3(5):489–94. intestinal tract malignancies: an uncommon

Emerging Technology
ment staging modality in gastric adenocarcino- Decadt B, Sussman L, Lewis MP, et al. Random- entity. Ann Surg Oncol 2002;9(7):632–6.
ma? Case report. Surgery 1995;118(3):562–6. ized clinical trial of early laparoscopy in the Shoup M, Winston C, Brennan MF, Bassman D,
Brooks AD, Mallis MJ, Brennan MF, Conlon KC. The management of acute non-specific abdominal Conlon KC. Is there a role for staging laparos-
value of laparoscopy in the management of amp- pain. Br J Surg 1999;86(11):1383–6. copy in patients with locally advanced, unre-
ullary, duodenal, and distal bile duct tumors. J Gas- Hasson HM. Open laparoscopy vs. closed laparos- sectable pancreatic adenocarcinoma? J Gastro-
trointest Surg 2002;6(2):139–45; discussion 145136. copy: a comparison of complication rates. Adv intest Surg 2004;8(8):1068–71.
Chol YB, Lim KS. Therapeutic laparoscopy for ab- Plan Parent 1978;13(34):41–50. Sweeney KJ, Dillon M, Johnston SM, Keane FB,
dominal trauma. Surg Endosc 2003;17(3):421–7. Hochwald SN, Weiser MR, Colleoni R, Brennan MF, Conlon KC. Training in laparoscopic appendec-
Conlon KC. Value of laparoscopic staging for Conlon KC. Laparoscopy predicts metastatic tomy. World J Surg 2006;30(3):358–63.
upper gastrointestinal malignancies. J Surg disease and spares laparotomy in selected pa- Warshaw AL, Gu ZY, Wittenberg J, Waltman AC. Pre-
Oncol 1999;71(2):71–3. tients with pancreatic nonfunctioning islet cell operative staging and assessment of resectability
Conlon KC. Staging laparoscopy for gastric cancer. tumors. Ann Surg Oncol 2001;8(3):249–53. of pancreatic cancer. Arch Surg 1990;125(2):230–3.
Ann Ital Chir 2001;72(1):33–7. Leppaniemi A, Haapiainen R. Diagnostic laparos- Ziprin P, Ridgway PF, Peck DH, Darzi AW. The theo-
Conlon KC, Brennan MF. Laparoscopy for staging ab- copy in abdominal stab wounds: a prospective, ries and realities of port-site metastases: a critical
dominal malignancies. Adv Surg 2000;34:331–50. randomized study. J Trauma 2003;55(4):636–45. appraisal. J Am Coll Surg 2002;195(3):395–408.

EDITOR’S COMMENT tend to use a left upper quadrant location to place laparoscopy is usually considered a basic proce-
the Veress needle. After drop test and insufflation dure, advanced laparoscopic skills may be neces-
pressures confirm intra-abdominal needle posi- sary if bleeding, perforation, or other complica-
As an early proponent of laparoscopic ultrasonog- tion, I will use an optical trochar. Radial expanding tions are encountered. Even though laparoscopy
raphy and diagnostic laparoscopy for staging of ports do not slip or require a fixation device. is usually safe, if laparotomy is planned, laparos-
malignancy, Professor Conlon is uniquely quali- In general, I will examine the pelvis, midabdo- copy offers little-to-no added benefit.
fied to summarize the indications, contraindica- men, right upper quadrant, and left upper quadrant Diagnostic laparoscopy is contraindicated
tions, and value of diagnostic laparoscopy. His in that order. Adjusting the patient and table posi- in the setting of a frozen pelvis, uncorrected co-
initial studies demonstrated the value of laparo- tions in Trendelenburg and steep reverse Trendelen- agulopathy, inability to tolerate general anesthe-
scopic evaluation prior to pancreatic resection, burg, or “airplaning” the table right and left makes sia, or inability to tolerate laparotomy. Previous
and today laparoscopic evaluation is a common use of gravity to better expose the operative field surgery increases the potential of visceral injury.
practice among hepatobiliary surgeons. from bowel loops. Pelvic structures are best visual- The authors review relative contraindications.
In order for diagnostic laparoscopy to be a ized with the patient in 40-degree Trendelenburg Morbid obesity requires longer instruments,
useful adjunct, surgeons need to develop a sys- (head-down) position. I will consult gynecology and sometimes higher insufflation pressures
tematic approach to ensure a thorough laparo- specialists if an abnormal ovary, fallopian tube, or to maintain an adequate pneumoperitoneum
scopic abdominal exploration. I use a 5-mm lap- uterus is identified at laparoscopy, and will digitally working space. Injury to the gravid uterus or fe-
aroscope, and will increase size and use a 10-mm record all abnormalities. The midabdomen is best tal distress may occur during pregnancy. Vascu-
laparoscope only if I intend a therapeutic inter- seen with the patient flat and in neutral position. lar injury is more likely in the presence of aortic
vention. A second port will facilitate adhesiolysis. The anterior stomach and intestine can be run with or iliac aneurysm. High insufflation pressures
A third port is usually required to retract, extract, blunt graspers. Next, with the patient head-up and may reduce cardiac preload and require abor-
or biopsy tissues. If intraoperative ultrasonogra- rotated to the left, the gallbladder can be inspected. tion of the procedure.
phy is planned, larger ports will be required. Lastly, the left upper quadrant is best seen with the Laparoscopic examination has proven to be
Drs Conlon and Riddway favor an open Hasson patient in reverse Trendelenburg and the table ro- valuable in a variety of clinical settings: acute
technique for abdominal access in order to avoid tated to the right. Laparoscopic examination must abdominal pain, chronic pain syndromes, fo-
bowel injury, vascular injury, bladder perforation, be done systematically or the surgeon may miss cal liver disease, abdominal masses, ascites, and
hematoma, and extraperitoneal insufflation. He abnormalities. retroperitoneal disease. Future applications for
uses the infraumbilical site. Alternatively, he de- Biopsies should be performed for suspicious diagnostic laparoscopy are evolving as surgeons
scribes a closed technique in which he lifts the skin lesions, although all lesions should not be biop- become more experienced with laparoscopy and
with two towel clips and inserts the Veress needle, sied. Biopsy of hepatic hemangiomas, for example, ultrasonography.
again at the umbilicus. A drop test is performed. I can cause brisk hemorrhage. Although diagnostic D.B.J.

www.medicalebookpdf.com

LWBK892_c18_p264-270.indd 269 10/28/11 3:50:59 PM

 www.medicalebookpdf.com

LWBK892_c18_p264-270.indd 270 10/28/11 3:50:59 PM

 The Head and Neck III

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 271 10/28/11 3:49:56 PM

 19 Anatomy of the Head and Neck
Aaron Ruhalter

SURFACE ANATOMY third cervical vertebra. The greater horn STRUCTURE OF THE NECK
of the hyoid bone can be traced to its lat-
Surface anatomy is the relationship between
structures that are visible and/or palpable
eral termination. This is the approximate Skeletal Background
level of origin of the lingual branch of
with structures that are not visible and/or The cervical portion of the vertebral col-
the external carotid artery. The superior
palpable. Visible and/or palpable structures umn creates the skeletal background. It is
thyroid branch arises just inferior to this
in the neck include the following: composed of seven cervical vertebrae, with
point, and the facial branch begins just
a characteristic anterior convex curvature.
1. Sternocleidomastoid (sternomastoid) superior to the same palpable landmark.
Vertebrae C3 through C6 are considered to
muscle that attaches to the superior 6. Fused laminae of the thyroid cartilage.
be typical cervical vertebrae. Vertebrae C1,
aspect of the manubrium sternum by The upper edge of this palpable structure
C2, and C7 are atypical cervical vertebrae.
a tendinous head and from the medial is situated at the level of the fourth cervi-
C1 (atlas) has no body. C2 (axis) has incor-
third of the clavicle by a muscular head. cal vertebra. It represents the site of bi-
porated the body of C1 in its structure. The
It passes superiorly in a lateral, and then furcation of the common carotid artery.
combination of the two bodies results in a
posterior, direction. Its superior attach- 7. Arch of the cricoid cartilage, palpable be-
tooth-like projection called the odontoid
ment is to the mastoid process, and the low the inferior end of the thyroid lami-
process, or dens epistrophe.
lateral end of the superior nuchal line. nae. A small defect separates them. The
This provides an axis of rotation for the
Unilateral contraction of the muscle cricoid cartilage represents an “anatom-
skull on the atlas. C7 has a large transverse
approximates the ear to the ipsilateral ical bonanza” because it is a landmark
mass with a primitive foramen and a prom-
shoulder, while rotating the chin to the for many anatomical occurrences. It may
inent spinous process (vertebra promin-
contralateral side. Bilateral contraction be referred to as the “cricoid plane.”
ens). The typical cervical vertebrae have a
of the muscle can result in either flexion ■ The larynx ends, and the trachea be-
bifid spinous process and a distinct fora-
or extension of the head. If the head is gins.
men in the transverse mass. There are ante-
slightly flexed, bilateral contraction will ■ The pharynx ends, and the esopha-
rior and posterior tubercles related to the
result in increased flexion. If the head is gus begins.
transverse mass. The first rib must be in-
slightly extended, bilateral contraction ■ The cricoid cartilage is at the level of
cluded in the skeletal background. Many
will result in increased extension. The the sixth cervical vertebra.
of the neck structures are attached to, or
pulsation of the carotid artery is palpa- ■ The intermediate tendon of the
pass over, the first rib. The superior surface
ble, anterior to the edge of the muscle. omohyoid muscle is found anterior
of the first rib is flattened. This will avoid
2. Trapezius muscle that has a very broad to the carotid sheath.
trauma to the neurovascular structures
origin from the medial portion of the ■ The inferior thyroid artery passes
that travel over it. Midway between the ver-
superior nuchal line, external occipi- posterior to the carotid sheath on its
tebral and the sternal ends of this rib is the
tal protuberance, ligamentum nuchae, way to the lateral lobe of the thyroid
scalene tubercle, point of insertion of the
spinous processes, and the supraspinous gland.
anterior scalene muscle. A vascular sulcus
ligaments of the thoracic vertebrae. The ■ The middle cervical sympathetic
is found on both sides of the scalene tuber-
muscle fibers converge and insert on the ganglion lies on the transverse mass
cle. The anterior sulcus provides passage
lateral third of the clavicle and the acro- of the sixth cervical vertebra.
for the subclavian vein. The subclavian ar-
mion process of the scapula. Because of ■ The recurrent laryngeal nerve enters
tery passes over the posterior sulcus. The
the extensive origin of the muscle, differ- the larynx.
anterior scalene muscle attaches to the first
ential contraction will create different ■ The ansa cervicalis is found anterior
rib between the subclavian vessels. The
movements. Contraction of the upper to the carotid sheath.
middle scalene muscle attaches to the first
fibers will cause elevation of the scapula. ■ The vertebral artery enters a foramen
rib posterior to the groove for the subcla-
Depression of the scapula is created by in the transverse mass of the sixth
vian artery. Therefore, the subclavian artery
contraction of the inferior fibers. The cervical vertebra. This occurs at the
passes through the scalene triangle that is
middle fibers will cause the medial edge apex of a muscular triangle formed by
created by the anterior and middle scalene
of the scapula to approach the midline. the anterior scalene and longus coli
muscles. This area is referred to as the root
The external branch of the accessory muscles. The base of the triangle is the
of the neck. It will be described in more de-
nerve provides innervation to the trape- first portion of the subclavian artery.
tail later in this chapter.
zius and sternocleidomastoid muscles. ■ The superior pair of parathyroid
Branches from the second and third cer- glands is often found at this level.
vical nerves provide added innervation. 8. Upper tracheal rings that are palpable
Ligamentous Background
3. Mastoid process. between the cricoid cartilage and the su- The ligamentous background includes sup-
4. Ramus of mandible. perior edge of the manubrium sternum. porting structures for the atlanto-occipital
5. Hyoid bone, palpable in the midline of 9. Superior edge of the manubrium of the and atlantoaxial joints. The anterior longi-
the neck when the mandible is slightly sternum. It is at the level of the second tudinal ligament is found on the anterior
depressed. It is located at the level of the thoracic vertebra. aspect of the vertebral bodies. It extends

272

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 272 10/28/11 3:49:57 PM

 Chapter 19: Anatomy of the Head and Neck 273

from the atlas down to the upper sacral seg- muscle. It passes from the base of the skull to Nerve Background
ment. It is attached to the intervertebral the tubercles of the typical cervical verte-
disc and that portion of the vertebral body brae. The muscles that are lateral vertebral in The nerve layer should now be inserted. The
lying just superior and inferior to the disc. position are the levator scapula, middle, and nerves and the muscles are intimately re-
The nuchal ligament covers the spinous anterior scalene muscles. The levator scapula lated, so that the term “neuromuscular
processes of all the cervical vertebrae. muscle is the most posterior of this lateral layer” is appropriate. The cervical and bra-
group. It arises from the posterior tubercles chial plexuses and the cervical sympathetic
of the transverse masses of the first four cer- chains are now encountered as we continue
Muscular Background vical vertebrae, descends, and attaches to the reconstruction of the neck.
The muscular background includes muscles the superior portion of the vertebral border The cervical sympathetic chain consists
that are attached to the anterior aspect of of the scapula. The middle scalene muscle is of three ganglia with connecting branches.
the vertebra (anterior vertebral) and mus- on a more anterior plane (Fig. 1). The superior ganglion is the largest, and it is
cles that are attached to the lateral mass of The middle scalene muscle may be at- found on the transverse mass of the second
the vertebra (lateral vertebral). Both of these tached to the posterior tubercles of all cer- and third cervical vertebrae. It is ⬎1 in.
groups are combined and are referred to as vical vertebrae. It descends and affixes to long and lies on the longus capitis muscle,
prevertebral muscles. The longus coli and the superior flattened surface of the first posterior to the carotid sheath. The middle
longus capitis muscles are anterior to the rib, posterior to the groove for the subcla- cervical ganglion is the smallest and lies on
vertebral column. The longus coli is a com- vian artery. A few muscle fibers extend the transverse mass of the sixth cervical
plex muscle that is attached inferiorly to the down to the second rib and create the pos- vertebra. The inferior cervical ganglion is
upper thoracic portion of the anterior longi- terior scalene muscle. The most anterior of related to the vertebral end of the first rib
tudinal ligament. These lower fibers pass the lateral vertebral muscles is the anterior and the transverse mass of the seventh cer-
superolaterally and attach to the transverse scalene (Fig. 1). It arises from the anterior vical vertebra. It frequently joins with the
masses of the typical cervical vertebrae. Fi- tubercles of the transverse masses of the first thoracic ganglion to form a dumbbell-
bers of this same muscle then pass supero- typical cervical vertebrae and attaches be- shaped structure called the cervicothoracic,
medially and attach to the anterior portion low to the scalene tubercle of the first rib. It or stellate, ganglion. Stellate refers to the
of the arch of the atlas. There are vertical fi- is in the same frontal plane as the longus star-like appearance created by the multi-
bers of this same muscle that lie between capitis muscle. The anterior vertebral mus- ple branches that are emitted. It is posterior
the two oblique portions laterally and the cles will flex the cervical spine. The lateral to the vertebral artery. At times, branches
anterior longitudinal ligament medially. vertebral muscles will cause lateral bending from the middle cervical ganglion will form
The longus capitis muscle lies anterior to of the same area. Motor innervation is pro- a loop around the subclavian artery before
the superomedial fibers of the longus coli vided by ventral rami of cervical nerves. entering the inferior ganglion. This is re-
ferred to as the ansa subclavia.
The cervical plexus is formed by the ven-
tral rami of the first four cervical nerves.
These nerves connect to each other by
forming loops that lie in the interval be-

The Head and Neck

tween the levator scapula, or the middle
scalene, muscle posteriorly, and the longus
capitis or its inferior continuation, the an-
Middle scalene muscle
terior scalene muscle, anteriorly (Fig. 2).
Each of the first four cervical ventral
Longus rami receives a branch from the superior
Coli
Anterior scalene muscle cervical ganglion. The cervical nerves lie
Muscle
within the prevertebral fascia. The cervical
plexus provides muscular and cutaneous
innervation. There are cutaneous branches
from a superficial cervical plexus and
muscular branches from a deep cervical
plexus. The cutaneous branches will be de-
scribed with the posterior triangle. Muscular
branches innervate the prevertebral mus-
cles. In addition, a branch from C1 travels
with the hypoglossal nerve and gives rise to
the superior limb (descending hypoglossal
nerve) of the ansa cervicalis. Branches from
C2 and C3 will form the inferior limb (de-
scending cervical nerve). The two limbs unite
and form the ansa cervicalis. This nerve loop
is on the anterior aspect of the carotid
sheath, in the cricoid plane. Branches arise
from the ansa cervicalis that provide motor
innervation to the strap muscles in the
Fig. 1. Structures of the Neck-1. Scalene muscles of the neck. muscular triangle. Other branches of C1,

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 273 10/28/11 3:49:57 PM

 274 Part III: The Head and Neck

the lips. The cutaneous nerves and the su-

Left sympathetic
perficial veins course below this muscle of
chain facial expression. The cervical branch of the
facial nerve innervates this muscle.
Superior cervical The deep cervical fascia consists of sev-
ganglion eral layers. The superficial, or investing,
Cervical plexus
layer of the deep cervical fascia splits to in-
Anterior scalene vest the trapezius and sternocleidomastoid
Middle cervical muscle muscles and the submandibular and pa-
ganglion
Trunks of rotid glands. It creates a complete tube that
brachial plexus surrounds the neck. The deep layer of the
deep cervical fascia, or prevertebral fascia,
encloses the vertebral column and the at-
tached erector spinae and prevertebral
muscles and proximal portions of the cervi-
cal and brachial plexuses. It creates a com-
Inferior cervical plete tube.
ganglion
The pretracheal fascia creates a tube
Phrenic that encircles the pharynx and esophagus,
nerve larynx and trachea, and the thyroid and
parathyroid glands. The buccopharyngeal
fascia is the posterior extension of the pre-
tracheal fascia that covers the constrictor
muscles of the pharynx. It is in contact with
the anterior, or prevertebral, portion of the
prevertebral fascia. This potential space be-
tween the prevertebral and the buccopha-
ryngeal fascia layers extends from the neck
down to the mediastinum. This retropha-
Fig. 2. Structures of the Neck-2. Ganglia and cervical plexus structures. ryngeal space can serve as a pathway for the
spread of an infection from the neck to the
thorax. The middle cervical fascia extends
from the hyoid bone to the sternum. It en-
traveling with the hypoglossal nerve, pro- These roots and trunks pass between the compasses all the strap muscles. This fascia
vide motor innervation to the thyrohyoid middle and the anterior scalene muscles. layer extends laterally to the omohyoid
and geniohyoid muscles. A branch from The lower trunk is draped over the first rib muscle and therefore is only related to the
C4 descends on the anterior surface of the immediately posterior to the subclavian ar- muscular and subclavian triangles.
anterior scalene muscle, within the pre- tery (Fig. 2). The carotid sheath is a protective, tubu-
vertebral fascia. It is the phrenic nerve The subclavian vein, unlike the accom- lar fascial sheath found between the base of
and it may receive branches from C3 and panying artery, does not pass between the the skull and the root of the neck. It receives
C5. It is, at first, seen on the lateral aspect scalene muscles. It passes anterior to the tissue contributions from all layers of the
of the anterior scalene muscle, but as it anterior scalene muscle. Enclosing the skel- deep cervical fascia and encloses the com-
descends it passes obliquely across the etal background and the neuromuscular mon carotid and internal jugular vascular
anterior surface of the muscle and reaches layer is the prevertebral portion of the deep conduits and vagus nerve. After the bifurca-
its medial edge in the root of the neck. It cervical fascia. The neurovascular struc- tion of the common carotid artery, the
then passes anterior to the subclavian ar- tures will pierce the deep cervical fascia internal carotid branch will assume its po-
tery and courses medial to the internal and drag a portion of it along with them, sition in the sheath. The vein is anterolat-
mammary artery before entering the tho- creating the axillary, or cervicoaxillary, eral to the artery, except at the base of the
rax. It provides sensory and motor innerva- sheath. skull, where the vein lies posterior to the
tion to the respiratory diaphragm (Fig. 2). artery. The vagus nerve is between, and
There are some proprioceptive branches slightly posterior to, the blood vessels. The
arising from the cervical plexus that pass
Fascia of the Neck
ansa cervicalis is on the anterior surface of
to the sternocleidomastoid and trapezius The cervical fascia is composed of superfi- the sheath in the cricoid plane. The sympa-
muscles. cial and deep layers. The superficial fascia is thetic chain is in contact with the posterior
As we pass inferiorly in the cervical re- not well developed and not easy to find. It surface of the sheath.
gion, the nerves now encountered will con- consists of fat and some connective tissue.
sist of the roots and trunks of the brachial The platysma muscle is in the superficial ROOT OF THE NECK
plexus. The brachial plexus is created by the fascia. It arises inferiorly from the fascia of
ventral rami of C5 through T1. These roots the pectoralis major muscle and its fibers The root of the neck is the anatomical inter-
will form three trunks. C5 and C6 join to converge as they ascend to their insertion section between the thorax, neck, and axilla.
form the upper trunk. The C7 root will be- in the inferior part of the mandibular re- The superior thoracic aperture, or thoracic
come the middle trunk, and roots C8 and gion. Some of the muscle fibers ascend and inlet, and axillary (or cervicoaxillary) sheath
T1 will merge and form the lower trunk. mix with the intrinsic depressor muscles of create a pathway for the neurovascular

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 274 10/28/11 3:49:57 PM

 Chapter 19: Anatomy of the Head and Neck 275

structures found in this area. Neck struc- may be represented by several small ducts. extend above the superior edge of the clavi-
tures also contribute to the complexity of It receives lymph from the right hemithorax, cle. A tent-like thickening of the preverte-
the anatomy in this important region. Pass- right upper extremity, and right side of the bral fascia extends from the transverse mass
ing between the clavicle and the first rib are head and the neck. Lymph from all other of C7 to the first rib. It is called Sibson, or
nerves, arteries, and veins of the upper ex- parts of the body is transported by the tho- vertebropleural, fascia and provides some
tremity. Narrowing of this costoclavicular racic duct. The sympathetic chains are in protection to the pleura when incisions are
canal can cause compression of these neu- contact with the head of the rib at this level. made in this area.
rovascular structures. The thoracic inlet is The recurrent laryngeal nerves, branches of Lateral structures include the subcla-
created by the upper end of the manubrium the vagus (X) nerve, are also medial. The vian artery and subclavian vein and their
anteriorly, the first rib and its costal carti- right recurrent laryngeal nerve arises in the branches, and nerve branches from the
lage laterally, and the first thoracic vertebra root of the neck, loops around the right sub- cervical and brachial plexuses. The cervical
posteriorly. Structures passing through this clavian artery, and passes superomedially or apical area of the lung is also found in
area are medial or lateral in position. The as it courses toward the tracheoesophageal the lateral portion of the root of the neck.
esophagus and the trachea are medial as groove. Its counterpart on the left arises in The first rib and the scalene muscles have
they enter the mediastinum. The thoracic the mediastinum, loops around the aortic important spatial relationships with the
duct lies just to the left of, and posterior to, arch, and then ascends into the neck by way anatomy in this area.
the esophagus. In the root of the neck, at of the left tracheoesophageal groove. The The brachiocephalic trunk is the first
the level of C7, the duct passes laterally. It right recurrent nerve, in the root of the neck, branch of the arch of the aorta (Fig. 4). It
courses anterior to the left vertebral and left travels toward the right tracheoesophageal passes superolaterally and bifurcates at the
inferior thyroid arteries and posterior to the groove, but it may not yet have reached this level of the right sternoclavicular joint into
carotid sheath. It then travels anterior to protected position and is therefore more ex- the right common carotid and right subcla-
the anterior scalene muscle. It is superficial posed to injury. vian arteries. The common carotid artery
to the prevertebral layer of the deep cervical The apex of the cervical parietal pleura will pass superiorly on the right side of the
fascia. The duct then descends anterior to ascends to the neck of the first rib. The an- neck in the carotid sheath. It will be dis-
the left subclavian artery and terminates at terior end of the rib is lower than the poste- cussed in more detail later in this chapter.
the lateral edge of the junction between the rior end; therefore, the apex of the lung can The next branch of the arch of the aorta is the
left internal jugular and the left subclavian ascend out of the thorax into the root of the left common carotid artery. The last branch
veins (see Fig. 5). neck (Fig. 3). This ascension is most marked of the aortic arch is the left subclavian artery
The equivalent of the thoracic duct on the during deep inspiration and occupies the (Fig. 4). The anterior scalene muscle divides
right side of the root of the neck is called the lateral portion of the superior thoracic in- the subclavian artery into three segments.
right lymphatic duct. It is much smaller and let. This portion of the cervical pleura may The first portion extends from the origin
of the vessel to the medial edge of the ante-
rior scalene muscle. The second part lies be-
hind the muscle, and the third segment ex-
tends from the lateral edge of the muscle to
the lower edge of the first rib. Most of the

The Head and Neck

branches of the subclavian artery arise from
the first portion. The first and largest branch
is the vertebral artery. It arises from the su-
Vertebral artery
perior edge of the parent vessel, ascends ver-
tically, and enters a foramen in the transverse
mass of the sixth cervical vertebra. The ac-
Middle
companying vein covers it.
Scalene
Muscle The foramen is situated at the apex of
a muscular triangle created by the longus
coli muscle medially and the anterior sca-
Anterior lene muscle laterally. This is referred to as
Scalene the triangle of the vertebral artery. The sec-
Muscle Phrenic nerve ond branch is the thyrocervical trunk,
Right Left which also arises from the superior surface
Lung
Lung and has a short course before it divides into
the following branches. The inferior thyroid
artery passes superiorly, anterior to the an-
terior scalene muscle. The phrenic nerve is
within the prevertebral fascia as it passes
inferiorly on the anterior surface of this
muscle. The inferior thyroid artery is super-
ficial to the prevertebral fascia. At about the
level of the apex of the triangle of the verte-
bral artery the inferior thyroid artery passes
medially, coursing posterior to the carotid
sheath but anterior to the vertebral artery,
Fig. 3. The apex of the lung ascends out of the thorax into the root of the neck. and enters the substance of the lateral lobe

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 275 10/28/11 3:49:58 PM

 276 Part III: The Head and Neck

artery. It arises from the inferior aspect of

Internal the subclavian artery across from the thyro-
carotid artery cervical trunk. It passes inferomedially,
External courses posterior to the subclavian vein,
carotid artery and initially is in contact with the cervical
Common pleura as it heads for the first costal carti-
carotid artery lage. It then assumes its characteristic loca-
Vertebral tion parallel to the lateral edge of the ster-
artery num. The subclavian vein begins at the outer
Common
Inferior thyroid carotid artery end of the first rib and then passes anterior
artery to the anterior scalene muscle (Fig. 5). It re-
Transverse ceives the external jugular vein before
cervical artery Upper trunk
Brachial
Middle trunk plexus
reaching the medial edge of this muscle.
Costocervical Lower trunk When the vein is medial to this muscle,
trunk
Left subclavian it is joined by the internal jugular vein,
Suprascapular artery forming the brachiocephalic vein. The left
artery
Phrenic brachiocephalic vein will pass to the right,
Right subclavian nerve just inferior to the superior edge of the
artery
manubrium sternum, and join with its right
Thyrocervical counterpart behind the right first costal
trunk
cartilage to create the superior vena cava.
Each brachiocephalic vein will receive the
corresponding vertebral vein. Each vagus
nerve passes anterior to the related subcla-
vian artery. The left nerve then passes pos-
Internal mammary
Brachiocephalic
terior to the left brachiocephalic vein. The
artery
artery right nerve is posterolateral to the related
Fig. 4. Structures of the Neck-3. Branch of the aortic arch. brachiocephalic vein.

of the thyroid gland. The transverse cervical

and the suprascapular arteries are branches
of the thyrocervical trunk that run trans-
versely as they head for the lateral aspect of
the neck. They cross the anterior scalene
muscle and the phrenic nerve, but are su-
perficial to the prevertebral fascia. The
transverse cervical artery will divide into an
ascending and descending branch when it
reaches the margin of the trapezius muscle. Thoracic duct
The suprascapular artery will dip down be-
low the clavicle after entering the posterior
triangle, pass inferiorly, and contribute to
the periscapular vasculature.
The next branch originating from the su-
perior aspect of the subclavian artery is the External jugular
costocervical trunk (Fig. 4). It may arise vein
from the second portion of the subclavian, Subclavian
and is therefore less at risk during surgical vein
procedures. It arches over the cervical
pleura and, when it reaches the neck of the
first rib, divides into the deep cervical ar- Brachiocephalic
tery that passes up and supplies the mus- vein
cles in the back of the neck and the supreme
intercostal artery that creates the first and
second posterior intercostal arteries. The
first posterior intercostal vein that will
enter the ipsilateral brachiocephalic vein, Internal jugular
accompanies it. Vertebral
vein
The last branch of the subclavian artery is vein
the internal thoracic or internal mammary Fig. 5. Structures of the Neck-4. Subclavian vein origin.

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 276 10/28/11 3:49:59 PM

 Chapter 19: Anatomy of the Head and Neck 277

Anterior to this anatomical jungle is ular space. The vein is in the narrowest por- 4. Carotid angiography: the common carot-
the thymus gland. It is largest during the tion of this space, and if additional narrow- id artery is palpable in the carotid trian-
childhood years, and then starts to regress ing occurs, venous outflow from the upper gle. It is partially covered by the sterno-
with the onset of sexual maturation. The extremity may be impaired. cleidomastoid muscle. Lateral retraction
gland may extend from the thyroid cartilage A cervical rib may present itself in several of the muscle will facilitate insertion of a
above, to the pericardial sac below. There- ways. It is frequently bilateral. It is an exten- catheter into the palpable artery.
fore, its superior portion is part of the me- sion of the transverse mass of the seventh cer- 5. Internal jugular vein catheterization:
dial, or anterior, aspect of the root of the vical vertebra and it may be a complete rib the internal jugular vein accompa-
neck. The gland is composed of two sepa- that articulates with the sternum. At times, it nies the common and internal carotid
rate, asymmetrical lobes. The gland is con- may fuse with the first rib or present as a vessels. They all lie within the carotid
tiguous with the large veins previously de- fibrous band that attaches to the first rib. In sheath. The vein is anterolateral to the
scribed. This explains why venous invasion some patients, it may have an anterior end palpable artery.
is frequently seen with malignant disease of that is free. The subclavian vessels and the 6. The right internal jugular and right
the gland. brachial plexus, especially the lower trunk, brachiocephalic veins, along with the
The roots of the brachial plexus, C5 will be affected adversely when they try to superior vena cava, create a straight
through T1, will create three trunks: an up- pass over this additional obstacle. conduit to the right atrium and the in-
per trunk (C5, C6), middle trunk (C7), and The anterior scalene compression syn- ferior vena cava.
lower trunk (C8, T1) (Fig. 4). They will pass drome results from spasm, or hypertrophy, 7. The subclavian vessels can be ap-
between the anterior and the middle scalene of the anterior scalene muscle, with resul- proached while passing through the
muscles on their way to the axilla. It is the tant constriction of the neurovascular ele- costoclavicular space. The artery is pal-
lower trunk that is in direct contact with the ments as they pass through the scalene tri- pable and the vein is situated anterior
upper surface of the first rib. It lies immedi- angle. If the clinician treats this condition and medial to the artery. The vein is the
ately posterior to the subclavian artery. The by transecting the anterior scalene muscle most medial structure passing through
trunks pass through the posterior triangle. near its insertion, the position of the phrenic the costoclavicular interval. A supra-
Each trunk will divide into an anterior and nerve and the subclavian vein, passing an- clavicular, or infraclavicular, technique
posterior division. These divisions, along terior to the muscle, must be remembered. can be used for catheterization.
with the accompanying subclavian vessels, The term “thoracic outlet compression 8. The brachial plexus block approaches
will then pass through the costoclavicular syndrome” is frequently used when defining the nerves as they pass through the
space. The subclavian vein is the most me- some clinical conditions encountered in costoclavicular space. The subclavian
dial of the structures passing through this the root of the neck. Thoracic outlet is a artery is anterior to the branches of the
space (Fig. 5). This vein is anteroinferior to misnomer when used to identify the clini- plexus.
the accompanying subclavian artery and cal problems in this area. The true anatomi- 9. In cricothyroidotomy, the interior of
can, therefore, be approached after the pul- cal thoracic outlet is the area related to the the larynx is entered through the cri-
sations of the accompanying artery are pal- respiratory diaphragm. Correct terms for cothyroid interval. The cricothyroid
pated. The roots and trunks of the brachial these conditions would include superior artery, a branch of the superior thyroid,
plexus are within the prevertebral layer of thoracic aperture compression syndrome pierces the cricothyroid ligament near

The Head and Neck

the deep cervical fascia. As they head for the or cervicoaxillary compression syndrome. the middle of the interval between the
axilla, accompanied by the subclavian ves- All of these compression syndromes can cricoid and the thyroid cartilages. A
sels, they drag some of this deep fascia along result in neurologic deficits and/or arterial transverse incision, made close to the
with them and create a protective tubular and venous circulatory problems in the up- upper border of the cricoid arch, will
sheath for these neurovascular items called per extremity. avoid injury to this artery. The vocal
the cervicoaxillary, or axillary, sheath. These ligaments are spared because they are
nerves and blood vessels, on their way to the superior to the point of entry.
Clinical Anatomical Applications
axilla, pass under the insertion of the pecto- 10. For drainage of the retropharyngeal
ralis minor muscle to the coracoid process 1. Cervical incisions should be made par- space, an incision is made at the level of
of the scapula. allel to the skin lines (lines of Langer) the cricoid cartilage. The sternocleido-
for good cosmesis. The neurovascu- mastoid muscle and carotid sheath are
The Anatomy of the Root of the lar structures lie deep to the platysma retracted posteriorly, and the lateral
Neck Compression Syndromes muscle. The muscle must be carefully lobe of the thyroid gland is retracted
repaired for the best cosmetic result. anteriorly.
The root of the neck compression syn- 2. The middle cervical ganglion block: this 11. Using the external jugular vein as a
dromes include the following: sympathetic ganglion is found anterior conduit for central venous access, the
to the transverse mass of the sixth cer- external jugular vein is readily accessi-
■ Costoclavicular compression syndrome
vical vertebra. At the level of the cricoid ble because of its superficial position. It
■ Cervical rib syndrome
cartilage, retract the carotid sheath lat- empties into the subclavian vein in the
■ Anterior scalene compression syndrome
erally and inject the medication after posterior triangle, but it may be diffi-
■ Pectoralis minor syndrome
the needle strikes the lateral mass of the cult to negotiate the angle at the termi-
If the space between the first rib and the vertebra. nation when attempting to introduce
clavicle should be decreased, there could be 3. Control of bleeding may be possible a device into the central portion of the
compression of the neurovascular structures if the common carotid artery is com- circulatory system. Direct approach to
traversing this area (Fig. 5). The subclavian pressed against the transverse mass of the larger veins, right internal jugular
vein is the most medial of the neurovascular the sixth cervical vertebra. This is the or right subclavian, would eliminate
structures passing through the costoclavic- cricoid plane. this technical problem.

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 277 10/28/11 3:50:00 PM

 278 Part III: The Head and Neck

TRIANGLES OF THE NECK triangle includes the area between the ante- digastric muscle. The tendon of insertion of
rior edges of the sternocleidomastoid mus- the stylohyoid muscle to the hyoid bone is
The layer-by-layer recreation of the neck cles. The superior limit is the mandible and a split and allows for passage of the interme-
anatomy now requires the addition of the line drawn from the angle of the mandible to diate tendon of the digastric muscle. The
carotid sheath with the vascular contents the tip of the mastoid process. Two double- anterior triangle includes the submandibu-
and their branches, the last four cranial bellied muscles, omohyoid and digastric, lar and carotid triangles. They are separated
nerves, and the viscera of the neck, which subdivide the triangles. The inferior belly of from each other by median submental and
includes the thyroid and parathyroid the omohyoid muscle attaches to the supe- muscular triangles.
glands, pharynx, and larynx. The superficial rior transverse scapular ligament and a por- The hyoid bone is a central structure in
cervical plexus will also be outlined. The tion of the adjacent superior edge of the the neck. It is directly or indirectly attached
cervical lymphatic pathways will then be scapula. It passes superior to the clavicle and to most of the muscular and membranous
described, and finally the superficial venous enters the lower portion of the posterior tri- entities in the anterior triangle and in the
circulation will be examined. This informa- angle. The intermediate tendon is in the cri- floor of the mouth. If one considers the hyoid
tion is presented with a discussion of the coid plane, anterior to the carotid sheath, bone and the attached posterior belly of
triangles of the neck. and is angulated by a fascial sling attached to the digastric muscle, it is possible to divide
the clavicle and the manubrium. The supe- the anterior triangle into suprahyoid and
Anterior and Posterior Triangles rior belly ascends to the hyoid bone. infrahyoid portions. The submandibular, or
The posterior triangle now consists of digastric triangles, and the submental trian-
The sternocleidomastoid and trapezius mus- the large occipital and the smaller subcla- gle, are suprahyoid entities and are related to
cles divide the neck into anterior and poste- vian triangles. The digastric is the other the floor of the mouth. They have been dis-
rior triangles (Fig. 6; also see Fig. 13). The double-bellied muscle that creates subdivi- cussed in another chapter. The carotid and
boundaries of the posterior triangle are the sions of the anterior triangle. The posterior the muscular triangles are found in the in-
trapezius muscle posteriorly and the sterno- belly attaches just medial to the mastoid frahyoid portion of the anterior triangle.
cleidomastoid muscle anteriorly. The middle process. The intermediate tendon is teth-
third of the clavicle creates the inferior limit, ered to the hyoid bone by a fold of deep cer-
and the apex of the triangle extends to the vical fascia. The stylohyoid muscle arises
Carotid Triangle
superior nuchal line. The triangle is spiral in from the styloid process of the temporal The muscular boundaries of the carotid tri-
shape. The inferior portion is anterior in the bone and is in intimate contact with the an- angle are the sternocleidomastoid muscle
neck, but the apex is posterior. The anterior terior surface of the posterior belly of the posteriorly, the posterior belly of the digas-
tric muscle anterosuperiorly, and the supe-
rior belly of the omohyoid muscle anteroin-
feriorly (Fig. 7). The greater horn of the
hyoid bone is part of the anterior and supe-
rior segment of the floor of this triangle.
The hyoglossus and thyrohyoid muscles are
Posterior belly of attached to this portion of the hyoid bone,
digastric muscle and are part of the anterior portion of the
Stylohyoid muscular floor. A small portion of the thy-
muscle rohyoid membrane is found just behind the
thyrohyoid muscle and makes up a small
area of the floor. The middle and inferior
CA IAN
TR
POS

Anterior belly of pharyngeal constrictor muscles create the

RO GL

digastric muscle posterior section of the muscular floor of

TER

Trapezius
TI E

the carotid triangle. The longus capitis, a

D

muscle Superior belly of

IOR

omohyoid muscle prevertebral muscle, also contributes to the

Sternocleidomastoid posterior portion of the muscular floor of
T RI

Inferior belly of muscle: this triangle. The pretracheal layer of the

AN

omohyoid muscle (Muscular head)

deep cervical fascia creates the fascial car-
GL

(Tendon head)
pet. The investing layer of the deep fascia
E

creates a fascial roof.

The contents of the triangle will be de-
Subclavian scribed beginning with the deepest struc-
Triangle tures (Fig. 8). The superior laryngeal nerve
is a branch of the vagus nerve that is given
off at the base of the skull. It travels inferi-
orly, in contact with the superior constric-
tor, courses deep to the internal and exter-
nal carotid arteries, passes under the
posterior belly of the digastric muscle, and
is now in the carotid triangle. When it
reaches the middle constrictor muscle, it
creates an internal and external branch.
Fig. 6. Boundaries of the triangles of the neck (see also Fig. 14). The internal branch enters the larynx after

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 278 10/28/11 3:50:00 PM

 Chapter 19: Anatomy of the Head and Neck 279

piercing the thyrohyoid membrane. It pro-

vides sensory innervation to the interior of
the larynx above the vocal ligaments. The
external branch passes inferiorly, in contact
Mylohyoid with the inferior constrictor, and gives some
muscle branches to this muscle. It also provides
motor innervation to the cricothyroid, one
of the intrinsic muscles of the larynx. This
Stylohyoid
muscle
Anterior belly nerve, for a portion of its course just supe-
of digastric muscle rior to the thyroid gland, is very close to the
Posterior belly
of digastric muscle
Middle constrictor medial side of the superior thyroid vascular
muscle bundle. It should be located and swept me-
Inferior constrictor Superior belly of dially in order to avoid its injury when ligat-
muscle omohyoid muscle ing and dividing these blood vessels. In the
Sternocleidomastoid superior part of this triangle, the spinal ac-
muscle cessory nerve is seen as it passes inferolater-
ally, deep to the sternocleidomastoid muscle,
and enters the posterior triangle.
The ascending pharyngeal artery, a
branch of the proximal portion of the exter-
nal carotid artery, ascends on the constric-
tor muscles as it heads for the base of the
skull. The remaining contents of this trian-
gle include the common carotid artery and
its branches, the internal jugular vein and
its branches, the cranial nerves X, XI, XII,
and the ansa cervicalis of the deep cervical
plexus.
Fig. 7. Muscular boundaries and muscular floor of the carotid triangle. The common carotid artery begins in
the root of the neck and passes cephalad
in the carotid sheath (Fig. 9). It is medial to
the accompanying internal jugular vein.
The vagus nerve (X) is between, but slightly
posterior to, the blood vessels. At about the
level of the superior aspect of the thyroid
cartilage, the common carotid artery bifur-

The Head and Neck

cates and gives rise to the internal and ex-
ternal carotid vessels. The internal carotid
artery, at its origin, has a small area of dila-
External branch of Ascending pharyngeal tation, the carotid sinus. It contains spe-
accessory nerve artery
cialized nerve cells, which regulate blood
pressure. This area receives autonomic,
glossopharyngeal, and vagus nerve branches
Internal branch of (Fig. 10). There is also an area of thickening
Superior laryngeal superior laryngeal
nerve
in the arterial wall at the site of bifurcation
nerve
of the common carotid artery. This is the
External branch of Thyrohyoid carotid body, which contains chemorecep-
superior laryngeal muscle
tor cells receiving branches from the
nerve glossopharyngeal nerve. The common and
internal carotid arteries do not provide any
branches in the neck.
The external carotid artery leaves the
carotid sheath and, at first, is anteromedial
to the internal carotid artery. It will become
anterolateral in position at a higher level,
after passing superficial to the carotid
sheath. It is the external carotid artery that
provides vascular flow to the cervical struc-
tures. The branches are medial and poste-
rior. The medial branches are the superior
thyroid, lingual, and facial (external maxil-
lary) arteries. The posterior branches in-
Fig. 8. The deepest structures of the carotid triangle. clude the ascending pharyngeal, occipital,

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 279 10/28/11 3:50:00 PM

 280 Part III: The Head and Neck

and posterior auricular arteries. The occipi-

tal branch runs along the inferior edge of
the posterior belly of the digastric muscle.
The posterior auricular branch follows a
similar course on the superior aspect of this
important muscle. The external carotid ar-
tery continues superiorly to the parotid re-
Vagus nerve gion. At the neck of the condylar process of
the mandible, the end branches arise. They
External carotid are the superficial temporal and internal
Internal carotid artery
maxillary arteries.
artery Lingual artery The internal jugular vein begins at the
Common carotid base of the skull (Fig. 11). At this point, it is
artery Superior laryngeal
artery
posterior to the internal carotid artery. The
last four cranial nerves pass between these
Superior thyroid vessels and then head for their specific des-
artery
tinations. The vein passes inferiorly, quickly
assuming a more anterolateral position to
the internal and common carotid arteries,
while in the carotid sheath. It receives the
following branches: common facial vein,
lingual vein, superior thyroid vein, branches
from the pharyngeal venous plexus, and the
middle thyroid vein. At its termination, it
will receive the thoracic duct (left) and the
right lymphatic duct (right). The vagus
nerve (X) is found with the vascular struc-
tures in the carotid sheath. It lies between,
and slightly posterior to, the artery and the
Fig. 9. Common carotid artery and branches.
vein. In the root of the neck, it will pass
posterior to the large veins and enter the
thorax. The spinal accessory nerve (XI) will
pass obliquely across the superior part of
the carotid triangle, continue under the
sternocleidomastoid muscle, travel across
the posterior triangle, and disappear under
the trapezius muscle (Fig. 12). It provides
motor innervation to both of those muscles.
The hypoglossal nerve (XII) passes between
Exernal branch of the internal jugular vein and the internal
accessory nerve carotid artery, and then descends below the
Sternocleidomastoid posterior belly of the digastric muscle to en-
artery ter the carotid triangle. It frequently hooks
Hypoglossal around a branch of the occipital artery,
nerve passes superficial to internal and external
Descending branch Superior thyroid carotid arteries, and then leaves the carotid
of hypoglossal artery triangle by passing back under the poste-
nerve rior belly to reenter the submandibular tri-
angle. The glossopharyngeal nerve (IX) is
also found between the internal jugular
vein and the internal carotid artery near
the base of the skull. It passes inferiorly,
travels between the internal and the exter-
nal carotid arteries, and then enters the in-
terval between superior and middle pha-
ryngeal constrictors. The stylopharyngeus
muscle accompanies this nerve. After pen-
etrating the wall of the pharynx, the muscle
attaches to the posterior free end of the thy-
roid cartilage lamina and is now part of the
muscular wall of the pharynx. The cervical
sympathetic chain lies on the prevertebral
Fig. 10. External carotid artery. fascia. It is posterior to the carotid sheath.

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 280 10/28/11 3:50:01 PM

 Chapter 19: Anatomy of the Head and Neck 281

The posterior belly of the digastric mus-

cle plays an important role in this area. It is
superficial to all of these neurovascular
structures. It presses them against the pha-
ryngeal wall. Incisions can be made on the
Anterior branch of posterior belly without risk of injury to
retromandibular vein nerves or arteries in this area. There may be
some superficial veins and, occasionally, a
low-lying cervical branch of the facial nerve
Anterior found in the area superficial to this rela-
Internal jugular facial vein tively safe landmark.
vein
Lingual
Superior thryoid
vein Muscular Triangle
vein
The boundaries of the muscular triangle are
the superior bellies of the omohyoid mus-
cles superolaterally and the inferior part of
the sternocleidomastoid muscles inferolat-
erally (Fig. 13). The hyoid bone is superior,
and the upper edge of the manubrium
sternum creates the inferior limit. The tri-
angle contains the thyroid and parathyroid
glands, larynx and trachea, and pharynx
and esophagus. These cervical viscera are
found below the muscular floor. The mus-
cles are paired and referred to as the strap
muscles. They are all infrahyoid in location
and present in two layers. The superficial
Fig. 11. Internal jugular vein. layer is composed of two long muscles. The
omohyoid muscle is lateral and is com-
posed of two muscle bundles that are sepa-
Maxillary
rated by an intermediate tendon. The inter-
artery mediate tendon is in the cricoid plane. The
Superficial inferior belly is attached to the superior
temporal artery surface of the scapula. It subdivides the
posterior triangle and then passes anterior

The Head and Neck

Occipital
Glossophayrngeal to the carotid sheath. The intermediate ten-
artery
nerve
don is tethered to the clavicle. The superior
External Facial artery
branch of belly passes up to the hyoid bone. Medial to
accessory
Lingual artery this is the sternohyoid muscle, which passes
nerve
from the sternum to the hyoid bone. The
Superior thyroid
Hypoglossal deeper layer is composed of shorter struc-
nerve artery
tures. The sternohyoid muscle is attached
External inferiorly to the manubrium of the sternum,
Internal
carotid artery
carotid artery and extends up to the oblique line of the
Ascending thyroid cartilage. This upper attachment is
Carotid sinus pharyngeal
just superior to the lateral lobe of the thy-
Vagus nerve artery
roid gland, and prevents enlargement of the
Ansa
Internal lobe from extending in a superior direction
cervicalis
jugular The thyrohyoid muscle seems to be its su-
vein Common perior continuation that passes from the
carotid artery oblique line to the hyoid bone. The inferior
pharyngeal constrictor is also attached to
the oblique line of the thyroid cartilage. The
middle layer of the deep cervical fascia sur-
rounds the strap muscles. It is not only
found in the muscular triangle, but also ex-
tends laterally to the inferior belly of the
omohyoid muscle. This belly creates the lat-
eral boundary of the subclavian subdivision
of the posterior triangle.
All the strap muscles are depressors of
Fig. 12. Carotid triangle with the sternocleidomastoid muscle removed. the larynx. The nerve supply comes from

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 281 10/28/11 3:50:02 PM

 282 Part III: The Head and Neck

Anterior belly of occipital triangle, and the smaller, inferior,

digastric muscle subclavian triangle. The muscular floor of
the entire posterior triangle is composed
Mylohyoid muscle mainly of three muscles whose fibers run in-
ferolaterally. They are, from above down, the
Hyoid bone splenius capitis, the levator scapula, and the
Posterior belly of middle scalene muscles (Fig. 14). The ante-
digastric muscle rior scalene muscle is not seen in the poste-
Omohyoid muscle rior triangle because the sternocleidomas-
Thyrohyoid muscle toid muscle covers it. In the apex are seen a
Sternohyoid few vertically oriented fibers of the semispi-
muscle Sternothyroid
nalis capitis muscle. It is, along with the sp-
muscle (cut) lenius capitis, classified as a back muscle.
Sternocleidomastoid
muscle
The muscles of the floor are covered by
prevertebral fascia, which creates a fascial
Trapezius carpet. There is also a fascial roof, gener-
muscle ated by the investing layer of the deep cer-
vical fascia. The contents of the triangle
will be described layer by layer, beginning
with the deeper contents found below the
fascial carpet in contact with the muscular
floor (Fig. 15). They include: (a) the occipi-
tal artery, which frequently exits the poste-
rior triangle at its apex; (b) branches of the
deep cervical plexus passing inferolaterally
on the surface of the levator scapula mus-
cle, destined to provide innervation to the
inferior portion of the trapezius muscle;
Fig. 13. The boundaries of the muscular triangle of the neck. and (c) portions of the brachial plexus. The
roots of the plexus combine deep to the

the deep cervical plexus (C1, C2, and C3) by

way of the ansa cervicalis. The nerves enter
the inferior portion of the muscle. A branch
of C1, which travels with the hypoglossal
nerve, innervates the thyrohyoid muscle.

Clinical Anatomical Aids

1. Transection of strap muscles should be
done closer to the superior end to pre-
serve nervous innervation, which enters
the muscle near its inferior end. Semispinalis muscle
2. Proper entrance into the cleavage plane Splenius capitis
between the sternothyroid muscle and muscle
the thyroid gland provides excellent
Levator scapula
exposure of, and facilitates surgical ap- muscle
proach to, the gland.
Middle scalene
muscle
Posterior Triangle
The boundaries of the posterior triangle are
the anterior border of the trapezius muscle
and the posterior edge of the sternocleido-
mastoid muscle, and the middle third of the
clavicle is the base. The apex of this triangle
is the superior nuchal line. This triangle,
therefore, presents as a spiral as the base is
anterior and the apex is posterior. The tri-
angle is subdivided by the inferior belly of
the omohyoid muscle into smaller entities
that are named for the blood vessels found
in them. There now is a larger, superior, Fig. 14. Muscular floor of the posterior triangle.

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 282 10/28/11 3:50:03 PM

 Chapter 19: Anatomy of the Head and Neck 283

give rise to the named nerves of the upper

extremity and the third portion of the sub-
clavian artery is also related to the fascial
floor of the posterior triangle. It can be pal-
pated as it passes under the midportion of
the clavicle and over the first rib. The sub-
Branch of ventral clavian artery and the brachial plexus
ramus C3 branches, after passing between the scalene
Branch of ventral muscles, will drag a portion of the preverte-
ramus C4 bral fascia along with them and create the
cervicoaxillary sheath (Figs. 16 and 17).
Root of long
thoracic nerve Structures that pass between the fascial
floor and the fascial roof include the trans-
Upper trunk of verse cervical and suprascapular (transverse
brachial plexus
scapular) branches of the thyrocervical
Middle trunk of trunk, originating from the first portion of
brachial plexus the subclavian artery. They pass transversely
Lower trunk of across the anterior aspect of the anterior
brachial plexus scalene muscle and are separated from the
phrenic nerve by the prevertebral fascia. Af-
ter entering the posterior triangle, the su-
prascapular artery will pass below the clav-
icle and participate in important collateral
vascular channels that exist in the scapular
region. The spinal accessory nerve (XI) as it
traverses the posterior triangle. It is found
on the anterior surface of, and runs with,
the levator scapula muscle. It will disappear
under the trapezius muscle about 2 in. su-
perior to the clavicle. There are some motor
Fig. 15. Structures below fascia floor of the posterior triangle. branches from the deep cervical plexus that

sternocleidomastoid. The C5 and C6 roots

combine to create the upper trunk, C7 be-
comes the middle trunk, and C8 and T1 cre-

The Head and Neck

ate the lower trunk. The trunks are seen in
the posterior triangle. There are branches
arising from these roots and trunks that are
seen in the posterior triangle. The dor-
soscapular nerve (C5) pierces the middle
scalene muscle and passes laterally toward
the rhomboid and levator scapula muscles, Prevertebral
which it innervates. The long thoracic nerve fascia
(C5, C6, and C7) courses inferiorly, passes
deep to the other portions of the brachial
plexus, and then passes over the first rib to
reach the superficial surface of the serratus
ventralis, where it innervates. Arising from
the upper trunk of the plexus is the supras-
capular nerve, which is seen just above the
upper trunk, passes across the posterior
triangle to the scapula, and innervates the
supraspinatus and infraspinatus muscles.
The subclavius nerve is also seen in the pos-
terior triangle. It arises from the upper
trunk, passes inferiorly, and crosses the
main portion of the brachial plexus superfi-
cially. It innervates the subclavius muscle.
The trunks create anterior and posterior
divisions that will pass under the clavicle,
and when reaching the axilla, create other
combinations called cords. The cords will Fig. 16. Fascial floor of the posterior triangle.

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 283 10/28/11 3:50:03 PM

 284 Part III: The Head and Neck

ficial cervical plexus also includes the great

auricular nerve (C2, C3), which emerges
from the cover of the sternocleidomastoid
muscle just inferior to the lesser occipital
nerve, hooks around the posterior edge of
the muscle, and now lies on its superficial
surface (Figs. 17 and 18). It then passes su-
periorly toward the parotid region and pro-
Lesser
occipital vides sensory innervation to the overlying
nerve skin and a portion of the ear. This nerve can
frequently be found just posterior to the ex-
Spinal Great auricular ternal jugular vein as it passes obliquely
accessory nerve
across the muscle. The transverse cervical
nerve nerve (C2, C3) also appears at the posterior
Transverse cervical
nerve edge of the sternocleidomastoid muscle in
Prevertebral
the vicinity of the other nerves of this
fascia External jugular
vein
plexus. It wraps itself around the posterior
edge of the muscle and passes transversely
across its external surface to reach the an-
Subclavian terior triangle. It will then divide into as-
artery cending and descending branches that will
provide cutaneous sensory innervation to
the anterior triangle.
The supraclavicular nerves (C3, C4) first
appear in the same area, just below the site
of emergence of the other nerves, and then
divide into medial, intermediate, and lat-
eral branches. They provide cutaneous sen-
sory innervation to the anterior aspect of
Fig. 17. Structures superficial to fascial floor of the posterior triangle. the thorax down to the level of the second
rib. All branches of the superficial cervical

travel with this cranial nerve. These nerves,

and the spinal accessory nerve, are the only
motor branches that are superficial to the
prevertebral layer of the deep cervical fascia
in the posterior triangle. Posterior
The external jugular vein, which passes auricular vein
obliquely across the sternocleidomastoid Great auricular
muscle, pierces the deep cervical fascial nerve
layers of the subclavian triangle, and ends Supraclavicular
in the subclavian vein. The transverse cervi- Posterior divison of
nerve
retromandibular vein
cal, suprascapular, and anterior jugular
Lateral branch of
veins are tributaries of the external jugular supraclavicular nerves
vein. The inferior belly of the omohyoid External jugular
muscle creates the lateral boundary of the Intermediate vein
subclavian triangle. It is attached inferiorly supraclavicular nerves
to the superior surface of the scapula, Transverse cervical Medial branch of
artery supraclavicular nerve
courses anterosuperiorly, and passes deep
to the sternocleidomastoid muscle, where Suprascapular
its intermediate tendon is angulated by at- artery
tachments of deep cervical fascia to the
clavicle. The superior belly continues to the
hyoid bone. The superficial cervical plexus
is created by the ventral rami of C2, C3, and
C4. It includes the lesser occipital nerve
(C2), which appears at the posterior edge of
the sternocleidomastoid muscle just infe-
rior to the spinal accessory nerve. It ascends
near the posterior edge of the muscle and
will provide sensory innervation to the ex-
ternal ear and the adjacent skin. The super- Fig. 18. Superficial structures of the posterior triangle.

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 284 10/28/11 3:50:04 PM

 Chapter 19: Anatomy of the Head and Neck 285

plexus, and the spinal accessory nerve, are VISCERA OF THE NECK The thyroid gland is composed of two
quite close to each other as they first ap-
Thyroid Gland pyramidal-shaped lateral lobes, connected
pear in the posterior triangle at the edge of
by a transverse bridge of glandular tissue,
the sternocleidomastoid muscle. If one di-
The development of the thyroid gland begins that crosses anterior to the second, third,
vides the posterior edge of this muscle into
with the appearance of the foramen cae- and fourth tracheal rings. This connection
thirds, at the junction of the middle and su-
cum (Fig. 19). This is a pit or depression that across the midline is the isthmus. There
perior third is the site where all these nerves
appears at the junction of the anterior two- may be a superior extension of glandular
can be found gathered in a small localized
thirds with the posterior third of the tongue. tissue originating from the left portion of
area. This is referred to as the nerve point.
It continues inferiorly and creates the thy- the isthmus. This is the pyramidal lobe, and
They will then diverge as they head toward
roglossal duct, which continues caudad and it may be connected to the hyoid bone by a
their specific destinations. As the nerves
becomes the thyroid gland. The duct is a fibrous band. If there are muscle fibers in
pass through the posterior triangle, it will
midline structure down to the thyroid carti- this band, it is called the levator glandulae
be seen that the spinal accessory nerve is
lage and then usually deviates to the left. thyroidea. The lateral lobe extends from the
the most superior of all the nerves that are
The pyramidal lobe of the gland represents oblique line of the thyroid cartilage down to
in the triangle. Therefore, incisions that are
the distal portion of this embryologic struc- the sixth tracheal ring. The gland possesses
made superior to the spinal accessory nerve
ture. The duct has a tortuous U-shaped a true capsule, created by condensation of
are not likely to encounter any important
course around the body of the hyoid bone. the normal stroma, and is enveloped by the
nerves. This area has been referred to as the
Portions of this duct may remain patent pretracheal layer of the deep cervical fascia,
carefree area; whereas, an incision made
and create thyroglossal duct cysts. These creating the false or surgical capsule. The
below this nerve can injure major struc-
will be median in position, but closer to the pretracheal fascia surrounding the isthmus
tures and is called the careful area.
gland they can deviate from the midline. is adherent to the trachea. This deep cervi-
Cysts found below the hyoid bone require cal fascia also attaches the posteromedial
Clinical Anatomical Aids excision of the central portion of this bone aspect of the lateral lobe to the first and
1. Superficial cervical plexus nerve block. in order to include the tortuous portion of second tracheal rings. This is the ligament
The nerve point is located and the local this persistently patent remnant of the thy- of Berry, which usually contains some small
anesthetic is injected in that region of roglossal duct. Accessory thyroid tissue blood vessels. These attachments are re-
the posterior edge of the sternocleido- may be found anywhere along the pathway sponsible for superior and inferior move-
mastoid muscle. It can provide adequate of this developmental entity. The most fre- ment of the thyroid gland during the act of
anesthesia to the anterior triangle if quent site is the posterior portion of the swallowing. Medial relations of the lateral
bilateral nerve point injection is per- tongue near the foramen caecum. lobe include thyroid and cricoid cartilages,
formed.
2. Catheterization of the subclavian artery
or vein. The third portion of the artery is Superior laryngeal
palpable as it passes between the mid- nerve
portion of the clavicle and the first rib. Internal

The Head and Neck

The accompanying vein is anteroinferior laryngeal External laryngeal
nerve nerve
to the artery and is the most medial of
the neurovascular structures that pass
through the costoclavicular space.
3. Dissection can be performed safely in Vagus nerve
the posterior triangle in the area supe- Superior
rior to the spinal accessory nerve (XI). thyroid
artery
4. There are one or two motor branches for
the trapezius muscle that originate from Cricothyroid
the deep cervical plexus. They run with, muscle
but are slightly inferior to, the spinal ac- Common
carotid Pyramidal lobe of
cessory nerve in the posterior triangle.
artery thyroid
In this area, these cervical nerves and
the spinal accessory nerve are the only
motor nerves that lie external to the
Inferior
prevertebral layer of the deep cervical thyroid
fascia. artery
Recurrent laryngeal
5. When veins pass through layers of fas-
nerve (retracted)
cia, the wall of the vein is adherent to
the margins of the opening in the tissue
being breached. If a vein is transected at Vagus nerve
the level of fascia penetration, bleeding
Arch of
may be prolonged because the attach- aorta
ments to the vessel wall may prevent it
from going into spasm. Spasm of the cut
end of a blood vessel assists in achieving
hemostasis. Fig. 19. Thyroid gland anatomy.

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 285 10/28/11 3:50:05 PM

 286 Part III: The Head and Neck

Superior laryngeal nerve. This nerve provides sensory

laryngeal innervation to the interior of the larynx
nerve
above the vocal ligaments. The superior thy-
Internal roid artery then passes vertically downward,
laryngeal
nerve
accompanied by the superior thyroid vein,
External as it heads for the superior pole of the lateral
laryngeal lobe. Accompanying these blood vessels is
nerve
Superior the external branch of the superior laryn-
thyroid geal nerve. It is medial, and very close to the
artery vessels. The nerve will turn medially, just su-
Anterior perior to the upper pole of the lateral lobe,
branch and head for the larynx. It provides motor
innervation to the inferior part of the infe-
Right lateral rior constrictor of the pharynx and the cri-
lobe of thyroid
cothyroid muscle of the larynx.
Common carotid The inferior thyroid artery arises from
artery Vagus the thyrocervical trunk, a branch of the first
nerve portion of the subclavian artery (Fig. 21). It
Inferior will ascend to the cricoid plane, passes pos-
thyroid terior to the carotid sheath, and then passes
artery inferomedially to reach the posterior sur-
Recurrent
laryngeal nerve face of the lateral lobe. In this area, the ar-
(retracted) tery is intimately related to the recurrent
laryngeal nerve, a branch of the vagus (X),
providing motor innervation to all the in-
Arch of trinsic muscles of the larynx except the
aorta cricothyroid.
The superior thyroid artery will provide an
anterior and posterior branch (Fig. 22). The
anterior branch will communicate with its
Fig. 20. Vascular supply to thyroid gland. contralateral counterpart through branches

trachea, esophagus, cricothyroid and infe-

rior constrictor muscles, external branch of
the superior laryngeal, and the recurrent
laryngeal nerves. The carotid sheath and
inferior thyroid artery are posterior. The
superior thyroid vessels and the external
laryngeal branch of the superior laryngeal
nerve approach the lobe from above. The
sternohyoid, omohyoid, and sternothyroid Superior
muscles are anterior relations. The left lat- parathyroid
gland
eral lobe is related to the thoracic duct as it Zenker area
travels superiorly, just to the left of the Cricopharyngeal (weak area)
esophagus. It maintains this position until muscle
C7, where it arches laterally. Right common
The superior and inferior thyroid arteries Laimer area carotid artery
(weak area)
provide the vascular supply (Fig. 20). In 8% Thyroid
to 10% of the individuals, a thyroid ima ar- Inferior thyroid gland
tery is present. It may be a direct branch of artery
the arch of the aorta, appearing between the
brachiocephalic and the left common ca-
Left recurrent
rotid vessels. Occasionally, it may arise from laryngeal nerve
the brachiocephalic trunk or the right com-
mon carotid artery. The superior thyroid ar-
tery is the first of the anteromedial branches Right subclavian
of the external carotid artery. It creates a artery
superior laryngeal vessel that enters the Right recurrent
larynx, after piercing the thyrohyoid mem- Brachiocephalic laryngeal nerve
brane, along with the superior laryngeal trunk
vein and the internal branch of the superior Fig. 21. Posterior view of thyroid gland.

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 286 10/28/11 3:50:05 PM

 Chapter 19: Anatomy of the Head and Neck 287

External the thyroid cartilage. Lateral expansion

carotid artery can occur.
Superior 3. Occasionally, there may be extralaryn-
laryngeal geal branching of the recurrent nerve,
artery resulting in loss of a single main trunk.
This will usually occur superior to the
inferior thyroid artery. Therefore, it is
Superior
Thyrohyoid better to look for the main trunk of the
membrane nerve inferior to the artery.
thyroid
artery 4. The inferior thyroid artery will usually
divide into two or three branches before
Anterior branch entering the parenchyma of the thyroid
of superior
thyroid artery
gland. The recurrent nerve usually pass-
es between these branches.
5. If the inferior thyroid artery is divided
Right common
carotid artery
laterally, just after passing posterior to
the carotid sheath, nerve injury is un-
likely.
6. Anteromedial retraction of the lateral
lobe of the thyroid gland will displace
the recurrent laryngeal nerve from its
expected position in the tracheoesopha-
geal groove, toward the posterolateral
aspect of the trachea.
Brachiocephalic 7. There may not be a recurrent laryngeal
trunk nerve found in the tracheoesophageal
groove if there is a high origin of the
nerve. This is referred to as a nonrecur-
Fig. 22. Right lateral view of thyroid gland. ring nerve.
8. A cricothyroidotomy provides access to
the infraglottic space. This area of the
larynx is below the vocal ligaments.
that cross the midline by way of the isthmus. tween the surgical and the true capsule (see
The posterior branch of the superior thyroid Fig. 21). They may also be situated outside
artery communicates with branches of the the surgical capsule, or within the true cap-
Pharynx
inferior thyroid artery. The venous drainage is sule (intraglandular). There are usually four The pharynx is a muscular tube, approxi-

The Head and Neck

via the superior thyroid vein into the internal glands, and each one measures only 5 to mately 5 in. long, that extends from the base
jugular or common facial vein, the short mid- 6 mm in diameter. The upper pair is found of the skull to the cricoid cartilage, where it
dle thyroid vein into the internal jugular vein, at the level of the cricoid cartilage and is is continuous with the esophagus (Fig. 23).
and the inferior thyroid veins into the bra- frequently adjacent to a descending branch An anterior wall is lacking where it faces the
chiocephalic vein. of the superior thyroid artery that anasto- nasal and oral cavities and the larynx. This
The lymphatic drainage of the thyroid moses with an ascending branch of the in- creates nasopharynx, oropharynx, and lar-
gland can be divided into superior or as- ferior thyroid artery. They are yellowish yngopharynx subdivisions. The nasophar-
cending, and inferior or descending path- brown and, therefore, distinguishable from ynx is between the soft palate and the base
ways. They can be further subdivided into normal thyroid tissue, which is reddish of the skull. The soft palate is attached to
lateral and medial components. The su- pink. The inferior pair of glands is found su- the posterior end of the hard palate. It is a
peromedial pathway leads to the prelaryn- perior or inferior to the inferior thyroid ar- soft tissue shelf, approximately 2 in. long. A
geal or Delphian node found anterior to tery, as this vessel passes transversely across small grape-like swelling, the uvula, is at-
the cricothyroid membrane. The supero- the posterior aspect of the lower pole of the tached to its free end. It contains the small,
lateral channels pass, with the superior lateral thyroid lobe. They receive their blood paired, uvular muscles. There are four addi-
thyroid artery, to nodes situated at the bi- supply from the superior and inferior thy- tional paired muscles in the soft palate area:
furcation of the common carotid artery, or roid arteries. Aberrant glandular tissue is palatoglossus, palatopharyngeus, levator,
to the omohyoid nodes of the internal not uncommon. and tensor palati. They narrow the oropha-
jugular chain. The inferomedial lymph ryngeal junction, tense the soft palate, and
vessels are related to nodes found anterior, elevate the uvula in order for the orophar-
Clinical Anatomical Aids
and adjacent, to the trachea. The inferolat- ynx to be separated from the nasopharynx
eral lymph flow is to the supraclavicular 1. A parathyroid gland may resemble a and oral cavity during deglutition. The pos-
nodes. small lymph node, but the glandular tis- terior and lateral walls are immobile; there-
sue is softer when palpated, compared fore, the nasopharynx is always patent. In
with the firmer feel of the node. the lateral wall, at the level of the inferior
Parathyroid Gland 2. Superior enlargement of the thyroid lobe nasal concha, is the opening of the auditory
The parathyroid glands are found on the is prevented by the insertion of the ster- tube (eustachian). There is a bulge at the
posterior surface of the thyroid gland be- nothyroid muscle into the oblique line of posterior end of the tube created by the

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 287 10/28/11 3:50:06 PM

 288 Part III: The Head and Neck

The laryngopharynx receives, in its up-

per portion, products of the digestive and
respiratory systems. Its lower segment is
related only to the digestive system. The an-
terior wall is created by the entrance into
Stylohyoid
Posterior belly the vestibule of the larynx, bounded later-
muscle
of digastric ally by the aryepiglottic fold, the arytenoid
muscle Uvula cartilages, and the lamina of the cricoid
Superior Retracting cartilage. The posterior wall is in contact
constrictor suture with the prevertebral fascia situated ante-
muscle rior to the lower cervical vertebrae. The an-
terior and posterior walls of the distal seg-
Stylopharyngeus
muscle Epiglottis
ment of pharynx are in contact but are
separated by the passage of food. The lat-
Middle eral wall is supported by the posterior free
constrictor Retracting edge of the thyroid lamina. A small piriform
muscle suture recess is found between the thyroid lamina
Inferior
laterally and the aryepiglottic fold medially.
constrictor This space receives sensory innervation
muscle from the internal laryngeal nerve, and if a
foreign body, or a morsel of food, is trapped
in this area, it will cause severe and persis-
Muscular
coat of
tent coughing.
esophagus
Ligamentous Background
Retracting 1. Stylohyoid ligament is found between the
suture tip of the styloid process of the skull and
Fig. 23. Posterior view of pharynx with right portion of constrictor muscle retracted laterally. the lesser horn of the hyoid bone (Fig. 25).
It supports the hyoid, and through the

cartilage in its wall. Passing inferiorly from

this elevation is the salpingopharyngeal
fold, created by the salpingopharyngeus
muscle. Posterior to the bulge and the fold
is the pharyngeal recess. On the posterior
wall, there may be collections of lymphatic
tissue referred to as pharyngeal tonsils, or
adenoids. An anterior wall is created by the
nasal cavity.
The oropharynx faces the oral cavity and
the posterior surface of the tongue (Fig. 24).
The palatoglossal arch is located at the Internal
pterygoid
junction between the mouth and the muscle
oropharynx. Posterior, and slightly lateral
to this arch, is the palatopharyngeal arch. Epiglottis
Uvula To n g u e
The arches are named for the muscles they Retracting
enclose. Between the arches is the palatine Retracting suture
or tonsillar fossa, a space for the palatine suture
tonsil. The fauces is considered as the area Internal
between the oral cavity and the pharynx. Superior laryngeal
The posterior third of the tongue contains laryngeal nerve
lymphatic tissue called lingual tonsil. Be- artery
hind the tongue is the upper free edge of the Inferior horn of
Posterior
epiglottis. Its anterior surface and lateral cricoarytenoid
thyroid cartilage
edges are attached to the tongue by mu- muscle Recurrent
cosal folds named glossoepiglottic folds. laryngeal
Shallow depressions between the folds are Inferior
nerve
the valleculae. The buccopharyngeal fascia laryngeal
artery
covering the posterior aspect of the pha-
ryngeal wall is in contact with the preverte- Esophagus
bral fascia lying anterior to the upper cervi-
cal vertebrae. Fig. 24. Interior view of pharynx.

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 288 10/28/11 3:50:07 PM

 Chapter 19: Anatomy of the Head and Neck 289

tongue, and the mylohyoid line of the mandi-

ble. The middle constrictor arises from the
inferior end of the stylohyoid ligament and
the lesser and greater horns of the hyoid bone.
The inferior constrictor arises from the
oblique line of the thyroid cartilage, the lateral
aspect of the arch of the cricoid, and from the
fascia overlying the cricothyroid muscle of the
larynx. These muscles widen as they pass lat-
erally and then posteriorly, where they insert
into the posterior midline pharyngeal raphe.
The lowest fibers of the inferior constrictor
that arise from the cricoid cartilage create the
cricopharyngeus muscle (Fig. 27). This is the
superior esophageal sphincter, which can
Stylohyoid ligament
regulate flow into the esophagus. The upper
fibers of the muscle pass superomedially and
Hyoid bone attach to the pharyngeal raphe, but the lower
Pharyngeal raphe
fibers pass transversely. There is a slight mus-
Oblique line
cular defect between the transverse and the
oblique portions of the cricopharyngeus mus-
Cricoesophageal
ligament cle. This is Zenker area, a weak point, where
pulsion diverticula may develop, and is a po-
tential site for endoscopic perforation.
The stylopharyngeus and palatopharyn-
geus muscles create the internal longitu-
dinal muscle layer. The stylopharyngeus
muscle receives motor innervation from
the glossopharyngeal nerve. The remainder
of the muscular wall is supplied by the va-
Fig. 25. Skeletal framework of pharynx.
gus and glossopharyngeal nerves via the

thyrohyoid membrane is also responsible

for suspension of the larynx.

The Head and Neck

2. Pharyngeal raphe is a fibrous seam, which
represents the posterior site of attach-
ment for the left and right constrictor
muscles. It is attached superiorly to the
pharyngeal tubercle found on the basal
portion of the occipital bone, 1/2 in. an-
terior to the foramen magnum. Inferiorly,
it merges with the esophageal wall.
3. Pterygomandibular raphe is a fibrous
structure between the pterygoid hamu-
lus and the mandible. It provides attach-
ment for the superior constrictor and Superior constrictor
the buccinator muscles.
Middle constrictor
Muscular Background Thyrohyoid
There are five paired voluntary muscles con- membrane
Inferior constrictor
tributing to the pharyngeal wall. The supe-
rior, middle, and inferior constrictors create
an external circular muscle layer (Fig. 26).
The stylopharyngeus and the palatopharyn-
geus create an inner longitudinal muscle
layer. Each constrictor muscle partially over-
laps, externally, the inferior edge of the mus-
cle above. The superior constrictor arises
from the posterior edge of the lower part of
the medial pterygoid plate, pterygoid hamu-
lus, pterygomandibular raphe, side of the Fig. 26. Constrictor muscles of pharynx.

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 289 10/28/11 3:50:07 PM

 290 Part III: The Head and Neck

these openings: (a) buccopharyngeal fascia,

which also creates an external covering of
the constrictors, and (b) pharyngobasilar
fascia, which is submucosal in position, and
internal to the muscular wall.
The pharyngeal nervous plexus and the
pharyngeal venous plexus are found be-
Posterior belly of tween the constrictor muscles and the buc-
digastric muscle copharyngeal fascia. In addition, there are
submucosal venous plexuses. The upper-
Stylohyoid muscle most opening, between the base of the skull
and the superior constrictor, provides pas-
Stylopharyngeus muscle
sage for the cartilaginous portion of the au-
ditory tube, levator palatine muscle, and
small palatine vessels. The stylopharyngeus
muscle and the glossopharyngeal nerve
pass between the superior and the middle
Pharyngeal raphe constrictor muscles (Fig. 28). The third gap,
between the middle and the inferior con-
strictors, includes the area between the
greater horn of the hyoid and the thyroid
cartilage. The thyrohyoid membrane is
Zenker area Cricopharyngeus
found here and is penetrated by the supe-
muscle
rior laryngeal artery arising from the supe-
rior thyroid, the internal branch of the su-
perior laryngeal nerve providing sensory
innervation to the laryngeal mucosa above
the vocal folds, and the superior laryngeal
Fig. 27. Posterior view of pharynx. vein. Passing between the inferior constric-
tor and the esophagus are the continuation
of the recurrent laryngeal nerve and the in-
pharyngeal plexus. The superior laryngeal Completion of the Wall of the Pharynx ferior laryngeal artery and vein (Fig. 24).
nerve arises from the vagus at the base of the There are defects in the pharyngeal wall su-
skull. It creates the external laryngeal nerve, perior and inferior to the narrow origins of Innervation of the Pharynx
which innervates the lower portion of the the constrictor muscles. There are struc- The pharyngeal plexus, created by the vagus
inferior constrictor, and the cricothyroid tures that pass through these areas of mus- (X) and glossopharyngeal (IX) nerves, sup-
muscle of the larynx. cular deficiency. Two layers of fascia close plies motor innervation to the pharyngeal

Body of Greater horn of

hyoid bone Epiglottis
hyoid bone
Epiglottis

Thyrohyoid Superior
membrane horn of
thyroid
Superior cartilage
horn of
thyroid
cartilage

Oblique
line
Inferior Arytenoid
horn of Thyroid cartilage
Inferior
thyroid cartilage
horn of
cartilage
thyroid
Lamina of cricoid cartilage
Annulus of Cricoid
cartilage
cartilage
Cricoid Trachea
Trachea Cricothyroid cartilage
ligament

Right Lateral View Anterior View Posterior View

Fig. 28. Cartilages of the larynx.

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 290 10/28/11 3:50:08 PM

 Chapter 19: Anatomy of the Head and Neck 291

muscles. The stylopharyngeus muscle receives inence. It is also referred to as Adam’s apple, muscles inferiorly and the quadrangular
motor innervation from the glossopharyngeal and is a more prominent structure in males. membrane superiorly. The arytenoid is com-
nerve. The superior laryngeal nerve arises The posterior border of each lamina is free posed of hyaline cartilage, but the apex is
from the vagus at the base of the skull. It cre- and creates projections called the superior created by elastic cartilage. The corniculate
ates the external laryngeal nerve that inner- and inferior horns. The superior horn ex- and cuneiform are small bars of elastic car-
vates the lower portion of the inferior con- tends up approximately 1/2 in. toward, and tilage that lie within the aryepiglottic fold,
strictor and the cricothyroid muscle of the is vertically inferior to, the tip of the greater just above the apex of the arytenoid.
larynx. The remainder of the muscular wall horn of the hyoid. The inferior horn is only
receives motor innervation from the pharyn- 1/4 in. long, and extends down from the free Membranes and Ligaments
geal plexus. Sensory innervation is provided edge of the thyroid lamina toward the pos- The thyroid cartilage is suspended from the
by the glossopharyngeal nerve via the pha- terior end of the arch of the cricoid cartilage. body and greater horn of the hyoid bone by
ryngeal plexus. There is a ridge beginning at the root of the the thyrohyoid membrane. This membrane
superior horn that extends inferomedially is thickened in the midline and at each edge,
Larynx toward the lower edge of the fused thyroid creating the median and lateral thyrohyoid
laminae. This is the oblique line, and it rep- ligaments. The median cricothyroid liga-
The larynx is responsible for vocalization. resents the point of attachment of three ment is a midline thickening between the
The superior opening faces the laryngo- muscles: sternothyroid, thyrohyoid, and the anterior aspect of the cricoid arch below,
pharynx. The inferior end is at the cricoid inferior constrictor of the pharynx. and the inferior end of the thyroid cartilage
cartilage, where it becomes continuous The cricoid cartilage creates a complete above (Fig. 28). Other strong fibers arise
with the trachea. It is anterior to vertebral ring. It is the only complete cartilaginous from the remainder of the arch of the cri-
bodies C3 through C6. The anterior wall of ring in the respiratory system. The anterior coid and pass superomedially. The anterior
the larynx is related to cervical fascia and and lateral portion of the ring is narrow and fibers pass to the internal aspect of the
skin. The strap muscles are anterolateral. creates the arch. The posterior part widens thyroid cartilage below the thyroid notch
The thyroid gland and the carotid sheath and creates the lamina. It does resemble a (Fig. 29). The posterior fibers attach to the
are lateral. The laryngopharynx separates signet ring. The arch has been identified as vocal process and the base of the arytenoids.
the larynx from the vertebral column. It has the cricoid plane. This is the level that was The fibers between these anterior and pos-
some degree of rigidity and is composed of referred to as an anatomical bonanza ear- terior attachments are free and are called
bone and cartilage that are held together by lier in this chapter. The cricoid participates the vocal ligaments. The vocal ligaments are
membranes, ligaments, and synovial joints. in two synovial joints: cricoarytenoid and the superior free edge of the cone-shaped
The hyoid bone is part of the anatomy of the cricothyroid. The epiglottis is the third of structure that attaches below to the arch of
floor of the mouth, but as it provides impor- the unpaired cartilages. It is composed of the cricoid cartilage. It is called the conus
tant support for the larynx, it will be dis- elastic cartilage, which allows this racket- elasticus and encloses the infraglottic space
cussed in this section. shaped structure to help seal off the en- of the larynx (Fig. 30). The cricotracheal lig-
trance into the larynx during deglutition. ament attaches the cricoid to the first tra-
Skeleton of Larynx Its lower pointed end is attached to the thy- cheal cartilage. Above the level of the vocal
The hyoid bone is a U-shaped structure with roid cartilage just inferior to the laryngeal ligaments is a thinner membrane, which

The Head and Neck

a central body, measuring 1 in. wide and 1/2 prominence by the thyroepiglottic liga- passes from the anterolateral surface of the
in. high. It is continuous, on each side, with ment. The superior edge extends above the arytenoid cartilage to the lateral edge of the
the greater horn that passes posterolater- body of the hyoid bone. The hyoepiglottic epiglottis, below its superior edge, and to
ally for approximately 1½ in. The free end of ligament attaches to the posterior aspect of the thyroepiglottic ligament. This is the
the greater horn is directly inferior to the the body of the hyoid. The anterior aspect is quadrangular membrane. The lower edge,
angle of the mandible. The lesser horns connected to the dorsum of the tongue by between the arytenoids and the thyroepi-
are small, superior protrusions found at the left, right, and median glossoepiglottic glottic ligament, is free, and forms the ves-
junction of the body and greater horns. folds. Between the folds are depressions re- tibular ligaments, or false vocal cords. The
The stylohyoid ligament, which suspends ferred to as vallecula epiglottica. The supe- distance between the vocal ligaments and
the hyoid bone from the base of the skull, is rior edge of the epiglottis may be visible the more superiorly located vestibular liga-
attached here. during oral examination if the dorsum of ments separates the conus elasticus and the
the tongue is depressed. The posterior sur- quadrangular membrane from each other
Laryngeal Cartilages face of this cartilage is part of the anterior inferiorly. The two structures create the fi-
There are three unpaired and three paired wall of the laryngeal vestibule. broelastic membrane of the larynx. Both are
cartilages (Fig. 28). The larger unpaired car- The arytenoids are the largest of the cone-shaped and are aligned so that they
tilages are the thyroid, cricoid, and epiglot- paired cartilages. They lie on the superior resemble an hourglass.
tis. The paired cartilages are the arytenoid, border of the lamina of the cricoid cartilage
corniculate, and cuneiform. and participate in the cricoarytenoid joint. Interior of the Larynx
The hyoid bone and the thyroid and cri- They are pyramidal in shape and measure The membranes and ligaments previously
coid cartilages provide the principal sup- 1/2 to 3/4 in. in height. The base is on the described are lined by mucosa. The larynx
port of the larynx. The thyroid cartilage is superior surface of the lamina of the cri- is divided into three portions (Fig. 29). The
palpable 1/2 in. below the body of the hyoid coid. The medial end of the base is pro- vestibule is superior and the infraglottic
bone. It is composed of hyaline cartilage longed anteriorly to create the vocal pro- space is inferior. Separating these two areas
and formed by two laminae that fuse anteri- cess. The posterolateral angle of the base is is the ventricle. The vestibule is bounded
orly. The anterosuperior point of fusion is enlarged and forms the muscular process. anteriorly by the epiglottis. The quadrangu-
incomplete, leaving a palpable V-shaped The medial surface faces its partner. The an- lar membrane is the lateral limit, and pos-
notch called the laryngeal, or thyroid, prom- terolateral surface provides attachment for teroinferiorly are the arytenoids and the

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 291 10/28/11 3:50:08 PM

 292 Part III: The Head and Neck

from this area ascends for a short distance,

lateral to the vestibular fold, and creates
Epiglottis the saccule. Numerous mucous-secreting
Aryepiglottic fold
glands are found here. The infraglottic space
is internal to the conus elasticus and the
cricoid cartilage. The rima glottidis is the
Quadrangular
upper limit, and inferiorly it is continuous
Saccule membrane
with the lumen of the trachea.

Ventricle Joints and Intrinsic Muscles

of the Larynx
Vocal ligament Thyroid cartilage The cricothyroid and cricoarytenoid joints
are synovial and created by hyaline carti-
laginous structures. The cricothyroid joint
allows a pivoting movement, which elevates
Vestibular the arch of the cricoid cartilage while de-
ligament
pressing the lamina and the arytenoid carti-
Conus elasticus lages found on its superior surface (Fig. 30).
This results in tensing of the vocal ligaments,
Cricoid which creates high-pitched sounds. The axis
cartilage of rotation is transverse, through both cri-
Fig. 29. Membranes of the interior of the larynx. cothyroid joints. The cricoarytenoid joint
permits two types of movements of the
arytenoid cartilage. Rotation around a ver-
interarytenoid fold. The mucosa covering squamous. The remainder of the laryngeal tical axis passing through the arytenoids
the superior edge of the quadrangular mucosa is pseudostratified ciliated colum- will result in adduction or abduction of the
membrane forms the aryepiglottic fold. The nar. The space between the vocal folds is vocal ligaments. In addition, a gliding move-
space between the aryepiglottic folds is the the rima glottidis. It is found 1/4 in. below ment can occur, which allows the arytenoids
entrance into the vestibule. It is the laryn- the rima vestibuli and is easily visualized by to move toward, or away from, each other.
geal aditus. The mucosa covering the ves- endoscopic examination through the wider The rima glottidis is triangular, and the base
tibular ligament creates the vestibular fold, rima vestibuli. is the interval between the vocal processes.
which is the inferior end of the vestibule. The middle portion of the larynx is the The transverse gliding movement, or the ro-
The space between the vestibular folds is ventricle. It separates the vestibule superi- tation of the arytenoids around a vertical
the rima vestibuli. Below the vestibular orly from the infraglottic space inferiorly. It axis, can result in either widening or nar-
folds are the vocal folds. The mucosa cover- is found between the rima vestibuli and the rowing of the rima glottidis. There are nine
ing the vocal ligaments creates the vocal rima glottidis. The mucosa extends laterally intrinsic muscles of the larynx, eight are
folds. It is very adherent and has a white col- between the vestibular and the vocal folds paired and one is unpaired. Six of the paired
oration. The mucosa of this fold is stratified and creates the sinus. A small outpouching and the unpaired act directly on the
arytenoids, with resultant effect on the ves-
tibular and vocal ligaments. The muscles
Thyroid can be divided into three functional groups.
cartilage The first provides protection by sphincter-
like activities. They are in the aryepiglottic
Cricothyroid fold. The aryepiglottic muscle passes from
ligament the posterior surface of the arytenoids to the
lateral aspect of the epiglottis (Fig. 31). The
thyroepiglottic muscle extends from the in-
ternal aspect of the thyroid lamina to the
lateral aspect of the epiglottis. These mus-
cles help close the laryngeal aditus. The sec-
ond group of muscles tenses, relaxes, or ad-
ducts the vocal ligaments. The cricothyroid
Conus Vocal muscle, found between the arch of the cri-
elasticus ligaments coid and the internal aspect of the fused
thyroid lamina, causes elevation of the arch
Cricoid
of the cricoid and depression of the lamina.
cartilage
This results in tensing of the vocal ligaments.
Vocal process The thyroarytenoid muscle, which is found
of arytenoid cartilage between the thyroid cartilage anteriorly,
Muscular process of and the arytenoids oppose this action pos-
arytenoid cartilage teriorly. It pulls the vocal processes anteri-
Vocal ligaments - superior view
orly and relaxes the vocal ligaments. Fibers
Fig. 30. Superior view of the vocal ligaments. from the medial aspect of this muscle attach

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 292 10/28/11 3:50:08 PM

 Chapter 19: Anatomy of the Head and Neck 293

Epiglottis laryngeal nerves, the abductors are occa-

sionally the only muscles affected. In addi-
Left thyrohyoid tion, the unopposed action of the cricothy-
membrane roid muscles, and narrowing of the rima
glottidis and respiratory difficulties are to
Aryepiglottic be expected.
Thyroepiglottic
muscle
muscle
SUPERFICIAL VENOUS SYSTEM
Saccule
Quadrangular These veins and the other superficial neuro-
membrane
vascular structures are deep to the platysma
muscle.
Thyroarytenoid
muscle
1. Common facial vein is formed by the
Cricothyroid ligament union of the anterior facial vein with the
Conus elasticus
anterior division of the retromandibular
(posterior facial) vein. It passes over the
submandibular triangle and the poste-
rior belly of the digastric muscle, and
Fig. 31. Interior of the larynx after removal of the right portion of hyoid and thyroid cartilages. empties into the internal jugular vein in
the superior portion of the carotid tri-
angle.
2. External jugular vein is created by the
directly to the vocal ligaments and can cause sensory innervation to the infraglottic space union of the posterior auricular vein
differential contraction and relaxation of and trachea. The external branch of the su- with the posterior division of the ret-
portions of the vocal ligament. These spe- perior laryngeal nerve innervates the crico- romandibular vein. The vein passes in-
cialized fibers are named the vocalis muscle. thyroid muscle. The inferior laryngeal nerve ferolaterally, runs obliquely across the
The lateral cricoarytenoid muscle, between supplies all the other intrinsic laryngeal superficial aspect of the sternocleido-
the posterior portion of the arch of the muscles. mastoid muscle, pierces the deep cervi-
cricoid and the muscular process of the Laryngeal nerve injury may occasionally cal fascia in the subclavian division of
arytenoids, is the main adductor of the occur during thyroid surgery. Knowledge of the posterior triangle, and empties into
vocal ligaments. The transverse arytenoid is anatomy will allow the surgeon to perform the subclavian vein. The great auricular
the only unpaired muscle of the larynx; it any procedure, anywhere in the body, expe- nerve (C2, C3) is posterior to this su-
passes between the arytenoids and causes ditiously and safely. perficial vein in the upper part of the
narrowing of the rima glottidis and the rima Division of the superior laryngeal nerve neck.
vestibuli. The third group of muscles is re- will cause loss of sensory innervation of the 3. Anterior jugular vein begins in the su-

The Head and Neck

sponsible for widening of the rima glottidis. larynx above the vocal folds (internal laryn- prahyoid portion of the neck and de-
The posterior cricoarytenoid muscle passes geal branch). The cough reflex will be lost. scends vertically, close to the midline,
obliquely between the posterior surface of In addition, there will be loss of motor in- down to the clavicle. It then pierces the
the cricoid lamina and the muscular pro- nervation of the cricothyroid muscle. The investing layer of the deep cervical fas-
cess of the arytenoid. It widens the rima voice will become husky and unable to cia, passes deep to the sternocleidomas-
glottidis by abducting the vocal process of reach high tones. toid, and ends in the ipsilateral external
the arytenoid cartilage. Unilateral division of the recurrent la- jugular vein. It frequently gives a branch
ryngeal nerve will result in the vocal liga- in the suprasternal area that crosses the
Blood Supply and Nervous Innervation ment being midway between adduction and midline and joins with the contralateral
of the Larynx abduction. This is the cadaveric position. anterior jugular vein. This transverse
The superior laryngeal branch of the supe- The uninjured cord can cross the midline communicating branch is referred to as
rior thyroid artery provides vascular flow. It and approach its partner so that the voice the jugular venous arch.
enters the larynx through the thyrohyoid changes may be minimal. If both recurrent 4. Vein of Kocher arises in the submandib-
membrane, along with the internal laryn- nerves are cut, the vocal ligaments become ular area as a branch of the anterior fa-
geal nerve and superior laryngeal veins. lax, resulting in voice changes but no respi- cial vein, descends on the anterior edge
Vascular inflow also occurs via the inferior ratory problems. Within several months, of the sternocleidomastoid muscle, and
laryngeal artery, a branch of the inferior the voice will begin to reappear as a result of terminates in the jugular venous arch,
thyroid that enters the larynx below the fibrotic changes and tightening of the vocal or the internal jugular vein.
lower edge of the inferior constrictor mus- ligaments. This will also result in narrowing
cle, along with the inferior laryngeal nerve. of the rima glottidis and the appearance of LYMPHATIC PATHWAYS
This nerve is the intralaryngeal continua- respiratory problems. If there is bilateral in-
tion of the recurrent laryngeal nerve. jury, created by crushing, stretching, or in-
OF THE NECK
Vagus nerve branches provide all sen- corporation in a ligature, without transec- The lymphatic pathways of the neck (Fig. 32)
sory and motor innervation. Sensory inner- tion, then a different set of symptoms may can be divided into a superior horizontal
vation, above the vocal folds, comes from occur. Respiratory problems appear early. group found at the junction of the head and
the internal branch of the superior laryngeal This may be explained by Semon’s law, which the neck. It includes the submental, sub-
nerve. The inferior laryngeal nerve supplies states that in progressive disease of motor mandibular, parotid (preauricular), mastoid

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 293 10/28/11 3:50:09 PM

 294 Part III: The Head and Neck

receives drainage from the tonsil. The

jugulo-omohyoid node receives drain-
age from the tongue. (c) The visceral
chain is the most anterior of the vertical
pathways and drains all the cervical vis-
cera. The individual components of this
nodal chain are parapharyngeal, parala-
ryngeal, prelaryngeal or Delphian, para-
tracheal, and pretracheal. The Delphian
node is a constant finding and receives
Jugular chain
lymphatic drainage from the larynx and
Common carotid Visceral chain the thyroid gland.
artery 2. An inferior horizontal group, called su-
praclavicular nodes, is found in the sub-
clavian triangle. They receive lymphatic
flow from the vertical cervical channels
and the upper extremity, axilla, and the
thoracic wall. They communicate, by
way of efferent channels, with internal
jugular and subclavian conduits. Some
of these supraclavicular nodes lying
anterior to the anterior scalene muscle
are referred to as scalene nodes. They
receive bronchomediastinal channels
from the thorax and may be enlarged as
a result of spread from an intrathoracic
disease process.
3. The thoracic duct receives inflow from
all lymphatics below the respiratory dia-
Deep Lymphatic Drainage
phragm, the left hemithorax by way of
the left bronchomediastinal trunk, the
Fig. 32. Deep lymphatic drainage. left side of head and neck via the left ver-
tical cervical trunks, and from the left

(postauricular), and occipital nodes. It cre-

ates a ring of lymph nodes in this area.
1. A vertical group that receives the lym-
phatic drainage from the superior hori-
zontal components (Fig. 33). There are
three pathways possible in this grouping.
(a) The posterior cervical group consists
Accessory nerve
of superficial nodes traveling with the lymphatics (deep)
external jugular vein and a deep group
of nodes that journey with the spinal
accessory nerve (XI). They are in the External jugular
posterior triangle. (b) The jugular group vein lymphatics
is intermediate in position and is fre-
quently referred to as the deep cervical
group. This pathway is the most impor-
tant. It consists of nodes at several levels,
as this vertical channel descends with
the internal jugular vein. There is a jugu-
loparotid node located near the angle
of the mandible, a jugulodigastric node
where the posterior belly of the digas-
tric muscle crosses the internal jugular
vein, a jugulocarotid node near the bi-
furcation of the common carotid artery, Lymphatic Drainage
and a jugulo-omohyoid node where the
omohyoid muscle crosses the internal
jugular vein. The jugulodigastric node Fig. 33. Lymphatic drainage.

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 294 10/28/11 3:50:09 PM

 Chapter 19: Anatomy of the Head and Neck 295

upper extremity through the left subcla- before entering the venous circulation. Healey JE, Hodge J. Surgical Anatomy, 2nd ed.
vian trunk. It empties into the venous They frequently empty, as separate enti- Philadelphia: BC Decker; 1990.
system on the lateral aspect of the junc- ties, into the vascular compartment. Leeson CR, Leeson TS. Human Structure: A Com-
panion to Anatomical Studies. Philadelphia: WB
tion between the left internal jugular Saunders; 1972.
and the left subclavian veins. The trunks Thorek P. Anatomy in Surgery. Philadelphia: JB
may enter separately into the venous cir- SUGGESTED READINGS Lippincott; 1951.
culation. On the right side, it is unusual Arnold M. Reconstructive Anatomy: A Method for
for the bronchomediastinal, subclavian, the Study of Human Structure. Philadelphia: WB
and vertical cervical trunks to combine Saunders; 1968.

EDITOR’S COMMENT those in the ENT field, it does appear as if per- symptom or sign of the presence of that
haps a 95% or 96% rate of success in “curing” tumor.
hypoparathyroidism is the norm. 5. The brachial plexus is formed by the ventral
There is little attention paid nowadays to the rami of C5 through T1. These nerve roots will
neck. It is almost as if general surgeons are ab- In addition, medical schools stopped teach- form three trunks—C5 and C6 form the up-
rogating their responsibility and interest in the ing anatomy. As medical schools became more per trunk, C7 root forms the middle trunk,
neck except in cases of diseases of the thyroid and research oriented, bragging rights was not about and C8 and T1 form the lower trunk. These
parathyroid, and even in those circumstances, in- how well the students were taught but was about pass between the middle and anterior sca-
terest may be waning, or at least the interest of the NIH grants and the total number of NIH dol- lene muscles.
others such as otorhinolaryngologists seems to lars appropriated to that school. In addition, in 6. The lower trunk of the brachial plexus is
have increased. The reason for this is difficult to schools that have not given up anatomy, there draped over the first rib immediately poste-
know. were inappropriate instructors who were utilized rior to the subclavian artery.
to [make] up the funds that were [not] appropri- 7. The fascia of the neck: The superficial fascia,
1. Otorhinolaryngologists were liberated from ated in their NIH grants. A classic example of this which is often is not well developed, forms
the destructive surgery, for example, in mas- is to have acute abdomen taught by internists the platysma, which may or may not be very
toids and with otitis media, with the advent who were not called to the emergency room robust; the cervical branch of the facial nerve
of effective antibiotics. In addition, pharyn- to see patients with acute abdomen. In many enervates the platysma, which contributes to
geal neck abscesses from various colds and schools, surgeons are no longer asked to teach facial expression.
infections also vanished from the scene the acute abdomen. It is also now thought that 8. The cutaneous branches and the superficial
with effective antibiotics. Thus, they tried to medical students can learn in a truncated gen- veins are below the muscles of facial expres-
reinvent themselves in the same area in eral surgery rotation, which is now increasingly sion, which are the platysma.
which they were trained, but in which much shared with other surgical specialties, such as 9. Deep cervical fascia: The superficial or invest-
of the destructive surgery based on infectious ophthalmology, in the time frame which in the ing layer of the deep cervical fascia splits to
disease was not cared for with antibiotics. past was solely utilized by general surgery. I am surround the trapezius and the sternocleido-
In those cases, they turned, as well as oth- not criticizing ophthalmology in this statement, mastoid muscle and the submandibular and
ers, from destructive surgery to constructive but I am just pointing out that those surgical spe- parotid glands.
surgery. cialties have now lost their own space to surgery 10. The carotid sheath, which is part of the
2. The rise of oral surgery. Oral surgery emerged time. deep cervical fascia, surrounds the com-

The Head and Neck

as differentiated from dentistry some time in One appreciable thing about this chapter is mon carotid, the internal jugular, and the
the early 1940s and gradually developed in the that Professor Ruhalter is very well aware of clini- vagus nerve. The vagus nerve is between the
1950s and 1960s. Carcinoma of the tongue, cal correlation and anatomic correlation. I just common carotid and the internal jugular,
carcinoma of the tonsil, and pharyngeal max- list these because I think they are of interest and which is somewhat posterior to the common
illary cancer to a certain extent. This was also have some clinical relevancy. carotid.
when submandibular cancer became part of Anatomic goodies: 11. When the common carotid artery divides the
the repertoire of the oral surgeon in some geo- 1. The cricoid bone is an anatomic bonanza, as internal carotid, it immediately goes anterior
graphical areas. is detailed in this chapter. to the carotid, except at the base of the skull;
3. General surgeons were held in sway by some 2. The superior surfaces of the first rib are flat- the vein is anterolateral to the artery.
leaders who didn’t believe in the resection tened, so that neurovascular structures can 12. The sympathetic chain is in contact with the
of nodes for thyroid cancer. A papillary car- travel over it without compression. This, of posterior sheath.
cinoma, of course, has a low mortality, and course, is true of thoracic outlet syndrome, 13. The thoracic duct is to the left of, and poste-
so it is difficult for some surgeons to believe in which the vasculature and sometimes the rior to, the esophagus. It enters at the junc-
that general surgeons, especially those tak- nerves are compressed. tion of the internal jugular vein and the sub-
ing care of thyroid cancer, should pursue the 3. The subclavian artery passes over the poste- clavian vein.
adenopathy, since mortality is so low. Others rior sulcus of the scalene tubercle. The ante- 14. The right lymphatic duct, which is the
believed that carcinoma of the thyroid could rior scalene muscle attaches to the first rib counterpart of the left thoracic duct, is not
be treated with psychiatry. In any event, this between the subclavian vessels and, there- large as the thoracic duct and consists of
tide has turned, and at this point in time, most fore, is in a position to compress the subcla- several smaller lymphatics. It drains the
surgeons dealing with thyroid cancer have vian artery, giving rise to the thoracic outlet right upper extremity and the upper right
gotten much more aggressive at attacking the syndrome. hemithorax.
adenopathy with node dissections. 4. The cervical sympathetic chain has as its 15. The right recurrent laryngeal nerve loops
4. Other specialties began to concentrate on apex a “dumbbell-shaped structure, called around the right subclavian. The left re-
parathyroid surgery, which previously was the cervicothoracic, or stellate, ganglion.” current nerve loops the aortic arch on the
the field of general surgery and endocrine ser- The reason for it being called stellate gan- left. The right recurrent nerve is less well
vices. In other chapters of this book, it does glion is that it is star-like and gives out the protected, as it comes up lateral to the
appear that the rates of success between ENT multiple branches. The stellate ganglion, tracheoesophageal groove, but, to get to
surgeons and general surgeons differ. In some when invaded by a tumor at the apex of the the tracheoesophageal groove on the right,
of the well-recognized centers for parathyroid lung on one side or the other, gives rise to it is more superficial and more widely
surgery, a success rate of 99% is expected. For the Horner’s syndrome and is often the first exposed.

(continued)

www.medicalebookpdf.com

LWBK892_c19_p271-295.indd 295 10/28/11 3:50:09 PM

 296 Part III: The Head and Neck

16. Sibson’s fascia is at the apex of the lung and neck—muscular and membranous—attach strap muscles, at times with a bulge in the
runs between C7 and the first rib. It is some- to the hyoid bone. If one considers the hyoid lower neck.
what protective of the apex of the lung. bone and the attached posterior belly of 27. When one enters the cleavage between the
17. The inferior thyroid artery is superficial to the digastic muscle, it is possible to divide sternothyroid muscle and the thyroid gland,
the prevertebral fascia. It courses posterior the anterior triangle into suprahyoid and in- this provides excellent exposure of and facili-
to the carotid sheath and anterior to the ver- frahyoid portions. tates surgical approach to the gland, which
tebral artery. 23. The vagus nerve is behind and slightly pos- is avascular.
18. The last branch given off by the subclavian terior to the carotid and internal jugular 28. The long thoracic nerve originates from C5,
artery, as it goes from medial to lateral, is vessels. C6, and C7 and courses inferiorly, passing to
the internal mammary, which then travels 24. The posterior belly of the digastic muscle is the other portions of the brachial plexus, and
behind the sternum and attaches to the ster- superficial to the neurovascular structures then passing over the first rib to reach the
num medial to the ribs. and presses them against the pharyngeal superficial surface of the serratus ventralis,
19. The anatomy of the root-of-the-neck com- wall. Therefore, owing to this structure, inci- which it innervates.
pression syndromes includes the following: sions can be made without the risk of injur- 29. Dissection on the posterior triangle is safe
(a) Costoclavicular compression syndrome. ing the nerves or arteries. in the area superior to the spinal accessory
(b) Cervical-rib compression syndrome. 25. The intermediate tendon of the omohyoid nerve.
(c) Anterior scalene compression syndrome between the two bellies is in the cricoid plane 30. A good landmark for the upper thyroid glands
(thoracic-outlet syndrome). with a number of other venous and tendinous is that they are usually at the level of the thy-
(d) Pectoralis minor syndrome. structures. roid cartilage.
26. The transection of the strap muscles closer 31. If there is a high origin of the recurrent laryn-
The following are the clinical anatomic appli- to the superior end will preserve the ner- geal nerve, it may not be in the tracheoesoph-
cations which are practical in the surgery of this vous innervation, since the nerve enters the ageal groove and it is called a nonrecurring
area. muscle near the inferior end. Most individu- nerve. Obviously, if there is a high origin, it is
20. Cervical incisions should be made parallel to als who divide the strap muscles to get at more exposed and not protected by not being
the skin lines for good cosmesis. the thyroid do so at the interior end. Per- in the tracheoesophageal groove.
21. Control of bleeding may be possible, if the sonally, I have never been taught that one
divides the strap muscles at the superior The neck is a very hostile place from the
common carotid artery is compressed against standpoint of anatomy. We are very privileged
the transverse mass of the sixth cervical ver- end because the nerve enters inferiorly, but
it is something good to remember, because to have an anatomist of Professor Ruhalter’s skill
tebra, which is the cricoid plane. and knowledge to keep us out of trouble.
22. The hyoid bone is the central structure of one of the cosmetic difficulties following
thyroid surgery is the denervation of the J.E.F.
the neck. Most of the structures of the

20 Surgery of the Submandibular and Sublingual

Salivary Glands
Carol M. Lewis and Michael E. Kupferman

INTRODUCTION superiorly by the mucosa of the floor of CLINICAL, RADIOLOGIC, AND

mouth, and inferiorly by the mylohyoid PATHOLOGIC EVALUATION
Surgery of the submandibular and sublin- muscle. This space contains the sublingual
gual salivary glands requires an under- gland and associated connective tissue, The evaluation of every patient begins with
standing of the anatomy of a small region of the hypoglossal nerve, and the deep a thorough history and physical examina-
the human body. Surgical knowledge of this portion of the submandibular gland tion. Significant tenderness usually indi-
area for either preservation or safe extirpa- (Fig. 1). cates acute infection, but can occasionally
tion of critical structures enables the sur- The submandibular triangle is bounded be attributed to neoplasms predisposed to
geon to determine appropriate indications anteriorly by the anterior belly of the digas- perineural involvement, such as adenoid
for surgical intervention and to compe- tric muscle, superiorly by the inferior bor- cystic carcinoma. Fluctuation of the size of
tently perform such procedures. This holds der of the body of the mandible and the my- the mass, most notably when eating, is a
true for trauma, infection, obstruction, or lohyoid muscle, inferiorly by the trochlea characteristic of an obstructed submandib-
neoplasm. This chapter focuses on the indi- and posterior belly of the digastric muscle, ular gland. Given the potential for disease
cations for surgery, as well as surgical ap- and posteriorly by the posterior border of metastatic to the lymph nodes of the sub-
proaches to the sublingual and subman- the submandibular gland (Figs. 1 and 2). mandibular triangle, any history of previ-
dibular glands. This triangle contains the submandibular ous cancer is relevant; in addition to can-
gland and associated Wharton’s duct, lin- cers of the upper aerodigestive tract, breast,
ANATOMY gual nerve and submandibular ganglion, lung, gastrointestinal tract, genitourinary
hypoglossal nerve, and neurovascular bun- tract, or cancers of the skin of the head and
The mylohyoid muscle separates the sub- dle to the mylohyoid muscle. It is impera- neck can metastasize to this region. Occa-
lingual space from the submandibular tri- tive to be familiar with these structures and sionally, squamous cell carcinomas of the
angle. The sublingual space is bounded their anatomic relationships both in neu- oral cavity can involve the gland by direct
anteriorly and laterally by the mandible, tral and surgical positions. extension.

www.medicalebookpdf.com

LWBK892_c20_p296-302.indd 296 10/28/11 3:49:02 PM

 Chapter 20: Surgery of the Submandibular and Sublingual Salivary Glands 297

not of salivary gland origin, the work-up

should involve identification of the primary
tumor. Of note, FNAB is 80% to 90% sensitive
for the diagnosis of salivary gland malignan-
cies. Thus, FNAB findings may impact both
work-up evaluation and surgical planning.
Computerized tomography can be help-
ful in determining if a mass is in, adjacent
to, or invading the gland, as well as its cys-
tic or solid qualities. It can also demon-
strate other associated lymphadenopathy
or, if the lesion is metastatic, the primary
tumor. Alternatively, ultrasound or mag-
netic resonance imaging scan may be per-
formed. A sialogram is useful if obstructive
sialadenitis is suspected.
Submandibular gland
Submental triangle
with extension
Submandibular triangle INDICATIONS FOR
Fig. 1. The submental triangle is bounded by the mandible, mylohyoid muscle (cut edge shown here),
SURGERY
and superiorly by the oral mucosa. The most common indications for removal
of the submandibular gland are suspicion
of neoplasm and chronic obstruction of
Prior to the specific examination of the evaluation of calculi along Wharton’s duct in Wharton’s duct by calculi with resultant
submandibular triangle, a thorough head cases of sialadenitis. sialadenitis. Neoplasms of the sublingual
and neck examination, including inspection The utility of fine-needle aspirate biopsy gland are rare, with most sublingual gland
of the upper aerodigestive tract and the skin (FNAB), often performed in conjunction excisions being performed for ranulas.
of the head and neck, is mandatory. Cervical with an ultrasound, is controversial. While
palpation should be performed to identify an FNAB may provide a preliminary diagno-
any associated lymphadenopathy or masses sis, some may argue that surgical removal
Neoplasm
in other levels of the neck. Bimanual palpa- will be necessary regardless. However, if the The incidence of salivary gland tumors in
tion is a useful diagnostic maneuver to eval- FNAB reveals a salivary gland malignancy, the general population is 2.5 per 100,000,
uate the floor of mouth or submandibular the surgical approach should include a com- representing 0.3% of all cancers and 1% to
triangle, performed with one finger palpat- plete submandibular triangle dissection at 3% of all head and neck tumors. There are
ing intra-orally and the other hand assessing minimum, and may also require a compre- various neoplasms that may involve the sub-
the mass from the neck. The mass should be hensive neck dissection. Further, the patient mandibular and sublingual glands; subman-

The Head and Neck

evaluated for qualities such as tenderness, may need to be counseled on the role of hy- dibular and sublingual salivary gland neo-
mobility, whether it feels cystic or solid, and poglossal nerve resection, should a malig- plasms represent 7% to 15% and ⬍1% of all
whether it is single, multiple, or lobulated. nancy involve this structure. In addition, if salivary gland tumors, respectively. Of these
In addition, intraoral palpation allows for the FNAB demonstrates carcinoma that is neoplasms, 40% to 50% of submandibular
gland and ⬎70% of sublingual gland neo-
plasms are malignant. The more common
submandibular gland neoplasms and their
defining characteristics are detailed here.
Pleomorphic adenoma (benign mixed
tumor) is the most common benign salivary
neoplasm, accounting for roughly 90% of
benign submandibular gland neoplasms.
Histologically, it contains mesenchymal,
epithelial, and myxoid stromal components.
This tumor is slow growing, nonpainful, and
nontender, and can recur if not completely
excised. It also has the potential for malig-
nant degeneration, often heralded by rapid
growth and/or neurologic symptoms.
Adenoid cystic carcinoma is the most
common submandibular gland malignancy,
comprising 15% to 43% of malignancies at
this site; 47% extend through the capsule on
presentation. A hallmark of this tumor is
perineural invasion, such that postopera-
Fig. 2. The muscular boundaries of the submandibular triangle. tive radiotherapy is indicated with this

www.medicalebookpdf.com

LWBK892_c20_p296-302.indd 297 10/28/11 3:49:03 PM

 298 Part III: The Head and Neck

diagnosis. Patients must have at least a Trauma biotics may be indicated if purulence is ex-
10-year follow-up due to the frequent oc- pressed from the duct with gland massage.
currence of delayed recurrence or distant Isolated trauma in the submandibular tri- Multiple recurrent sialadenitis with calculi
metastasis; a 39% 10-year survival is ex- angle necessitating surgical intervention is can be treated with lithotripsy, sialoendos-
pected. There are three histological variet- rare, and usually involves neurovascular copy with basket retrieval of stones, or exci-
ies: cribriform, tubular, and solid; the solid disruption caused by a sharp object. The sion of the submandibular gland.
variety carries a worse prognosis. This dis- vascular structures at greatest risk for such Other causes of sialadenitis include neo-
ease is associated with a high rate of local injury are the facial vessels. The nerves in plastic obstruction and ductal stenosis. The
recurrence, and distant metastasis—most jeopardy are the marginal mandibular latter can be addressed using sialendoscopy
commonly, pulmonary occurs in ⬃50% of branch of the facial nerve, the lingual nerve, with sialoplasty or with removal of the sub-
patients. These patients have a median sur- and the hypoglossal nerve. Bleeding from mandibular gland.
vival of 3.5 years after the identification of the facial artery can sometimes be so brisk
distant disease. as to suggest a carotid artery injury. Identi-
Mucoepidermoid carcinoma is the second fication of the source for the hemorrhage is Ranula
most common malignant tumor, compris- essential and is best obtained by a complete The term ranula derives from the Latin
ing 17% of all submandibular malignancies. exploration of the triangle. The removal of word for frog, so named because of the ap-
Histologically, it is composed of mucoid and the submandibular gland and identification pearance of patients with plunging ranulas.
epithelial elements; the higher the amount of the posterior belly of the digastric muscle A simple ranula can be either a mucus re-
of the epithelial component, the higher the greatly facilitates this. Proximal control of tention cyst or pseudocyst from mucus ex-
grade of the tumor. Low-grade tumors have the facial artery can be accomplished by travasation that is confined to the floor of
a good prognosis (71% 5-year survival); high- dissecting just deep and inferior to the pos- the mouth. A plunging ranula is a mucus
grade tumors are more aggressive and are terior belly of the digastric muscle. extravasation pseudocyst arising from the
associated with worse prognoses. The latter With any exploration, all cranial nerves sublingual gland that extends into the neck,
usually requires postoperative radiation. should be identified and their integrity as- either through the muscular dehiscence for
Controversy exists regarding the outcomes sessed. The marginal mandibular branch the neurovascular bundle of the mylohyoid
of patients with intermediate-grade tumors, of the facial nerve is reliably located along muscle or around the posterior border of
but emerging data suggests that these pa- the inferior edge of the horizontal ramus the mylohyoid muscle. This usually presents
tients have favorable outcomes that approx- of the mandible within the fascia surround- as a soft, cystic neck swelling. If any portion
imate those with low-grade tumors. ing the facial artery and vein. The lingual of the suspected ranula is solid to palpation,
Adenocarcinoma accounts for 11% of sub- nerve is located inferior to the mandible and the possibility of a neoplasm should remain
mandibular gland malignancies. Histological deep to mylohyoid muscle; it is most easily in the differential diagnosis. Also, although
patterns include papillary, acinus, and solid; identified with anterior retraction of the rare, lymphatic malformations should re-
the amount of glandular elements deter- posterior border of the mylohyoid muscle. main in the differential diagnosis, particu-
mines the grade. These tumors are aggressive The hypoglossal nerve should also be identi- larly in children.
and tend to recur; intermediate- and high- fied with anterior retraction of the mylohyoid Drainage of the cyst, either spontaneously
grade histology usually indicates the need muscle, since it is located deep to the plane or by aspiration, usually results in recurrence.
for postoperative radiotherapy. of the lingual nerve and submandibular duct, Observation is appropriate if the ranula is
Squamous cell carcinoma comprises 9% and is usually flanked by veins. By identify- small and does not interfere with tongue
of submandibular gland malignancies. The ing these nerves proximal or distal to the function. Marsupialization of the cyst results
differential diagnosis should include high- injury and dissection along their courses, in a 50% recurrence rate. The most definitive
grade mucoepidermoid carcinoma, metas- the extent of the potential disruption can be treatment of a ranula is excision of the sub-
tases, and contiguous spread. There is a ascertained and appropriate steps taken to lingual gland with the pseudocyst; this re-
very poor prognosis (24% 5-year survival) repair them, if necessary. In the presence of duces the recurrence rate to ⬍2%. Most small
associated with this disease and postopera- edema, hematoma, or hemorrhage, this ranulas can be excised with the sublingual
tive radiotherapy is generally indicated. identification can be difficult and time-con- gland transorally, taking care to identify and
Malignant mixed tumor generally pres- suming. If there is only a preoperative suspi- preserve the lingual nerve. The approach for
ents as a slowly growing mass that has a cion of a neural injury, it is better to postpone a sublingual gland neoplasm that is suspi-
sudden increase in size, and accounts for any procedure and do the exploration at a cious for cancer should be done transcervi-
9% of all submandibular malignancies. The later date, preferably within 7 to 14 days. cally by retracting the mylohyoid muscle an-
malignant component of the tumor may be teriorly for a more definitive procedure.
undifferentiated carcinoma, adenocarci-
noma, or squamous cell carcinoma. A 56%
Sialadenitis
SUBMANDIBULAR TRIANGLE
5-year survival and 31% 10-year survival are A submandibular or sublingual mass is most
to be expected. commonly sialadenitis caused by sialolithia-
DISSECTION
Undifferentiated carcinoma comprises sis. Eighty percent and 1% of salivary calculi Lateral Transcervical Approach
⬍5% of submandibular malignancies. Histo- occur in the submandibular gland and sub-
logically, this is a small cell tumor that may lingual gland, respectively. A single stone is This is performed through a curvilinear in-
exhibit neuroendocrine differentiation. There the cause in 75% of cases. If the calculus can cision from the lateral hyoid to the anterior
is an elevated incidence in Greenlandic Eski- be palpated along the course of Wharton’s border of the sternocleidomastoid muscle,
mos, attributed to the Epstein-Barr virus. duct intra-orally, an incision may be made approximately three fingerbreadths below
These tumors are very aggressive, character- just above the stone to release it. Medical the lower border of the horizontal ramus of
ized by significant local invasion, early dis- management includes frequent massage of the mandible (Fig. 3). The surgeon must make
tant metastases, and low survival rates. the gland, sialogogues, and hydration; anti- a determination as to whether the depth of

www.medicalebookpdf.com

LWBK892_c20_p296-302.indd 298 10/28/11 3:49:03 PM

 Chapter 20: Surgery of the Submandibular and Sublingual Salivary Glands 299

of this nerve, even if it is minimal, will un-

doubtedly result in some weakness of the
ipsilateral corner of the mouth. Therefore,
all patients should be informed of this pre-
operatively. In most patients, this weakness
is temporary.
Once the nerve is retracted out of harm’s
way and the facial artery lymph nodes are
retracted inferiorly, the facial vessels can be
ligated. If the mass is fixed to the perios-
teum on the lower border of the mandible,
this should be included with the specimen
as an oncologic margin (Fig. 6). If the mass
is not adherent to the periosteum, a plane
of dissection should be developed along the
free inferior edge of the ramus of the man-
dible from the midline to just posterior to
the angle of the mandible. Dissection then
continues, sweeping the fibrofatty lymph
node packet inferiorly. This exposes the an-
terior belly of the digastric muscle and the
nerve supplying the mylohyoid muscle. The
latter must be divided in order to release the
gland posteriorly. If the mass is malignant,
Incision for submandibular triangle dissection
pathologic examination of this nerve may
Extension for combined neck dissection (Schobinger)
be necessary, particularly if the mass is an
Fig. 3. Incision site for a submandibular triangle dissection and extension for combined neck dissection. adenoid cystic carcinoma; it is important to
know if this nerve has been invaded because
it defines the behavior and the extent of the
disease, and may determine whether the
the incision should be deep to the platysma allows the adjacent facial artery lymph
patient requires postoperative radiation.
muscle or superficial to it (Fig. 4); this is im- nodes, which lie superior to the nerve as it
The surgeon can now proceed by dissect-
portant if the procedure is being performed courses lateral to the ramus of the mandible,
ing the fibrofatty lymph node packet infero-
for a mass that is close to the skin such that to be removed with the mass while preserv-
posteriorly, exposing the anterior belly of
including platysma in the resection pro- ing the nerve (Fig. 6). The procedure of ligat-
the digastric muscle. Once this is accom-
vides an oncologic margin. In most cases, ing the facial artery and vein at the lower
plished, the anterior belly of the digastric

The Head and Neck

the flap is elevated in a subplatysmal plane border of the mandible and reflecting them
muscle can be retracted medially. All nodal
(Fig. 5). superiorly (Hayes Martin maneuver) pre-
and adipose tissues are removed from deep
As the flap elevation approaches the man- serves this nerve, and also preserves the fa-
to this muscle down to the lateral surface of
dible, the surgeon must be aware of the cial artery lymph nodes. Removing these
the mylohyoid muscle; this is particularly
course of the marginal branch of the facial lymph nodes is oncologically important if the
important if disease in the submandibular
nerve. It is important to identify this nerve mass is a metastasis or a primary tumor of
triangle represents extension of or metasta-
and mobilize it for retraction superiorly; this the submandibular gland. The manipulation
ses from a floor of mouth malignancy. Dis-
section should then continue along the lat-
eral aspect of the mylohyoid muscle and will
reveal the distal portion of the mylohyoid
nerve and associated vascular bundle,
which need to be transected. Blunt dissec-
tion should then define the plane along the
deep surface of the mylohyoid muscle, al-
lowing it to be retracted medially. This ex-
poses the hypoglossal nerve and associated
veins inferiorly, the duct to the submandib-
ular gland, and, superiorly, the genu of the
lingual nerve with its attachment to the
submandibular ganglion (Figs. 7 and 8). As
with the nerve to the mylohyoid muscle, if
malignancy is suspected, this nerve attach-
ment should undergo pathologic examina-
tion. This nerve should be divided superior
to the submandibular ganglion such that
the ganglion is included with the specimen.
Fig. 4. Skin flap raised superiorly with platysma muscle left in place. If the mass extends under the mylohyoid

www.medicalebookpdf.com

LWBK892_c20_p296-302.indd 299 10/28/11 3:49:03 PM

 300 Part III: The Head and Neck

the mass is malignant and there is concur-

rent nodal disease in the neck, a selective
neck dissection should be performed. If
there is perineural or lymphovascular inva-
sion, or if there are multiple positive lymph
nodes in the resection specimen, postoper-
ative radiation is indicated. Likewise, if the
mass is a high- or intermediate-grade sali-
vary gland malignancy, postoperative radia-
tion is indicated for the dissected site and,
in some cases, should include the entire ip-
silateral neck to the clavicle.
Complications of a submandibular tri-
angle dissection through a lateral transcer-
vical incision include hematoma (2% to
10%), fistula formation (1% to 3%), wound
infection (2% to 9%), injury to the marginal
mandibular (7.7% to 36%), lingual (0% to
22.5%), and hypoglossal (0% to 7%) nerves.
Fig. 5. Skin flap raised superiorly in a subplatysmal plane.

Other Transcervical Approaches

muscle to the submucosa of the floor of the should be dissected along the posterior belly Two other transcervical approaches have
mouth, Wharton’s duct must be removed in of the digastric muscle, continuing posteri- been described: submental and retroauric-
its entirety with a portion of the surround- orly until the facial vein is encountered cross- ular. Neither of these is suited for complete
ing floor of mouth mucosa (Fig. 8) as an on- ing over this muscle, where it should be li- submandibular triangle dissection and
cologic margin. gated. As the remainder of the fibrofatty should be reserved for cases in which the
Now that the attachments to the subman- lymph node packet is dissected free along the pathology is confirmed preoperatively to be
dibular gland have been released anteriorly deep plane, the last remaining attachment benign, requiring only removal of the sub-
and superiorly, the gland can be retracted should be the facial artery, as it crosses deep mandibular gland. The reader should note
posteriorly and inferiorly. If the mass is not to the posterior belly of the digastric muscle that these are nonstandard approaches.
adherent to the fascia overlying the hypoglos- (Fig. 7). This should be ligated with at least a The submental approach occurs through
sal nerve and associated venous plexus, the 1-cm cuff to prevent retraction under the a midline horizontal incision determined
plane of dissection is very easily established muscle, thus releasing the contents of the by the submental-cervical crease, usually
superficial to these structures such that the submandibular triangle. at the level of the hyoid. Dissection pro-
entire gland with its preglandular and postg- The full indications for an associated ceeds posterolaterally in a subplatysmal
landular nodes can be elevated. With this el- neck dissection and adjuvant treatment are plane until the gland is encountered. It is
evation, the inferior aspect of the triangle beyond the scope of this chapter. Briefly, if bluntly dissected free of fascial attach-
ments, and the facial vessels are ligated.
Lastly, the attachments of the submandib-
ular ganglion and duct are divided, releas-
Marginal branch of 7th cranial nerve with ing the gland.
Parotid gland facial vessels and lymph node(s)
The retroauricular approach occurs
through an incision placed in the lower
portion of the postauricular sulcus, con-
tinuing posteriorly along the hairline, as in
a facelift incision. Dissection, which can be
extensive, continues in the plane superficial
to the fascia of the sternocleidomastoid
muscle, taking care to preserve the external
jugular vein and greater auricular nerve,
continuing anteriorly in a subplatysmal
plane. Extirpation of the gland then pro-
ceeds in a posterior to anterior direction.

Submandibular Transoral Approach

gland
As with the submental and retroauricular
approaches, this nonstandard approach is
only indicated in confirmed benign dis-
Fig. 6. Marginal branch of the facial nerve and its relationship with the facial vessels. Note also the ease, as it only allows for extirpation of the
lymph nodes in the area of the marginal branch of the facial nerve and underneath the mandible on top submandibular gland and not the entire
of the mylohyoid muscle. contents of the submandibular triangle.

www.medicalebookpdf.com

LWBK892_c20_p296-302.indd 300 10/28/11 3:49:04 PM

 Chapter 20: Surgery of the Submandibular and Sublingual Salivary Glands 301

for delivery into the wound using gentle

transcervical pressure. The hypoglossal
Submandibular gland
nerve is identified and preserved. The facial
Nerve to mylohyoid muscle vessels are then divided, allowing removal
and anterior belly of of the gland.
digastric muscle

Endoscopic Approaches
As with the previously described nonstan-
dard approaches, endoscopic approaches
should not be undertaken when oncologic
Anterior belly of resection is indicated. Endoscopic-assisted
digastric muscle
approaches have been described for tran-
Mylohyoid muscle soral and submental approaches, enabling
successful extirpation of the submandibu-
12th cranial nerve
lar gland through smaller incisions. Com-
pletely endoscopic approaches have only
Trochlea of digastric muscle been described in animal models.
Facial artery

REVISION SURGERY
Fig. 7. Detail of the submandibular triangle with the submaxillary gland resected superiorly, showing its Often, there is a dilemma as to how best to
duct going underneath the mylohyoid muscle. Note also the nerve to the mylohyoid muscle, the anterior proceed when a cancer has been previ-
belly of the digastric muscle, the 12th cranial nerve, the facial artery, and the trochlea of the digastric ously “shelled out” of the submandibular
muscle between the anterior and posterior belly of the digastric muscles. triangle and the patient is referred for fur-
ther treatment. If the previous resection
margins are positive for tumor, but there is
Complications associated with this proce- Wharton’s duct to the retromolar trigone, no residual disease by palpation or imag-
dure include abnormal tongue sensation leaving a cuff of mucosa between the inci- ing, then there is nothing to be gained by
in 43% to 74% and restriction of tongue sion and the gingival to limit postoperative further surgery and postoperative radia-
movement due to scar contracture in up contracture. The lingual nerve is identified tion is indicated. If gross residual disease
to 10%. and the submandibular ganglion and duct is present, however, either clinically or ra-
Briefly, an incision is made in the floor of attachments are divided. The gland is dis- diologically, revision surgery is necessary,
the mouth mucosa from the papilla of sected free of fascial attachments, allowing but is fraught with potential problems and
the patient should be appropriately coun-
seled. Not only are the critical structures at

The Head and Neck

Submandibular gland with
greater risk for injury, but many times, the
extension and duct extent of the procedure must be more radi-
Facial vessels
cal and may involve resection of these
structures to ensure an adequate onco-
logic margin. The type of incision used to
accomplish this is dictated by the previous
surgery; the existing scar should be excised
and consideration should be given to ex-
tension along a modified Schobinger inci-
sion (Fig. 3).

SUGGESTED READINGS
Lingual nerve
Batsakis JG. Neoplasms of the minor and lesser
salivary glands. Surg Gynecol Obstet 1972;135:
12th cranial nerve 289.
Baurmash HD. Marsupialization for treatment
of oral ranula. J Oral Maxillofac Surg 1992;50:
Hyoglossus muscle 1274.
Beahm DD, Peleaz L, Nuss DW, et al. Surgical ap-
Lingual artery proaches to the submandibular gland: A review
of the literature. Int J Surg 2009;7:503–9.
Bentz BG, Hughes CA, Ludemann JP, et al. Masses
of the salivary gland region in children. Arch
Otolaryngol Head Neck Surg 2000;126:1435.
Chiosea SI, Barnes EL, Lai SY, et al. Mucoepider-
moid carcinoma of upper aerodigestive tract:
clinicopathologic study of 78 cases with immu-
Fig. 8. Facial vessels with the submandibular gland resected back. Note also the lingual nerve and the nohistochemical analysis of Dicer expression.
12th cranial nerve. Virchows Arch 2008;452:629–35.

www.medicalebookpdf.com

LWBK892_c20_p296-302.indd 301 10/28/11 3:49:04 PM

 302 Part III: The Head and Neck

Cohen EG, Patel SG, Lin O, et al. Fine-needle as- Koch M, Zenk J, Henrich I. Algorithms for treat- Schobinger R. The use of a long anterior skin flap
piration biopsy of salivary gland lesions in a ment of salivary gland obstructions. Otolaryn- in radical neck dissections. Ann Surg 1957;
selected patient population. Arch Otolaryngol gol Clin N Am 2009;42:1173–92. 146:221.
Head Neck Surg 2004;130:773. McGurk M, Brown J. Alternatives for the treat- Solomon MP, Rosen Y, Gardner B. Metastatic ma-
Gold DR, Annino DJ. Management of the neck in ment of salivary duct obstruction. Otolaryngol lignancy in the submandibular gland. Oral Surg
salivary gland carcinoma. Otolaryngol Clin N Am Clin N Am 2009;42:1073–85. Oral Med Oral Pathol 1975;39:469.
2005;38:99–105. Parekh D, Stewart M, Joseph C, et al. Plunging Spiro RH, Hadju SI, Strong EW. Tumors of the sub-
Hockstein NG, Samadi DS, Gendron K, et al. Pedi- ranula: a report of three cases and a review of mandibular gland. Am J Surg 1976;132:463.
atric submandibular triangle masses: a fifteen- the literature. Br J Surg 1987;74:304–9. Weber RS, Byers RM, Petit B, et al. Submandibu-
year experience. Head Neck 2004;26:675. Rice DH. Noninflammatory, non-neoplastic disor- lar gland tumors: adverse histologic factors
Ichimura K, Nibu K, Tanaka T. Nerve paralysis ders of the salivary glands. Otolaryngol Clin N and therapeutic implications. Arch Otolaryngol
after surgery in the submandibular triangle: Am 1999;42:835–42. Head Neck Surg 1990;116:1055–60.
review of the University of Tokyo Hospital ex-
perience. Head Neck 1997;19:48.

EDITOR’S COMMENT intensity-modulated radiotherapy achieved good metic result for the treatment of benign disease
local control in a 2.5-year-follow-up period and is improved by avoiding a cutaneous incision.
was well tolerated. The use of chemotherapy Bhatt reported on 18 patients without conversion
Although the operations described in this chap- should probably be reserved for patients with to incisional surgery. Although a majority of the
ter are not commonly performed by general particularly poor prognostic indicators (Int J Rad patient’s experienced at least transient limita-
surgeons, it is essential that the general surgeon Oncol Biol Phys 2010 [Epub ahead of print]). Noh tions in tongue movement postoperatively, there
competently evaluate lesions of the head and published a series of 94 patients with salivary were no facial or hypoglossal nerve injuries in
neck when asked to perform consultations for gland tumors treated with or without postopera- the series (Laryngoscope 2010;120(Suppl 4):S143).
“lymph node biopsy.” The consultant needs a tive radiation. They found that very early stage As the surgical robot continues to search for its
working knowledge of the alternative diagnoses tumors could be treated successfully with surgery ultimate place in the surgical world, (if any), we
and conditions that may be present. In addition, alone without additional risk of recurrence (Clin should not be surprised by reports of its use in
understanding the operative approach for these Exp Otorhinolaryngol 2010;3(2):96–101). head and neck surgery of this type (Laryngoscope
lesions will prevent counterproductive incisions Resection of salivary glands is not without 2010 [Epub ahead of print]). It will be difficult to
that could negatively impact the patient’s out- consequence. Removal of the submandibular assess the cost efficiency of this approach.
come. Fine needle aspiration should be employed glands potentially leads to the added compli- The authors state that the most common op-
liberally in the event of an uncertain diagnosis. cation of xerostomia. Although some authors eration on the sublingular glands is for ranula.
Ashraf reported high sensitivity and specific- postulate that compensatory increased flow They note correctly that drainage and marsu-
ity when benign lesions were sampled; however, from the remaining salivary glands ensues post- pialization are associated with high incidence
only intermediate sensitivity and specificity ma- operatively, recent detailed experimental data of recurrence and definitive excision is the best
lignancies were evaluated using this technique by Jaguar suggests that this is not the case (Oral long-term therapy. Plunging ranula result in cer-
(Diagn Cytopathol 2010;38(7):499–504). Oncol 2010;46(5):349–54 [Epub 2010 Mar 15]). vical swelling and may be approached from cervi-
As the authors note in this chapter, neoplasm Frey’s syndrome which is gustatory sweating, cal or intraoral approaches. Samant describes the
and chronic obstruction of Warthen’s duct by cal- more commonly occurs after parotidectomy, results of 95 patients treated for plunging ranula
culi leading to sialadenitis are the most common but can also occur after submandibular gland using a transoral technique. They experienced
indications for removal of the submandibular resection. one recurrence and only minor complications
gland. The presence of ranula is the most com- The treatment of submandibular gland duct (Eur Arch Otorhinolaryngol 2011 [Epub ahead of
mon indication for sublingual gland excision. obstruction varies with the extent of disease, in- print]). Patel compared the results of transoral
The authors describe the submandibular cidence of recurrence, and size of the calculi as versus cervical approaches for the treatment of
triangle dissection in detail. Reports in the noted by the authors. A recent series by Nahliei ranula. Their results demonstrate a much higher
otolaryngology literature describing the use of describes combining miniature lithotripsy with complication rate associated with cervical ap-
advanced energy devices to facilitate dissection the endoscopic techniques to clear advanced proaches (Laryngoscope 2009;119(8):1501–509).
are now emerging (Otolaryngol Head Neck Surg cases of sialolithiasis with <95% success rate, Ranula in children requires some unique consid-
2005;132(3):487–89). Excellent hemostasis in a thus preserving the salivary gland. Extremely erations. This lesion seems to occur more often
variety of head and neck procedures has been small endoscopes, ranging from 0.5 to 1.1 mm, in females and on the left side of the floor of the
recently described (Otolaryngol Head Neck Surg are employed for duct cannulation (J Oral Max- mouth. Traditional recommendations suggest a 5
2005;133(5):725–28). Minimally invasive tech- illofac Surg 2010;68(2):347–53). Luer studied the to 6 month period of observation after presenta-
niques for benign tumors such as using a com- learning curve associated with performing this tion and prior to surgical treatment in order to de-
bination of a hairline incision and video con- small duct endoscopy. He noted performance termine whether or not spontaneous resolution
trolled surgery in order to improve cosmesis improvements after the first 10 cases and then may ensue. Bonet-Coloma reported on 57 cases
have been described by Song for benign lesions, again after doing approximately 30 cases (Arch of pediatric ranula. They treated their patients
such as pleomorphic adenoma, of the sub- Otolaryngol Head Neck Surg 2010;136(8):762–65). primarily with epithelial disruption or marsupi-
mandibular gland (Laryngoscope 2010;120(5): Escudier prospectively studied 142 patients with alization; however, they observed a <12% recur-
970–74). either submandibular or parotid calculi who rence rate (Med Oral Patol Oral Cir Bucal 2011;16
In general, submandibular gland tumors are were treated by various regimens of extracorpo- (2):e158–62). Seo et al. reported no instance of
uncommon. Shoenfeld et al reported on a series real shockwave lithotripsy (ESWL). They found spontaneous resolution in 17 pediatric patients
of 35 patients’ salivary gland malignancy treated success was greater in the parotid group and was observed for 5 to 14 months. All were treated with
by surgery and radiation therapy with and with- inversely proportional to the size of the stone complete excision without recurrence. These
out adjuvant chemotherapy. The most common when ESWL was employed alone in patients who findings suggest that shorter period of observa-
tumors were adenoid cystic carcinoma in 43% are otherwise surgical candidates. tion may be sufficient prior to complete excision
and mucoepidermoid carcinoma in 17% of the The authors correctly note that transoral ap- as definitive therapy (Int J Pediatr Otorhinolaryn-
patients. They concluded that when combined proaches to the submandibular gland should be gol 2010;74(2):202–5).
with surgical extirpation and neck dissection, avoided in cases of potential malignancy. The cos- J.E.F.

www.medicalebookpdf.com

LWBK892_c20_p296-302.indd 302 10/28/11 3:49:08 PM

 Chapter 21: Anatomy and Surgery of the Parotid Gland 303

21 Anatomy and Surgery of the Parotid Gland

Glenn E. Peters, Isaac A. Bohannon, and J. Scott Magnuson

ANATOMY bifurcates into the superficial temporal and lary second molar. Often there can be ac-
maxillary arteries at the level of the man- cessory glandular tissue along the duct. The
The paired parotid glands are the largest of dibular condyle. The transverse facial artery buccal branch of the facial nerve usually
the major salivary glands and are located and vein, a branch of the superficial tempo- follows a very close course with the duct.
in the preauricular region of the face. The ral vessels, travels between the parotid duct The parotid gland is made up of a tubu-
facial nerve creates a division between the and the zygomatic arch to supply the parotid loacinar system of ducts, which produces
lateral and deep lobes of the gland, which is duct, masseter muscle, and parotid tissue. abundant watery saliva when stimulated by
more surgical than anatomic in nature. The The retromandibular (posterior facial) the parasympathetic nervous system. Once
parotid is bounded posteriorly by the exter- vein is made up of the superficial temporal preganglionic parasympathetic neurons in
nal auditory canal (EAC), superiorly by the and maxillary veins. Located deep to the fa- the salivary nucleus of the brainstem syn-
zygoma, and inferiorly by the styloid pro- cial nerve, it is the dominant vein draining apse with autonomic ganglia they enter
cess, the styloid muscles, as well as the in- the parotid. The retromandibular vein is the parotid via their sensory nerves. The
ternal carotid artery and the internal jugu- lateral to the carotid artery and exits the glossopharyngeal nerve (cranial nerve IX)
lar vein. Also, a portion of the parotid gland gland at the inferior aspect where it also supplies parasympathetic innervation to
extends posteroinferiorly over the mastoid joins the postauricular vein to make up the the parotid. Thus, the parasympathetic
tip and the sternocleidomastoid muscle, external jugular vein. It is also important to fibers are transported to the otic ganglion
commonly known as the tail of parotid. note that the retromandibular vein con- via the lesser petrosal nerve. Postganglionic
During the first 6 to 8 weeks of fetal nects to the more anterior facial vein form- fibers are then carried to the parotid gland
development the major salivary glands ing the common facial vein, which finally by the auriculotemporal nerve (a branch of
develop. Outpouchings of oral ectoderm empties into the internal jugular vein (Figs. the cranial nerve V3).
surrounded by mesoderm form the parotid 1 and 2). The greater auricular nerve is encoun-
anlage. As the anlage grows posteriorly, the The parotid (Stensen’s) duct exits the tered in elevating skin flaps. It is the largest
facial nerve advances anteriorly toward the gland on the anterior surface approximately branch of the cervical plexus and supplies
midline. Thus the facial nerve becomes sur- 1.5 cm inferior to the zygoma. The duct sensation to the postauricular skin and the
rounded by glandular tissue. Lymph nodes courses 4 to 6 cm anteriorly to pierce the lobule of the ear. The nerve is often surgi-
are encapsulated by the mesenchymal cap- buccinator muscle. The papilla of the duct cally divided as it passes over the posterior
sule surrounding the gland, creating intrap- opens intraorally just opposite the maxil- border of the sternocleidomastoid muscle.
arotid lymph nodes in both the lateral and
deep lobes.
The parotid is surrounded by a continu-

The Head and Neck

ation of the superficial layer of the deep
cervical fascia. The thick superficial divi-
sion of this fascial layer extends from the
zygoma to the sternocleidomastoid, and
Temporal branch
the masseter anteriorly. The plane superfi-
cial to this fascia allows the surgeon to raise
skin flaps without venturing too superfi-
cially into the subcutaneous tissues. This
parotid capsule is very inelastic, and in the
face of expansile masses or infectious pro-
cesses can cause significant discomfort for
patients.
The fascia deep to the deep lobe of the pa-
rotid forms the stylomandibular membrane;
it is made up of the fascia of the posterior
portion of the digastric muscle. This mem- Marginal mandibular branch
brane divides the parotid space from the sub-
mandibular gland, spanning anteriorly from
the mandible, inferiorly from the styloman-
Cervical branch
dibular ligament, and posteriorly from the
styloid process. When parotid masses herni-
ate medially through the stylomandibular
membrane, they can present as lateral pha-
ryngeal wall masses as expansion continues
in the parapharyngeal space.
Branches of the external carotid artery Fig. 1. The parotid gland and the facial nerve. Note that the nerve exits the stylomastoid foramen lateral
are the major blood supply to the parotid. It to the styloid process. Also, note the relationship of the nerve branches to the surrounding structures.

www.medicalebookpdf.com

LWBK892_c21_p303-306.indd 303 10/28/11 4:53:50 PM

 304 Part III: The Head and Neck

weaknesses of MRI and CT sometimes mean

that complex cases may need both imaging
modalities to better understand the clinical
picture.
FNA is known to be safe, simple to per-
form, and relatively inexpensive. Many
studies have indicated that FNA has a high
degree of sensitivity and specificity. Diag-
nostic accuracy tends to be better for be-
nign rather than malignant tumors. The
accuracy is most dependent on the experi-
ence of the cytopathologist and the volume
of salivary tumors reviewed at the institu-
tion. Diagnostic error most commonly oc-
curs with an inadequate sampling of the
mass. Cell sampling can be improved by us-
ing ultrasonography in conjunction with
FNA.
FNA is a common diagnostic practice in
the head and neck region, but FNA of a pa-
Fig. 2. Stylomandibular membrane (deep layer of parotid fascia). Herniations of parotid tissue through
this membrane can result in a parapharyngeal mass.
rotid mass is a controversial issue. Is FNA
really worth doing in the workup of salivary
tumor? Will it change the course of treat-
ment? Heller and colleagues demonstrated
The facial nerve leaves the skull base wall of the oropharynx may reveal a tumor that only 35% of patients who underwent
through the stylomastoid foramen, which of the deep lobe of the parotid or a FNA had a change in their clinical approach
is located medial to the mastoid tip and parapharyngeal space mass. As with any to management of the tumor. Such changes
lateral to the styloid process. As the nerve mass, size, location, fixation to adjacent included avoiding surgery in masses of in-
exits the foramen it gives off motor structures or skin, and quality of the mass flammatory or lymphoma origin, and also
branches to the stylohyoid muscle, the can greatly contribute to treatment deci- simple observation in high-risk surgical pa-
posterior belly of the digastric, and postau- sion making and preoperative planning. tients with benign tumors.
ricular muscles. The nerve then turns later- Parotid masses can also present with fa- Although a benign diagnosis on FNA is
ally to enter the parotid gland where it can cial nerve paralysis or weakness, which not always a certainty, due to some cyto-
be identified by the relationship to sur- can be a herald of tumor invasion of the logic similarities, a definitive diagnosis of
rounding structures. The “tragal pointer” is nerve. Nerve weakness should be charac- malignancy based on FNA can aid in preop-
a triangular extension of the cartilaginous terized by the House–Brackmann scale of erative counseling of the patient. Discus-
EAC, which points toward the facial nerve. facial function. sion can include extent of the resection,
Generally, the nerve has been found 6 to 8 Routine preoperative imaging of well- treatment of the facial nerve, and possible
mm medial to the tympanomastoid suture defined masses of the superficial parotid the need for neck dissection.
line. In addition, the facial nerve is located gland are unlikely to change the course of Facial nerve monitoring is a useful
inferiorly and just lateral to the styloid pro- treatment. However, those tumors that method to help the surgeon identify and
cess, and is at the same level as the inser- raise clinical suspicions of malignancy, deep preserve function of the facial nerve. The
tion of the posterior belly of the digastric lobe, or parapharyngeal space origin should goals of facial nerve monitoring are to de-
muscle. be evaluated with high-resolution imaging. crease mechanical trauma to the nerve,
The main trunk of the facial nerve then The choice of imaging technique mainly de- warn the surgeon of unanticipated stimula-
splits at the pes anserinus (goose’s foot) pends on presumed pathology. Sialography, tion, identify the course of the nerve, and
into cervicofacial and temporofacial divi- positron emission tomography, and techne- test its function during and after the proce-
sions. It should be recognized that consid- tium scanning are rarely used, having lim- dure. The nerve can be monitored in one
erable variability exists in the length of the ited application to the majority of common of two ways. First, visually monitoring the
main trunk and the branching pattern of salivary tumors. Ultrasonography has some face for movement; usually assistants notify
the facial nerve as it courses through the application to identification of parotid ab- the surgeon of twitches in the face with
parotid gland. Generally, the two divisions scesses, stones, or cysts, but is often used in mechanical or electrical stimulation. Sec-
of the nerve branch again to form five major conjunction with fine needle aspiration ond, electrophysiologic monitoring relies on
branches: temporal, zygomatic, buccal, (FNA) biopsy. Computed tomography (CT) facial electromyographic (EMG) activity to
marginal mandibular, and cervical. Inter- produces excellent images of the entire pa- notify the surgeon of nerve stimulation. The
communicating branches are common be- rotid gland, parapharyngeal space, mandi- most common nerve monitor in the United
tween the major branches and should be ble, temporal bone, and base of skull. CT is States is NIM-Response 2.0 Nerve Integrity
preserved when possible. the most commonly used preoperative im- Monitor (NIM-2; Medtronic Xomed, Jack-
aging tool. Alternatively, magnetic reso- sonville, FL). Electrophysiologic monitors
nance imaging (MRI) has superior distinc- can quantify the degree of facial nerve ac-
PREOPERATIVE PLANNING tion of tumor, fat, and muscle based on tivity on the EMG and can be associated
During physical examination, palpation different signal intensity. MRI is most often with audible alerts. The reasons to use a fa-
and bimanual manipulation of any parotid used to evaluate parapharyngeal space cial nerve monitor during parotidectomy
mass is critical. Examination of the lateral masses. The complementary strengths and are variable, including experience of the

www.medicalebookpdf.com

LWBK892_c21_p303-306.indd 304 10/28/11 4:53:50 PM

 Chapter 21: Anatomy and Surgery of the Parotid Gland 305

surgeon, cost of monitoring equipment, locate the nerve and its branches. The facial addition to normal serosanguinous drain-
and the ability to troubleshoot and inter- nerve can be identified in the temporal bone age. Usually a parotidectomy drain is left in
pret alerts during dissection. via mastoidectomy. The marginal mandibu- place for 2 to 3 days before removal.
lar nerve branch can be located where it
crosses over the anterior facial vessels and
SURGICAL TECHNIQUE traced in a retrograde manner toward the
COMPLICATIONS
With the patient in the supine position the main trunk. Also, the buccal branch is an-
head is turned away from the side of opera- other very constant branch that can be lo-
Facial Nerve Paresis or Paralysis
tion. The most common and versatile inci- cated along its course with the parotid duct. Dysfunction of the facial nerve can occur
sion is the modified Blair incision. It is With the facial nerve identified, a fine with mechanical traction during dissection.
placed in a preauricular skin crease begin- clamp should be used to meticulously elevate As long as the nerve remains intact, the re-
ning just at the root of the helix and it ex- the parotid tissue off of the nerve branches. sulting neuropraxia will typically recover
tends around the lobule over the skin of the The parotid tissue overlying the nerve is then over time. Temporary facial nerve dysfunc-
mastoid tip. Finally, the incision gently divided between the tips of the clamp. Bipo- tion happens in as many as 20% to 40% of
curves down over the sternocleidomastoid lar cautery aids in hemostasis, and should be patients who undergo parotidectomy, com-
muscle and forward into a neck skin crease. used in close proximity to the nerve. Given pared with permanent paralysis occurring
Alternatively, the “face lift” incision can be the variability of branching patterns, some in 0% to 4% of patients. Recovery of function
used in patients with known benign tumors surgeons do not divide overlying parotid tis- can be variable from several days to several
located in the midparotid bed or the tail of sue until both main divisions of the nerve at months. To minimize injury, the surgeon
parotid. The superior portion of the “face the bifurcation are visualized. Each subse- must develop meticulous dissection tech-
lift” incision begins at the tragus; it curves quent branch is dissected in the same fash- niques for management of the facial nerve.
around the lobule and then extends into ion until all tissue lateral to the facial nerve Excessive traction on the nerve and exces-
the hairline of the postauricular skin. The is excised. This completes a lateral or super- sive nerve stimulator use should also be
incision can follow the hairline inferiorly to ficial parotidectomy. If total parotidectomy avoided. Even during a brief period of upper
provide adequate visualization. is required the dissection must extend in an division facial nerve weakness, eye care is
Skin flaps are raised to expose the pa- atraumatic fashion to free the deep tissue paramount. Judicious use of lubricating eye
rotid tissue in the plane just superficial to from the medial surface of the nerve, allow- drops, ointment, and taping of the lateral
the parotid fascia and in the subplatysmal ing preservation of nerve function. eye can prevent corneal drying, until func-
plane in the neck portion of the incision. Patients with recurrent tumors who un- tion improves. Long-term rehabilitative sur-
Caution should be exercised as skin flaps dergo revision parotidectomy are at signifi- geries include eyelid gold weight implants,
are raised beyond the anterior border of the cantly increased risk of facial nerve paralysis. static facial slings, aesthetic surgery, and
parotid gland where facial nerve branches However, nerve-sparing surgical treatment nerve grafting when possible.
exit the gland to innervate muscles of facial remains the mainstay of treatment for recur-
expression. rent benign parotid tumors. There is little Gustatory Sweating: Frey’s Syndrome
The greater auricular nerve and the pos- difference in technique for revision proce-
terior facial vein are identified and com- dures. Skin flaps must be elevated. The main Frey’s syndrome includes symptoms such as

The Head and Neck

monly sacrificed to free the tail of the parotid trunk of the facial nerve or one of its branches sweating, redness, and warmth in the preau-
from the sternocleidomastoid muscle. The will be identified with anatomic landmarks. ricular region while eating. Although Frey’s
posterior belly of the digastric muscle is ex- The authors typically use facial nerve moni- syndrome is most often discussed in associa-
posed beyond its attachment to the tempo- toring in revision parotid surgeries. Exces- tion with parotidectomy, this phenomenon
ral bone. Thus, the inferior portion of the sively scarred regions of the dissection can can occur with trauma to the parotid or in-
gland is quickly mobilized from its inferior, sometimes be managed with the aid of an fection. Multiple studies suggest that at least
posterior, and medial attachments. Next the operating microscope to trace and preserve 40% of patients experience one symptom, but
fascial attachments between the EAC and nerve branches. Recurrent tumors are fre- the true incidence is unknown. The suggested
the parotid tissue are divided to identify the quently multifocal. This requires wide exci- pathophysiology is due to aberrant regrowth
tragal pointer. This step can be accomplished sion, often with surrounding structures to of parasympathetic postganglionic fibers as-
with the surgeon’s retraction of the ear at the obtain clear margins. sociated with the auriculotemporal nerve
lobule and countertraction on the gland it- Once the parotidectomy is completed, into the sweat glands of the skin overlying the
self. Monopolar cautery can facilitate dissec- an acellular dermal matrix graft can be parotid causing sweating, which under nor-
tion. Using the multiple landmarks men- placed in the wound to cover the main mal circumstances would cause salivation.
tioned previously, the main trunk of the facial trunk and major divisions. There is evidence The diagnosis of Frey’s syndrome depends
nerve can be identified. Unless the tumor has that this onlay grafting can prevent scarring upon the patient’s symptoms. An objective
displaced the nerve, the main trunk is lo- of the skin flaps to the facial nerve, thereby test to confirm the diagnosis is Minor’s
cated approximately 1 cm inferior and deep making the facial nerve more identifiable in starch/iodine test. The affected side of the
to the tragal pointer. The tympanomastoid revision surgeries. Acellular matrix grafts face is painted with iodine solution and al-
suture line will be encountered below the have also been shown to decrease the inci- lowed to dry. A starch powder is then applied
tragal pointer. The suture line can be fol- dence of Frey’s syndrome (gustatory sweat- to the same area. The patient is asked to
lowed medially to identify the nerve. The fa- ing) by providing a barrier to auriculotem- chew on a sialogogue (i.e., lemon or sour
cial nerve is usually 6 to 8 mm below the tym- poral nerve regrowth. candy) for several minutes. The confirmation
panomastoid suture line. It is at the level of A suction drain should be placed in the of Frey’s syndrome is blue spots on the skin
the posterior belly of the digastric insertion. bed of the parotidectomy wound, without where the dissolved starch and iodine mix.
In cases where tumor prevents exposure contacting the main trunk of the nerve. The Treatment can be as simple as applying
of the main trunk as it exits the stylomastoid cut surface of the parotid tissue does leak antiperspirant over the skin. Anticholin-
foramen, several techniques may be used to some saliva in the postoperative period, in ergic glycopyrrolate lotion is also effective.

www.medicalebookpdf.com

LWBK892_c21_p303-306.indd 305 10/28/11 4:53:51 PM

 306 Part III: The Head and Neck

Recent research has shown botulinum toxin dectomy showed no difference in deficit and seroma collection within the wound below
A to be effective in halting symptoms re- recovery over time. Generally, this sensory the skin flap. Management includes repeat
fractory to topical medications. Surgical deficit decreases over the postoperative pe- aspiration, drain placement, pressure dress-
interruption of the secretory fibers can be riod, especially between 6 and 12 months. ing, and oral anticholinergics to reduce sali-
done with tympanic neurectomy if no other Of those patients that do report symptoms, vary flow during the healing process.
measures are successful. 77% had little trouble caused by symptoms
and 90% had no or almost no interference in
their daily activities due to their symptoms. SUGGESTED READINGS
Sensory Abnormalities Although many patients do experience sen- Eisele DW, Wang SJ, Orloff LA. Electrophysiologic
The greater auricular nerve is frequently sory deficit, it appears that overall quality of facial nerve monitoring during parotidectomy.
life was not affected by greater auricular Head Neck 2010;32(3):399–405.
sacrificed during parotidectomy in order to Heller KS, Dubner S, Chess Q, et al. Value of fine needle
mobilize the tail of the parotid from the nerve division during parotidectomy.
aspiration biopsy of salivary gland masses in clini-
sternocleidomastoid. Patients develop a cal decision-making. Am J Surg 1992;164(6):667–70.
sensory deficit in the dermatomal distribu- Mehle ME. Facial nerve morbidity following parotid
tion that includes the lower third of the ex-
Salivary Fistula and Seroma surgery for benign disease: the Cleveland Clinic
ternal ear including the lobule and sur- Salivary fistula and seroma is an uncommon Foundation experience. Laryngoscope 1993;
103:386–8.
rounding pre- and postauricular skin. occurrence with proper postoperative suc- Patel N, Har-El G, Rosenfeld R. Quality of life after great
Studies comparing patients with nerve sac- tion drain usage. Most commonly it presents auricular nerve sacrifice during parotidectomy.
rifice versus nerve sparing during paroti- with clear sialorrhea from the wound or Arch Otolaryngol Head Neck Surg 2001;127:884–8.

EDITOR’S COMMENT of the facial nerve, which is most at risk. There is the position of the facial nerve in anterograde
also a cervical branch off the facial nerve, which parotidectomy. They believe that there are four
enervates the platysma as is indicated in another landmarks that can be used to point to where the
The parotid gland occupies a major part of the commentary, and injury to this small branch may facial nerve will travel. They studied 26 embalmed
cheek and contributes much of the bulk of the be manifested in paralysis facial expression. Thus, cadavers using four of the most commonly used
cheek on either side. It is a salivary gland which a misadventure in the facial nerve and damage to surgical landmarks of where the facial nerve is,
exists in two lobes. Our interest in it is because the facial nerve when doing a parotid dissection particularly between the bony and cartilaginous
of the occasional parotitis or stones in Stensen’s may result in a very significant cosmetic damage ear canal and the tympanomastoid suture. As they
duct, which may actually be a significant infection in the expression of the face. The nerve plane as Dr. say, the main trunk of the facial nerve was found
and with neoplastic lesions, many of which are be- Ruhalter says is deep to the venous plane, which is 5.5 ⫾ 2.1 mm from the posterior belly of the digas-
nign. This chapter is also in this book because gen- superficial to the arterial plane, as shown in Figure tric muscle. Another landmark included the tragal
eral surgeons get to deal with this in their everyday 3. In Figure 4, the nerve plane is clearly shown. pointer, the junction between the bony and car-
surgical practice in the areas in which there are Much of what is currently being described in tilaginous ear canal. I am not certain that these
not a great many otorhinolaryngologists who have the literature really is about the anatomy of the landmarks are very helpful because in the paper
a significant portion of the surgery for neoplastic parotid gland and related structures for successful they not only draw them on four bony landmarks,
disease. In Dr. Ruhalter’s nice chapter on anatomy, parotid surgery. There are various types of paroti- as shown in Figure 2 in a cadaver head, but also
one can see from Figure 2 the superficial area of dectomies. The most common procedures are for a they are not very clear in the other photographs of
the parotid lesion. Note that there is an external neoplasm of the parotid gland or metastases to the the dissection or where the nerve is supposed to
jugular vein which comes up off of the internal parotid lymph node, for example, in melanoma of be. I suspect it is really easier to learn the anatomy
jugular vein and heads down slightly posteriorly in the scalp (Leverstein H, et al. British Journal of Sur- rather than depend on bony landmarks.
the neck. The parotid gland extends to right below gery 1997;84:399–403; Superficial Parotidectomy Finally, Eisele et al. suggest that facial nerve
the ear and to below the mandible or at least the as in O’Brien CJ, Head and Neck 2003;25:946–52 monitoring might be helpful during parotidectomy
tip of it is below the mandible. The critical issue and Lai SY, et al. Parotidectomy in the treatment to prevent facial nerve injury. They point out that
about operating on the parotid gland is the fa- of aggressive cutaneous malignancies. Archives of temporary facial nerve dysfunction occurs in 20%
cial nerve, which actually splits it into a superfi- Otorhinolaryngology and Head and Neck Surgery to 40% of the patients undergoing parotidectomy,
cial lobe and a deep lobe. The facial nerve, which 2002;128:521–6). In this paper, Figure 3 demon- whereas this only permanently occurs in 0% to 4%
is the seventh cranial nerve, exits from the skull strates a left parotid neoplasm and Figure 4 a of the patients. Parotid nerve monitoring, however,
through the stylomastoid foramen. At this point, modified Blair incision coming down anterior to is also useful in any possible litigation, which may
it is usually in association with the stylomastoid the ear and then curving around underneath the occur, and that is the reason enough to learn how
branch at the posterior auricular artery, which en- mandible in order to take out the parotid. The fig- to do it. Basically, this is carried out by electrically
ters the cavity and should not be interrupted since ures, which are intended to show parotid surgery, evoked facial nerve responses during electrophysi-
it supplies the mucosa of the tympanic cavity, the are unfortunately not figures but poor photographs ological facial nerve stimulation with a close nerve
mastoid cells, and the semicircular canals. The ar- and they do not have line drawing with them so monitoring. Facial nerve injury may of course result
tery is usually superficial to the facial nerve and that I do not believe that they are very helpful. from overstimulation that may occur from a long
the only reason I bother to point this out is that Tahwinder et al. (European Archives of Oto- stimulation. However, with a direct current nerve
the facial nerve is the critical aspect of surgery rhinolaryngology 2010;267:793–800) deal with the stimulator, which is battery powered, this is unlikely.
on the parotid gland. The facial nerve, as I said rhytidectomy incision which has been used to ap- Like any type of mechanical or electrical stimulator,
earlier, comes out of the stylomastoid foramen proach the gland and showing that it goes around overstimulation or mis-stimulation may result in
and then courses between the superficial and the the ear and directly posteriorly as a retrotragal injury as well, and here we are dealing with the face,
deep lobe of the parotid gland. The five branches skin incision. It also enters the scalp anterior to and a profound influence in facial expression.
of the facial nerve take different courses between the top of the tragus. Again, in the photographic One other thing about after parotidectomy,
the superficial and deep lobe of the facial nerve pictures in cadaveric dissections it looks like you have the facial nerve which is exposed and
between the superficial and deep lobes of the pa- it gives very complete exposure, but it looks to in the chapter they make suggestions as far as the
rotid gland and they break up into the auricular me like the incision that is here is considerably material that may be used to overlay the nerve
temporal nerve and the temporal branch of the greater than that seen in Figure 5, which looks after superficial parotidectomy. This barrier to ir-
facial nerve, which course superiorly the zygo- like it is in a living human being. ritation may result in a lesser incidence of Frey’s
matic branch of the facial nerve, which usually is Rea et al. (Annals of Anatomy 2010;192:27–32) syndrome, which may occur if the nerve is rela-
also out of harm’s way for the most part, and then deal with trying to provide some landmarks, which tively exposed without any covering, except a thin
the two branches at risk, the buccal branch of the the authors claim, in addition to intraoperative flap of skin and a subcutaneous tissue.
facial nerve and the marginal mandibular branch facial nerve monitoring, will help to determine J.E.F.

www.medicalebookpdf.com

LWBK892_c21_p303-306.indd 306 10/28/11 4:53:51 PM

 Chapter 22: Anatomy of the Parotid Gland, Submandibular Triangle, and Floor of the Mouth 307

22 Anatomy of the Parotid Gland, Submandibular

Triangle, and Floor of the Mouth
Aaron Ruhalter

ANATOMY OF THE Parotid Gland between the lobes, however, created by

PAROTID GLAND bridges of glandular tissue. A large area of
The superficial surface of the parotid gland communication, referred to as the isthmus,
The parotid gland is the largest of the paired is triangular in shape, with the apex point- is related to the proximal part of the intrap-
salivary glands. The gland is wedged into ing inferiorly (Fig. 2). The deep surface of arotid portion of the facial nerve.
the parotid space. the gland is wedged into this parotid space The parotid duct is approximately 5 cm
and presents anteromedial and posterome- long and lies on the superficial surface of the
dial surfaces. The gland frequently extends masseter muscle, approximately 1 cm below
Parotid Space beyond the limits of the parotid space. the zygomatic arch. The transverse facial ar-
The parotid space has a skeletal background Glandular tissue may extend from the an- tery is interposed between the duct and the
created by the ramus of the mandible anteri- terosuperior edge of the superficial surface, arch, whereas the buccal branches of the fa-
orly, the styloid process medially, the mas- creating what is called the facial process, cial nerve can be found inferior and superior
toid process posteriorly, and the external and is superior to the parotid duct. The ex- to the duct. When this conduit reaches the
acoustic meatus and the posterior part of tension of glandular tissue may be separate anterior margin of the masseter muscle, it
the temporomandibular joint posterosupe- from the main portion of the gland. This turns sharply, penetrates the buccinator mus-
riorly (Fig. 1). A soft tissue background is cre- isolated segment of gland (accessory pa- cle, and ends in the vestibule of the oral cavity
ated by the muscles that are attached to rotid) has a duct that empties into the main opposite the upper second molar tooth.
these bony landmarks—the masseter, me- duct. Frequently, extensions are found from
dial pterygoid, and temporalis muscles on the deep surface of the gland toward the
the mandible; the stylohyoid, styloglossus, pharynx or the medial pterygoid muscle.
Fascial Relations
and stylopharyngeus muscles arising from The parotid gland is somewhat artifi- The gland is encased by a split in the invest-
the styloid process of the temporal bone; and cially divided into two lobes by the facial ing layer of the deep cervical fascia. The deep
the sternocleidomastoid and digastric mus- nerve as it passes through. Endofacial layer passes superiorly and attaches to the
cles related to the mastoid process and the (deep) and exofacial (superficial) portions base of the skull. A portion of this fascia be-
lateral portion of the posterior occipital line. are created. Multiple communications exist tween the tip of the styloid process and the
angle of the mandible is thickened, creating
the stylomandibular ligament. This ligament
supports the temporomandibular joint and

The Head and Neck

separates the parotid gland from the sub-
mandibular gland. The superficial layer of
this fascial split is much thicker, invests the
masseter muscle, and attaches to the zygo-
matic arch. Its thickness and unyielding na-
ture are responsible for the severe pain that
results from enlargement of the gland.

Neurovascular Relations
Neurovascular structures pass through the
parenchyma of the gland and can conve-
niently be described in layers or planes.
From deep to superficial are found the arte-
rial, venous, and nerve layers.
Arterial Plane
The arterial layer includes the external ca-
rotid artery, which enters the parotid space
after passing deep to the posterior belly of
the digastric muscle (Fig. 3). At this point
the external carotid artery gives rise to the
posterior auricular artery, which gives off a
stylohyoid branch that enters the stylomas-
toid foramen. This blood vessel is usually
superficial to the facial nerve trunk as it ex-
its from the skull by way of this same fora-
Fig. 1. Parotid bed. men. The posterior auricular artery then

www.medicalebookpdf.com

LWBK892_c22_p307-314.indd 307 10/28/11 4:53:24 PM

 308 Part III: The Head and Neck

between the external acoustic meatus and

the temporomandibular joint. Accompany-
ing these vascular structures at this level is
the auriculotemporal nerve, which arises
from the mandibular branch of the trigeminal
nerve in the roof of the infratemporal fossa. It
provides sensory innervation to the external
acoustic meatus, external surface of the tym-
panic membrane, and temporomandibular
joint, and cutaneous sensory innervation to
the auricle and temporal scalp region.

Venous Plane
The venous plane is superficial to the arte-
rial plane (Fig. 3). It includes the retroman-
dibular vein and its branches. The retro-
mandibular vein is created by the union
of the superficial temporal and maxillary
veins. The maxillary vein is formed by the
union of veins that are part of a large plexus
of veins surrounding the lateral pterygoid
muscle. This venous plexus communicates
with veins of the face as well as with the cav-
ernous sinus within the skull. The parotid
veins also communicate with the pterygoid
venous plexus. This pterygoid venous plexus
in turn represents a potential pathway for
the spread of superficial cutaneous infec-
tions to the cavernous sinus. This is a poten-
Fig. 2. Superficial view of the parotid region. tially lethal condition.

continues posteriorly, running under cover

of, and parallel to, the superior edge of the
posterior belly of the digastric muscle. One
should note that this muscle passes superfi-
cial to and protects almost all of the struc-
tures passing between the submandibular
triangle superiorly and the carotid triangle
inferiorly. This includes the internal jugular
vein and the internal carotid artery in the
carotid sheath, the last four cranial nerves,
and the external carotid artery. The retro-
mandibular vein or its branches, the cervi-
cal branch of the facial nerve, and the greater
auricular nerve, however, pass superficial to
the posterior belly of the digastric muscle.
The external carotid artery then pierces
the medial surface of the parotid gland, and
when it reaches the neck of the condylar pro-
cess of the mandible it ends by giving rise to
the maxillary artery and the superficial tem-
poral artery. The maxillary artery passes me-
dial to the condylar process of the mandible
and enters the infratemporal fossa. The su-
perficial temporal artery continues superi-
orly, accompanied by superficial temporal
veins. The transverse facial artery, which arises
from the proximal part of the superficial tem-
poral artery, courses just superior to the pa-
rotid duct. The superficial temporal artery
then enters the temporal region after passing Fig. 3. Vascular background.

www.medicalebookpdf.com

LWBK892_c22_p307-314.indd 308 10/28/11 4:53:25 PM

 Chapter 22: Anatomy of the Parotid Gland, Submandibular Triangle, and Floor of the Mouth 309

The retromandibular vein passes inferi-

orly through the substance of the parotid
gland and is found between the branches
of the facial nerve and the arterial layer. The
retromandibular vein terminates at the
lower edge of the gland by giving off anterior
and posterior branches. The posterior branch
joins with the posterior auricular vein to form
the external jugular vein, which continues
inferiorly, superficial to the posterior belly of
the digastric muscle, then passes obliquely
across the sternocleidomastoid muscle. It is
frequently found just anterior to the great
auricular nerve, which is on its way to the
skin overlying the parotid gland. The ante-
rior branch of the retromandibular vein
unites with the anterior facial vein, forming
the common facial vein. This passes inferi-
orly, superficial to the digastric muscle, to
empty into the internal jugular vein.

Nerve Plane
The nerve plane is created by the facial nerve
and its branches (Fig. 4). The facial nerve
(seventh cranial nerve) exits from the skull
through the stylomastoid foramen. At this
point it is found with the stylomastoid
branch of the posterior auricular artery,
which enters the foramen and supplies the
mucosa of the tympanic cavity, the mastoid
cells, and the semicircular canals. The artery Fig. 4. Nerve plane.
is usually superficial to the facial nerve. After
emerging from the foramen, two branches
arise from the facial nerve before it enters
the parotid gland. The first branch, the deep (endofacial) lobe. Multiple communica- These are related to the external jugular vein
posterior auricular nerve, provides innerva- tions are found between the nerve branches and pass to the supraclavicular nodes in the

The Head and Neck

tion to the posterior auricular muscles and as they pass through the gland. The zygo- posterior triangle. The second set of nodes is
the intrinsic muscles of the auricle. The sec- matic and temporal nerves are frequently found within the fascial covering of the pa-
ond branch, arising from the extraparotid multiple, whereas the mandibular and cervi- rotid gland. These nodes drain into the deep
portion of the facial nerve, provides motor cal branches are often single. The cervical cervical nodes and the jugular chain.
innervation to the posterior belly of the di- and mandibular branches can extend below
gastric and stylohyoid muscles. This portion the mandible, whereas the cervical branch
of the nerve, approximately 1 cm in length, passes superficial to the posterior belly of the
Anatomic Aids
then penetrates the posteromedial surface digastric muscle. The nerves become more The main trunk of the facial nerve can be
of the parotid gland. This nerve trunk passes superficial as they pass distally. found by tracing one of its branches proxi-
forward in the glandular parenchyma for a mally. The mandibular and cervical branches
distance of approximately 1 cm or less, then are more frequently used because they are
divides into two branches—a larger temporo-
Innervation often single and more convenient to find.
facial branch, which creates temporal and The parotid gland receives postganglionic The parotid duct is approximately 1 cm
zygomatic nerves, and a smaller cervicofacial sympathetic fibers from a plexus of nerves inferior to the lower edge of the zygomatic
branch, which gives rise to buccal, marginal that travel with the external carotid artery. Se- arch. The pathway of the duct can be recre-
mandibular, and cervical nerves. An isthmus cretomotor postganglionic parasympathetic ated by a line between the lower end of the
of glandular tissue separates the temporofa- fibers reach the infratemporal fossa by way of tragus of the ear and the commissure of the
cial branch from the cervicofacial branch. the lesser petrosal nerve, synapse in the otic mouth.
The facial nerve provides motor innerva- ganglion, and then travel to the parotid gland Two nerves may be found with the su-
tion to the muscles of facial expression. The by way of the auriculotemporal nerve. perficial temporal vessels. The auriculotem-
platysma is included in this category of mus- poral nerve is posterior, whereas the tempo-
cle. The nerve branches, as they pass through ral branches of the facial nerve lie anterior
the parotid gland, divide it into two portions.
Lymphatic Drainage to these vessels.
The part of the gland that is superficial to the The lymphatic drainage of the parotid gland The great auricular nerve is frequently
nerves is referred to as the superficial (exofa- is related to two systems. Superficial nodes found posterior to the external jugular vein.
cial) lobe, and the portion of the gland that is in the superficial fascia (preauricular) drain This nerve and vein travel together until the
internal to the nerve layer is referred to as the into the superficial system of cervical nodes. inferior edge of the parotid gland is reached.

www.medicalebookpdf.com

LWBK892_c22_p307-314.indd 309 10/28/11 4:53:25 PM

 310 Part III: The Head and Neck

The nerve passes to the subcutaneous tissues Muscular Boundaries latter nerve is a branch of the posterior divi-
superficial to the gland, providing sensory sion of the mandibular nerve.
innervation to the skin overlying the parotid The muscular boundaries of the subman-
gland. The remainder of the face receives its dibular triangle are the posterior belly of the Muscular Floor
sensory innervation only from the trigeminal digastric and stylohyoid muscles posteriorly, The muscular floor of the submandibular tri-
nerve. The vein is seen to emerge from the and the anterior belly of the digastric muscle angle consists of four muscles (Fig. 5). The
substance of the gland. anteriorly (Fig. 5). The inferior margin of the direction of the muscular fibers of each of the
The external carotid artery is related to body of the mandible creates a superior muscles is characteristic and allows for rec-
the medial boundary of the parotid space. boundary to this triangular area. The digas- ognition of the boundaries between neigh-
The internal carotid artery is slightly deeper. tric muscle attaches posterosuperiorly to boring muscles. These muscles do not lie in
The two vessels should not be confused. the mastoid process of the temporal bone, the same plane. The anterior muscles are
One must remember that the internal ca- posterior to the stylohyoid muscle, which more superficial than those posterior, which
rotid artery does not have any branches in arises from the posterolateral surface of the creates a step-like pattern to this muscular
the neck. Separating the external carotid styloid process. The two muscles quickly floor of the submandibular triangle. Passing
artery from the internal carotid artery are approach each other and remain in inti- from anterior to posterior, one encounters
the styloid process or stylohyoid ligament, mate contact down to the region of the the mylohyoid and then the hyoglossus mus-
the stylopharyngeus muscle, and the glosso- hyoid bone, where an intermediate tendon cle. The inferior portion of the superior con-
pharyngeal nerve. of this double-bellied muscle is found. This strictor muscle and the superior portion of
The stylohyoid muscle and the posterior tendon passes through a split in the tendon the middle constrictor muscle complete the
belly of the digastric muscle diverge at their of insertion of the stylohyoid muscle. The floor of the submandibular triangle.
points of attachment to the skull. The main intermediate tendon is bound to the hyoid The mylohyoid muscle (Fig. 6) is the
trunk of the facial nerve passes through this bone by a fascial thickening. The anterior most anterior and superficial of the muscles
interval. belly then passes superomedially and ends creating the floor of the mouth. It arises
At the junction of the cartilaginous por- by attaching to the internal aspect of the from the inner aspect of the mandible, and
tion and the osseous portion of the auditory mandible near the midline. The digastric the two halves pass inferomedially where
canal, a downward projection of cartilage muscle elevates the hyoid bone and assists the majority of the fibers insert into a mid-
frequently exists that points to the main in depression of the mandible. The poste- line fibrous raphe extending from the mid-
trunk of the facial nerve. rior belly of the digastric and the stylohyoid portion of the mandible to the center of the
When the external jugular vein is traced muscles is innervated by the facial nerve, body of the hyoid bone. The more posterior
superiorly to its parent structure, the retro- and the anterior belly of the digastric mus- fibers insert into the body of the hyoid bone.
mandibular vein, it leads to the interval be- cle is innervated by the mylohyoid nerve The two halves of the muscle create a floor
tween the superficial and deep lobes of the branch of the inferior alveolar nerve. This for the oral cavity. The mylohyoid muscle
parotid gland. It is also a means of locating
the cervical or mandibular branches of the
facial nerve, because they pass superficial
to the vein.
The stylomastoid branch of the posterior
auricular artery enters the stylomastoid fo-
ramen and is superficial to the facial nerve
trunk.
The internal jugular vein may be in con-
tact with the deep surface of the gland.

ANATOMY OF THE
SUPRAHYOID PORTION OF
THE ANTERIOR TRIANGLE
The posterior belly of the digastric muscle
and the hyoid bone divide the anterior trian-
gle of the neck into suprahyoid and infrahyoid
areas. The submandibular and submental
triangles are suprahyoid in position, and are
described in this chapter.

ANATOMY OF THE
SUBMANDIBULAR
TRIANGLE
The submandibular triangle is part of the an-
terior triangle of the neck and is suprahyoid
in position. It is sometimes referred to as the
digastric or submaxillary triangle. Fig. 5. Musculoskeletal background and floor of the mouth.

www.medicalebookpdf.com

LWBK892_c22_p307-314.indd 310 10/28/11 4:53:25 PM

 Chapter 22: Anatomy of the Parotid Gland, Submandibular Triangle, and Floor of the Mouth 311

Neurovascular Structures
The structures that are superficial to the sub-
mandibular gland include the cervical
branch of the facial nerve and the distal ends
Lingual nerve
of the anterior facial vein and anterior branch
of the retromandibular (posterior facial)
vein (Fig. 7). These veins unite in the tissues
overlying the submandibular triangle, creat-
ing the common facial vein, which passes
Inferior
alveolar
inferiorly to empty into the internal jugular
nerve vein. Occasionally, the mandibular branch of
the facial nerve descends below the inferior
Hypoglossal nerve edge of the mandible and can be injured
when incisions are made in this area.
Structures in the submandibular triangle
Mylohyoid nerve found between the submandibular gland and
the mylohyoid muscle include the facial ar-
tery and the mylohyoid nerve and vessels.
The facial artery is the most superior of the
Sublingual gland
vessels that arise from the anteromedial sur-
Submandibular duct face of the external carotid artery. It begins in
Mylohyoid muscle (cut)
the carotid triangle, just superior to the tip of
the greater cornu of the hyoid bone, passes
Submandibular gland deep to the posterior belly of the digastric
(superficial portion)
muscle, and enters the submandibular tri-
angle. It passes superiorly and reaches a point
well above and medial to the lower edge of
Fig. 6. Submandibular triangle and floor of the mouth. This figure illustrates nerve contents and super-
the body of the mandible. It then passes over
ficial and deep portions of the submandibular gland.
the superior and lateral surfaces of the gland
and is adherent to these surfaces. It now
arches superiorly in contact with the exter-
nal surface of the mandible, creating a groove
just anterior to the insertion of the masseter
presents a posterior free edge. When this Fascial Coverings muscle. It gives a submental branch that runs
muscle contracts, it raises the floor of the A fascial roof and carpet are created by the along the inferior surface of the mandible in

The Head and Neck

mouth, causing elevation and posterior dis- investing layer of the deep cervical fascia contact with the upper surface of the gland.
placement of the tongue. This is an integral when it splits to invest the submandibular Appearing at the anterior edge of the
part of the swallowing mechanism. gland. The superficial layer attaches to the gland are the mylohyoid nerve and vessels.
The hyoglossus is a quadrangular muscle inferior edge of the mandible, whereas the The nerve arises from the inferior alveolar
that arises from the entire length of the deep layer attaches to the inner aspect of branch of the mandibular nerve. Neurovas-
greater horn of the hyoid bone. It passes su- the mandible, just below the attachment of cular structures are found deep to the sub-
periorly and attaches to the lateral surface the mylohyoid muscle. mandibular gland, but on the other side of
of the tongue. Its deep relations include the (deep to) the mylohyoid muscle. They are
stylohyoid ligament, the glossopharyngeal Contents of the located in the interval between the hyoglos-
nerve, and the lingual artery. Passing super- sus and mylohyoid muscles, and are respon-
ficial to the hyoglossus muscle are the lin-
Submandibular Triangle sible for tongue function and nutrition.
gual nerve, the hypoglossal nerve and its two Submandibular Gland The lingual nerve, a branch of the man-
venae comitantes, and the submandibular The submandibular gland is the main con- dibular nerve, passes through the interval
duct. Those structures that are superficial tent of the submandibular triangle (Fig. 6). It until it reaches the anterior margin of the
to the hyoglossus muscle become deep rela- actually overflows and extends beyond its hyoglossus muscle. It then turns medially,
tions of the mylohyoid muscle when they boundaries. The gland wraps itself around after looping around the submandibular
reach the free posterior edge of the my- the posterior free edge of the mylohyoid mus- duct, and penetrates the tongue. It provides
lohyoid muscle and then travel in the inter- cle. This creates a superficial lobe that lies on general sensation for the anterior two thirds
val between these muscles. The hypoglossal the external surface of the mylohyoid and a of the tongue.
nerve innervates the hyoglossus muscle smaller deep lobe that lies internal to the my- The chorda tympani (arising from the fa-
and the other extrinsic tongue muscles, as lohyoid muscle. The duct of the gland passes cial nerve) joins the lingual nerve in the up-
well as all of the intrinsic muscles of the medial to the deep lobe and ends in the floor per part of the infratemporal fossa. It carries
tongue. The mylohyoid muscle and the an- of the mouth at a small elevation just lateral taste fibers from the tongue and brings
terior belly of the digastric muscle are in- to the frenulum. The lingual nerve at first is preganglionic parasympathetic fibers to the
nervated by the mylohyoid nerve, which superior to the duct as they both pass super- submandibular ganglion. This ganglion is
arises from the inferior alveolar branch of ficial to the hyoglossus muscle. The hypoglos- attached to the lingual nerve and is the site
the mandibular nerve. sal nerve is at a more inferior level. of synapse for these preganglionic fibers.

www.medicalebookpdf.com

LWBK892_c22_p307-314.indd 311 10/28/11 4:53:26 PM

 312 Part III: The Head and Neck

are also superficial to this muscle and are

closely related to the hypoglossal nerve.
The lingual nerve is superior to the deep
process of the submandibular gland and its
duct before forming a loop around the duct
by passing lateral and then inferior to it be-
fore penetrating the framework of the
tongue. The hypoglossal nerve and its venae
comitantes are inferior to the duct.
The hypoglossal nerve crosses the inter-
nal and external carotid arteries superfi-
cially. The glossopharyngeal nerve, the pha-
ryngeal nerves arising from the vagus, and
the stylopharyngeus muscle pass between
these same arteries, whereas the superior
Retromandibular
laryngeal nerve (arising from the vagus
vein nerve near the base of the skull) passes deep
to those arteries.
External Small nerve branches arise from the lin-
Facial artery gual nerve and submandibular ganglion,
carotid
and vein
artery which enter the submandibular gland. These
must be transected during excision of the
Internal gland to prevent avulsion injuries to the lin-
jugular
vein Submental vein
gual nerve.
(artery located
Common carotid
artery
under vien) ANATOMY OF THE
Submandibular SUBMENTAL TRIANGLE
gland
This space is found in the suprahyoid por-
tion of the neck (Fig. 8). It separates the sub-
Fig. 7. Submandibular triangle. mandibular triangles and contributes to the
structure of the floor of the mouth. The an-
terior bellies of the digastric muscles create
lateral boundaries of this triangle. The body
Postganglionic secretomotor fibers then cessory nerve). Named lymph nodes are lo- of the hyoid bone is the base, and the apex is
pass to the sublingual and submandibular cated in the internal jugular channels, which the symphysis menti. The mylohyoid creates
glands. The hypoglossal nerve and lingual are found where double-bellied muscles a muscular floor. Its fibers arise from the
veins are also seen in this region. Accompa- pass superficial to the internal jugular vein mylohyoid line, on the medial aspect of the
nying these neurovascular structures is the (i.e., jugulodigastric and jugulomylohyoid). mandible; pass inferomedially; and attach
submandibular duct (Wharton duct). The to the body of the hyoid bone and a midline
deep lobe of the submandibular gland is also raphe found between the hyoid and the
found internal to the mylohyoid muscle.
Anatomic Aids mandible. Contraction of the muscle will re-
The mandibular and cervical branches of sult in elevation of the floor of the mouth.
the facial nerve may extend below the lower The mylohyoid branch of the inferior alveo-
Lymphatic Drainage edge of the mandible. All other structures of lar nerve provides motor innervation. The
The lymphatics of the submandibular gland concern lie deep to the posterior belly of the investing layer of the deep cervical fascia
are found within its parenchyma, whereas digastric muscle. Incisions can be made creates a fascial roof. The only contents of
other lymph nodes are outside the fascial down to this muscle with little fear of injur- the triangle are the submental lymph nodes,
covering of the gland. The lymphatics of the ing any vital neurovascular structures. which drain the tip of the tongue, floor of
mandibular region can be divided into hori- The fascial coverings of the submandib- the mouth, lower lip, and chin. Efferent
zontal and vertical systems. The horizontal ular gland are less adherent to the gland channels pass to the submandibular nodes,
chain runs along the mandible from the pa- surface than are the coverings of the pa- or to jugular nodes of the vertical cervical
rotid gland to the midline, receiving afferent rotid gland. This allows for easier enucle- chain. Anterior jugular veins are found in
channels from the ipsilateral face and oral ation of the submandibular gland. the tissues superficial to the submental tri-
cavity. The lymphatics of the submental tri- The facial artery is very adherent to the in- angle. Incisions made in this area will not
angle also drain into this horizontal system. ternal and superior surfaces of the gland and injure major neurovascular structures.
From this submandibular collecting area, must frequently be removed with the gland
vertical channels pass to the system of nodes after proximal and distal control is obtained. ANATOMY OF THE FLOOR
related to the internal jugular vein (deep The hyoglossus muscle is an anatomic OF THE MOUTH
cervical nodes). Other vertical channels pass landmark. It is superficial to the glossopharyn-
into the posterior triangle to the superficial geal nerve and the lingual artery but is found The mylohyoid muscle is the anatomic
posterior cervical system ( found with the internal to the lingual and hypoglossal nerves, structure that separates the oral cavity from
external jugular vein) and the deep posterior the submandibular duct, and a deep process of the neck, and thereby creates the floor of
cervical system ( found with the spinal ac- the submandibular gland. The lingual veins the mouth. The attachments of this muscle

www.medicalebookpdf.com

LWBK892_c22_p307-314.indd 312 10/28/11 4:53:27 PM

 Chapter 22: Anatomy of the Parotid Gland, Submandibular Triangle, and Floor of the Mouth 313

Submandibular Sensory innervation of the anterior portion

triangle Anterior belly of of the floor of the mouth is provided by the
digastric muscle
lingual nerve. Traveling with this nerve are
fibers of the chorda tympani (seventh) nerve,
which provides taste sensation for the ante-
Submental
triangle rior portion of the tongue, and pregangli-
onic secretomotor fibers on their way to
Hyoid bone synapse in the submandibular ganglion be-
fore proceeding to the submandibular and
Posterior belly of
sublingual glands. Sensation and taste for
digastric muscle the posterior one-third of the tongue are
Omohyoid muscle
provided by the glossopharyngeal nerve.
Thyrohyoid muscle
Sternohyoid
muscle Sternothyroid Vascular Supply
muscle (cut)
The vascular supply to the tongue is provided
Sternocleidomastoid by the lingual artery, which arises from the
muscle
external carotid artery in the carotid trian-
gle, passes into the submandibular triangle,
and enters the region of the floor of the
mouth after passing deep to the hyoglossus
muscle. It gives a sublingual branch and then,
as the deep lingual artery, passes to the apex
of the tongue just lateral to the midline. Little
communication exists across the midline be-
tween the left and right deep lingual vessels.

Contents of the Floor of the Mouth

Geniohyoid Muscle
The geniohyoid muscle originates just be-
low the origin of the genioglossus and
passes anteroinferiorly to attach to the body
Fig. 8. Submental triangle.
of the hyoid bone. The left and right parts of
this muscle lie side by side. When they con-
tract, the hyoid bone is displaced anteriorly
teroinferiorly and attach to the lateral sur- and superiorly.
have been mentioned previously. The hyo-

The Head and Neck

face of the tongue, where they interdigitate
glossus muscle contributes a posterolateral with the fibers of the hyoglossus muscle.
boundary to this separation between the Salivary Glands and Their Ducts
floor of the mouth and the submandibular The sublingual gland is found in the floor of
Intrinsic Muscles the mouth, between the geniohyoid muscle
triangle (part of the anterior neck). The floor The intrinsic muscles of the tongue consist
of the mouth can also be defined as the area and the mandible (Fig. 9). It is the smallest of
of longitudinal, horizontal, and vertical fi- the three paired salivary glands and frequently
between the tongue and its lateral mucosal bers that create an interlocking network.
reflections, and the mylohyoid muscle. has two systems of ducts. One is composed of
multiple ductules, which empty directly into
Movements the floor of the mouth. The second system
Tongue Because of the extensive interdigitation of consists of a duct (or ducts) of varying size
The tongue is a massive muscular structure the muscles of the tongue, a wide variety of emptying into the larger submandibular duct.
that faces the oral cavity and the pharynx movements are possible. In addition, the In this same area is found the deep process of
(Figs. 5 and 6). It is attached to the floor of the mylohyoid muscle is displaced by move- the submandibular gland and its duct. This
mouth, the mandible, and the hyoid bone. ments of the hyoid bone. These movements deep process may be of significant size and
are created by contraction of the suprahyoid may appear to blend in with the sublingual
Extrinsic Muscles and infrahyoid muscle groups. The mandi- gland. The submandibular duct, lingual nerve
The extrinsic muscles of the tongue include ble can be depressed by contraction of the and veins, and the hypoglossal nerve are me-
the genioglossus, hyoglossus, styloglossus, mylohyoid, stylohyoid, digastric, and ge- dial to the sublingual gland. Anatomic flow
and palatoglossus. The genioglossus muscle niohyoid muscles if the hyoid bone is fixed exists between the submandibular triangle
arises from the genial tubercles found on in position by contraction of the infrahyoid and the floor of the mouth (sublingual space),
the internal aspect of the midportion of the musculature. which allows for passage of the contents of
mandible and passes to most of the dorsum one area into the domain of the other.
of the tongue. The hyoglossus arises from Innervation
the hyoid bone, passes superiorly, and at- All of the intrinsic and extrinsic muscles of Lymphatic Drainage
taches to the lateral aspect of the tongue. the tongue receive their innervation from The lymphatic drainage of the floor of the
The styloglossus muscle arises from the tip the hypoglossal nerve. The one exception is mouth is complex. Lesions from the central
of the styloid process and the proximal part the palatoglossus muscle, which is inner- part of the floor of the mouth and the tip of
of the stylohyoid ligament. Its fibers pass an- vated by the pharyngeal plexus of nerves. the tongue can drain into submandibular

www.medicalebookpdf.com

LWBK892_c22_p307-314.indd 313 10/28/11 4:53:27 PM

 314 Part III: The Head and Neck

Submandibular glands on either side, or drain directly into

ganglion submental nodes, and then into subman-
Cut edge of dibular nodes (horizontal system). The
hyoglossus drainage is then directed primarily toward
muscle
the deep cervical system, which is associ-
Lingual nerve ated with the vertical system of lymphatics
found with the internal jugular vein. Some
spread may occur to the superficial poste-
External rior cervical system in the posterior trian-
carotid artery
gle, which is found with the external jugular
vein. The lymph drainage from the poste-
rior part of the tongue is directly into the
Digastric muscle Tongue Deep lingual deep cervical nodes of either or both sides.
(posterior belly) artery

Anatomic Aids
Little communication is found across the
midline of the tongue between the deep lin-
Internal
gual arteries. This limits blood loss at the
jugular vein Submandibular time of hemiglossectomy.
duct
Lingual artery
SUGGESTED READINGS
Lingual veins
Arnold M. Reconstructive Anatomy, 1st ed. Phila-
delphia: WB Saunders; 1968.
Delmas A. Atlas Aide-memoire d’Anatomie (Rou-
viere). Paris: Masson; 1991.
Hollinshead WH. Anatomy for Surgeons, 2nd ed.
New York: Harper & Row; 1971.
Fig. 9. Submandibular triangle and floor of the mouth (deep structures).

EDITOR’S COMMENT have led to tremendous differences in approach. of up to 80%. Shock-wave lithotripsy represents a
Interventional sialography and other radiologi- therapeutic alternative of the first choice in the
cally controlled methods such as ultrasound- parotid gland and the fragments may be extracted
This is not an area in which general surgeons have guided techniques and sialendoscopy all have in an endoscopically controlled manner.
a great deal of experience. Even theparotid gland been developed lately and make the therapy of in- Stones are difficult to feel manually. I recently
which does appear every now and then in a busy flammation of the gland a much more direct and had a patient who had a neck procedure elsewhere
surgical practice yields little familiarity to the av- informed concept than just taking the gland out. and developed pain in her neck and it appeared as
erage general surgeon. This may be different in the If there is direct visualization of the findings with- she pointed to the right side of the neck that she
case of the rural general surgeon in which setting out the use on contrast material and with lack of probably did have a sialadenitis of the submandib-
there is probably no ear, nose and throat surgeon exposure to radiation, there is a high success rate. ular gland with a sympathetic adenopathy going
and the area of tenderness may be beyond the There are other gland preserving techniques such down the entire right neck. I had started her on
expertise of the general practitioner or the fam- as transoral duct slitting or transcutaneous stone antibiotics prior to seeing her because that what it
ily physician. While the general surgeon may have retrieval which likely will not be utilized by the sounded like and indeed she told me that an ENT
some familiarity with parotid disease in this case average general surgeon. In this nicely authored person she had seen years ago that she had stones
the most important aspect is to know the differ- article there is an algorithm for the treatment of in her duct. I could not feel it nor could I milk any-
ence between a parotitis and some type of tumor, various diseases of the salivary glands starting thing out through the bottom of the mouth but I
many of which are benign, in the case of the sub- with the necessity of oral therapeutic diagnostic am certain that’s what she had. It subsided.
mandibular gland and the submaxillary gland examination which include, as mentioned earlier, In the parotid gland which is not the subject
there is even less familiarity with inflammation. ultrasound and sialendoscopy. Ultrasound en- of this particular exposition the 25% of all stones
The most common malady that the general ables the presumptive diagnosis to make quickly, have an intraparenchymal location and therefore
surgeon is called upon to treat is a chronic sialad- safely and cost effectively and in the hands of ex- are more difficult to deal with.
enitis. It’s commonly associated with an acute perienced people with great precision. Endoscopy Stenoses are another major cause of symp-
chronic inflammation and an obstruction of the serves as a direct determination of the obstruc- tomatic sialadenitis and may be seen by endos-
excretory duct. But the differentiation between tion. Endoscopy controlled treatment such as in- copy. However some stenoses may be multiple,
chronic sialadenitis and obstruction of the excre- terventional sialendoscopy also is a boon to non- they may be in difficult locations, they may be
tory duct is difficult even the best of circumstances. destructive operations on the salivary glands. long and the tissue of the stenosis may be fi-
Stones are responsible for about 60–70% and may Less than 5 mm stones and mobile stones brotic. Sialendoscopy has the advantage of a
occasionally be palpated, stenosis in 15–25%, and located in the main excretory ducts and possi- direct assessment and does allow an inflamma-
inflammation of the duct alone in about 5–10%. bly even as far as the first and second branching tory stenosis to be differentiated from a fibrous
Anatomic variations or foreign bodies (the latter ducts may be successful in the hands of the skilled stenosis. The major of the inflammatory stenoses
difficult to comprehend) are only about 1–3%. In endoscopist of which most general surgeon will may be treated non-operatively with irrigation
the past as Koch M, et al. (Otolaryngology Clinics not be. The stones may be fragmented during in- and intraductal steroid placement. In regard to
of North America 2009;42:1173–1192) point out tervention and the fragments then retrieved by the submandibular gland, symptom free steno-
the operative removal of the gland was recom- endoscopically controlled means. Micro-instru- sis, especially if one can recognize atrophy of the
mended as the therapeutic method of choice after ments also exist but probably will require a spe- gland require no or exclusively conservative form
unsuccessful non-operative treatment. As with cialist. Radiologically controlled or fluoroscopic of treatment. The basic treatment rule applies for
many other things, minimally invasive techniques methods can be preformed with a success rate symptomatic stenosis, as inflammatory stenoses

www.medicalebookpdf.com

LWBK892_c22_p307-314.indd 314 10/28/11 4:53:27 PM

 Chapter 23: Lip Reconstruction 315

are treated primarily non-operative whereas fi- Ranulas, so named for frogs, may be the result Finally Yu C, et al. Journal of Oral and Maxillo-
brous stenoses are operated on. This is an exten- of inspissated mucus and may not be an indica- facial Surgery 2010; 68:1770–1775 writing from the
sive paper and the detail that is contained in it is tion of malignancy or a situation which requires Shanghai 9th People’s Hospital at Shanghai Univer-
beyond the scope of what I wish to impart but it excision of the duct or the gland. Should such sity report on endoscopy observation and manage-
is readable and informative and the practitioner excision be required however Kauffman RM, ment of obstructing submandibular sialadenitis.
who deals with these may want to avail them- et al., Laryngoscopoe 2009;119:502–507 propose 128 cases, a very substantial number, were identi-
selves of the wisdom in this particular paper. a transoral surgical approach to excising the fied endoscopically and radiographically. They had
Beahm, David D, et al. (International Journal submandibular gland. They describe relevant three types of sialoliths in 114 or 89%, mucus plugs
of Surgery 2009;7:503–509) reviewed the surgical anatomy and what to avoid. They describe nine in 8 (6%) and stenosis in 5% (6). 47 were removed
approaches to the submandibular gland. Surgi- patients in which this approach was attempted successfully for a success rate of 92% of 51 obstruc-
cal incision of the submandibular gland is com- over the past ten years. Of the nine patients who tions treated surgically. Of 63 patients treated us-
monly indicated in patients with neoplasm or oc- underwent attempted transoral submandibu- ing interventional sialendoscopy, 52 were removed
casional with chronic sialadenitis and ranula and lar gland excision, eight operations were com- with a success rate of 83%. The remaining unsuc-
drooling. In the past, traditional SMG surgery has pleted transorally and only one operation was cessful cases were treated endoscopically or surgi-
involved a direct transcervical approach while aborted and converted to a standard external cally. Obstructive symptoms were relieved in 12 of
more recently alternative approaches through approach because of severe scarring. Six of the 14 patients without stones using dilation and ir-
the submandibular gland excision have been de- nine patients had chronic sialadenitis and three rigation under sialendoscopy. Of the 114 patients
scribed to avoid scarring and to offer minimally had obstructing sialoliths. Three other patients with a stone, the sialoliths of 67 (59%) in the distal
invasive options with better cosmetic results. presented with other benign cystic lesions con- region behind the first molar. It stands to reason
In this paper the authors utilize dissection of sistent with a ranula, an infected mucocele, and that their conclusion that the more posterior the
cadavers which were dissection via both the a cystic teratoma. The only complication with a stone the more difficult it was to remove and that
transcervical and transoral approaches together patient with incisional breakdown and delayed was correct. Three patients with treatment failure
with the use of endoscopic assistance when indi- healing because of a prior irradiated field. The underwent resection of the gland. A basin-like
cated. The authors conclude that while tradition lingual nerve, or hypoglossal nerves, were spared structure in the hilus region was found in 67%. In
submandibular gland excision (nobody seems to and there were no hemostatic complications. The 5 patients a fishbone was found surrounded by a
both much with the submaxillary gland) a direct authors conclude that this option actually is safe sialolith. The authors conclude that this is a rela-
transcervical approach is what is preferred. The and there are no external scars. Obviously some tively new technique and is sparing of the subman-
modes of excision include open, endoscopic and skill and association with a thorough knowledge of dibular gland and holds great promise. I agree.
robotic-assisted dissections. anatomy is useful. J.E.F.

23 Lip Reconstruction
Bernard T. Lee and Samuel J. Lin

The Head and Neck

Partial or total reconstruction of the lip may There is an additional distinction be- Wound healing by secondary intention
arise in settings such as trauma, recon- tween the reconstruction of the upper or should not be an option in lip reconstruction
struction of an ablative defect, and congeni- lower lip. The two structures provide differ- except in the most dire of circumstances.
tal settings. As carcinoma of the lip is the ent degrees of function and aesthetics. Aes- Generally, healing by secondary intention
most common oral cavity malignancy (ap- thetic restoration of the upper lip is more will cause the formation of cicatrix, limiting
proximately 30%), it is crucial to have a challenging as the result is more visible and mobility, speech, and oral competence. Split-
clear plan for reconstruction. The major the scars are less forgiving. Functional res- thickness skin grafts provide temporary cov-
goals of lip reconstruction are to provide a toration of the upper and lower lip have dif- erage of defects but have less than satisfac-
functional and aesthetic outcome. To re- ferent goals as both structures are dynamic tory aesthetic results in most areas of the lip
store function, access to the oral cavity independently. The lower lip functions in and are clearly seen even years postopera-
must be restored along with oral compe- multiple axes in order to maintain oral com- tively. Full-thickness skin grafts are useful for
tency. Restoration of aesthetic appearance petence; however, the upper lip function in- secondary correction of lip contracture but,
is equally important as the lips are a focal cludes not only oral competency, but it also like split-thickness grafts, leave noticeable
point for facial and verbal expression. plays a role in phonation and speech. scarring.
Defects of the lip are classified by thick- Although there are many different op- The quality and texture of the lips are ex-
ness, location, and overall size. As these de- tions and specific eponyms associated with tremely difficult to recreate; therefore local
fects may involve skin, muscle, and mucosa, lip reconstruction, an understanding of the flaps represent the best option for defects
the treatment plan must be tailored to re- principles is far more important. As with that cannot be closed primarily. Specialized
construct each layer individually. The loca- any defect, the reconstructive “ladder” ap- structures of the lip such as the vermilion or
tion is also critical as the vermilion border, plies to lip reconstruction with respect to mucosa are ideally reconstructed with avail-
philtral column, and commissure prove to be defect size, patient condition, and goals of able local tissue, as there are no adequate al-
difficult areas to reconstruct. Finally, the size the operation. The range of options span ternatives. Although local flaps provide suit-
of the defect correlates with the ease (or dif- from wound healing by secondary intention, able color match, adequate thickness of lip
ficulty) of reconstruction; in general, defects primary closure, skin grafting, composite reconstruction, and generally acceptable
⬍30% can be closed with local advancement grafting, local flaps, regional flaps, and free scarring in the setting of trauma or tumor ex-
flaps; however, defects ⬎60% often require tissue transfer with incremental degrees of tirpation, there are several points of caution.
complex or multiple options for closure. complexity based on the presenting defect. The transposed segment may be somewhat

www.medicalebookpdf.com

LWBK892_c23_p315-320.indd 315 10/28/11 4:52:54 PM

 316 Part III: The Head and Neck

adynamic following transfer; additionally, nose. The vermilion–cutaneous border has carcinoma, which affects the lower lips pre-
secondary revision may be required due to a white roll that can be easily seen at Cupid’s dominantly. The most common tumor of the
the “pin-cushioning” effect of the differing bow. The vermilion is separated into dry upper lip is basal cell carcinoma. Complete
levels of native tissue versus flap. Recon- and wet surfaces; the dry vermilion repre- excision of the tumor with clear margins is
struction of the commissure requires special- sents the red color of the external lip and necessary prior to a complex reconstruc-
ized local tissue rearrangement that is be- the wet surface is the mucosal border where tion; Mohs’ micrographic surgery is preferred
yond the scope of this chapter (i.e., Z-plasties, the upper and lower lips contact. at many centers to achieve local control.
V–Y advancement flaps). The muscular anatomy mainly consists of Lip reconstruction after trauma is most
Wound contracture can create further the elliptical orbicularis oris muscle, which commonly seen after dog bites. These inju-
distortion after reconstruction and lead to encircles the lips as a sphincter. The muscle ries are often complex and of full thickness.
poor functional and aesthetic outcomes. Scar has eight segments, each in a fan-shaped dis- In the setting of a large composite ampu-
contracture is problematic and even with tribution from the modiolus. In the upper tated part, microsurgical replantation is
ideal planning of scar location can compro- lip, the orbicularis oris muscle inserts into indicated if the labial vessels can be identi-
mise excellent results over time. Microstomia the opposite philtrum and functionally com- fied. Pediatric burns to the commissure
is another complication seen in lip recon- presses and everts the lip. Accessory muscles were previously common from children bit-
struction and should be avoided if possible. serve to elevate or depress the lips. The leva- ing on electrical cords; however, these inju-
Finally, unlike other specialized structures of tor labii superioris, levator anguli oris, and ries are becoming exceedingly rare.
the face (ears, nose, eye), there are no pros- the zygomaticus major and minor elevate
thetics that can substitute reconstruction. the upper lip. The depressor labii inferioris
Before proceeding with any reconstruc- and the depressor anguli oris muscle depress
TREATMENT
tive procedure, it is important to discuss the lower lip; the latter also moves the com- Reconstruction of the lip requires an indi-
with the patient and family realistic expec- missure inferior and lateral. Finally, the men- vidualized approach as no two defects are
tations. As it is not possible in most circum- talis muscle elevates and protrudes the cen- the same. Defects of the upper lip (Table 1)
stances to restore a perfectly normal lip, tral portion of the lower lip. are treated differently from defects of the
the surgeon must establish realistic goals. The buccal branch of the facial nerve in- lower lip (Table 2) and will be discussed
Along with informed consent, preoperative nervates the orbicularis oris and elevator separately. As the treatment of a superficial
and postoperative photographic documen- muscles. The marginal mandibular branch of defect is extremely different compared with
tation is important for the medical record, the facial nerve innervates the lower lip de- a full-thickness defect, they will also be dis-
especially in the setting of traumatic inju- pressors. The infraorbital nerve provides sen- cussed separately. Finally, reconstruction of
ries that may lead to medicolegal review. sory innervation to the upper lip whereas the the vermilion and commissure are both im-
mental nerve supplies the lower lip. The main portant and difficult and will be addressed
ANATOMY vascular supply to the lips is from branches at the end of the chapter.
of the facial artery as the superior and infe-
The lips can be pictured as having a hexago- rior labial arteries supply the upper and
nal shape with a superior and inferior bor- lower lips, respectively. The facial artery sup-
UPPER LIP
der, and paired lateral borders both superi- plies the lateral nasal and angular arteries, Regional anesthesia for the upper lip can be
orly and inferiorly. These borders consist of both important for local flap blood supply. performed with an infraorbital nerve block.
a junction of specialized tissue, the vermil- The infraorbital nerve is located 7 mm be-
ion, between the hair-bearing skin and mu- low the infraorbital rim and at the midpupil-
cosa. The superior border is in the form of
INDICATIONS lary line lateral to the ala. A 25-gauge needle
the Cupid’s bow, a curvilinear shape with The indications for lip reconstruction are is introduced lateral to the alar base and di-
two apices. These two apices represent the straightforward as the most common etiol- rected superiorly toward the infraorbital fo-
lower junction to the philtral columns, ogy is from neoplasm or trauma. The most ramen. An intraoral approach can also be
which extend superiorly to the base of the common tumor of the lips is squamous cell used by injecting directly above the canine.

Table 1 Reconstruction of the Upper Lip

Method Use Advantage Disadvantage Potential complications
Primary closure Defects up to 30% of lip No additional incisions May shorten lip Change in oral competence
A to T closure Superficial defects up to 30% Closure of defects adjacent to Only for small defects Vermilion notching
vermilion
Perialar crescentic Lateral lip defects 30% to 60% Good scar location Can only be used for Vermilion notching
excision isolated defects at
the lateral lip
Abbe/Estlander Defects 30% to 60% of lip Potential for sensory Staged surgery Vascular compromise
restoration Relative microstomia Vermillion notching
Full-thickness lip tissue Lip asymmetry
transfer
Restoration of orbicularis oris
Karapandzic (reversed) Defects greater than 60% of lip Preservation of muscle and Microstomia Poor scar location
sensory function

www.medicalebookpdf.com

LWBK892_c23_p315-320.indd 316 10/28/11 4:52:55 PM

 Chapter 23: Lip Reconstruction 317

Table 2 Reconstruction of the Lower Lip

Method Use Advantages Disadvantages Potential complications
Primary closure Defects up to 30% No additional incisions May shorten lip Change in oral competence
Visible hypertrophic scar
A to T closure Superficial defects Closure of defects adjacent to vermilion Only for small defects Vermilion notching
Abbe/Estlander Defects 30% to 60% Potential for sensory restoration Staged surgery Vascular compromise
Full-thickness lip tissue transfer Relative microstomia Vermillion notching
Restoration of orbicularis oris Temporary denervation Lip asymmetry
Gillies fan Defects 30% to 60% Less microstomia Lack of motor and sensory Oral incompetence
function
Karapandzic Defects 30% to 60% Preservation of muscle and sensory Microstomia Poor scar location
function Inversion of vermillion
Bernard–Burrow– Up to total lip defect Good aesthetic result Microstomia Postoperative drooling
Webster Potential for preservation of muscle Insensate
function
Fujimori gate Up to total lip defect Closure of large defects Adynamic reconstruction Vascular compromise

Superficial Defects adjacent to the vermilion border are best re- Primary closure of defects adjacent to the
constructed with an A to T closure. Defects philtrum that are closed primarily may shift
Superficial defects of the upper lip are com- located within the philtrum can be left to the philtrum; however, over time it will re-
mon from resection of basal cell carcinoma. heal secondarily or reconstructed with a full- turn toward its midline position.
Defects smaller than 1 cm in size are com- thickness skin graft. Finally, an inferiorly Defects of the central upper lip are more
monly closed primarily with judicious un- based nasolabial flap can provide coverage of difficult to correct when they are full thick-
dermining. The direction of closure prefer- large defects of the upper lip. ness. Primary closure of the philtrum will
ably creates a vertical incision to mask result in a flat appearance of the upper lip.
within the relaxed skin tension lines. Mu- The best option for reconstruction of a cen-
cosal defects are often closed primarily or
Defects Less than 30% tral defect is an Abbe lip-switch flap (Fig.
allowed to heal secondarily. Full-thickness defects require closure of the 2A,B). This two-stage procedure transfers a
Options for closure of defects that are 1 to inner mucosal layer, the muscle, and the full-thickness lower lip flap with a vascular
2 cm in size are based on location. For lateral skin. In defects that are less than 30% of the pedicle at the vermilion border that in-
defects, a cheek advancement flap can facili- upper lip, primary closure is possible after a cludes the labial artery. The flap is designed

The Head and Neck

tate closure as lateral tissue is recruited to- wedge resection without significant risk of to reconstruct the entire philtral subunit
ward the midline. For medial defects adjacent tightening. It is critical that the vermilion although typically the width of the flap is
to the philtrum, a perialar crescentic ad- border is reapproximated meticulously as 50% of the defect. After 2 weeks, the blood
vancement flap is often used (Fig. 1). Lesions any break in the white roll is easily visible. supply and pedicle are divided.

A B

Fig. 2. Upper lip reconstruction with an Abbe flap. (A) Lesion of upper lip and Abbe flap creation at
Fig. 1. Upper lip reconstruction with a perialar lower lip, (B) after flap transposition to the upper lip. Note that a second-stage procedure is necessary
crescentic excision and advancement flap to divide the vascular supply.

www.medicalebookpdf.com

LWBK892_c23_p315-320.indd 317 10/28/11 4:52:55 PM

 318 Part III: The Head and Neck

Defects between 30% and 60% mental crease if possible as a hypertrophic

band may form. Conversion of the incision
In defects that range from 30% to 60% mul- to a flared W-plasty or barrel-shaped exci-
tiple local flaps are often necessary as pri- sion may be necessary.
mary closure is not possible. Lateral por-
tions of the defect are often closed with a
laterally based cheek advancement flap or a Defects between 30% and 60%
perialar crescentic flap. Central defects in- As in the case of the upper lip, closure of
volving the philtrum are often reconstructed lower lip lesions of this size may require
with the aforementioned Abbe flap; how- multiple flaps. A two-staged Abbe flap can
ever, large defects up to 50% of the lip can be be used for reconstruction of the lower lip,
reconstructed with this flap as well. A naso- recruiting tissue from the lateral upper lip.
labial flap is another alternative for defects The Abbe flap should be designed at 50% of
in this size range. Lateral lip defects that the width of the lower lip defect. The maxi-
involve the commissure are best recon- mum amount of donor tissue from the up-
structed with an Estlander flap, which is a per lip is one-fourth of the lip, or 2 cm. In
modification of an Abbe flap and also uses lesions that involved the commissure, an
lower lip tissue for reconstruction. Estlander flap can also be used for small de-
fects Fig. 4A,B). This flap, however, can lead
Defects Greater than 60% Fig. 3. Primary closure of lower lip defect. to microstomia.
For larger lesions that do not involve the
Large upper lip defects are rare and pose a commissure, a Gillies fan flap can be de-
difficult challenge. Once again, multiple flaps signed (Fig. 5). Like the Estlander flap, the
will be necessary. For example, bilateral na- lower lip exhibits a great amount of elastic- Gillies flap is a rotation advancement of
solabial flaps and an Abbe flap can be used ity. When necessary, bilateral advancement cheek tissue based on the superior labial
to recreate a large central defect. Patients flaps can be designed to facilitate closure. artery. The flap is based laterally and ro-
with little skin laxity are best reconstructed Defects adjacent to the vermilion border tates around the commissure, advancing
with reversed Karapandzic flaps. By recruit- can be reconstruction with an A to T flap. tissue from the nasolabial fold. The design
ing large areas of adjacent tissue, microsto- Mucosal defects can be either closed pri- of the flap denervates the tissue, which can
mia is common after a Karapandzic flap. marily or left to secondary healing. be problematic with function.
In the absence of suitable local tissue, a The Karapandzic flap is essentially a
free tissue transfer may be necessary. The modification of the Gillies flap; however,
most common free flap used for this pur- Defects Less than 30% it maintains motor and sensory function
pose is a radial forearm flap. The main dif- In full-thickness defects less than 30% of (Fig. 6). As muscle function is maintained,
ficulty with free flaps for lip reconstruction the lower lip, primary closure is simple as it provides certain advantages over a Gilles
is the difference between the donor and re- mucosa, muscle, and skin are reapproxi- flap. Perioral incisions are made along the
cipient tissue as the free flap is often bulky mated with alignment of the vermilion bor- nasolabial crease and the innervation to
with a poor color match. In addition, the der. The lack of a central structure in the the orbicularis muscle is preserved. Micros-
lack of muscle in the reconstruction pre- lower lip facilitates closure. The inferior ex- tomia is common and the cutaneous scars
vents proper lip mobility and motion. There tent of this incision should avoid the labio- are not well hidden.
may be a tendon graft that is used in con-
junction with a radial forearm free flap for
structure placed from one modiolus to the
other modiolus.

LOWER LIP
Regional anesthesia for the lower lip can be
performed with a mental nerve block. The
mental nerve is located in the same vertical
plane as the infraorbital nerve and the mid-
pupillary line. Eversion of the lower lip will
expose the nerve, which is visible in the
mucosa. A 25-gauge needle is introduced at
the mucosa 1 cm lateral to the canine at the
buccal sulcus.

Superficial Defects
Primary closure of superficial defects of the
A B
lower lip is often possible as reduction in
the width of the lower lip is tolerated with Fig. 4. Lower lip reconstruction with an Estlander flap. (A) Lesion of lower lip and Estlander flap cre-
minimal distortion (Fig. 3). In addition, the ation at lateral upper lip. (B) After transposition to the lower lip.

www.medicalebookpdf.com

LWBK892_c23_p315-320.indd 318 10/28/11 4:52:57 PM

 Chapter 23: Lip Reconstruction 319

facial skin to the mucosal surfaces within

the lip. “Wet” vermilion is defined as the
area of mucosa in contact between the up-
per and lower lip. “Dry” vermilion is defined
as the pink to red external color of the lip
not in contact between the upper and lower
lips. The white roll of the vermilion is the
area of tissue positioned between the ver-
milion mucosa and lip skin. This structure is
crucial for serving as a landmark when re-
constructing the lip. As with any structure
in the body, it is important to reconstruct
the anatomic layers involved. Specifically,
the orbicularis musculature is important to
repair in addition to the mucosal surface of
the lip and the wet/dry vermilion. Generally,
at repose the upper lip projects 2 to 3 mm
anterior to the lower lip. Furthermore, re-
construction of the lip should resolve any lip
Fig. 5. Lower lip reconstruction with a Gillies fan Fig. 7. Lower lip reconstruction with a Bernard– incompetence; for instance, with the upper
flap. Burrow–Webster flap. and lower teeth in a closed position, the up-
per and lower lips should meet. Any discrep-
ancy or step-offs on the order of 1 to 2 mm
vermilion. Near-total lower lip defects can in the vermilion may be noted at conversa-
Defects Greater than 60% tional distance.
be reconstructed with this flap.
Reconstruction of defects greater than 60% Total lower lip may be reconstructed us- When marking the white roll and land-
of the lower lip poses a difficult challenge. ing bilateral Fujimori gate flaps (Fig. 8). marks of the lip, many surgeons utilize a
Multiple flaps are often necessary as in the These large nasolabial flaps are inferiorly 25-gauge hypodermic needle. The hollow
upper lip and an Abbe flap is often used in based on the angular artery; however, up- aspect of a hypodermic needle can be useful
combination with other procedures. Clo- per lip animation can be affected from den- in controlling the amount of dye that is
sure of subtotal lower lip defects often in- ervation. Reconstruction of the vermilion is transferred to the cutis. It is important to
volve bilateral Gillies or Karapandzic flaps. performed by recruiting adjacent mucosa apply methylene blue sparingly when de-
The Bernard–Burrow–Webster flap may or tongue flaps. In the absence of available marcating the anatomic borders of the lip
be used for large lower lip defects (Fig. 7). local options for reconstruction a free tis- to avoid runoff of the dye into the surgical
Advancement of medial cheek skin and sue transfer may be necessary. field distorting the marks.
subcutaneous tissue is combined with tri- For smaller defects of the vermilion, pri-

The Head and Neck

angular excisions at the nasolabial fold and mary closure or partial wedge resection are
lateral chin. The neurovascular structures
VERMILION potentially first-line options. Free mucosal
can be preserved to maintain muscle func- The vermilion extends from the junction of grafts from the palate are another option
tion and mucosa is used to reconstruct the the upper and lower lips with the external for limited defects of the vermilion less than
2 cm. Though this adds an additional re-
mote donor site, this is a potentially useful
graft donor site that has other uses in re-
construction.
For minor discrepancies of the white bor-
der and vermilion border, a simple Z-plasty
may be adequate. For more extensive defects
of the vermilion, a V–Y advancement flap
may be required. In the case of near-total or
total ablation of the vermilion (e.g., lip shave
or total vermilionectomy), there are several
options. One option involves advancement
of the existing labial mucosal tissue as a
bipedicled flap. Though initially there may
exist a color difference between the mucosal
flap and the native lip, the chronic exposure
outside the oral cavity causes a keratiniza-
tion of the reconstruction over time. Another
local pedicled flap option is the anterior
tongue flap. This local flap requires a staged
procedure that involves the initial attach-
Fig. 6. Lower lip reconstruction with a Karapandzic Fig. 8. Lower lip reconstruction with a Fujimori ment of the flap to the lip and subsequent
flap. gate flap. flap pedicle division.

www.medicalebookpdf.com

LWBK892_c23_p315-320.indd 319 10/28/11 4:53:00 PM

 320 Part III: The Head and Neck

For defects involving the oral commis- release of cicatrix and providing greater ex- ACKNOWLEDGMENTS
sure, local mucosal advancement of the cursion of the lip.
buccal mucosa is available. The facial artery For smaller defects of the oral commis- The authors would like to thank Carin H.
musculomucosal flap (FAMM) is a useful sure that involve the commissure and no Han for her help with pictures and illustra-
axial flap that can be used for various de- greater than 1 cm of either the upper or tions.
fects of the oronasal cavity; the FAMM flap lower lip, a vermillion advancement flap and
is an option for resections of the vermilion an A to T closure of the commissure is one SUGGESTED READINGS
greater than 40%. In selected cases, an or- option. In this setting, a vermillion advance-
bicularis oris local muscle flap is an option ment flap is performed for the oral lining, Abbe R. A new plastic operation for the relief
of deformity due to double harelip. Med Rec
for adding bulk to the lip reconstruction. and the external defect is converted to nearly 1898;53:477.
an isosceles triangle prior to excision of cu- Estlander JA. A method of reconstructing loss of
taneous cones in order to close the defect. substance in one lip from the other lip. Arch
Commissure For larger defects of the upper or lower Klin Chir 1872;14:22.
Reconstruction of the commissure requires lip involving the commissure, the most Fujimori R. Gate flap for the total reconstruction
an understanding of the unique anatomic common method of reconstruction is the of the lower lip. Br J Plast Surg 1980;33:340.
Godek CP, Weinzweig J, Bartlett SP. Lip recon-
structure of this area. The commissure, Estander flap. This flap is relatively easy to struction following Mohs’ surgery: the role for
rather than simply being the “corner” of the conceptualize and perform, as it can be composite resection and primary closure. Plast
mouth, has the distinctive ability of having adapted for reconstruction of either upper Reconstr Surg 2000;106:798.
the appearance of an angle at repose or with or lower lip defects that involve the com- Karapandzic M. Reconstruction of lip defects by
the mouth slightly open, while at the same missure. One drawback of the Estlander local arterial flaps. Br J Plast Surg 1974;27:93.
time being able to fully extend to length flap is its inherent effect on overall lip cir- MacGregor IA. Reconstruction of the lower lip.
when the mouth is fully open. Similarly, it is cumference, which decreases when per- Br J Plast Surg 1983;36:40.
Tobin GR, O’Daniel TG. Lip reconstruction with
a pitfall to simply attempt to reconstruct the forming this flap. motor and sensory innervated composite flaps.
commissure as an acute angle intraopera- Other described methods of commissure Clin Plast Surg 1990;17:623.
tively. Invariably, this acute angle acts as a reconstruction include the Fries, Gillies and Walton RL, Beahm EK, Brown RE, et al. Microsur-
stricture that may limit the patient’s ability Millard, Platz and Wepner, Converse, Zisser, gical replantation of the lip: a multi-institution-
to enunciate certain words, feed orally, fully Converse, and Kazanjian Roopenian I and II al experience. Plast Reconstr Surg 1998;102:358.
be able to use their mouth/lips for facial methods. Although these flaps are beyond Webster JP. Crescentic peri-alar cheek excision
for upper lip flap advancement with a short
expression, and have full excursion of the the scope of this chapter, in general the history of upper lip repair. Plast Reconstr Surg
mouth. In patients who present for revisional other methods utilize a combination of ad- 1955;16:434.
procedures following lip reconstruction, re- vancement flaps from the lateral existing Zide BM. Deformities of the lips and cheeks. In:
vision commissuroplasty remains a required cheek and may involve advancement flaps McCarthy JG, ed. Plastic surgery, Vol 3. 9th ed.
performed procedure frequently involving from the oral mucosa. Philadelphia: WB Saunders; 1990;2009.

EDITOR’S COMMENT closure. It is important, as the authors state, be- are generally restricted to defects confining less
tween the upper and the lower lip. The two struc- than two-thirds of the lip to avoid microstomia.
tures provide different degrees of function and In the current practice the reconstruction of
Reconstruction of the lip is perhaps one of the aesthetics. The upper lip is more challenging; the defects in excess of this usually involves advanc-
most sensitive and functionally important re- result is more visible; and, as the authors state, ing flaps that require significant cheek laxity or
pairs in plastic surgery. While carcinoma of the “the scars are less forgiving.” A functional restora- free tissue transfer. In this paper the authors
lip is the most common oral cavity malignancy, tion of the upper and lower lip has different goals describe a lower lip reconstruction technique in
it is crucial to have a clear plan for reconstruc- as both structures are dynamic “independently”; which the flaps are extended by recruiting tissue
tion. Briefly stated, the major goals of lip recon- the lower lip functions in multiple axes and is re- from the perioral cheek, allowing reconstruction
struction (lips after all are one of the first things quired to retain oral competence so the patient “of near-total and total lower lip defects which
that an individual sees in another human being) does not drool and is able to hold their food. The would normally not be reconstructible using the
are to provide both a functional and an aesthetic upper lip functions include not only oral compe- standard technique.” Of course, neurovascular
outcome and access to the oral cavity for eat- tency, but also speech and phonation. structures are carefully dissected and maintained
ing, which must be restored together with oral Many of the repairs that are described are to ensure enervation and perfusion. They report
competency so that the patient does not drool. specifically eponymic but the understanding of eight patients underwent successful single-stage
The lips are the focal point for facial and verbal principle is much more important. The healing lower lip reconstruction. Three cases required
expression, so doing a first-class cosmetic recon- needs to be by primary intention; otherwise, bilateral extended Karapandzic flaps for total
struction is essential. scarring is extraordinarily difficult. Having said lower lip defects. In five additional cases, only
The defects may involve muscle, mucosa, that, the evolution of the various types of flaps unilateral Karapandzic flaps were combined with
skin, the vermillion, the white roll, the philtral has gone in one direction, that is, incorporation other flaps, done locally, for near-total defects.
column, and the commissure, which may prove of other different types of tissue including muscle The critical test of success was that all patients
to be difficult areas to reconstruct. The success in from orbicularis oris, for example, or parts of the achieved oral competence at normal or near-
lip reconstruction relates to the size of the defect cheeks that are innervated and in general things normal mouth opening. Complications included
and the ease or difficulty of reconstruction. De- that will extend the range of lip repair has be- one fistula that healed with conservative therapy
fects less than 30% are usually closed with local come more common. For example, Hanasono and and one hematoma. The authors in denominating
advancement flaps as the author states. However, Langstein (Plast Reconstr Surg 2011;127:1199– the advantages of this approach indicate that the
when defects in the upper or low flips are greater 205) describe Karapandzic flaps, which consist color match of the reconstructed lip is superior
than 60%, the repairs require complex and mul- of well-vascularized, sensate lip tissue that have to reconstructions relying on tissue transfer from
tiple reconstructions and different options for been elongated because the Karapandzic flaps distant sites. Given the fact that one looks at an

www.medicalebookpdf.com

LWBK892_c23_p315-320.indd 320 10/28/11 4:53:01 PM

 Chapter 24: Surgery for Cancer of the Oral Cavity 321

individual straight on with a local reconstruction, However, considering the defect that one began significance was achieve in columella-to-Cupidís
it is no wonder that the authors claimed that this with, the proper Cupidís bow that relates this bow distance, nostril gap area, and nostril height
extensive repair is complex, takes a long time, but seems to be an excellent way to go about a dif- (P  0.08, P  0.001, and P  0.001.) The alar
probably does extremely well for the patient. ficult repair. base-to-interpupillary distance is shown in Fig-
Another extension of partial-thickness ver- Cleft lips and palates are some of the most ure 2 and the nostril gap area is measured in
milion defect with a mucosal V-Y advancement difficult repairs for young people particularly in Figure 1. Both pictures are convincing, and, of
flap encompassing the orbicularis oris muscle developing countries. Gosla-Reddy et al. (Plast course, as the old wheeze a typical result is shown
is reported by Jin et al. from Peking Union Medi- Reconstruct Surg 2011;127:761–7) reported on a (meaning itís our best one) but it is impressive.
cal College ( J Plast Reconstr Aesthetic Surg 2011, complete unilateral cleft lip utilizing an Afroze In commenting on this paper, S. Anthony Wolfe,
64:472–6). They once again begin by stating that incision with primary septoplasty and evaluated a Millard trainee working in Florida, compared
when the length of defect is greater than half the by a standardized two-dimensional photographic two incisions to repair a complete unilateral cleft
vermilion and the width of the defect is greater analysis. This is a high-volume center in which lip. The author again comes down on the side of
than 1.5 cm it is impossible to correct this defect there were 1,200 patients reported, of which a the rotation advancement for all unilateral clefts.
using the traditional mucosal V-Y advancement prospective cohort study of 190 consecutive pa- He states that he does not perform precisely the
flap. They therefore describe a modified mu- tients with complete unilateral cleft lip and al- way Millard illustrated in Cleft Craft but by using
cosal V-Y advancement flap in which they have veolus with cleft lip were treated with or without the McComb method for nasal correction, which
recruited the orbicularis oris muscle and point septoplasty using the Afroze incision technique. often does not require a vestibular incision. The
out that this flap possesses the mobility sufficient Of the 190, 76 patients with primary septoplasty photographs look very nice and it would appear
to serve as the pedicle for transfer and for repair were evaluated and compared with 82 operated that when Dr. Wolfe is finished with this that it is
of large vermilion defects. Eight patients were on without septoplasty. The evaluation was car- very difficult to tell that the patient was born with
repaired in this fashion between August 2006 ried out by assessing symmetry with alar base- a crippling cosmetic defect. Certainly activities
and January 2009. A satisfactory cosmetic and to-interpupillary line distance, columella-to- such as this are in the highest level of craft and
functional outcome occurred in all cases, which Cupidís bow distance, nostril gap area, nostril can be commended for any child who has his or
in fact is correct utilizing the viewing of Figure 2 width, and nostril height. The result in this large her life ahead of him and it is nice to know that
and Figure 3 in the case of the upper lip despite volume of patients indicated that patients oper- it can be reconstructed as well as these children
the fact that in Figure 3 one can tell that there has ated on with primary septoplasty showed more can be.
been some work done on the left side of the face. nasal symmetry than patients without. Statistical J.E.F.

24 Surgery for Cancer of the Oral Cavity

William R. Carroll

In 1893, the 24th president of the United States overall 5-year survival rate is 61.2. Racial/ ryngeal cancers. These cancers more com-
set sail on a clandestine cruise from New York ethnic disparity for oral cancer is among monly arise in the oropharynx than in the

The Head and Neck

to his summer home in Massachusetts. On the most striking of all cancer types and is oral cavity, often involving the oral cavity by
board, physicians had transformed the deck most evident among men. Five-year sur- direct extension. HPV-related cancers often
to a makeshift operating room. Grover Cleve- vival rates are 63.7% for white men and develop in younger patients and have a bet-
land was anesthetized and a malignant oral 38.3% for black men. Causes of the dispa- ter prognosis than non-HPV tumors. Cancer
cavity tumor was resected. The president re- rate survival rates likely include comorbidi- of the lip is classified with oral cancer and is
covered and lived another 16 years. The oper- ties, later-stage disease at presentation, dif- strongly correlated with sun exposure in
ation was later described as a remarkable ferences in treatment received, and possible fair-skinned individuals. Acquired immune
procedure for the time. Ulysses Grant, Sig- biologic differences in the tumor and host. deficiency syndrome (AIDS) patients, trans-
mund Freud, George Harrison, and Sammy Eighty to ninety percent of oral cancers plant recipients, and others who are immu-
Davis Jr. all suffered from oral cancer. are squamous cell carcinoma. Roughly 90% nocompromised by disease or medical ther-
of patients use tobacco in some form and apy are at increased risk for oral cancer. The
INCIDENCE, MORTALITY, 75% use alcohol. The effect is synergistic and cancers that occur in these individuals are
AND ETIOLOGY the relative risk of developing oral cancer is unfortunately biologically very aggressive.
increased 16-fold for individuals who use Genetic changes within the oral mucosa
Worldwide, oral cavity cancer is the sixth both. The risk of developing a second pri- are measurable well before the development
most common cancer type. The American mary tumor is also dramatically increased of invasive carcinoma. Chronic exposure to
Cancer Society estimates that 28,500 new in those who continue to smoke following carcinogens damages DNA over the mucosal
cases of cancer of the oral cavity and phar- initial treatment (37% vs. 6% risk). field. The “field effect” of altered mucosa may
ynx occurred in the United States in the Disturbing cases of oral cancer are also be evident as far as 7 cm from an established
year 2010. Approximately 7,600 die of the seen in patients without obvious risk factors. malignancy. These alterations may activate
disease. The mean age at diagnosis is 63 Other possible causes include prolonged mi- or amplify oncogenes that promote tumor
years and over 70% of patients are male. Un- nor trauma from poor dentition, a diet low cell proliferation and inhibit or inactivate tu-
fortunately, the overall survival rates for in fruits and vegetables, immunosuppres- mor suppressor genes. Tumor cells are able to
oral cancer have not improved significantly sion, and exposure to the human papilloma- escape programmed cell death and prolifer-
in the past 20 years. Surveillance Epidemi- virus (HPV). HPV subtypes 16 and 18 are ate self-sufficiently. Seventy to eighty percent
ology and End Results (SEER) data from the closely linked with cervical cancer and are of oral premalignant lesions contain changes
National Cancer Institute reveal that the implicated in 15% to 20% of oral and oropha- in chromosome 9p21, which encodes the

www.medicalebookpdf.com

LWBK892_c24_p321-333.indd 321 10/28/11 4:52:05 PM

 322 Part III: The Head and Neck

tumor suppressor genes p16 and p14ARF. The symptoms include a mass, persistent hali- investigators have shown, however, that
epigenetic process of methylation of these tosis, or bleeding. Trismus, loose teeth, neck depth of invasion correlates directly with
genes is the apparent mechanism of inactiva- mass, and difficulty with speech or swal- frequency of nodal metastasis. Most sur-
tion. Mutation of the p53 tumor suppressor lowing usually indicate more advanced dis- geons feel that a T1 tumor with a depth of
gene has received much attention in the lit- ease. When symptoms persist longer than invasion greater than 4 mm has a greater
erature but is probably a later event in malig- 3 weeks, a focused examination for oral chance of developing nodal metastases than
nant transformation. p53 mutations at the cancer is imperative. a T2 or T3 tumor that is very superficial.
margin of resection have also been correlated Oral cancer arises most commonly in The staging workup for oral cavity tu-
with increased rate of recurrence despite his- the floor of mouth, followed by the lateral mors includes a complete physical examina-
tologically clear margins. tongue. The distribution by site is summa- tion with focused mucosal examination of
rized in Figure 1. Diagnosis is usually made the upper aerodigestive tract and careful
ANATOMY in the office by simple physical examination nodal examination. Careful palpation of the
AND CLINICAL and biopsy using local anesthesia. Oral can- oral cavity is crucial in the staging workup
cer is often very curable when detected at as many of these tumors have unsuspected
PRESENTATION an early stage. The same is not true of later- submucosal extension (particularly tongue
The oral cavity extends from the vermillion stage disease. The ease of examination and cancers). Computed tomography (CT) scans
border of the lips to the anterior tonsillar access for biopsy make late recognition of of the primary site and neck may assist ac-
pillar (Fig. 1). For staging purposes, the fol- disease particularly regrettable. curate locoregional staging. A search for dis-
lowing subsites are considered part of the tant metastases includes a chest radiograph
oral cavity: lip, oral tongue (anterior two- STAGING AND and liver function tests at a minimum. CT
thirds), floor of mouth, buccal mucosa, up- DIAGNOSTIC WORKUP scans of the chest and abdomen are indi-
per and lower alveolus, hard palate, and cated in patients considered to be at higher
retromolar trigone. The oral cavity has rich Oral cavity cancers are staged according to risk of distant disease. Positron emission to-
lymphatic supply and regional nodal metas- 7th edition (2010) American Joint Commit- mography (PET) scans are not considered a
tases are typically the first site of spread. tee on Cancer (AJCC) guidelines. T1 to T3 routine part of the staging workup for head
The primary lymphatic drainage basins are tumors are staged only on the basis of size and neck cancer at this time. Because sec-
the perifacial, upper jugular, submandibu- (Table 1). T4 tumors are subdivided into T4a ond primary tumors are detected in about
lar, and submental nodes. Sites close to the and T4b according to the degree of invasion 10% of patients, an examination under anes-
midline often drain bilaterally. of surrounding structures and ultimate re- thesia (direct laryngoscopy, esophagoscopy)
The most common symptom of oral can- sectability. The TNM staging system does is performed prior to treatment initiation.
cer is a nonhealing ulcer in the mouth fol- not yet include depth of invasion as a stag- Bronchoscopy is recommended only for pa-
lowed by persistent pain. Other common ing variable for oral cavity tumors. Many tients with evidence of subglottic disease,
persistent cough, or suspicious chest radi-
ography findings.
Imaging techniques designed to detect
dysplastic changes in oral mucosa may ulti-
mately improve early detection and margin
control for oral cavity cancer. Confocal mi-
Gingiva croscopy, radiolabeled antibodies to tumor
markers, narrow band imaging, and multi-
Hard palate wavelength fluorescence and reflectance
technology are technologies designed to
detect subclinical disease in at-risk patients
Buccal mucosa or to identify dysplasia at the margins of
known cancers.

Retromolar TREATMENT
trigone
Current treatment guidelines for head and
neck squamous cell carcinoma are pub-
Tongue
lished by the National Comprehensive Can-
Frenulum cer Network (www.nccn.org). The guidelines
include staging information, recommenda-
Floor of mouth
tions for pretreatment assessment, and a
balanced approach to treatment options for
oral cavity cancers. Optimal treatment of
head and neck cancer requires a multidisci-
plinary effort. Team members include a head
H
and neck surgeon, reconstructive surgeon,
RF

radiation oncologist, and medical oncolo-

‘0 6

gist. Speech and swallowing pathologists

rehabilitate function lost during multimodal
Fig. 1. Subsites of the oral cavity. therapy. Other important team members

www.medicalebookpdf.com

LWBK892_c24_p321-333.indd 322 10/28/11 4:52:05 PM

 Chapter 24: Surgery for Cancer of the Oral Cavity 323

Table 1 2002 American Joint Committee on Cancer TNM Staging System for the Lip and Oral Cavity
Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor 2 cm or less in greatest dimension
T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension
T3 Tumor more than 4 cm in greatest dimension
T4 (lip) Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face (i.e., chin or nose)
T4a (Oral cavity) tumor invades adjacent structures (e.g., through cortical bone, into deep (extrinsic) misuse of tongue (genioglossus,
hyoglossus, palatoglossus, and styloglossus), maxillary sinus, skin of face)
T4b Tumor invades masticator space, pterygoid plates, or skull base and/or encases internal carotid artery
Regional Lymph Nodes (N)
NX Regional nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
N2 Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension; or in multiple
ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none
more than 6 cm in greatest dimension
N2a Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
N3 Metastasis in a lymph node more than 6 cm in greatest dimension
Distant Metastasis (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Stage Grouping Histologic Grade (G)

N k
H d andd Neck
Stage 0 Tis N0 M0 GX Grade cannot be assessed
Stage I T1 N0 M0

The Head
Stage II T2 N0 M0 G1 Well differentiated
Stage III T3 N0 M0 G2 Moderately differentiated
T1 N1 M0
T2 N1 M0 G3 Poorly differentiated
T3 N1 M0
Stage IVA T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
Stage IVB Any T N3 M0
T4b Any N M0
Stage IVC Any T Any N M1

Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCC Cancer
Staging Manual, Sixth Edition (2002) published by Springer-Verlag, New York ( for more information, visit www.cancerstaging.net). Any citation or quotation of this material
must be credited to the AJCC as its primary source. The inclusion of this information herein does not authorize any reuse or further distribution without the expressed,
written permission or Springer Verlag, New York, Inc., on behalf of the AJCC.
Note: Superficial erosion alone of bone/tooth socket by gingival primary in not sufficient to classify as T4.

www.medicalebookpdf.com

LWBK892_c24_p321-333.indd 323 10/28/11 4:52:05 PM

 324 Part III: The Head and Neck

include dentists, prosthodontists, nutrition- these superficial defects to granulate. Heal- pairment of form or function. The typical
ists, and social workers. For patients with ing by secondary intention is preferable to a hospital stay is one or two nights, oral in-
advanced or recurrent disease, treatment closure that impairs mobility. Occasionally, take is resumed quickly, and patients typi-
recommendations are optimally considered a larger but very superficial lesion will be cally resume full activity within 3 weeks.
in a multispecialty tumor-board format. A excised at the submucosal layer. A thin split- Even those individuals with occupations
coordinated team approach is essential. thickness skin graft will cover a larger area demanding precise oral function (attorneys,
In this chapter, treatment of oral cancer effectively and speed the recovery process. professors, salespersons) have typically en-
will be divided into two main sections: A Commercially available dermal allografts joyed very favorable outcomes.
general discussion of early-stage and locally have been uniformly unsuccessful in the In planning resection, the surgeon must
advanced disease followed by specific rec- oral cavity in our hands. consider route of access, margin status,
ommendations for each subsite. The pri- bone involvement, and whether or not lym-
mary focus is surgical management. Alter- T1 and T2 Carcinoma phatics require treatment. Route of access
native options will be included but detailed of the Oral Cavity is preferably transoral for smaller lesions.
descriptions are beyond the scope of this The margins must be clearly visible, how-
chapter. Treatment of metastatic neck dis- Five-year survival rates are 85% to 90% for ever, and patients with full dentition or lim-
ease is covered elsewhere in this text and is stage I and 70% to 80% for stage II squamous ited oral opening can present access chal-
integral to proper management of the pri- cell carcinomas of the oral cavity. Single- lenges for even small lesions. A lip split and/
mary site. modality therapy is usually adequate. Sur- or mandibulotomy may be required for ad-
gery and radiotherapy are generally consid- equate visualization of margins. Margins of
Carcinoma In Situ or ered equally effective but in most cases 2 cm on all sides are ideal for these lesions.
surgery is preferred for early-stage disease. As a word of caution, the first attempt at
Microinvasive Carcinoma Radiation therapy for early-stage oral cavity removing these lesions has the greatest
Early, very superficial disease within the oral cancer is effective when delivered by either chance of success. Each subsequent at-
cavity is best treated by wide local excision. external beam or brachytherapy. Xerosto- tempt at salvage has a decreasing yield. To
When disease is limited to carcinoma in situ mia and dental disease are more commonly withhold a full curative effort for a minimal
on final pathology, an excisional biopsy with seen following radiotherapy and there is risk cosmetic or functional benefit is a disser-
clear margins is adequate therapy. The site of osteoradionecrosis of the mandible. Few vice to the patient.
should be followed closely clinically with studies have critically compared functional Bone will not be grossly invaded in these
a low threshold for rebiopsy or reexcision. outcomes of radiation therapy with surgery. early-stage I and II lesions, though dysplastic
Microinvasive carcinoma should be excised Whichever modality is chosen, treatment of mucosa or the main malignancy may ap-
with a 1- to 2-cm margin on the peripheral the primary site and neck should be consis- proach the teeth or mandibular periosteum.
and deep aspects. Frozen sections are stud- tent. In other words, if the primary site is In general, the periosteum is an effective bar-
ied intraoperatively as severe dysplasia at treated surgically and there is concern over rier if not previously radiated. If the tumor
the margin can be difficult to discern grossly micrometastases, the neck should be treated is freely mobile with relation to the bone,
(Fig. 2). Early-stage cancers of the floor of surgically as well. Likewise, if the oral cavity the periosteum is resected as a margin and
the mouth may involve the salivary ducts, is treated with radiation, the lymphatics are the bone preserved. The alveolar surface of the
and gain early access to the neck. The nodal treated similarly. mandible is vulnerable to microinvasion and
status requires careful assessment. Surgical treatment for stage I and II oral allows access to the medullary cavity through
Primary closure of the site is optimal if it cavity cancer is consistently recommended the tooth sockets. The risk of microinvasion of
can be accomplished without tethering the initially by our institution’s multispecialty the mandible is higher in an edentulous or
tongue or obliterating normal sulci. The sur- tumor board. Surgical treatment is effective previously radiated mandible. When tumor
geon should have little hesitation to allow and completed quickly with minimal im- directly invades the periosteum, that segment
of mandible should be resected with at least a
rim mandibulectomy.
The risk of micrometastasis to cervical
lymphatics is increased proportionally with
the depth of tumor invasion. As a general
rule, tumors that measure greater than 4 mm
in thickness are at risk, and treatment of cer-
vical lymphatics should be considered.

T3 and T4 Carcinoma
of the Oral Cavity
Large oral cavity cancers and those that
deeply invade the tongue, bone, or adjacent
spaces require multimodal therapy. Survival
rates for T3 and T4 squamous cell carci-
noma of the oral cavity are 50% to 65% in the
absence of nodal metastases. Nodal metas-
tases generally cut survival rates in half.
Primary surgical resection remains the pre-
Fig. 2. Leukoplakia of the lateral tongue. One nodular area contained microinvasive carcinoma. ferred initial treatment option. In contrast,

www.medicalebookpdf.com

LWBK892_c24_p321-333.indd 324 10/28/11 4:52:05 PM

 Chapter 24: Surgery for Cancer of the Oral Cavity 325

advanced oropharyngeal malignancies are can be closed primarily when no bone recon- incidence of nodal metastasis and an elec-
often treated initially with chemoradiation. struction is planned. The disfigurement is tive selective neck dissection should be con-
When planning resection, the surgeon again pronounced, however, and most patients sidered. Transoral access without lip split or
must consider the lymphatics, access, bone prefer immediate surgical reconstruction. mandibulotomy is often possible. Full den-
involvement, and reconstruction as these Return of a more normal appearance and tition or poor oral opening can make access
defects can rarely be closed primarily. ability to chew are important aspects of surprisingly difficult for small lesions. The
Surgical treatment of the neck to con- quality of life. Large glossectomy and full- patient should be prepared for mandibulo-
trol lymphatic disease and to provide ac- thickness buccal defects cannot be closed tomy for access should this occur.
cess to the primary tumor is routine. Rarely without supplemental tissue. Vascularized When deep dissection in the lateral floor
can a T3 or T4 lesion be adequately resected free tissue transfer has become the mainstay of mouth is combined with level 1 neck dis-
by a transoral-only approach. Exposure of of surgical reconstruction for large oral cav- section, a through-and-through defect often
the neck allows preservation of important ity defects. Soft tissue defects are usually re- results that can be surprisingly difficult to
neurovascular structures and facilitates paired with radial forearm, lateral thigh, or close. Pedicled flaps such as the platysma flap
management of the deep margin of resec- rectus abdominus flaps. Mandibular defects or submental island flap are useful to close
tion. Well-lateralized lesions that do not are managed with osteocutaneous flaps, the these small defects. Radial forearm free flaps
involve the deep tongue muscle may be ad- fibular flap being the most common. work very nicely as well. Pectoralis flaps are
equately managed with a unilateral neck often too bulky for small defects in this site.
dissection. Clinically N0 necks are treated SITE-SPECIFIC SURGICAL
with a selective neck dissection, which car-
ries very little morbidity (see Chapter 26).
MANAGEMENT T3 and T4 Carcinoma of the
Floor of Mouth
Edentulous patients with pliable perioral Floor of Mouth T3 and T4 floor-of-mouth lesions are usu-
soft tissue may not require a lip split for ac- ally resected in conjunction with cervical
cess from the oral side. Again, if visualiza- The floor of mouth is the most common site lymphadenectomy. A reasonable plan of
tion of the margins is impaired, lip split or for oral squamous cell carcinoma. The adja-
surgical progression is outlined below.
mandibulotomy is recommended as neces- cent ventral tongue and lingual surface of
These steps will be adaptable for other sub-
sary to allow proper exposure. Complete the mandibular alveolus are involved early
sites in the oral cavity as well.
tumor resection should be the primary as the tumor enlarges. Anteriorly, floor-of-
concern. mouth lesions often involve the subman- 1. Repeat examination under anesthesia.
Gross invasion of the mandible man- dibular ducts and contralateral nodes are Assess size, depth, structures involved,
dates a segmental resection. Whenever at risk. CT scans are useful in preoperative and proximity to mandible. Finalize
possible, the entire medullary cavity of the staging to assess tumor extent, nodal sta- thoughts on access and bone invasion.
mandible should be resected. Tumor invad- tus, and early mandibular invasion. 2. Tracheotomy
ing the mandible can spread widely through 3. Percutaneous gastrostomy. If a short pe-
the loose cancellous bone. For example, if a T1 and T2 Carcinoma of the riod of tube feeding is anticipated, place
lesion invades the midbody of the mandible, Floor of Mouth a nasogastric tube at the conclusion in-
segmental resection of bone with a 2-cm T1 and T2 lesions of the floor of mouth are stead.

The Head and Neck

margin is combined with rim removal of treated with wide local excision (Fig. 3). A 4. Neck dissection. Extent determined by
the remaining medullary cavity back to the margin of 2 cm is recommended and frozen nodal status. See Chapter 26 for details.
sigmoid notch. section control of margins intraoperatively 5. Approach primary. Split lip and perform
Reconstruction will often require more may avoid overlooking severe dysplasia stair-step mandibulotomy anterior to the
than primary closure. In some lateral com- in surprisingly normal-appearing mucosa. mental foramen if necessary for access
posite resections, surprisingly large defects Lesions deeper than 4 mm have a higher (Fig. 4). For large tumors with gross bone
invasion, plan the mandibulotomy at the
anterior margin of bone resection. Bend
and apply reconstruction or fracture
plates prior to cutting bone unless the
tumor extends through the lateral cor-
tex. This step optimizes dental occlusion
postoperatively. If segmental composite
resection is planned, tumor visualization
will be easier if the posterior bone cuts
are completed at this time as well.
6. For tumors that contact the mandible
without gross bone destruction, per-
form a rim mandibulectomy to remove
the occlusal surface and medullary cavi-
ty of the involved bone (Fig. 5). Take care
in edentulous patients as the inferior
mandibular remnant may be very thin
and prone to pathologic fracture.
7. Distract the mandible at the anterior
osteotomy and visualize tumor margins.
Fig. 3. Early-stage carcinoma of the anterior floor of mouth. Make mucosal cuts 2 cm from obvious

www.medicalebookpdf.com

LWBK892_c24_p321-333.indd 325 10/28/11 4:52:07 PM

 326 Part III: The Head and Neck

H RF ‘ 0 6
Horizontal
part of
incision
HR

in labiomental
‘0 Stair-step
F

6 crease
osteotomy
A B

r ‘0 6
Fische
HR

Fig. 4. Transmandibular access to the floor of mouth. A: The

Tumor lip split incision. The angles, based on the labiomental crease,
prevent downward contracture from scarring. B: Stair-step
osteotomy anterior to the mental foramen spares sensation
of the lip. C: Distraction of the segments allows exposure of
the floor-of-mouth lesion.
C

disease. As dissection progresses deeper, with ligatures. Do not rely on cautery for 9. Inspect the defect and determine closure
revisualize the hypoglossal nerve in the the larger branches. method. Avoid primary closure under
neck as it will often enter the tongue 8. Remove the specimen and inspect. Ori- tension or closures that will significant-
medial to the tumor and can be pre- ent the specimen for pathology. Check ly tether the tongue. Often, the recon-
served. Control lingual artery branches margins with frozen sections structive team will have proceeded with
flap elevation during the final phases of
tumor extirpation.

Tongue
T1 and T2 Carcinoma of the Oral Tongue
Tongue cancers frequently have submu-
cosal extension well beyond the visible
margin. Palpation and imaging studies are
helpful in accurate staging. T2 and deep T1
06
F‘

(4 mm) tongue cancers have occult meta-

HR

static rates approaching 30%. Treatment of

the neck is usually recommended.
Small lateral tongue lesions can be
widely excised with very little morbidity.
These malignancies are generally more
easily visualized than floor-of-mouth
Fig. 5. Rim mandibulectomy to resect disease involving periosteum or minimally invading the mandible. lesions and rarely require lip split or man-
Resection includes the medullary cavity of the mandible. dibulotomy. If possible, a deep wedge

www.medicalebookpdf.com

LWBK892_c24_p321-333.indd 326 10/28/11 4:52:07 PM

 Chapter 24: Surgery for Cancer of the Oral Cavity 327

A B

Fig. 6. Resection of T1 carcinoma of the lateral tongue. A: Pedunculated lesion of the lateral tongue. B: Vertical excision and
closure maintains optimal mobility.

resection is designed in a vertical plane

maintaining 2-cm margins at the periph-
eral and deep margins. The vertical resec-
tion allows closure of lateral tongue to cor-
responding lateral tongue and minimizes
tethering (Fig. 6). Horizontal closure, in
contrast, tethers the dorsal tongue to the
floor of mouth and impairs mobility. Re-
section of superficial T2 tumors of the
lateral tongue results in a defect involving
most of the lateral surface (Fig. 7). These
defects should be covered with a thin
skin graft or allowed to granulate. The pa-
tient begins tongue mobility exercises early
to prevent scar contracture and loss of
function.
Dorsal tongue cancers are less common.

The Head and Neck

Fig. 7. Following resection of a T2 superficial lesion of the lateral tongue, primary closure is not feasible These lesions are resected in a sagittal plane
without severe restriction of motion. Options for closure include a split-thickness skin graft or healing if possible and closed primarily. Function is
by secondary intention. usually excellent.
T3 and T4 Carcinoma of the Oral Tongue
As noted, larger tongue cancers will require
multimodal therapy. No treatment option
has been found to be superior to surgery
followed by radiotherapy for carcinoma of
the oral tongue. These tumors may extend
laterally into the adjacent mandible, or me-
dially into the deep root of tongue muscu-
lature.
Large lateral tongue lesions are ap-
proached as described above under “Floor
of Mouth.” Osteotomies render the resec-
tion easier because the exposure is gener-
ous. These resections are the classic “com-
mando” or “tongue–jaw–neck” procedures
described for decades in the head and neck
literature (Fig. 8). Primary closure of the
A B buccal mucosa to the tongue remnant is of-
ten possible and speech and swallowing
function are surprisingly good. The patient
Fig. 8. Composite resection for advanced oral tongue cancer involving the mandible. A: The cheek flap is unable to chew, however, and the appear-
is reflected following a lip split. The bone cuts are positioned after determining the location of tumor ance is dramatically altered. Immediate
invasion. B: If the tumor does not extend lateral to the mandible, a reconstruction plate can be coapted flap reconstruction is usually employed in
prior to making the bone cuts. modern resections.

www.medicalebookpdf.com

LWBK892_c24_p321-333.indd 327 10/28/11 4:52:07 PM

 328 Part III: The Head and Neck

5. No lip split is usually required for access.

The uninvolved floor-of-mouth mucosa
is incised on the side of the tumor and
continued onto the uninvolved contral-
ateral tongue, maintaining 2-cm mar-
gins. Dissection will frequently extend
across the midline. The mylohyoid mus-
cle is transected from below. Working
from above and below, the dissection
progresses until the anterior and lateral
cuts communicate from neck to oral
cavity. The specimen is then delivered
downward, under the intact mandible
and into the neck. Following this ma-
Fig. 9. Deeply invasive T3 carcinoma of the anterior tongue.
neuver, visualization of the posterior
cuts is simplified and resection is com-
pleted (Fig. 10).
For lesions that extend more centrally 1–3. Same as “Floor of Mouth” above. 6. Assess margins grossly and by frozen
into the deep root of tongue musculature, an 4. Neck dissection should be bilateral for section. Do not overlook deep tongue
alternative pull-through approach to resec- deep lesions extending toward the central margins, which will extend down to the
tion is required (Fig. 9). The steps are dis- tongue. A visor flap of the neck skin is raised hyoid bone.
cussed below. to the inferior border of the mandible.

Visor flap

Mandible Dorsal tongue

Mucosal incision
HR
HR

F ‘0

ch
Fis

er
‘ 06

A B

Tongue
HR

ch
Fis

er
‘ 06
Fig. 10. Pull-through approach for glossectomy. A: The skin flaps are elevated to the
lower border of the mandible. B: Intraoral cuts along the uninvolved floor of mouth
are connected with external cuts dividing the floor-of-mouth diaphragm. C: The spec-
imen is pulled downward and into the neck, allowing visualization of more posterior
C
cuts.

www.medicalebookpdf.com

LWBK892_c24_p321-333.indd 328 10/28/11 4:52:12 PM

 Chapter 24: Surgery for Cancer of the Oral Cavity 329

7. With an intact mandible, these lesions

are nearly impossible to close without a
pedicled or free flap.
8. If a large volume of tongue muscle is re-
sected, the flap reconstruction should
provide sufficient bulk to allow the
neo-tongue to contact the palate. This
will optimize speech and swallowing
postoperatively. A radial forearm flap
may not provide adequate volume in
this setting.
Large oral tongue lesions that arise more
posteriorly warrant special mention. Th ese
lesions often involve the base of tongue
extensively and/or may cross the midline
Fig. 11. A patient demonstrates an early buccal mucosal carcinoma caused by smokeless tobacco use.
anteriorly. Under these circumstances, Note the adjacent leukoplakia extending into the gingivobuccal sulcus.
surgical resection will require a near-total
glossectomy. The surgeon must carefully
explain the functional implications of such
a resection and ensure that the patient un-
derstands the alternative of concurrent ses occur early (40% for T2 lesions in one keep the following facts in mind when
chemotherapy and radiation with surgical meta-analysis). Early-stage carcinomas of planning treatment for advanced tumors
salvage. In this particular circumstance, this region are treated in a fashion similar in this region:
posttreatment function is probably supe- to the floor of mouth. Wide local excision
1. The layers of the buccal region are buccal
rior with initial chemoradiation. The pa- with 2-cm margins is recommended and
mucosa, submucosa, buccinator muscle,
tient may wish to try nonsurgical treat- primary closure for smaller defects is usu-
subcutaneous fat, and cheek skin. Once a
ment for organ preservation initially. ally easily accomplished. Thin skin grafts
lesion is deep enough to invade the buc-
Surgical salvage, if necessary, would still also provide adequate coverage if the un-
cinator muscle, the overlying cheek skin
require a total glossectomy. Though no di- derlying buccinator muscle is intact. For all
is potentially involved. Resection fre-
rect prospective comparisons exist for but the most superficial lesions, the bucci-
quently results in a through-and-through
oral tongue primaries, case series data nator should be taken as the deep margin
defect requiring at minimum local flap
suggest that concurrent chemotherapy of resection. Failure rates for early buccal
coverage.
with surgical salvage should provide com- carcinomas are high. Treatments for T1/T2
2. Deep posterior invasion from both
parable cure rates to surgery and adjuvant retromolar trigone (Fig. 12) lesions are
buccal and retromolar trigone tumors
radiation. similar.
extends toward the masseteric space.

The Head and Neck

Meticulous attention to this potential
T3 and T4 Carcinoma of the Buccal direction of spread is required to avoid
Buccal Mucosa and Mucosa and Retromolar Trigone local recurrence (Fig. 14).
Retromolar Trigone Large tumors of the buccal mucosa or ret- 3. The retromolar trigone mucosa provides
The buccal mucosa includes the pliable in- romolar trigine are difficult to manage reasonably thin cover over the ascending
ner lining of the cheek, extending from the (Fig. 13). The head and neck surgeon should mandible. Larger tumors quickly invade
maxillary alveolus superiorly to the man-
dibular alveolus inferiorly. Posteriorly, the
buccal mucosa is contiguous with the ret-
romolar trigone. The mucosa of the retro-
molar trigone covers the ascending ramus
of the mandible and extends posteriorly to
the anterior tonsillar pillar at the start of
the oropharynx. Carcinomas in this region
usually are squamous cell and may be ulcer-
ative, exophytic, or verrucous. Smokeless
tobacco users are at higher risk of forming
buccal cancer.
T1 and T2 Carcinomas of the Buccal
Mucosa and Retromolar Trigone
Tumors of the buccal mucosa are relatively
uncommon in the United States but are the
most common site of oral cancer in coun-
tries of Southeast Asia (Fig. 11). In India,
buccal cancer is the most common of all Fig. 12. T1 carcinoma of the retromolar trigone. These lesions often invade the adjacent mandible or
cancers occurring in men. Nodal metasta- masseteric space early.

www.medicalebookpdf.com

LWBK892_c24_p321-333.indd 329 10/28/11 4:52:14 PM

 330 Part III: The Head and Neck

A B

C D

Fig. 13. T4 carcinoma of the buccal mucosa with extension through overlying skin. A: Transbuccal extension B: Exten-
sive involvement of overlying skin C: Wide resection to include most of the right cheek; rectus free flap reconstruction.
D: Eighteen months postoperative. The patient was not interested in further flap debulking.

the bone and continue into the mastica- When there is bulky extension into the surgery and adjuvant radiation for buccal
tor space as noted above. tonsil or soft palate, concurrent radia- or retromolar trigone carcinomas.
4. Retromolar trigone tumors often extend tion and chemotherapy are given more 5. Perifacial nodes and parotid nodes are
posteriorly into the oropharynx. Many consideration as first-line therapy to pre- first-level nodal basins for these tumors.
clinicians consider the biologic behavior serve speech and swallowing function. As 6. Transoral exposure may be limited. Be
to be more consistent with oropharynge- is true for other oral cavity sites, however, prepared for a transfacial approach to
al carcinoma than oral cavity carcinoma. no treatment has been proven superior to improve access.

Masseter
muscle

Tumor in
masseteric
space

Tumor in
buccalmucosa
HRF ‘0

Tumor in
mandible
6

A
B
Fig. 14. T4 carcinoma of buccal mucosa. A: Extensive involvement of masseteric space demonstrated by CT scan. B: The
mandible and masseteric spaces illustrated here are the most common locations for failure of complete resection.

www.medicalebookpdf.com

LWBK892_c24_p321-333.indd 330 10/28/11 4:52:16 PM

 Chapter 24: Surgery for Cancer of the Oral Cavity 331

T3 and T4 Carcinoma of the Hard Palate

Larger palatal lesions characteristically in-
volve bone. Preoperative CT scans are very
helpful in assessing superior extension of
disease into the nose or maxillary sinus (Fig.
15). An inferior maxillectomy is usually re-
quired for complete resection. These lesions
may escape posteriorly into the pterygoid
plates and pterygoid musculature and ex-
tend to the skull base. The pterygomaxillary
space and foramen rotundum are sites of
disease persistence in deeply invasive pala-
tal carcinoma.
Reconstruction of palatal defects is es-
sential for speech and swallowing. Recon-
struction can be either prosthetic or surgi-
cal. A temporary dental obturator can be
placed intraoperatively or after the first
postoperative visit around day 10. A final ob-
turator can be fashioned a few months later
when soft tissue contraction has stabilized
(Fig. 16). The advantages are an open cavity
Fig. 15. Carcinoma of the palate extending upward into the maxillary sinus and illustrating the impor- for tumor surveillance and no additional
tance of preoperative scanning in tumor staging. surgical morbidity for the patient. The dis-
advantage is the requirement to maintain a
well-fitting obturator in order to enjoy nor-
Hard Palate of the hard palate may be managed with mal speech and swallowing. Many patients
wide local excision. Peripheral margins are frustrated by minor leaks or pain with an
T1 and T2 Carcinoma of the Hard Palate are managed as discussed above. If unin- improper fit.
Palatal carcinomas are uncommon. More volved periosteum is interposed between Surgical closure of larger defects typi-
nonsquamous cell cancers occur in the the tumor and underlying bone, bone re- cally requires free flap reconstruction. The
palate than in any other oral cavity loca- section may be unnecessary. If any doubt option is worthwhile for younger patients
tion. Minor salivary gland malignancies exists, the palatal bone can be drilled who will not be forced to maintain a well-
comprise the majority of other malignan- away down to the nasal mucosa without fitting prosthesis for the remainder of their
cies. All but the most superficial palatal creating an oronasal fistula. If a small fis- lives. Flap reconstruction is usually offered
lesions have the potential to invade the tula must be created, a rotational flap of at the time of primary excision. If doubt

The Head and Neck

underlying bone. The incisive and greater palatal mucosa or a buccinator myomu- about margins remains, a temporary obtu-
palatine foramina also provide pathways cosal flap will usually close the defect rator can easily be fashioned and the defect
for perineural dissemination. Thin lesions effectively. reconstructed secondarily.

A B C

Fig. 16. Minor salivary gland adenocarcinoma of the palate. A: Lesion involving left side of hard palate.
D
B: Defect with clear margins. C: Initial obturator fashioned by prosthodontist to fill defect. D: Obturator in
position allowing normal oral function.

www.medicalebookpdf.com

LWBK892_c24_p321-333.indd 331 10/28/11 4:52:19 PM

 332 Part III: The Head and Neck

thology involvement in the rehab process is tional support had fewer complications of
POSTOPERATIVE CARE recommended. Ultimate recovery of swal- treatment but decreased overall survival;
low function correlates inversely with the perhaps the nutritional support encour-
Oral cavity cancer patients average 62 volume of normal tissue resected. aged tumor growth. A reasonable approach
years of age at diagnosis and over 80% are Speech is also impacted by surgery for is to establish nutritional support during
long-term tobacco users. Cardiac disease, oral cancer. While speech is not a vital the initial patient contact but not to delay
peripheral vascular disease and chronic ob- function, the patient should be prepared treatment in the hopes of diminishing com-
structive pulmonary disease (COPD) are for the likelihood of speech difficulty and plications.
common comorbidities that impact post- provided with a means of communicating Previously radiated patients warrant
operative recovery and must be considered postoperatively. Hospitalized patients who special attention. Radiation dosages have
in the perioperative setting. While resec- are trach tube dependent and cannot escalated over the past decade and patients
tions for advanced head and neck cancer speak require special monitoring by nurs- commonly receive 70 gy—often with
may be tedious and time-consuming, re- ing staff as they cannot use the “nurse-call” concurrent chemotherapy. Fistula rates as
covery from surgery can also be surprisingly intercom system. high as 70% are reported with salvage sur-
brisk. The fluid shifts and physiologic stress gery for head and neck lesions following
common to intra-abdominal and intratho- chemoradiation. Tension-free closure and
racic surgery are often less severe. Patients COMPLICATIONS liberal use of vascularized tissue from re-
are typically encouraged to resume ambula- The best predictors of complications follow- gional or free flaps have been shown to di-
tion and enteral nutrition on the first post- ing surgery for oral cavity cancer are medi- minish fistula rates in salvage situations.
operative day. Whenever the upper aerodi- cal comorbidities, prior treatment with Fortunately, oral cavity cancers are less
gestive tract is surgically altered, however, radiation/chemotherapy, and cancer-related commonly treated with primary radiation,
the airway, swallowing, and speech require cachexia. The common cardiovascular, pul- and salvage surgery in a heavily radiated
special consideration. monary, renal, and wound-healing compli- field is not required as often as laryngeal of
The oral airway is compromised by post- cations encountered in general surgical pharyngeal primaries.
operative edema and added bulk from re- patients are seen in oral cancer patients
constructive flaps or gauze bolsters. Small as well.
lesions are typically removed with minimal Major complications in head and neck SUGGESTED READINGS
alteration in airway patency. Larger resec- surgery occur in approximately 10% of pa- American Cancer Society. Cancer Facts & Fig-
tions, particularly when combined with tients. Major complications include those ures 2009. Atlanta: American Cancer Society;
neck dissection, have the potential to pro- that require additional hospital stay, return 2009.
duce significant airway edema. Tracheot- to the operating room, or result in dimin- Beenken SW, Krontiras H, Maddox WA, et al. T1 and
omy is preferred over prolonged intubation ished recovery of function. The most com- T2 squamous cell carcinoma of the oral tongue:
because the patient can be ambulatory im- mon are wound infection, wound dehis- prognostic factors and the role of elective
mediately and the operative site more easily cence with fistula formation, bleeding, and lymph node dissection. Head Neck 1999;21:124.
Chhetri DK, Rawnsley JD, Calcaterra TC. Carci-
monitored. The surgical adage, “If you think aspiration pneumonia. noma of the buccal mucosa. Otolaryngol Head
you might need a trach, do it . . .” remains With small oral cavity resections, de- Neck Surg 2000;123:566.
relevant today. layed wound healing is a nuisance but not Choi S, Myers JN. Molecular pathogenesis of oral
There are two considerations related to often lethal. With larger resections, particu- squamous cell carcinoma: implications for
swallowing that are important to consider. larly those in continuity with the neck, therapy. J Dent Res 2008;87(1):14–32.
The first is when have the wounds healed wound complications can be lethal. Sali- Cooper J, Pajak TF, Forastiere A, et al. Postoperative
adequately to resume oral intake. The sec- concurrent radiotherapy and chemotherapy for
vary leak into the neck produces a polymi- high-risk squamous-cell carcinoma of the head
ond consideration is when can the patient crobial infection manifesting as cellulitis, and neck. N Engl J Med 2004;350:1937.
swallow again without aspirating. If the re- abscess, wound dehiscence, and potential Gillespie MB, Brodsky MB, Day TA. Swallowing-re-
section has created an opening from the hemorrhage from the great vessels. Steps to lated quality of life after head and neck cancer
oral cavity into the neck, the patient is at prevent wound complications include peri- treatment. Laryngoscope 2004;114(8):1362.
risk for salivary fistula formation. If there is operative antibiotics, meticulous attention Horner MJ, Ries LAG, Krapcho M, et al. SEER
no evidence of a leak, oral intake may re- Cancer Statistics Review, 1975–2006. Bethesda,
to obtaining a water-tight oral defect clo- MD: National Cancer Institute. http://seer.
sume for most patients on postoperative sure, and resumption of appropriate nutri- cancer.gov/csr/1975_2006/, based on Novem-
day 6 or 7. Even though an adequate seal tion. The question of whether to delay sur- ber 2008 SEER data submission, posted to the
is obtained, the swallow mechanism may gery while improving nutrition remains SEER web site, 2009
still be impaired. Altered capacity to move controversial in head and neck surgery. Hunter KD, Parkinson EK, Harrison PR. Profiling
food through the oral cavity and pharynx Baseline nutritional parameters may im- early head and neck cancer. Nat Rev Cancer
creates aspiration risk. Nasogastric or per- prove with aggressive preoperative nutri- 2005;5:127.
Urken ML, Moscoso JF, Lawson W, et al. A systematic
cutaneous endoscopic gastrostomy (PEG) tional support. There are data from a approach to functional reconstruction of the oral
tubes are commonly placed intraoperatively chemoradiation trial, however, suggesting cavity following partial and total glossectomy.
in anticipation of dysphagia. Speech pa- that patients receiving pretreatment nutri- Arch Otolaryngol Head Neck Surg 1994;102:589.

www.medicalebookpdf.com

LWBK892_c24_p321-333.indd 332 10/28/11 4:52:23 PM

 Chapter 24: Surgery for Cancer of the Oral Cavity 333

EDITOR’S COMMENT proven node-negative upon presentation are Speksnijder CM, et al. (Head Neck 2010, with-
generally just observed. The news, however, in out citation, published online, DOI, 10.1002/hed
this paper is that of the patients who recurred, 21573) dealt with a difficult area of deteriorated
Cancer of the oral cavity is a disease which in the mean time of neck recurrence was 6.2 masticatory performance. This series was taken
society is often associated with the underprivi- months. This suggests that the metastases were from several universities in the Netherlands, in-
leged. As a basis for the cancer of the oral cav- present in the neck at the time of presentation cluding Utrecht and the Nijmegen Medical Cen-
ity, they may smoke, they may take snuff, they and node resection was not carried out. Thirty- ter and dealt with the difficulties of mastica-
make drink alcohol to excess, and they may be two of the patients who were node-negative on tion, which affects quality of life (certainly) and
patients who are underprivileged or derelicts. physical examination at presentation recurred food choice (perhaps). The authors believe that
Because of this, they have not received ap- in the neck (30%). Two of the patients who were the altered food choice may result in lower in-
propriate care in a timely fashion. In addition, node-positive at presentation also recurred takes of key nutrients and weight loss, which is
the therapy for cancer of the oral cavity, which in the neck and the mean time for recurrence probably true. This proved to determine dental
manages to save lives, is very destructive and was 6.2 months. Among the 32 initially “node- status, bite force, and masticatory performance
results in surgical outcomes, which while may negative” patients who developed regional re- in 45 patients with squamous cell carcinoma
be curative of the disease, may be an ongoing currence, there were antecedent seven cases of the tongue and/or floor of mouth. These
problem for the patient in swallowing, nutri- of local recurrence, and 22 cases of isolated patients were examined and weighed before
tion, and so forth. regional recurrence. Figure 1 of this paper re- surgery and various times after surgery and/or
Because of this, the paper by Morris LGT, veals the regional failure rate with 38% of pT4 radiotherapy.
et al. (Head Neck 2011;33:824–830), from the Head and 18.7% of pT1, and the rest in between. In The authors conclude, not surprisingly, that
and Neck Service at Memorial Sloane Kettering, Figure 3, disease-specific survival according to surgical intervention had a large, negative im-
is most welcome. This is not a common disease, regional recurrence status is given, and at the pact on all functions. Postoperative radiotherapy
and so the 139 patients with squamous cell car- end of 60 months, those patients without re- actually worsened oral function. Recovery of oral
cinoma of the hard palate and maxillary alveolus, gional recurrence had an 81% survival, and 41% function 1 year after surgery was less prominent
from 1985 to 2006, represent a fairly large series. of patients who did have regional recurrence in the group receiving both surgery and radio-
The incidence rates of regional metastasis at survived, which is statistically significant at the therapy than surgery alone.
presentation and at recurrence were calculated. P  0.001 level. The results suggest strongly for It is difficult to ascertain whether or not
They also attempted to determine what the etiol- elective node resection independent of what these patients had significant weight loss. The
ogy was of recurrence and what was associated the nodes feel like, and if there are a significant authors seem more interested in maximum
with it. hard palate or alveolus cancer, elective node re- bite pressure and dentition and mixing ability
Not surprisingly, regional failure occurred section should be carried out. than the actual outcome as far as weight loss,
in 28.4% of patients and was of course associ- Another troublesome tumor is reviewed by preferring dentition index. Presumably, the
ated with the extent of disease and the patho- Kokemuller H, et al. (Head Neck Oncol 2011;3), loss of dentition index and bite force resulted
logic T classification, which ranged from 18.7% who reviewed the German experience over 30 in a poorer outcome as far as weight mainte-
(pT1) to 37.3% (pT4). T classification was an years of 341 patients with squamous cell carci- nance with these patients.
independent predictor of regional recurrence- noma of the tongue treated in the Department An attempt was made to determine whether
free survival on multivariate analysis. Sadly, as of Head and Neck Surgery in Hanover, Germany. or not there are various growth factor influences
the authors state, most patients (66%) with re- Average follow-up was 5 years. A total of 309 of with tumor differentiation in oral squamous
gional recurrence were not able to be salvaged. the 341 patients received surgical therapy, and cell carcinoma. Hanabata Y, et al. (Odontology,
Interestingly, however, the recurrence was not of these, 10% had neoadjuvant therapy and 20% published online, 2011) determined whether or
local, despite the alarming title of the paper, with postoperative radiation and occasionally not overexpression of epidermal growth factor
“High Rates of Regional Failure in Squamous chemotherapy. Primary radiation remained receptor (EGFR) is associated with resistance to
Cell Carcinoma of the Hard Palate and Maxil- the primary and only course of treatment of 32 various forms of treatment, including and not

The Head and Neck

lary Alveolus.” Regional recurrence was defined patients who were excluded from surgery. Not limited to, chemotherapy and radiation therapy,
as the development of biopsy-proven neck me- surprisingly, there was a total failure rate of 37% advanced tumor stage, invasion, metastasis, and
tastases at any time after definitive treatment, after an average duration of 1.6 years. The pri- poor prognosis in malignant tumors. They point
in the absence of a secondary head and neck mary factors for survival, which was 54.5% after out that the overexpression of EGFR has been
primary. Patients with tumors from adjacent 5 years, were nodal status, extracapsular spread, made more difficult because the response rates
subsites, such as the maxillary sinus, buccal and clear margins. The authors recommend a were at most 20%. An accompanying factor may
mucosa, or oropharynx extending to the hard categorical bilateral neck dissection to remove be that the sodium–glucose cotransporter, which
palate or alveolar region were not included. occult node metastases. Adjuvant therapy should is a membrane protein, mediates the transport
However, the principal place of occurrence was be applied more frequently in controlled clinical of glucose across cellular membranes. EGFR ap-
in neck metastases. It has heretofore been be- trials and should generally be implemented in parently is also associated with SGLT1 and pro-
lieved that the chance of nodal metastases is cases with lymphatic spread and unclear mar- motes glucose uptake into cancer cells through a
rather low in squamous cell carcinoma of the gins, which I assume means that patients have kinase-independent process.
hard palate and upper (maxillary) alveolus. positive margins. The immunohistochemical study showed
Therefore, the clinical node-negative neck is The overall survival rate after 1, 2, 5, and a significant correlation between SGLT1 and
usually observed rather than electively treated. 10 years of all comers (including the nonsurgi- EGFR. Moreover, expression of SGLT1/EGFR
There have been a large number of historical cal group) was 80.5%, 67.7%, 50.6%, and 36.6%. was inversely related to tumor differentiation
studies as these authors refer to in references The results of the surgical group were a little among the five clinicopathological factors
one to nine in this paper, including a paper by better, with overall survival being 83.8%, 71.5%, (P  0.004). The combination of these two
Martin H (Am J Surg 1941;54:770–806), but be- 54.5% at 5 years (already noted), and 39.6% at factors might be required in the dedifferentia-
cause of the grouping of these tumors together, 10 years. The nonsurgical group did not fare as tion of oral squamous cell carcinoma, but the
the whole idea of what the outcome is in hard well, with 47.8% survival after 1 year, 30.7% af- authors were reticent to name it as a factor in
palate and maxillary alveolus is lacking. What- ter 2 years, 13.7% after 5 years, and 6.8% after recurrence or in death.
ever is thought, however, the patients who are 10 years. J.E.F

www.medicalebookpdf.com

LWBK892_c24_p321-333.indd 333 10/28/11 4:52:23 PM

 334 Part III: The Head and Neck

25 Neck Dissection
Jatin P. Shah and Ian Ganly

INTRODUCTION STAGING SYSTEM FOR lymph nodes has a very poor prognosis. An-
METASTATIC SQUAMOUS CELL other important prognostic factor is the
The single most important factor affecting presence of extranodal spread where the
prognosis of squamous cell carcinoma of CARCINOMA OF THE NECK capsule of the lymph node is ruptured, re-
the head and neck, the sixth most common A uniform staging system for regional me- sulting in invasion of the surrounding soft
cancer worldwide, is the status of the cervi- tastases to cervical lymph nodes was estab- tissues. This increases both the incidence
cal lymph nodes. Metastases to the regional lished by the American Joint Committee on of regional recurrence and also distant me-
lymph nodes reduces the 5-year survival Cancer and the International Union Against tastases. In a clinically positive N1 neck,
rate by 50% compared with that of patients Cancer. The staging system for squamous there is a 30% incidence of extranodal spread,
with early stage disease (Fig. 1). The Ameri- cell carcinoma is shown in Table 2 and Fig. 4. whereas in the clinically positive N2a/N3
can Cancer Society has reported that 40% of The staging system for thyroid carcinoma is neck, extranodal spread is present in 50% to
patients with squamous carcinoma of the shown in Table 3. The staging system is 70%. Perivascular and perineural infiltration
oral cavity and pharynx present with re- based on both the size and the number of by tumor also have a negative effect on prog-
gional metastases (Fig. 2). Therefore, man- enlarged lymph nodes. Both these factors nosis. All these factors must be considered
agement of the cervical lymph nodes is an have important prognostic significance. The when planning adjuvant treatment follow-
important component in the overall treat- prognosis worsens with increasing N stage. ing neck dissection.
ment plan for patients with squamous cell However, there are other nodal factors af-
carcinoma of the head and neck. fecting prognosis that are not included in
the staging system.
RISK FACTORS FOR
NODAL METASTASIS
ANATOMY OF THE NODAL FACTORS The risk for cervical node metastases is
CERVICAL LYMPHATICS AFFECTING PROGNOSIS influenced by characteristics of the primary
tumor such as location, size, and histology.
Cervical lymph nodes are classified accord- Characteristics of regional nodes that affect As a general rule, the risk for lymph node
ing to the system developed at Memorial prognosis include the presence of pathologi- metastases increases for more posteriorly
Sloan-Kettering Cancer Center in the 1930s. cally positive nodes, size of the metastatic located tumors, such as those of the
This system divides the lymph nodes in the lymph node, the number of lymph nodes in- oropharynx and hypopharynx compared
lateral aspect of the neck into five nodal volved, and the location of the lymph nodes. to lips and oral cavity (Fig. 5). For example,
levels, I through V, as shown in Fig. 3. In ad- Involvement of the lower cervical nodes oropharyngeal cancers are at higher risk
dition, lymph nodes in the central com- (level IV) and the lower posterior triangle than oral cavity tumors. Lesions of the tonsil
partment are categorized into level VI and
those in the anterior superior mediastinum
as level VII. Table 1 lists the clinical and
surgical landmarks used to describe these
levels. Recently, level I, II, and V nodes were
subclassified into levels IA and IB, IIA and
IIB, and VA and VB. Level IA includes the
submental lymph nodes, whereas level IB
includes the submandibular lymph nodes.
Level IIA includes lymph nodes below the
accessory nerve, whereas IIB includes
nodes above the accessory nerve. The pos-
terior triangle has been subdivided into
levels VA and VB, with the dividing line be-
ing the accessory nerve in the posterior tri-
angle. This subdivision is based on patterns
of lymph node spread from various prima-
ries. For example, level IA lymph node
spread is rare except for tumors of the lower
lip and anterior floor of mouth. Recent
studies have shown that, in the patients
with no level IIA nodes clinically, meta-
static spread to level IIB nodes is rare. Simi-
larly, in thyroid cancer, studies have shown
that metastatic spread to level VA lymph Fig. 1. Five-year survival rates of squamous cell carcinoma of the head and neck in relation to extent of
nodes is exceedingly rare. disease.

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 334 10/28/11 4:21:25 PM

 Chapter 25: Neck Dissection 335

Fig. 2. Distribution of patients with squamous cell carcinoma of the head and neck in relation to extent
of disease at the time of initial diagnosis.

Fig. 3. Memorial Sloan-Kettering Cancer Center leveling system of cervical lymph nodes (A); current modification of leveling
system (B); and levels VI and VII (C).

Table 1 Clinical and Surgical Landmarks for Neck Node Levels

The Head and Neck

N
Node level Clinical landmarks Surgical landmarks
Level I Submental and submandibular Superior-lower border of the body of the
Table 2 Staging System of Regional
Lymph Nodes (N Stage) for
triangles mandible; posterior-posterior belly of Squamous Cell Carcinoma
digastric; inferior-hyoid bone

The
of the Upper Aerodigestive
Level II Upper jugular lymph nodes Superior-base of skull; posterior-posterior Tract Excluding
border of sternocleidomastoid muscle; Nasopharynx
anterior-lateral limit of sternohyoid;
inferior-hyoid bone Nx Regional lymph nodes cannot be
assessed
Level III Middle jugular lymph nodes Superior-hyoid bone; posterior-posterior
border of sternocleidomastoid muscle; N0 No regional lymph node metastases
anterior-lateral limit of sternohyoid; N1 Metastases in a single ipsilateral
inferior-cricothyroid membrane lymph node, 3 cm or less in
Level IV Lower jugular lymph nodes Superior-cricothyroid membrane; posterior- greatest dimension
posterior border of sternocleidomastoid N2a Metastases in a single ipsilateral
muscle; anterior-lateral limit of ster- lymph node, ⬎3 cm but ⬍6 cm
nohyoid; inferior-clavicle in greatest dimension
Level V Posterior triangle lymph nodes Posterior-anterior border of trapezius N2b Metastases in multiple ipsilateral
muscle; anterior-posterior border of lymph nodes, none ⬎6 cm in
sternocleidomastoid muscle; inferior- greatest dimension
clavicle
N2c Metastases in bilateral or contralat-
Level VI Anterior compartment of the Superior-hyoid bone; inferior-suprasternal eral lymph nodes, none ⬎6 cm in
neck notch; lateral-medial border of carotid greatest dimension
sheath on either side
N3 Metastases in a single ipsilateral
Level VII Superior mediastinal lymph Superior-suprasternal notch; inferior- lymph node ⬎6 cm in greatest
nodes innominate artery dimension

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 335 10/28/11 4:21:25 PM

 336 Part III: The Head and Neck

fected by primary tumor location. Cancers

of the oral cavity typically spread first to the
nodes in levels I to III, whereas cancers of
the oropharynx, hypopharynx, and larynx
spread first to the nodes in levels II to IV.
This observation is based on the philosophy
that nodal spread of cancer proceeds in an
orderly and predictable fashion as deter-
mined by the lymphatic drainage pattern in
the neck. In 1972, Lindberg, from the M.D.
Anderson Cancer Center, was the first to re-
port that the lymph node groups most fre-
quently involved in cancer of the oral cavity
were level II/III, and in patients with cancer
of the floor of mouth, oral tongue, and buc-
cal mucosa, the nodes most frequently in-
volved were located in the submandibular
triangle (level IB). Lindberg also reported
that cancers can metastasize to both sides
of the neck and can skip the submandibular
and jugulodigastric nodes metastasizing
first to the midjugular nodes (level III).
The patterns of nodal metastasis were
later well described by Shah, from Memo-
rial Sloan-Kettering Cancer Center, in 1990.
To determine lymph node levels at risk from
a particular primary site, Shah analyzed pa-
Fig. 4. Staging system of regional lymph nodes (N stage) for squamous cell carcinoma of the upper thology specimens from 1,119 classic radi-
aerodigestive tract, excluding the nasopharynx. cal neck dissections (RNDs) for squamous
cell carcinoma of the upper aerodigestive
tract. This consisted of 343 RNDs for the
and base of tongue have a very high inci- invasion, and perineural invasion also de- clinically negative neck (N0) and 776 RNDs
dence of nodal metastases. Tumors of the termine the risk of cervical metastases. for the clinically positive neck. From these
hypopharynx universally have lymph node studies, the incidence of pathologically pos-
metastases. The risk of nodal metastases is PATTERNS OF NODAL itive neck specimens was 82% for the clini-
higher for tumors of the supraglottic larynx cally positive neck and 33% for the clinically
compared with the glottic larynx because METASTASES negative neck. Tables 4 and 5 show the per-
of the relative absence of lymphatic vessels The location of metastases is mainly deter- centage of patients with pathologically pos-
in the glottic larynx. The greater the T size mined by the location of the primary site. itive nodes at each level for clinically posi-
of the primary tumor, the greater the prob- Figure 6 illustrates the nodes typically af- tive and clinically negative disease.
ability of having lymph node metastases.
For example, T1, T2, and T3 tongue cancers
have an incidence of metastatic disease to
the neck of 30%, 50%, and 70%, respectively.
Pathologic features such as endophytic
versus exophytic tumors, poorer degree of
differentiation, depth of invasion, vascular

Table 3 Staging System of Regional

Lymph Nodes (N Stage) for
Thyroid Carcinoma
Nx Regional lymph nodes cannot be
assessed
N0 No regional lymph node metastases
N1 Regional lymph node metastases
N1a Metastases in central compartment
lymph nodes
N1b Metastases in unilateral, bilateral,
contralateral cervical or superior
mediastinal lymph nodes F 5. The risk of nodal metastasis increases in relation to location of the primary squamous cell carci-
Fig.
nnoma of the head and neck.

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 336 10/28/11 4:21:26 PM

 Chapter 25: Neck Dissection 337

Fig. 6. Regional lymph nodes draining at a specific primary site.

In the clinically positive neck setting the larynx, most positive nodes were in lev- has spread to the submaxillary gland, com-
(Table 4), patients with primary oral cavity els II to IV; levels I and V were involved in plete removal of the disease is impossible.”
tumors had the majority of positive nodes 14% and 7%, respectively. In 1847, Warren described the attempted
in levels I to III; levels IV and V were involved The question of level V metastases was removal of cancer in the neck through an
in 20% and 4% of specimens, respectively. In addressed in a separate study on 1,277 RNDs incision from the masseter muscle to the
patients with primary oropharyngeal tu- by Davidson et al. in 1993. Metastases were clavicle, although this must have been an
mors, the majority of positive nodes were in found in 40 (3%) patients. Level V metasta- unplanned procedure, not based on any an-
levels II to IV; levels I and V were involved in ses were highest in patients with hypopha- atomical considerations. Kocher in 1880 de-
17% and 11% of specimens, respectively. In ryngeal and oropharyngeal primary sites scribed the removal of the tongue for cancer
patients with hypopharyngeal tumors, most (7% and 6%, respectively). Only 3 out of 40 through the submaxillary triangle, first re-
positive nodes were in levels II to IV; levels I patients with a clinically negative neck had moving the lymphatics and submaxillary
and V were involved in 10% and 11% of a positive level V lymph node. Therefore, the and sublingual salivary glands. He later pro-
specimens, respectively. In patients with incidence of level V metastases is small and posed that the cervical lymphatics should
primary tumors of the larynx, most positive extremely unlikely in the clinically negative be removed more widely and described the
nodes were in levels II to IV; levels I and V neck setting. “Kocher” incision, a Y-shaped incision with

The Head and Neck

were involved in 8% and 5%, respectively. the long arm running from the mastoid tip
In the clinically negative neck setting CLASSIFICATION OF down the anterior border of sternocleido-
(Table 5), patients with primary oral cavity NECK DISSECTION AND mastoid muscle to the omohyoid muscle,
tumors had the majority of positive nodes INDICATIONS FOR NECK and the short limb running at right angles
in levels I to III; levels IV and V were in- to the submental region. Later in 1885, But-
volved in 9% and 2% of specimens, respec-
DISSECTION lin described the removal of cervical lymph
tively. In patients with primary oropharyn- History nodes for tongue cancer and even discussed
geal tumors, the majority of positive nodes the prophylactic removal of these “glands”
were in levels II to IV; levels I and V were The importance of the regional cervical lym- for tongue cancer.
involved in 7%. In patients with hypopha- phatics in oral cavity cancer was noted by Solis-Cohen of Philadelphia, America’s
ryngeal tumors, most positive nodes were Chelius in 1847 who commented, “the first head and neck surgeon, later advocated
in levels II to IV; levels I and V were not in- neighboring lymphatics become hard and the removal of cervical lymph nodes during
volved. In patients with primary tumors of painful” and “once the growth in the mouth total laryngectomy. However, most of the
credit for neck dissection as a curative opera-
tion for cervical metastases belongs to
G
George Washington Crile from the Cleveland
Table 4 Percentage of Positive Lymph Nodes in the CN⫹ Neck C
Clinic. In 1900, he performed different types
oof neck dissections and subsequently de-
Clinical N⫹ neck
sscribed the classic operation of RND in his
% Positive nodes at each lymph node level according to primary site sseminal article of 1905 published in the
Primary site I II III IV V T
Transactions of the Southern Surgical and Gy-
Oral cavity 61 57 44 20 4 nnecological Association. This operation is now
cconsidered to be the basic neck dissection
Oropharynx 17 85 50 33 11 aand all other procedures are considered to be
Hypopharynx 10 78 75 47 11 m
modifications. George Crile later described
Larynx 8 68 70 35 5 his experience with 132 operations of RND in
h
11906. In this operation, all lymphatic tissues

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 337 10/28/11 4:21:26 PM

 338 Part III: The Head and Neck

ly
lymph nodes in levels I to V, and also the
Table 5 Percentage of Positive Lymph Nodes in the CN0 Neck ssternocleidomastoid muscle, internal jugu-
Clinical N0 neck llar vein, spinal accessory nerve, and sub-
mandibular salivary gland. MRND is divided
m
% Positive nodes at each lymph node level according to primary site iinto type I, II, or III, depending on the struc-
Primary site I II III IV V ttures that are preserved. Type I MRND in-
Oral cavity 58 51 26 9 2 vvolves preservation of one structure, the
spinal
s accessory nerve. Type II involves pres-
Oropharynx 7 80 60 27 7
eervation of two structures: the spinal acces-
Hypopharynx 0 75 75 0 0 ssory nerve and the sternocleidomastoid
Larynx 14 52 55 24 7 muscle. Type III involves preservation of the
m
sspinal accessory nerve, internal jugular vein,
aand the sternocleidomastoid muscle. Type I
MRND is the most commonly employed
in the lateral neck from levels I to V are sys- for these different types of neck dissection neck dissection for squamous cell carcinoma
tematically removed in conjunction with the are shown in Table 6. of the upper aerodigestive tract with clini-
sternocleidomastoid muscle, internal jugu- cally positive neck disease. Type III MRND is
lar vein, the spinal accessory nerve, and the most commonly employed for metastatic-
submandibular salivary gland. The operation
Comprehensive Neck Dissection
differentiated carcinoma of the thyroid.
was popularized by Hayes Martin from Me- Comprehensive neck dissections involve the
morial Sloan-Kettering Cancer Center, who removal of all lymphatic tissues in the lateral
described the stepwise procedure of RND in neck (levels I to V) and are generally carried
Selective Neck Dissection
his classic article in 1951. However, this op- out for the clinically positive neck (N⫹). Selective neck dissection spares all nonlym-
eration is not without morbidity, as it results They can be classified into RND and MRND phatic tissues, including the sternocleido-
in a cosmetic deformity and dysfunction of (Fig. 7), depending on what other structures mastoid muscle, internal jugular vein, and
shoulder movement. are excised. RND involves the removal of spinal accessory nerve. However, it does not
This led to the development of modified/
functional neck dissections. Oswaldo Suarez
from Argentina was the first to describe
functional neck dissection in 1963, now
Table 6 Classification of Different Types of Neck Dissection with Clinical
Indications
called modified radical neck dissection
Nodal levels Structures
(MRND). He described the removal of all five
Comprehensive removed preserved Indications
lymph node levels in the neck while preserv-
ing the spinal accessory nerve, sternocleido- Radical neck dissection Levels I–V None N⫹ neck for SCC where SAN
mastoid muscle, and internal jugular vein to involved
limit any functional disability in the shoul- Modified radical neck Levels I–V SAN N⫹ neck for SCC where SAN
der. However, his publications were in Span- dissection type I free of disease
ish and therefore the technique was not Modified radical neck Levels I–V SAN, SCM N⫹ neck for SCC where IJV
popularized until Ettore Bocca, who learned dissection type II involved but SAN free of
the technique from Suarez, and published it disease
in the English literature in 1967. Selective
Modified radical neck Levels I–V SAN, SCM, IJV Metastatic differentiated
removal of regional nodal groups based on dissection type III thyroid carcinoma
predictable patterns of lymph node spread
were later popularized by Ballantyne from Selective
M.D. Anderson Cancer Center. In 1985, Byers Supraomohyoid neck Levels I–III SAN, SCM, IJV N0 neck for SCC of oral cavity
from M.D. Anderson Cancer Center used the dissection and oropharynx (include
terms “anterior” and “supraomohyoid” neck level 4)
dissection to describe the selective neck dis- N0 neck malignant melanoma
section procedure for cancers of the oral where primary site is
cavity and pharynx. These neck dissections anterior to ear (include
parotidectomy for face and
were described for use in patients with clini- scalp)
cally negative neck and were based on the
philosophy that nodal spread of cancer pro- Extended suprao- Levels I–IV SAN, SCM, IJV N0 neck for SCC of lateral
ceeded in an orderly and predictable fash- mohyoid neck tongue
dissection
ion. Unfortunately, the terms “modified
neck dissection,” “functional neck dissec- Lateral neck dissection Levels II–IV SAN, SCM, IJV N0 neck for SCC of larynx and
tion,” and “selective neck dissection” led to hypopharynx
considerable confusion. Therefore, in 1991 Posterolateral neck Levels II–V, SAN, SCM, IJV N0 neck malignant melanoma
the American Academy of Otolaryngology- dissection suboccipital, where primary site is
Head and Neck Surgery published an article retroauricular posterior to ear
classifying neck dissections into compre- nodes
hensive and selective. This was later updated
SAN, spinal accessory nerve; SCM, sternocleidomastoid muscle; IJV, internal jugular vein.
in 2002. Structures removed and indications

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 338 10/28/11 4:21:27 PM

 Chapter 25: Neck Dissection 339

Fig. 7. Classification of comprehensive neck dissections.

The Head and Neck

remove all the lymphatic tissues on the in- mohyoid neck dissection (SOHND), in which recurrence rate of 11%. In 1999, Byers re-
volved side of the neck as does a compre- lymph nodes in levels I to III and the sub- ported that the regional recurrence rate was
hensive neck dissection, but rather uses the mandibular salivary gland are removed (Fig. 36% in patients with pathologically positive
selective removal of nodal regions at risk. 8A); the extended SOHND, in which lymph N1 neck disease who had not received radia-
This is determined by the predictive pattern nodes in levels I to IV and the submandibu- tion therapy, but was 5.6% among those who
of metastases based on the location of the lar gland are removed (Fig. 8B); the antero- had received postoperative radiation. For
primary tumor. It is based on the clinical lateral neck dissection (LND), in which pathologically positive N2b disease, the fail-
observation that squamous cell carcinoma lymph nodes in levels II to IV are removed ure rate was 8.8% with radiation and 14%
of the upper aerodigestive tract metasta- (Fig. 8C); posterolateral neck dissection without. Spiro et al. in 1996 reported a
sizes in a predictable and sequential pat- (PLND), in which lymph nodes in levels II to recurrence rate of 6% in patients who had
tern. Selective neck dissections are there- V and also the suboccipital and retroauricu- received postoperative radiation following
fore generally carried out for the clinically lar lymph nodes are removed (Fig. 8D); and SOHND.
negative neck (N0), where there is at least a central or anterior compartment neck dis- Extended SOHND is recommended for
15% to 20% risk of occult metastatic dis- section, in which lymph nodes at level VI in squamous cell carcinoma of the lateral
ease. Additional indications may be situa- the prelaryngeal, pretracheal, and paratra- tongue. This is based on the observation
tions in which surgical access to the primary cheal regions are removed (Fig. 8E). that patients with primary carcinoma of
extends to lymph node groups at risk of me- SOHND is recommended for squamous the lateral border of the oral tongue have a
tastases. More controversially, it may be cell carcinoma of the oral cavity with a high small but increased risk of skip metastases
used for nodal metastases confined to the risk of micrometastases in a neck that is to level IV compared with other sites in the
first-echelon nodes (usually N1) when the clinically negative for disease. Byers re- oral cavity. Therefore, selective treatment of
primary is being treated by surgery. How- ported a recurrence rate of 5.8% in 154 N0 the N0 neck in lateral tongue cancer should
ever, it is important to point out that the patients treated with SOHND. Similar recur- include level IV.
neck requires postoperative radiation ther- rence rates were reported by Spiro et al. and LND is recommended for squamous cell
apy in this setting, as reported by Byers, O’Brien. For node-positive disease, the re- carcinoma of the larynx or pharynx with a
Pellitteri et al., Spiro et al., and Traynor et al. sults of selective SOHND are more variable. high risk of micrometastases in a neck that is
Common selective neck dissections are Byers reported a regional recurrence rate clinically negative for disease. If the primary
shown in Fig. 8. These include the suprao- of 15%. Pellitteri et al. reported a regional tumor crosses the midline, this procedure is

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 339 10/28/11 4:21:27 PM

 340 Part III: The Head and Neck

Fig. 8. Classification of selective neck dissections.

carried out bilaterally. LND is indicated for both sides of the neck. Therefore, bilateral pathologically negative neck (pN0) disease.
cancer of the oropharynx when the primary LND is recommended in patients with a He also reported a recurrence rate of 7.3%
tumor is treated with surgery in a neck that clinically negative neck setting. In supra- among 41 patients with pathologically posi-
is clinically negative for disease. If postopera- glottic and advanced glottic cancer, bilat- tive neck disease (pN⫹) who underwent
tive radiation therapy is indicated, it is not eral neck dissection is generally recom- LND; 37 of the 41 patients received postop-
necessary to perform bilateral LND because mended. LND is not indicated for early erative radiation. However, in patients with
radiation alone is effective in treating the glottic lesions. In 1985, Byers reported effi- multiple positive lymph nodes, Byers re-
node-negative contralateral neck. Cancer of cacy data for recurrence rates following ported a regional failure rate of 30% for
the hypopharynx frequently metastasizes to LND of 3.9% among 256 patients with those treated with postoperative radiation

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 340 10/28/11 4:21:28 PM

 Chapter 25: Neck Dissection 341

and 33% for those who were not. Selective Mucosal Squamous Cell Cancer Lau et al. reported that in patients who are
neck dissection is therefore not indicated The majority of oral cavity cancers are also observed following complete response post-
when there is evidence of multiple positive easily visualized and are, in general, acces- chemoradiation with N2/3 neck disease, the
nodes. sible to a direct injection. This has led to the 2-year locoregional recurrence-free survival
PLND is recommended for primary cu- suggestion that the sentinel node biopsy was 95%. However, another study reported
taneous malignancies of the posterior scalp technique may be useful in neck manage- on 65 patients who had a complete response
(e.g., melanoma and squamous cell carci- ment for oral cavity cancer. This technique to CTRT managed by neck observation.
noma). Central compartment neck dissection for squamous cell carcinoma of the oral With a median follow up of 9 years, there
is recommended for differentiated thyroid cavity was first reported by Shoaib et al. was a 10% to 15% incidence of neck recur-
carcinoma in which the disease is limited to where sentinel node biopsy was carried out rence. Patients who had a complete response
the pretracheal and paratracheal nodes. prior to an elective neck dissection (END) to induction chemotherapy were less likely to
in patients with a clinically negative neck. A recur raising the suggestion that response to
Sentinel Node Biopsy report examined SLNB in 57 clinically N0 induction chemotherapy could be used as
necks in 48 patients and reported that 15 the indicator to who should have a planned
The sentinel lymph node is defined as the (35%) were upstaged by SLNB and 28 (65%) neck dissection.
first echelon lymph node to which cancer were staged SLN negative. With a mean fol-
spreads. The technique of sentinel lymph low up of 18 months, only one patient de- Planned Neck Dissection
node biopsy (SLNB) allows focused exami- veloped regional neck disease after being Planned neck dissection is normally carried
nation of the lymph nodes at highest risk staged negative on SLNB. The overall sensi- out in patients with N2 and N3 neck dis-
for metastases, so that neck dissection is tivity of the technique was 94%. However, ease, irrespective of the response to CTRT.
performed only in patients with a positive this technique is still experimental and The neck dissection is usually carried out
node and the rest can be spared the mor- should only be carried out in centers with 6 weeks after completion of chemoradia-
bidity of the operation. Identification of the the necessary expertise and the appropri- tion; this has the advantage of carrying out
sentinel node requires the use of preopera- ate volume of cases as it has been shown the neck dissection before the onset of fibro-
tive lymphoscintigraphy using radioactive that centers who carry out this technique sis, thereby making the neck dissection
technetium and then blue dye injection with ⬍10 cases per year have a much lower technically similar in complexity to a
(toluidine blue) at the time of surgery. The sensitivity. Technical problems of “shine nonchemoradiation neck dissection. Evi-
sentinel node is identified using a gamma through,” where the radioactivity level in dence for a policy of planned neck dissection
probe and confirmed with the injection of the primary site potentially obscures the comes from studies, which have shown the
blue dye at the time of biopsy. Pathology of sentinel node, is one potential problem. The presence of tumor in neck dissection speci-
the sentinel node requires both hematoxy- role of SLNB in advanced oral cavity cancers mens in patients who have complete or near
lin and eosin staining and also immunohis- is limited due to false negatives resulting complete radiological and clinical response
tochemistry. The node requires serial sec- from obstruction of lymphatic flow caused in the neck. Before the introduction of PET
tioning at 150 μm sections for accurate by tumor and redirecting of flow to neigh- scan, planned neck dissection was the con-
analysis. boring nodes. ventional method for managing the neck
following CTRT. Some groups still practice

The Head and Neck

Melanoma Neck Dissection this policy due to limitations or nonavail-
Cutaneous melanoma is ideally suited to ability of PET. However, most groups now
this technique because the primary tumor is
Post-chemoradiation
use a policy of salvage neck dissection.
easily visualized making injection into the An increasing proportion of patients with
tumor relatively straightforward. The useful- advanced stage squamous cell carcinoma Salvage Neck Dissection
ness and reliability of the technique has been of the larynx and pharynx are treated with Salvage neck dissection is normally carried
well described in numerous publications organ preservation protocols of radiother- out if there is clinical and/or radiological evi-
since it was first reported in 1990 by Morton. apy with chemotherapy. Management of dence of neck disease after completion of
In head and neck melanoma, SLNB is the the cervical lymph nodes in these patients chemoradiation. The use of FDG-PET has
most accurate way of staging the neck and is treated with a clinically positive neck re- helped to identify patients at risk for residual
an important predictor of outcome. Studies mains an area of controversy. The neck may cancer following CTRT, allowing us to select
showed that the 2-year disease-specific sur- be managed in one of three ways; by obser- patients who will benefit from a policy of sal-
vival for SLN-negative patients was 93% vation, by planned neck dissection, or by vage neck dissection. FDG-PET is usually
compared to 50% for SLN-positive patients salvage neck dissection. carried out at 12 weeks following completion
(P ⫽ NS). If patients are SLN positive, they of CTRT to minimize any false-positive re-
can be managed either by neck dissection or Observation sults from residual inflammation from CTRT.
by systemic therapy with immunomodulat- Observation of the neck can be done in pa- Salvage neck dissection in patients who have
ing agents such as interferon, interleukin, or tients who have a complete or near com- PET-positive nodes is therefore carried out
vaccine-based therapy. A systematic review plete response to treatment. Evidence for after 12 weeks post-CTRT. This has the dis-
reported that there was no evidence to sug- this approach comes from studies that have advantage of making the operation techni-
gest that neck dissection in patients who are reported low regional recurrence rates. One cally more difficult due to the onset of fibro-
SLN positive improves overall survival com- study reported on 102 patients with N2/3 sis. This can result in increased morbidity in
pared to patients who did not have neck dis- neck disease with a complete response clini- terms of shoulder dysfunction, wound com-
section. Whether or not to carry out a neck cally and radiologically at 12 weeks post- plications, and quality of life compared to
dissection in patients who are SLN positive chemoradiation where no planned neck dis- neck dissection carried out without chemo-
is therefore an individual decision between section was done. With a median follow up radiation. In addition, pathological examina-
surgeon and patient. of 4.3 years, no patient had neck recurrence. tion of specimen often fails to show evidence

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 341 10/28/11 4:21:28 PM

 342 Part III: The Head and Neck

of disease outside the positive nodes (po) on dissection is associated with a high inci- survival, overall survival, or local recurrence
the initial CT scan. This has led many sur- dence of temporary and permanent hy- at 80 months follow up.
geons to question the need to carry out com- poparathyroidism as well as increasing the
prehensive neck dissection in this situation risk of damage to the recurrent laryngeal MANAGEMENT OF THE
and there are now several reports describing nerves. As such, dissection of the central com-
the use of selective or superselective (re- partment should only be done if any nodes NECK IN MELANOMA
moval of two or less contiguous neck levels) appear enlarged or suspicious.
neck dissection to treat residual disease with Management of the
no increase in regional recurrence. Lateral Compartment Nodes Clinically Negative Neck
Even though occult metastases are seen in Regional nodal metastases are relatively
MANAGEMENT OF THE NECK up to 40% of patients, studies have shown rare in thin cutaneous melanomas (⬍1 mm
that in patients having a lateral neck dissec-
IN THYROID CANCER tion and those that do not, the regional re-
in thickness) of the head and neck region,
and END is therefore not recommended.
In patients with a clinically negative neck, currence rates were equivalent, suggesting Thicker lesions (⬎4 mm) are associated
the incidence of occult micrometastases in that routine elective dissection of the lateral with a high incidence of distant metastases
the neck ranges from 30% to 70%. The inci- neck is not indicated. Radioactive iodine and therefore END is unlikely to impact on
dence depends on the size of the primary therapy may be sufficient to treat occult met- survival in this population. The role of END
(26% in tumors ⬍1 cm and 66% in tumors astatic disease. Elective treatment of the lat- in patients with intermediate thickness (1.0
⬎1 cm). Machens et al. reported that the eral neck is therefore not standard practice. to 4 mm thick) melanomas continues to be
central nodes and lateral nodes were in- debated, as only about 15% of patients will
volved in 29% each, whereas Wada et al. re- Management of the Clinically have histologically demonstrable metastatic
ported 61% for the central compartment Positive Neck nodes so that the remaining 85% may be
and 40% for the lateral compartment. Miral- considered to have undergone an unneces-
lie reported that the paratracheal nodes If nodes are present in the central compart- sary procedure. These patients are selected
were the most common site involved (50%). ment, central compartment neck dissection for sentinel node biopsy to facilitate further
Shaha reported on 1,038 patients at MSKCC is done. If nodes are present in the lateral management. Four randomized trials and a
that 56% of patients had a clinically positive compartment, then a lateral neck dissection large, retrospective study in patients with
neck at the initial evaluation. Given the fact should also be carried out. Patients who intermediate thickness melanomas have
that lymph node metastases are so com- have positive lateral nodes but no nodes in failed to demonstrate any improvement in
mon, it may seem somewhat surprising that the central compartment clinically, that is, survival following END.
thyroid cancer has a 93% to 98% 10-year sur- skip metastases, are treated with a com-
vival rate. There remains controversy about bined lateral and central neck dissection; a
the impact of nodal metastasis on survival. recent study by Khafif et al. reported that in Management of the
Several studies suggest that there is no de- patients with positive nodes in the lateral Clinically Positive Neck
crease in survival in the presence of nodal neck compartment, 84% of these patients
disease, especially in the younger popula- will also have positive nodes in the central Clinically apparent regional lymphatic
tion of patients ⬍45 years of age. Other compartment. The main debate is over what spread to the parotid gland or to cervical
studies report a reduced survival. Nodal size type of lateral neck dissection should be car- lymph nodes should be managed with su-
⬎3 cm and extracapsular spread are poor ried out. Several studies have shown that perficial parotidectomy and comprehensive
prognostic signs. The management of the multiple neck levels are involved when the neck dissection, with likely adjuvant radia-
neck therefore is a controversial subject. lateral neck is clinically positive. This is an tion therapy. Originally believed to be a ra-
argument against “berry picking” or super- dioresistant tumor, cutaneous melanoma
selective neck dissection as this may lead to has a radiation response different from that
Management of the Clinically of squamous cell carcinoma, demonstrating
a higher rate of missed disease and recur-
Negative Neck rent operations. It is recommended that a effective tumor cell death at a higher dose
Central Compartment Nodes comprehensive modified RND type III be per fraction than that of SCC. As a result, hy-
Due to the high incidence of occult metas- carried out for the positive neck. In the Kup- pofractionation schemes utilizing large-dose
tases, many have recommended elective ferman study of 44 neck dissections in 39 fractions have been employed. Adjuvant hy-
treatment of the central compartment patients, all patients had levels II to V dis- pofractionated radiotherapy has been shown
lymph nodes. In a case control study of 195 sected; the incidence of metastases was 52% to improve 5-year actuarial locoregional
patients having central compartment neck in level II, 57% in level III, 41% in level IV, and control rates for patients with stage II and III
dissection, one study reported that the 10- 21% in level V. Roh reported that 76% level disease.
year survival was greater in the group hav- IV and 70% level IIA and III nodes were in-
ing neck dissection compared to those who volved, 17% of level IIB, 4% in level I, and MANAGEMENT OF THE NECK
did not (98.4% vs. 89% to 92%). Another sug- 16% in the infraaccessory compartment of IN SALIVARY GLAND CANCER
gested that only the ipsilateral central com- level V but 0% in the supraaccessory nerve
partment needs to be dissected for tumors compartment of level V. These authors Management of the Clinically
⬍2 cm; posttreatment thyroglobulin levels therefore recommended dissection of levels
for patients having ipsilateral versus com- II to V including level IIB but sparing the su-
Negative Neck
plete central compartment were equivalent. praaccessory compartment of level V. In Occult cervical metastases are uncommon
Other authors suggest that adjuvant radio- contrast, however, a study comparing MRND in cancers of the major salivary glands.
active iodine therapy may be an alternative type III to selective neck dissection (levels II Armstrong et al. reported an incidence of
treatment because central compartment to IV) showed no differences in disease-free occult metastases of 12% in 407 patients

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 342 10/28/11 4:21:28 PM

 Chapter 25: Neck Dissection 343

who were clinically node negative. Signifi-

A B C
cant risk factors for occult nodal metasta-
ses from cancers of the major salivary
glands include primary tumor size ⬎4 cm
in size (20% vs. 4%), and high tumor grade
(49% vs. 2%). END should therefore be con-
sidered in patients with high-grade malig-
nancies and T3/ T4 tumors. Selective neck
dissection for parotid cancer should en-
compass levels I to IV. Alternatively, if it is
anticipated that postoperative radiotherapy
will be given to the primary site, then the Comprehensive Supraomohyoid Jugular
ipsilateral neck can be treated by radiother-
apy at the same time rather than by END.
D E F

Management of the
Clinically Positive Neck
For clinically apparent nodal metastases,
patients should be treated by parotidec-
tomy, and comprehensive neck dissection
followed by postoperative radiotherapy.
Klussman et al. have reported that on mul-
tivariate analysis, lymph node involvement
of level I was an independent predictor of
poor disease-specific survival. Posterolateral Comprehensive Modified
(Thyroid) (Parotid)
The benefit of adjuvant radiotherapy has
been demonstrated in a matched-pair anal- Fig. 9. Skin incisions for various types of neck dissections.
ysis of patients receiving combined surgery
and postoperative radiotherapy compared
to patients treated with surgery only. Five- Procedure nerve with an Adson clamp under direct
year determinate survival for the combined The dissection begins with elevation of the vision at all times.
therapy group was improved compared to posterior skin flap. Skin is incised with the Retracting the anterior portion of the
the group undergoing surgery only (48.9% scalpel and then the remainder of the pro- sternocleidomastoid muscle cephalad and
vs. 18.7%), and locoregional control was im- cedure is carried out using electrocautery. the posterior portion caudad assists in the
proved as well (69.1% vs. 40.2%). The benefit The skin incision is deepened through the dissection of the nerve. The nerve is then

The Head and Neck

of postoperative radiation therapy was es- subcutaneous tissue and then through the carefully dissected out in a cephalad direc-
pecially pronounced in patients with high- platysma muscle. The posterior flap is then tion along the lateral border of the internal
stage and high-grade primary tumors. raised in the subplatysmal plane by apply- jugular vein up to its exit from the jugular
ing traction to the flap with skin hooks and foramen at the skull base under the poste-
TECHNIQUE OF NECK countertraction of the deeper soft tissues. rior belly of the digastric muscle. Once this
The flap is elevated up to the anterior bor- is done, the nerve is then carefully sepa-
DISSECTION der of the trapezius muscle (Fig. 10). During rated from underlying tissue using the
this elevation, care is taken not to enter the Martin forceps and Reynolds scissors. The
Comprehensive Modified posterior triangle fat pad to prevent any in- superior attachment of the sternocleido-
Neck Dissection: Type 1 jury to the spinal accessory nerve. The ante- mastoid muscle is then detached from the
This is currently the most frequently per- rior border of trapezius muscle is skeleton- mastoid process, and fibrofatty tissue lying
formed operation in patients with clinically ized and then care is taken to identify the in the supraaccessory triangle is dissected
positive neck disease (cN⫹) where the acces- spinal accessory nerve (Fig. 11). This can be off the muscular floor, working from a later-
sory nerve is not grossly involved by cancer. done either by identifying it as it passes al-to-medial direction. The tissue is sequen-
onto the undersurface of the trapezius tially dissected off the splenius capitis mus-
Anesthesia muscle in the lower part of the neck, or by cle, followed by the levator scapulae muscle.
General endotracheal anesthesia with mus- identifying it 1 cm superior to Erb’s point At this point, the tissue is then able to be
cle relaxation is essential for performing a (which is a plexus of cervical cutaneous passed under the dissected accessory nerve
neck dissection. The patient is usually nerves on the posterior border of the stern- and dissected off the rest of the muscular
placed in a supine position with the head ocleidomastoid muscle ⬃6 cm from the in- floor of the posterior triangle (Fig. 12).
elevated to 30 degrees. The neck is hyperex- ferior lobule of the ear). Once identified, the Working in a lateral-to-medial direction,
tended and rotated to the opposite side. nerve is dissected out from its entry in the the anterior border of each subsequent
trapezius muscle up to the posterior border muscle is exposed. The posterior scalene
Incision of sternocleidomastoid muscle. The nerve muscle is exposed and then the inferior
For MRND type I, a single trifurcate neck is then followed up through the sterno- belly of omohyoid muscle is divided at its
incision is the most frequently employed cleidomastoid muscle, dividing the muscle attachment on the scapula. Transverse cer-
incision (Fig. 9A). with electrocautery while protecting the vical vessels are encountered inferiorly and

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 343 10/28/11 4:21:28 PM

 344 Part III: The Head and Neck

are divided between clamps and ligated

with silk ties. This allows the specimen to
be retracted medially, allowing further dis-
section of the muscular floor, first exposing
the middle scalene muscle and then the
anterior scalene muscle with the brachial
plexus in between.
On the anterior surface of the anterior
scalene muscle, the phrenic nerve is identi-
fied passing in a lateral-to-medial direction
(Fig. 13). Care must be taken not to elevate
this nerve with the overlying block of soft
tissue. Once the phrenic nerve is identified
and preserved, the dissection then contin-
ues in a cephalad direction, identifying the
cutaneous cervical branches as they sepa-
rate off the cervical rootlets. These branches
are divided and the stumps of the nerve
roots are ligated. This allows the specimen
to be further retracted medially to expose
the internal jugular vein, common carotid
artery, and the vagus nerve.
At this point, the specimen is allowed to
drop back into its natural position in the
posterior triangle. Attention is then turned
to the anterior skin flap. The transverse skin
incision is completed from the trifurcation
point up to its medial end. The skin, subcu-
taneous tissue, and platysma muscle are
divided, and an anterior subplatysmal flap
Fig. 10. Elevation of the posterior skin flap. is elevated up to the midline superiorly and
to the medial end of the sternocleidomas-
toid muscle at its attachment to the ster-
num inferiorly. A large loop retractor is used
to increase exposure inferiorly. Using elec-
trocautery with coagulating current, the
sternal and clavicular heads of sternocleido-
mastoid muscle are divided. The muscle is
then retracted in a cephalad direction and
loose areolar tissue is dissected to expose
the carotid sheath. The lateral border of the
strap muscles are retracted medially, allow-
ing the carotid sheath to be fully exposed.
The sheath is opened and the common
carotid artery, vagus nerve, and internal
jugular vein identified and dissected. The
internal jugular vein is then divided between
clamps and doubly ligated with 2-0 silk ties
(Fig. 14). A 3-0 chromic catgut transfixion
suture is used to secure the distal end of the
vein. Lymphatic tissue lying lateral to the
internal jugular vein encompassing the tho-
racic duct on the left side and unnamed
lymphatics on the right-hand side of the
neck are carefully divided in clamps and
ligated with silk ties to prevent chyle leak-
age. At this juncture, the proximal portion of
the transverse cervical vessels are dissected,
divided, and ligated with 3-0 silk.
The soft tissue, including sternocleido-
mastoid muscle and internal jugular vein, is
now retracted in a cephalad direction and
Fig. 11. Identification of the spinal accessory nerve in the posterior triangle of the neck. carefully dissected in the avascular plane off

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 344 10/28/11 4:21:28 PM

 Chapter 25: Neck Dissection 345

the vagus nerve and carotid artery (Fig. 15).

The middle thyroid vein needs to be identi-
fied, divided, and ligated with 3-0 silk as it
enters the medial aspect of the internal jug-
ular vein. Working in a cephalad direction,
the hypoglossal nerve is then identified be-
yond the bifurcation of the carotid artery.
Additional medial mobilization of the spec-
imen is obtained by dividing the superior
cervical plexus. The anteromedial limit of
the dissection is the anterior belly of the
omohyoid muscle. This is incorporated into
the specimen by dissecting it up to its at-
tachment to the hyoid bone, where it is then
detached. Careful dissection at this level al-
lows identification of the superior thyroid
vessels. The superior thyroid vein is divided
and ligated and the superior thyroid artery
is preserved.
The superior skin flap is then elevated.
Having divided the platysma muscle, the
fascia on the inferior aspect of the subman-
dibular gland is divided and dissected, al-
lowing the superior skin flap to be raised in
this plane. This allows the marginal man-
dibular branch of the facial nerve to be ex-
posed, protected, and preserved. This nerve
lies just anterior to the submandibular fas-
Fig. 12. Dissection of fibrofatty tissue in the posterior triangle of the muscular floor proceeds in a lateral-
cia and superficial to the posterior facial
to-medial direction.

The Head and Neck

Fig. 13. Identification of the phrenic nerve on the surface of the anterior scalene muscle.

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 345 10/28/11 4:21:29 PM

 346 Part III: The Head and Neck

Fig. 14. The lower end of the internal jugular vein is identified, dissected, and then divided between clamps.

Fig. 15. Dissection of the sternocleidomastoid muscle and internal jugular vein proceeds in a cephalad direction off the
carotid artery and vagus nerve.

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 346 10/28/11 4:21:30 PM

 Chapter 25: Neck Dissection 347

anterior belly of the digastric muscle, fol-

lowed by the mylohyoid muscle. The neuro-
vascular bundle to the mylohyoid muscle is
identified, divided, and ligated (Fig. 18).
Several clamps are used to apply gentle
traction on the submandibular gland, al-
lowing it to be mobilized from its bed. A
loop retractor is placed under the free edge
of the mylohyoid muscle, retracting it su-
peromedially. This maneuver allows expo-
sure of the lingual nerve and the secretomo-
tor fibers to the submandibular ganglion.
These fibers are divided, taking care to pro-
tect and preserve the lingual nerve (Fig. 19).
Following this, the submandibular duct is
dissected, divided, and ligated. Care is taken
not to enter the fascia of the hyoglossus
muscle as it is in this plane that the hypo-
glossal nerve is located. The submandibular
gland is now retracted laterally and sepa-
rated from the posterior belly of the digas-
tric muscle. The proximal portion of the
facial artery is then identified on the pos-
teromedial aspect of the posterior belly of
the digastric muscle. It is divided in clamps
and ligated with 3-0 silk (Fig. 20).
Following this, the tail of parotid is re-
tracted cephalad, allowing access to the
posterior belly of the digastric muscle. Sev-
eral small pharyngeal veins need to be
divided and ligated. After this, the posterior
belly of the digastric muscle is retracted ce-
phalad with a deep right-angled retractor.
The occipital artery and vein lying superfi-
cial to the internal jugular vein are divided
and ligated, allowing exposure of the upper

The Head and Neck

end of the internal jugular vein at the base
of the skull. The vein is then skeletonized
Fig. 16. Identification of the marginal branch of the facial nerve anterior to the submandibular fascia circumferentially and then doubly ligated
and superficial to the posterior facial vein. with 2-0 silk (Fig. 21). The specimen is then
able to be delivered.
Meticulous hemostasis is then secured
with ligation or electrocautery and the
vein (Fig. 16). The vein is ligated and its the cervical branch of the facial nerve is wound irrigated with a plentiful amount of
upper stump retracted cephalad, protect- identified and it may be divided distal to its saline. Large suction drains are inserted
ing the marginal branch of the facial nerve separation from the marginal mandibular through stab incisions in the lower skin
(Fig. 17). Anteriorly, this dissection is car- branch. Dissection now proceeds along the flaps (Fig. 22). One drain is placed along the
ried out sharply, elevating the nerve with lower border of the mandible. The fascial anterior border of the trapezius muscle and
the skin flap. In performing this maneuver, attachment between the sternocleidomas- held in position with a loop of chromic cat-
toid muscle and angle of mandible are di- gut suture. An anterior drain is placed along
vided, and then dissection along the infe- the strap muscles, medial to the carotid ar-
rior border of the mandible allows the tery, and again secured in place with a loop
delivery of the prevascular facial lymph of chromic catgut suture. Both drains are
nodes. The facial vein and artery are divided secured to skin with a purse-string silk
at this point on the posterior superior as- suture. The incision is then closed in two
pect of the submandibular gland. Identifi- layers using 3-0 chromic catgut interrupted
cation of the anterior belly of the ipsilateral sutures for the platysma muscle and 5-0
and contralateral digastric muscles is then nylon for skin.
carried out. Nodal tissue in the submental Suction on the drains is maintained while
triangle is dissected out, ligating vessels in the wound is being closed. An airtight clo-
Fig. 17. Ligation of the posterior facial vein with the apex of the triangle with 3-0 silk ties. sure is required to ensure adherence between
retraction of its upper stump cephalad to protect The soft tissue from the submental tri- the skin and deep structures of the neck. The
the marginal branch of the facial nerve. angle is then dissected off the ipsilateral drains remain in place for 4 to 7 days and are

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 347 10/28/11 4:21:30 PM

 348 Part III: The Head and Neck

Fig. 18. The neurovascular bundle to the mylohyoid muscle is identified, divided, and ligated.

removed only once minimal serous drainage Dissection of the submental and subman- superior thyroid artery as they enter the
is present. dibular triangles is then carried out in an sternocleidomastoid muscle.
identical fashion to that described for Next, the spinal accessory nerve is iden-
MRND type I. Dissection then proceeds to tified as it pierces the upper third of the
Selective Neck Dissection level II and III lymph nodes. An inferior skin sternocleidomastoid muscle. Using Reyn-
Supraomohyoid Neck Dissection flap is raised in the subplatysmal plane olds scissors, the nerve is dissected out, up
The skin incision used for the SOHND is in a down to the posterior edge of the sterno- toward the proximal end of internal jugular
skin crease approximately two finger- cleidomastoid muscle laterally and the vein and posterior belly of the digastric
breadths below the inferior border of the sternal attachments of sternocleidomas- muscle. The fat pad and lymph nodes lying
mandible (Fig. 9B). The skin incision is toid muscle inferiorly. A loop retractor is in level IIB are then carefully dissected out
deepened through the platysma muscle used to retract the inferior flap. Fascia on using electrocautery, taking great care not
with electrocautery. Care is taken to pre- the anterior border of the sternocleidomas- to damage the spinal accessory nerve. This
serve the greater auricular nerve as it toid muscle is incised, and the fascial at- tissue is then passed under the spinal
courses over the sternocleidomastoid mus- tachments between the tail of parotid gland accessory nerve and retracted in a medial
cle. The superior flap is raised first in the and sternocleidomastoid muscle are dis- direction using a clamp. With the sterno-
subplatysmal plane. Fascia overlying the sected, allowing exposure of the posterior cleidomastoid muscle retracted laterally
submandibular gland containing the mar- belly of the digastric muscle. A large loop using a Richardson retractor and counter-
ginal branch of the facial nerve is incised retractor is used to retract the sternocleido- traction on the soft tissue medially, the tis-
and this layer is raised along with the supe- mastoid muscle laterally, dividing multiple sue overlying the cervical plexus of nerves
rior skin flap using blunt-end retractors. small feeding vessels from the occipital and is divided. Clamps are placed on the soft

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 348 10/28/11 4:21:31 PM

 Chapter 25: Neck Dissection 349

The Head and Neck

Fig. 19. Exposure of the lingual nerve and the secretomotor fibers to the submandibular ganglion.

tissue and retracted medially, allowing the dissection is the superior belly of the glossal nerve; these need to be individually
underlying nerves from the cervical plexus omohyoid muscle. The junction between ligated with 3-0 silk ties.
to be visualized. this muscle, the sternocleidomastoid mus- The specimen encompassing levels I to
Dissection then proceeds in a lateral-to- cle, and the internal jugular vein is identi- III is then delivered. The wound is irrigated
medial direction in a plane just superficial fied using a loop retractor. The soft tissue with saline, hemostasis obtained with elec-
to these nerves. The lower limit of the dis- containing lymph nodes from the midjugu- trocautery, and a single suction drain in-
section is the inferior belly of the omohyoid lar chain is then retracted in a cephalad di- serted via a separate stab incision and se-
muscle lying in the inferior aspect of the rection and dissected off the internal jugu- cured to skin with a purse-string suture.
posterior triangle. The phrenic nerve is then lar vein and superior belly of omohyoid The incision is closed in two layers with in-
identified on the anterior scalene muscle muscle. Dissection is in a plane just superfi- terrupted 3-0 chromic catgut for the plat-
and carefully preserved. The carotid sheath cial to the superior thyroid vessels. The su- ysma muscle and 5-0 nylon for skin. The
fascia is divided, allowing exposure of the perior thyroid artery is preserved but the resultant functional and cosmetic defor-
vagus nerve, carotid artery, and internal vein needs to be divided and ligated on the mity is insignificant.
jugular vein. This is best done working from medial aspect of the internal jugular vein.
a cephalad-to-caudal direction using the Superiorly, the common facial vein is then Anterolateral Neck Dissection
Adson clamp to spread the fascial envelope identified on the medial aspect of the inter- This dissection is usually carried out as a
for division with the electrocautery. Work- nal jugular vein and divided in clamps and staging procedure in conjunction with exci-
ing from a lateral-to-medial direction, the ligated with 3-0 silk. The hypoglossal nerve sion of primary carcinoma of the larynx or
soft tissue encompassing levels II and III is identified and tissue lying lateral and in- pharynx in a patient with a neck with clini-
lymph nodes are dissected off the internal ferior to it dissected. Several pharyngeal cally negative disease. This involves dissec-
jugular vein. The anteromedial limit of the veins are encountered close to the hypo- tion of lymph nodes from levels II to IV. The

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 349 10/28/11 4:21:31 PM

 350 Part III: The Head and Neck

incision is therefore planned according to

resection of the primary tumor. This is usu-
ally a transverse incision at the level of the
thyrohyoid membrane from the posterior
border of one sternocleidomastoid muscle
to the midline (Fig. 9C). Upper and lower
skin flaps are raised in the subplatysmal
plane. Fascia on the anterior border of the
sternocleidomastoid muscle is incised and
elevated medially to expose the underlying
jugular lymph nodes. The posterolateral ex-
tent of the dissection is the cervical nerve
roots as they emerge from the vertebral col-
umn. The omohyoid muscle is divided infe-
riorly to allow dissection of level IV nodes.
As in the SOHND, the accessory nerve is
identified as it pierces the medial aspect of
the sternocleidomastoid muscle and is
traced superiorly. Lymph nodes in level IIB
superior and lateral to the nerve are dis-
sected as described for the SOHND.
Dissection again proceeds lateral to me-
dial, identifying the anterior scalene mus-
cle, phrenic nerve, and roots of the cervical
plexus. The carotid sheath is opened to
identify the vagus nerve, carotid artery, and
internal jugular vein. Middle thyroid, supe-
rior thyroid, and common facial veins on
the medial aspect of the internal jugular
vein are divided and ligated with 3-0 silk to
allow the specimen to be reflected medially.
The specimen may be left attached to the
primary tumor or may be removed sepa-
rately. Insertion of drains and wound clo-
sure are as described previously.

Posterolateral Neck Dissection

This is carried out for clinically negative neck
disease for either melanoma or squamous
cell carcinoma of the posterior scalp. It in-
Fig. 20. Separation of the submandibular gland from the posterior belly of the digastric muscle is volves the removal of lymph nodes in levels
achieved by ligating the proximal part of the facial artery.
II to V, including the suboccipital and ret-
roauricular lymph nodes. A hockey-stick in-
cision is used (Fig. 9D), extending from the
mastoid tip along the anterior border of the
trapezius muscle and then curving anteri-
orly just superior to the clavicle. An anterior
skin flap is elevated in the subplatysmal
plane up to the anterior border of the stern-
ocleidomastoid muscle. The spinal acces-
sory nerve is identified in the posterior tri-
angle as described previously and dissected
out from the inferior aspect of the trapezius
muscle up to the posterior border of the ster-
nocleidomastoid muscle. Dissection of the
posterior triangle lymph nodes proceeds as
described previously. To dissect out the up-
per, middle, and lower jugular lymph nodes,
the sternocleidomastoid muscle is retracted
medially. The fascia of the carotid sheath is
divided, identifying the carotid artery, va-
gus nerve, and internal jugular vein. Dissec-
Fig. 21. Exposure of the upper end of the internal jugular vein. tion of level II to IV lymph nodes proceeds in

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 350 10/28/11 4:21:32 PM

 Chapter 25: Neck Dissection 351

9. Davidson BJ, Kulkarny V, Delacure MD, et al.

Posterior triangle metastases of squamous
cell carcinoma of the upper aerodigestive
tract. Am J Surg 1993;166:395.
10. Kocher. Ueber radicalheilung des Krebses.
Deutsche Zlschr J Chir 1880;13:134.
11. Kupferman ME, Patterson M, Mandel SJ, et al.
Patterns of lateral neck metastasis in papillary
thyroid carcinoma. Arch Otolaryngol Head
Neck Surg 2004;130:857–60.
12. Lau H, Phan T, Mackinnon J, Matthews TW.
Absence of planned neck dissection for the
N2-N3 neck after chemoradiation for locally
advanced squamous cell carcinoma of the
head and neck. Arch Otolaryngol Head Neck
2008;134:257–61.
13. Lindberg R. Distribution of cervical lymph
node metastases from squamous cell carci-
noma of the upper respiratory and digestive
tracts. Cancer 1972;29:146.
14. Machens A, Hinze R, Thomusch O, et al. Pat-
tern of nodal metastases for primary and re-
operative thyroid cancer. World J Surg 2002;
26:22–28.
15. Mirallie E, Vissset J, Sagan C, et al. Localisation
of cervical node metastases of papillary thy-
roid carcinoma. World J Surg 1999;23:970–3.
16. Morton DL, Cagle LA, Wong JH, et al. Intra-
operative lymphatic mapping and selective
lymphadenectomy: technical details of a new
procedure for clinical stage I melanoma. Pre-
sented at the Annual Meeting of the Society of
Surgical Oncology. Washington, DC, 1990.
Fig. 22. Suction drains are inserted through separate stab incisions in the lower skin flaps and posi- 17. O’Brien CJ. A selective approach to neck dis-
section for mucosal squamous cell carcinoma.
tioned as shown.
Aust N Z J Surg 1994;64:236.
18. Roh JL, Kim JM, Park CI. Lateral cervical
lymph node metastases from papillary thy-
roid carcinoma: pattern of nodal metastases
a caudal-to-cephalad fashion, and the spec- 2. Armstrong JG, Harrison LB, Thaler HT, et al. and optimal strategy for neck dissection. Ann
imen including the posterior triangle soft The indications for elective treatment of the Surg Oncol 2007;15:1177–82.

The Head and Neck

tissue is delivered. In order to include the neck in cancer of the major salivary glands. 19. Sato N, Oyamatsu M, Koyama Y, et al. Do the
Cancer 1992;69:615–9. level of nodal disease according to the TNM
postauricular and suboccipital lymph 3. Balch CM, Soong SJ, Bartolucci AA, et al. classification and the number of involved cer-
nodes, a lateral extension of the upper end Efficacy of an elective regional lymph node vical nodes reflect prognosis in patients with
of the skin incision from the mastoid pro- dissection of 1 to 4 mm thick melanomas for differentiated carcinoma of the thyroid gland?
cess to the occipital tubercle is carried out. patients 60 years of age and younger. Ann Surg J Surg Oncol 1998;69:151–5
The trapezius muscle is then detached from 1996;224:255–63. 20. Shah JP. Patterns of lymph node metastases
its nuchal attachment, allowing exposure of 4. Bocca E, Pignataro O, Sasaki CT. Functional from squamous cell carcinomas of the upper
neck dissection: a description of operative aerodigestive tract. Am J Surg 1990;160:405.
lymph nodes in the suboccipital triangle, technique. Arch Otolaryngol 1980;106:524. 21. Shaha AR, Shah JP, Loree TR. Risk group stratifi-
which are then removed as a separate speci- 5. Byers RM. Modified neck dissection: a study cation and prognostic factors in papillary carci-
men. Closed suction drains are inserted of 967 cases from 1970 to 1980. Am J Surg noma of thyroid. Ann Surg Oncol 1996;3:534–8.
through a separate stab incision and the 1985;150:414. 22. Shoaib T, Soutar DS, MacDonald DG, et al. The
wound is closed in layers with 3-0 chromic 6. Chelius JM. A System of Surgery (South JT, accuracy of head and neck carcinoma sentinel
catgut for the platysma muscle and 5-0 trans.), Vol 3. Philadelphia: Lea & Blanchard; lymph node biopsy in the clinically N0 neck.
nylon for the skin. 1847:515. Cancer 2001;91(11):2077–83.
7. Cooper DS, Doherty GM, Haugen BR, et al. 23. Wada N, Duh QY, Sugino K, et al. Lymph node
Management guidelines for patients with thy- metastasis from 259 papillary thyroid micro-
SUGGESTED READINGS roid nodules and differentiated thyroid can- carcinomas: frequency, pattern of occurrence
cer. Thyroid 2006;16:109–42. and recurrence, and optimal strategy for neck
1. Ang KK, Peters LJ, Weber RS, et al. Postopera- 8. Crile GW. Excision of cancer of the head and dissection. Ann Surg 2003;237:399–407.
tive radiotherapy for cutaneous melanoma of neck with special reference to the plan of dis- 24. Warren JC. Surgical Observations on Tumours:
the head and neck region. Int J Radiat Oncol section based on one hundred and thirty two with Cases and Operations. Boston: Crocker
Biol Phys 1994;30:795–8. operations. JAMA 1906;47:1780. and Brewster; 1847.

www.medicalebookpdf.com

LWBK892_c25_p334-351.indd 351 10/28/11 4:21:33 PM

 352 Part III: The Head and Neck

EDITOR’S COMMENT tients, not surprising, but only 74 percent in sentinel ity to the spinal accessory nerve (27 percent). In this
node-positive patients, and this difference was sta- study, the majority of the tumor-bearing nodes were
tistically significant. The authors comment that the found in the posterior triangle (72 percent). Wei, WI,
In the past five years, there has been a continuing sentinel node biopsy was a safe and accurate staging et al., Archives of Otolaryngology—Head and Neck
evolution in the place of the radical neck dissec- modality in select patients with clinical stages I and Surgery, 2001, 127:1457–1462, and found that the
tion in the treatment of head and neck cancer. II. The results are not only promising short-term, most common area was Level II in 53 percent of
Specifically, as individuals have gotten experi- but long-term as well. The significant outcome to patients. Taken all together, Khafif, et al., conclude
ence in the place of radical neck dissection in the me is the degree of control of the neck, even follow- that the best choice of recurrent nasopharyngeal
treatment of oral, hypopharyngeal, oropharyn- ing a positive sentinel lymph node result. carcinoma is dissection of N2 and N3 because this is
geal, and carcinoma of the thyroid and squamous What happens after the salvage dissections in where the recurrence generally occurs.
cell of the various orifices of the head and neck as local regional failures vs. isolated nodal failures in In a later paper from Wei’s group (Tsang, RKY,
well as melanoma, there has been a tendency to nasopharyngeal carcinoma as reported by Khafif, et al., with Wei, WI being the senior and last author,
be freer in the case of head and neck carcinoma A., et al., European Archive Otorhinolaryngology, Head and Neck, published online, 2011) conclude
to do radical neck dissections. Although chemo- 2010, 267:997– 999. Khafif and his co-authors wrote that neck dissection is efficacious in nasopharyn-
radiation has its supporters, in fact, recently there an editorial entitled, “Is it Necessary to Perform geal carcinoma with nodal failure despite or with
has been a recognition that despite treatment Radical Neck Dissection as a Salvage Procedure for synchronous local failure. In this paper, a retro-
with chemoradiation, the use of radical neck dis- Persistent or Recurrent Neck Disease after Chemo- spective review of all patients who underwent neck
section as salvage or in the case of recurrence, has radiotherapy in Patients with Nasopharyngeal dissections for nodal failure, the five year overall
something to offer as far as long-term survival. Cancer?” The answer appears to be that it is. This survival was 58 percent. Wei is credited with a lot
Thus, individuals have turned to sentinel node is a multi country report, including data from the of the excellent papers in this particular area.
biopsy for oral and oropharyngeal squamous cell Sackler Faculty of Medicine at Tel Aviv University in To switch gears, Porterfield, JR, et al., Archives
carcinoma to stage these lesions. Such an approach Israel (Dr. Khafif), The University of Udine, Italy (Dr. of Surgery, 2009, 144:567–574, presented data
has been recently published by Broglie, MA, et al., Ferlito), the Nijmegen Medical Center, The Nether- in the management of lymph node metastases,
Annals of Surgical Oncology, published online, lands (Dr. Takes), and the Division of Otolaryngol- which they claim represents approximately 90
2011, reviewed the long term results of sentinel ogy-Head and Neck Surgery at Southern Illinois percent of disease recurrence in papillary thyroid
node biopsy in early (T1/T2) oral and oropharyn- University School of Medicine in Springfield (Dr. carcinoma. According to their data, they define
geal squamous cell carcinoma in the Department Robbins). Initially, they referred to the radical neck (Clive Grant is the chief of the section at the
of Otolaryngology, Head and Neck Surgery, of the dissection (Khoo, ML, et al., Australia and New Zea- Mayo Clinic) of the techniques by which recur-
Kantonhospital St. Gallen, Switzerland. In this sin- land Journal of Surgery, 1999, 69:354–356) of 68 pa- rent carcinoma of the thyroid can be treated in
gle institution study, a prospective consecutive co- tients with nasopharyngeal cancer who underwent a stepwise fashion with good salvage in papillary
hort analysis of 79 patients with a median age of 60 radical neck dissection for regionally recurrent dis- thyroid carcinoma. Dr. Sally Carty of Pittsburgh in
years, and an age range of 34 to 87 years, 67 percent ease, and there were 74 neck dissection specimens. the discussion is not as sanguine as Clive Grant’s
of whom were male, was carried out between 2000 They wanted to analyze the site of positive resec- group in dissection of recurrence of papillary car-
and 2006. Lymphatic mapping was carried out in tions. Level II had the highest rate of metastases, cinoma of the thyroid, although she believes that
this study, although I am not certain that this is very and Level V immediately thereafter. 68 percent of being that aggressive may not be as much as is
commonly carried out, but utilizing a preoperative the patients had metastatic disease at a single level. called for.
lymphoscintigram and an intraoperative use of a They believe that radical neck dissection is the Finally, Falchook, AD, et al., from the Univer-
handheld gamma probe. The endpoints of this study treatment of choice because of the multiple levels sity of Florida in Gainesville (American Journal
were naturally disease overall, disease-specific, and of metastases, with Level II being the highest rate of Otolaryngology—Head and Neck Medicine and
disease-free survival, as well as neck control rate. with 88 percent. The authors of this paper include Surgery, 2011, published online) took up the ques-
Sentinel node biopsy was carried out in the 79 that Level II and Level III disease after concurrent tion of the second primary after previously defini-
patients of which 37 percent (29) had positive senti- chemo radiation is appropriate, because Ferlito, tive radiotherapy. They concluded that there was
nel nodes. Isolated tumor cells only were present in A., et al., Head and Neck, 2010, 32:253–261, believes a small yield in which only one (eight percent) of
six of the 29 (21 percent), 48 percent (14 out of 29) that these would be the most fertile for metastases. 13 neck dissection specimens was positive in ten
micrometastases and nine of 29 (31 percent) mac- Wei, et al., “Pathological Basis of Surgery in the patients. Local regional control was 67 percent,
rometastases. For the entire cohort, overall survival Management of Post-Radiotherapy Cervical Me- in this group local control was 88 percent, disease
(OS) was 80 percent, disease specific survival (DSS) tastasis in Nasopharyngeal Carcinoma.”, Archives of free survival was 62 percent, overall survival was
was 85 percent, and disease-free survival (DFS) was Otolaryngology—Head and Neck Surgery, 1992, 118: 33 percent, and cause specific survival rate was
87 percent; for sentinel node-negative patients; 923–929 with discussion at page 930, examined the 77 percent. There were a fair number of complica-
overall survival was 88 percent; disease specific sur- specimens of 43 patients with either persistent or tions of treatment, but it did appear that the au-
vival was 96 percent; and disease-free survival was recurrent nasopharyngeal carcinoma in the neck thors thought that it was worthwhile carrying out
96 percent. For the sentinel node biopsy positive as metastases. The tumors showed a fair amount of collective neck dissections for a second primary.
patients, the results were 74 percent OS, 73 percent aggressiveness including extracapsular spread in 70 Clearly, as Dr. Carty said in her discussion of
DSS, and 77 percent DFS. The DSS reached statis- percent of patients, tumor cells and isolated clusters, Clive Grant’s group’s paper, there is ample room
tical significance. The neck control rate after five again outside of the capsule (30 percent), and proba- for discussion, and this area is not yet settled.
years was 96 percent in sentinel node-negative pa- bly most troubling of all, tumor cells lying in proxim- J.E.F.

26 Congenital Lesions: Thyroglossal Duct Cysts,

Branchial Cleft Anomalies, and Cystic Hygromas
Michael A. Skinner

Congenital anomalies of the neck are man- malities resulting from errors in the em- phatic malformations. The surgical man-
ifested clinically as either a subcutaneous bryologic development of structures in the agement of these abnormalities is aimed
nodule or a mass lesion, a skin pit, or a head and neck include thyroglossal duct at complete resection and preventing in-
draining sinus. The most common abnor- cyst, branchial cleft remnant, and lym- fections.

www.medicalebookpdf.com

LWBK892_c26_p352-358.indd 352 10/28/11 4:20:38 PM

 Chapter 26: Congenital Lesions: Thyroglossal Duct Cysts, Branchial Cleft Anomalies, and Cystic Hygromas 353

THYROGLOSSAL DUCT CYST

Embryology and Anatomy
The thyroglossal duct is a remnant structure
resulting from the downward descent of the
median thyroid anlage during the 3rd week
of gestation. The structure courses inferiorly
in the neck from the base of the developing
tongue to fuse with the lateral thyroid
anlage. During descent, the structure passes
through or near the developing hyoid bone,
which is an important feature in definitive
surgical management. During weeks 5 to 8
of gestation, the thyroglossal duct normally
obliterates, leaving only the foramen cecum
at the base of the tongue. However, in some
cases, there is the residual thyroglossal duct Fig. 2. Thyroglossal duct cyst anterior to the hyoid bone with the thyroglossal duct tract passing through
extending inferiorly into the neck (Fig. 1). the hyoid bone and extending to the foramen cecum.
The structure is lined with secretory epithe-
lium that is activated for unknown reasons
to cause the development of a cyst.
The diagnosis can usually be established cyst is mobilized from the surrounding
from the history and physical examination. structures using electrocautery (Fig. 3). The
Clinical Presentation and Evaluation It is most important to exclude the pres- surgeon should resist the temptation to dis-
More than half of all thyroglossal duct cysts ence of remnant ectopic thyroid, which may sect too closely to the duct, as it progresses
are diagnosed within the first 10 years of be the only source of thyroid hormone for posteriorly and superiorly to the hyoid bone.
life. The lesions typically present as a pain- the patient. If the presence of a normal thy- Rather, a generous amount of surrounding
less, asymptomatic cystic nodule in the roid gland can be established on physical tissue should be taken in the dissection up
midline of the neck (Fig. 2). At times, they examination, no other evaluation is neces- to the hyoid bone, to reduce the likelihood
may be located off the midline by 1 to 2 cm. sary. However, it is usually appropriate to of missed accessory ducts with consequent
The lesion is typically inferior to the hyoid go for an ultrasound study to confirm the recurrence. Inability to clearly identify a
bone, and moves with swallowing. The dif- presence of normal thyroid gland. It is usu- duct extending to the hyoid bone suggests
ferential diagnosis includes dermoid cyst, ally not necessary to obtain a thyroid scinti- that the diagnosis is a dermoid cyst rather
enlarged midline lymph node, teratoma, graphic scan. than a thyroglossal duct cyst; these lesions
and ectopic thyroid tissue. Owing to its cannot usually be distinguished on preop-

The Head and Neck

communication with the base of the tongue, SURGICAL MANAGEMENT erative ultrasound study. Electrocautery
thyroglossal duct cysts may initially mani- can be used to divide the muscle inferior
fest with the typical signs of infection in-
AND OUTCOME and superior on the hyoid bone, and bone
cluding swelling, redness, and pain. When the initial presentation is one of in- cutter can be used to remove a 1- to 1.5-cm
fection, management should consist of section of the hyoid bone (Fig. 4). In younger
needle aspiration of the cyst contents and patients, when the bone is incompletely
administration of antibiotics selected to ossified, the hyoid can be divided using
control oral flora. If possible, formal incision electrocautery. Then, dissection continues
and drainage should be avoided since this posteriorly and superiorly to the base of the
will complicate definitive surgical treat- time, again leaving a generous amount of
ment. It should be noted that thyroglossal tissue around the duct (Fig. 5). Suture liga-
ducts initially presenting with an infection tion and division of the duct at the base of
are associated with increased incidence of the tongue is then accomplished, and the
recurrence after surgical resection. Elective specimen removed (Fig. 6). In some cases, a
removal of an infected lesion should be per- gloved hand can be inserted in the mouth to
formed 6 to 8 weeks after resolution of the assess progress of the dissection to the base
acute infection. of the tongue. The wound can be closed in
In the uncomplicated case, elective sur- layers of absorbable suture. Routine place-
gical resection with the Sistrunk procedure ment of a drain is unnecessary.
has been shown to be effective, with a recur- The most serious complication is the ex-
rence risk of about 2% to 5%. The procedure ceedingly rare incidence of hemorrhage with
can usually be done on an outpatient basis. airway impingement. This can be avoided by
The patient should be placed in the supine careful hemostatic dissection during the op-
position, with the neck extended. Preopera- eration. Recurrence of thyroglossal duct cyst
tive antibiotics to cover skin and oral flora occurs in 2% to 5% of cases; this usually be-
should be administered. A transverse inci- comes evident within 1 year of initial resec-
Fig. 1. Photograph of a thyroglossal duct cyst. sion is made over the palpable cyst, and the tion. These recurrences typically present

www.medicalebookpdf.com

LWBK892_c26_p352-358.indd 353 10/28/11 4:20:38 PM

 354 Part III: The Head and Neck

Fig. 5. Dissection proceeds cephalad to the fora-

men cecum where the tract and investing tissues
are suture-ligated.

BRANCHIAL CLEFT ANOMALIES

Embryology and Anatomy
The structures of the face and neck arise
Fig. 3. Thyroglossal duct cyst—technique of excision. A: Incision is placed over the presenting cyst. No from the fourth embryonic pharyngeal or
skin is excised. B: The thyroglossal duct cyst has been dissected from surrounding tissues. The hyoid is branchial arches, appearing in the 4th and
exposed after division of the sternohyoid and thyrohyoid muscles at insertion. The bone is encircled with
5th weeks of embryonic development. They
a short right-angle clamp 1.0 cm from its midpoint, where it is divided with a bone cutter or cautery.
consist of bars of mesenchymal tissue sepa-
rated by deep clefts, known as pharyngeal
clefts. This process resembles the develop-
with inflammation and infection in the an- cant inflammation resolves, and then reop- ment of gills in fish; however, since humans
terior neck; there may be recurrent drainage eration must be performed. To prevent do not possess gills (branchia), it is more
from the incision site. The recurrence rate is another recurrence, reoperation should be correct to use the term “pharyngeal” rather
increased in patients who have had a previ- performed with an elliptical incision around than “branchial” in describing the arches,
ous infection prior to surgery, or if an insuf- the previous incision, and removal of in- clefts, and pouches in the human embryo.
ficient amount of the hyoid bone has been flamed tissue with a generous hyoid bone What are commonly called branchial
removed. To manage such recurrences, anti- resection, and wide excision of the midline anomalies consist of cysts, sinuses, or con-
biotics should be administered until signifi- and geniohyoid muscle. genital cartilaginous remnants resulting from

Fig. 4. Traction on the divided hyoid facilitates Fig. 6. Resected specimen, demonstrating the thyroglossal duct cyst on the left, and the hyoid bone in
exposure and division of the opposite ramus. the center of the specimen.

www.medicalebookpdf.com

LWBK892_c26_p352-358.indd 354 10/28/11 4:20:39 PM

 Chapter 26: Congenital Lesions: Thyroglossal Duct Cysts, Branchial Cleft Anomalies, and Cystic Hygromas 355

errors in development of the embryonic pha- cleft from which the lesion derived. Computed likelihood of recurrence after surgery. These
ryngeal apparatus. Such lesions represent tomographic (CT) scanning is recommended risks should be balanced against the in-
about 30% of congenital neck masses. It is for surgical planning. In about 80% of cases, creased difficulty of protecting the diminu-
somewhat misleading to call these branchial the CT scan will be able to accurately define tive nerves and vessels in the infant that
cleft anomalies, since in actuality these ab- the course of the fistulous tract. If a third or may be in intimate contact with the fistu-
normalities have contributions from bran- fourth branchial cleft fistula is suspected, en- lous tract. On balance, it is probably reason-
chial clefts, arches, or pouches. When a pha- doscopy is also recommended just prior to able to defer surgery until the age of 9 to
ryngeal arch exhibits incomplete obliteration, surgery to identify the fistula entry into the 12 months, to facilitate dissection.
and communicates with either the skin or pyriform sinus. Cannulation of this ostium The most common bronchial anomalies
mucosa, a sinus results. If there is failure of with a small feeding catheter can assist in are remnants of second pharyngeal clefts.
both the cleft and the pouch to obliterate, complete removal of the fistulous tract. Branchial cleft cysts are most common,
there will be a continuous communication representing about 63% of second pharyn-
between the mucosa and the skin, resulting Surgical Management and Outcome geal cleft anomalies, presenting as a nodule
in a branchial fistula. Finally, when a pharyn- in the lateral neck adjacent to the sterno-
geal cleft remnant forms an epidermis-lined Definitive management of pharyngeal cleft cleidomastoid muscle (Fig. 7). The differen-
cavity without other communication, a cyst remnants requires complete surgical exci- tial diagnosis includes an enlarged lymph
will result. sion. Incomplete excision is associated with node, dermoid cyst, or lymphatic malfor-
Recollection of which normal structures a high incidence of subsequent infection. If mation. Second branchial cleft sinuses rep-
of the head and neck arise from particular the lesion initially presents with an acute resent about a third of lesions arising from
pharyngeal clefts or pouches helps predict infection, needle aspiration and antibiotics the second cleft. In these cases, the sinus
the location of associated abnormalities. should be used to manage the acute pro- tract will pass superiorly between the inter-
Since the first arch ultimately develops into cess. Surgery should be delayed for 6 to nal and external carotid arteries, and adja-
the structures of the middle ear and the facial 8 weeks. The timing of surgery in asymp- cent to the glossopharyngeal and hypoglos-
nerve, first branchial cleft cysts typically tomatic patients is somewhat controver- sal nerves, on its way to the pharynx and
present as draining fistulae in the preauricu- sial. Some authors recommend definitive the tonsillar fossa (Fig. 8).
lar or postauricular area, or can be associ- surgical resection at the time of diagnosis, Surgical resection should be performed
ated with a fistulous tract or cysts adjacent to even in the neonatal period. Others recom- under general anesthesia, and perioperative
the facial nerve and possibly involving the mend waiting until the children are some- antibiotics should be administered. The ini-
parotid gland. Similarly, the second pharyn- what older, perhaps 2 or 3 years of age. The tial incision should elliptically resect any
geal arch forms the hyoid bone and associ- principal risk of waiting until the child is external ostium. Identification and dissec-
ated areas of the neck, and gives rise to the older is the intercurrent development of an tion of the tract can be facilitated by the
tonsillar and supratonsillar fossas. Thus, infection, making definitive surgery more placement of a small lacrimal duct probe
second cleft anomalies are located in the lat- difficult; also, this is associated with a higher into the ostium, and by using a small surgical
eral neck adjacent to the sternocleidomas-
toid muscle, and typically possess a fistulous
tract that enters the supratonsillar fossa.

The Head and Neck

Finally, the third and fourth pouches form
the inferior pharynx, and these sinuses and
fistulae typically enter the pyriform sinus.
They are visible externally as a cyst or a sinus
located at the lower and anterior border of
the sternocleidomastoid muscle. Third and
fourth pharyngeal sinuses can course through
the thyroid gland, and the initial clinical pre-
sentation can be a suppurative thyroiditis.

Clinical Presentation and Evaluation

Branchial anomalies are generally discov-
ered within the first 10 years of life. Sinuses
and fistulas are generally diagnosed earlier
than cysts, owing to obvious drainage. In
about a third of cases, the initial presenta-
tion will be that of an infection. Between 70%
and 95% of cases are derived from the sec-
ond pharyngeal arch apparatus, and about
10% to 20% arise from first arch anomalies.
The balance of the lesions will be third and
fourth pharyngeal arch anomalies.
Evaluation begins with a careful history
and physical examination. As noted above,
the location of the sinus or mass can generally Fig. 7. Typical location of a second branchial cleft cyst. The cyst is at the level of the carotid bifurcation.
be correlated with the pharyngeal arch or No external opening is present. Note the relationship to regional nerves. CN, cranial nerve.

www.medicalebookpdf.com

LWBK892_c26_p352-358.indd 355 10/28/11 4:20:40 PM

 356 Part III: The Head and Neck

tinue the dissection until either blindly and

was or enters the tonsillar fossa (Fig. 11).
Care should be taken to avoid injuring adja-
cent cranial nerves IX and XII, as well as the
carotid artery as the tract passes between
the external and internal branches. The fis-
tulous tract should be resected and suture-
ligated as it enters the pharynx (Fig. 12). The
platysma layers and skin can be reapproxi-
mated using absorbable suture, skin tapes
can be applied, and the patient can usually
be discharged home.
Second branchial cleft cysts do not usu-
ally have a skin opening. They are resected
through a cosmetically acceptable trans-
verse skin incision, located in a neck skin
crease if possible. Care should be taken to
avoid entering the cyst during the dissec-
tion. If there is a tract to the tonsillar fossa,
it should be carefully dissected and suture-
ligated.
Bronchial anomalies arising from the
third and fourth pharyngeal arches are sim-
ilarly removed. At times, the associated fis-
tulous tract will course through the thyroid
gland, requiring thyroid lobectomy for com-
plete resection.
Possible complications following resec-
tion of branchial cleft remnants include
infection, injury of associated structures,
Fig. 8. Course of a second branchial cleft fistula. The external ostium is at the anterior border of the and recurrence of the lesion. As with thy-
sternocleidomastoid muscle. The fistula passes between the internal and external carotid arteries and roglossal duct cysts, the incidence of re-
enters the pharynx at the tonsillar fossa. currence is increased in lesions that have
been previously infected. There is also
some evidence that recurrence is more fre-
clamp to hold it in place during the proce- progresses superiorly, it may be necessary to quent following resection of lesions arising
dure. Precise sharp dissection using fine make a “ladder” counterincision higher in from the first branchial cleft, probably ow-
scissors or electrocautery should be per- the neck (Fig. 10). The dissected tract can be ing to the difficulty in completely remov-
formed along the tract (Fig. 9). As the tract transposed up to the second incision to con- ing the lesion that is in intimate associa-
tion with the facial nerve and the parotid
gland.

LYMPHATIC MALFORMATIONS
Embryology and Anatomy
The lymphatic system functions to return
extravascular tissue fluid back to the blood
circulation. The system arises from lymph
sacs developing throughout the body
where large veins merge. They initially
share embryonic derivation with the blood
vessels but ultimately the lymphatics sepa-
rate into a separate circulatory system.
From these sacs emerge lymphatic en-
dothelial cells that multiply, migrate, and
sprout to form the lymphatic channels,
capillaries, and vessels for lymph transport
between the lymph sacs. It is thought that
congenital lymphatic malformations occur
when there is a failure of the fusion of lym-
Fig. 9. Technique of excision of second branchial cleft fistula. The skin ostium is incorporated in the el- phatic vessels arising from these various
liptical incision. Note the lacrimal duct probe in the tract to facilitate its dissection. lymph sacs.

www.medicalebookpdf.com

LWBK892_c26_p352-358.indd 356 10/28/11 4:20:40 PM

 Chapter 26: Congenital Lesions: Thyroglossal Duct Cysts, Branchial Cleft Anomalies, and Cystic Hygromas 357

Fig. 11. The previously mobilized tract is passed from the original incision to
the counterincision.
Fig. 10. The extent of the tract eventually limits the dissection. A clamp
is passed along the dissected tract to guide the performance of a coun-
terincision or “stepladder” incision.
Surgical Management and Outcome
Complete surgical resection remains the
preferred therapy for lesions that are local-
Clinical Presentation and Evaluation lesions with progressively larger lymph ized and that do not have evidence of in-
cysts. sinuation around other vital neck struc-
The majority of congenital lymphatic mal- Lymphatic malformations are benign pro- tures on magnetic resonance imaging. The
formations arise in the neck, nearly all of cesses, for which complete surgical resection procedure should be done under general
which become evident before 2 years of has traditionally been recommended. The le- anesthesia, with the administration of peri-
age. They occur most commonly in poste- sions often insinuate around the nerves and operative antibiotics. A transverse incision
rior or anterior triangles of the neck, typi- vessels, so complete resection is quite diffi- should be made, followed by careful dissec-
cally presenting as a painless compressible cult. Owing to the benign nature of the pro- tion through the platysma layer to the le-
neck mass (Fig. 13). There may be the sud- cess, it is not appropriate to remove normal sion. It is preferable to avoid entering the
den growth of the lesion over several days, structures to ensure complete resection of lesion during the course of dissection, since
owing to an upper expiratory infection. lymphatic malformation. Magnetic reso- a distended malformation is easy to dissect
Lymphatic malformations are classified nance imaging is the most effective method from the surrounding tissues. Care should
according to the size of the endothelial of determining the anatomic extent of the

The Head and Neck

cysts within them; the terms capillary lesion.
lymphangioma, cavernous lymphangioma,
and cystic hygroma are used to describe

CN XI

Fig. 12. Passage of the previously mobilized tract to the counterincision facilitates fur-
ther dissection of the tract in a superomedial direction to its termination at the tonsillar
fossa, where it is suture-ligated and divided. Fig. 13. Depiction of a cystic hygroma. CN, cranial nerve.

www.medicalebookpdf.com

LWBK892_c26_p352-358.indd 357 10/28/11 4:20:41 PM

 358 Part III: The Head and Neck

be taken to avoid injuring adjacent vessels sions, and especially for those with large for lesions that have recurred following
and nerves; normal structures should not cystic sacs. surgery.
be sacrificed to achieve complete resection. Sclerotherapy with ethanol, bleomycin,
In most cases, a closed-suction drain is left or Picibanil (OK-432) has demonstrated suc-
at the completion of surgery. The drain re- cessful management of lymphatic malfor- SUGGESTED READINGS
mains until the drainage has declined to nil, mations in many studies. The treatment usu- Acierno SP, Waldhausen JH. Congenital cervical
which in some cases may take several ally consists of ultrasound-guided aspiration cysts, sinuses and fistulae. Otolaryngol Clin North
weeks. Following surgical resection, the re- of the cyst, followed by instillation of the Am 2007;40:161–76, vii–viii.
Blei F. Congenital lymphatic malformations. Ann
ported recurrence rate is about 10% if the sclerosant for 10 to 15 minutes. The treat- N Y Acad Sci 2008;1131:185–94.
surgeon thought that the lesion was com- ment may need to be repeated several times Grasso DL, Pelizzo G, Zocconi E, et al. Lymp-
pletely resected; recurrence is 50% to 100% for larger and more complicated lesions, and hangiomas of the head and neck in children.
in lesions known to not have been incom- is most effective with cystic hygromas of the Acta Otorhinolaryngol Ital 2008;28:17–20.
pletely resected. macrocystic variety. Rosa PA, Hirsch DL, Dierks EJ. Congenital neck
Because of the high recurrence rate fol- Complications of operative or nonopera- masses. Oral Maxillofac Surg Clin North Am 2008;
lowing surgical resection, there is an emerg- tive management of lymphatic malforma- 20:339–52.
Schroeder JW Jr, Mohyuddin N, Maddalozzo
ing consensus view that initial management tions include recurrence, infection, and in- J. Branchial anomalies in the pediatric popu-
with sclerotherapy, rather than surgery, be jury to adjacent structures. Most surgeons lation. Otolaryngol Head Neck Surg 2007;137:
recommended for complex lymphatic le- recommend treatment with sclerotherapy 289–95.

EDITOR’S COMMENT underwent a Sistrunk procedure, but in addition, cauterization of the sinus tract opening, 15%; and
a total thyroidectomy was performed in eight of open neck surgery with partial thyroidectomy,
the nine patients. Interestingly, the median size of 8%. The complications after surgery primarily oc-
Thyroglossal duct cysts, branchial cleft anoma- the TGD carcinomas was 10 mm. The therapeutic curred in children eight years or younger.
lies, and cystic hygromas are among the most neck dissection was included in two patients at The authors believe that their experience
common abnormalities of the neck. They may be the time of total thyroidectomy. There were two shows that fourth arch anomalies are more com-
manifested, as the authors say, as a subcutaneous patients with a regional recurrence. Eight of nine mon than once thought. Incision and drainage
nodule, a mass, a skin pit, or a draining sinus. The patients received radioactive iodine therapy. Of won as one would expect and yielded a fairly high
intent of the surgery is to completely rid the pa- the nine patients with TGD carcinoma, there was recurrence rate. Therefore, they devised evidence
tient of the lesion and of any infection associated one patient who was awaiting surgery at the time that complete incision of the entire fistula tract
with it. The authors give a no-nonsense approach of writing the article. appears preferable, which I agree with. Whether
to these lesions, whether or not it is an infection, Cystic hygromas are generally thought of as or not partial thyroidectomy will further de-
in which case needle aspiration is appropriate, being quite benign and not causing too much crease the recurrence rate, as the authors claim,
with subsequent antibiotics after culture of the trouble, yet we know that lymphatic malforma- is not clear. The authors suggest that neck open-
cystic contents. tions in children can sometimes be troublesome. ing surgery be delayed, the bases be treated with
On the other hand, there is a significant dif- Therefore, it is not surprising that a report of four antibiotics until the inflammation is decreased,
ference between thyroglossal duct cysts in chil- cases of cystic hygromas invading the brachial and then proceed to tract incision. This sounds
dren and adults. A comparison between chil- plexus or compressing it were reported by Tubbs like an appropriate approach to me.
dren and adults was reviewed by Lin et al. (Am J et al. ( J Neurosurg Pediatr 2011;7:282–5). The au- Finally, Bajaj et al. (Int J Pediatr Otorhinolar-
Otolaryngol—Head Neck Med Surg 2008;29:83–7), thors wanted to bring attention to the fact that yngol 2011, published online) reviewed all of the
in which the authors with a retrospective chart cystic hygromas, although generally not thought branchial cleft anomaly cases operated on at the
reviewed the thyroglossal duct cysts of both chil- of and with a differential diagnosis of tumors Great Ormond Street Hospital over the past 10
dren and adults between 1997 and 2002. A total of that apparently compress the brachial plexus, years. The second cleft lesions accounted for 95%
84 patients comprising 32 children and 52 adults do nonetheless occur. Although the resection of of the branchial abnormalities. They had 80 pa-
were analyzed. There was no significant sex dif- this lesion was ambivalent in the sense that not tients, evenly split—38 female and 42 male—from
ference. As compared with children, adults had all could be resected; nonetheless, there were no 1 to 14 years. There were 15 patients who had a
more left-sided and infrahyoid cyst locations. As recurrences and no damage to the neurological first branchial cleft anomaly, which is not the sub-
expected, the size of the cysts was significantly structures. ject of this paper, and 62 had a second branchial
larger in adults. Ninety percent of the adults and Other anomalies of the thyroglossal duct cleft anomaly. Complete excision was achieved in
75% of children underwent a Sistrunk operation, cysts and cystic hygromas involve congenital all first cleft cases; there was a temporary mar-
which consists of a cystectomy and excision of fourth branchial arch abnormalities as reported ginal mandibular nerve weakness in this group.
the middle of the hyoid bone and a continua- by Nicoucar et al. ( J Pediatr Surg 2008;44:1432–9), In the 62 children with a second branchial cleft
tion of excision to the thoracic inlet. There were in which a series of patients was reviewed be- anomaly, there were 12 who were bilateral and
only five recurrences, three in adults and two in tween the Department of Head and Neck Surgery the remaining 50 were unilateral. A note of cau-
children. The authors suggested that the Sistrunk at the University Hospital in Switzerland, McLean tion: in the vast majority of children, the tract ex-
operation, which has been in service since 1920, Hospital in Harvard Medical School, and the Pe- tended through a carotid bifurcation and ended
should continue to be the operation of choice. diatric Intensive Care Unit at the University Hos- up in the pharyngeal constrictor muscles. There
Not every thyroglossal duct cyst is benign. I pital in Geneva. There were 526 cases reported were two operative complications, one patient
must confess that I had never heard of a thyroglos- and fourth arch anomalies were usually located developed a seroma and one had incomplete ex-
sal duct cyst carcinoma until I read the paper by on the left and generally presented as acute sup- cision. The results suggest that even with carotid
Forest et al. (J Otolaryngol—Head Neck Surg 2011; purative thyroiditis in 45%. Recurrent neck ab- bifurcation, may be close and involved and a clean
40:151–6), in which 139 patients were reviewed scess occurred in 42%, which was surprising. Di- excision can give excellent results. One does have
from the Royal Prince Alfred Hospital in Camper- rect laryngoscopy was the most useful diagnostic to be careful in these patients because, in fact, the
down, Australia. Of those with thyroglossal duct tool. There were a variety of treatment options, tentacles, as it were, of the branchial cleft cysts,
cysts, nine patients—comprising 6.5%—had a but most of them were related to the technique be they first, second, or fourth, tend to conglom-
thyroglossal duct carcinoma. All were papillary that was used. Treatment options differed in re- erate, since they go to very strange places, and it
carcinoma. The median age at diagnosis was 44 currence rates: open neck surgery and tract inci- will give people difficulty.
years and the follow-up was 6.7 years. All patients sion, 15%; incision and drainage, 89%; endoscopic J.E.F.

www.medicalebookpdf.com

LWBK892_c26_p352-358.indd 358 10/28/11 4:20:41 PM

 Chapter 27: Vascular Anomalies of Infancy and Childhood 359

27 Vascular Anomalies of Infancy and Childhood

John B. Mulliken and Arin K. Greene

Vascular anomalies is a newly emerging (LM)) and fast-flow lesions (arterial malfor- trunk (25%), or extremity (15%). The me-
field involving several medical and surgical mations (aneurysm, ectasia, stenosis, fistu- dian age of appearance is 2 weeks; 30% to
specialties. Vascular anomalies all look las) or arteriovenous malformation (AVM)) 50% of lesions are noted at birth as a telang-
quite similar, in varying shades of red, pink, (Fig. 2). There are also combined vascular iectatic stain or ecchymotic area. IH grows
and blue. The field has been handicapped by anomalies, often eponymous because of the faster than the child during the first
its own confusing clinical and histopatho- physician credited for the initial descrip- 9 months of age (proliferating phase). When
logic terminology. The traditional diagnos- tion. One example of a combined vascular IH involves the superficial dermis it appears
tic terms failed to guide management. The anomaly is Klippel–Trenaunay syndrome red. A lesion beneath the skin may not be
word “hemangioma” is the most egregious (KTS), a capillary–lymphatic–venous mal- appreciated until 3 to 4 months of age when
example; it has been used in a generic sense formation (CLVM) associated with soft-tis- it has grown large enough to cause a visible
for any type of vascular lesion. sue and skeletal hypertrophy. deformity; the overlying skin may appear
A biological classification of vascular Patients with a vascular anomaly often bluish. By age 9 to 12 months, growth of IH
anomalies, first proposed in 1982, was based wander from one specialist to another. Their reaches a plateau. After 12 months of age
on clinical findings, natural history, and cel- problem seems to fall outside the purview the tumor begins to regress (involuting
lular characteristics. This binary scheme of the general surgeon and vascular surgeon. phase), the color fades, and the lesion flat-
was accepted by the International Society Since most vascular anomalies present in tens. Involution ceases in approximately
for the Study of Vascular Anomalies (ISSVA) the skin, these “medical nomads” are usu- 50% of children by age 5 years (involuted
in 1996. Vascular anomalies are broadly ally seen by a dermatologist or plastic sur- phase). After involution, one-half of chil-
divided into two groups: tumors and malfor- geon, and sometimes an oncologist because dren will have an abnormality: residual te-
mations (Table 1). Vascular tumors are char- their lesion is considered to be some kind of langiectasias, scarring, fibrofatty residuum,
acterized by endothelial cell proliferation. tumor. redundant skin, or destroyed anatomical
Vascular malformations arise by dysmor- The biological separation of the two ma- structures.
phogenesis and have normal endothelial jor categories, tumors and malformations,
cell turnover. Based on this classification, has stimulated the formation of vascular Head and Neck Hemangiomas
vascular anomalies can be diagnosed by anomalies centers in the major referring The majority of IHs are small, harmless le-
history and physical examination in 90% of hospitals. It is clear that no one specialist sions that can be monitored under the
patients. Ten percent of patients require ra- can have sufficient knowledge to care for watchful eye of a pediatrician. Ten percent
diographic studies for diagnostic confirma- these patients. The field of vascular anoma- of proliferating IHs, however, cause signifi-
tion; histopathology is rarely necessary. lies insinuates among all the surgical spe- cant deformity or complications, usually
The most common vascular tumors are cialties, many of the medical disciplines, as when located on the head or neck. Ulcer-

The Head and Neck

infantile hemangioma (IH), congenital he- well as interventional radiology and pathol- ated lesions may destroy the eyelid, ear,
mangioma (rapidly involuting congenital ogy. Molecular geneticists are also involved. nose, or lip. IH of the scalp or eyebrow can
hemangioma (RICH), noninvoluting con- Causative genes for inheritable lesions have result in alopecia. Periorbital hemangioma
genital hemangioma (NICH)), kaposiform been discovered and many of these syn- can block the visual axis or distort the cor-
hemangioendothelioma (KHE), and pyo- dromes involve vascular lesions of the hol- nea, causing amblyopia. Subglottic heman-
genic granuloma (PG) (Fig. 1). Malforma- low and solid viscera. gioma may obstruct the airway.
tions are divided into slow-flow lesions This chapter was written as a primer to
(capillary malformation (CM), venous mal- encourage general surgeons to adopt the Multiple Hemangiomas
formation (VM), lymphatic malformation modern terminology of vascular lesions. Approximately 20% of infants have more
Surgeons who are curious and fascinated than one IH. The term hemangiomatosis
by these common and often insoluble dis- designates five or more small (⬍5 mm) tu-
o
orders are encouraged to join a vascular mors. These children are at increased risk
Table 1 Biological Classification of a
anomalies team. for IH of internal organs, although the risk
Vascular Anomalies is low. The liver is most commonly affected;
Malformations the brain, gut, or lung are rarely involved.
VVASCULAR TUMORS Ultrasonogram should be considered to
Tumors Slow flow Fast flow
IInfantile Hemangioma rule out hepatic IH.
IH Capillary AVM
(CM) C
Clinical Presentation Hepatic Hemangiomas
Congenital Venous (VM) Combined IIH is a benign endothelial tumor that oc- The liver is the most common extracutane-
hemangioma ccurs in approximately 4% to 5% of Cauca- ous site for IH. Ninety percent of fast-flow
(CH) ssian infants. The old terms “capillary,” “cav- hepatic lesions are IH. The differential diag-
KHE Lymphatic eernous,” and “strawberry” hemangioma are nosis includes AVM, hepatoblastoma, and
(LM) iimprecise and no longer used. IH is more metastatic neuroblastoma, which do not
PG Combined ffrequent in premature children and in demonstrate significant shunting on imag-
females
f (4:1). IH typically is single (80%) ing. There are three subtypes of hepatic
Angiosarcoma
aand involves the head and neck (60%), hemangioma: focal, multifocal, and diffuse.

www.medicalebookpdf.com

LWBK892_c27_p359-368.indd 359 10/28/11 4:20:03 PM

 360 Part III: The Head and Neck

A B C D

Fig. 1. Vascular tumors of infancy and childhood. (A) A 5-month-old male with superficial IH of cheek. (B) Newborn infant
with RICH of lower extremity. (C) A 11-month-old male with KHE of trunk. (D) A 23-month-old female with PG of right lower
eyelid.

Although most hepatic IHs are nonprob- Hemangiomas and Structural Anomalies typical IH, reticular tumors are likely to ul-
lematic and discovered incidentally, large There are uncommon presentations of IH cerate and rarely cause cardiac overload.
tumors can cause heart failure, hepatomeg- with malformations, either in the head/ Reticular hemangioma is often associated
aly, anemia, or hypothyroidism. Focal he- neck or in the lumbosacral regions. PHACE with ventral–caudal malformations (ompha-
patic hemangioma usually are asymptom- association affects 2.3% of patients with IH, locele, recto-vaginal fistula, vaginal/uterine
atic and not associated with cutaneous and consists of a plaque-like IH in a regional duplication, solitary/duplex kidney, imper-
lesions; they are often identified prenatally. distribution of the face with at least one of forate anus, tethered cord lipomyelomenin-
There is evidence that solitary hepatic he- the following anomalies: Posterior fossa gocele). After involution small veins often
mangioma is a RICH. Occasionally this tu- brain malformation; Hemangioma; Arterial remain, which may be treated by sclerother-
mor can cause cardiac overload and throm- cerebrovascular anomalies; Coarctation of apy. Ultrasonography (US) is obtained to
bocytopenia; however, these symptoms the aorta and cardiac defects; Eye/Endocrine rule out associated anomalies in infants less
resolve as the tumor regresses. Multifocal abnormalities. When ventral developmental than 4 months of age. MRI is indicated in
hepatic IHs are often accompanied by cuta- defects (Sternal clefting or Supraumbilical older infants or when US is equivocal.
neous lesions. Although usually asymptom- raphe) are present, an “S” is added (PHACES).
atic, multifocal lesions can cause high- Ninety percent of infants are female and Diagnosis
output cardiac failure, which is managed by cerebrovascular anomalies are the most Most IHs are easily diagnosed by history and
corticosteroid or embolization. Diffuse he- common associated finding (72%). Because physical examination. Fast flow is confirmed
patic IH can cause massive hepatomegaly, 8% of children with PHACE have a stroke in using a hand-held Doppler device. By formal
respiratory compromise, or abdominal infancy, patients should have magnetic reso- US, IH appears as a soft-tissue mass with
compartment syndrome. Infants are also at nance imaging (MRI) to evaluate the brain fast flow, decreased arterial resistance, and
risk for hypothyroidism and irreversible and cerebrovasculature. Infants are referred increased venous drainage. On MRI the
brain injury because the large tumor vol- for ophthalmologic, endocrine, and cardiac tumor is isointense on T1, hyperintense on
ume expresses enough deiodinase to inacti- evaluation to rule out these associated T2, and enhances during the proliferating
vate thyroid hormone. Patients require anomalies. phase. Involuting IH has increased lobularity
thyroid stimulating hormone monitoring Reticular hemangioma is an uncommon and adipose tissue; the number of vessels
and, if abnormal, intravenous thyroid hor- variant of IH that most commonly affects and flow is reduced. Rarely, biopsy is indi-
mone replacement until the IH begins to the lumbosacral area and lower extremity. cated if malignancy is suspected or if the di-
regress. Females (83%) are usually affected. Unlike agnosis remains unclear following imaging

A B C D E

Fig. 2. Vascular malformations. (A) Newborn infant with CM of the trunk. (B) A 9-year-old female with left facial LM. (C) A
2-year-old female with upper labial VM. (D) A 14-year-old male with left facial AVM. (E) A 18-month-old female with a com-
bined capillary–lymphatic–venous malformation of right lower extremity and overgrowth (KTS).

www.medicalebookpdf.com

LWBK892_c27_p359-368.indd 360 10/28/11 4:20:03 PM

 Chapter 27: Vascular Anomalies of Infancy and Childhood 361

studies. Positive erythrocyte-type glucose treated with different doses of corticosteroid residual tissue after the tumor has regressed.
transporter (GLUT 1) immunostaining dif- will have (a) stabilization of growth or (b) ac- Nevertheless, in experienced surgical hands,
ferentiates IH from other vascular tumors celerated regression. Almost all patients, there are indications for operative interven-
and malformations. however, will respond to 3 mg/kg. Treatment tion during the proliferating phase: (a) fail-
response is usually evident within 1 week of ure or contraindication to corticosteroid; (b)
Nonoperative Treatment therapy by signs of involution: decreased well-localized tumor in an anatomically fa-
Most IHs are simply observed because 90% growth rate, fading color, and softening of vorable area; (c) resection will be necessary
are small, localized, and do not involve ana- the lesion. The location of the hemangioma in the future and the scar would be the same.
tomically important areas. During the pro- does not influence response rate. For the rare Circular lesions located in visible areas, par-
liferative phase 16% of lesions will ulcerate; lesion that fails to stabilize with corticoster- ticularly the face, are best removed by circu-
most commonly on the lips, neck, and ano- oid, the dose may be increased up to 5 mg/ lar excision and purse-string closure. This
genital region. Other complications include kg, which may improve treatment response. technique minimizes the length of the scar
bleeding and infection. IH is kept moist Alternatively, the child may be switched to as well as distortion of surrounding struc-
during the proliferative phase with hydrated vincristine. Interferon is no longer recom- tures. Lenticular excision of a circular he-
petroleum to minimize desiccation as well mended in children less than 12 months of mangioma results in a scar as long as three
as to protect against incidental trauma. IH age because it can cause neurologic sequela, times the diameter of the lesion (Fig. 3). In
may be further protected by using a petro- particularly spastic diplegia. comparison, a two-stage circular resection
leum gauze barrier. If an ulceration devel- Complications of systemic corticosteroid followed by lenticular excision/linear clo-
ops it is managed with local wound care; for the management of IH have been studied; sure 6 to 12 months later will leave a scar ap-
often healing takes 4 to 6 weeks. there are no adverse effects on neurodevel- proximately the same length as the diameter
opment. Short-term morbidity may include of the original hemangioma (Fig. 4).
Topical Corticosteroid cushingoid face, personality change, gastric
Topical corticosteroid has minimal efficacy; irritation, fungal (oral or perineal) infection, Involuting Phase (Early Childhood)
especially against IH involving the deep der- myopathy, decreased gain in height, and de- While operative management of IH is gener-
mis and subcutis. Ultrapotent agents may be creased gain in weight. These findings resolve ally not indicated during the proliferative
effective for a very superficial IH. Although after the completion of therapy. Over 90% of phase, resection during involution is much
lightening may occur, if there is deep com- children return to their pretreatment growth safer because the lesion is less vascular and
ponent it will not be affected. Adverse effects curve for height by 24 months of age. smaller. Because the extent of the excision is
include hypopigmentation, skin atrophy, reduced, the outcome is superior. Approxi-
and even adrenal suppression. Embolic Therapy mately 50% of IHs leave behind fibrofatty
Large IHs, most commonly multifocal he- tissue or damaged skin after the tumor re-
Intralesional Corticosteroid patic lesions, can cause high-output conges- gresses, causing a deformity. Sometimes a
Small, well-localized IHs that obstruct the tive heart failure. Embolization may be indi- child requires reconstruction of damaged
visual axis or nasal airway or those at risk for cated for the initial control of cardiac overload structures (e.g., nose, ear, lip). Staged or total
damaging important structures (e.g., eyelid, while systemic corticosteroid therapy takes excision should be considered during this
lip, nose) are best managed by intralesional effect. Cardiac failure often recurs even after period, rather than waiting for complete in-

The Head and Neck

corticosteroid. Triamcinolone (3 mg/kg) sta- initial improvement, and drug therapy should volution if (a) it is clear that the lesion will
bilizes the growth of the lesion in at least 95% be continued after embolization until the require resection (e.g., postulceration scar-
of patients; 75% of tumors will decrease in child is approximately 12 months of age when ring, destroyed structures, expanded skin,
size. The corticosteroid lasts 4 to 6 weeks and natural involution begins. significant fibrofatty residuum); (b) the
thus infants may require one to two more in- length of the scar would be similar if the
jections during the proliferative phase. In- Laser Therapy procedure was postponed to the involuted
tralesional corticosteroid may cause subcu- There is little, if any, role for pulsed-dye laser phase; (c) the scar is in a favorable location.
taneous fat atrophy. Blindness has been treatment for proliferating IH. The laser Advantages of operative intervention dur-
reported following injection of deep perior- penetrates only 0.75 to 1.2 mm into the der- ing this period, compared with late child-
bital hemangioma due to embolic occlusion mis, and thus only affects the superficial hood, is that reconstruction is under way
of the retinal artery. portion of the tumor. Although lightening prior to the child’s development of memory
may occur, the mass of IH is not affected. In- or awareness of a facial difference.
Systemic Corticosteroid stead, patients have an increased risk of skin
Any problematic IH that is larger than 3 to atrophy and hypopigmentation. The ther- Involuted Phase (Late Childhood)
4 cm in diameter is managed by daily oral mal injury delivered by the laser to the isch- Waiting until IH has fully involuted prior to
prednisolone. The patient is started on 3 mg/ emic dermis increases the risk of ulceration, resection ensures that the least amount of
kg/d for 1 month, which then is tapered by pain, bleeding, and scarring. Pulsed-dye la- fibrofatty residuum and excess skin is re-
0.5 cc every 2 to 4 weeks until it is discontin- ser is indicated during the involuted phase sected, resulting in the smallest possible
ued between 10 and 12 months of age when to fade residual telangiectasias. scar. Postponing intervention until complete
the tumor is no longer proliferating. Recently, involution has occurred must be weighed
propranolol has been described for the treat- Operative Treatment against the possible psychosocial implica-
ment of IH, but its efficacy and safety, com- Proliferative Phase (Infancy) tions of maintaining a deformity until late
pared with corticosteroid, has not been Operative treatment in infancy is generally childhood. Allowing for full involution is
studied. Corticosteroid, in contrast, has been not recommended. The tumor is highly vas- recommended for lesions when it is unclear
used to treat IH for over 40 years and has cular during this period and there is a risk for if a surgical scar would leave a worse defor-
proven to be very safe and effective. Meta- blood loss, iatrogenic injury, and an inferior mity than the appearance of the residual he-
analysis has shown that 84% of patients aesthetic outcome, compared with excising mangioma.

www.medicalebookpdf.com

LWBK892_c27_p359-368.indd 361 10/28/11 4:20:06 PM

 362 Part III: The Head and Neck

A B

Fig. 3. A 2-year-old female with involuting phase IH of the scalp resulting in fibrofatty residuum and alopecia: lenticular
excision and linear closure.

A B C

D E F

Fig. 4. (A,B) A 2.5-year-old female with frontal IH and fibrofatty residuum. (C) Lenticular excision would result in a scar
approximately three times the diameter of the tumor. (D,E) Circular excision/purse-string closure. (F) Small scar 3 months
postoperatively.

www.medicalebookpdf.com

LWBK892_c27_p359-368.indd 362 10/28/11 4:20:06 PM

 Chapter 27: Vascular Anomalies of Infancy and Childhood 363

Congenital Hemangiomas IH, KHE is usually present at birth as a flat, may be out of the reach of the pulsed-dye la-
reddish-purple, edematous lesion. It does ser, cautery, or shave excision. Consequently,
Clinical Presentation not exhibit rapid postnatal growth; how- these modalities have a recurrence rate of
There are rare hemangiomas that arise in ever, the tumor can expand with the onset 43.5%. Full-thickness skin excision is more
the fetus, are fully grown at birth, and do not of KMP. MRI is indicated for diagnostic con- definitive.
have postnatal growth. These congenital he- firmation and to asses the extent of the tu-
mangiomas are red-violaceous with coarse mor. MRI shows poorly defined margins,
telangiectasias, central pallor, and a periph- small vessels, and invasion of adjacent tis-
VASCULAR MALFORMATIONS
eral pale halo. These lesions are more com- sues. There is T2 hyperintensity and postg-
mon in the extremities, have an equal sex
Capillary Malformation
adolinium enhancement; signal voids may
distribution, and are solitary with an aver- also be present. Histologically, KHE has in- Clinical Presentation
age diameter of 5 cm. There are two forms: filtrating sheets or nodules of endothelial CM is now the accepted term for the famil-
RICH and NICH. RICH regresses rapidly af- cells lining capillaries. Hemosiderin-filled iar “port-wine” stain. Histopathological ex-
ter birth; 50% have completed regression by slit-like vascular spaces with red blood cell amination shows dilated capillaries and
7 months of age. RICH affects the head or fragments, as well as dilated lymphatics, venular vessels in the superficial dermis.
neck (42%), limbs (52%), or trunk (6%). RICH are present. CM is most often solitary; it can be localized
does not leave behind a significant adipose or extensive. Over time the stain darkens
component, unlike IH. NICH, in contrast, Treatment and exhibits fibrovascular overgrowth. It
does not undergo involution; there is persis- Most lesions are extensive, involving multi- can be associated with soft-tissue and skel-
tent fast flow. It involves the head or neck ple tissues, and are beyond the limits of re- etal hypertrophy. Sturge–Weber syndrome
(43%), limbs (38%), or trunk (19%). section. Patients with KMP require systemic is characterized by CM in the ophthalmic
treatment to prevent life-threatening com- (V1) trigeminal dermatome associated with
Treatment plications. Large, asymptomatic tumors ipsilateral ocular and leptomeningeal vas-
RICH usually does not require resection in without KMP are also managed with phar- cular anomalies. Leptomeningeal anomalies
infancy because it undergoes accelerated re- macotherapy to minimize fibrosis and sub- can cause seizures, contralateral hemiple-
gression. Occasionally, RICH is complicated sequent long-term pain and stiffness. Vin- gia, and delayed development. Patients are
by congestive heart failure, which is con- cristine is first-line therapy; the response at risk for retinal detachment and glaucoma;
trolled by corticosteroid or embolization as rate is 90%. KHE does not respond as well to they should be followed closely by an oph-
the lesion involutes. After regression RICH second-line drugs, interferon (50%), or cor- thalmologist. Over one-half of patients with
may leave behind atrophic skin and subcu- ticosteroid (10%). Thrombocytopenia will Sturge–Weber syndrome have patchy capil-
taneous tissue. Reconstruction with autolo- not be significantly improved with platelet lary stains on the trunk and extremities.
gous grafts ( fat, dermis) or acellular dermis transfusion because the platelets are trapped This presentation causes confusion with
may be indicated. NICH is rarely problem- in the tumor. Transfusion also worsens combined vascular anomalies and accounts
atic in infancy; it is observed until the diag- swelling and should be avoided unless there for the erroneous label “Klippel–Weber–
nosis is clear. Resection of NICH may be is active bleeding or a surgical procedure is Trenaunay syndrome.”
indicated to improve the appearance of the planned. By 2 years of age, the tumor often

The Head and Neck

affected area, as long as the surgical scar will undergoes partial involution and the plate- Treatment
be less noticeable than the lesion. let count normalizes. There is evidence that Pulsed-dye laser (585 nm) therapy can im-
KHE never totally regresses. prove the appearance of CM; the head and
Kaposiform Hemangioendothelioma neck region responds better than the ex-
Pyogenic Granuloma tremities. Outcome is also superior for
Clinical Presentation smaller lesions and those treated at a younger
KHE is a rare vascular neoplasm that is lo- PG is neither “pyogenic” nor “granuloma- age. Fifteen percent of patients achieve at
cally aggressive, but does not metastasize. tous.” Some pathologists call it lobular capil- least 90% lightening, 65% improve 50% to
Although one-half of lesions are present at lary hemangioma. PG is a solitary, red papule 90%, and 20% respond poorly. Multiple treat-
birth, KHE may develop during infancy (58%), that grows rapidly on a stalk. It is small, with ments, spaced 6 weeks apart, are often re-
between age 1 and 10 years (32%), or after an average diameter of 6.5 mm; the mean quired until the CM no longer improves with
11 years of age (10%). KHE has an equal sex age of onset is 6.7 years. The male:female ra- additional treatments. After laser treatment,
distribution, is solitary, and affects the head/ tio is 2:1. PG is commonly complicated by CM often redarkens over time.
neck (40%), trunk (30%), or extremity (30%). bleeding (64%) and ulceration (36%). PG pri- CM can also be associated with soft-
The tumor is often greater than 5 cm in diam- marily involves the skin (88%), but can in- tissue and skeletal overgrowth. Labial hy-
eter, and thus larger than the typical IH. KHE volve mucous membranes as well (11%). PG pertrophy is improved by contour resection.
causes a visible deformity as well as pain. In is distributed on the head or neck (62%), Enlargement of the maxilla or mandible can
addition, 50% of patients have the Kasabach– trunk (19%), upper extremity (13%), or lower result in an occlusal cant and malocclusion.
Merritt phenomenon (KMP) (thrombocy- extremity (5%). In the head and neck region, Malocclusion may be corrected in adoles-
topenia ⬍25,000/mm3, petechiae, bleeding). affected sites include cheek (29%), oral cav- cence by orthodontic manipulation and/or
KHE partially regresses after 2 years of age, ity (14%), scalp (11%), forehead (10%), eyelid an orthognathic procedure. CM of the trunk
although it usually persists long term causing (9%), or lips (9%). or extremity may be associated with fatty
chronic pain and stiffness. PGs require intervention to control likely overgrowth causing asymmetry and leg-
ulceration and bleeding. Numerous meth- length discrepancy. In severe cases, cutane-
Diagnosis ods have been described: curettage, shave ous thickening and cobblestoning can be
The diagnosis is established by history, excision, laser therapy, or excision. Because resected and reconstructed by linear closure,
physical examination, and imaging. Unlike the lesion can involve the reticular dermis, it skin grafts, or local flaps. Facial asymmetry

www.medicalebookpdf.com

LWBK892_c27_p359-368.indd 363 10/28/11 4:20:14 PM

 364 Part III: The Head and Neck

caused by overgrowth of the zygoma, max- with septations of variable thickness. It is hy- peated sclerotherapy over the course of their
illa, or mandible can be improved by contour perintense on T2-weighted sequences and lifetime. If a problematic LM recurs and
burring. does not show diffuse enhancement. Al- macrocysts are no longer present in the le-
though US is not as accurate as MRI, it may sion, then resection is the next alternative.
Lymphatic Malformation provide diagnostic confirmation or docu-
ment intralesional bleeding. US findings for Resection
Clinical Presentation macrocystic LM include anechoic cysts with Attempts at extirpation of LM can cause
LM is caused by an error in the embryonic internal septations, often with debris or flu- significant morbidity: major blood loss, iat-
development of the lymphatic system. LM is id-fluid levels. Microcystic LM appears as ill- rogenic injury, and deformity. For example,
characterized by the size of the malformed defined echogenic masses with diffuse in- resection of cervicofacial LM can injure the
channels: microcystic, macrocystic, or com- volvement of adjacent tissues. Histological facial nerve (76%) or hypoglossal nerve
bined. Macrocystic lesions are defined as confirmation of LM is rarely necessary. LM (24%). Excision is usually subtotal because
cysts large enough to be punctured by a nee- shows abnormally walled vascular spaces LM involves multiple tissue planes and im-
dle and treated with sclerotherapy. Because with eosinophilic, protein-rich fluid, and col- portant structures; recurrence is thus com-
the lymphatic and venous systems share a lections of lymphocytes. Immunostaining mon (35% to 64%). Resection is reserved for
common embryological origin, lymphatic– with the lymphatic markers D2–40 and (a) symptomatic microcystic LM causing
venous malformation (LVM) can also occur. LYVE-1 are positive. bleeding, infection, distortion of vital struc-
LM is usually noted at birth or within the tures, or significant deformity; (b) symp-
first 2 years of life. LM is most commonly lo- Treatment tomatic macrocystic/combined LM that no
cated on the head and neck; other frequent LM is a benign lesion; intervention is not longer can be managed with sclerotherapy
sites include the axilla, chest, and perineum. mandatory. Small or asymptomatic lesions because all macrocysts have been treated;
Lesions are soft and compressible. The over- may be observed. An infected LM often can- (c) small, well-localized LM (microcystic
lying skin may be normal, have a bluish hue, not be controlled with oral antibiotics and or macrocystic) that may be completely
or be studded with pink-red vesicles. intravenous antimicrobial therapy is usually excised. When considering resection, the
LM typically causes deformity and psy- required. Intervention for LM is reserved for postoperative scar/deformity following re-
chosocial issues, especially when it involves symptomatic lesions that cause pain, signif- moval of the LM should be weighed against
the head and neck. The two most common icant deformity, or threaten vital structures. the preoperative appearance of the lesion.
complications associated with LM are For diffuse malformations, staged resec-
bleeding and infection. Intralesional bleed- Sclerotherapy tion of defined anatomic areas is recom-
ing occurs in up to 35% of lesions, causing Sclerotherapy is first-line management for mended. Subtotal excision of problematic
ecchymotic discoloration, pain, or swelling. large or problematic macrocystic/combined areas, such as bleeding vesicles or a hyper-
Infection complicates as many as 70% of le- LM. Cysts are aspirated followed by the trophied lip, should be carried out rather
sions and can progress rapidly to sepsis. Cu- injection of an inflammatory substance, than “complete” resection of a benign lesion,
taneous vesicles can bleed and cause mal- which causes scarring of the cyst walls to which would result in a worse deformity
odorous drainage. Oral lesions may lead to each other. Sclerotherapy has superior effi- than the malformation itself. Macroglossia
macroglossia, poor oral hygiene, and caries. cacy and a lower complication rate than may require reduction to return the tongue
Swelling due to bleeding, localized infec- excision. Several sclerosant(s) are used to to the oral cavity or to correct an open-bite
tion, or systemic illness may obstruct vital shrink LM: doxycycline, sodium tetradecyl deformity. Bony overgrowth is improved by
structures. Two-thirds of infants with cervi- sulfate (STS), ethanol, bleomycin, and OK- osseous contouring and malocclusion may
cofacial LM require tracheostomy. Bony 432. We prefer doxycycline because it is require orthognathic correction, usually af-
overgrowth is another complication; the effective (83% reduction in size) and safe ter skeletal maturity.
mandible is most commonly involved, re- (less than 5% risk of skin ulceration). STS is Bleeding or leaking cutaneous vesicles
sulting in an open bite and prognathism. our second-line agent. Ethanol is an effec- may be managed by resection if they are
Thoracic or abdominal LM may lead to tive sclerosant(s) but has the highest com- localized and the wound can be closed by
pleural, pericardial, or peritoneal chylous ef- plication rate. It can be used for small le- direct approximation of tissues. Vesicles
fusions. Periorbital LM causes a permanent sions, but large volumes should be avoided often recur through the scar. Large areas of
reduction in vision (40%), and 7% of patients to reduce the risk of local and systemic tox- vesicular bleeding or drainage are best man-
become blind in the affected eye. General- icity. Ethanol can injure nerves and thus aged by sclerotherapy or carbon dioxide la-
ized LM presents with multifocal or oste- should not be used in proximity to impor- ser; alternatively, wide resection and skin
olytic bony lesions in association with pleu- tant structures. The use of OK-432 is limited graft coverage is required. Microcystic vesi-
ral and/or pericardial effusions; so-called because it is not widely available. cles involving the oral cavity respond well to
lymphangiectasia of the bowel with protein- The most common complication of scle- radiofrequency ablation. Patients and fami-
losing enteropathy may also be present. rotherapy for LM is cutaneous ulceration lies are counseled that LM can expand fol-
(⬍5%). Ethanol is associated with additional lowing any intervention, and thus additional
Diagnosis systemic toxicity: central nervous system treatments are often required in the future.
Ninety percent of LMs are diagnosed by his- (CNS) depression, pulmonary hypertension,
tory and physical examination. Small, super- hemolysis, thromboembolism, and arrhyth- Venous Malformation
ficial lesions do not require further diagnos- mias. Extravasation of the sclerosant(s) into
tic evaluation. Large or deep lesions are muscle can cause atrophy and contracture. Clinical Presentation
assessed by MRI to (a) confirm the diagnosis; LM often reexpands over time; 9% recur VM results from an error in vascular morpho-
(b) define the extent of the malformation; within 3 years following OK-432 treatment genesis; the anomalous channels are dilated
and (c) plan treatment. LM appears as a mac- and most will reexpand with longer follow- with thin walls and abnormal smooth muscle.
rocystic, microcystic, or combined lesion up. Consequently, patients often need re- Consequently, flow stagnates, lesions expand,

www.medicalebookpdf.com

LWBK892_c27_p359-368.indd 364 10/28/11 4:20:14 PM

 Chapter 27: Vascular Anomalies of Infancy and Childhood 365

and clotting occurs. Lesions are blue, soft, and pulmonary embolism. Gastrointestinal when injectable vascular spaces are no lon-
and compressible; calcified phleboliths may VM can cause bleeding and chronic anemia. ger present. Although sclerotherapy effec-
be palpated. VMs range from small, localized Stagnation within a large VM results in a tively reduces the size of the lesion and im-
cutaneous lesions to diffuse malformations localized intravascular coagulopathy (LIC) proves symptoms, the malformation remains.
involving multiple tissue planes and vital and painful phlebothromboses. Consequently, patients have a mass or visible
structures. VM is typically sporadic and soli- deformity after treatment that may be im-
tary in 90% of patients; however, 50% have a Diagnosis proved by resection. In addition, VM usually
somatic mutation in the endothelial receptor At least 90% of VMs are diagnosed by history reexpands after sclerotherapy, and thus pa-
TIE2. Sporadic VM is usually greater than and physical examination. Dependent posi- tients often require additional treatments.
5 cm (56%), single (99%), and located on the tioning of the affected region usually confirms The preferred scleroscents for VM are
head/neck (47%), extremities (40%), or trunk the diagnosis. Small, superficial VMs do not STS and ethanol; STS is most commonly
(13%). Almost all lesions involve the skin, mu- require further diagnostic workup. Large or used. Although ethanol is more effective
cosa, or subcutaneous tissue; 50% also affect deeper lesions are evaluated by MRI to (a) than STS, it has a higher complication rate.
deeper structures (e.g., muscle, bone, joints, confirm the diagnosis; (b) define the extent of Most patients, especially children, are man-
viscera). the malformation; and (c) plan treatment. VM aged under general anesthesia using US or
Approximately 10% of patients with VM is hyperintense on T2-weighted sequences. fluoroscopic imaging. The most common lo-
have multifocal, familial lesions. Glomu- Unlike LM, VM enhances with contrast, often cal complication of sclerotherapy for VM is
venous malformation (GVM) is the most shows phleboliths as signal voids, and is more cutaneous ulceration (⬍5%). Extravasation
common type, cutaneomucosal–venous mal- likely to involve muscle. US may be used for of the scleroscent into muscle can cause at-
formation (CMVM) is rare. GVM is an auto- some localized lesions; findings include com- rophy and contracture. Posttreatment swell-
somal dominant condition with abnormal pressible, anechoic–hypoechoic channels ing may necessitate close monitoring. Com-
smooth muscle-like glomus cells along the separated by more solid regions of variable partment syndrome is a serious consequence
ectactic veins. It is caused by a loss-of- echogenicity. Phleboliths are hyperechoic of sclerotherapy for extremity VM. Systemic
function mutation in the glomulin gene. Le- with acoustic shadowing. Computed tomog- adverse events from sclerotherapy, includ-
sions are typically multiple (70%), small raphy (CT) is occasionally indicated to assess ing hemolysis, hemoglobinuria, and DIC,
(two-thirds ⬍5 cm), and located in the skin osseous VM. Histological diagnosis of VM is are more common if large lesions are treated.
and subcutaneous tissue; deeper structures rarely necessary, but may be indicated to rule Patients with low fibrinogen levels are given
are not affected. GVM involves the extremi- out malignancy or if imaging is equivocal. LMWH 14 days before and after the proce-
ties (76%), trunk (14%), or head/neck (10%). dure. Anticoagulation is held for 24 hours
Lesions are more painful than typical VM. Treatment perioperatively (12 hours before and after
CMVMs are small, multifocal mucocuta- Patients with an extensive extremity VM are the intervention) to prevent bleeding com-
neous lesions caused by a gain-of-function prescribed custom-fitted compression gar- plications.
mutation in the TIE2 receptor. The condition ments to reduce blood stagnation and thus
is autosomal dominant and less common minimize expansion, LIC, phlebolith forma- Resection
than GVM. Lesions are small (76% ⬍5 cm), tion, and pain. Patients with recurrent pain Extirpation of VM can cause major morbid-
multiple (73%), and located on the head/ secondary to phlebothrombosis are given ity; blood loss, iatrogenic injury, and defor-

The Head and Neck

neck (typically tongue or buccal mucosa) prophylactic daily aspirin (81 mg) to prevent mity. In contrast to sclerotherapy, resection
(50%), extremity (37%), or trunk (13%). thrombosis. Large lesions are at risk for co- is rarely primary treatment because (a) the
Cerebral cavernous malformation (CCM) agulation of stagnant blood, stimulation of entire lesion is difficult to remove; (b) the
is a rare familial disorder with VM involving thrombin, and conversion of fibrinogen to risk of recurrence is high because channels
the brain and spinal cord; patients may also fibrin. LIC can become disseminated intra- adjacent to the visible lesion are not treated;
have hyperkeratotic skin lesions. The disor- vascular coagulopathy (DIC) following trauma and (c) the risk of blood loss and iatrogenic
der results from mutations in CCM1/(KRIT1), or therapeutic intervention. The chronic con- injury is greater. Resection should be con-
CCM2, and CCM3 genes and patients are at sumptive coagulopathy can cause either sidered for (a) small, well-localized lesions
risk for development of new intracranial le- thrombosis (phleboliths) or bleeding (hemar- that can be completely removed or (b) per-
sions and hemorrhage. throsis, hematoma, intraoperative blood loss). sistent mass or deformity after completion
Blue rubber bleb nevus syndrome (BRBNS) Low molecular weight heparin (LMWH) is of sclerotherapy (patent channels are no
is a rare condition with multiple, small considered for patients with significant LIC longer accessible for further injection).
(⬍2 cm) VMs involving the skin, soft tissue, who are at risk for DIC. Patients who develop When considering resection, the postoper-
and gastrointestinal tract. Morbidity is as- a serious thrombotic event require long-term ative scar/deformity following removal of
sociated with gastrointestinal bleeding, re- anticoagulation or a vena caval filter. the VM should be weighed against the pre-
quiring chronic blood transfusions. operative appearance of the lesion. Subtotal
Complications of VM include pain, swell- Sclerotherapy resection of a problematic area, such as la-
ing, and psychosocial issues. Head and neck Intervention for VM is reserved for symp- bial hypertrophy, is indicated rather than
VMs may present with mucosal bleeding or tomatic lesions that cause pain, deformity, attempting “complete” excision of a benign
progressive distortion leading to airway or obstruction (e.g., vision, airway), or gastro- lesion that might result in a worse defor-
orbital compromise. Extremity VM can cause intestinal bleeding. First-line treatment is mity than the malformation itself. Patients
leg-length discrepancy, hypoplasia due to sclerotherapy, which is safer and more effec- and families are counseled that VM can ex-
disuse atrophy, pathologic fracture, hemar- tive than resection. Diffuse malformations pand following excision, and additional op-
throsis, and degenerative arthritis. VM of are managed by targeting specific symptom- erative intervention may be required in the
muscle may result in fibrosis and subsequent atic areas; often the entire lesion is too ex- future.
pain and disability. A large VM involving the tensive to treat at one time. Sclerotherapy is Almost all VMs should have sclerother-
deep venous system is at risk for thrombosis repeated until symptoms are alleviated or apy prior to operative intervention. After

www.medicalebookpdf.com

LWBK892_c27_p359-368.indd 365 10/28/11 4:20:14 PM

 366 Part III: The Head and Neck

adequate sclerotherapy, the VM is replaced a

atomically important location (e.g., trunk,
by scar and thus the risk of blood loss, iatro- Table 2 Schobinger Staging of AVM pproximal extremity) may be resected without
genic injury, and recurrence is reduced. In cconsequence, before it progresses to a higher
Stage Clinical findings
addition, fibrosis facilitates resection and sstage where resection is more difficult and
reconstruction. Because GVMs are usually I (Quiescence) Warm, pink-blue, tthe recurrence rate is greater. Similarly, a
small and less amenable to sclerotherapy, shunting on ssmall, well-localized AVM in a more difficult
Doppler
first-line therapy for painful lesions may be llocation (e.g., face, hand) may be excised for
resection. Nd:YAG photocoagulation can II (Expansion) Enlargement, ppossible “cure” before it expands and com-
be an adjuvant to sclerotherapy for the man- pulsation, thrill, pplete extirpation is no longer possible.
agement of difficult airway lesions. Gastro- bruit, tortuous In contrast, a large, asymptomatic AVM
intestinal VMs with chronic bleeding, anemia, veins located in an anatomically sensitive area is
lo
and transfusion requirements are typically III (Destruction) Dystrophic skin bbest observed, especially in a young child who
managed by resection. Solitary lesions can be changes, iis not psychologically ready for major resec-
treated by endoscopic banding or sclerother- ulceration, ttion and reconstruction. Resection and re-
apy. Multifocal lesions of BRBNS require re- bleeding, pain cconstruction may result in a more noticeable
moval of as many lesions as possible through IV (Decompensation) Cardiac failure ddeformity or functional problem than the
multiple enterotomies, instead of bowel re- malformation. Although the recurrence rate
m
section, to preserve the length of intestine. iis lower when Stage I AVM is resected, it is still
Diffuse, problematic colorectal VMs may re- and draining veins, enhancement, and flow high, and thus even after major resection and
quire colectomy, anorectal mucosectomy, voids on T2-weighted imaging. In rare in- reconstruction the malformation can recur.
and endorectal pull-through. stances, diagnostic angiography is needed. Some patients (17.4%) do not have significant
Angiography is also indicated if emboliza- morbidity from their lesion long term.
tion or resection is planned to determine the Intervention for Stage II AVMs is similar to
Arteriovenous Malformation flow dynamics of the lesion. AVM exhibits that for Stage I lesions. The threshold for
Clinical Presentation tortuous, dilated arteries with venous shunt- treatment is lower if an enlarging lesion is
AVM results from an error in vasculogenesis ing and dilated draining veins on angiogram. causing a worsening deformity or if functional
during embryonic development. An absent Often, a blush illustrates the nidus of the problems are occurring. Stage III and IV AVMs
capillary bed causes shunting of blood di- lesion. Histopathological diagnosis of AVM require intervention to control pain, bleeding,
rectly from the arterial to venous circulation, is rarely necessary, but may be indicated ulceration, or congestive heart failure.
through a fistula (direct connection of an ar- to rule out malignancy or if imaging is
tery to a vein) or nidus (abnormal channels equivocal. Embolization
bridging the feeding artery to the draining Embolization is the delivery of an inert sub-
veins). Genetic abnormalities cause certain Treatment stance, through a catheter proximal to the
types of familial AVM. Hereditary hemor- Because AVM is often diffuse, involving mul- AVM, to occlude blood flow and/or fill a vas-
rhagic telangiectasia (HHT) is caused by mu- tiple tissue planes and important structures, cular space. Ischemia and scarring reduce
tations in endoglin and activin receptor-like cure is rare. The goal of treatment is usually arteriovenous shunting, shrink the lesion,
kinase 1 (ALK-1), which affect transforming to control the malformation. Intervention is and diminish symptoms. Embolization is
growth factor-beta (TGF-␤) signaling. Capil- focused on alleviating symptoms (e.g., bleed- used either as a preoperative adjunct to re-
lary malformation–arteriovenous malforma- ing, pain, ulceration), preserving vital func- section or as monotherapy for lesions not
tion (CM–AVM) results from a mutation in tions (e.g., vision, mastication), and improv- amenable to extirpation. Because the AVM
RASA1. ing a visible deformity. Management options is not removed, almost all lesions eventually
The head and neck is the most common include embolization, resection, or a combi- reexpand after treatment. Stage I AVM has a
site of extracranial AVM, followed by the nation. Resection offers the best chance for lower recurrence rate than higher-staged le-
limbs, trunk, and viscera. Although present long-term control, but the reexpansion rate sions. Most recurrences occur within the
at birth, AVM may not become evident until is high and extirpation may cause a worse de- first year after embolization, and 98% reex-
childhood. Arteriovenous shunting reduces formity. Almost all AVMs will reexpand after pand within 5 years. Despite the high likeli-
capillary oxygen delivery causing ischemia; embolization. Consequently, embolization is hood of reexpansion, embolization can ef-
patients are at risk for pain, ulceration, most commonly used preoperatively to re- fectively palliate an AVM by reducing its
bleeding, and congestive heart failure. AVM duce blood loss during resection, or some- size, slowing expansion, and alleviating pain
may also cause disfigurement, destruction times for palliation of unresectable lesions. and bleeding. Preoperative embolization
of tissues, and obstruction of vital struc- Asymptomatic AVM should be observed also reduces blood loss during extirpation,
tures. AVM worsens over time; the lesion unless it can be completely removed with but not the extent of resection.
can be classified according to the Schobin- minimal morbidity; embolization or incom- Substances used for embolization are
ger staging system (Table 2). plete excision of an asymptomatic lesion may either liquid (n-butyl cyanoacrylate (n-BCA),
stimulate it to enlarge and become problem- Onyx) or solid (polyvinyl alcohol particles
Diagnosis atic. Intervention is determined by (a) the (PVA), coils). The goal of embolization is oc-
Most AVMs are diagnosed by history and size and location of the AVM; (b) the age of clusion of the nidus and proximal venous out-
physical examination. If AVM is suspected, the patient; and (c) the Schobinger stage. Al- flow. The embolic material is delivered to the
the diagnosis should be confirmed by US though resection of an asymptomatic Stage I nidus, not to the proximal arterial feeding
with color Doppler examination showing AVM offers the best chance for long-term vessels. Occlusion of inflow will cause collat-
fast flow and shunting. MRI is also obtained control or “cure,” intervention must be indi- eralization and expansion of the AVM; access
to (a) confirm the diagnosis; (b) determine vidualized based on the deformity that would to the nidus will also be blocked, preventing
the extent of the lesion; and (c) plan treat- be caused by resection and reconstruction. future embolization. For preoperative embo-
ment. MRI shows dilated feeding arteries For example, a large Stage I AVM in a nonan- lization, temporary occlusive substances

www.medicalebookpdf.com

LWBK892_c27_p359-368.indd 366 10/28/11 4:20:14 PM

 Chapter 27: Vascular Anomalies of Infancy and Childhood 367

(gelfoam powder, PVA, embospheres) that Capillary Malformation–Arteriovenous other hemihypertrophy syndromes, patients
undergo phagocytosis are used. Permanent Malformation with KTS are not at increased risk for Wilms
liquid agents capable of permeating the nidus CM–AVM is a familial disorder; the preva- tumor and screening US is unnecessary. En-
(n-BCA, Onyx) are used when embolization is lence is 1 in 100,000 Caucasians. CM–AVM largement of the foot may require a ray, mid-
the primary treatment. The most frequent is an autosomal dominant condition caused foot, or Syme amputation to allow the use of
complication of embolization is ulceration. by a loss-of-function mutation in the RASA1 footwear. Management of the VM compo-
Resection gene. Patients have atypical CMs that are nent of KTS is conservative with compressive
Resection of AVM has a lower recurrence small, multifocal, round, pinkish-red, and stockings for insufficiency and aspirin to
rate than embolization alone and is consid- often surrounded by a pale halo (50%). minimize phlebothrombosis. Symptomatic
ered for well-localized lesions or to correct Thirty percent of individuals also have an varicose veins may be removed or sclerosed.
focal deformities (e.g., bleeding or ulcerated AVM: Parkes–Weber syndrome (PWS) A functioning deep venous system is present,
areas, labial hypertrophy). Wide extirpation (12%), extracerebral AVM (11%), or intrace- although it is often difficult to visualize be-
and reconstruction of large, diffuse AVMs rebral AVM (7%). PWS refers to a diffuse cause of flow in the superficial veins. Occa-
should be exercised with caution because (a) AVM in an overgrown extremity with an sionally, sclerotherapy and surgical excision
cure is rare and the recurrence rate is high; overlying CM. PWS involves the lower ex- are necessary for the LM component.
(b) the resulting deformity is often worse tremity approximately twice as often as the
than the appearance of the malformation; upper extremity; patients have microshunt- SUGGESTED READINGS
(c) resection is associated with significant ing in muscle. A patient presenting with
Bennett ML, Fleischer AB, Chamlin SL, et al. Oral
blood loss, iatrogenic injury, and morbidity. multiple CMs, especially with a family his-
corticosteroid use is effective for cutaneous he-
When excision is planned, preoperative em- tory of similar lesions, should be evaluated mangiomas. Arch Dermatol 2001;137:1208–13.
bolization will facilitate the procedure by for possible AVMs on physical examination. Choi DJ, Alomari AI, Chaudry G, et al. Neuroint-
reducing the size of the AVM, minimizing Because 7% of patients with CM–AVM will erventional management of low-flow vascular
have an intracranial fast-flow lesion, brain malformations of the head and neck. Neuroim-
blood loss, and creating scar tissue to aid the aging Clin N Am 2009;19:199–218.
dissection. Multiple embolizations, spaced 6 MRI should be considered. Exploratory im-
aging of other anatomical areas is not nec- Finn MC, Glowacki J, Mulliken JB. Congenital vas-
weeks apart, may be required prior to resec- cular lesions: clinical application of a new clas-
tion. Excision should be done 24 to 72 hours essary because extracranial AVMs have not sification. J Pediatr Surg 1983;18:894–90.
after embolization, before recannalization been found to involve the viscera. Although Limaye N, Boon LM, Vikkula M. From germline
restores blood flow to the lesion. the CM is rarely problematic, associated towards somatic mutations in the pathophysi-
Resection margins are best determined AVMs can cause major morbidity. ology of vascular anomalies. Hum Mol Genet
2009;18:65–75.
clinically, by assessing the amount of bleed- Liu AS, Mulliken JB, Zurakowski D, et al. Extracra-
ing from the wound edges. Most defects can
Combined Vascular Malformations nial arteriovenous malformations: natural pro-
be reconstructed by advancing local skin Klippel–Trenaunay Syndrome gression and recurrence after treatment. Plast
flaps. Skin grafting ulcerated areas has a KTS is an eponym denoting a slow-flow Reconstr Surg 2010;125(4):1185–94.
high failure rate because the underlying tis- CLVM in association with soft-tissue and/or Mulliken JB, Glowacki J. Hemangiomas and vas-
cular malformations in infants and children: a
sue is ischemic; excision with regional flap skeletal overgrowth. KTS affects the lower classification based on endothelial characteris-

The Head and Neck

transfer may be required. Free-flap recon- extremity in 95% of patients, the upper ex- tics. Plast Reconstr Surg 1982;69:412–22.
struction permits wide resection and pri- tremity in 5% of patients, and least commonly Mulliken JB, Rogers GF, Marler JJ. Circular exci-
mary closure of complicated defects, but the trunk. Leg-length discrepancy is docu- sion of hemangioma and purse-string closure:
does not appear to improve long-term AVM mented by plain radiography and MRI con- the smallest possible scar. Plast Reconstr Surg
control. Despite subtotal and presumed firms the diagnosis as well as determines the 2002;109:1544–54.
“complete” extirpation, most AVMs treated Mulliken JB, Anupindi S, Ezekowitz RA, et al. Case
extent of the anomalies. A large embryonal 13—2004: a newborn girl with a large cutane-
by resection recur. The majority of recur- vein in the subcutaneous tissue (the marginal ous lesion, thrombocytopenia, and anemia.
rences occur within the first year after in- vein of Servelle) is often located in the lateral New Engl J Med 2004;350:1764–75.
tervention and 86.6% reexpand within 5 calf and thigh and communicates with the North PE, Waner M, Mizeracki A, et al. GLUT1: a
years of resection. Nevertheless, many of deep venous system. Complications include newly discovered immunohistochemical mark-
these patients remain asymptomatic. Pa- thrombophlebitis (20% to 45%) and pulmo- er for juvenile hemangiomas. Hum Pathol 2000;
tients and families are counseled that AVM 31:11–22.
nary embolism (4% to 24%). KTS of the lower Wu IC, Orbach DB. Neurointerventional manage-
is likely to reexpand following resection, extremity can involve the pelvis, causing he- ment of high-flow vascular malformations of
and thus additional treatment may be re- maturia, hematochezia, constipation, and the head and neck. Neuroimaging Clin N Am
quired in the future. bladder outlet obstruction. Unlike some 2009;19:219–40.

EDITOR’S COMMENT knowledge is needed to ascertain what exactly there are others in which steroids should be used,
one is dealing with. That is important because and as we see subsequently there are some ad-
the disfigurement and destruction of various ditional therapeutic innovations lately such as
We are especially pleased to have Professor John organs, bones, and especially of face, ears, etc., propanolol and sirolimus (rapamycin). In addi-
Mulliken write the chapter because he is cred- which can be destroyed because of these lesions, tion, with some lesions, such as lymphatic VMs,
ited by numerous papers as writing a defini- requires an expert. It is quite rare that a general operations without knowing the implications can
tive paper in 1982 (Mulliken JB and Glowacki J. practitioner, a pediatrician, a general surgeon, or result in uncontrollable hemorrhage and death of
Hemangiomas and vascular malformations in somebody who is not part of the vascular malfor- the infant.
infants and children: a classification based on mation (VM) team can really make an accurate According to the authors, 90% of the lesions
endothelial characteristics. Plast Reconstr Surg diagnosis. This is important because there are can be diagnosed by history and physical exami-
1982;69:412–22). As the authors state, detailed certain lesions that one should operate on and nation. They usually fall within a binary system,

(continued)

www.medicalebookpdf.com

LWBK892_c27_p359-368.indd 367 10/28/11 4:20:14 PM

 368 Part III: The Head and Neck

in which there are vascular tumors and VMs. With VMs, the anomalous channels are di- treated as one disease that these patients suf-
Vascular tumors are characterized by endothelial lated with thin walls and abnormal smooth fered from in the manifestation; for example, the
cell proliferation, and VMs are comprised of cells muscle. What happens is that the flow stagnates, second patient was able to have the chest tube re-
that have dysmorphogenesis but have normal cell lesions expand, and clotting occurs. There may moved in 14 days and the bone and lesions were
turnover. Thus, it is not a tumor, but it consists of be pulmonary emboli. Lesions are generally blue; stabilized. The third patient no longer required
abnormal cells that do not grow rapidly. There is they are soft unless a clot occurs. They may be red cells and had decreased leg circumference and
a life history to many of these lesions, which sug- sporadic and solitary (90%); however, sporadic improvements in the lymphatic blebs; the fourth
gest that watchful waiting, injection of steroids, VMs are usually ⬍5 cm (56%), single (99%), and patient had the chest tube removed in 8 days with
sclerotherapy, etc., will tide the infant or child located unfortunately on the head and neck the resolution of chylous pleural effusion, which
over until such a time that spontaneous regres- (47%), trunk only (13%), and extremities (40%). as you know, can be extremely difficult, and the
sion occurs. A person who is not knowledgeable However, approximately 10% of the patients with bony lesions were stabilized; the fifth patient re-
about the different forms of this disease will not VM have multifocal familial lesions. They may oc- sponded in 8 days with removal of the first chest
be able to make an educated diagnosis of this type. cur in various organs and need to be checked so tube, and in 9 days the second chest tube was
Many of these lesions involve syndromes that that if there are lesions in certain places that are removed, the bony lesions were stabilized; and
have eponymic names not known to the general potentially dangerous the physician or surgeon the sixth patient was extubated after 15 days, and
surgeon, and which involve lesions of the solid or knows that that is the case. after 5 weeks, the first chest tube was removed,
hollow viscera, such as the liver. Rapid flow arte- The authors come down on the side of scle- and after 6 weeks the second chest tube, and after
rial venous malformations may result in cardiac rotherapy as the principal means of therapy. 9 weeks the third chest tube. Consequently, bony
failure and are associated in many instances with However, Sidbury (Curr Opin Pediatr 22:432–37) lesions improved. In addition, they were near
intralesional thrombosis with depression of the believes that propanolol, which has come to light complete resolution of the abdominal lesions,
platelet count. in the past 2 years, may be the first line. There are normalization of coagulation, and improvement
Just a general cosmetic statement: when the some excellent pictures especially and an impres- of gross motor skills. This seems to be rather a
lesions, especially those of the face, have regressed sive set (Figure 2) that reveal complete resolution breakthrough and probably will get a randomized
to the point where there is a relatively small le- of such a lesion in infantile hemangioma of an prospective trial.
sion, the authors advocate a circular incision, ear. One does not know whether this applies to a An interesting article originates largely from
which leaves almost no scar. While some of you malformation, but chances are since Sidbury re- the Children’s Hospital in Boston and is entitled
may be horrified at this, let me tell you, when I fers to tumors, it applies to tumors but not to he- “Vascular Anomalies of the Male Genitalia”
was a surgical resident, I had a lentigo on my right mangiomas, and therefore sclerotherapy should (Kulungowski AM et al.—Professor Mulliken is one
cheek and I was excised by Dr. Bradford Cannon, be the mainstay of therapy. of the authors—J Pediatr Surg 2011;46:1214–21).
the noted Boston plastic surgeon in a dentist Of greater interest is the occasional patient They reviewed 3,889 male patients referred to the
chair in his office, and my incision was closed in whom interventional radiologic therapy in VM Children’s Hospital for various vascular tumors,
with 2-0 chromic double needle and a surgical such as hemangiomas by Legiehn GM and Heran and selected 117 with a vascular anomaly of the
closure. Needless to say, I was horrified, but I had MKS, writing from the Division of Neuroradiol- genitalia. There were 12 tumors and 105 malfor-
no scar and I just have a minor discoloration. ogy at the Vancouver General Hospital in British mations. The referring diagnosis was accurate in
Some of the most dangerous lesions, accord- Columbia, showing that sclerotherapy at times 72% of the patients with a tumor; however, 46%
ing to the authors, are lymphatic malformations is very complicated to treat VMs. An MRI some- of the malformations were misdiagnosed. Com-
(LMs), which are theoretically benign. LMs are times is useful and when dealing with an arterial mon VMs were lymphatic, venous, and capillary-
characterized by the size of the malformed chan- venous malformation of some size, superselective lymphatic venous. The presenting symptoms of
nels, microcystic, macrocystic, or combined. Mac- transarterial and transvenous access with flow tumors were ulceration, ambiguous genitalia,
rocystic lesions are defined as cysts large enough reduction techniques may be required. Figure 12 swelling, and fluid leakage. Further, 79% of the
to be punctured by a needle and treated with shows a good illustration of the technique that patients required therapy, and the others were
sclerotherapy. Because the lymphatic and venous they used, in which tourniquets are used to slow observed. Management included pharmaco-
systems share a common embryological origin, flow out of a lesion and the delivery of sclerosant therapy and excision, and malformations were
lymphatic-venous malformations can also occur. is carried out under radiographic guidance to largely treated with sclerotherapy and surgical
Attempts at excision of an LM may cause major control reflux from the lesion, local compression, procedures. Results do show that the expertise
blood loss, deformity, and a cosmetic injury, as and tourniquets and intraluminal outflow occlu- in such therapies in referring to therapy actually
well as neurologic injury. Dissection of the surgi- sive techniques may be required. was lacking and the diagnosis was inappropriate
cal facial LM, according to the authors, injures a A seemingly important progress is the use in a large number of cases.
facial nerve in 76% or a hypoglossal nerve in 24%. of sirolimus (rapamycin) for the treatment of Finally, in some rarer lesions, such as Klippel-
In addition, excision ends up usually being subto- complicated vascular anomalies as reported by Trénaunay syndrome (KTS), there is a tendency
tal because there are multiple tissue planes and Hammill et al., from the Cincinnati Children’s to undergo pulmonary embolism and clotting.
important structures and recurrence is between Hospital, in five cases, and the Minnesota Three adult patients with KTS, comprising two
34% and 64%. Thus, resection is dangerous, prob- Children’s Hospital in one case. The hypothesis women (aged 19 and 46 years) and one male (aged
ably injurious in most situations and reserved for here is that of the many genetic abnormalities 26 years), underwent pulmonary thromboendar-
asymptomatic microcystic LM, which that occur is the PI3K/mTOR pathway that has terectomy (PTE) in KTS. An impressive resection
been implicated in the generation and prolifera- of a fully resected organized thrombus was taken
1. Causes infection, distortion of vital struc- tion of vascular anomalies. In addition, and not from the right pulmonary artery in patient 1, and
tures, deformity, or bleeding surprisingly, vascular endothelial growth factors is shown in Figure 1. This technique, which was
2. Symptomatic macrocystic combined LM that (VEGFs) are key regulators in lymphangiogenesis developed by Jamieson and colleagues (Jamieson
no longer can be managed with sclerothera- and angiogenesis and may be abnormal and act et al. J Thorac Surg 2003;76:1457–64), describing
py because all of the macrocysts have been as an upstream stimulator(s) and a downstream 1,500 cases of pulmonary thromboenderectomy,
treated effector(s) in the mTOR signaling pathway. indicates that even in thrombotic situations, this
3. Small, well-localized microcystic or macro- Of the six patients, the most impressive is the can be carried out by someone knowledgeable.
cystic LM that may be completely excised. patient with KHE, in which there is an enormous Patients received inferior caval filters, the average
One should always remember that a total ex- leg, and the response started in 4 days with nor- follow-up was 2.6 years, and no deep vein throm-
cision may not be necessary, that there may malization of fibrinogen and a rise in the platelet bosis or pulmonary embolism was seen. The
be lesions which have problematic areas, for count. In addition, there was resolution of a high second patient was symptomatically improved,
example, a lesion of the face which is close output cardiac failure and improvement in the but had no changes in pulmonary pressures post-
to the lip and leads to an enlargement of the size and improvement in the lesions and the leg, operatively, whereas the others did. All patients
lip; excision of that portion of the LM that although not normal. The platelet count, which reported marked symptomatic relief postopera-
involves the lip may give enough relief as far was near zero, is now normal and the leg is shown tively despite the absence in one with no relief of
as the cosmetic appearance that the entire le- 21 months on sirolimus. A series of lymphatic pulmonary hypertension.
sion need to be resected. and lymphatic venous malformations were also J.E.F.

www.medicalebookpdf.com

LWBK892_c27_p359-368.indd 368 10/28/11 4:20:14 PM

 Chapter 28: Surgical Treatment of Laryngeal Cancer 369

28 Surgical Treatment of Laryngeal Cancer: A Legacy of

Minimally Invasive Innovation and the Preservation
of Airway, Swallowing and Vocal Function
Steven M. Zeitels and John C. Wain

INTRODUCTION tion. Independent and interdependent for illumination, he performed the first di-
advances have led to current philosophies rect laryngoscopy.
Successful surgical management of laryn- in which curative treatment is routine with Having successfully viewed the laryngeal
geal cancer requires that the clinician serviceable airway and swallowing function introitus directly, he observed a ball-valving
integrate a complex algorithm of interde- while optimal vocal outcome remains a fibroepithelial polyp that was obstructing
pendent host and tumor issues. The patient pursuit. the glottal aperture. He proceeded to use a
and surgeon must mutually consider the curved forceps to remove the mass. This be-
optimal treatment modality. This is based came the first visually controlled endoscopic
on the efficacy of cure along with the poten- HISTORY AND DEVELOPMENT OF resection of a laryngeal lesion, which pre-
tial detrimental effects of those interven- GLOTTIC CANCER TREATMENT: dated the routine use of mirror laryngoscopy
tions on airway patency, voice, and swal- THE 19TH CENTURY and mirror-guided endolaryngeal surgery.
lowing. The functional outcomes must be
assimilated into patients’ age, vocal needs, Horace Green: The First Direct
and pulmonary reserve, as well as the skill Laryngoscopic Resection of a THE EARLY CURES FOR
sets of the surgeon, availability of technol-
ogy, and prior oncological history of the pa-
Laryngeal Neoplasm LARYNGEAL CANCER
tient. These concepts were initiated in the The first endolaryngeal resection of a laryn- Remarkably, several years after Green’s tri-
19th century and progressively established geal neoplasm can be traced to the monu- umph, Garcia presented mirror laryngos-
through the 20th century due to the increas- mental achievements of Horace Greene copy, which catalyzed the formal develop-
ing frequency of laryngeal cancer subse- (Fig. 1A, B) in the 1840s. ment of laryngology by Czermak and Turck.
quent to the introduction of mass-produced Having been first to routinely treat the Laryngology became highly developed as a
cigarettes. trachea transorally, Green’s skill and confi- result of office-based indirect endolaryn-
The surgical treatment of laryngeal can- dence mounted so that his next achieve- geal diagnoses and procedures.
cer during the last two centuries comprises ment became one of the most important in During this period, Solis Cohen (Fig. 2)
a rich history chronicling the development human airway management. He was faced likely achieved the first cure of laryngeal can-
of minimally invasive endoscopic laryngeal with a child who had developed obstructive cer by performing a laryngofissure and cord-
surgery, upper airway management, swal- apnea with accompanying stridor. Using a ectomy for early glottic cancer (1869). To the

The Head and Neck

lowing rehabilitation, and voice preserva- bent-tongue spatula, along with sunlight best that the author can determine he is the

A
B
Fig. 1. A: Horace Green (1802–1866) was the “Father of American Laryngology.” B. Green demonstrating blind intubation of
the tracheobronchial tree. (From Harper’s Weekly: Dr. Horace Green and His Method. 1859, February 5:88–90.)

www.medicalebookpdf.com

LWBK892_c28_p369-380.indd 369 10/28/11 4:19:01 PM

 370 Part III: The Head and Neck

established this technique as a routine sur-

gical methodology. It can be argued that this
advancement was the most influential in
the history of laryngology given the ensuing
development of general endotracheal anes-
thesia, cardiopulmonary resuscitation, and
critical care management. Pursuant to our
specialty, direct laryngoscopy became the
foundation for a majority endoscopic cancer
treatment of the upper aerodigestive tract.
Kirstein also predicted that Oertel’s laryn-
geal stroboscope would be combined with
direct laryngoscopy to enhance patient
management of vocal-fold lesions. It was the
promise of increased precision associated
with direct laryngoscopy and commensu-
rate advancements in anesthesia that subse-
Fig. 2. Jacob Solis Cohen (1838–1927). (Photo- quently promulgated the migration of direct
graph circa 1868, courtesy of Thomas Jefferson Fig. 4. Bernhard Fraenkel (1836–1911). endolaryngeal cancer surgery to the operat-
University, Archives & Special Collections, Scott ing room, where most complex endolaryn-
Memorial Library, Philadelphia.) geal surgery was done in the 20th century.
(Fig. 4) performed the first successful tran- Killian (Fig. 6) acknowledged Kirstein’s
soral endoscopic resection of glottic cancer achievements and based on this work intro-
first surgeon to specialize in laryngology hav- using mirror guidance. It is possible that this duced rigid bronchoscopy and suspension
ing been trained by Samuel Gross and serv- represents the first minimally invasive endo- laryngoscopy. After modifying the Killian
ing the Union as a general surgeon for 4 years scopic cancer cure as well. There were fur- suspension laryngoscope, Lynch (Fig. 7)
of the Civil War. Although there was inter- ther similar isolated reports over the next published a series of 39 patients whose early
mittent use of laryngofissure and cordectomy 30 years. This early endoscopic cancer treat- glottic cancers were excised en bloc by sus-
with varied success in the late 19th century, ment achievement did not significantly alter pension laryngoscopy. This became the first
the procedure was established by Semon, management strategies for glottic cancer, substantial series of endoscopic glottic can-
Butlin, and Jackson. Billroth (Fig. 3) per- which were primarily comprised of transcer- cer resections. He carefully selected lesions
formed the first total laryngectomy for laryn- vical open laryngectomy procedures. that were exposed adequately, of small vol-
geal cancer (1874). Although Billroth suc- ume, limited to a single vocal cord, and did
cessfully achieved the resection, Solis Cohen HISTORY AND DEVELOPMENT OF not extend to the anterior commissure or
and Gluck perfected the procedure by sutur- vocal process. Due to the technical difficul-
ing the trachea to the skin and separating the
GLOTTIC CANCER TREATMENT: ties of suspension laryngoscopy without
airway from the pharyngo-esophagus. THE 20TH CENTURY general endotracheal anesthesia, this ap-
In 1884, Koller and Jelinek introduced Formal Direct Laryngoscopic proach remained obscure.
topical cocaine for mucosal anesthesia, Jako commenced experiments with laser
which became a key chemical platform tech-
Treatment of Glottic Cancer technology to remove human tissue in the
nology that greatly advanced office-based In 1895, Kirstein (Fig. 5) reintroduced direct mid-1960s. By the early 1970s, Jako, Strong,
laryngeal surgery. Soon thereafter, Fraenkel laryngoscopy, described tracheoscopy, and and Vaughan were likely the first surgeons

Fig. 3. Theodor Billroth (1829–1894). Fig. 5. Alfred Kirstein (1863–1922). Fig. 6. Gustav Killian (1860–1921).

www.medicalebookpdf.com

LWBK892_c28_p369-380.indd 370 10/28/11 4:19:02 PM

 Chapter 28: Surgical Treatment of Laryngeal Cancer 371

the larynx: (a) patent adequate airway cali- like XRT, endoscopic treatment preserves
ber, (b) competent valve to preclude aspira- all treatment modalities including further
tion during deglutition, and (c) phonation endoscopic management.
and voice. Radiotherapy treatment of early glottic
Glottic carcinoma is unique as the site cancer successfully controls local disease in
of an organ cancer since very small lesions a majority of cases; however, this advantage
(2 mm) or even precancerous dysplasia is mitigated by the fact that XRT is a single-
can cause a discernable functional deficit, use treatment and patients with laryngeal
hoarseness. Furthermore, in the overwhelm- cancer frequently have metachronous neo-
ing majority of patients, voice loss is the sole plasms. However, despite a century of suc-
or dominant symptom, which is easily rec- cess with higher cure rates employing
ognizable to friends and family. Since local transoral and transcervical function-sparing
control is routine and aspiration can typi- surgical procedures, glottic carcinoma is
cally be avoided, the primary metrics for typically treated with external beam radio-
success in management are airway patency therapy (XRT) in a majority of western coun-
and voice restoration/preservation. tries. T1 and T2 diseases are treated with ra-
Due to the relative paucity of lymphatics diotherapy alone while T3 and T4 lesions are
in the true vocal folds, it is uncommon for typically treated with XRT and chemother-
patients to present with regional metasta- apy. The primary advantage of this approach
sis with T1 and T2 disease. Therefore, small- is uniformity of management not necessitat-
to mid-sized glottic cancers are ideal for ing highly individualized skills, a key requi-
Fig. 7. Robert Clyde Lynch (1880–1931).
single-modality endoscopic minimally in- site of optimal surgical interventions.
vasive treatment. Remarkably, even those For early disease, the disadvantages of
with T3 and T4 lesions often do not have as- XRT include damage to noncancerous glot-
sociated adenopathy. However, the surgical tal tissue including (e.g., contralateral vocal
to remove human tissue with a laser and treatment majority of T3 and T4 glottic can- fold), which is the primary voice source as
shortly thereafter employed this ground- cers require an open (transcervical) resec- well as ablation of the saccular glands,
breaking technology to resect glottic can- tion with removal of some or all of the carti- which are vital for lubrication of the glottis
cer. Thirty years later, Zeitels et al. intro- lage framework (total laryngectomy). to facilitate vocal-fold vibration. For ad-
duced angiolytic laser treatment of glottic Laryngeal cancer is staged using the stan- vanced disease, it is commonplace for radi-
cancer based on Folkman’s principles of dard TNM classification system (Table 1) ation and chemotherapy to cause airway
neoplastic angiogenesis. based on the subsite affected (supraglottis, swelling and/or stenosis requiring a trache-
glottis, or subglottis). As with other cancers, otomy as well as severe dysphagia and/or
GLOTTIC CANCER the TNM staging has prognostic value for sur- pharyngo-esophageal stenosis, both of which
vival. As treatment decisions are often made are usually not present pretreatment and
Disease Presentation and based on the staging of the cancer, it is valu- extremely difficult to resolve.

The Head and Neck

Philosophy of Management able to become familiar with this system. Radiation also commonly causes chronic
mucositis often masking recurrence while
In the United States, glottic cancer com- resulting in discomfort, dryness, and taste
prises ⬃6,500 of the new ⬃10,000 laryngeal
Surgery Versus Radiation changes. Less common, patients develop
cancer cases per annum. Hoarseness is the The two definitive treatment modalities for frank osteoradionecrosis of the laryngeal
primary presenting symptom, however, glottic carcinoma are radiation therapy cartilages resulting in any of the aforemen-
with larger neoplasms, patients may also (XRT) and surgery. Surgical therapy for glot- tioned functional symptoms as well as wound
report airway restriction, discomfort, he- tic cancer can be divided into open or endo- infections. Finally, it is well recognized that
moptysis, dysphagia, odynophagia, and re- scopic techniques. Unlike radiotherapy, sur- a majority of the undesirable effects of ra-
ferred ear pain (otalgia). Glottic cancer is gery treats only the areas of disease without diation therapy are long lasting and often
unique as compared with other sites of the ablating and distorting the remaining nor- irreversible.
upper aerodigestive tract due to the low in- mal anatomy. Glottic cancer surgery can be In the latter 20th century, radiotherapy
cidence of regional metastasis and the ease done with millimeter margins thereby de- became the mainstay of treatment for most
in which the disease is cured locally if the creasing surgical morbidity by sparing nor- stages of laryngeal cancer with chemother-
correct surgical procedure is selected. mal tissue several millimeters away from apy used adjunctively. This was in part due
The success of local control of the pri- the tumor margin. Therefore, surgical resec- to the fact that surgeons lack confidence
mary tumor arises from the fact that the tion of selected glottic cancer can be per- that they could achieve optimal functional
anatomy of the larynx is a relatively isolated formed with phonosurgical techniques, results. However, it is now been recognized
“box.” It is bounded by a thick cartilaginous which allow for precise control of disease that there is substantially diminished sur-
frame and dense connective tissue that are with preservation of the vocal ligament, thy- vival in a variety of stages if surgery is not
resistant to local and regional cancer spread roarytenoid muscle, and the superficial employed as a primary initial treatment
while creating a series of self-contained lamina propria (SLP). Accordingly, postop- modality. Furthermore, complications and
compartments. This structural composi- erative voice results are excellent, especially poor functional outcomes (voice, swallow-
tion facilitates a variety of transoral (endo- when phonosurgical reconstruction is done. ing, and airway) from the nonsurgical regi-
scopic) and transcervical (open neck) par- Other advantages of surgery include lower mens are being increasingly recognized. For
tial laryngectomy procedures that strive to cost, diminished time of intercurrent dis- both initial and salvage treatments, this has
preserve the three most critical functions of ease, and a very low complication rate. Un- catalyzed new opportunities for surgeons

www.medicalebookpdf.com

LWBK892_c28_p369-380.indd 371 10/28/11 4:19:02 PM

 372 Part III: The Head and Neck

s
skilled in endoscopic approaches for small-
Table 1 TNM Staging of Laryngeal Cancer tto mid-sized tumors as well as open partial
Primary tumor (T) ttechniques for larger tumors. The endo-
sscopic methods for supraglottic primaries
■ TX: Primary tumor cannot be assessed
■ T0: No evidence of primary tumor
will likely be further advanced by robotic
w
■ Tis: Carcinoma in situ iinnovation due to frequent restrictions in
ooptimal laryngoscopic exposure.
Supraglottis
■ T1: Tumor limited to one subsite* of supraglottis with normal vocal cord mobility
■ T2: Tumor invades mucosa of more than one adjacent subsite* of supraglottis or glottis or
C
Classical Endoscopic Glottic Surgery
region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, or medial wall of ffor Early Cancer
pyriform sinus) without fixation of the larynx The overarching key to successful endo-
■ T3: Tumor limited to larynx with vocal cord fixation and/or invades any of the following:
postcricoid area, pre-epiglottic tissues, paraglottic space, and/or minor thyroid cartilage
sscopic treatment of laryngeal cancer is
erosion (e.g., inner cortex) oobtaining the best possible laryngoscopic
■ T4a: Tumor invades through the thyroid cartilage, and/or invades tissues beyond the larynx eexposure, which comprised of optimal ana-
(e.g., trachea, soft tissues of the neck including deep extrinsic muscle of the tongue, strap ttomic positioning along with the largest
muscles, thyroid, or esophagus) well-designed speculum and laryngoscope
w
■ T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal holder. Toward that end, we methodically
h
structures ddescribed the key principles for success as
Subsites include the following: well as designing a universal modular glot-
w
■ Ventricular bands ( false cords)
ttiscope and a new suspension gallows.
■ Arytenoids The goal of endoscopic treatment of
■ Suprahyoid epiglottis eearly glottic cancer is eradication of the dis-
■ Infrahyoid epiglottis eease with maximal preservation of the nor-
■ Aryepiglottic folds (laryngeal aspect) mal layered microstructure. This approach
m
Glottis rresults in the optimal postoperative voice
■ T1: Tumor limited to the vocal cord(s), which may involve anterior or posterior commissure,
without compromising oncologic cure.
w
with normal mobility There are four basic procedures that are
■ T1a: Tumor limited to one vocal cord bbased on the depth of treatment (Fig. 8):
■ T1b: Tumor involves both vocal cords ((a) dissection just deep to the epithelial
■ T2: Tumor extends to supraglottis, subglottis, and/or with impaired vocal cord mobility bbasement membrane and superficial to the
■ T2a: Tumor limited to one vocal cord ssuperficial lamina propria for epithelial aty-
■ T2b: Tumor involves both vocal cords ppia and microinvasive cancer, (b) dissection
■ T3: Tumor limited to the larynx with vocal cord fixation, invades paraglottic space, and/or within the superficial lamina propria mi-
w
minor thyroid cartilage erosion (e.g., inner cortex) ccroinvasive cancer that is not attached to
■ T3a: Tumor limited to one vocal cord
tthe vocal ligament, (c) dissection between
■ T3b: Tumor involves both vocal cords
■ T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx
tthe deep lamina propria (vocal ligament)
(e.g., trachea, soft tissues of neck, including deep extrinsic muscle of the tongue, strap muscles, aand the vocalis muscle for lesions that are
thyroid, or esophagus) aattached to the ligament but not through it,
■ T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal aand (d) dissection within the thyroarytenoid
structures muscle for lesions penetrating the vocal
m
(The authors employ the (a, b) unilateral versus bilateral designation used for T1 lesions with T2 lligament and invading the vocalis. This
and T3 lesions as well) aapproach can be fine-tuned further by
Subglottis pperforming partial resections of any of the
■ T1: Tumor limited to the subglottis
llayered microstructure.
■ T1a: Tumor limited to one vocal cord In the classical surgical paradigm, if dis-
■ T1b: Tumor involves both vocal cords ssection is performed in the SLP, cold instru-
■ T2: Tumor extends to vocal cord(s) with normal or impaired mobility m
ments facilitate precise tangential dissec-
■ T2a: Tumor limited to one vocal cord ttion around the curving vocal fold. This
■ T2b: Tumor involves both vocal cords aallows for maximal preservation of the su-
■ T3: Tumor limited to larynx with vocal cord fixation pperficial lamina propria and for pliability of
■ T3a: Tumor limited to one vocal cord tthe regenerating epithelium. Dissection be-
■ T3b: Tumor involves both vocal cords
ttween the vocal ligament and the vocalis
■ T4a: Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g.,
trachea, soft tissues of neck, including deep extrinsic muscles of the tongue, strap muscles,
m
muscle can be performed equally well with
thyroid, or esophagus) ccold instruments alone or with assistance
■ T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal bby a laser. Dissection within the muscle is
structures pperformed most precisely with a cutting la-
(The authors employ the (a, b) unilateral versus bilateral designation used for T1 glottic lesions sser, which allows for improved visualization
with T1, T2, and T3 subglottic lesions as well) bbecause of hemostatic cutting properties.
Subepithelial saline-epinephrine infusion
iinto Reinke’s space improves pre-excisional
assessment of lesion depth. If the tumor has
invaded the vocal ligament, the SLP at the

www.medicalebookpdf.com

LWBK892_c28_p369-380.indd 372 10/28/11 4:19:02 PM

 Chapter 28: Surgical Treatment of Laryngeal Cancer 373

4 3
Epithelium
2
5 1 Superficial lamina propria

6 Vocal ligament
V
I
II

III
Vocalis muscle

IV
Fig. 8. Coronal section of the mid-vocal fold displaying. A: different potential depths of tumor invasion. B: Classifica-
tion of different resection depths.

perimeter of the lesion will distend creating ing millions of voices including hundreds of without chemical enhancement (e.g., pho-
a contour depression in the region of the thousands hoarse laryngeal cancer pa- tosensitizing agents) to involute and treat
cancer. The subepithelial infusion assists tients. It will likely even facilitate voice en- cancer without resection or gross ablation.
with the surgeon’s technical execution of the hancement in patients who have undergone This approach combines elements of sur-
surgery in a number of other ways: (a) The partial or total laryngectomy. In the latter, gery and radiation to create a unique hybrid
infusion facilitates mucosal incisions by im- the mucosal vibration associated with esoph- approach. The voice results that we have
proving visualization of the lateral border of ageal speech and phonation with tracheo- achieved in the cohort of patients herein
the lesion and by distending the SLP so that esophageal valve speech will be made more are typically superior to what we have been
the overlying epithelium is under tension. effective. able to achieve in the past. This is especially
(b) The infusion also increases the depth of so for those patients who have bilateral dis-

The Head and Neck

the superficial lamina propria, which facili- Endoscopic Angiolytic Laser ease. There are a number of reasons for the
tates less traumatic dissection in this layer Treatment of Early Glottic Cancer improved voices, all of which can be ex-
and leads to regenerated epithelium that is plained by improvements in posttreatment
more pliable. (c) The epinephrine and hydro- Recently, the surgical resection model was aerodynamic competency of the glottis
static pressure of the infusion vasoconstricts developed further so that fiber-based angi- and/or enhanced phonatory mucosal pli-
the microvasculature in the SLP and this im- olytic lasers were employed. We had intro- ability through increased preservation of
proves visualization and precise dissection. duced angiolytic lasers (585 nm pulsed-dye glottal soft tissue including noncancerous
(d) If a laser is used, the saline acts as a heat laser, 532 nm pulsed-KTP laser) to facilitate superficial lamina propria, the layer neces-
sink, which decreases thermal trauma to the microflap resection of glottal dysplasia in sary for glottal vibration.
normal vocal-fold tissue. the late 1990s. Photoangiolysis of the Unlike prior microlaryngeal laser tech-
When substantial soft tissue of the glottis subepithelial microcirculation allowed for niques that are used exclusively as a scalpel
was resected, it was commonplace to have extremely precise microflap epithelial re- or indiscriminate ablating device (e.g.,
some vocal dysfunction due to aerodynamic section, preservation of histopathological CO2, continuous-wave KTP, and Thulium),
glottal insufficiency. During the 1990s, we architecture, and minimal collateral ther- angiolytic lasers concentrate the energy
developed a variety of procedures to recon- mal damage to the perivascular superficial within the dense aberrant angiogenic mi-
struct the glottal valve, which were adopted lamina propria. crocirculation of the tumors while not pen-
domestically and abroad. The lost paraglot- The promise of the angiolytic laser treat- etrating deeply into the normal soft tissue
tic soft tissue was augmented with fat and/ ment of early glottic cancer was further of the vocal fold. Thick tumors are vaporized
or Gore-tex and the anterior commissure supported by concepts of aberrant neovas- in a continuous wave mode with simultane-
tendon was reconstructed by means of an cularity described by Jako and Kleinsasser ous cooling until the interface with normal
anterior laryngofissure and thyroid-lamina (Fig. 9) in 1966 and intralesional tumor an- underlying soft tissue. The interface is
subluxation. However, restoring phonatory giogenesis (Figs. 10 and 11) established by treated in a pulsed mode and frozen section
mucosal pliability remains a challenge. Folkman shortly thereafter in 1971. margins are obtained from the patient to es-
After a decade of research, we have de- Over the past 8 years, ⬃100 lesions have tablish that the tumor has been removed. By
signed a promising vocal biogel and expect been treated by angiolysis with ⬃95% cure confining the pulse width to ⱕ15 ms, the
to commence human trials in 2012. This rate. It is likely that this is the first demon- angiolytic laser induces selective heating
vocal biogel retains the possibility of restor- stration of employing nonionizing radiation of the lesions’ intralesional/subepithelial

www.medicalebookpdf.com

LWBK892_c28_p369-380.indd 373 10/28/11 4:19:03 PM

 374 Part III: The Head and Neck

A B

D
C

Fig. 9. A. Vascular pattern of normal arborizing microcirculation seen through the transparent epithelium and within the
superficial lamina propria of the phonatory mucosa. B: Precancerous dysplasia of the epithelium obscures visualization of the
subepithelial microcirculation. C and D: Invasive carcinoma is comprised of aberrant disordered and dense microvasculature.
(Redrawn after Jako GJ, Kleinsasser O. Endolaryngeal Micro-diagnosis and Microsurgery. Reprint from the Annual Meeting of
the American Medical Association, 1966.)

microcirculation. This minimizes thermal angiolytic pulsed-laser treatment of early Cancer involvement of the anterior-
trauma and fibrosis of the extralesional un- glottic cancer has the capability of preserv- commissure tendon and/or the arytenoid
derlying normal glottal soft tissue, thereby ing paraglottic-space soft tissue in deeper cartilage is not a contraindication to this tech-
optimally preserving vocal-fold soft tissue neoplasms as well as mucosal SLP in more nique if adequate laryngoscopic exposure can
necessary for phonatory vibration. Photo- superficial tumors (Fig. 12). be obtained. Thyroid cartilage invasion is a
contraindication to this approach and re-
quires a transcervical removal of the thyroid
lamina. To preserve the architecture of the an-
terior commissure, it is common to remove
tumors with bilateral disease in two stages.
Two-staged pulsed photoangiolytic laser
treatment by surgeons using nonionizing ra-
diation retains elements of current phono-
microsurgery and radiotherapy models syn-
thesizing key assets of both and comprises a
significant revision of the typical surgical
paradigm, which implies effective manage-
ment as a solitary intervention. This is in
contradistinction to radiotherapy and che-
motherapy, which are incremental. For the
promise of enhanced function, these non-
surgical cancer treatments have achieved
acceptability despite the fact that patients
Fig. 11. Histology of a T1 vocal-fold cancer. Note have intercurrent disease during months of
the vascular channels at the base of the nests of treatment. Moreover, it has been common-
Fig. 10. Early vocal-fold cancer demonstrating malignant epithelial cells and the ingrowth of ves- place for decades for patients with advanced
complex looping angiogenic microcirculation. sels within the neoplasm. primary disease and regional metastasis to

www.medicalebookpdf.com

LWBK892_c28_p369-380.indd 374 10/28/11 4:19:03 PM

 Chapter 28: Surgical Treatment of Laryngeal Cancer 375

A B

C D

Fig. 12. A: Microlaryngoscopic examination of a right vocal-fold cancer with a 0.4-mm KTP laser fiber directed at the tumor.
B: A 15-ms pulse of green light is absorbed at the intralesional microcirculation. C: Toward the end of the cancer treatment.
D: Office laryngoscopic examination after healing—the patient is over 4 years without recurrence.

The Head and Neck

undergo incremental chemotherapy and Endoscopic Angiolytic Laser be introduced through rigid or flexible en-
XRT while intercurrent disease is left for Treatment of Cancer: Future doscopes. Angiolytic lasers could also be
3 to 6 months. Considering this, and the considered as a useful adjunct treatment at
fact that from microlaryngoscopic biopsy
Considerations the perimeter of conventional resections if
to completion of XRT is typically at least Vocal folds are a unique site to study local- there are questionable close margins or in
2 months for early glottic cancer, there is no ized minimally invasive cancer of the upper fields of condemned mucosa at resection
reason to believe that incremental staged aerodigestive tract. As stated earlier, metas- margins.
endoscopic surgical treatment over the tasis associated with early glottic cancer is The findings from the initial investiga-
same time period will result in added risk extraordinarily rare so that intercurrent tion supports the fact that further research
to patients. disease is of minimal risk. This provides a into developing laser technology that is ca-
Considering that the three conventional unique window of opportunity to design pable of selectively ablating intralesional/
cancer treatments (surgery, radiotherapy, novel strategies that accommodate the dis- sublesional tumor vascularity is a laudable
and cytotoxic chemotherapy) evolved from tinctive biomechanical and functional re- goal. It is not difficult to envision that laser
the primary basic sciences (biology, physics, quirements of vocal-fold soft tissue. The photoangiolytic treatment can be used as a
and chemistry), anti-angiogenesis agents be- impediment to future translation will likely single modality as in this report or it might
came the fourth cancer treatment. However, be the cost of the instrumentation, which is serve as a cytoreduction and adjuvant treat-
these agents are used as an adjuvant with ⬃$70,000. Considering that ⬃60% of organ ment. Induction light treatment could be
other conventional treatment modalities. cancer is mucosal in origin, concepts devel- applied at the time of staging endoscopy.
Based on discussions with Dr. J. Folkman oped for the vocal fold might be extrapo- Given our office experience with the pulsed
(personal communication), pulsed-photoan- lated to other sites such as the bladder, gut, photoangiolytic laser treatment of glottal
giolytic laser treatment of the glottis is likely tracheo-bronchial tree, and cervix. Further- dysplasia with topical anesthesia, it is con-
the first single-modality organ cancer treat- more, pulsed-laser photoangiolysis can be ceivable that further induction treatment
ment, which capitalizes on his philosophy done during open procedures or endo- could be continued in the clinic prior to full-
and represents the fifth cancer treatment. scopic ones and the small laser fibers can course radiotherapy for larger primaries.

www.medicalebookpdf.com

LWBK892_c28_p369-380.indd 375 10/28/11 4:19:03 PM

 376 Part III: The Head and Neck

Given the migration of many surgical inter-

ventions to be minimally invasive and/or
office procedures, these prospects are not
inconceivable.

Endoscopic Vertical
Partial Laryngectomy
Endoscopic laser vertical partial laryngec-
tomy can technically be done for a majority
of T2 glottic lesions; however, it does require
substantial experience. Steiner championed
these techniques after visiting with the
Boston University group (Jako, Strong, and
Vaughan) in the late 1970s. These tumors
often encroach or invade intrinsic glottic
muscles in the paraglottic compartment.
Three-dimensional geographic determina-
tion of tumors is done by means of careful
staging endoscopy and imaging studies (CT Fig. 13. Different types of vertical partial laryngectomy procedures based on the size of the lesion to
scan or MRI). These resections may be done treat glottic carcinoma.
with a CO2 laser, with or without a fiber, as
well as the thulium and KTP lasers, which
are both delivered with a fiber. The primary
difference between endoscopic and open reader being encouraged to review compre- ing through the ventricle to the lower false
transcervical partial laryngectomy proce- hensive specialized sources for details. cords but not to the epilaryngeal regions.
dures is that the cartilage framework is re- This initial procedure is similar to laryng-
sected in open procedures. Although laryn- ofissure and cordectomy including a tra-
Transcervical Laryngofissure cheotomy. However, the anterior thyroid
goscopic procedures can usually be done
without a tracheotomy, transoral proce- and Cordectomy lamina as well as the false cord, true cord,
dures preclude immediate vocal reconstruc- Open cordectomy can be used for patients and subglottis are resected en bloc. The
tion. After healing has taken place, various with T1 and selected T2 lesions of the true classical vertical partial laryngectomy can
reconstructive procedures (previously men- vocal fold and subglottis who are not candi- be extended to include the arytenoid, upper
tioned) can be utilized (injection laryngo- dates for endoscopic laser resection be- cricoid cartilage, and portions of the con-
plasty with or without medialization thyro- cause of limited laryngoscopic exposure. tralateral thyroid ala. The reconstruction is
plasty) to restore a laryngeal phonation In this procedure the thyroid cartilage is achieved by rotating local tissues such as
source. Because of the delayed reconstruc- preserved. After exposing the laryngeal the hypopharynx mucosa, epiglottis, poste-
tion, some surgeons still opt to employ clas- cartilage framework, a tracheotomy is per- rior thyroid lamina, and extrinsic strap
sic open partial laryngectomy techniques. formed prior to entering the larynx. Then musculature. There are extensive variations
thyroid cartilage is separated anteriorly in the use of these local tissues, which are
without entering the airway. Next, the cri- beyond the scope of this chapter and
Open (Transcervical) Cancer cothyroid membrane is entered to view the detailed in dedicated texts for laryngeal
Surgery: General Considerations glottic tumor from below to adequately re- cancer surgery. The primary goals are to
sect it. Care is taken to preserve each side of preserve deglutition and when possible, to
As reviewed earlier, there has been a rich create an airway caliber that allows for
history in surgical innovation for transcervi- the anterior-commissure tendon inser-
tions. As the laryngofissure is opened, ade- removal of the tracheotomy tube. Until
cal removal of laryngeal cancer. Many of the recently, tracheotomy decannulation was
early designs for cancer resection proce- quate visualization of the neoplasm is
achieved; magnifying loupes can be helpful. unlikely when substantial full-thickness seg-
dures were based on surgeons’ experiences ments of the cricoid cartilage require resec-
in the management of penetrating trauma Once the tumor has been resected, the false
cord can be unfolded to reconstruct the re- tion and/or one cricoarytenoid joint. Al-
from hand-to-hand combat as well as homi- though a lung-powered laryngeal sound
cides and suicides. Furthermore, the tech- sected glottic soft tissue. The thyroid lamina
is reapproximated with two 2-0 prolene su- source is routinely achieved, the voice typi-
niques for tumor removal and reconstruc- cally has limited pitch range and is often
tion have not substantially changed in tures above and below the glottis. The strap
muscles are reapproximated and a subplat- strained and breathy.
decades. Furthermore, nuances in variation
of the details of these methods are expansive ysmal penrose drain is placed, which helps
with textbooks devoted to this subject and prevent subcutaneous emphysema.
Supracricoid Laryngectomy
therefore well beyond the scope of this chap- with Cricohyoidopexy
ter. Finally, open partial laryngectomy is be- Transcervical Partial
ing done with decreasing frequency except Selected patients with T2 lesions of the glottis
for selected centers of excellence. Therefore,
Vertical Laryngectomy or T2 and T3 infrahyoid lesions of the supra-
highlights of transcervical resection tech- Vertical partial laryngectomy is typically glottis who have adequate pulmonary func-
niques (Fig. 13) will be provided with the used for T2 transglottic neoplasms extend- tion (similar to horizontal partial

www.medicalebookpdf.com

LWBK892_c28_p369-380.indd 376 10/28/11 4:19:07 PM

 Chapter 28: Surgical Treatment of Laryngeal Cancer 377

A B

C D

The Head and Neck

Fig. 14. A: Clinic examination of a medium–large recurrence of a left glottic carcinoma with substantial extension to the
subglottis and contralateral right vocal fold. B: The specimen is shown including the glottis and subglottis. The undersurface
of the false cords is seen remaining in the patient. C: The arch of the aortic homograft will be used for the reconstruction.
D: The aortic homograft is sutured in position to replace the resected areas of the cartilage framework.

laryngectomy patients) are candidates for su- resection with retaining enough structural age. With aortic homograft reconstruc-
pracricoid laryngectomy. Typically, the glot- cartilaginous scaffolding and internal soft tion, there were no fistulas or significant
tic tissue from the arytenoid forward along tissues to achieve tracheotomy decannula- complications, all patients resumed a full
with the false cords and underlying thyroid tion. Local soft tissues and/or regional flaps per-oral diet, and all cases have been de-
laminae are removed. Initial postoperative typically close the defect adequately, but cannulated. It is remarkable that there had
aspiration is common as in horizontal partial also collapse and narrow the intralaryngeal been prior bench work using aortic ho-
laryngectomy patients. Preservation of both airway lumen, frequently limiting the abil- mograft for tracheal reconstruction over
cricoarytenoid joints facilitates eventual tra- ity to decannulate the patient. 50 years ago and renewed interest in re-
cheotomy decannulation and recover of In 2009, we initiated wide-field recon- cent years.
swallowing function. The phonatory sound struction of extended partial laryngectomy Reliably replacing the aforementioned
source is low-pitched and monotone; how- defects with cryopreserved homograft volume of laryngeal cartilage framework with
ever, it is frequently quite strong and arises aorta (Fig. 14). Preliminary results thus far consistent restoration of airway and swallow-
from oscillation of the peri-corniculate are extremely promising, suggesting that ing function has not been achieved previ-
arytenoid mucosa and aryepiglottic folds. this approach will provide new opportuni- ously. The cryopreserved aortic homograft is
ties for organ and function preservation unique in several aspects. It is essentially an
Extended Open Partial for patients with large laryngeal cancers. acellular scaffold so that chemical immuno-
Laryngectomy with Aortic In the initial pilot group of seven patients, therapy is unnecessary. The aortic homograft
Homograft Reconstruction all of the patients had ⬎40% of the cricoid is pliant and retains its rheology in a tubular
cartilage removed along with ⬎50% of the form, which maintains the airway lumen. The
Classical extended partial laryngectomy laryngeal thyroid cartilage. Four of seven graft is texturally robust so that it is easy to
methods are often constrained by the bal- patients had previously failed radiother- suture into place as a patch and its use re-
ance of achieving an adequate oncological apy and five of seven were over 65 years of quires routine surgical oncologic skills.

www.medicalebookpdf.com

LWBK892_c28_p369-380.indd 377 10/28/11 4:19:07 PM

 378 Part III: The Head and Neck

The aortic homograft appears to be ex- cases per annum in the United States. Dis- Endoscopic Resection
tremely tolerant of exposure to upper comfort and a neck mass are of the most of Supraglottic Cancer
aerodigestive tract reflux, barotrauma from common presenting symptoms, however,
coughing, and microbial flora. It maintains with larger neoplasms, patients may also Jackson described piecemeal endoscopic
its structural integrity following implanta- report voice changes, airway restriction, removal of supraglottic cancer over 70 years
tion for prolonged periods of time. Based dysphagia, odynophagia, hemoptysis, and ago this philosophy is conformed to and
on our observations, there is ingrowth of referred ear pain (otalgia). Unlike glottic deemed acceptable to the present. Vaughan
microcirculation from the soft tissues of cancer, supraglottic cancer frequents championed this approach and performed
the neck, which maintains the viability of presents with regional metastasis, which the first endoscopic supraglottic laryngec-
the graft. However, there is a prolonged pe- is the primary determinant of survival. tomies in the 1970s when the Boston Uni-
riod of intraluminal granulation in the air- Similar to glottic cancer, controlling the versity Otolaryngology group introduced
way (2 to 4 months) prior to epithelializa- disease at the primary site is typical with laser technology to facilitate soft-tissue dis-
tion that is similar to wide-field endoscopic careful treatment selection and vigilant section and surgical oncology. Cutting the
resections. This is more substantial in pre- surveillance. However, achieving local tumor into segments was done because the
viously irradiated patients but does not control with preservation of optimal air- field of resection was substantially larger
preclude decannulation during this period. way, swallowing, and vocal function re- than the laryngoscope speculae. Steiner,
In the future, it is likely that these grafts will mains as a challenge. who has been the primary proponent of this
be seeded with patients’ mucosal epithe- The general success of controlling supra- philosophy over the past 2 decades, visited
lium retrieved in a clinic biopsy, prior to the glottic cancer locally is similar to glottic Boston in the late 1970s and subsequently
cancer resection, to hasten epithelializa- cancer. It is due to the fact that the anatomy advanced this approach technically. Through
tion of the reconstruction, which we have of the larynx is comprised of a thick carti- steadfast perseverance as well as relentless
observed to eventually occur. laginous frame and dense connective tissue lecturing and teaching, he has secured
that are resistant to local invasion outside worldwide recognition of the effectiveness of
Total Laryngectomy the larynx thereby creating a series of self- endoscopic treatment of laryngeal cancer.
contained compartments. Like glottic can- Endoscopic resection of supraglottic
Complete extirpation of the larynx has cer, this structural composition facilitates a cancer provides several advantages over
not changed dramatically over the past variety of transoral (endoscopic) and tran- open supraglottic laryngectomy (Fig. 15). In
125 years apart from diminishing the perim- scervical (open neck) partial laryngectomy most circumstances, a perioperative tra-
eter margins to preserve uninvolved phar- procedures. cheotomy is not necessary. In addition, the
yngo-esophageal soft tissue and developing Unlike the glottis, supraglottic carci- superior laryngeal nerves are not cut so
innovative methods of pharyngo-esophageal noma typically presents with advanced critically important sensory function of the
reconstruction. Fortunately, this procedure disease. Initial presentation of precancer- neosupraglottic valve is retained. This is a
with its attendant morbidity of a permanent ous mucosa and early cancer are relatively key determinant of posttreatment swallow-
tracheostomy and the loss of a lung-pow- rare since these lesions are unaccompa- ing function in preventing aspiration. With
ered laryngeal phonation has become rela- nied by symptoms. They are typically iden- endolaryngeal treatment, wound break-
tively infrequent in recent decades. The rea- tified because a patient is under surveil- down leading to fistula formation does not
son for this decline is multifactorial and lance for previous aerodigestive tract occur. Finally, supraglottic cancer, even in
includes extensive experience with endo- cancer. Pathologic assessment of tumors the deep compartments is typically encased
scopic and transcervical partial laryngec- initially staged as T1 and T2 reveal that the by a capsule, which enhances endoscopic
tomy techniques along with enhanced re- largest majority are T3 and T4. Because of feasibility and efficacy.
sults with radiotherapy and chemotherapy. the rich lymphatics of the supraglottis, it The piecemeal resection philosophy
Despite these advancements, total larynge- commonplace for patients with supraglot- has always remained problematic for a
ctomy remains a valuable treatment option tic cancer to present with clinical evidence majority of surgeons trained in classical
that is often life-preserving in patients who of regional lymph-node metastasis or oc- techniques requiring en bloc removal of
have extremely large neoplasms or have cult adenopathy discovered on elective the tumor. To address this, over 20 years
failed prior treatments. A clear concern of neck dissection. ago, Zeitels designed a wide bivalve ad-
surgeons who must perform total laryngec- Preservation of laryngeal function can justable supraglottiscope that would allow
tomy in those who have failed prior radio- be a substantial challenge with advanced for en bloc supraglottic cancer resection.
therapy and chemotherapy is the high inci- supraglottic primaries regardless of treat- Despite the success in simulating en bloc
dence of severe pharyngo-cutaneous fistula ment modality. Smaller volume neoplsms open surgery through an endoscopic ap-
formation. Vascularized nonirradiated flaps are typically controlled locally with endo- proach, the technique remained time-con-
have only provided limited mitigation of this scopic removal, open supraglottic larynge- suming and difficult. Remarkably, en bloc
morbid routine outcome. ctomy, or radiotherapy. Larger supraglottic resection is being resurrected today with
tumors often require surgery and radio- the technical advantages of transoral ro-
therapy often including chemotherapy as botic surgery.
SUPRAGLOTTIC CARCINOMA well. Preservation of normal laryngeal There have been two general approaches
function can be extremely difficult with to endoscopic treatment of supraglottic
Disease Presentation and large supraglottic cancers. Regardless of cancer. This is comprised of single-modal-
Philosophy of Management treatment selection of the primary site, ity transoral resection and the use of endo-
neck lymphatics should always be consid- scopic resection combined with postoper-
Supraglottic cancer comprises approxi- ered carefully when designing a treatment ative radiotherapy. The logic of the latter
mate-ly one-third of new laryngeal cancer regimen. approach is that treating most supraglottic

www.medicalebookpdf.com

LWBK892_c28_p369-380.indd 378 10/28/11 4:19:11 PM

 Chapter 28: Surgical Treatment of Laryngeal Cancer 379

well as balancing respiration and degluti-

tion. Surgical treatment of larynx cancer
has been recognized for over a century as
an extremely effective treatment. Regard-
less of size, the overwhelming majority of
larynx cancers are controlled locally with
surgical removal if the tumor is removed
with the correct procedure. Preservation of
an adequate airway, as well as swallowing
and voice function, becomes the key goal
while performing larynx cancer surgery. Re-
markably, transoral surgery of laryngeal le-
sions chronicles a 150-year development of
minimally invasive surgery. Solis Cohen es-
tablished that managing laryngeal disease
required high-level skills in endoscopic and
open surgery and this continues to be a re-
quirement of laryngeal surgeons today.
These disparate skill sets are especially
A B valuable for larynx cancer surgery. It is not
Fig. 15. A: Infrahyoid epiglottic cancer demonstrating the resection boundaries for a wide-field supra- surprising that Solis Cohen was probably
glottic laryngectomy and a narrow-field tumor removal. B: The same tumor is seen on a sagittal. the first surgeon to become a laryngologist
and he was also likely the first individual to
cure larynx cancer.
cancers with radiation (alone or with che- vallecula, glossoepiglottica, or in the pyri-
motherapy) results in local failure in 25% form sinus as a lateral pharyngotomy. In
to 40% of cases and subsequent total laryn- 1991, Zeitels described a reliable precise SUGGESTED READINGS
gectomy becomes necessary. If the primary suprahyoid pharyngotomy technique that Anderson R, Parrish J. Selective photothermoly-
cancer has been removed endoscopically is valuable for a majority of cancers in the sis: precise microsurgery by selective absorp-
prior to radiotherapy (induction surgery), tongue base, larynx, and/or hypopharynx. tion of pulsed radiation. Science 1983;220:
local failure is ⬍10%. This endoscopic ap- It is useful to preserve some soft tissue of 524–7.
proach mitigates functional deficits while the supraglottis and its neurovascular Folkman J. Clinical applications of research on an-
maximizing larynx preservation. In accor- pedicle if oncologically feasible since it giogenesis. N Engl J Med 1995;333:1757–63.
Fraenkel B. First healing of a laryngeal cancer tak-
dance with this philosophy, our group now can be valuable for reconstructing the en out through the natural passages. Archiv fur
performs total or near-total endoscopic neo-supraglottic valve for swallowing re- Klinische Chirurgie 1886;12:283–6.
tumor removal with the angiolytic KTP habilitation. Green H. Morbid growths within the larynx.

The Head and Neck

laser. In a classic supraglottic laryngectomy In: On the Surgical Treatment of Polypi of the
the upper thyroid laminae are resected with Larynx, and Oedema of the Glottis. New York:
Open Horizontal Supraglottic the tumor, however, often this is not neces- G.P. Putnam; 1852;46–65.
Gussenbauer C. Ueber die erste durch Th. Billroth
Laryngectomy (Supraglottic sary if the neoplasm is not adjacent to the am Menschen, Ausgerfuhrte Kehlkopf Exstir-
cartilage. It is valuable to use magnifying
Laryngectomy) loupes when it is necessary to preserve crit-
pation und die Anwendungeines kunstlichen
Kehlkopfes. Archiv fur Klin Chir 1874;17:343–
The horizontal supraglottic laryngectomy ical soft tissue such as the anterior-com- 56.
procedure was perfected in the mid-20th missure infrapetiole region. To mitigate Hoffman HT, Porter K, Karnell LH, et al. Laryngeal
century for T1 to T3 carcinomas confined postoperative aspiration, it is important to cancer in the United States: changes in demo-
to the supraglottic soft tissues. This proce- resuspend the residual larynx by affixing graphics, patterns of care, and survival. Laryn-
goscope 2006;116(9 Pt 2 Suppl 111):1–13.
dure can be extended in all directions to the thyroid laminae to the hyoid bone with Jako GJ, Kleinsasser O. Endolaryngeal micro-
include portions of the tongue base, pyri- 0 prolene sutures. Complete mucosal clo- diagnosis and microsurgery. Reprint from the
form sinus, and glottis. Understandably, sure is not typically feasible so that epitheli- Annual Meeting of the American Medical As-
with wider swaths of pharyngeal and laryn- alization occurs by regional approximation sociation, 1966.
geal soft tissue, there is increased difficulty of soft tissues. The tracheotomy tube is re- Kirchner JA. What have whole organ sections con-
preserving airway, swallowing, and vocal moved when the perioperative edema di- tributed to the treatment of laryngeal cancer?
Ann Otol Rhinol Laryngol 1989;98:661–7.
function. Since aspiration and pneumonia minishes to sustain an adequate airway lu- Kirstein A. Autoscopy of the larynx and trachea
are common complications, patients must men and when aspiration is mostly resolved (Direct Examination without Mirror). 1897.
have adequate pulmonary reserve and will so that tracheobronchial access is not nec- Kirstein A. Autoskopie des larynx und der trachea
need to work with a speech language pa- essary. (Laryngoscopia directa, Euthyskopie, Besichti-
thologist postoperatively for swallowing gung ohne Spiegel). Archiv fur Laryngol Rhinol
rehabilitation. 1895;3:156–64.
A tracheotomy is necessary to perform
SUMMARY Kitamura T, Kaneko T, Togawa K, et al. Supracri-
coid laryngectomy. Ann Otol Rhinol Laryngol
a supraglottic laryngectomy. Once this is The larynx retains the most complex neuro- 1970;79(6):1027–32.
done, a pharyngotomy entry to view the muscular function of any human organ, Lynch RC. Intrinsic carcinoma of the larynx, with
tumor is performed in the oropharyngeal which supports human communication as a second report of the cases operated on by

www.medicalebookpdf.com

LWBK892_c28_p369-380.indd 379 10/28/11 4:19:11 PM

 380 Part III: The Head and Neck

suspension and dissection. Trans Am Laryngol of phonomicrosurgical management. Laryngo- Zeitels SM, Hillman RE, Franco RA, et al. Voice
Assoc 1920;40:119–26. scope 1995;105(Suppl 67):1–51. and treatment outcome from phonosurgical
Martinod E, Seguin A, Pfeuty K, et al. Long-term Zeitels SM. Phonomicrosurgical treatment of early management of early glottic cancer. Ann Otol
evaluation of the replacement of the trachea glottic cancer and carcinoma in situ. Am J Surg Rhinol Laryngol 2002;111(Suppl 190):1–20.
with an autologous aortic graft. Ann Thorac 1996;172:704–9. Zeitels SM, Burns JA, Dailey SH. Suspension lar-
Surg 2003;75(5):1572–78; discussion 1578. Zeitels SM. Jacob Da Silva Solis-Cohen: America’s yngoscopy revisited. Ann Otol Rhinol Laryngol
Pressman JJ, Simon MB. Observations upon the first head and neck surgeon. Head Neck 1997: Suppl 2004;113(1):16–22.
experimental repair of the trachea using au- 342–6. Zeitels SM, Franco RA Jr, Dailey SH, et al. Office-
togenous aorta and polyethylene tubes. Surg Zeitels SM. A universal modular glottiscope based treatment of glottal dysplasia and pap-
Gynecol Obstet 1958;106(1):56–62. system: the evolution of a century of design illomatosis with the 585-nm pulsed dye laser
Silver CE, ed. Surgery for Cancer of the Larynx. New and technique for direct laryngoscopy. Ann Otol and local anesthesia. Ann Otol Rhinol Laryngol
York: Churchill Livingstone; 1981. Rhinol Laryngol Suppl 1999;108(Suppl 179):1–24. 2004;113(4):265–76.
Solis-Cohen J. Clinical history of surgical affec- Zeitels SM. Atlas of Phonomicrosurgery and oth- Zeitels SM, Akst L, Burns JA, et al. Office Based
tions of the larynx. Med Rec 1869;4:244–7. er Endolaryngeal Procedures for Benign and 532 nm pulsed-KTP laser treatment of glottal
Steiner W. Experience in endoscopic laser surgery Malignant Disease. San Diego, CA: Singular; papillomatosis and dysplasia. Ann Otol Rhinol
of malignant tumours of the upper aerodiges- 2001. Laryngol 2006;115:679–85.
tive tract. Adv Otorhinolaryngol 1988;39:135–44. Zeitels SM, Davis RK, ed. Cancer of the supraglot- Zeitels SM, Burns JA, Akst LM, et al. Office-based
Strong MS, Jako GJ. Laser surgery of the larynx: tis: endoscopic laser management. In: Smee R, and microlaryngeal applications of a fiber-
early clinical experience with continuous CO2 Bridger P, eds. Laryngeal Cancer: Proceedings based thulium laser. Ann Otol Rhinol Laryngol
laser. Ann Otol Rhinol Laryngol 1972;81:791–8. of the 2nd World Congress on Laryngeal Can- 2006;115:891–6.
Tucker GF. Human Larynx Coronal Section Atlas. cer. Amsterdam: Elsevier; 1994;444–56. Zeitels SM, et al. Carbon dioxide laser fiber for
Washington, DC: Armed Forces Institute of Pa- Zeitels SM, Healy GB. Laryngology and phonosur- laryngeal cancer surgery. Ann Otol Rhinol Lar-
thology; 1971. gery. New Engl J Med 2003;349(9):882–92. yngol 2006;115(7):535–41.
Vaughan CW. Transoral laryngeal surgery using the Zeitels SM, Vaughan CW. A submucosal vocal fold Zeitels SM, Blitzer A, Hillman RE, et al. Foresight
CO2 laser. Laboratory experiments and clinical infusion needle. Otolaryngol Head Neck Surg in laryngology and laryngeal surgery: a 2020
experience. Laryngoscope 1978;88:1399–420. 1991;105:478–9. vision. Ann Otol Rhinol Laryngol 2007;116
Weinstein GS, O’Malley BW Jr, Snyder W, et al. Zeitels SM, Vaughan CW. Preepiglottic space inva- (Suppl 198):1–16.
Transoral robotic surgery: supraglottic partial sion in “early” epiglottic cancer. Ann Otol Rhinol Zeitels SM, Burns JA, Hillman RH, et al. Pho-
laryngectomy. Ann Otol Rhinol Laryngol 2007; Laryngol 1991;100:789–92. toangiolytic laser treatment of early glottic
116(1):19–23. Zeitels SM, Jarboe J, Franco RA. Phonosurgical cancer: a new management strategy. Ann
Zeitels SM. Premalignant epithelium and micro- reconstruction of early glottic cancer. Laryngo- Otol Rhinol Laryngol Suppl 2008;117 (Suppl
invasive cancer of the vocal fold: the evolution scope 2001;111:1862–5. 199):1–24.

EDITOR’S COMMENT The inability to speak or to speak with esopha- that a transcervical approach should be reserved
geal speech is one of the more flagrant, and I use for selected cases where the individual “anatomic
this word not in an accusatory fashion, disabilities factors do not permit complete tumor exposure
As with both this chapter and the following chap- that patients ever have to suffer. Their interplay during diagnostic microlaryngoscopy.” How well
ter the surgeons and therapists who deal with and integration into society is distinctly prohib- did these people do as far as long-term survival?
the larynx and the pharynx bear a heavy burden. ited. There are some individuals who really cannot Quite well. Five-year disease-specific survival was
The patients who present certainly with laryngeal tolerate esophageal speech in somebody that they 96.5% for T1a and 94.3% for T1b cases. The differ-
and hypopharyngeal cancers are habituated to are talking with. The ability to make speech less of ence between these two categories was statisti-
tobacco and perhaps alcohol, they are not well- a difficult event and also not to be as labored will cally significant largely because of the large num-
to-do, and they are often neglected medically. enable these patients to return to society. ber of patients. Local disease control was 93.6%
They have significant comorbidities and present The theme certainly since the last edition is for T1a and 90.6% for T1b cases, but this was not
with an advanced stage of disease. The surgeon’s the continuation of otorhinolaryngology in par- significant. No significant differences were noted
purpose here is to preserve whatever one can: a ticular laryngologists who continually try and use between the different types of procedures.
voice, swallowing, nutrition, and respiration, a surgical approaches, which are less destructive in Takes et al. (Head and Neck DOI 10.1002/
large number of complex functions that take place the early stages of glottic cancer (T1s) and they hed;2010:1–15) reviewed the initial management
in a very small area. The senior author gets credit utilize the oncological results of transoral surgi- of hypopharyngeal cancer. As with many other
for some of the early and continuing transoral la- cal techniques in glottic cancers as well as in oth- papers in this particular area the subhead, the
ser therapies for carcinoma of the larynx and hy- ers intraoral and intralaryngeal diseases. Karat- declining use of open surgery, is another theme,
popharynx. The purpose of this therapy, research zanis et al. (The Laryngoscope 2009;119:1704–8) which abounds throughout this area. This group
into which continues, is to preserve as much func- reviewed 438 T1a and T1b glottic cancers man- is the International Head and Neck Scientific
tion as possible in as many different areas. aged with primary surgery. Transoral laser sur- Group and while it consists mostly of European
One of the absolutely brilliant innovations gery (TOLS) and open surgical procedures were and U.S. members the flavor is distinctly European.
that is mentioned casually as almost in pass- used to treat these cases, which include resec- Why do I say that? Because it seems to me that
ing is an almost casual mention “after a decade tion of the cord, vertical partial laryngectomy, regardless of whether one talks of Wilms tumor,
of research we have designed a promising vocal and frontolateral partial laryngectomy, and all Chapter 187, or in this particular tumor the re-
biogel and expect to commence human trials in of these were compared for disease-specific sur- liance on radiation and chemotherapy seems to
2011. This vocal biogel retains the possibility of vival and local control rates. Major complications be fixture in the European approach. However
restoring millions of voices including hundreds and tracheostomies were one of the criteria by the outcome is not terrific. “While most patients
of thousands of hoarse laryngeal cancer patients. which results were evaluated. No statistically present with significant comorbidities and ad-
It will likely even facilitate voice enhancement significant differences between laser surgery vance stage disease, the over all survival is rela-
in patients who have undergone partial or total and open procedures were obvious with regard tively poor because of high rate of regional and
laryngectomy. In the latter, mucosa vibration to disease-specific survival and local control of distal metastasis at presentation or early in the
associated with esophageal speech inphonation both T1a and T1b cases. Laser surgery, interest- course of the disease.” There is the usual appeal for
with tracheal esophageal valve speech will likely ing enough, showed a significantly lower inci- multidisciplinary management but there is a dis-
be made more effective.” dence of tracheostomies. The authors conclude tinct bias in this paper away from laryngectomy

www.medicalebookpdf.com

LWBK892_c28_p369-380.indd 380 10/28/11 4:19:11 PM

 Chapter 29: Surgical Treatment of Pharyngeal Cancer 381

and/or partial or circumferential pharyngectomy classified as T1, had TOLS only and 23 receiving The senior author of the chapter, Professor
followed by reconstruction and postoperative more extensive therapy because of more extensive Zeitels, continues with his microlaryngoscopic
radiotherapy in most cases. The authors readily tumors. All patients were N0. They received addi- and office-based attack of glottal papillomatosis
admit that squamous cell carcinoma of the hypo- tional radiotherapy locally and to the neck. Unfor- (Annals of Otology, Rhinology & Laryngology 2009;
pharynx is less prevalent than at most major sites tunately, 7 of the 23 cases had positive margins and Suppl 201:1–24). This is again somewhat a leap
of the head and neck, such as the oral cavity. The 5 or 26% of the total group failed locoregionally. of faith in trying to minimize the destructive ef-
traditional operation of laryngopharyngectomy However, the recorded 5-year recurrence-free sur- fects of laryngeal cancer or its precursor, in this
with reconstruction of the pharynx has been the vival rate for stage I and II was 95% as compared case glottal papillomatosis. Apparently, photo-
preferred initial treatment modality for hypopha- with a stage III and IV disease at 69%, respectively. angiolytic laser treatments while they effectively
ryngeal cancer. That is pretty respectable salvage as far as I am treat this condition do not reliably treat reoccur-
Whatever therapy one uses, this is a bad dis- concerned. In summary, the oncological result rence and I assume, if they do reoccur, ultimately
ease in a very bad place. Nonsurgical treatments of TOLS appears comparable with open results they turn malignant. Therefore, the authors have
appeared to have gain popularity, at least in with an overall survival rate of between 50% and attempted to inject sublesional injections of the
Europe and treatment with radiotherapy alone, 70% for stage I and II disease and 40% or 50% with antiangiogenic agent bevacizumab (Avastin) in-
however, has a worse prognosis as compared stage II and IV disease. There is a high incidence jected sub-epithelially. This was a pilot group of
with the combined treatment of surgery and of larynx preservation in these selective cases but 10 adult patients with bilateral glottal papilloma-
radiotherapy particularly of Stage 4 disease. In most patients continue to require postoperative tosis who had undergone angiolitic laser treat-
addition, adding chemotherapy to a primary radiotherapy. Here, of course, the emphasis is on ment but recurred as one would expect. They
radiotherapy protocol apparently does result in nonsurgical management by which I assume the underwent five injections of 5 to 10 mg into the
improved outcome, which is comparable to sur- authors mean open resectional management. To diseased vocal folds along with 532-nm pulsed-
gery and postoperative radiotherapy but with the me, TOLS is surgical treatment. KTP laser photoangiolysis 4 to 6 weeks apart.
advantage of larynx preservation in a large num- Another article which begins “nonsurgical They were compared with prior treatments alone
ber of cases. (Lefebvre JL, et al. Journal of National management of oropharyngeal cancer and hy- and a voice-related quality of life survey. Accord-
Cancer Institute 1996;88:890–9). popharyngeal cancer” is brought forth by Gen- ing to the results all 10 patients had a “greater
There are a number of ways of reconstruct- evieve Andrews et al., largely from the Fox Chase than 90% reduction in recurrence.” I am not sure
ing this area with, for example, a pectoralis myo- Cancer Center (Head and Neck DOI 10.1002/ what does this mean since only 4 of the 10 had
cutaneous flap, which may be useful for lesions hed;2010:1–9). They reviewed 180 patient records resolution, 4 of the 10 had limited recurrence or
with minimal extension into the esophagus and form 1993 to 2004 and found that the number of persistent disease and received injections of Avas-
“has proved useful in severely depleted or elderly patients with oropharyngeal cancer treated nearly tin at 8- to 12-week periods and have not had la-
patients.” Similarly, gastric “pull-up” or transposi- doubled, whereas the number of patients with ser treatment. Two of the 10 required office-based
tion is utilized for patients for whom the tumor laryngeal and hypopharyngeal cancers declined KTP laser treatment along with the injections. No
has extended as far down as the middle third of (P ⫽ 0.006). Chemotherapeutic regimens delivered patient has required microlaryngeal surgery with
the esophagus. These patients apparently can concurrently rather than radiation alone appears general anesthesia and all 10 have had “substan-
present rather late indeed. Microvascular flaps to be the dominant approach with associated tial improvement in vocal function.”
have increased the surgeons’ armamentarium in improvements in recurrence-free and overall sur- This is another extension of minimally in-
range with microvascular transplants of jejunum, vival, which is statistically significant. The survival vasive transoral surgery in an attempt to make
the workhorse radial forearm free flap, or antero- of patients with oropharyngeal cancer improved treatment of this disease effective and less de-
lateral thigh flap. Nonetheless, the morbidity after markedly, whereas the survival rate of patients structive. This is indeed a noble goal because we
flap construction is considerable, as one might with laryngeal cancer did not change. The recur- have all seen, regardless of how well the patient
expect. Fistulas and wound complications were rence-free survival of nonsmokers was statistically does as far as survival, the inability to phonate
seen especially after radiation therapy in 33% different from that of former or current smokers. effectively and to communicate with one’s fellow
and 25%, respectively. Not surprisingly stricture The initial site of failure remained the primary site man is a severe limitation, which has all sorts of

The Head and Neck

rates were 26% and 15%, respectively and 16% of of oropharyngeal cancer but not laryngeal cancer. social problems associated with it. The authors
patients required permanent feeding through a In conclusion, from the Fox Chase experience it and their fellow surgeons wish to make the treat-
gastrostomy tube. appears as if the survival with oropharyngeal and ment of this disease less destructive and allow
Professor Zeitels was the first to initially em- hypopharyngeal cancers has improved over the the patients to remain more functional and re-
ploy TOLS in the resection of laryngeal cancer, but last 15 years. This was not observed with laryngeal join their normal place in society, and are to be
its use was later extended to hypopharyngeal can- cancers but it may in other institutions such as the congratulated.
cer. He reported on 45 cases in which 22, mostly one in which Dr. Zeitels works. J.E.F.

29 Surgical Treatment of Pharyngeal Cancer

Bruce H. Haughey and Parul Sinha

The complexity of anatomical and physio- Cancer estimated the age-standardized rate
logical structure makes pharyngeal can- NASOPHARYNX (ASR) for NPC, worldwide, to be 1.7 per
cer surgery one of the most challenging 100,000 males per year. Higher rates have
tasks for head and neck surgeons. Cancer INTRODUCTION been observed in South East Asia, particu-
originating in each of the pharyngeal larly Southern China, and in certain other
subsites—nasopharynx, oropharynx, and Nasopharyngeal carcinomas (NPC) are rare ethnic populations like Alaskans and Green-
hypopharynx—is unique in its biology, head and neck neoplasms characterized by land Eskimos. A genetic susceptibility con-
epidemiology, and response to treatment marked geographical, environmental, and ferred by alterations in human leukocyte
and merits a site-specific discussion of ethnic variations. The most recent report of antigen typing or chromosomal patterns
the appropriate surgical approach. the International Agency of Research on and environmental risk factors including

www.medicalebookpdf.com

LWBK892_c29_p381-393.indd 381 10/28/11 4:56:51 PM

 382 Part III: The Head and Neck

consumption of nitrosamine-rich salted the mucosa, pharyngobasilar fascia, pharyn- phatic disease spreads to the upper deep
fish have been postulated to play an impor- geal muscles, and bucco-pharyngeal fascia. jugular nodes (level II) or the spinal acces-
tant role in the etiology of NPC. Epstein–Barr The lateral walls of the nasopharynx contain sory chain of nodes (level V). Lymphatics can
virus (EBV) infection has also been docu- the opening of the eustachian tubes (ET). also cross the midline to drain in the contral-
mented as a strong oncogenic precursor. Posterior and medial to the mucosal eleva- ateral neck nodes.
tion formed by the ET opening (torus tubar-
ius) is a deep recess, “fossa of Rosenmüller,”
ANATOMY considered to be the commonest site for har-
CLINICAL PRESENTATION
The nasopharynx (Fig. 1) is approximately a 4 boring NPC. The tumor may spread anteriorly Patients with NPC commonly present with
⫻ 4 ⫻ 2 cm space behind the posterior aper- from the fossa to block the ET opening. The painless metastatic neck mass(es), otologic
tures of the nasal cavities (opposite C1 to C2) proximity of this fossa to skull base structures symptoms such as conductive deafness, au-
bound superiorly by the body of sphenoid, and parapharyngeal space accounts for di- ral fullness, otalgia or tinnitus, and nasal
petrous apices, and basiocciput and inferiorly rect spread of disease across and through the symptoms including epistaxis or obstruc-
by the upper surface of the soft palate. The skull base via invasion of the pharyngobasilar tion. Cranial nerve involvement can result
mucoperiosteum of the roof merges with the fascia. The nasopharyngeal mucosa is rich in in diplopia (VI, III, IV), facial pain or dyses-
posterior soft tissue wall. The posterior wall lymphatics, with the lateral retropharyngeal thesias (V), palatal and vocal cord paralysis
consists of four layers that run across the en- group being the first echelon of nodes (upper- (IX, X), or Horner’s syndrome (sympathetic
tire length of the pharynx—from inside out, most known as node of Rouvière). The lym- trunk). The characteristic symptoms of lo-
cal tumor spread in NPC—conductive deaf-
ness, facial pain and palatal paralysis—are
Basiocciput collectively referred to as Trotter’s triad.

STAGING AND
PREOPERATIVE PLANNING
A complete head and neck evaluation in-
Nasopharyngeal wall cluding rigid or flexible endoscopy with
Nasal turbinate Nasopharynx careful assessment of the posterior nasal
Opening of space along with the examination of the
eustachian tube cranial nerves should be performed. Radio-
logical investigations including computed
Soft palate tomography (CT) and magnetic resonance
Uvula imaging (MRI) are important to determine
the extent and stage (Table 1) of tumor and
Palatine tonsil Oropharynx also the appropriate surgical approach.

Base of tongue
Epiglottis
TREATMENT
The radiosensitivity of NPC and restricted
Aryepiglottic fold surgical access owing to the proximity of vital
structures has made nonsurgical therapy the
primary modality of treatment. The role of
Piriform sinus surgery is limited to salvage of recurrent or
persistent cancer at the primary site without
Post cricoid region
Hypopharynx any intracranial spread or neck dissection.
The size, location, and extent of tumor as well
as involvement of the adjacent soft tissue de-
Hypopharyngeal wall
termine the appropriate surgical approach.

Cervical esophagus SURGICAL APPROACH

Endoscopic
Small lesions without any lateral extension
may be amenable to transnasal endoscopic
excision but often, the exposure is not suf-
ficient for oncological resection.

Transpalatal
Retraction or division of the soft palate can
provide access to the nasopharynx. Wider
Fig. 1. Posterior view depicting subdivisions of pharynx. exposure is achieved by detaching the soft

www.medicalebookpdf.com

LWBK892_c29_p381-393.indd 382 10/28/11 4:56:51 PM

 Chapter 29: Surgical Treatment of Pharyngeal Cancer 383

p
palate from the hard palate or by incising
Table 1 American Joint Committee on Cancer TNM Staging of Pharyngeal tthe palate in midline, which allows retrac-
Cancer (2010)
ttion after elevating the mucoperiosteum
Primary Tumor (T) oover the hard palate. These approaches need
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
minimal reconstruction but provide limited
m
Tis Carcinoma in situ eexposure. For lateral wall tumors, surgical
rrobot has been combined with transpalatal
Nasopharynx aapproach to enhance visualization and ma-
T1 Tumor confined to the nasopharynx, or extends to oropharynx and/or nasal cavity
without parapharyngeal extensiona
neuverability of the instruments.
n
T2 Tumor with parapharyngeal extensiona
T3 Tumor involves bony structures of skull base and/or paranasal sinuses TTranscervical
T4 Tumor with intracranial extension and/or involvement of involvement of cranial A incision is made parallel to the lower
An
nerves, hypopharynx, orbit, or with extension to the infratemporal fossa/ bborder of mandible. Skin flaps are elevated
masticator space
aand the mandible is retracted to expose
Oropharynx pparapharyngeal and nasopharyngeal space.
T1 Tumor 2 cm or less in greatest dimension A wider exposure is acquired through divi-
T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension ssion of lip and mandibular symphysis.
T3 Tumor more than 4 cm in greatest dimension or extension to lingual surface of
epiglottis
T4a Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate,
Maxillary Swing
M
or mandibleb F described by Hernandez Altemir (1986),
First
T4b Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or tthis approach provides a wide exposure for
skull base or encases carotid artery rresection of nasopharyngeal tumor. A cheek
Hypopharynx flap is elevated to expose the anterior wall of
T1 Tumor limited to one subsite of hypopharynx and/or 2 cm or less in greatest dimension maxilla. The osteotomy cuts are made below
m
T2 Tumor invades more than one subsite of hypopharynx or an adjacent site, or measures tthe roof of orbit, across the zygomatic arch,
more than 2 cm but not more than 4 cm in greatest dimension without fixation of medial wall of maxilla below the middle tur-
m
hemilarynx bbinate, and hard palate in the midline. The
T3 Tumor more than 4 cm in greatest dimension or with fixation of hemilarynx or
extension to esophagus
ppterygoid plates are removed from the max-
T4a Tumor invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, or central iillary tuberosity and after detaching all bony
compartment soft tissuec cconnections the whole maxilla is dropped
T4b Tumor invades prevertebral fascia, encases carotid artery, or involves mediastinal iinferiorly with the attached cheek flap for
structures ppreserving vascular supply. The entire osteo-
Regional Lymph Nodes (N) ccutaneous complex is swung laterally to ex-
NX Regional lymph nodes cannot be assessed ppose the nasopharynx for complete extirpa-
N0 No regional lymph node metastasis ttion of tumor (Fig. 2).

The Head and Neck

Nasopharynx
N1 Unilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the LLateral
supraclavicular fossa, and/or unilateral or bilateral, retropharyngeal lymph nodes,
6 cm or less, in greatest dimensiond F
Fisch’s lateral infratemporal fossa approach
N2 Bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the ccan be used to remove tumors in the lateral
supraclavicular fossad nasopharyngeal region. The procedure in-
n
N3 Metastasis in a lymph node(s)d ⬎6 cm and/or extension to supraclavicular fossa ccludes a radical mastoidectomy, delinea-
N3a Greater than 6 cm in dimension ttion and mobilization of the facial nerve
N3b Extension to the supraclavicular fossa aand internal carotid artery, and division
Oropharynx and Hypopharynx aand displacement of zygomatic arch and
N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension tthe mandibular condyle with the muscular
N2a Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in aattachments to expose the infratemporal
greatest dimension ffossa. The mandibular branch of trigeminal
N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest nerve is divided and the bone at the middle
n
dimension ccranial skull base is removed to access the
N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest nasopharyngeal space.
n
dimension
N3 Metastasis in a lymph node more than 6 cm in greatest dimension
Distant Metastasis (M) COMPLICATIONS
M0 No distant metastasis P
Palatal fistula may occur in transpalatal ap-
M1 Distant metastasis pproaches, especially in irradiated patients.
a
Parapharyngeal extension denotes posterolateral infiltration of tumor. Maxillary swing approach can lead to ectro-
M
b
Mucosal extension to lingual surface of epiglottis from primary tumors of the base of the tongue and vallecula ppion, trismus, and/or malocclusion. The lat-
does not constitute invasion of larynx. eeral approach is associated with significant
c
Central compartment soft tissue includes prelaryngeal strap muscles and subcutaneous fat. ffunctional morbidity including hearing loss
d
Midline nodes are considered ipsilateral nodes.
aand damage to cranial nerves V and VII.

www.medicalebookpdf.com

LWBK892_c29_p381-393.indd 383 10/28/11 4:56:51 PM

 384 Part III: The Head and Neck

A B

Fig. 2. Maxillary swing approach: (A) elevation of left cheek flap, (B) lateral swing of left maxilla with attached skin flap to
expose nasopharynx.

OROPHARYNX ANATOMY AND SURGICAL tonsils, palatine tonsils, and inferior part of
PATHOLOGY adenoids, may give rise to primary tumors
that metastasize at an early stage and often
INTRODUCTION The oropharynx is anatomically subdivided present as unknown primaries. A rich lym-
Cancer of the oropharynx constitutes about into (a) base of tongue, (b) tonsils and faucial phatic network is responsible for the high
10% to 12% of all head and neck cancers and pillars, (c) soft palate, and (d) pharyngeal probability of cervical metastasis from the
annually accounts for about 10,000 cases in wall (Fig. 1). Anteriorly, the oropharynx is oropharyngeal tumors. The primary echelon
the United States. The growing recognition demarcated by circumvallate papillae, junc- of drainage is the jugulodigastric nodes in
of a disparate shift in its epidemiology, par- tion of hard and soft palate, and the anterior the upper jugular chain (level II) and the ret-
ticularly in the Western world, has made faucial pillars. The bucco-pharyngeal fascia ropharyngeal and parapharyngeal nodes.
oropharyngeal malignancy an intriguing in the posterior pharyngeal wall (PPW) acts Lymphatic spread may advance from level II
clinical entity amongst all head and neck as a natural barrier to prevent the posterior to middle jugular (level III) and lower jugu-
sites. The numbers of newly diagnosed extension of carcinoma. Lateral pharyngeal lar nodes (level IV). The medial base of
oropharyngeal squamous cell carcinomas wall, palatine tonsils, and the faucial pillars tongue and other midline structures often
(OPSCC), mainly tonsillar and tongue base, delineate the lateral limits of the orophar- drain bilaterally.
are reported to be increasing in certain pop- ynx. Inferiorly the oropharynx extends to the
ulations at an approximate rate of 4% and vallecula and includes the glossopharyngeal
2% each year, respectively. The rise is attrib- and pharyngoepiglottic folds. Absence of
CLINICAL PRESENTATION
uted to a strong etiological association with anatomic barriers between the subsites al- Oropharyngeal cancer tends to present at
oncogenic human papillomavirus (HPV) lows oropharyngeal tumors to spread locally an advanced stage. Patients often present
exposures. HPV-related OPSCC classically in contiguity without restriction. Tumor ex- with a mass in the neck detected by direct
presents at younger ages and in persons tending through the lateral wall can involve observation or with symptoms of fullness in
with none or minimal tobacco exposure. the parapharyngeal space, including the the primary site such as sore throat, otalgia,
The mode of HPV transmission is yet to be pterygoid muscles and the carotid sheath dysphagia, or trismus by which time the tu-
fully elucidated but high-risk sexual behav- structures. Waldeyer’s ring, a circumferen- mor has usually progressed to a significant
iors like orogenital contact and multiple tial, mucosa-associated lymphoid tissue size (Fig. 3). A frequent presentation of
lifetime partners are likely contributors. ring in oropharynx comprising the lingual OPSCC, particularly submucosal tongue

A B

Fig. 3. (A) Exophytic tumor of left tongue base, (B) endophytic tumor of right tonsil.

www.medicalebookpdf.com

LWBK892_c29_p381-393.indd 384 10/28/11 4:56:52 PM

 Chapter 29: Surgical Treatment of Pharyngeal Cancer 385

base tumors, is in the form of an unknown potential sites of occult primaries or other optimal therapeutic modality is often taken
primary, in which patients present with en- suspicious mucosal lesions are biopsied, fol- by a multidisciplinary team based on tu-
larged metastatic neck nodes but no clini- lowed by frozen section and finally by pala- mor site and stage, patient preference, co-
cally detectable or symptomatic primary tine and lingual tonsillectomies if no pri- morbidity, performance status, and avail-
tumor. OPSCC is also associated with a high mary site is identified. The tumor is staged able technical expertise.
incidence of distant metastases and syn- according to the American Joint Commis-
chronous primaries at the time of presenta- sion Cancer staging system based on all in-
tion. formation gleaned from clinical, radiologi- SURGICAL APPROACH
cal, and endoscopic evaluations (Table 1).
An evaluation of the patient’s dentition and Transoral Laser Microsurgery
STAGING AND necessary restorative dental procedures are Transoral carbon dioxide (CO2) laser mi-
PREOPERATIVE PLANNING also recommended prior to initiation of crosurgery can be used for resection of
A complete workup to assess the site and treatment. both early and advanced stage tumor at all
stage of primary tumor and presence of cer- oropharyngeal subsites depending on the
vical lymphadenopathy is indicated. This individual’s surgical skills and training.
includes history, physical examination, and
TREATMENT The basic requirements for TLM include a
a thorough head and neck evaluation in- Definitive surgery with adjuvant radiother- competent surgical training, knowledge
cluding mirror examination, palpation, and apy has been the cornerstone of curative of pharyngeal and neck anatomy “from
office flexible fiberoptic laryngoscopy for treatment for OPSCC. Issues of organ pres- the inside out,” good anatomic access,
direct visualization. Radiological evaluation ervation and functional morbidity subse- and strict enforcement of laser-specific
with a CT/MRI is performed to determine quent to conventional open en bloc surgery precautions in the operating room. The
the extent of primary with greater accuracy have instigated advocation of nonsurgical core principles of TLM for oropharynx
as well as to assess the retropharyngeal me- management of OPSCC with chemoradio- cancer, as first enunciated by Steiner, are
tastasis. The cervical lymphadenopathy can therapy (CRT), a modality associated with summarized below:
be reliably assessed by Gray scale ultra- modest survival outcomes and a higher 1. Utilization of microscope for adequate
sonography, supplemented by ultrasound- acute and long-term toxicity profile. Rapid illumination, magnification of the oper-
guided fine needle aspiration, if indicated. advances in technology have shifted the ative field, and clear distinction between
The latter is particularly useful in decision paradigm of surgical management of healthy and tumor tissue.
making for or against treating the contral- OPSCC toward minimally invasive endo- 2. Expeditious coring of large bulky tumors
ateral neck. Chest radiography, CT, or posi- scopic transoral approaches (Fig. 4). These (with cautery or laser) to leave a thin rim
tron emission tomography (PET) is used approaches allow primary tumor-targeted of tumor.
to evaluate distant metastasis or second treatment, minimal blood loss, rapid wound 3. Multiple transtumoral cuts to assess the
primary tumors. healing, avoidance of tracheostomy except deepest extent.
A systematic rigid pharyngolaryngos- for extensive oropharyngeal resections with 4. Mutibloc resection with meticulous
copy examination under anesthesia (EUA) flap reconstruction, better functional pres- inking and labeling for orientation.
of the upper aerodigestive tract (UADT) ervation, shorter hospital stay, faster reha-

The Head and Neck

5. Securing clear margins with frozen sec-
along with photo documentation should be bilitation, and also facilitation of a less tion analyses; a 1- to 1.5-cm margin of
performed to assess the primary tumor, de- morbid, pathologically stratified, risk-based normal tissue beyond the invading front
tect synchronous primaries, obtain biopsies, adjuvant therapy. Biofactors like presence of the tumor is recommended.
and decide the ideal surgical approach— of HPV or its surrogate marker, p16, are re-
transoral or open. This procedure forms a ported to confer a favorable prognosis in An optimum visualization of the operative
significant component of tumor staging, surgically managed OPSCC. Other indepen- site is paramount for TLM and is achieved
treatment, and reconstruction planning. dently prognostic variables in such reports with various modified mouth gags, for ex-
For patients with unknown primaries, a of advanced OPSCC were T stage, margins, ample, Dingman or Feyh–Kastenbauer, and
common mode of presentation for OPSCC, and use of adjuvant radiotherapy. These laryngoscopes, such as Steiner or Klein-
we employ transoral laser microsurgery findings bear strong implications for ther- sasser, which may need repositioning dur-
(TLM) with traditional EUA, wherein the apy of OPSCC in future. The decision for the ing the procedure to obtain a satisfactory
exposure; as exposure diminishes, the sur-
geon progresses from the expanding scopes
to the smaller fixed-bore laryngoscopes.
Transoral resection of OPSCC is performed
with laser via either microendoscopy or a
hand-held device, following the above-
mentioned principles. Surgical techniques
specific to an oropharynx subsite are de-
scribed below. The contraindications to
TLM include inadequate endoscopic ac-
cess and tumor extent that may result in
incomplete resection, for example, lateral
extension through the infratemporal fossa
with invasion of the great vessels. An in-
adequate access is rare for oropharynx
cancers but if encountered transoral ap-
Fig. 4. Minimally invasive TLM approach for oropharynx. proach can be combined with transhyoid or

www.medicalebookpdf.com

LWBK892_c29_p381-393.indd 385 10/28/11 4:56:55 PM

 386 Part III: The Head and Neck

rior and inferior extent of the tumor should

be adequately exposed to secure clear mar-
gins. The tumors in this subsite and in the
tonsil or soft palate may extend superiorly
into the nasopharynx and their resection
may result in varying degrees of velopha-
ryngeal incompetence or nasopharyngeal
stenosis, which can be prevented by ade-
quate reconstruction.

Hemostasis
It is important to achieve meticulous he-
mostasis at the completion of all proce-
dures for oropharyngeal tumors, particu-
larly tonsillar and tongue base lesions,
Fig. 5. Limited partial pharyngectomy for tonsil primary—TLM approach. because of proximity or transection of large
named branches of the external carotid
artery. If the lingual, facial arteries or their
lateral pharyngotomy, using the same inci- Base of Tongue major branches are involved in the resec-
sion as neck dissection. The requirement of tion, the named vessel of origin is clipped in
free flap reconstruction is not a contraindi- The significant intramuscular, submucosal the neck during the neck dissection, obviat-
cation to the TLM approach and we have extension of tongue base tumors requires a ing secondary hemorrhage, which can be
developed techniques to accomplish sutur- careful histological analysis for margin nega- catastrophic.
ing in free flaps through the mouth, with tivity in all dimensions of the resected tumor
the vascular pedicle exiting to the neck segment. Achieving negative margins may re-
quire complete internal skeletonization of
Transoral Robotic Surgery
through a small pharyngotomy.
hyoid bone and exposure/excision of pre- Transoral surgery with robotic assistance
epiglottic fat. The lingual artery or its branches (da Vinci S surgical system) is an emerging
Tonsil need to be clipped if they are exposed, heat- approach that has been found to be feasible
Small (⬍10 mm), well-circumscribed, and injured, or transected during the dissection. for adequate small oropharyngeal tumor
truly superficial tonsillar lesions can be Just lateral to this, from the inside out, is the removal, with minimal disruption of func-
resected en bloc by performing a tonsillec- hypoglossal nerve, which may be exposed or tion and structure (Fig. 6). Unlike TLM, tu-
tomy. Larger tonsillar tumors require occasionally removed. When the tumor ex- mor is usually removed en bloc in transoral
partial lateral pharyngectomy (Fig. 5). They tends in an anterior direction, the lateral pos- robotic surgery (TORS) with a cuff of nor-
are transected at multiple levels and a dis- terior floor of mouth needs to be accessed, mal tissue. The setup time, expense, access
section plane is developed deep to the pha- which is usually accomplished with fixed- difficulty for rigid robotic arms, and com-
ryngeal constrictors into the parapharyn- bore laryngoscopes. Here the lingual nerve patibility issues of TORS with the routine
geal space and out to the medial pterygoid and submandibular gland may be exposed. operating requirements such as neck dis-
and/or styloglossus muscle more inferiorly. section currently confine its niche to select
The tonsillar bed is excised thoroughly by Posterior Oropharyngeal Wall treatment centers and smaller, less deeply
continuing the dissection in the parapha- invasive primaries. However, if there are
ryngeal space from superior to inferior. The Tumors of the PPW can be completely re- technology improvements, robot use may
superior loop of the facial artery is fre- sected with the TLM approach. The supe- become more widespread.
quently transected here and requires clip-
ping, also often exposing the lingual nerve
and the posterior submandibular gland.
The resection is extended to the base of the
tongue as required and connected with a
cut down the posterolateral pharyngeal
wall, thus excising the posterior tonsillar
pillar and completing the partial pharyn-
gectomy. The lingual branch of the
glossopharyngeal nerve may need to be
sacrificed while working around the infe-
rior pole of the tonsil. In very deep tumors
of the tonsillar fossa or lateral oropharyn-
geal wall, it is helpful to perform neck dis-
section prior to transoral resection since
the internal carotid artery can be delin-
eated and cottonoids inserted in the space
between the artery and the pharyngeal wall
for protection. Fig. 6. TORS approach for oropharynx.

www.medicalebookpdf.com

LWBK892_c29_p381-393.indd 386 10/28/11 4:56:56 PM

 Chapter 29: Surgical Treatment of Pharyngeal Cancer 387

OPEN PROCEDURES cavity, it is extended laterally in the gingi- and prevention of aspiration. Free fasciocu-
vobuccal sulcus, leaving a cuff of approxi- taneous have become the standard tech-
Transhyoid Pharyngotomy mately 5-mm mucosa for closure at the nique of reconstruction for tongue base
completion of procedure. As an alternative defects, with radial free forearm flap (RFFF)
Small base of tongue tumors can be ac- to the lip-splitting incision, a visor flap can being the most commonly used followed by
cessed through a transverse incision made be raised with a horizontal incision in the anterolateral thigh (ALT) flap. For RFFF, ad-
at the level of hyoid. The suprahyoid mus- submandibular skin crease carried across equacy of radioulnar collaterals should be
cles are divided from the hyoid bone and to the angle of the mandible on either side. ascertained preoperatively with Allen’s test.
the oropharynx can be entered through in- The soft tissues and periosteum are incised Free musculocutaneous flaps like inner-
cision of the vallecular mucosa. Care should and elevated from the bone in the region of vated latissimus dorsi can provide adequate
be taken to avoid injury to the superior la- the mandibular split. At the site of intended reconstruction for total glossectomy defect.
ryngeal nerve, the hypoglossal nerve, and osteotomy, fixation plates are placed and Regional myocutaneous flaps are used for
the lingual artery. screw holes are drilled and sized to facili- patients who are poor candidates for free
tate accurate alignment of bone during re- tissue transfer.
Lateral Pharyngotomy construction. A stepped midline or para-
median mandibulotomy is performed using Soft Palate
A temporary tracheostomy is usually rec- an electric saw, anterior to the mental fora-
ommended in patients undergoing lateral men and through the middle of a tooth Large, full-thickness soft palate defects (50%
pharyngotomy to prevent the potential air- socket or between teeth. The floor of mouth or more) result in velopharyngeal incompe-
way obstruction secondary to postoperative mucosa, mylohyoid muscle, and other soft tence, in turn resulting in nasal regurgita-
pharyngeal edema. The skin incision is tissues are divided, preserving the lingual tion and unintelligible speech. The aim of
made at the level of the superior border of nerve medially, and the mandible is re- palatal reconstruction is to fabricate a func-
the thyroid cartilage extending from the tracted laterally to expose the oropharyn- tional velum and minimize unwanted com-
midline to the posterior border of sterno- geal tumor. Proper stabilization of the man- munication between the nasopharynx and
cleidomastoid. The suprahyoid muscles are dibular segments and a close approximation the oropharynx. Local flaps like uvulopala-
detached from the hyoid above its lateral of mucosa and soft tissue at the end of pro- tal rotation flap, superior or inferior pharyn-
end, the mucosa is divided, and the pharynx cedure are imperative to minimize compli- geal flap, and palatal island flap can provide
is entered through the vallecula. A pharyn- cations with healing. adequate reconstruction for limited lateral
gocutaneous fistula may develop as a com- palatal defects but for through and through
plication in cases with significant mucosal Oropharyngeal Reconstruction defects, RFFF is the technique of choice.
resection, warranting a careful pharyngeal The oropharynx subserves the fundamental
closure with inverting mucosal sutures. functions of swallowing, speech, and respi-
ration and any reconstruction technique
Tonsil and Pharyngeal Wall
for oropharyngeal defects should be in ut- Tonsillar and pharyngeal wall defects of
Mandibular Swing most consonance with the physiological less than 4 cm can be left to heal by second-
Advanced oropharyngeal tumors in pa- mechanisms underlying these functions. ary intention. Split skin grafting may be

The Head and Neck

tients with factors limiting transoral sur- The size and site of defect as well as various used for superficial pharyngeal defects. For
gery may require an en bloc resection patient-, surgeon-, and hospital-related fac- larger defects with significant palatal in-
through the transmandibular approach tors are considered to determine the appro- volvement, we prefer use of a folded RFFF.
(Fig. 7). A tracheostomy is performed prior priate form of reconstruction.
to these procedures. A stepped skin incision Management of the Neck
is usually performed through the midline of A selective or modified radical neck dissec-
Tongue Base tion is performed in patients with clinically
the lip (full thickness) down to the mentum,
and is continued into the neck dissection Tongue base reconstruction is particularly positive necks. The ipsilateral clinically N0
incision below the mandible. Inside the oral challenging as it is critical to deglutition neck should be addressed electively due to
a high incidence of occult nodal metastases
in oropharynx. Tumors of tongue base and
tonsil approaching or extending across the
midline present a rationale for contralat-
eral elective neck dissection due to a greater
risk of occult contralateral metastases.

Postoperative Care
A vigilant monitoring of vital signs, flap via-
bility, nutritional status, and wound care is
performed. A nasogastric tube is inserted for
feeding in the immediate postoperative pe-
riod. Swallowing recovers faster in patients
undergoing TLM; however, a gastrostomy
tube may be required in patients with exten-
sive resection, slower recovery of swallowing
or in those planned for adjuvant therapy.
Fig. 7. Mandibular swing access following en bloc resection of advanced oropharynx cancer. Prophylactic antibiotics and mouthwashes

www.medicalebookpdf.com

LWBK892_c29_p381-393.indd 387 10/28/11 4:57:00 PM

 388 Part III: The Head and Neck

are administered to maintain oral hygiene border of cricoid. The lateral and medial wall determine access for transoral approaches,
and prevent infections subsequent to sali- of the PFS is continuous with the PPW and criteria for partial operations versus total
vary pooling or food retention in tongue postcricoid area, respectively. The PFS is laryngopharyngectomies, and type of recon-
base or vallecular wound defects. richly supplied by lymphatics that drain into struction of the pharyngeal defect following
the lower deep jugular chain (level IV); the tumor resection. In patients possibly requir-
Complications inferior part along with the postcricoid area ing a flap reconstruction, the adequacy of
Injury to blood vessels and cranial nerves V, can also drain into paratracheal chain (level potential donor sites should be ascertained.
VII, IX to XII; trismus; wound breakdown; VI) nodes. The lymphatics from the PPW Routine blood tests along with a preopera-
dysphagia; and dysarthria may occur with drain into the deep cervical lymph nodes bi- tive baseline level for calcium and thyroid
the open approach. Mandibular nonunion laterally through the lateral pharyngeal or function is performed. The pulmonary func-
can result due to incomplete stabilization retropharyngeal nodes. tion status should be assessed during preop-
of the mandibulotomy site. The complica- Extension of hypopharyngeal tumors erative planning of a conservation surgery
tions rates are significantly reduced with beyond their subsite of origin is critical for since patients with inadequate pulmonary
TLM and skilled reconstruction techniques. surgical planning. PFS tumors tend to reserve are at a greater risk of aspiration.
Pain, bleeding, aspiration, dysphagia, or spread medially around on to the postcri-
velopharyngeal insufficiency may occur fol- coid area and invade the posterior cri-
lowing TLM resection, with a varying inci- coarytenoid muscle. Laterally they extend
TREATMENT
dence for different oropharyngeal subsites. around or invade the posterior border of A combined therapy comprising surgical re-
the thyroid cartilage, to reach the neck and section followed by adjuvant radiotherapy is
carotid sheath area. Postcricoid tumors the standard treatment for all stages of hy-
HYPOPHARYNX tend to spread inferiorly and submucosally popharyngeal cancers as recommended by
toward the esophagus, and likewise poste- the United States National Cancer Institute.
rior wall tumors. The latter may also invade Conventionally, open neck procedures have
INTRODUCTION posteriorly outside the bucco-pharyngeal been used to resect hypopharyngeal cancers
Hypopharyngeal squamous cell carcinoma fascia into the prevertebral space. but in recent years, as an organ preserving
accounts for about 4% of all tumors in head minimally invasive strategy, the application
and neck, with about 2,850 cases diagnosed of transoral approaches is increasing for
CLINICAL PRESENTATION specific subsites. TLM is an established
each year in the United States, according to
the most recent estimates of the American The chief presenting symptoms of patients technique for early and selected advanced
Cancer Society. It has been considered to with hypopharyngeal cancer include dys- tumors whereas transoral robotic hypopha-
portend a poor prognosis mostly due to the phagia, referred otalgia, neck mass, and sen- ryngectomy is at this stage an evolving ap-
advanced stage of disease at presentation. sation of lump in throat. Approximately two- proach, currently being evaluated for T1/T2
The incidence varies depending on the geo- thirds of patients have nodal metastases at PFS and PPW tumors.
graphical location, with an ASR of more than presentation and most patients complain of
10 per 100,000 males in certain regions of weight loss consequent to impairment of
swallowing. Other symptoms of hoarseness,
SURGICAL APPROACH
France, India, the Slovak Republic, and Croa-
tia. The variation in incidence is less pro- aspiration, and hemoptysis may occur de-
pending on the extension of the tumor.
Transoral Laser Microsurgery
nounced in females, and has been observed
mainly for postcricoid tumors. Heavy alco- Early stage hypopharyngeal tumors with
hol and tobacco consumption are the two STAGING AND minimal or no extension to the apex of the
well-established risk factors. A dietary factor PFS or cricoid cartilage invasion can be ad-
in the form of iron deficiency has been impli-
PREOPERATIVE PLANNING equately resected through transoral ap-
cated in causation of postcricoid carcinoma A complete head and neck examination with proach using CO2 laser microsurgery as first
in females with Plummer–Vinson syndrome, office fiberoptic laryngoscopy should be per- described by Steiner (Fig. 8). The indica-
mainly in Scandinavian regions like Sweden. formed to evaluate the primary tumor and tions have expanded to include advanced
mobility of vocal cords and arytenoids. CT/ PFS tumors in the hands of experienced
ANATOMY AND SURGICAL MRI is required for assessment of tumor surgeons depending on the extension of tu-
stage (Table 1) and extent in hypopharyngeal mor, with some resections being possible
PATHOLOGY cancers, particularly inferior, extralaryngeal, down to the esophageal inlet. In compari-
The hypopharynx extends from the level of and cartilage involvement. Ultrasound ex- son with open surgery, the TLM approach
hyoid to the lower border of the cricoid carti- amination of neck is the preferred method leads to avoidance of extensive reconstruc-
lage (opposite C3 to C6 vertebrae) and is sub- for evaluating nodal metastases. Hypopha- tion due to minimal resection of healthy tis-
divided into three regions—the pyriform si- ryngeal tumors are associated with high sues and also a diminished need of trache-
nus (PFS), the postcricoid area, and the PPW rates of distant metastasis ranging from 10% otomy or dependency on feeding tubes.
(Fig. 1). The PFS lies on either side of the lar- to 27% and need adequate investigation with The surgical principles for TLM of hypo-
ynx and extends from the pharyngoepiglot- chest X-ray, PET, and relevant laboratory pharyngeal tumors are similar to those for
tic fold superiorly down to the upper end of tests. A direct endoscopic examination of the resection of oropharyngeal cancer. The PFS
esophagus. It is bound by the thyroid carti- pharynx, larynx, and upper esophagus under tumors are transected to estimate the depth
lage laterally and the aryepiglottic fold and general anesthesia is important for accurate of tumor and resections are “multibloc,” un-
arytenoids medially. The postcricoid area ex- evaluation of the tumor spread, for detection til healthy tissue is identified and a negative
tends from the level of arytenoids to the infe- of synchronous primaries, and for obtaining margin achieved. For PFS tumors, resection
rior border of cricoid. The PPW extends from both diagnostic and mapping biopsies. A is commenced laterally, from proximal to
the plane of floor of vallecula to the inferior careful endoscopic evaluation also serves to distal, and followed around the anterior

www.medicalebookpdf.com

LWBK892_c29_p381-393.indd 388 10/28/11 4:57:00 PM

 Chapter 29: Surgical Treatment of Pharyngeal Cancer 389

cartilage laterally, or postcricoid mucosa

posteriorly. A preliminary tracheostomy
under local anesthesia is preferred at the
onset. A long curvilinear incision is made
from mastoid to mastoid and skin flaps are
elevated superiorly and inferiorly in the
subplatysmal plane, exposing the sterno-
cleidomastoid and strap muscles. The in-
vesting layer of deep fascia is incised
longitudinally along the medial border of
sternocleidomastoid on either sides and
the muscle is retracted laterally to identify
the carotid sheath. The omohyoid tendon
is divided, and the carotid artery is re-
tracted laterally along with the internal
jugular vein. The middle and inferior thy-
roid vein are divided and the paracarotid
Fig. 8. Tumor in left PFS. tunnel is dissected down to the clavicle to
allow adequate laryngeal mobilization on
both sides. The strap muscles are divided
extent toward the medial side. A margin of excised adequately without compromising inferiorly above the sternum and are ele-
at least 5 mm for superficial small tumors laryngeal or pharyngeal function. The tu- vated to skeletonize the larynx and expose
and 5 to 10 mm for larger infiltrating tumors mor should not have any involvement of the thyroid gland. The superior and infe-
is recommended. If there is no frank inva- apex of PFS, base of tongue, postcricoid mu- rior thyroid pedicles are divided on the
sion of the aryepiglottic fold, a relatively cosa, or thyroid cartilage. The ipsilateral vo- side on which ipsilateral thyroid lobectomy
narrower margin can be kept for medial wall cal cord and arytenoid should be fully mo- is to be performed. The contralateral thy-
PFS tumors to avoid resection of arytenoids bile and there should not be any transglottic roid lobe is dissected away from the larynx
by carefully removing the mucosa alone in laryngeal involvement. Inadequate pulmo- and caution is exercised to preserve the in-
order to prevent impairment of swallowing. nary function is a contraindication to this ferior thyroid artery on the side. The supe-
This precautionary technique also preserves procedure. rior laryngeal pedicle is divided on each
the lateral cricoarytenoid muscle and the A transverse incision is made at the level side carefully, preserving the hypoglossal
terminal recurrent laryngeal nerve. of the thyrohyoid membrane. Skin flaps are nerve and the lingual artery. The su-
Tumors confined to the postcricoid area elevated and strap muscles are divided for ex- prahyoid muscles are separated from the
and the posterior hypopharyngeal wall can posure of hyoid and thyroid cartilage. The su- hyoid and the inferior constrictors are di-
also be excised by TLM, the former lesions prahyoid muscles are separated from hyoid, vided from the posterolateral aspect of the
thyroid lamina. The PFS mucosa is sepa-

The Head and Neck

being most suitable if they are superficial. and the pharynx is entered through the con-
Posterior wall lesions usually afford excel- tralateral vallecula. The upper part of the thy- rated from the undersurface of the thyroid
lent access and are often ideal candidates for roid cartilage is cut inferiorly and laterally lamina. The tracheal wall is skeletonized
transoral approaches. Extension beyond the with an oblique cut from the midline. Under and neck dissection is completed, ensur-
prevertebral fascia into the muscles and an- direct view, tumor in the hypopharynx is re- ing removal of paratracheal, level IV, and
terior spinal ligament are not limitations for sected, ensuring an adequate mucosal mar- VI nodes. The trachea is divided with an
TLM but may lead to complications like ver- gin along with resection of the ipsilateral half upward bevel about two rings inferior to
tebral osteomyelitis or abscess formation. of the supraglottic larynx by incising through the previously placed tracheostoma, fol-
the ventricle. A cricopharyngeal myotomy is lowing which the larynx is separated from
performed and the larynx is resurfaced by su- below upward with a sharp dissection of
OPEN PROCEDURES the tracheoesophageal party wall. Intuba-
turing the cut edges of hypopharyngeal mu-
cosa to the edges of false cords. The base of tion is continued through the newly cre-
Partial Pharyngectomy ated stoma.
tongue is impacted into the larynx by placing
Tumors of PPW that do not extend below sutures between the muscles and the thyroid The pharynx is entered through the
the arytenoids inferiorly or into the PFS lat- perichondrium to close the pharyngeal di- contralateral vallecula by placing a Deaver
erally can be excised through a lateral phar- rectly without tension. The cut ends of strap retractor in the vallecula and making an
yngotomy. Smaller tumors in the lower part muscles are sutured to provide an additional incision at the site of its protrusion in the
of PPW without any extension to postcricoid layer of closure. For larger defects a small free neck. The epiglottis is grasped through the
area can be adequately resected through a fasciocutaneous flap provides faster healing pharyngotomy and pulled anteriorly. Lat-
transhyoid partial pharyngectomy. The pha- and better functional recovery. eral to the epiglottis, the pharyngeal mu-
ryngeal defects can be left to heal by second- cosa is first resected on the less involved
ary intention or a split-thickness skin graft side, preserving maximal normal mucosa
can be used. Total Laryngectomy with and progressing inferiorly toward the pos-
terior part of the arytenoid. The pharyngeal
Partial Pharyngectomy wall on the side of the tumor is resected,
Partial Laryngopharyngectomy This procedure is indicated for PFS tumors ensuring adequate margins. The pharyn-
Partial laryngopharyngectomy is appropri- that extend to involve the apex of PFS infe- geal cuts are joined posteriorly inferior to
ate for PFS or PPW tumors, which can be riorly, larynx medially, thyroid or cricoid the cricoarytenoid joint and the specimen

www.medicalebookpdf.com

LWBK892_c29_p381-393.indd 389 10/28/11 4:57:01 PM

 390 Part III: The Head and Neck

is removed, followed by frozen section vical esophagus may require resection in

analysis of the pharyngeal margins. continuity. The initial steps are similar to
For primary voice restoration, a trache- total laryngectomy with partial pharyngec-
oesophageal puncture (TEP) is made be- tomy except that the PFS mucosa is not
tween the upper esophagus and the tra- separated free from the thyroid lamina and
cheostome and a soft Silastic feeding tube is the larynx and pharynx are mobilized to-
advanced through the tracheoesophageal gether. Caution should be exercised to
party wall into the esophageal lumen. A pri- check for posterior extension into the pre-
mary closure in a T-shaped configuration is vertebral fascia. These patients may require
performed for a pharyngeal defect of less microvascular reconstruction; thus suit-
than one-third of the circumference (suffi- able arteries and veins should be preserved
cient mucosa to wrap around a 36 French during the neck dissection. The pharynx is
dilator). Interrupted sutures between the entered through the contralateral vallecula
tongue base and the pharyngeal wall form or a lateral pharyngotomy if the tumor has
the horizontal segment of T and the vertical significant superior extension into orophar-
segment comprises interrupted/running ynx. Ensuring adequate margins, the pha-
extra mucosal inverting sutures between ryngeal cuts are made horizontally around
the edges of pharyngeal mucosae. Approxi- the posterior wall to release the laryngo-
mation of the strap muscles reinforces the pharyngeal unit followed by division of the
pharyngeal repair. A tight pharyngeal clo- trachea (Fig. 9).
sure may result in dysphagia and fistula for- Resection of cervical esophagus is indi-
mation and should always be avoided. For cated if hypopharyngeal tumors extend into
resections with greater pharyngeal defect, the esophagus and complete oncological
“patch” flap augmentation should be con- clearance cannot be achieved with resec-
sidered with either a pedicled myocutane- tion of hypopharynx alone (Fig. 10). This re- Fig. 10. Specimen depicting total laryngopharyn-
ous or a microvascular-free fasciocutaneous quires careful blunt dissection of esophagus goesophagectomy.
flap, for example, the anterolateral thigh. to prevent injury of the posterior tracheal
wall and absolute hemostasis of esophageal
blood supply. Extensive esophagectomy will swallowing. Any treatment-related anatomi-
Total Laryngopharyngectomy/Total necessitate a gastric pull-up repair unless cal and physiological disruption leads to
Laryngopharyngoesophagectomy the upper esophageal stump is accessible varying severity of swallowing dysfunction
A total laryngopharyngectomy is indicated for anastomosis to a tubed free flap. and aspiration, emphasizing the importance
for circumferential postcricoid tumors, PFS of a competent reconstruction within any
tumors with posterior extension across Hypopharyngeal Reconstruction surgical procedure for pharyngeal cancers.
midline, and advanced PPW cancer extend- The hypopharynx represents a major func- A variety of techniques have been described
ing inferiorly below the arytenoids. The cer- tional conduit related to respiration and for reconstruction of circumferential pha-
ryngeal defects resulting from total larynge-
ctomy with pharyngectomy. Free jejunal
graft had been a popular option historically
but the association with donor site morbid-
ity and poorer functional outcomes in terms
of dysphagia due to persistent muscular
contractility and an unsatisfactory tracheoje-
junal voice shifted the focus over use of mi-
crovascular fasciocutaneous flaps (Fig. 11).
The preferred option in our practice is a
tubed radial forearm free flap. As compared
with a pedicled pectoralis major myocuta-
neous flap, which is difficult to tube due to
the muscle bulk, and enteric grafts with
greater morbidity, use of a thinner, pliable
tubed RFFF provides better functional re-
construction with minimal donor site prob-
lems. In patients unfit for RFFF, an ALT flap
may be used if permitted by the patient’s
body habitus (Fig. 12). Free jejunal autografts
are an option if none of the above techniques
are feasible. Patients with total esophagec-
tomy require a gastric pull-up procedure,
which entails mobilization and thoracic
transposition of stomach into the neck to re-
store continuity of the alimentary tract. The
Fig. 9. Specimen depicting total laryngopharyngectomy. key surgical issues, herein, are a tensionless

www.medicalebookpdf.com

LWBK892_c29_p381-393.indd 390 10/28/11 4:57:01 PM

 Chapter 29: Surgical Treatment of Pharyngeal Cancer 391

anastomosis at the junction between the

oropharynx and stomach and an adequate
pyloromyotomy for efficient gastric drain-
age in order to prevent postoperative regur-
gitation of food.

Management of Neck
A high incidence of occult metastases (30%
to 40%) in hypopharyngeal cancer warrants
addressing the N0 necks with selective neck
dissection (level II, III, and IV). In clinically
positive necks, a functional neck dissection
clearing levels II, III, IV, and VI should be part
of the neck management for PFS and postcri-
coid tumors, with inclusion of retropharyn-
geal nodes in the PPW. A contralateral selective
neck dissection is recommended for circum-
ferential tumors and tumors extending to or
across the midline.

Postoperative Care
Patients are kept on negative pressure
Fig. 11. Hypopharyngeal reconstruction with a fasciocutaneous flap. Inset shows a tubed flap with an drains with perioperative antibiotics. Naso-
attached skin paddle that may be used for resurfacing any deficient neck skin along with pharyngeal gastric alimentation is continued for 7 to
reconstruction.

The Head and Neck

A

Fig. 12. Hypopharyngeal reconstruction with an ALT flap: (A) surgical defect
after total laryngopharyngectomy, (B) fabrication of a tubed ALT flap with
C vascular pedicle, (C) reconstructed hypopharynx after microvascular anas-
tomosis.

www.medicalebookpdf.com

LWBK892_c29_p381-393.indd 391 10/28/11 4:57:03 PM

 392 Part III: The Head and Neck

10 days in primary and 12 to 14 days in ir- the infrastomal trachea, prior to anastomo- Haughey BH, Taylor SM, Fuller D. Fasciocutane-
radiated patients. Adequate fluid balance, sing the lower end of the flap to the esopha- ous flap reconstruction of the tongue and floor
nutritional intake, and wound and tracheo- gus. This eliminates any leakage around the of mouth: outcomes and techniques. Arch Oto-
stomy tube care are taken care of. Patients prosthesis and leads to better voice out- laryngol Head Neck Surg 2002;128:1388–95.
Haughey BH, Hinni LM, Salassa JR, et al. Transoral
with flap reconstruction should undergo a comes. Other methods of voice rehabilita- laser microsurgery as primary treatment of
vigilant monitoring of the flap viability tion include electromechanical devices and advanced stage oropharynx cancer: a United
along with care of the donor site. Calcium esophageal speech. States Multicenter Study. Head Neck 2011; doi:
and thyroid levels should be assessed. 10.1002/hed.21669. [Epub ahead of print].
Licitra L, Perrone F, Bossi P, et al. High-risk human
Complications SUGGESTED READINGS papillomavirus affects prognosis in patients
with surgically treated oropharyngeal squamous
The early complications include hemor- Denis F, Garaud P, Bardet E, et al. Final results of cell carcinoma. J Clin Oncol 2006;24:5630–6.
rhage, postoperative wound infection/de- the 94-01 French Head and Neck Oncology and Martin A, Jäckel MC, Christiansen H, et al. Or-
hiscence, pharyngocutaneous fistula, and Radiotherapy Group randomized trial compar- gan preserving transoral laser microsurgery
ing radiotherapy alone with concomitant ra- for cancer of the hypopharynx. Laryngoscope
complications related to neck dissection diochemotherapy in advanced stage orophar- 2008;118:398–402.
and flap necrosis if performed. Gastric ynx carcinoma. J Clin Oncol 2004;22:69–76. Moore EJ, Olsen KD, Kasperbauer JL. Transoral
pull-up procedures are associated with sig- Fischer CA, Zlobec I, Green E, et al. Is the im- robotic surgery for oropharyngeal squamous
nificant pulmonary complications. Late proved prognosis of p16 positive oropharyngeal cell carcinoma: a prospective study of feasi-
complications include stomal stenosis and squamous cell carcinoma dependent of the treat- bility and functional outcomes. Laryngoscope
dysphagia, structural due to stricture for- ment modality? Int J Cancer 2010;126:1256–62. 2009;119:2156–64.
mation at the inferior end of pharyngeal Flint PW, Haughey BH, Lund VJ, et al., eds. Cum- Rich JT, Milov S, Lewis JS Jr, et al. Transoral laser
reconstruction or functional due to recon-
mings otolaryngology head and neck surgery, Vol. microsurgery (TLM) ⫾ adjuvant therapy for
2. 5th ed. Philadelphia, PA: Mosby Elsevier; 2010. advanced stage oropharyngeal cancer: out-
struction-related dysmotility. Haughey BH. Tongue reconstruction: concepts comes and prognostic factors. Laryngoscope
and practice. Laryngoscope 1993;103:1132–41. 2009;119:1709–19.
Haughey BH, Colin WB. Pharyngoesophageal re- Steiner W, Ambrosch P. Endoscopic laser surgery
Rehabilitation construction. In: Gates GA, ed. Current therapy of the upper aerodigestive tract: with special
Swallowing and voice rehabilitation are in otolaryngology—head and neck surgery, 6th emphasis on cancer surgery. New York: Thieme
major components of management in pa- ed. St. Louis, PA: Mosby Publishing; 1998:285–8. Medical Publishers; 2001.
tients undergoing surgery for hypopharyn- Haughey BH, Forsen JW. Free jejunal graft: effects Sturgis EM, Cinciripini PM. Trends in head and neck
geal cancer. A primary TEP is the most of longitudinal myotomy. Ann Otol Rhinol Lar- cancer incidence in relation to smoking preva-
commonly used technique for voice resto- yngol 1992;101:333–8. lence: an emerging epidemic of human papil-
Haughey BH, Fredrickson JM, Sessions DG, et al. lomavirus-associated cancers? Cancer 2007;
ration. In patients undergoing total laryn- Vibratory segment function after free flap re- 110:1429–35.
gopharyngectomy, we create the TEP in the construction of the pharyngoesophagus. Lar- Wei WI. Cancer of the nasopharynx: functional
inlet of the esophageal stump through to yngoscope 1995;105:487–90. surgical salvage. World J Surg 2003;27:844–8.

EDITOR’S COMMENT Another major issue is the unknown primary chapter written by Professor Haughey and Dr.
with level II upper jugular chain of nodes. This Sinha, gave an excellent review of the current
may be in the medial base of the tongue, it also status of squamous cell carcinoma of the hypo-
The surgical treatment of pharyngeal cancer has may be in the submucosal tongue base, which pharynx, which is less prevalent, than most other
in the past been a very disfiguring exercise and takes the form of an unknown primary. major sites such as the oral cavity. Tumors arising
the functional results have been not too great, to Also commented on in the chapter is the in- in the hypopharynx have their own characteris-
put it mildly. Over the past decade, global leader- ternal carotid artery. I remember when I was a tics and considerations. As the authors say in this
ship of individuals such as Professor Haughey and young surgeon on the staff at the Mass General, very nice review, a high proportion of patients are
Professor Zeitels, among others, the field has be- I was called into the operating room by the head heavy drinkers of alcohol, and have additional
come much more conservative as far as function of oral and maxillofacial surgery because there significant comorbidities, in which I might add
and appearance and wishes to restore reasonable was a massive bleed from the back of the pharynx tobacco use, snuff use, etc. Approximately 70 to
function as well as cosmesis. To be sure, the iden- where there was a cut into what I believe to be 85 percent of these patients report and present
tification of the role of Epstein barr virus was an the external or the internal carotid artery. With themselves in stage III or IV of the disease, and
exciting chapter in nasopharyngeal cancer, and a torrential hemorrhage, I could get control, but the overall five year survival compared with other
has probably resulted in the decrease in neces- I could not repair it at that time with the instru- areas is only 15 to 45 percent. The traditional
sity for large procedures. But large procedures are mentation that we had, so what I did was ligate it treatment is impaired by approximately 60 to 80
required, and over the past five or ten years there without seemingly any central nervous system or percent at the time of presentation, the patients
have been efforts on the part of otolaryngologists other deficiency. have apparent tumor involvement of the regional
and head and neck surgeons to reduce the amount The literature of this field has not been very lymph nodes and even contralateral occult nodal
of cosmetic disfigurement and to improve func- significant as far as its scientific basis, but has metastases are present in nearly 40 percent of
tion. We will deal with that in this commentary. in the past 15 years undergone tremendous im- cases. Distant metastases occur in, to a greater
To begin with, not long into the chapter, in the provement with a very robust attempt in various extent, between 10 and 30 percent. The treatment
beginning of the section on the oropharynx, there journals to give the reader an excellent opportu- choices have traditionally been laryngopharynge-
is a procedure known as the maxillary swing in nity to review the management of hypopharyn- ctomy with reconstruction of the pharynx, which
which one reproduces—as best as one can—the geal and other forms of cancer. In particular, the has been the preferred initial treatment modality
function of the oropharynx. It is a traditional tour clinical reviews with various editors in Head and for hypopharyngeal cancers. But because of the
de force when radiotherapy, which is the stan- Neck, published online, in this case in 2010, Takes, morbidity of surgical therapy, radiation therapy
dard of oropharyngeal treatment of cancer, is too RP, et al., “Current Trends in Initial Management alone was reported to decrease the morbidity
disfiguring and the cosmesis needs to be restored of Hypopharyngeal Cancer: the Declining Use of of surgery and it is gaining in popularity. How-
after recurrence of radiotherapy. Open Surgery”. This, in addition to the text book ever, as this review points out, treatment with

www.medicalebookpdf.com

LWBK892_c29_p381-393.indd 392 10/28/11 4:57:06 PM

 Chapter 29: Surgical Treatment of Pharyngeal Cancer 393

radiotherapy alone is reported to have a worse They do take some time to talk about the tox- report on the impact of laryngectomy and surgi-
prognosis compared with surgery and chemo- icity of chemo radiation protocols and the quality cal closure technique on swallowing biomechan-
therapy, particularly in stage IV disease, as re- of life, which leaves something to be desired. The ics and dysphagia. The incidence of self-reported
ferred to by Pingree, TF, et al., Laryngoscope, 1987, toxic effects, both early and late (xerostomia, skin dysphagia following laryngectomy is high, and
97:901–904, Sewnaik, A, et al., Clinical Otorhino- toxicity, cervical fibrosis and lymphedema, oto- the surgical closure technique is not known on
laryngology, 2005, 30:52–57, and Buckley, JG and toxicity, significant swallowing dysfunction) is a biomechanics and dysphagia severity. By a so-
MacLennan, K, Head and Neck, 2000, 22:380–385. common finding after intensive chemo radiother- phisticated mechanism of measuring mid-pha-
The authors of this review state that “unlike ad- apy. In patients with head and neck squamous ryngeal pressures, the authors found that mid-
vanced laryngeal cancers, the question of organ cell carcinoma, the rate of symptomatic stric- pharyngeal pressures were significantly reduced
preservation in hypopharyngeal cancer has not tures is estimated to be about 20 percent, and a in pharyngectomy patients and hypopharyngeal
been thoroughly evaluated, precluding firm con- hypopharyngeal primary site as a significant pre- intrabolus pressures were significantly higher
clusions as to which is the optimal treatment.” dictive factor. in patients when compared to controls. The pa-
They then go on to say that primary surgery with Another situation, which comes to mind and tients who had undergone mucosa-and-muscle
postoperative radiation therapy seems to give the which is emphasized throughout the literature is pharyngeal reconstruction had higher peak and
best oncologic outcome for hypopharyngeal can- salvage surgery. As the authors say, although the mid-pharyngeal pressures compared to those
cer. However, the role of initial surgery seems to focus in this article is on initial treatment, salvage who had mucosa-alone closure. The authors con-
have fallen a little bit in favor of nonsurgical treat- surgery is part of the planned treatment by non cluded that following laryngectomy surgery, the
ment regimens of radiotherapy combined with surgical approaches. “High rates of patient sur- propulsive contractile forces are impaired, and
platinum-based chemotherapy. Surgery is still an vival in larynx preservation trials are achieved there is increased resistance, especially to bolus
option in early stage disease and later on, the au- because of effective salvage surgery for locore- flow across the distal pharyngoesophageal seg-
thors of this very nice paper make a point of say- gional recurrences.” This type of approach is in its ment. They intend to continue this work and try
ing that the side effects of radical radiotherapy as early period, and in the era where planned neck and discern what kind of technique is required
primary therapy is much worse functionally than dissections were the rule. Later it was realized for bolus propulsion.
well carried out surgery and reconstruction. that not all patients needed neck dissection, but Of course the transoral utilization of the ro-
Total laryngopharyngectomy has been re- a number did. Five year local and regional control botics has made its importance in this field. The
served for lesions that involve more than two rates for salvage pharyngectomy have been re- impact of patient reported quality-of-life and
thirds of the circumference of the hypopharynx, ported in 71 and 70 percent of cases, respectively, function has been measured by Leonhardt, FD,
and these have been treated with total laryn- although there are many other less favorable re- et al., Head and Neck, published online, 2011. In
gectomy and circumferential pharyngectomy sults. In addition, the rate of complications from this study, another quality-of-life study, this time
including varying amounts of the cervical or surgery after chemo radiation has increased up to in response to transoral robotic surgery (TROS).
even thoracic esophagus, followed by radia- 75 percent rate of fistulas. Clearly, this is an area, Patients were followed up with a short-form
tion therapy. Remarkably, the five year disease while important, needs to be carefully evaluated. (SF-8) and Performance Status Scale (PSS), six
specific survival has been 40 to 50 percent, and The authors conclude that total laryngopharyn- and twelve months of follow-up as compared
postoperative chemo radiation therapy rather gectomy is declining and that other approaches, with pre-surgical testing. For PSS Eating and Diet
than radiation alone is said to result in further such as partial laryngopharyngectomy as an domains, significant decreases occurred at six
tumor control. The resulting surgical pharyngeal open procedure or even performed endoscopi- months, which was statistically significant, but
defects require a very talented team, such as in cally have offered the opportunity of preserving not at twelve months. Speech was impaired at six
the authors’ chapter, and the deltopectoral flap, function of the larynx in selected cases. However, and twelve months, but there were no significant
not heretofore pictured, was the only reconstruc- the authors assume that only selective cases will declines in the SF-8 domains, except for bodily
tive approach until the myocutaneous flap, which be reasonable. pain and global health. The authors concluded
gives a better cosmetic outcome. Endoscopic la- In another paper, a different approach to that combination TROS and adjuvant therapy
ser microsurgery, endoscopic robotic surgery, larynx-preserving function is the partial pha- caused a temporary decrease in several domains

The Head and Neck

lateral pharyngectomy, and hemilaryngopharyn- ryngectomy via lateral pharyngotomy, again, in at six months, perhaps at twelve months, and
gectomy are additional advances, which are less the treatment of small (T1, T2) hypopharyngeal returned to baseline, including swallowing func-
destructive. However, they cannot be utilized in squamous cell carcinoma. This report from the tion in all patients at longer intervals.
the 75 or 80 percent of the people that present Yonsei University College of Medicine in Seoul by Finally, transoral laser microsurgery is ap-
with stage III or stage IV. The open procedures, T1 Lim, YC, et al., Clinical and Experimental Otorhi- plied to one of the mysteries of head and neck
may be utilized into T1 or T2, with either induc- nolaryngology, 2011, 4:44–48, emphasizes a group surgery, and that is the unknown primary of head
tion chemotherapy followed by surgery or surgery of 23 patients who underwent laryngeal partial and neck (Karni, RJ, et al., Laryngoscope, 2011,
followed by chemotherapy. pharyngectomy as a primary treatment for T1 and 121:1194–1201). In this study, the 30 patients
Additional conservative and restoration pro- T2 hypopharyngeal squamous cell carcinoma. presenting with occult primary met the study
cedures were introduced by Zeitels, the author Fourteen patients had adjuvant postoperative ra- criteria. They collected data and the treatment
of another chapter on the larynx in this volume, diotherapy, making 61 percent. The results were approach, the detection rate, and the primary
who introduced transoral minimally invasive pro- pretty reasonable with a two year and five year site. The occult primary was identified in 20 of 30
cedures for supraglottic and hypopharyngeal can- disease specific survival rate of 77 percent and patients, and the majority of these (95 percent)
cer with a report of 45 cases, of which 22, mostly 61 percent, respectively. Unfortunately, nine pa- had a primary in the oropharynx (19 out of 20).
classified T1, had TOLS (transoral laser surgery) tients (39 percent) had tumor recurrence, and the Transoral laser microsurgery was used to resect
and 23 with more extensive tumors. All were N0, most common pattern of recurrence was isolated 16 of the 20 occult primaries. There was a 42 per-
and they received additional radiotherapy locally distal failure, which occurred in four patients, fol- cent recurrence rate in the traditional exam un-
and to the neck. Seven of the 23 cases had positive lowed by local loco-regional recurrence. However, der anesthesia (EUA) group. Disease free interval
margins, and five of these failed locoregionally. the ultimate cure rate of the primary tumor with was 100 percent for the TLM—or transoral laser
The hypopharynx unfortunately is not opti- aggressive follow-up is 87 percent, with 22 of the microsurgery—under examination under anes-
mally accessible with even the minimally invasive 23 patients could be decannulated, tolerated an thesia, and there was no recurrence in this group.
technique or a more recently transoral robotic oral diet, and “had acceptable postoperative pho- The recurrence rate in the traditional EUA was 44
surgery. Other series contain, according to the natory function”, whatever that means. They em- percent. The authors conclude that transoral la-
authors, “very small numbers of hypopharyngeal phasize that this is only possible in patients that ser microsurgery of occult primaries allowed high
cancer cases and mention the ary-epiglottic fold are selected for small hypopharyngeal squamous detection rates of the primary tumor and was as-
or posterior wall as primary tumor sites suitable cell tumors. sociated with a high level of DFS. The combina-
for this approach.” There is a wealth of informa- What if the laryngeal lesion is large enough tion of EUA and TLM is an effective way of dealing
tion concerning the appropriate chemotherapeu- to require for laryngectomy, what then? Maclean, with this difficult group of patients.
tic agent in this paper. J, et al., Head and Neck Surgery, 2011, 144:21–28, J.E.F.

www.medicalebookpdf.com

LWBK892_c29_p381-393.indd 393 10/28/11 4:57:06 PM

 394 Part III: The Head and Neck

30 Malignant Melanoma and Squamous Cell

Carcinoma of the Skin
Hiram C. Polk Jr. and Motaz Qadan

An often overlooked part of mastery is ele- grated to Australia over 100 years ago. should not become pregnant during the first
gant and specific simplification, which ap- Another factor is the number of moles that 5 years after such diagnosis. These alterna-
plies directly to most forms of skin cancer. exist in an individual patient, which may or tive factors of thickness, ulceration, and con-
Dramatic improvements in the early diagno- may not be complicated by a history of sun- formation supervene to indicate that preg-
sis of malignant melanoma have clearly oc- burns. The tendency to have multiple small nancy avoidance or termination becomes
curred in the last 30 years. Within that, over- dark moles is frequently inherited. As such, clinically more significant. Here lies a major
all improvement has been a remarkable parents of melanoma patients should be test of a patient’s trust in her melanoma sur-
increase in genuinely early diagnosis, yield- readily inspected, not only to determine geon. Few obstetricians are aware of this un-
ing more in situ and other very favorable what the pattern of their moles may be but usual risk. Whether or not pregnancy itself
forms of early invasive melanoma. The ac- also to look for new primary melanomas in predisposes to melanoma is less clear. How-
tual data regarding these changes are some- an often-unsuspecting population. ever, oral contraception is well known not to
what complex, since the majority of melano- Sun exposure, particularly of the blistering predispose to melanoma.
mas are diagnosed in the offices of type, during the period of teenage hormone Overt immunosuppression, either as the
dermatology specialists and family practi- bursts is especially important. Although the result of cancer chemotherapy or as agents
tioners. Much treatment is accomplished method by which data were collected is ques- used to suppress host responses to solid or-
either in the dermatologists’ office or in am- tionable, the reference to two or more blister- gan or bone marrow transplants, also pre-
bulatory surgery centers and not reported ing sunburns during teenage years as a caus- disposes to new or recurrent melanoma.
through traditional hospital-based tumor ative factor has found its way into the literature Obviously, physicians and patients do not
registries. The remarkable change for the and is probably accurate. undertake transplant immunosuppression
better by improving early diagnosis, how- In the same sense, it is commonly said lightly. However, in patients with previously
ever, has been offset, to some degree, by a that large birthmarks are innocent, includ- diagnosed and treated melanoma, in-
rising incidence of the disease related to in- ing bathing trunk nevi. This assertion is creased surveillance is warranted. Also, it
creased exposure to the sun, especially as a clearly untrue. A high proportion of these in- appears that de novo melanomas can de-
larger portion of the North American popu- dividuals acquire invasive melanoma at mul- velop more readily in this scenario. The im-
lation have moved to the Sunbelt. The tiple sites within the large nevus at a later munosuppressed patient warrants special
broader use of tanning beds, which is largely stage. When they begin to develop in such attention, with at least annual examina-
unregulated, is another factor which un- long-standing large pigmented lesions, mel- tions for a variety of skin cancers that in-
doubtedly contributes to this rise. anomas are virtually impossible to detect clude either new or recurrent melanoma
Information about squamous cell cancer even in the most attentive patients, family and squamous cell cancer.
is much less specific. Again, basic lesions members, and specialist–physicians. The dysplastic nevus syndrome is a rela-
are usually diagnosed in doctors’ offices. In Again, periods of maximum risk coincide tively rare phenomenon that generally con-
recent decades, the traditional victim, a with hormonal aberration, particularly the sists of ⬎100 moles, and, frequently, as
family farmer who has suffered sun expo- teenage years and pregnancy. Pregnancy, in many as a 1,000 on a fair-complected per-
sure, has been altered politically and demo- and of itself, has been debated as predispos- son. Here, the dominant pattern is a relent-
graphically to include nearly anyone. The ing to the development, or the overt clinical less conversion of these moles to invasive
same sun exposure that predisposes toward spread, of existing melanoma. The authors’ melanoma, again apparently accentuated
melanoma appears to promote the likeli- opinion is that pregnancy is an adverse risk by the waxing and waning of hormones
hood of development of squamous cell factor for melanoma, and the senior author during teenage years or early adulthood.
cancer, especially in the head and neck has cared for at least five women who subse- The optimum surgical management of these
regions. quently produced soon-to-be orphans, ow- patients is unclear, although the senior au-
ing to progression of their melanoma during thor has never been able to clear the num-
PATHOGENESIS their pregnancies. The elaboration of mel- ber of lesions as rapidly as multiple primary
anocyte-stimulating hormone (MSH) re- melanoma appear to progress during the
Some melanomas arise as changes in existing sponsible for darkening of the nipple areolar course of this illness once the first mela-
ordinary moles, while others appear to arise complex in pregnant women is believed to noma is detected.
de novo. Risk factors for development of ma- be a factor, although this remains largely un-
lignant melanoma are fairly well described. proven. This risk factor requires some very CLINICAL
Particularly at risk are fair-complected peo- careful thought by the treating physician, PRESENTATION
ple, often with blond or red hair, and who particularly related to the tendency of AND DIAGNOSIS
typically reside between the Tropic of Cap- women at present to have their first preg-
ricorn and the Tropic of Cancer, which pre- nancies at a later age, which naturally dimin- Diagnosis of melanoma has been simplified
disposes them to heightened sun exposure ishes the opportunity to have subsequent through the brilliant and imaginative work
and ultraviolet irradiation. A good example children. Our own recommendation is that a of the Queensland Melanoma Project, led by
of the prototype high-risk population would woman who has, or had, a melanoma thicker the late Professor Neville Davis. “A-B-C-D” is
be individuals of Celtic heritage who emi- than 1.5 mm, and/or is ulcerated or nodular, a simple mnemonic that can be applied by

www.medicalebookpdf.com

LWBK892_c30_p394-400.indd 394 10/28/11 4:17:35 PM

 Chapter 30: Malignant Melanoma and Squamous Cell Carcinoma of the Skin 395

physician who suspects melanoma. Lesions

tend to itch, bleed, and change in size or
color. Any of these is significant, particu-
larly when combined with the observational
“A-B-C-D” algorithm.
Squamous cell cancers continue to be
A
enigmas for most nondermatologists. In
fact, any elevated lesion or nonhealing ulcer
on the skin of a patient, particularly in a pa-
tient older than 50 years, and with sunburn,
either presently or by history, warrants an
excisional biopsy. In most cases, the biopsy
can be a local excision with 1 to 2 mm mar-
gins, with simple repair of the wound.
B BIOPSY CONFIRMATION
This important step has been described ex-
haustively, particularly for melanoma. In fact,
as we have encouraged practitioners at all
levels to do at the slightest provocation, “bi-
opsy any symptomatic skin lesion!” Any form
of tissue diagnosis is acceptable. Actually, we
C
have often said that the only form of biopsy
that is absolutely contraindicated is cauter-
ization; smoke under the microscope seldom
looks like melanoma. As a result, this must
be avoided at all costs. In fact, any piece of a
melanoma that helps make the diagnosis is
helpful. By accepting imperfect diagnoses,
one at the same time promotes an earlier bi-
opsy on the part of practitioners, who, either
D by training or geographic location, do not
Fig. 1. On the left are abnormal malignant melanomas with benign moles for comparison on the right have access to broader surgical skills. A shave
side. Moving from top to bottom shows asymmetry (A) within the malignant mole, irregular borders biopsy, in our opinion, is absolutely accept-
(B), different colors (C) within the melanoma (black, brown, and tan), and a diameter (D) ⬎6 mm, able. The preferred biopsy, however, unless

The Head and Neck

which is indeed suspicious. (From the National Cancer Institute.) the lesion is very large, is a local excision with
1 to 2 mm margins, which will effectively deal
with the occasional benign pigmented seb-
virtually any physician or nurse practitioner There are two other variants of mela- orrheic keratosis, and, at the same time, pro-
to distinguish moles that possess malignant noma that remain difficult to diagnose. The vide an accurate depth of melanoma and cell
characteristics. Figure 1 demonstrates the first is the amelanotic melanoma, which is type, if it is present. In other words, this
different stages. difficult to differentiate among a variety of should extend just into the full thickness end
exotic dermatologic lesions, squamous cell of the subcutaneous fat (Fig. 2). In part, be-
■ Asymmetry, where one half looks dis-
cancer, and local fungal infections. A high cause of the progressively earlier diagnosis of
similar to the other half.
degree of suspicion may be a trite phrase, melanocytic lesions, errors of omission have
■ Irregular borders are notched margins
but it is virtually the only guide for any non- begun to occur. It is sobering to recognize
seen to occur in some relatively large
pigmented ulcerated skin lesion. The other that nearly 2% of melanomas are not called
moles.
variant with this special difficulty in diagno- such. To some degree, the clinician can over-
■ Uneven coloration is characteristic of
sis is the subungual melanoma that occurs ride such a potential effect by simply re-
melanoma, with parts of the lesion often
commonly on the feet. Inevitably, all patients excising (1 to 2 mm margins) any suspicious
being light tan to brown to black.
have a history of having struck their toenails; or ambiguous lesions locally, and subse-
■ Finally, diameters ⬎6 mm are more
many thoughtful physicians will have made quently asking for a second, or even third,
prone to be associated with melanoma
a diagnosis of subungual hematoma. The na- pathologic opinion. The minimal increase in
and are therefore suspicious.
ture of the subungual melanoma, however, is scar or scarring is more than offset by im-
As simple as this concept is, it is the back- indicated by its tendency to push the nail, to proved accuracy of pathologic diagnosis.
bone of early diagnosis by doctors, nurses, elevate the nail, to bleed, and to be painful. If the lesion is large, or located on the
and other healthcare professionals in highly Any question about the presence of a subun- face, one may opt to excise a simple 1 to
developed countries. It can readily be applied gual melanoma needs to be followed by 2 mm pie-shaped wedge from the edge of
to self-diagnosis through the distribution of deroofing of the lesion and an adequate inci- the lesion, choosing whichever edge by pal-
simple patient education material. It should sional biopsy or curettage of the specimen. pation is the more highly elevated. In fact,
be part of the diagnosis for every melanoma, The patient’s signs or symptoms in these any ulcerated and/or elevated nonhealing
both in patients and their blood relatives. circumstances are enormously helpful to a skin lesion is at risk of being a malignant

www.medicalebookpdf.com

LWBK892_c30_p394-400.indd 395 10/28/11 4:17:35 PM

 396 Part III: The Head and Neck

in the hands of surgeons who care for can-

cer patients is a process that is accurate to
approximately 80%. However, that is not
sufficient. The practice of sentinel lymph
node biopsy (SLNB) has arisen for melano-
mas ⬎1 mm thick, and has been shown by
our unit and others to be of increasing value
toward the overall care of the patient. The
importance of detection and careful assess-
ment of lymph node involvement is high-
lighted in Fig. 3. The number of lymph nodes
involved correlates with overall survival,
which decreases as the number of involved
nodes increases.
Any patient who has a palpable lymph
node in the immediate regional distribu-
tion in which the melanoma has developed
needs to be considered for a lymph node
biopsy and/or often a formal node dissec-
tion (based on palpation of the nodes) at
Fig. 2. The preferred biopsy is a local excision with 1 to 2 mm margins, which will effectively deal with the
the time when the primary lesion would be
occasional benign pigmented seborrheic keratosis, and, at the same time, provide an accurate depth of mela- excised. There is no excuse for any more
noma and cell type, if it is present. This should extend just into the full thickness end of the subcutaneous fat. limited operation on lymph nodes, which
represent metastases in malignant mela-
noma, less than a full standard radical
lymphadenectomy in the relevant body
melanoma, squamous cell carcinoma, or TREATMENT OF THE part. This applies particularly to the neck,
basal cell carcinoma, and it is properly PRIMARY LESION AND in which a sternocleidomastoid muscle can
treated with a 1 to 2 mm margin of excision. be preserved, to the groin in which the
Depending on the location, once again, it is SURGICAL TECHNIQUE deeper iliac nodes should generally not be
closed using simple suture with reconstruc- The treatment of malignant melanoma fo- excised, and to the axilla. Surgeons must
tive methods used only where necessary. cuses upon adequate local excision. In fact, recall that lymph node dissection should
this is true for most forms of cancer, but is be completed to fascial plane margins as
MELANOMA THICKNESS especially important here. To some degree, described by Spratt et al. More than one-
this has been fairly well defined as needing fourth of such patients are salvaged by a
The initial observations by Clark and associ- 1 cm of peripheral margin around the pig- delayed complete regional lymph node
ates suggested that the depth of invasion of mented lesion for every invasion of 1 mm dissection only.
melanoma down to the skin and even into depth , unless the lesion is large, located on Initially, SLNB was applied to melano-
the subcutaneous tissues was important the face, or very thick, when common sense mas with ambiguous drainage with respect
prognostically. This observation was given permits modification of that dictum. Pro- to the dorsal and ventral surfaces of the
much sharper focus by the work of Breslow, ceeding via an elliptical incision in the line body and/or the waistline. These sites have
who simply quantified the depth of inva- of skin creases allows for a generous wide ambiguous lymph node drainage. Occa-
sion, not by the various layers of the skin but local excision of the primary tumor and sionally, more than one lymph node basin
by the depth of maximum melanoma inva- simple expansion of the resected margins will contain sentinel nodes in the same pa-
sion in millimeters. This latter figure is regu- as required. The elliptical wound permits tient. This technique and many of its ramifi-
larly interpreted accurately and has nearly a simple wound closure, with or without cations were developed by Morton in Cali-
one-to-one relationship with prognosis. flaps, and cosmetic defects are kept to a fornia and subsequently perfected in our
Prognostically, it is well known that mela- minimum when the wound is closed in line region by Edwards and McMasters. Its im-
nomas ⬍0.75 mm thick approach 99% cure with skin creases. Skin grafts are seldom re- portance is evident in Table 1. Technical is-
rates with long-term survival. The senior au- quired now, unless lesions are in function- sues have been discussed repeatedly. It is
thor has only seen 2 of ⬎1,000 such cases ally important areas such as the hand, the important to realize how valuable the SLNB
metastasize without explanation, even upon ankle, and around the elbow. can be in the overall care of the melanoma
reexamination of the original specimen. In general, a melanoma as great as 1 mm patient. Obviously, melanomas ⬍1 mm
As the extent of tumor invasion progres- thick or greater that occurs in the subun- thick very rarely have node involvement,
sively deepens, sentinel lymph node assess- gual position needs to be treated by digit and patients should not be subjected to this
ment becomes necessary. The margin of ex- amputation. extraordinarily expensive procedure. In pa-
cision increases as do both the depth of tients with melanomas thicker than 1 mm
excision and the need for continuous close LYMPH NODE CONSIDERATIONS (including those between 1 and 2 mm), pa-
observation. One of the hallmark character- tients should probably have SLNB, unless
istics of malignant melanoma, as a disease Our own first work in the assessment of there is a compelling reason to the contrary.
with which to deal, is its readily documented regional lymph nodes was simplistic in the In fact, the break point for indicated SLNB,
propensity for invasion with justification extreme, but it turned out to be remarkably based on our clinical studies, is approxi-
for additional adjunctive therapy. accurate. Clinical palpation of lymph nodes mately 1.2 mm thick. At that point, the

www.medicalebookpdf.com

LWBK892_c30_p394-400.indd 396 10/28/11 4:17:39 PM

 Chapter 30: Malignant Melanoma and Squamous Cell Carcinoma of the Skin 397

Although seldom emphasized, the great-

est benefit of SLNB is the one that does not
yield microscopic positive melanoma but
permits the psychological benefit gained
in a patient who can avoid a high degree
of anxiety, unnecessary testing, unhelpful
medical oncologic consultation, and the
considerable side effects and expense of
biochemotherapy. An individual with a
3-mm-thick melanoma that has been ade-
quately excised and treated and then has
negative lymph nodes simply needs to see
her or his surgeon on a regular basis and be
examined for local recurrence, not only at
the site but also in the regional draining
lymph nodes. Palpation of the groin, axilla,
and supraclavicular spaces in the head and
neck is easily done and affords a high de-
gree of accuracy. Depending on the thick-
ness of the melanoma, this examination
needs to be done relatively frequently in the
Fig. 3. Overall survival curves of 1,528 patients with ⬎1, 2, 3, or 4 positive lymph nodes. As number of
early years following excision, and progres-
lymph nodes involved in the disease process increases, overall survival progressively and significantly
decreases. Note that the horizontal axis is 15 years. (From Balch CM, Soong SJ, Gershenwald JE, et al. sively less frequently across a follow-up pe-
Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on riod that should last for at least 5 years and
Cancer melanoma staging system. J Clin Oncol 2001;19(16):3622–34, with permission.) in many cases, 10 years. Such examination
(annually thereafter) must include an ex-
amination of all skin aspects. Have the pa-
tient, wearing minimal underclothes, stand
procedure yields sufficient lymph node pos- sulfur radioisotopes, exceeds 95%, with a and be inspected from head to toes, paying
itivity to be posited worth its substantial capacity to detect micrometastases when close attention to the soles of the feet and
cost. combined with microscopic pathologic ex- the backs of the thighs, which are spots fre-
It is interesting that literature on the ex- amination (Fig. 4). It is never perfect; how- quently missed by most patients. A second
pense of the procedure and imaging is rela- ever, the alert clinician should always be primary melanoma occurs in about 8% of
tively sparse, despite the substantial costs. aware that the procedure is not infallible. patients who have been successfully treated
Therefore, it is very important that it be ap- For example, it is infinitely less helpful with for a first primary lesion. This is especially
plied primarily to melanoma patients who head and neck melanomas, in which the important because these people with an

The Head and Neck

have lesions with unfavorable histological primary lesion, which must be injected with early diagnosis favorable to disease have a
characteristics sufficient to justify the SLNB radioisotope, and the pertinent nodes are high likelihood that other areas will also de-
procedure. in very close proximity. This is in contrast to velop disease, as these areas will also have
In general, the accuracy of the SLNB, us- a melanoma on the foot, which drains to been similarly sunburned, similarly blis-
ing isosulfan blue dye and technetium-99m the groin in virtual uniformity. tered, and at similar times. Nearly one-third
of patients who develop a second invasive
melanoma will have a third melanoma, and
tthe rate of metachronous primaries contin-
Table 1 Prognostic Factors Relative to Disease-Specific Survival u
ues to rise from there.
In the current surgical literature, guid-
Disease-specific survival aance on how to proceed with patients who
Prognostic factor Hazard ratio 95% CI P h
have positive SLNB is not always immedi-
aately apparent. In the first instance, under-
Age 1.01 0.98–1.01 0.57 sstanding that these patients will require a
Sex 1.11 0.45–1.82 0.78 sstandard lymphadenectomy in the involved
Tumor thickness 1.23 1.10–1.38 ⬍0.0004 bbody part is critical. Once the procedure
h
has been completed, one can, with confi-
Clark level ⬎III 2.32 1.03–5.23 0.04
ddence, provide pathologic data from the
Axial location 1.72 0.85–3.45 0.13 ooriginal lesion and regional draining nodes
Ulceration 1.62 0.85–3.08 0.14 tto medical and surgical oncologists for as-
ssessment of the need for additional sys-
SLN statusa 6.53 3.39–12.58 ⬍0.00001 ttemic therapy. If there is only a single node
a
Sentinel lymph node (SLN) status can be seen to be significantly more important than any other prognostic factor. iinvolved and the patient’s ability to tolerate
However, tumor thickness and Clark level ⬎III are also statistically significant prognostic indicators for disease- tthe morbidity of therapy is impaired, then
specific survival. oone could occasionally choose to withhold
(Adapted from McMasters KM, Reintgen DS, Ross MI, et al. Sentinal lymph node biopsy for melanoma: controversy
despite widespread agreement. J Clin Oncol 2001;19(11):2851–2855, with permission.)
aadditional therapy. In general, positive
ssentinel lymph nodes warrant systemic

www.medicalebookpdf.com

LWBK892_c30_p394-400.indd 397 10/28/11 4:17:39 PM

 398 Part III: The Head and Neck

A B

C D

Fig. 4. A: Lymphoscintigraphy with dermal injection of technetium-99m sulfur colloid around a melanoma reveals a sentinel
node. B: Injection of isosulfan blue dye performed immediately before skin incision. C: Blue lymphatic channels lead to a blue
sentinel node. D: Sentinel lymph node histology. Arrows depicting metastatic melanoma. (From Wargo JA, Tanabe K. Surgical
management of melanoma. Hematol Oncol Clin North Am 2009;23(3):565–81, with permission.)

therapy of some sort. We continue to feel as many false positives as true positives. able, the likelihood of systemic metastases
that the advantages are slightly in favor Having said that, it may be enormously decreases precipitously. Local recurrence,
of treatment. However, the side effects of helpful in patients who have had previous or in-transits, an inner circle name for in-
interferon alpha-2b are substantial. Many positive lymph nodes, where it should be tradermal lymphatic metastases, can be
highly motivated patients do not complete done annually or possibly even more fre- readily identified by physical examination.
their course of therapy because of signifi- quently. A major issue, aside from its ex- In-transit lesions are more readily palpable
cant side effects. Conversely, the value of pense, is that the positive PET scan often than they are visible. Any nodular lesion
systemic therapy in these patients contin- needs to be confirmed by tissue diagnosis, that occurs on the body part from which
ues to be debated. Systemic treatment may and that needs to be done in both a mini- the melanoma arose should be biopsied
slightly enhance 5- to 10-year survival. mally morbid and, yet, definitive way. It within a few weeks of its detection. When
However, a substantial number of thought- should be assumed that the PET scan fol- these lesions are confined to an extremity,
ful patients may choose to decline such lowed by biopsy confirmation would cre- hyperthermic isolated chemotherapeutic
treatment and simply depend upon their ate a treatment environment that can be perfusion is a standard therapy that will
surgeons for further regular follow-up, tolerated by the patient to proceed ac- stop progression permanently for about
treating recurrent melanoma when and cordingly. one-third of patients, significantly arrest
where found. The majority of melanomas that recur progression for another third, and will have
The outrageously expensive use of posi- either do so locally or in the body region relatively little impact on the final third. We
tron emission topography (PET) scanning initially involved, and are detected on phys- have experienced a large number of iso-
for patients must be carefully considered ical examination by the treating surgeon. lated extremity perfusions undertaken ei-
before requesting such tests. PET scanning Systemic disease occurs in less than one- ther for prophylaxis, or for extremely unfa-
for melanoma, unless carefully applied to third of patients treated surgically. As the vorable primary tumors (i.e., ⬎5 mm thick,
select, genuinely, high-risk patients, yields tumor becomes progressively more favor- positive regional lymph nodes, or in-transit

www.medicalebookpdf.com

LWBK892_c30_p394-400.indd 398 10/28/11 4:17:40 PM

 Chapter 30: Malignant Melanoma and Squamous Cell Carcinoma of the Skin 399

recurrence). More than 400 patients yielded dermatology) and pathologists skilled in not to be of value in patients with unknown
2 deaths and 2 amputations. Fourteen pa- skin lesions as to who identifies melanomas primary melanoma because one simply
tients developed significant leaks of the most accurately. In fact, as we have now ad- cannot determine what is being treated.
chemotherapeutic material, which resulted vanced toward more in situ disease and the
in leukopenia that required additional development of dysplasia, atypia, and oth- CONCLUSION
treatment. These patients all recovered, erwise normal moles, the landscape has
however. In-transit disease that is not ame- become increasingly confusing. The fact After a diagnosis of melanoma has been
nable to perfusion can often be treated by that these lesions may be missed by even a made by an informed primary care physi-
simple local excision. The process through good pathologist paradoxically simplifies cian or dermatologist, the first, second, and
which the disease progresses is highly vari- their surgical management! If in doubt, any third consideration in the patient’s care is
able; simple local excision can allow the new lesion in a patient who had been adequate local excision and appropriate me-
patient to remain lesion free for long peri- treated for melanoma should be presumed ticulous personal follow-up, with an empha-
ods of time. There is clear evidence that the to be a new primary, and a full thickness sis on the potential for disease recurrence.
dermatotrophic variant of melanoma (i.e., local excision should be carried out by the In contrast to melanoma, the manage-
those that are prone to recur in the skin or treating surgeon, again, as guided by the ment of squamous cell cancer is extraordi-
metastasize in the subdermal lymphatics) body part involved and size of the lesion in narily simple in that margins should gener-
runs a very leisurely and rarely aggressive question. ally be adequate and consistent with the
course, which adds an element of confi- The second unusual characteristic re- function of the body part. An adequate mar-
dence to the conservative management of lates to occasional reports which still ap- gin can often be as little as 1 microscopic
the patient. pear about the extirpation of melanoma millimeter with garden variety squamous
metastases to other viscera. In general, cell cancers. In general, if the lesion is not in a
these are associated with a grave prognosis. functionally or cosmetically important area,
DISEASE RECURRENCE somewhat wider margins are warranted, but,
Survival is approximately 100 days and sur-
There are at least two unusual characteris- gical approaches in treating such metasta- again, whatever is consistent with simple
tics of melanoma. The first is the late recur- ses are seldom successful. Aggressive sys- closure of the wound.
rence of disease. While unlikely, there is a temic therapy will arrest disease in only a
variant of very late (some ⬎25 years) recur- few patients. Among them are submucosal THE FUTURE
rence of melanoma; in all those whom the alimentary tract metastases that bleed or
senior author has seen, progression of dis- obstruct. However, one must also remem- Whether or not one is a devotee of the
ease was rapid. This is easy to recognize and ber that malignant melanomas are on that Green Movement, it is clear that the ozone
understand in patients who have been af- curious list of tumors that undergo sponta- layer has been impacted by some events,
fected by systemic immunosuppression, neous regression for reasons that we do not and it is less protective than it has been. If
such as that associated with organ trans- understand. we continue a scenario where leisure time
plantation. However, late recurrence does is enhanced, then the likelihood that more
occur in otherwise unaltered patients and people will be exposed to the sun for longer
justifies some form of longer-term follow-up,
THE UNKNOWN PRIMARY periods of time without the protection of

The Head and Neck

either through the conscientious referring From time to time, a surgeon caring for mel- the natural ozone layer that benefited our
physician, or by the surgeon. Follow-up for anoma patients will see an individual who generation will increase. When com-
such recurrence is, once again, easily con- often has an isolated lymph node that, upon pounded by the liberal use of tanning beds,
ducted by thoroughly examining the un- biopsy, shows metastatic malignant mela- which today exist in an increasing variety
dressed patient in good light. The other issue noma but without a visible primary lesion. of stores including launderettes and gym-
worthy of attention, of course, is manage- Careful and detailed study of the vaginal, nasiums, that leads to the inevitable con-
ment of a second primary. Interestingly anal, nasopharyngeal, and oral mucosa is clusion that there will be more skin can-
enough, these tumors are prognostically warranted. However, the most common un- cers, including both melanoma and
only slightly, but not significantly, better identified primary lesions arise from the squamous cell cancer. We can only hope
than the first primary. One might assume scalp, which incidentally may disappear sub- that the progress made in early diagnosis
that patients who have had one melanoma sequently. This is a good time to remember by dermatologists and other physicians is
would demonstrate a heightened awareness that melanoma may undergo spontaneous maintained by surgeons who respect the
to themselves using the “A-B-C-D” algo- regression; it may be that there was, indeed, potential gravity of these diseases and, yet,
rithms and looking for simple symptoms. an invasive melanoma that has regressed. A at the same time, possess a healthy aware-
One might also assume that they would have careful history about previous suspicious ness of its biologic variation. The most im-
the wisdom to stay out of the sun on Memo- lesions that have either been treated or cau- portant biologic variable in malignant
rial and Labor Day holidays, with a complete terized is critical in this setting. melanoma is adequate excision of the pri-
avoidance of tanning beds. However, those In patients who present with single mary lesion.
assumptions are only infrequently true, and nodes associated with metastatic mela-
the informed physician’s attention to these noma but without an obvious primary SUGGESTED READINGS
patients is especially valuable. lesion, there is a substantial likelihood of
What complicates this issue is the fact being cured by an isolated node dissection American Cancer Society. Why you should know
that 1% to 2% of all melanomas now identi- confined to that particular body part. By about melanoma. 2005. No. 261900-Rev.07/08.
Available at: http://www.cancer.org/acs/groups/
fied in many states will have had the diag- doing so, at least a quarter of these patients content/documents/document/acspc-024621.
nosis missed by board-certified patholo- are cured. In a self-selected way, they offer pdf
gists. There is an ongoing argument between substantial salvage to the patient and to the Davis NC. Cutaneous melanoma. The Queensland
dermato-pathologists (that is a specialty of surgeon. Systemic chemotherapy appears experience. Curr Probl Surg 1976;13:1–63.

www.medicalebookpdf.com

LWBK892_c30_p394-400.indd 399 10/28/11 4:17:43 PM

 400 Part III: The Head and Neck

Edwards MJ, Martin KD, McMasters KM. Lymphatic Knutson CO, Hori JM, Spratt JS Jr. Melanoma. Curr Polk HC Jr. Surgical progress and understanding
mapping and sentinel lymph node biopsy in the Probl Surg 1971; 3:55. in the treatment of the melanoma epidemic.
staging of melanoma. Surg Oncol 1998;7:51–57. Morton DL, Stern S, Elashoff I. Surgical resection Am J Surg 1999;178:443–448.
Emmett AJJ, O’Rourke MGE. Malignant skin tu- for malignant metastatic to distant sites. Pre- Reintgen DS, McCarty KS Jr, Vollmer R, et al.
mours. 2nd ed. Churchill Livingstone, 1991. sented at the 64th Annual Meeting of the Soci- Malignant melanoma and pregnancy. Cancer
Kirkwood JM, Strawderman MH, Ernsto MS et al. ety of Surgical Oncology, March 2–5, 2011, San 1985;55:1340–1344.
Interferon alfa-2b adjuvant therapy of high-risk Antonio, TX. Roberts DJ, Hornung CA, Polk HC Jr. Another duel
resected cutaneous melanoma: the Eastern Penn I. Malignancies associated with renal trans- in the sun: weighing the balances between sun
Cooperative Oncology Group Trial EST 1684. plantation. Urology 1977;10:57–63. protection, tanning beds, and malignant mela-
J Clin Oncol 1996;14:7. noma. Clin Pediatr (Phila) 2009;48:614.

EDITOR’S COMMENT with the prevalence of other specialties dealing Augustine, et al. (Mol Cancer Ther 2010;9:
with what are clearly melanomas, it does ap- 779–790) investigated a series of gene sampling
pear as if a 1-cm margin has become accept- and responses to various chemotherapeutic
This is a new chapter in the sixth edition which able. These data provide evidence that it may agents in the treatment of in-transit metastases.
for some reason was not present in the fifth edi- not be. The problem is that a 3- to 5-cm margin They would agree that the current state of the
tion. An appropriate question is how we could makes this “a real operation.” A 1-cm margin is art is not sufficient to allow widespread clinical
have missed it, since this is a real public health not “a real operation” and can be done in the application of this gene selection.
problem in this country. Dr. Robert Stern, writ- office. Whether or not we are accepting results While immunosuppression is a necessary
ing in the Archives of Dermatology (2010;146:279– that are not in the best interest of the patient evil in patients who receive transplants, one of
282) attempted to estimate 2007 prevalence of population for political reasons has been raised the cutaneous complications of immunosup-
common types of nonmelanoma skin cancer by these papers. pression with cyclosporine is squamous cell
(NMSC) and basal cell carcinoma, squamous An additional series of papers for wide carcinoma which manifests a 65 to 100 times
cell carcinoma, or both. The model used was an excision deals with desmoplastic mela- increased risk from the normal population. The
evidence-based mathematical model to compare noma, a relatively rare but perhaps more incidence of basal cell is less. Writing in Nature,
the prevalence of NMSC with other common virulent melanoma. Wasif et al. ( J Surg Oncol Wu et al. (Nature 2010;465:368–372) point out
cancers which appeared to have much more at- 2011;103:158–162) from the Mayo Clinic in that the incidence of basal cell carcinoma, the
tention. Scottsdale recalled their results with 505 pa- other major keratinocyte-derived tumor of the
Approximately 13 million white, non-Hispan- tients of which mean thickness was 2.97 mm. skin, and melanoma and internal malignan-
ics living in the United States at the beginning of Patients undergoing a wide excision (⬎1 cm) cies increase to a significantly lesser extent. The
2007 have had at least one NMSC. Of 70-year-olds had an improved 5-year overall survival com- pharmacological suppression of calcineurin/
and older, at least one in five have had multiple pared with simple excision (⬍1 cm) or bi- nuclear factor of activated T cells (NFAT) pro-
nonmelanoma skin cancers, most of which were opsy alone (67% vs. 60% vs. 45%, respectively, motes tumor formation in experimental ani-
basal cell carcinomas. This model proposes that P ⬍ 0.01). Twenty nine percent of patients un- mals and xenografts. Calcineurin/NFAT inhibi-
the prevalence of a skin cancer history is five derwent sentinel node biopsy but only 2.8% tion counteracts p53-dependent cancer. Thus,
times higher than that of breast or prostate can- were positive. Breslow thickness, nodal positiv- intact calcineurin/NFAT signaling is critically
cer and greater than the 31-year prevalence of all ity, and ulceration did not predict survival, but required for p53 and senescence-associated
other cancers combined. Despite the fact that on multivariate analysis only adjuvant radia- mechanisms that protect against skin cancer
this represents a major public health problem, tion therapy and wide local excision correlated development.
much less attention is being paid to it and these with survival. The results indicate that in this Finally, an interesting initiative to elucidate
are widely regarded as not important and not of- somewhat aggressive melanoma, only wide (3 the incidence of melanoma and how it begins
ten related to mortality. This is probably because to 5 cm margin) excision may be acceptable as was reported by Rezze et al. (Hum Pathol 2010;
with the exception of squamous cell carcinoma the appropriate treatment. Epub ahead of print), proposing that the loss of
and of course melanoma, they are not viewed as Another variant of squamous cell carcinoma connectivity in early melanomas is an expression
lethal lesions. which may be associated with increased risk of of kallikrein 6 and 7 as well as desmocollin 3 and
A basic question for all of the treatment for local recurrence and metastasis is desmoplastic connexin 43 was higher in melanomas. They pro-
melanoma is the extent of resection and whether cutaneous squamous cell carcinoma. Velasquez pose that the kallikrein expression in melanomas
wide margins (i.e., 1 to 3 cm, largely 3) are the et al. (Am J Dermatopathol 2010;32:333–339) ar- may play a particular role in melanocyte develop-
only adequate resections. Until 30 years ago, it gue for a more aggressive approach to this tumor ment and the expression of kallikrein 6 and 7 may
was commonly accepted that a wide, 3-cm mar- with elongated cords of atypical epithelial cells very well be responsible for the loss of cell–cell
gin on biopsy-proven melanomas or melanomas associated with a “prominent (usually reactive) adhesion, which they propose is essential for the
that are clinically diagnosed is related to survival. desmoplastic stroma.” development of melanoma.
Mocellin et al. (Ann Surg 2011;253:238–243) per- A rather interesting historical and epide- This commentary would not be complete
formed a meta-analysis of five randomized clini- miological vignette is recounted by Autier et al. without recalling the controversy between
cal trials (RCT) in which narrow margins (namely (Curr Opin Oncol 2011;23:189–96) bringing in the Dr. Polk, a good friend for whom I have im-
1 to 2 cm) were compared with wide margins (3 evidence that sunbeds are carcinogenic; even mense respect, and myself as to the meaning of
to 5 cm). The meta-analysis suggests that narrow in Australia where the incidence of melanoma increased long-term survival in patients with
margins might be associated with an increased is endemic, sunbeds increase the incidence. An negative nodes on node dissection in the era
risk of both locoregional disease recurrence and epidemic of melanoma began in 1985 in Ice- before sentinel node biopsy and before more so-
death by disease ( for both, P ⫽ 0.01). Disease- land where truncal exposure by women in this phisticated techniques of assaying for positive
specific survival (DSS) and overall survival (OS) northern country began when sunbeds were in- adenopathy by molecular means. This phenome-
were available for three and five RCT, respectively. troduced and truncal melanoma surpassed the non of node-negative lymph nodes in lymph node
The borderline disadvantage of narrow margins incidence in lower legs. Icelandic women had a dissection resulting in up to 20% improvement in
(P ⫽ 0.06) becomes statistically significant when lower incidence of melanoma; after the intro- survival probably reflects the fact that these neg-
enrolled patients with thicker melanomas were duction of sunbeds surpassed Norway and Den- ative nodes would likely be positive at this point
compared. In these data, locoregional disease- mark. In 2001, the incidence started decreasing in time were they tested by the currently avail-
free survival (LDFS) and disease-free survival as regulation decreased the ability to use sun- able biologic means. I suspect that is the reason
(DFS) were statistically significant. When death beds. A similar experience was recorded by Dif- for these seemingly paradoxical results. I doubt
by any cause was analyzed, no risk difference was fey in an article entitled “Sunbeds, Beauty, and whether these experiments will be repeated, but
found. Melanoma” in the British Journal of Dermatology it is nonetheless important to remember what
These results are disturbing. Although previ- (2007;157:350–356) and elsewhere (Autier et al., these results showed.
ously a 3-cm margin was seen to be adequate, Am J Epidemiol 2010;172:762–767). J.E.F.

www.medicalebookpdf.com

LWBK892_c30_p394-400.indd 400 10/28/11 4:17:43 PM

 Chapter 31: Evaluation and Repair of Common Facial Injuries 401

31 Evaluation and Repair of Common Facial Injuries

Eduardo D. Rodriguez with the assistance of Gerhard S. Mundinger

Craniofacial trauma occurs in broad demo- cause they are often dramatic in appear- life-threatening. These are (a) airway ob-
graphic and severity spectra, and is fre- ance and instinctually interesting, cranio- struction, (b) aspiration, and (c) hemor-
quently associated with multisystem facial injuries have the potential to deter rhage.
trauma. Multidisciplinary cooperation be- the clinician from appropriate evaluation
1. Airway obstruction: The craniofacial
tween trauma surgeons, orthopedists, of other more serious occult injuries. The
trauma patient frequently has an im-
neurosurgeons, oral surgeons, ophthalmol- presence of a facial injury implies that a
paired level of consciousness, and there-
ogists, otolaryngologists, and plastic sur- simultaneous injury to adjacent areas such
fore cannot adequately protect his or
geons is central to facilitating timely and as the neck, brain, and skull may have oc-
her airway. Additionally, massive facial
effective reconstruction. Every facial injury curred. Therefore, brain injury, skull frac-
swelling, displaced fractures, extensive
results in damage to soft tissue, with many ture, and cervical spine injury must be ex-
soft-tissue injuries, and cervical spine
involving injury to both soft tissue and cluded, as such injuries often have more
injury are common. Each of these sin-
bone. While well-trained general surgeons serious immediate consequences. In all
gular factors, let alone in combination,
can easily manage most soft-tissue injuries circumstances, the American College of
greatly increases the risk of aspiration
with fundamental wound care, common Surgeons principles of advanced trauma
and the inability to maintain oxygen
bony injuries and injuries to complex struc- life support (ATLS) remain paramount.
saturation. The maintenance of a safe
tures are best managed by surgeons with Assessment of airway, breathing, and cir-
airway is crucial in craniofacial trau-
craniofacial expertise. Although there are culation are performed in the primary sur-
ma, and, as in all trauma cases, must
few true facial emergencies, the advantages vey. The level of consciousness according
be the first management priority. Intu-
and superior aesthetic results of prompt, to the Glasgow Coma Scale (Table 1)
bating the craniofacial trauma patient
definitive anatomical reconstruction of fa- should be succinctly recorded and serially
can be very challenging, and the airway
cial bone and soft-tissue injuries has been reassessed.
team must be prepared to perform
historically underemphasized. As the face Evaluation of craniofacial injuries takes
emergency cricothyroidotomy or trache-
is vital for communication, perception, nu- place in the secondary survey. The observa-
otomy when standard orotracheal intuba-
trition, and interpersonal relationships, tion of other organ systems must be contin-
tion is not possible. Cricothyroidotomy
appropriate management of craniofacial ued throughout the entire period of facial
should be converted to tracheotomy
trauma is thus essential for maintenance of injury treatment and continuous monitor-
as soon as feasible, especially in pa-
patient livelihood and identity. ing provided where appropriate. That said,
tients who are comatose or not expect-
This chapter provides an overview of the there are three mechanisms by which cran-
ed to control their own airway within
evaluation, management, and treatment of iofacial trauma alone can be inherently
1 week.
the most common manifestations of cran-

The Head and Neck

One special scenario is noteworthy:
iofacial trauma that a trauma surgeon is
bilateral mandible fractures that lead
likely to encounter. Aspects of the history Table 1 The Glasgow Coma Scale to airway compromise due to prolapse
and physical examination that dictate spe-
Eyes open of the central segment. Airway compro-
cial management are emphasized, along
Never 1 mise can be temporized in this scenario
with indications for radiologic examina-
To pain 2 by bridle wiring around two teeth on
tion. Injuries to complex structures, includ-
To verbal stimuli 3 either side of the fracture segment, or,
ing the lacrimal system, facial nerve, and
Spontaneously 4 in the case of a prolapsed medial seg-
Stensen’s duct, are reviewed. Preferred tech-
Best verbal response
ment due to bilateral parasymphyseal
niques for the treatment of soft-tissue
No response 1 fractures, with anterior traction on the
injuries, including wound management,
Incomprehensible sounds 2 tongue using a towel clamp or suture.
antibiotics, local anesthetics, and closure
Inappropriate words 3 This pulls the prolapsed medial segment
methods, are comprehensively discussed.
Disoriented and converses 4 anteriorly as an airway-preserving mea-
The chapter concludes with an overview of
Oriented and converses 5 sure.
common facial fracture patterns and their
Best motor response 2 Aspiration: The confused or obtunded
2.
operative management. The information in
No response 1 trauma patient may aspirate oral secre-
this chapter will facilitate appropriate,
Extension (decerebrate rigidity) 2 tions, blood, or gastric contents. The risk
timely multidisciplinary care that reduces
Flexion abnormal (decorticate 3 of aspiration and subsequent aspiration
the need for late operations, avoids pro-
rigidity) pneumonia is exacerbated by simultane-
longed rehabilitation, and minimizes
Flexion withdrawal 4 ous midface and mandibular fractures,
psychological scarring of the craniofacial Localized pain 5 and is more common in patients with
trauma patient. Obeys 6 cerebral injuries. Rapid, noisy respira-
Total 15 tions, a low arterial oxygen content, de-
crease in oxygenation, and a decrease in
INITIAL EVALUATION From Teasdale G, Jennett B. Assessment of coma and pulmonary compliance are seen early on.
impaired consciousness. A practical scale. Lancet 1974 Simple intubation prevents aspiration
Facial trauma, though deserving of prompt Jul 13;2(7872):81–4.
attention, is rarely life-threatening. Be- and should be performed early when

www.medicalebookpdf.com

LWBK892_c31_p401-411.indd 401 10/28/11 5:18:07 PM

 402 Part III: The Head and Neck

there is evidence that the airway is not Once the initial trauma evaluation is should be taken in the emergency depart-
being protected. complete, and life-threatening trauma (sys- ment, or sketches of wounds should
3. Hemorrhage: Life-threatening hemor- temic or isolated craniofacial) has been ad- be included as part of the craniofacial
rhage from craniofacial trauma has equately addressed, management can focus evaluation.
two mechanisms: (a) bleeding from fa- on craniomaxillofacial injury. Details sur- Two types of physical examination
cial lacerations, and (b) bleeding from rounding the traumatic episode including should be performed: sequential and di-
the sinuses and cranial base. Bleeding mechanism of injury and elapsed time until rected. In the sequential examination, an
from facial lacerations is the result of presentation are crucial determinants of orderly examination of all facial structures
transected arteries and veins. The par- next steps in diagnostic and therapeutic is methodically performed. Examination
tially transected major artery can result measures. Historians, including witnesses, proceeds from cephalad to caudal (or cau-
in near exsanguination. Arterial hem- family members, and emergency medical dal to cephalad), and lateral to medial in
orrhage is best controlled by direct su- staff, can provide valuable information. each of the following facial regions: fore-
ture, carefully avoiding the locations of Many craniofacial trauma patients are un- head, orbits, nose, maxilla, and mandible.
branches of the facial nerve. Similarly, der the influence of intoxicating substances, Extensive palpation of all bony surfaces
major veins may require suture ligation. and this potentiality should be investigated should note tenderness and deformity. In
While blunt contusion causes bleeding through appropriate toxicology screens particular, the superior and inferior orbital
within facial soft tissue, this bleeding is when indicated. The patient’s current medi- rims, zygomatic arches, and malar promi-
usually tamponaded by facial soft-tissue cations and past medical history, including nences should be palpated. The mandible
pressure. The result is a hematoma that tetanus immunization status, should be should be thoroughly evaluated with an in-
is either diffuse or localized. Localized documented. traoral examination including direct palpa-
hematomas should be drained, as the The diagnosis of most facial injuries is tion of the maxillary and mandibular dental
pressure generated from the expanding accurately suggested by thorough clinical arches, mandibular teeth, and the horizon-
hematoma may produce tissue necro- examination. Discoloration, pain, localized tal and vertical portions of the mandible.
sis. Additionally, pressure produced by tenderness, numbness or paralysis, maloc- The occlusal relationship of the maxillary
osmotic imbibition as the hematoma clusion, crepitus step-off or level discrepan- and mandibular dental arches should be
dissolves may impair circulation, caus- cies over the margins of facial bones, double noted. If lucid and cooperative, the patient
ing tissue atrophy and even infarction. vision, decreased visual acuity, facial asym- should be asked if his or her teeth feel like
The treatment of localized hematomas metry, gross facial deformity, changes in fa- they are meeting together normally. The ex-
is discussed later in this chapter. Obser- cial contour, and changes in eye position cursion of the mandible while palpating the
vation is the only treatment for diffuse (exophthalmos or enophthalmos, vertical temporomandibular joint and the relation-
hematomas. dystopia, etc.) are all symptoms suggestive of ship of the mandible to the maxilla should
deeper structural trauma. Soft-tissue inju- also be evaluated. Midface instability sug-
Cranial base, orbital, and midface frac- ries are inevitable and one should suspect an gestive of maxillary fractures can be deter-
tures may produce hemorrhage from lac- existing fracture of the underlying facial mined by bimanual palpation (Fig. 1). In
erations of arteries and veins within the bones beneath any contusion, bruise, or lac- this technique, the upper alveolar ridge is
sinus cavities. Cranial base bleeding can eration. Ideally, photographs of trauma sites manipulated with one hand while the other
involve major arteries and veins, cannot
be controlled by tamponade, and must al-
ways be considered in cases of massive
facial hemorrhage. It must be quickly rec-
ognized when present as it can cause
rapid exsanguination. Generally, bleeding
from midface fractures can be controlled
by four mechanisms: (a) the maxilla can
be repositioned and secured in the best
“rest” position by applying maxilloman-
dibular fixation (MMF); (b) a posterior
pack can be placed as an obturator in the
nasopharynx, and anterior packing can be
placed against the posterior pack; this
provides tamponade pressure for lacer-
ated vessels in sinus walls; (c) selective
arterial embolization may be utilized for
those cases that do not respond to manual
maxillary repositioning and anterior–
posterior nasal packing; (d) rarely, and
when the above measures fail, bilateral
external carotid and superficial temporal
artery ligation or coil embolization, per-
formed simultaneously, reduces the pres-
sure in the external carotid system and
may assist in control of massive orbital
and midface hemorrhage. Fig. 1. Bimanual palpation of the facial skeleton for the diagnosis of midface fractures.

www.medicalebookpdf.com

LWBK892_c31_p401-411.indd 402 10/28/11 5:18:07 PM

 Chapter 31: Evaluation and Repair of Common Facial Injuries 403

hand stabilizes the head while palpating ined. The repair of injuries to the lacrimal Three-dimensional CT scans can greatly aid
the nasal root. system is discussed later in the chapter. in operative planning of complex craniofa-
The presence of “step-off ” or “level” de- Fractures that involve the frontal or cial trauma, and will likely play an increas-
formities in the dentition, bleeding, loose basilar skull may lacerate the dura, leading ing role in the imaging of craniofacial
teeth, and intraoral lacerations all suggest to pneumocephalus (passage of air inside trauma as this technology becomes more
areas of deeper bony involvement. Irregu- the skull) or cerebrospinal fluid (CSF) leak. widely available.
larities in the dental arch and abnormal ar- CSF may exit from the nose (CSF rhinor- In most cases, CT evaluation of the cran-
eas of occlusion are all suggestive of local- rhea) or ear (CSF otorrhea). This implies a iofacial trauma patient supplements and
ized fractures. Avulsed or missing teeth and communication between the subdural confirms, but never replaces, the findings of
intraoral or gingival lacerations indicate space and the external environment, rais- a thorough clinical examination. A review
the possibility of an underlying fracture of the ing the possibility of meningitis. CSF rhin- of both bone and soft-tissue CT windows
alveolus, or more extensive fracture of the orrhea or otorrhea is often obscured by the should be promptly completed, and the
mandible or maxilla. Lacerations of the lips, presence of blood mixed with draining CSF, specific areas with radiographically identi-
chin, palate, and floor of the mouth often making the detection and confirmation of a fied fractures reexamined. This is particu-
accompany fractures of the jaws. The search CSF leak difficult. A “double ring” or “halo” larly useful in cases of suspected intraocu-
for occult lacerations must include the eye- sign may be visible when draining blood lar muscle entrapment as discussed later.
lids, ear canal, mouth, floor of the mouth and CSF is absorbed to a paper towel. This
under the tongue, pharynx, and nasal cav- may be subsequently confirmed via serum TREATMENT OF FACIAL
ity. Nasal examination is greatly facilitated electrophoresis. In the presence of dis-
by using a nasal speculum. Pain and pres- placed fractures, intracranial repair of the SOFT-TISSUE INJURIES
sure sensation, including complete anes- dura is indicated. Definitive operative treat-
thesia or hypoesthesia, should be documented ment is accompanied by the administration General Considerations
in the supraorbital, corneal, infraorbital, of prophylactic antibiotics for several days. After completion of the primary survey, sec-
and mental nerve distributions. Crucially, Therefore, rhinorrhea and/or otorrhea in ondary survey, and radiographic imaging,
the neurologic facial examination, includ- the setting of craniofacial trauma should be soft-tissue injuries of the face may be de-
ing evaluation of all cranial nerves, must be evaluated thoroughly for the presence of finitively treated. Lacerations are thor-
completed and documented before the ad- CSF, warranting detailed computed tomog- oughly inspected and accessed for depth
ministration of any local infiltrative anes- raphy (CT) evaluation of the cranial base. and direction. Any foreign bodies are iden-
thesia or nerve blocks. Any history of Conversely, the presence of pneumocepha- tified, the level of wound contamination is
posttraumatic neck pain or alteration in pe- lus on CT imaging raises high clinical suspi- assessed, and damage to deeper structures,
ripheral motor or sensory function pre- cion for a CSF leak that should be thor- such as muscles, nerves, or bone, is identi-
cludes operative treatment of facial inju- oughly investigated and ruled out. fied. Tetanus prophylaxis is essential, and is
ries, as this raises suspicion for concomi- administered according to the guidelines of
tant cervical spine injury. RADIOLOGIC EVALUATION the American College of Surgeons (Table 2).
The eye and function of vision must be The goals of initial treatment are the cleans-
specifically evaluated in the sequential ex- Computed tomographic scans of the face, ing of wounds, debridement of devitalized

The Head and Neck

amination with ophthalmologic consulta- cervical spine, and head are warranted in tissue, evacuation of hematomas, and ten-
tions called when appropriate. The symme- nearly all cases of facial trauma. A thin-cut sion-free reapproximation of wound edges.
try of the pupil, speed of pupillary reaction, (⬍3 mm/slice) axial face CT with coronal Puncture wounds are managed by thorough
presence of hyphema, and range of extraoc- and sagittal reconstructions is the current irrigation and debridement without formal
ular motion should be evaluated. The pres- “gold standard” for radiographic evaluation closure. Many soft-tissue injuries can be
ence of periorbital or subconjunctival ec- of the craniofacial trauma patient. Histori- treated in the emergency department, pro-
chymosis implies the possibility of an cally, plain radiographs were ordered to vided the patient is hemodynamically sta-
orbital fracture or globe injury. Visual acu- evaluate facial and cervical fractures. This ble, wounds are not severely contaminated,
ity, field deficits, diplopia, afferent pupillary modality has been outdated due to the su- and there is no threat of airway compro-
defect, or decreased light perception must perior image quality and three-dimensional mise. If any of these criteria are not met, if
be promptly evaluated. anatomic relationships afforded by CT. CT fractures are present, or if the patient is un-
Following the sequential physical exam- scans provide reliable, accurate informa- cooperative (i.e., pediatric patients), opera-
ination, a directed physical examination tion that aids in surgical planning, and have tive repair in a formal surgical theater is
should then thoroughly reevaluate specific been shown to be more cost-effective than warranted.
areas where fractures or injury to specific radiographic series.
structures are suspected as suggested by CT images should include the frontal Anesthesia
the sequential examination. The following bone, frontal sinus, orbital and nasal re-
key injuries are common, and warrant ex- gions, midface, and mandible, including the For most soft-tissue injuries, local anesthe-
tensive directed examination. temporomandibular joints. If there is tooth sia is adequate to achieve debridement and
Any lacerations of the eyelid suggest the involvement in any identified fracture on closure. Before injecting a local anesthetic,
possibility of globe rupture, and the globe CT, a Panorex image should be obtained to a complete motor and sensory neurological
must be examined for integrity if an eyelid assess tooth and tooth root injury. This is examination of the face must be docu-
laceration is discovered. Lacerations occur- the only situation in craniofacial trauma mented. This not only serves medico-legal
ring in the medial third of the lower or up- where thin-cut, multiplanar CT imaging is purposes, but also conveys important infor-
per eyelids suggest the possibility of lacri- not the gold standard for bony injury. Pa- mation to other specialists that may par-
mal system injury, and the punctae and tients with multiple injuries cannot be sent ticipate in subsequent patient care outside
lacrimal duct should be thoroughly exam- unmonitored for radiographic evaluation. of the emergency department.

www.medicalebookpdf.com

LWBK892_c31_p401-411.indd 403 10/28/11 5:18:08 PM

 404 Part III: The Head and Neck

Local anesthesia can be administered

Table 2 Recommendations for Tetanus Prophylaxis of the Committee v direct field injection, or through ana-
via
on Trauma, American College of Surgeons
ttomical nerve blocks. Topical application of
Previously Immunized Individuals llocal anesthesia to the laceration may pro-
When the attending physician has determined that the patient has been previously fully vvide a level of analgesia that allows subse-
immunized and the last dose of toxoid was given within 10 years:
qquent injection with minimal discomfort.
For non–tetanus-prone wounds, no booster of toxoid is indicated. Direct field injections, while requiring less
D
For tetanus-prone wounds and when more than 5 years have elapsed since the last dose, give ttechnical skill, distort anatomy, making
0.5 mL adsorbed toxoid. If excessive prior toxoid injections have been given, this may be omitted. pprecise closure difficult, and often result in
When the patient has had two or more prior injections of toxoid and received the last dose
iincomplete or fleeting anesthesia due to
more than 10 years previously, give 0.5 mL absorbed toxoid to patients with both tetanus-prone
and non–tetanus-prone wounds. Passive immunization is not considered necessary. iimprecise infiltration. Therefore, important
aanatomical landmarks, including the ver-
Individuals Not Adequately Immunized million border and brow line, should be
m
When the patient has received only one or no prior injections of toxoid or the immunization marked before local anesthetic infiltration
m
history is unknown:
sso that these crucial areas can be accurately
For non–tetanus-prone wounds, give 0.5 mL absorbed toxoid. rrepaired (Fig. 2). These regions benefit
For tetanus-prone wounds: greatly g from trigeminal nerve blocks and
Give 0.5 mL absorbed toxoid.
therefore t avoid local soft-tissue distortion.
Give 250 U (or more) of human tetanus antitoxin. Anatomical nerve blocks require less an-
Consider providing antibiotics. esthetic e volume (typically 2 mL) and allow
for f accurate tissue reapproximation because
From Oreskovich MR, Carrico CJ. Trauma: management of the acutely injured patient. In: Sabiston DC, ed. Text they t do not distort anatomic landmarks.
book of surgery, 13th ed. Philadelphia: WB Saunders, 1986:328; and Bull Am Coll Surg 1979;69:19. Nerve N blocks of the supraorbital, supratro-
chlear, c infraorbital, and mental areas are ef-
fective f and easily performed (Fig. 3). When
performing nerve blocks, injection must be
immediately stopped and the needle with-
drawn if the patient experiences sharp pain
in the distribution of the nerve being anes-
thetized. This indicates direct intraneural in-
jection, which can lead to permanent dener-
vation. The ear is a notoriously difficult area
to anesthetize due to multiorigin and redun-
dant innervation. A great auricular block is
effective for the inferior ear and superior
mandible areas. Complete ear anesthesia re-
Fig. 2. Marking the vermilion border before local infiltration of anesthetic aids precise repair of lacera- quires local injection in a diamond/ring pat-
tions of the lip. tern circumferentially around the ear.
It is best to choose one local anesthetic
and become comfortable and versatile with
its use. 1% lidocaine with 1:100,000 epineph-
rine mixed with 8.4% sodium bicarbonate at a
ratio of 9:1 (i.e., 9 mL lidocaine:1 mL sodium
bicarbonate) or 4:1 provides excellent anes-
thesia and aids in hemostasis. The addition
of sodium bicarbonate neutralizes the an-
esthetic, making the injection less painful.
Bupivacaine is a long-acting local anes-
thetic, providing pain relief for up to 8
hours. When compared with the roughly
1-hour period of pain relief provided by li-
docaine, bupivicaine may spare the patient
repeated anesthetic injections when repair-
ing multiple, large, or complex lacerations
in the emergency department. Especially in
the pediatric population, LET (lidocaine
2%, epinephrine 1:100,000, and tetracaine
2%) can be used as a topical preinjection
anesthetic. Cotton or gauze dipped in 4%
cocaine can be packed into the nares to
anesthetize the nasal mucosa.
Conscious sedation is also an anesthetic
Fig. 3. Sites for injection and affected areas for supraorbital, infraorbital, and mental nerve blocks. option that may be safely used in the

www.medicalebookpdf.com

LWBK892_c31_p401-411.indd 404 10/28/11 5:18:08 PM

 Chapter 31: Evaluation and Repair of Common Facial Injuries 405

emergency department in certain situations. be placed on the face. Superficial sutures

This technique is quite helpful in children, should be removed in 4 to 7 days. Penrose
especially for perioral lacerations. Patients drains can facilitate the elimination of dead
must be closely monitored throughout treat- space in wounds, and are removed in 24 to
ment and recovery by an anesthesiologist. 48 hours. Wounds requiring drain place-
ment or local soft-tissue rearrangement for
Wound Preparation closure are generally the result of significant
soft-tissue loss, in which case a plastic sur-
Following injection of local anesthesia and gery consult is warranted. Additionally, a
time for it to take effect, the site is prepped consult should be called for any amputa-
and draped in a sterile fashion. Depilation tions of large portions of the lip, scalp, or
is generally not necessary, though 0.5-cm ear, as microvascular replantation may be
borders can be shaved around scalp lacera- possible. In these instances, if the ampu-
tions. The eyebrows should never be shaved tated tissue is still present, it should be
as they are major anatomic landmarks that cleansed with saline irrigation, cleansed of Fig. 4. Location of the facial nerve and Stensen’s
may not regrow satisfactorily. The field is gross debris, wrapped in saline-moistened duct.
cleansed with surgical prep solution (Beta- gauze, and placed in a plastic bag on ice. Dry
dine, or a similar prep solution), taking care ice should not be used. Referral to a micro-
to protect the eyes. Hibiclens solution surgical replantation center is warranted. injuries that occur on a line between the
should be avoided in the head and neck Dermabond (2-octyl cyanoacrylate), mastoid process and the lateral brow (Fig. 4).
region, as it can cause conjunctivitis. The though approved for skin closure, should be In most cases, weakness of the muscles of fa-
site is then draped in a sterile fashion. Bilat- avoided on the face. It does not adhere to cial expression will be evident. Microsurgical
eral exposure is preferred, as it allows for mucosal surfaces or the scalp, and generates repair in the operating room is warranted.
visualization of normal landmarks on the a foreign body reaction if placed into an open The parotid or Stensen’s duct is a short
unaffected side. If the patient is particularly wound. Furthermore, wounds closed super- structure that travels from the anterior
anxious, the entire face can be prepped and ficially under tension risk suture breakdown margin of the parotid gland approximately
included in the surgical field. in the short term, and hypertrophic scarring 1 inch anterior to the tragus to the area of
Cleansing of soft-tissue lacerations is ac- in the long term. The placement of deep su- the upper maxillary bicuspid tooth where it
companied by scrubbing or pressure irriga- tures allows for tension-free repair. Lacera- enters the intraoral mucosa at the parotid
tion of the involved tissue, and sharp tions in the face are also often complex in papilla. It roughly follows a line drawn from
debridement of the immediate contused tis- geometry, making precise closure with the floor of the nostril to the tragus. Any in-
sue edge if possible. Thorough tissue irriga- Dermabond difficult to achieve. For these jury along this line should be considered to
tion helps to decrease contamination and reasons, Dermabond has very little utility in involve the parotid duct. When injury to the
remove foreign material. Care should be the management of craniofacial lacerations. parotid duct is suspected, a number 22 an-
taken to remove all foreign material at the Antibiotics are not routinely necessary giocath sleeve may be introduced intraorally
time of the initial treatment. Ground-in dirt for simple lacerations of the face because its into the parotid duct via the parotid duct

The Head and Neck

or particles of debris cannot be satisfacto- rich vasculature is protective against infec- papilla in the buccal mucosa. Saline in-
rily removed after healing of the skin. Mag- tion. However, antibiotic use is required jected through the angiocath will then be
nifying loupes greatly aid in thorough re- when the wound cannot be made “clean” by visible in the wound in the presence of a pa-
moval of debris and closure. Resection of 1 surgical debridement, or in the presence of rotid duct laceration. Lacerations of the
or 2 mL of a contused soft-tissue edge re- high-level contamination, such as from ani- parotid duct are almost invariably accom-
sults in a fresh skin edge for layered repair. mal or human bites. Although animal and panied by buccal facial nerve branch lacer-
Areas where debridement should be conser- human bite wounds are generally not rou- ation because the two structures travel next
vative or avoided altogether include the ver- tinely repaired, bite wounds of the face may to one another. Duct repair should be per-
million border, lips, eyelids, eyebrow, nostril safely be closed primarily following a thor- formed in the operating room over a sili-
rims, ciliary margin, and distal nose. Scar ough debridement and the administration of cone stent to prevent cutaneous salivary
formation is minimized by irrigation and antibiotics. A first-generation cephalosporin fistulae and cheek swelling.
sharp debridement that achieves a minimally administered at the time of closure and pre- Localized hematomas commonly occur
contaminated, flat wound surface. This al- scribed for 5 days after repair is sufficient. in five places: (a) the ear (where cartilage
lows for precise closure of wound margins. necrosis or a “cauliflower ear” may result
Direct primary closure of facial wounds Special Considerations following perichondral hematoma) (Fig. 5),
is generally preferred, although open man- (b) the cheek (where the buccal space cre-
agement is considered in special circum- Several important major anatomic struc- ates an area for accumulation), (c) the eyelid
stances, such as animal bites. Wounds are tures may be injured with lacerations that (where fibrosis and ectropion may result),
typically closed in two layers: one deep layer occur in specific areas. These injuries require (d) the forehead (where pressure injury to
of buried absorbable sutures and a superfi- specialized management. Lacerations of ma- the overlying skin frequently results in skin
cial layer of nonabsorbable suture, gener- jor sensory or motor nerves such as the necrosis), and (e) the nasal septum (which
ally monofilament nylon. In children or trigeminal and facial nerve branches and can lead to avascular septal necrosis and
adult patients where there is concern that lacerations of the parotid duct should be subsequent nasal collapse if not promptly
the patient will not return for suture re- managed in the operating room by direct re- drained). Any localized facial hematoma
moval, absorbable suture can be used for pair with fine suture material under loupe or should be drained by making an incision
superficial closure. Staples are suitable for microscopic magnification. Facial nerve in- over the fullest point with a #11 blade. A
closure of scalp lacerations, but should not jury should be suspected with penetrating small suction tip can then be inserted to

www.medicalebookpdf.com

LWBK892_c31_p401-411.indd 405 10/28/11 5:18:09 PM

 406 Part III: The Head and Neck

and tissue loss. Following stabilization of

the patient with ATLS protocol as described
previously, the soft tissues are cleansed, de-
brided, and closed over any associated frac-
tures without fracture fixation. The patient
is then returned to the operating room every
48 hours for opening of the wound, inspec-
tion, and further debridement if needed.
These serial wound inspections prevent
further tissue damage, and allow for early
detection and treatment of infection. Miss-
ing bone and soft tissue can be recon-
structed once tissue necrosis is no longer
present and any infection controlled.
A B
SOFT-TISSUE INJURIES
TO THE EYE, ORBIT, AND
LACRIMAL APPARATUS
Globe injuries require special attention and
management. Superficial lacerations of the
eyelid lateral to the punctum are approxi-
mated with skin sutures. Full-thickness lid
lacerations can be accompanied by globe
injury. If a globe injury is suspected, an oph-
thalmologic consult is mandatory. Once an
injury to the globe has been excluded, the
Fig. 5. Evacuation of a hematoma of the external ear. A: An in- lid margin is closed using a layered ap-
cision is made in a dependent position. B: The hematoma is proach (Fig. 6). The eyelash line, gray line,
evacuated and the anatomic detail of the ear is restored. C: A and conjunctiva are reapproximated with
light compressive head dressing is applied.
C fine sutures. Monofilament absorbable su-
tures are used to repair the tarsus, and the
external skin is closed with a 6-0 nylon
aspirate the hematoma. Alternatively, the
suture. Care should be taken to pull the
hematoma cavity can be evacuated with se-
quential manual pressure. The cavity should
be thoroughly irrigated after evacuation to
remove any remaining clot and assess for
recurrent bleeding. A soft lubricated com-
pression dressing should then be applied to
minimize the likelihood of recurrence. Sec-
ondary drainage procedures within 24 to
48 hours are commonly necessary.
Black powder injuries and traumatic
tattooing represent a special case of facial
injury demanding unique treatment. If
untreated, myriad foreign bodies present
at the injury site can result in deformity.
To minimize deformity, debridement with
aggressive scrubbing of the wound in the
operating room is recommended with the
aid of magnification. Multiple rounds of
subsequent dermabrasion and/or laser
treatment can aid in optimizing cosmesis.
Wound care for facial gunshot wounds is
determined by the type of weapon, range of
injury, and path of the projectile. Low-
velocity gunshot wounds may be managed
as closed injuries (i.e., the involved soft tis-
sues are cleansed, excised as needed, and A B
closed primarily with immediate fixation of Fig. 6. Repair of a laceration across the margin of the lower eyelid. A: The tarsal plate is reapproximated
associated fractures). High-velocity gunshot with fine absorbable sutures that do not penetrate the conjunctiva. B: The lid margin is reapproximated
wounds or avulsive high-energy facial inju- with fine nonabsorbable sutures anatomically. The ends of the lid margin sutures are tied under the first
ries can produce extensive tissue damage external suture to prevent corneal abrasion.

www.medicalebookpdf.com

LWBK892_c31_p401-411.indd 406 10/28/11 5:18:09 PM

 Chapter 31: Evaluation and Repair of Common Facial Injuries 407

Fig. 7. The nasolacrimal system.

A B
marginal suture tails under the first exter-
nal skin suture to prevent corneal irritation,
and possible corneal abrasion. External skin
sutures are removed in 4 to 7 days, and mar-
ginal sutures are removed in 7 to 10 days.
Lacrimal duct injury should be sus-
pected with laceration to the upper or lower
lid margin medial to the lacrimal punctum,
or following injury to the medial canthus.
The lacrimal duct in these areas is superfi-
cial, and thus easily injured by vertical lac-
erations (Fig. 7). Specialty consultation is
indicated if duct injury is suspected. In a
similar fashion to the repair of parotid duct C
injuries, repair of lacrimal duct injury
involves intraoperative cannulation of the Fig. 9. Repair of complex nasal laceration. A: The nasal mucosa is reapproximated with absorbable sutures.
nasal lacrimal duct with silastic tubing, fol- B: The cartilage is repaired with absorbable sutures on a noncutting needle. C: The skin is reapproximated.
lowed by microsurgical repair of the duct
over the stent and repair of the lid lacera-
tion. The stent is usually left in place for able monofilament sutures as previously MANAGEMENT OF FACIAL
6 months to avoid duct stenosis. described. Similarly, in full-thickness lacer-
ations to the nose, the nasal lining is re-
FRACTURES
INJURIES TO THE EXTERNAL paired with chromic sutures, the cartilage The advent of rigid plate and screw fixation

The Head and Neck

EAR AND NOSE is repaired with monofilament absorbable and the development of the facial buttress
suture using tapered needles, and the over- concept of facial structural support in the
Lacerations involving the external ear car- lying skin is then approximated with a 1980s revolutionized the treatment of facial
tilage are reapproximated with monofila- monofilament 6-0 nylon suture (Fig. 9). He- injuries. Additionally, absorbable plates
ment absorbable suture using a tapered matomas can occur in both the nose and and screws became available for use in pe-
needle (Fig. 8). The auricular skin surfaces ear, and should be managed as previously diatric patients in 1998. Adequate exposure
are then approximated using nonabsorb- described. is crucial for precise anatomic reduction of
fracture segments. Access incisions, includ-
ing coronal, lateral eyebrow, subciliary,
transconjunctival, intraoral buccal sulcus,
and submandibular, can provide adequate
access to the facial skeleton with aestheti-
cally acceptable scars. Prompt, definitive
anatomical reconstruction of facial bone
injury affords superior aesthetic results and
can minimize the need for revision proce-
dures. Goals of fracture management are
early anatomic reduction of the fracture
fragments, rigid internal fixation, and res-
toration of preinjury dental occlusion.
Following complete directed physical ex-
amination and evaluation of CT/Panorex
imaging, grossly displaced tissues and frac-
tures can be manually repositioned. If de-
A B C sired, MMF can be applied to the jaws to
Fig. 8. Repair of a laceration of the external ear. A: The cartilage is reapproximated with absorbable temporarily stabilize fractures involving the
suture on a noncutting needle. B, C: The skin of the posterior and anterior surfaces is reapproximated occlusal segments. Bony injuries to the facial
with nonabsorbable sutures. skeleton are organized by anatomical region

www.medicalebookpdf.com

LWBK892_c31_p401-411.indd 407 10/28/11 5:18:09 PM

 408 Part III: The Head and Neck

and complexity. Fractures may be simple

(nondisplaced or slightly displaced), moder-
ate (requiring standard anterior incisonal
approaches), or extensive, requiring the
combination of anterior and posterior inci-
sions. The management of facial fractures
therefore first requires identification of frac-
tures in each anatomic region of the cranio-
facial skeleton as visualized on CT imaging.
The fracture pattern in each anatomic region
of the face is then classified, and manage-
ment options for the regional fracture pat-
tern weighed. Regions are then considered
in combination to generate a logical, graded
operative treatment sequence. In some in-
stances, immediate bone grafting is war-
ranted if significant bone loss is present.
Common donor sites include split calvarium,
iliac crest, and rib. Prophylactic antibiotics
are not generally required for open reduction
and internal fixation procedures, though this
remains controversial. We are attempting to
address this issue through an ongoing ran-
domized controlled trial at our institution.
The most common craniofacial fracture pat-
terns and their management are discussed
in the remaining sections of this chapter.
Due to its prominence and anatomy, frac-
tures of the nose are the most common fa-
cial bone injury in adults. Fractures of the
nose are diagnosed by history and physical
examination. In most cases, nasal fractures Fig. 10. Maxillary fractures.
are treated by closed reduction. While re-
duction can be achieved with external nasal
field blocks, general anesthesia facilitates
accurate closed reduction. Following reduc-
tion, the nasal pyramid should be supported
by an external nasal splint. In cases involving
the septum, the septum should be supported
by intranasal Doyle splints. Severe cases may
require cartilage or bone grafting with late
revisions. Revisions should be delayed for at
least 3 months following reduction.
Isolated zygoma fractures and zygomati-
comaxillary complex (ZMC) fractures com-
monly occur after midface trauma (Fig. 10).
The malar eminence and inferior orbital rim
are commonly depressed posteriorly and/or
inferiorly. When the zygoma is completely
dislocated at the zygomaticofrontal suture,
the lateral canthus may be inferiorly displaced
as its attachment to Whitnall’s tubercle is just
inside the inferior surface of the lateral
orbital rim. Surgical indications include the
presence of displaced bony segments that in-
terfere with the coronoid process of the man-
dible, flattened or displaced malar eminence,
enophthalmos, diplopia, vertical globe or lat-
eral canthus malposition, or anesthesia of the
infraorbital nerve from impingement. Occa-
sionally, orbital floor reconstruction with an Fig. 11. Favorable versus unfavorable mandible fractures. Favorable mandibular fractures, pictured
alloplastic implant or bone graft is necessary to the left, do not necessarily need to be plated as muscle pull impacts the fracture. In unfavorable
because of severe comminution. fractures, pictured to the right, muscle pull distracts the fracture. Rigid fixation is thus required.

www.medicalebookpdf.com

LWBK892_c31_p401-411.indd 408 10/28/11 5:18:09 PM

 Chapter 31: Evaluation and Repair of Common Facial Injuries 409

Classically, “blowout” orbital fractures in-

volve the inferomedial and inferior portion of
the orbit, and result from direct blunt trauma
to the orbit. Medial or lateral gaze diplopia
may be present. This is rarely due to incarcera-
tion of the medial or inferior rectus, although
incarceration must be excluded. Rather, mus-
cle entrapment is usually mimicked by trau-
matic changes in the tensile strength of the
medial rectus muscle that result in alterations
in muscle moment arm. Nonetheless, true
muscle entrapment must be excluded with a
forced-duction examination and careful CT
imaging evaluation if diplopia is present. Or-
bital floor defects greater than 2 cm2 have tra- A B
ditionally been reconstructed, although this is
controversial. Absolute indications for surgery
to prevent late enopthalmos are significant
globe displacement, enophthalmos, or muscle
entrapment as diagnosed by forced duction
and confirmed with CT scan imaging. Recon-
struction is usually performed with open
techniques, although some centers are explor-
ing endoscopic repair. Minimally displaced or
nondisplaced fractures without visual distur-
bance may be managed by observation.
Mandibular fractures, though common
and appearing in predictable patterns, are
often missed on initial examination. Surgi-
cal fixation and MMF can be avoided if there
is no malocclusion, the patient is able to
function, and occlusal relationships are ac-
ceptable (i.e., “favorable” fracture) (Fig. 11).
In these cases, a soft diet is all that is re-
quired. In most cases, MMF is required to
restore and maintain normal occlusal rela-

The Head and Neck

tionships. Unfavorable fractures involving
the dentition generally benefit from MMF
with open reduction. Upper and lower man-
dibular border fixation is common as it en-
sures stability of the reconstruction. Upper
border fixation is usually unicortical. With
bilateral subcondylar fractures, one side
should usually be opened and rigidly fixated
to restore posterior facial height. MMF is
generally maintained for 4 to 6 weeks post-
operatively. Every effort should be made to
minimize time in MMF, as patients in fixa-
tion will frequently loose 15 to 20 pounds
over this period of treatment despite a blen-
derized diet. Patients kept in elastics can
maintain a soft diet. Fractures of the eden-
tulous mandible should be managed with
C
open reduction procedures. However, bone
height and quality often do not permit plate Fig. 12. Approach to panfacial fracture management using reconstruction of the horizontal and verti-
and screw fixation. These fractures may be cal buttresses as guiding principle. The (A) horizontal and (B) vertical facial buttresses are the support
effectively fixated with circumferential pillars of the face and overlying soft tissues. Disrupted buttresses must be reduced and reconstructed to
optimize results. Nondisrupted buttresses adjacent to fracture sites serve as anchor points for fixation
wires, splints, or acrylic saddles.
hardware. (C) In panfacial fractures, buttresses are sequentially reconstructed by dividing the face into
Maxillary fractures are classified accord- upper and lower units. Once reconstruction is complete in each unit, the two units are combined to
ing to the general patterns originally de- complete reconstruction.
scribed by Rene Le Fort in 1901 (Fig. 12).
Before fracture reduction is attempted,
patients are placed in MMF to maintain

www.medicalebookpdf.com

LWBK892_c31_p401-411.indd 409 10/28/11 5:18:09 PM

 410 Part III: The Head and Neck

normal occlusal relationships. Fractures level is a useful framework for reconstruc- conservatively. Debilitating scar contrac-
are typically exposed through gingivobuc- tion. In this schematic division, the “lower tures can occur at the eye, nose, and mouth.
cal sulcus incisions and then reduced and face” refers to the mandible and the maxilla Scars in these areas are therefore more
fixated. If highly accurate rigid fixation is up to the Le Fort I level. The “upper face” re- likely to require revision. Laser treatments
obtained, intermaxillary fixation may be fers to the zygoma, nose, nasoethmoidal re- and dermabrasion have been suggested as
released postoperatively or light elastic gion, and frontal bone. Distant soft tissue is ancillary methods to manage hypertrophic
traction in occlusion can be utilized. If the frequently required to replace missing bone scars, but supporting evidence is lacking,
bone segments are highly comminuted and and soft tissue. While microsurgical free tis- especially for use of these treatments early
fixation is not as stable or accurate as de- sue transfer for the reconstruction of cran- in the wound-healing process.
sired, MMF is maintained for 3 to 4 weeks. iofacial trauma is well beyond the scope of
While in MMF, chlorhexidine gluconate this chapter, bone and soft tissues from dis-
oral rinse and tooth brushing with a small tant regions can be transferred to the area of
CONCLUSIONS
toothbrush ensure adequate oral hygiene. injury using free microsurgical techniques Many common facial injuries can be appro-
Displaced fractures of the frontal sinus to achieve multiple reconstructive aims in a priately managed by the trauma surgeon
are treated to prevent deformity, telecan- single-stage procedure. through adherence to basic surgical princi-
thus, and late infections, including pyomu- ples. More complex injuries require spe-
cocele and intracranial infection. While de- POSTOPERATIVE cialty consultation. Effective treatment of
pressed fractures of the anterior wall may be these injuries is maximized by early recog-
treated by simple elevation, posterior wall
MANAGEMENT nition, referral, and treatment as outlined
fractures imply the possibility of a dural Postoperative wound hygiene is accom- in this chapter. Knowledge regarding treat-
laceration, especially when the depth of plished daily with cleansing of sutures and ment of these complex injuries can facili-
displacement exceeds the thickness of the application of an antibiotic ointment. In- tate interspecialty communication, allevi-
posterior table. Fractures blocking the naso- traoral lacerations are cleansed by irrigation ate patient concerns early in the posttrauma
frontal duct are treated by obliteration or and oral mouth washes. Strenuous physical period, and optimize long-term reconstruc-
cranialization of the sinus cavity. These tech- activity should be avoided 48 hours after in- tive outcomes.
niques minimize the possibility of intracra- jury. Cold compresses can minimize swelling
nial infection and mucocele development. and discomfort. Incisions can be washed 24 SUGGESTED READINGS
Following exposure through a coronal inci- hours after closure. Application of a 50/50 Clark N, Birely B, Manson PN, et al. High-energy
sion, the mucous lining of the frontal sinus mix of hydrogen peroxide and normal saline ballistic and avulsive facial injuries: clas-
is stripped in its entirety, and a burr is used can help remove crusts that have formed sification, patterns, and an algorithm for
to lightly abrade the sinus walls. Burring along the suture line. Frequent postrepair primary reconstruction. Plast Reconstr Surg
eliminates invaginations of mucosa into the wound inspection should be performed to 1996;98(4):583.
bone ( foramina of Breschet), preventing detect hematoma or infection. Sutures are Glassman N, Iliff N, Vander Kolk C, et al. Rigid
fixation of orbital fractures. Plast Reconstr Surg
mucosal regrowth. In sinus obliteration, the generally removed in 4 to 7 days. Contact 1990;86:1103–9.
nasal frontal ducts are then plugged with sports can be resumed after craniofacial Luyk NH, Ferguson JW. The diagnosis and initial
bone grafts. The remainder of the sinus is trauma requiring plate and screw fixation, management of the fractured mandible. Am
then obliterated with bone shavings. This but there is no consensus as to the duration J Emerg Med 1991;9(4):352–9.
procedure attempts to convert the sinus of time patients should refrain from contact Manson P. Facial injuries. In: Mathes SJ, ed. Plastic
into a portion of the bony skull through bone sports postinjury. In our practice, contact surgery, 2nd ed. Philadelphia, PA: Elsevier, Inc;
2006.
transplantation. An acceptable alternative sports can be resumed after radiographic Manson PN. Fractures of the zygoma. In: Booth
is sinus cranialization. In this procedure, the evidence of bone healing, which varies de- PW, Schendel SA, Hausamen JE, eds. Maxillo-
posterior wall of the frontal sinus is removed pending on the location and extent of injury. facial surgery, 2nd ed. St. Louis, PA: Churchill
following mucosal stripping and abrasion. Patients are generally concerned about Livingstone Elsevier; 2007:120–54.
The brain and dura are then allowed to rest scarring and the negative cosmetic seque- Manson P, Clark N, Robertson B, et al. Subunit
on the remaining sinus floor and anterior lae of their injury. They should be informed principles in midface fractures: the importance
wall. The sinus is thus incorporated into the that all wounds and surgical incisions cre- of sagittal buttresses, soft tissue reductions and
sequencing treatment of segmental fractures.
intracranial space. Nose blowing is restricted ate scars, but simple measures can reduce Plast Reconstr Surg 1999;103:1287–306.
for a few weeks postoperatively. scars. Gentle wound massage with moistur- Markovitz BL, Mandon PN, Sargent L, et al. Man-
The term “pan facial fractures” refers to izing lotion can minimize scarring and pig- agement of the medial canthal tendon in na-
midface fractures in combination with man- mentation changes. Massage can begin soethmoid orbital fractures: the importance of
dibular and/or frontal bone fractures. These 2 days after suture removal. Surgical scar the central fragment in classification and treat-
injuries are frequently the result of high- revision should only be considered after ment. Plast Reconstr Surg 1991;87:43.
Rodriguez ED, Stanwix MG, Nam AJ, et al. Twenty-
velocity gunshot wounds or massive blunt wound maturation at 6 months to 1 year six-year experience treating frontal sinus frac-
trauma. Once no more soft-tissue necrosis postinjury. Mature scars are characterized tures: a novel algorithm based on anatomical
is seen following soft-tissue debridement as by return of skin pliability and resolution of fracture pattern and failure of conventional
previously described, the missing bone and induration. Scar revision is highly benefi- techniques. Plast Reconstr Surg 2008;122:1850.
soft tissue can be reconstructed either seri- cial for cases where primary healing of the Taub D, Jacobs JS, Bessette RW. Treatment of
ally or simultaneously. In reconstructing wound was compromised by local infec- disorders of the temporomandibular joint. In:
Guyuron B, Erikkson E, Persing JA, eds. Plastic
complex craniofacial trauma, fractures are tion, hematoma, or suboptimal wound care surgery: indications and practice. Philadelphia,
sequentially fixated to reconstruct disrupted due to associated life-threatening trauma. PA: Saunders Elsevier; 2009:591–603.
facial buttresses. Dividing the face into two As scars are generally made larger by exci- Zide B, Swift R. How to block and tackle the face.
conceptual units relative to the Le Fort I sion, scar revision should be undertaken Plast Reconstr Surg 1998;101(3):840–51.

www.medicalebookpdf.com

LWBK892_c31_p401-411.indd 410 10/28/11 5:18:09 PM

 Chapter 31: Evaluation and Repair of Common Facial Injuries 411

EDITOR’S COMMENT antibiotic coverage, the antibiotic coverage was junctival incision without canthotomy, was the
in different areas in different ways. Some were most successful surgical outcome. The authors
only perioperative antibiotics, whatever that stated that when a major surgical procedure is
Injuries to the face are like injuries to the lips, as means, and I could not find in this paper the necessary, a subciliary incision is recommended.
mentioned in Chapter 23, one of the things that definition of what was considered satisfactory There are some nice photographs in this article;
one sees first, and so an injury to the face, which as far as perioperative antibiotic use was con- Figure 3 shows a subciliary approach in the left
is not well repaired, or in which the bones are not cerned. Then, there were patients who received eye and the scar appearance 11 months postre-
aligned, or the eyes with an orbital fracture in perioperative antibiotics and postoperative an- pair; a transconjunctival incision with follow-up
which there is some difference between one eye tibiotics presumably after the repair was closed. 10 months postoperatively; and a transconjunc-
and the other, is easily recognizable. The most antibiotic use was in those patients tival approach with canthotomy, in which unfor-
Facial fractures, particularly in high-speed au- who received pre-, peri-, and postoperative tunately at 3 months there is an ectropion. The
tomobile accidents and other such injuries, can antibiotics, and these apparently had a bias in authors conclude that any lateral canthotomy
be destructive. Patients can lose their lives from that these facial injuries were more severe than very often will have poor healing, scleral appear-
bleeding, which can occur within the cranium or those in the cohort that received only periopera- ance, and unfortunately an ectropion. They ad-
from lacerations of arteries and veins within the tive antibiotics. Trauma and assault constituted vise against this repair.
sinus cavities. Bleeding from a mid-face fracture 39% of these patients, motor vehicle accidents As the authors state, the subtarsal incision,
can be controlled by four mechanisms, as the au- 28%, and 11% suffered falls. Interestingly, there which is also known as the mid-lower eyelid or
thors state: is no difference between infection rates for the mid-lid approach, was popularized in the 1940s
patients in each antibiotic group. The authors by the great plastic surgeon at New York Hospital
1. The maxilla can be repositioned and secured
concluded that the use of additional antibiotics John Converse. It is made at a level more inferior
in the best “rest” position by maxillomandib-
outside of the perioperative time frame did not to the lower lid margin in one of the subtarsal
ular fixation.
reduce the rate of postoperative infection. They creases and extends laterally into one of the rest-
2. A posterior pack can be placed as an obtura-
hedged their bets and said that perhaps antibi- ing skin tension lines located along the lateral
tor in the nasopharynx, and an anterior pack
otic use might be warranted in the case of se- aspect of the orbit.
against the posterior pack. This is the best
vere contamination, trauma, and multiple open As the authors conclude, whatever approach
tamponade pressure for lacerated vessels in
fracture wounds. That may well be, but what is is used to access the orbital floor, lower eyelid
the sinus walls.
disturbing here is that they actually could not malposition is the most common long-term com-
3. Selective arterial embolization may be uti-
vouch for the time frame in which the periop- plication following the surgical repair of orbital
lized in those cases that do not respond to
erative antibiotics were given; in other words, fractures. A canthotomy should be avoided in the
manual maxillary repositioning and anterior-
although the rate of infection was fairly low, it is hope that there will not be an ectropion.
posterior nasal packing.
not clear that patients who were to receive anti- Orbital fractures that go through the naso-
4. And on occasion, external carotid and su-
biotics received the antibiotics in a timely fash- ethmoid area are among the most complex of
perficial temporal artery ligation is utilized.
ion prior to the repair of the injury so that there reductions. Sargent LA, in a single-author paper
In my own experience, when I found my way
was a reasonable level of antibiotics while the from Chattanooga, Tennessee, and the University
into a large vessel in the back of the throat,
wound was being repaired. To really solve this of Tennessee at Chattanooga (Plast Reconstruct
I had no alternative but to ligate the vessel,
question once and for all, one would probably Surg 2007;120(Suppl 2):16S), provided a review of
and in fact it could have been a vessel with a
have to conduct a randomized prospective trial his experience with 450 nasoethmoid fractures.
major vascular supply to the brain, although I
in which one looked carefully at the time frame He used a computed tomographic scan with a
did not think so.
in which antibiotics were given. simple classification: Fractures that are displaced
There are some nice tidbits here, which I think Orbital trauma is one of the most frequent or moved upon examination require open reduc-
the readers should be aware of. I entirely agree traumatic episodes and is important to restore tion and stabilization. Wide exposure with me-
that Dermabond (2-octyl cyanoacrylate) should the orbit so that patients could have a reason- ticulous reduction and hemostasis is necessary.

The Head and Neck

not be used in facial injuries. First, it does not able appearance. A comparative study of various The author proposes a plate-and-screw fixation
adhere to mucosal surfaces or the scalp, as the approaches to the repair of orbital trauma was of the superior and inferior rims, performed with
author states, and generates a foreign body reac- reviewed by Salgarelli AC, et al. (Oral Maxillofac bone graft reconstruction of the nose, as needed.
tion if placed in an open wound. “If the wounds Surg 2010;14:23–27, published online). In this Attention to redraping of soft tissue in the naso-
are closed superficially under tension risk suture study, 274 patients, 169 men and 105 women with orbital valley with the use of nasal compression
breakdown in the short-term, and hypertrophic a broad spectrum of ages, 16 to 78 years, who had bolsters is a critical step in the repair. The author
scarring in the long-term.” The best sutures to orbital trauma without soft tissue lacerations in states, “Early diagnosis combined with the ag-
close such injuries are either long-acting absorb- the orbital region. Long-term follow-up, which gressive new surgical techniques will optimize
able sutures, which can be placed deep, or very was defined as 6 to 48 months, and the patients results and minimize the late post-traumatic
fine proline in the skin and the appropriate re- were reviewed as these trauma occurred, 2000 to deformity.” Along these lines, Figure 5 in this
moval at a time that the surgeon thinks will not 2007. Their return to the clinic was evaluated in nice paper shows how one deals with the com-
leave hatch marks across the skin. terms of aesthetics and function for the presence minuted bilateral nasoethmoid orbital fracture.
Since such injuries are likely to be in con- of a visible scar and lower eyelid malposition The central bone segments are stabilized to each
taminated areas, it is interesting to note that (scleral show or ectropion). Fifty of the 274 pa- other with transnasal wires, and the superior and
as the authors state that it is rare that antibiot- tients (28.2%) experienced complications. Since inferior orbital rim fractures are stabilized with
ics are needed. It is true that the face has a rich there was no laceration, the approach to the or- miniplates or microplates. The author claims that
blood supply and as a result great resistance to bit had to be through one of three approaches: nasal projection contour is essential with a can-
infection, although I would think that under The largest group was in the subciliary approach, tilever calvarial bone graft to restore the frontal
traumatic circumstances, the antibiotics might of which 41 experienced complications; of the 32 view as well as the nasal fullness.
be useful and should be used. A recent study uti- patients with the transconjunctival approach, Another approach of frontal sinus repair and
lizing mandibular trauma, as the authors state there was only one complication; and among injury is put forth by Noury M, et al. (Ann Plast
(Lauder A, et al. (Laryngoscope 2010;120:1940– the 23 patients treated with the transconjuncti- Surg 2011;66:451–459), along with the empha-
1945), there is no standard for the use of pre- val approach with canthotomy, there were eight sis on a frontalis rhytid approach. The authors
and postoperative antibiotics in other facial complications, or 35%. The purpose of these state that frontal sinus fractures have tradition-
trauma. To determine whether there should be various approaches was to make certain that ally been repaired through a bicoronal approach,
any recommendation, they reviewed 223 pa- there was not a scar that was visible. However, which provides wide exposure but has its com-
tients with traumatic facial injuries between the results clearly revealed that once one did a plications particularly in a patient with a risk for
January 1, 2003, and January 1, 2009, which were canthotomy with a transconjunctival approach, hairline recession—something that this editor is
included in the retrospective cohort analysis. there was a higher rate in lower eyelid malpo- quite prone to. These authors present a series of
Although all patients received perioperative sition. The most successful repair, a transcon- 15 patients who underwent open reduction and

(continued)

www.medicalebookpdf.com

LWBK892_c31_p401-411.indd 411 10/28/11 5:18:09 PM

 412 Part III: The Head and Neck

internal fixation of the anterior table with frontal Finally, Bezuhly M, et al. (Plast Reconstruct lateral position were 2.5, 2.7, and 2.3 mm, respec-
sinus fracture for an incision. There are some very Surg 2008;121:948–955) review once again the tively. The mean difference in ocular globe projec-
nice results in this paper, showing in particular surgical technique between accurate fracture re- tion was 1.23 mm. Other than a small punctate
the approach in Figure 3, including the fracture duction and soft tissue morbidity. They reviewed scar noted in one patient at the site of Kirschner
reduction obtained with microplates and layered 50 patients who they believed were eligible for wire insertion, there were no other negative cuta-
anatomical closure. In the 6 months postopera- review for an isolated simple zygoma fracture, neous scars. Thus, even in a destructive periorbital
tive photograph, the authors claim that there is a using a combination of Gillies elevation and per- fracture, which truly can result in a bad cosmetic
near inconspicuous scar and that there is intact cutaneous Kirschner wire fixation between 1992 result, with care, microplates, microscrews, and a
and symmetrical frontalis function 6 months and 2003. Fourteen patients were available for careful attention to detail, even patients with bad
postoperatively. I assume, although I have very examination at a mean follow-up of 8.7 years. The fractures, which are likely to be somewhat asym-
little experience with this, that this is a critical mean differences between injured and uninjured metrical, a good result can be obtained.
part of a good repair. sides for malar eminence projection, height, and J.E.F.

32 Resection and Reconstruction of Trachea

Joel D. Cooper and Stacey Su

INTRODUCTION or separate segments in series. Each of local transmural invasion, or endoluminal

these factors is considered in planning the obstruction. Indications for tracheal resec-
The management of tracheal stenosis is a most appropriate intervention. tion for malignant tumors include adenoid
logistic as well as technical exercise requir- Benign conditions for which tracheal re- cystic carcinoma, locally invasive thyroid
ing the multidisciplinary input of thoracic section is considered include traumatic in- cancer, and primary squamous carcinoma of
surgeons, pulmonologists, otolaryngologists, jury, inhalational injury, postintubation and the trachea. Adenoid cystic carcinoma is
experienced anesthesiologists, and inten- posttracheostomy stricture, postintubation characterized by extensive microscopic in-
sivists at different stages of the patient’s tracheoesophageal fistula, and a variety of volvement of the tracheal wall well beyond
care. Patients with acquired tracheal steno- inflammatory conditions. The most com- the visible borders of involvement. Resection
sis often present with comorbidities, which mon cause of tracheal stricture is postintu- in these cases may be of value even if the final
require medical optimization prior to surgi- bation stenosis, either attributable to pro- margins show microscopic involvement as
cal resection. In carefully selected patients, longed endotracheal intubation or as a subsequent postoperative radiation may be
however, surgical resection of tracheal complication from a previous tracheostomy associated with survival of 10 years or more.
stenosis offers a definitive treatment with (Fig. 1). Idiopathic subglottic stenosis is a Resection for primary squamous carcinoma
excellent outcomes and low perioperative disease in young women and typically of the trachea is rare due to the advanced
risk. The management of tracheal stenosis affects the cricoid and proximal trachea, stage at the time of diagnosis and likelihood
encompasses diagnosis, initial assessment thus requiring a laryngotracheal resection. of mediastinal nodal involvement.
and management of a critical airway, tem- Airway obstruction from malignant tu-
porizing maneuvers, and definitive surgical mors may result from extrinsic compression, PREOPERATIVE WORKUP
treatment. AND EARLY AIRWAY
There are broadly three different types of
tracheal resections, each of which requires
MANAGEMENT
a specific operative approach and tech- Routine preoperative assessment includes a
nique depending on the location and extent history, physical examination, radiographic
of tracheal involvement. The most straight- imaging, and bronchoscopic evaluation.
forward of these is a segmental resection Whenever possible, patients undergo pul-
with end-to-end anastomosis of a stenosis monary function tests, including a flow-
located in the proximal to mid-trachea. Re- volume loop, which shows a decrease in
sections at either end of the trachea, namely both maximal inspiratory and expiratory
a laryngotracheal resection at the proximal flows. Standard radiographs include antero-
end or a carinal resection at the distal end, posterior and lateral cervical views. A 3D CT
may require unique release maneuvers, dif- reconstruction of the airway yields mea-
ferent approaches, and more complicated surements of the length of the stenosis and its
anatomic procedures. relationship to the rest of the airway (Fig. 2).
These measurements serve as a guide before
ETIOLOGY proceeding to more precise confirmation by
bronchoscopy. The use of bronchoscopy is
Characterization of tracheal stenosis is essential to show the anatomy of the larynx
based on the etiology of the stenosis, its Fig. 1. Bronchoscopic view shows a nearly oblit- and glottis, the function of the vocal cords,
location and length, whether the stenosis is erated upper airway, which may result from as well as the configuration of the stenosis
evolving or mature in nature, and whether postintubation stenosis and high tracheostomies and remaining trachea. It is important to
the stenosis is limited to a single segment incorrectly placed near the cricoid. note the distance from the stenosis to

www.medicalebookpdf.com

LWBK892_c32_p412-417.indd 412 10/28/11 5:16:22 PM

 Chapter 32: Resection and Reconstruction of Trachea 413

any ongoing requirement for ventilatory

support set the stage for a higher rate of
anastomotic dehiscence and other compli-
cations of tracheal resection. Any patient
with reversible medical conditions should
have resection deferred until the time at
which they are deemed best equipped from
a cardiopulmonary standpoint and optimal
physical conditioning. Reoperation after a
failed tracheal resection is associated with
increased risk, complexity, and may produce
an inferior result compared to an initial, suc-
cessful reconstruction.

Principles of Tracheal Resection

The principles of tracheal resection are de-
rived from elementary surgical tenets: a
healthy anastomosis will result from metic-
ulous mucosal apposition between well-
vascularized tissues opposed without un-
due tension. To that end, the following
Fig. 2. Three-dimensional CT reconstructions of the airway are useful to assess the configuration corollaries hold: (a) the limits of tracheal
of tracheal stenosis before precise measurements are obtained by bronchoscopy. resection must extend to healthy, normal
tissues, and (b) circumferential dissection
beyond the resected ends should be mini-
mized so as to not jeopardize the segmental
anatomic landmarks (vocal cords, carina, of the airway is formulated. Taking into nature of tracheal blood supply. Up to half of
and tracheal stoma) in addition to the length consideration the patient’s overall medical the trachea (about 12 cm) may be resected
of the stenotic segment and the health of the condition and surgical candidacy, the op- with primary end-to-end anastomosis.
surrounding mucosa. tions include repeated dilation, elective re- However, if more than three to four carti-
The immediate management of the air- ferral for surgical resection, or placement of laginous rings are resected, then tension-
way once the diagnosis of tracheal stenosis an airway prosthesis (stent, tracheostomy, releasing maneuvers beyond flexion of the
has been made requires as much skill, ex- or T-tube). If tracheal resection is planned head and mediastinal mobilization within
pertise, and collaboration as the surgical in the ensuing few weeks, dilation alone the avascular pretracheal plane must be
resection itself. There are few indications may be adequate to carry the patient until considered. Such maneuvers include the su-

The Head and Neck

for emergent tracheal resection, and nearly this time. If internal tracheal stents are to prahyoid release, as described by Montgom-
all cases of tracheal stenosis may be man- be used, only silicone stents or T-tubes ery, and the hilar release, with each of these
aged initially by establishing a patent air- should be utilized since expandable metal permitting an additional 1 to 2 cm of resec-
way. After initial evaluation of the anatomy stents potentially lead to further mucosal tion. In general, dissection immediately ad-
by flexible bronchoscopy (usually through damage and complicate a subsequent sur- jacent to the tracheal wall will prevent in-
a laryngeal mask airway), dilation across gical resection. In some cases, a T-tube or jury to the recurrent laryngeal nerves and
the stenosis may be accomplished by rigid tracheostomy affords a long-term solution esophagus. An exception is the posterior
bronchoscopy or by balloon dilation. Bal- to airway stenosis, either in patients with cricoid plate, behind which the recurrent
loon dilation may be performed over a Bent- multiple segments of affected trachea or in laryngeal nerves ascend to enter the cri-
son guidewire placed through the working poor surgical candidates for resection. coarytenoid joint on either side. When the
channel of a bronchoscope, with or without condition to resect back to healthy tissue
the use of fluoroscopy. Especially in the case
of critical stenosis, it is important to main-
TRACHEAL RESECTION cannot be met, for example, in many inflam-
matory conditions where there are multiple
tain the patient’s spontaneous breathing In the last few decades, refinements in the affected segments in series or globally in-
and to avoid muscle relaxants until a safe surgical and anesthetic techniques for tra- flamed mucosa, then surgical candidacy for
airway has been established. One should be cheal resection have yielded excellent out- tracheal resection must be questioned.
ready with available equipment for an emer- comes with tolerable morbidity and mortal-
gent tracheostomy if needed. Rigid bron- ity. Tracheal resection carries multiple
choscopy can be performed with broncho- benefits. The question of which patient char- Important Landmarks
scopes of increasing caliber in order to acteristics portend a good outcome requires The cartilaginous skeleton of the larynx,
dilate in a safe, controlled way while main- a consideration of the risk factors for poor which houses the vocal cords, is comprised
taining the ability to ventilate, visualize, outcomes in tracheal resection. As there is of the thyroid, cricoid, and arytenoid carti-
and suction at the same time. seldom a situation which requires emergent lages. The narrowest fixed part of the airway
Most cases of critical stenosis can be ini- tracheal resection and reconstruction, care- is marked by the cricoid ring. The recurrent
tially treated with a single dilation session, ful patient selection and appropriate timing laryngeal nerves lie in the tracheoesopha-
the benefits of which lasts 7 to 10 days while of surgery are central to successful outcomes geal groove and enter the larynx at the level
an overall plan for long-term management of resection. The routine use of steroids and of the inferior cornu of the thyroid cartilage.

www.medicalebookpdf.com

LWBK892_c32_p412-417.indd 413 10/28/11 5:16:22 PM

 414 Part III: The Head and Neck

When attempting to excise unhealthy mu- release maneuvers if necessary, and (6)
cosa overlying the posterior cricoid plate, reconstruct.
the excision should not be carried ⬎2 cm The patient is placed supine with an in-
proximal to the inferior edge of the plate to flatable roll beneath the upper back to ex-
avoid injury to the cricoarytenoid joint. tend the neck. An esophageal bougie (size 30
Maloney) or nasogastric tube can be placed
to facilitate later dissection of the trachea
Incisions from the esophagus. A transverse cervical in-
The surgical approach is dictated by the lo- cision centered at the cricoid cartilage is
cation and extent of diseased trachea. Ma- made. Skin flaps are elevated in the subplat-
lignant lesions involving the upper and ysmal plane, extending from the superior ex-
mid-thirds of the trachea and benign condi- tent of the larynx to the sternal notch inferi-
tions extending down to within four rings of orly. The strap muscles and thyroid isthmus
the carina may be managed through a cervi- are divided along the midline. Blunt dissec-
cal incision. This may require a partial ster- tion to separate the superficial and deep
notomy for adequate visualization. Malig- strap muscles facilitates exposure and subse-
nant lesions involving the distal third and quent tracheal mobilization. The pretracheal Fig. 3. Once the thyroid isthmus is divided, the
benign conditions extending to within four plane is bluntly developed with a finger in the tracheal stenosis is evident through the outward
rings of the carina may be accessed via a anterior mediastinum toward the carina. appearance of narrowing, dense scar, and sur-
right thoracotomy, although a transsternal The level of the tracheal stenosis is usu- rounding inflammation. A circumferential trache-
approach can also be considered. The latter ally evident through the outward appearance al dissection is carefully performed, and the tra-
approach allows an exposure of the carina of narrowing, dense scar, and surrounding chea is transected through the stenotic segment.
by incising the posterior pericardium while inflammation. If in doubt, the tracheal steno-
retracting the superior vena cava to the sis can be localized with the use of a flexible
right and the ascending aorta to the left. bronchoscope inserted through the endotra-
cheal tube from above. Under bronchoscopic the shoulder roll deflated, the proximal and
control, the stenosis is then identified by distal traction sutures are now temporarily
Operative Steps transillumination or by direct localization approximated to determine whether ade-
The management of the airway requires using a transtracheal 25-gauge needle. The quate mobilization has been performed to
synchronized communication between the tracheal wall at this point is then marked allow a tension-free anastomosis or whether
surgeon and anesthesiologist. At the start with a fine stitch. After mobilization is com- a release maneuver is required. If no release
of the procedure, assessment by bronchos- plete, circumferential tracheal dissection at maneuvers are needed, a single layer of in-
copy guides whether initial dilatation with the level of the affected segment is performed terrupted 4-0 vicryl sutures (lubricated with
a ventilating scope is required to permit sharply, taking care to remain close to the mineral oil) is placed along the posterior
the passage of an orotracheal endotracheal tracheal wall in order to minimize risk of in- membranous wall in an end-to-end fashion
tube beyond the stenosis. In the setting of jury to the recurrent laryngeal nerves and to with the knots inside the lumen. Sutures are
nearly obstructive lesions, induction via in- avoid airway devascularization. placed 3 to 4 mm apart and 3 to 4 mm away
haled agents should be employed to pre- Before the trachea is incised, proximal from the edge. The armored tube is removed
serve spontaneous ventilation. If possible, and distal full-thickness 2-0 silk traction su- and replaced as needed to allow the meticu-
intubation across the lesion is performed tures are placed 1 to 2 cm away from the pro- lous placement of sutures. Alternatively, a jet
following dilatation. Sterile anesthesia tub- posed line of resection on either side in the catheter into the distal airway can be used,
ing and connectors are passed to the anes- mid-lateral position. The trachea is partially either through the partially withdrawn en-
thesiologist for use across the operative transected anteriorly through the stenotic dotracheal tube or across the field directly
field. Upon tracheal division, the orotra- segment (Fig. 3). Subsequent parallel incisions into the distal end of the trachea. Folded
cheal tube is retracted out of the field, and can be made distally until the airway lumen is blankets are placed under the head to main-
a sterile cuffed 6-0 flexible armored endo- sufficient to allow direct tracheal intubation tain the head in a flexed position while the
tracheal tube is intermittently inserted into and cross-table ventilation. Transection of the posterior wall sutures are tied.
the cut end of the distal trachea to provide posterior wall of the trachea is performed Once the posterior wall is complete, the
cross-table ventilation. Alternatively, a jet under direct vision from the luminal as well anesthesiologist advances the jet catheter
ventilation catheter can be directly placed as external aspects, using the esophageal within the oropharyngeal endotracheal
into the cut distal airway from the field or a bougie as a guide to help avoid esophageal tube and continues ventilation in this man-
separate jet catheter can be advanced from injury when separating the membranous ner, while the sutures for the lateral and an-
within the lumen of the partially with- wall of the airway from the esophagus. The terior anastomosis are placed with knots
drawn oropharyngeal endotracheal tube. caliber and thickness of the airway wall at on the outside of the lumen (Fig. 4). Before
Once the posterior half of the anastomotic the distal extent of the resection is evalu- the anterior wall sutures are tied, the oropha-
sutures is complete, the original orotra- ated. If the distal end is not free of disease, ryngeal endotracheal tube is advanced un-
cheal tube is advanced into the distal air- then further resection is done, incising 1 to der direct vision past the anastomosis. After
way during completion of the procedure. 2 mm at a time in a “breadloaf ” fashion to the anastomosis is complete, the anesthesi-
The steps of tracheal resection and re- avoid removing normal airway. ologist then tests for a leak by insufflating
construction can be reduced to the follow- Attention is then turned to the proximal to 30 cm H2O airway pressures, with the en-
ing: (1) localize the diseased segment, (2) end of the stenosis, which is gradually incised dotracheal tube cuff deflated.
mobilize the trachea, (3) transect the tra- in stepwise fashion until normal airway is If the airway damage involves the cri-
chea, (4) resect the affected area, (5) employ encountered. With the head in flexion and coid as in the case of idiopathic subglottic

www.medicalebookpdf.com

LWBK892_c32_p412-417.indd 414 10/28/11 5:16:23 PM

 Chapter 32: Resection and Reconstruction of Trachea 415

Fig. 4. While the trachea remains transected, the airway may be managed with a jet ventilation catheter
placed into the distal airway either across the field or through the lumen of a partially withdrawn oral
Fig. 5. Through the cervical incision, skin flaps are
endotracheal tube. The posterior wall of the anastomosis is performed with the jet catheter in position.
elevated, extending from the larynx superiorly to
Before the anterior wall sutures are secured, the endotracheal tube is carefully advanced over the jet
the sternal notch inferiorly. In laryngotracheal re-
catheter and past the anastomosis.
sections, a suprahyoid release may be performed
through a separate transverse incision over the
hyoid bone.

stenosis or postintubation injury due to a anesthesia, a final bronchoscopy is per-

high tracheostomy, the anterior cricoid ring formed via laryngeal mask in order to ob-
can be removed to the midpoint of its lat- serve vocal cord function, glottic edema, allowing the central portion of the released
eral aspect on either side. The posterior cri- and anastomotic patency. bone to descend along with the larynx. The
coid plate can be partially reamed out with pre-epiglottic tissue is then incised with a
a pituitary rongeur or a diamond burr, but Special Considerations for scalpel down to the mucosa.

The Head and Neck

its posterior perichondrium must be pre- In the case of a laryngotracheal resection,
served to protect the recurrent laryngeal
Laryngotracheal Resection a vertical laryngofissure may improve access
nerves. For a high intralaryngeal anastomo- When tracheal length is deemed inadequate to the posterior mucosa along the subglottic
sis, we sometimes use fine stainless steel for the creation of an end-to-end anastomo- region. With the thyroid alae partially or
wire (#34 gauge) for the posterior portion of sis without tension, it is advisable to perform completely separated, careful coring out or
the anastomosis. This provides a strong, in- a release maneuver to release the larynx reaming of the cricoid plate can be per-
ert suture line and decreases the formation from its superior attachments. As a guide- formed, leaving the posterior perichondrium
of granulation tissue, which can result from line, a release is usually anticipated if 4 cm or intact and preserving the cricoarytenoid
the use of absorbable sutures. more of tracheal length is resected. The su- joints. If posterior scar tissue extends be-
To protect the anterior tracheal suture prahyoid release, described by Montgomery, tween the arytenoids, collaboration with an
line from erosion into surrounding struc- is preferred to the infrahyoid release, de- otolaryngologist will allow the advancement
tures such as the innominate artery, the scribed by Dedo, Fishman, and Ogura, as it of a supraglottic mucosal flap to cover the
anastomosis may be buttressed by reap- is associated with a lesser risk of aspiration posterior portion of the anastomosis. The
proximating the thyroid isthmus or strap in the early postoperative period. The su- posterior and lateral aspects of the anasto-
muscles over it. If necessary, a pedicled prahyoid release may be carried out through mosis are completed before the laryngofis-
strap muscle may be used. A penrose drain a separate short transverse incision over sure is closed. After closure, the anterior
is placed in the subplatysmal plane prior to the hyoid bone and is ideally performed portion of the anastomosis between the an-
reapproximating the platysma and skin. At prior to tracheal transection (Fig. 5). The terior wall of the trachea and to the inferior
the end of the procedure, a “guardian” chin- subplatysmal plane between the two inci- rim of the thyroid cartilage anteriorly can be
stitch is placed full-thickness through the sions is fully developed so as to maximize completed. When possible, preserving a por-
submental skin and the skin of the anterior the descent of the larynx. Once the hyoid tion of the cricothyroid membrane along the
chest wall near the sternomanubrial junc- bone is exposed, the muscle attachments to lower edge of the thyroid cartilage facilitates
tion. The stitch serves as a reminder to the its superior surface are sharply divided and the anterior portion of the anastomosis.
patient to keep the neck flexed and thus the lesser cornua of the hyoid bone are If there is any concern about the safety
avoid excessive tension on the anastomosis. transected. The hyoid bone is vertically of the airway, a mini-tracheostomy (Por-
As the patient resumes spontaneous venti- divided anterior to the attachment of the tex #4) or small cuffed tracheostomy
lation and slowly awakens from general tendinous portion of the digastric muscle, may be placed a couple of rings below the

www.medicalebookpdf.com

LWBK892_c32_p412-417.indd 415 10/28/11 5:16:23 PM

 416 Part III: The Head and Neck

airway anastomosis for airway protection. ter tracheal resection. They documented a
On occasion, a silicone T-tube may be POSTOPERATIVE progressive rise in anastomotic tension with
placed following a laryngotracheal resec- MANAGEMENT increasing length of resection and suggested a
tion. The judgment to place a tracheos- There is no role for routine use of pro- safe limit of 4.5 cm (corresponding to 1,000 g
tomy postoperatively is determined by ex- longed postoperative systemic steroids. A of tension) to avoid anastomotic failure.
pected vocal cord edema more than by dose of solumedrol may be administered Anastomotic complications are uncom-
anticipation of an ongoing need for posi- at the completion of the procedure, fol- mon but can lead to severe morbidity when
tive pressure ventilation. The tracheos- lowed by one or two doses for the first 24 to they occur. They result from excessive ten-
tomy assures airway patency until resolu- 36 hours. To further decrease glottic and sion across the suture line, as well as failure
tion of perioperative edema and also supraglottic edema, an algorithm of con- to resect back to healthy mucosa, and to
facilitates pulmonary toilet. Mini-tracheo- current maneuvers can be employed. These postoperative infection. The incidence of
stomies require nursing education for safe, include voice rest, racemic epinephrine complications varies according to the un-
informed handling. nebulizers, humidified air, upright posi- derlying pathology of tracheal stenosis and
tion, gentle diuresis, and heliox adminis- whether or not the anastomosis involves
Special Consideration for Distal tration. To decrease the movement of the the larynx. In the largest series of tracheal
resections examining 901 cases over 28
Tracheal Resection larynx and avoid aspiration, patients are
years, Wright et al. reported that the high-
maintained NPO for the first few days, with
Based on the nature of the operative indi- a longer interval prescribed the closer the est rate of anastomotic complications oc-
cation, distal tracheal and carinal resec- anastomosis lies relative to the glottis. curred in diagnoses such as tracheoesopha-
tions may be approached via either median Bedside swallow evaluations are initially geal fistula and postintubation stenosis,
sternotomy or right posterolateral thorac- performed by the staff starting with jello, rather than idiopathic subglottic stenosis
otomy. For benign disease or a tumor that followed by oral intake monitored for and tracheal tumors.
appears confined to the airway without sig- cough or other signs that accompany aspi- Successful results following resection
nificant extension beyond the trachea, the ration. Patients are slowly advanced in were identified in 95% of patients, anasto-
median sternotomy approach is suitable. their diet accordingly. motic complications occurred at a rate of
For bulky tumors or tumors with subcari- Laryngotracheal resections are associ- 9%, and overall perioperative mortality was
nal or posterior extension, a right thoraco- ated with a higher rate of transient pharyn- 1.2%. A multivariate analysis identified the
tomy is preferred. To promote maximal geal dyscoordination with the potential risk following risk factors to be associated with
mobilization of the trachea, a right hilar of aspiration, attributable to postoperative anastomotic complications: diabetes, reop-
release is performed, which is possible pain and edema, regardless of the status of eration, longer resections (⬎4 cm), young
from either a sternotomy or thoracotomy glottic sensory feedback. Physical restric- age (pediatric patients ⬍17 years of age),
approach. The hilar release refers to the re- tions against hyperextension are initially need for tracheostomy before the opera-
lease of the right hilum from pericardial at- reinforced through the maintenance of the tion, and laryngotracheal resection. Some
tachments to the inferior vena cava, afford- chin stitch for the first 5 to 7 days after re- of these factors, such as preoperative tra-
ing a couple of centimeters in cephalad section. cheostomy, longer resections, and laryngot-
mobility of the trachea and is the same ma- One week postoperatively, a surveillance racheal resection, are surrogate markers of
neuver often used to reduce anastomotic bronchoscopy, often at the bedside, is per- advanced disease with greater severity of
tension following a right upper lobe sleeve formed to evaluate the health and patency tracheal involvement. In patients who had
resection. Of note, there is no release ma- of the anastomosis. Subsequently, patients anastomotic complications, the mortality
neuver associated with the left hilum. A are scheduled for outpatient visits at estab- was 7.4%; in those without them, it was
curved pericardial incision is made ante- lished intervals and monitored for symp- 0.01%.
rior and posterior to the lower border of toms, which may herald the development of This series established the excellent
the right inferior pulmonary vein in a “U”- anastomotic strictures. outcomes of surgical resections and the
shaped fashion. The cut edge of the pericar- associated low mortality rate that are
dium inferior to the pulmonary vein is OPERATIVE RESULTS possible in the hands of experienced sur-
grasped with a Kocher clamp. This exposes geons. It also emphasized the use of rou-
the fibrous septum extending between the The rationale behind rigorous planning of tine bronchoscopy before hospital dis-
pericardium and the inferior vena cava to- the timing and selection of surgical candi- charge in the early detection of anastomotic
ward the diaphragm. The septum is subse- dates before tracheal resection is to avoid complications. Depending on the severity,
quently incised within the pericardium. complications, which can be life-threatening anastomotic complications are managed
The airway proximal and distal to the le- if an adequate airway is not maintained. by bronchoscopic interventions such as
sion to be resected should be encircled, Airway complications can be divided into debridement and dilation, placement of
taking care to avoid injury to the left recur- those that involve the anastomosis and an airway appliance, or reoperation. The
rent laryngeal nerve, which lies in the tra- those that do not. Airway-related compli- complications vary along a spectrum of
cheoesophageal groove at this level. Tra- cations that do not involve the anastomo- differing severity: granulation tissue,
cheal rings are successively removed, with sis include glottic edema, aspiration, stenosis, and disruption. Granulation tis-
attention to not exceed the safe limits of vocal cord paralysis, and the need for sue may be handled with bronchoscopic
tension upon the anastomosis. In the case temporary tracheostomy. These are more cautery, progressive debridement, and
of adenoid cystic carcinoma, incomplete common after a laryngotracheal resection gentle dilation. Airway stenosis following
resection and postoperative radiation than with simple segmental tracheal re- tracheal resection will usually respond
treatment may be preferable to a complete section. to serial dilation using balloon dilation
resection with a tenuous anastomosis un- Grillo et al. were among the first to pub- or rigid bronchoscopy. In rare cases, the
der tension. lish their experience with complications af- treatment of recurrent airway stenosis

www.medicalebookpdf.com

LWBK892_c32_p412-417.indd 416 10/28/11 5:16:23 PM

 Chapter 32: Resection and Reconstruction of Trachea 417

may require the use of tracheal stent or T- SUGGESTED READINGS Grillo HC, Mathisen DJ, Wain JC. Laryngotra-
tube. Local therapies such as mucosal in- cheal resection and reconstruction for sub-
jections of steroids may be employed in Ashiku SK, Kuzucu A, Grillo HC, et al. Idiopathic glottic stenosis. Ann Thorac Surg 1992;53(1):
laryngotracheal stenosis: effective definitive 54–63.
cases of refractory stenosis but usually treatment with laryngotracheal resection. J Grillo HC, Donahue DM, Mathisen DJ, et al. Postin-
have limited long-term benefit. Initial Thorac Cardiovasc Surg 2004;127(1):99–107. tubation tracheal stenosis. Treatment and results.
management of disruption at the suture Cooper JD, Grillo HC. The evolution of tracheal J Thorac Cardiovasc Surg 1995;109(3):486–92;
line requires airway control through a tra- injury due to ventilatory assistance through discussion 92–3.
cheostomy or T-tube. Limited separation cuffed tubes: a pathologic study. Ann Surg 1969; Mathisen DJ. Surgery of the trachea. Curr Probl
may heal over temporary silicone stents or 169(3):334–48. Surg 1998;35(6):453–542.
Cooper JD, Grillo HC. Analysis of problems re- Montgomery WW. The surgical management of
T-tubes without further intervention. If lated to cuffs on intratracheal tubes. Chest supraglottic and subglottic stenosis. Ann Otol
deemed necessary, reoperation is usually 1972;62(2):21S–27S. Rhinol Laryngol 1968;77(3):534–46.
deferred for at least 6 months to a year Cooper JD, Todd TR, Ilves R, et al. Use of the sili- Pearson FG, Cooper JD, Nelems JM, et al. Primary
until peritracheal inflammation resolves cone tracheal T-tube for the management of tracheal anastomosis after resection of the cri-
maximally. complex tracheal injuries. J Thorac Cardiovasc coid cartilage with preservation of recurrent
Surg 1981;82(4):559–68. laryngeal nerves. J Thorac Cardiovasc Surg 1975;
Cooper JD, Pearson FG, Patterson GA, et al. Use 70(5):806–16.
SUMMARY of silicone stents in the management of airway Pearson FG, Todd TR, Cooper JD. Experience
Tracheal resection is performed for benign problems. Ann Thorac Surg 1989;47(3):371–8. with primary neoplasms of the trachea and cari-
Gaissert HA, Grillo HC, Shadmehr BM, et al. Laryn- na. J Thorac Cardiovasc Surg 1984;88(4):511–8.
causes of stenosis, fistula to surrounding gotracheoplastic resection for primary tumors Pearson FG, Brito-Filomeno L, Cooper JD.
structures (esophagus or innominate ar- of the proximal airway. J Thorac Cardiovasc Surg Experience with partial cricoid resection and
tery), and for malignancy. The process of 2005;129(5):1006–9. thyrotracheal anastomosis. Ann Otol Rhinol
evaluating a patient for tracheal resection Geffin B, Grillo HC, Cooper JD, et al. Stenosis Laryngol 1986;95(6 Pt 1):582–5.
and reconstruction begins with a careful following tracheostomy for respiratory care. Perelman M. Surgery of the Trachea. Moscow: Mir;
evaluation of the anatomy and the estab- JAMA 1971;216(12):1984–8. 1976.
lishment of a patent airway. Selective refer- Grillo H. Surgery of the Trachea and Bronchi, 1st ed. Urschel HaC, JD. Atlas of Thoracic Surgery, 1st ed.
Hamilton, Ontario: BC Decker; 2004. New York: Churchill Livingstone; 1995.
ral of operable candidates for tracheal re- Grillo HC, Cooper JD, Geffin B, et al. A low-pressure Wright CD, Grillo HC, Wain JC, et al. Anastomotic
section leads to excellent outcomes and a cuff for tracheostomy tubes to minimize complications after tracheal resection: prog-
low associated mortality rate in experi- tracheal injury. A comparative clinical trial. nostic factors and management. J Thorac Car-
enced hands. J Thorac Cardiovasc Surg 1971;62(6):898–907. diovasc Surg 2004;128(5):731–9.

EDITOR’S COMMENT but rather to have a program that was pyramidal served on the front of North Africa as the special
in nature by which the surviving excellent sur- consultant to the Mediterranean theater, which
geons who stayed around at Johns Hopkins as a resulted in the transfusion of blood products
One cannot talk about surgery of the trachea sort of junior faculty after or before they finished during war-time conditions, saving numerous in-
without mentioning Dr. Hermes Grillo, a great the program but when they finished the program jured soldiers. This has been remembered by the

The Head and Neck

thoracic surgeon, who may have invented it, they left Hopkins to become full professors and Excelsior Society. The Excelsior Society consisted
but certainly popularized and made possible to chairs at various institutions. Their excellence of 51 or so of Dr. Churchill’s medical officers and
do extensive resections of the trachea including need not be debated and most of them were the lecture that has been taken over by the Ameri-
the carina. Dr. Grillo was a meticulous surgeon. highly successful in establishing renowned pro- can College of Surgeons as a memorial to both the
I do not remember how much time he spent in grams. Indeed, even the trainees, once removed Society and to Dr. Churchill.
the dog lab. I suspect it was significant because from Halstead, such as my predecessor in Cin- Dr. Grillo was killed while driving on a moun-
it would be unlike of him and out of character for cinnati, Dr. William Altemeir, founded or kept in tain road in Italy, a place he loved, and his wife
him to carry out operations on humans, which excellence the program in Cincinnati, which was had said, “He died happy.”
he did not carry out on experimental animals. founded by George Heuer and Mont Reid, both of Having successfully introduced and popular-
While in doing and working out the technique of whom were Halstead products. ized tracheal resection and spawned a number of
resection of trachea and reanastomosis it became It is not a question of credit, but in the illumi- offspring, as it were, of which the author is one,
clear that 5 cm was the limit even with the Mont- nation of history of Dr. Churchill’s great contribu- it would be only natural that attention would go
gomery release, which he used to bring down the tion to the American residency, which basically from being able to do the operation to not being
laryngeal structures and chin stitch, which I re- stated that one could recognize at the beginning dependent on native trachea. In the past 5 years
member as a resident, that kept elevation of the of the application process an individual who there have been substantial improvements or at
chin from stretching the anastomosis. could be trained over 5 years and graduated, per- least initial attempts, some successful, and im-
Dr. Grillo and I became very good friends haps not as a chairman, but as a competent sur- provement in substitutes for trachea.
and we had talked about doing a biography of his geon. Dr. Churchill produced many chairs. I count One of the problems with trachea is that it
mentor, Dr. Edward Churchill, long-time chief at myself among them, and certainly Dr. Grillo could has little in the way of specific vascular supply
the MGH and my first surgical mentor, in keeping have gone on to be a chair in practically any place that one can identify and perform a microsurgi-
with our belief that it was the Churchill program, he wished to be, but he did not want to. That and cal anastomosis. Thus, the reconstruction of a
which is the surviving program in the United the fact that Dr. Churchill’s great contribution long segmental tracheal defect requires a vas-
States, intended to populate the United States among others including some of the very early cularized allograft. The vascularity needs to be
with well-trained surgeons. This is not an attempt work doing the first lobectomy, as it turned out induced. In order to do so, Delaere et al., from
to take away credit from Professor William Stew- the patient had a metastasis of an hyperneph- the Leuven Tracheal Transplant Group (NEJM,
art Halstead of Hopkins whose tremendous con- roma and lived for 20 years after its resection 2010;362:138–45), detail a profusely illustrated
tribution to residency programs in general were and Dr. Churchill’s seminal work on constrictive tracheal allograft, which was wrapped in the re-
what brought the European-type residency pro- pericarditis as well as pulmonary resection. Most cipient’s forearm fascia. At 4 months the tracheal
gram to the United States. It was not Halstead’s of all, it was Dr. Churchill’s contribution in World chimera, which was now fully lined with mucosa
intention to produce large numbers of surgeons, War II to recognizing that the shock that he ob- that consisted of respiratory epithelium from the

(continued)

www.medicalebookpdf.com

LWBK892_c32_p412-417.indd 417 10/28/11 5:16:23 PM

 418 Part III: The Head and Neck

donor and buccal mucosa from the recipient, had the tracheal transplant was not utilized but its vi- another model that can be used for this impor-
begun to be placed once “revascularization was ability was documented for at least 60 days. tant work.
achieved.” The recipient had been placed on im- Another way of approaching the same prob- Finally, a chronic problem in patients with
munosuppressive therapy, which was then with- lem is to use a scaffold of inert material. Jansen tracheostomies, other than stenosis, is trache-
drawn and then the tracheal allograft was moved et al. (Archives of Otolaryngology, Head and Neck oinnominate arterial fistula. I do not know how
to its correct anatomical position with an intact Surgery 2009;135:472–8) used a porous titanium many of the readers were exposed to the rupture
blood supply. This is a surgical tour de force. The scaffold, which was then created in rabbits, po- of a tracheoinnominate artery fistula, but it is
patient reported was a 55-year-old woman who rous titanium and mucosa on a pedicled fascia impressive indeed and I would not recommend a
had been involved in a car accident and had un- flap utilizing a two-stage procedure. They noted person other than one with a stomach that was
dergone a tracheotomy with a long history of long normal mucosa in a submucosal layer and vital really cast iron to be around to watch this par-
tracheal stenosis. The fact that she is a woman cells on top of the titanium. The also noted mul- ticular situation.
and the cadaver donor was male made it rela- tiple blood vessels from the muscle layer through Sung et al. ( Journal of Korean Neurosurgery
tively easy to tell which cells in the allograft were the titanium strut. Cytokeratin expression was Society 2011;49:107–11) focused on different
which and indeed the 8-cm tracheal allograft present in the suprabasal and basal layers of the measurements by CT angiography on 22 patients
from the recipient’s forearm could be traced to mucosal epithelium. All animals survived the who had tracheostomies. They wish to evaluate
having male donor respiratory cells as well as the reconstruction. As far as I am aware, this type of the relationship between the tracheal anastomy
tracheal allograft. experiment has not been tried in humans. tube and the innominate artery utilizing the
This is not a new idea. In 1979, Rose et al. Another approach was tried by Hodjati et proximal tube position on the cervical vertebra,
(Lancet 1979;1:433) reported the first allogenic al. (Annals of Thoracic Medicine, January–March the distal tube position, and the course of innom-
tracheal transplant in a human. The donor tra- 2011;17–21) in which 10 adult mongrel dogs inate artery and the gap between the tube and
chea was originally implanted heterotopically, had a segment of seven tracheal rings resected the innominate artery. After some complicated
very much as here, in the sternocleidomastoidal circumferentially and a submuscular tunnel measurements they came to the conclusion that
recipient and transferred to the orthotopic po- was induced between the muscular layers of the a low tracheostomy tube departure level (TTDL)
sition 3 weeks later. The recipient was not given adjacent esophagus right next to the trachea. was an indicator that some mischief would occur.
immunosuppressive therapy, however. The report Implated Gore-Tex passed through reinforcing Only 6 of the 22 patients were free of difficulties in
did not document the viability of the allograft, the trachea and the anastomosis was made be- these observations. These writings suggest that if
and no information has been made available tween distal ends of Gore-Tex and the trachea. one is concerned about this disastrous complica-
about the long-term outcome. Their criteria and end points were air tightness, tion, there may be a way to avoid it.
Klepetko et al. (Journal of Thoracic Cardiovas- good re-epithelialization, and no limitation on Tracheal resection, reanastomosis, and the
cular Surgery 2004;127: 862–7) reported a pre- esophageal length, which were all important. The elimination of tracheostomy and tracheal steno-
served viability of a heterotopically revascular- Gore-Tex grafts were implanted and harvested 12 sis are excellent advances in thoracic surgery. I
ized allograft, which was revascularized in the weeks after the implantation and the ephithelial- am pleased to have been able to call Dr. Hermes
omentum of a patient who ultimately received a ization that resulted was with mixed squamous/ Grillo my friend.
lung transplant from the same donor. However, mucociliary metaplasia. It does seem as if this is J.E.F.

33 Penetrating Neck Injury

Andrew B. Peitzman and Alain Corcos

But one spot lay exposed, where collarbones portance of the platysma muscles. the sternocleidomastoid muscle. Cours-
lift the neckbone off the shoulders, the open Spreading subcutaneously as a sheet across ing obliquely from the skull base to the
throat, where the end of life comes quickest the entire length of the lower border of the sternum and medial clavicle, the sterno-
Book 22: The Death of Hector, The Iliad mandible down to and across the length of cleidomastoid separates anterior and pos-
the clavicle below, this muscle serves to terior triangles. The anterior triangle is
distinguish superficial from deep. Deeper further bounded by the midline and lower
fasciae envelope the infrahyoid “strap” border of the mandible and contains the
ANATOMY muscles (sternohyoid, omohyoid, and ster- “carotid bundle” (carotid artery and bifur-
Few areas of the body concentrate vital nothyroid) laterally, and encircle the esoph- cation, internal jugular vein, and vagus
anatomy as the neck. Notable structures agus and trachea centrally. Palpable land- nerve) (Fig. 2). Zone I of the neck extends
include the pharynx, larynx, trachea, marks along the midline of the neck, which from the clavicle to the cricoid cartilage,
esophagus, common carotid artery, inter- is not covered by platysma muscle, include zone II from the cricoid to the angle of the
nal carotid artery, external carotid artery the thyroid cartilage superiorly, the cricoid mandible, and zone III from the angle of
and its branches, the vertebral and subcla- cartilage caudally, and the suprasternal the mandible to the skull base. Surgeons
vian arteries, the internal and external notch at the base of the neck between the have historically favored the classification
jugular veins and their tributaries, cranial clavicles. by zones because it is useful in prediction
nerves IX to XII (glossopharyngeal, vagus, Traditionally, anatomists divide the of operative access to structures of surgi-
spinal accessory, and hypoglossal), thyroid, neck into triangular areas (Fig. 1), bor- cal importance. While injuries within
parathyroid, and submandibular glands, dered by musculature and bony land- zone II are easily exposed and repaired,
and the bony spine and spinal cord. Knowl- marks, while surgeons refer to Monson’s operative approaches to zones I (the tho-
edge of the anatomy of this region is essen- three “zones” of the neck. The dominant racic outlet) and III (the skull base) are
tial. To begin, one must appreciate the im- muscular landmark of the lateral neck is challenging.

www.medicalebookpdf.com

LWBK892_c33_p418-425.indd 418 10/28/11 5:15:56 PM

 Chapter 33: Penetrating Neck Injury 419

Fig. 1. Anatomic zones of the neck.

Fascia investing
External carotid artery submandibular gland
Common trunk of facial
and lingual arteries
Stylohyoid

Occipital artery

Hypoglossal nerve (CN XII)

Spinal accessory nerve (CN XI) Facial artery

Submental artery
Superior root of ansa cervicalis

Sternocleidomastoid artery Nerve to mylohyoid

Internal carotid artery Anterior belly of digastric

The Head and Neck

External carotid artery Fascial sling of digastric
Mylohyoid
Inferior root of ansa cervicalis
Hyoid bone
Common carotid artery Nerve to thyrohyoid
Internal jugular vein Internal branch of superior laryngeal nerve
Sternocleidomastoid Inferior pharyngeal constrictor

Sternocleidomastoid branch Thyrohyoid

Superior belly of omohyoid
External branch of superior laryngeal nerve
Prevertebral layer of
deep cervical fascia Superior thyroid artery
Intermediate tendon of omohyoid
Sternohyoid

Transverse cervical vein Sternothyroid

Inferior belly of omohyoid

Anterior jugular vein

Omohyoid fascia

Clavicle

Clavicular head
Lateral View Sternocleidomastoid
Sternal head

Fig. 2. Deep dissection of the carotid triangle. (From Agur AMR, Dalley AF. Grant’s atlas of anatomy, 12th ed. Philadelphia:
Lippincott Williams & Wilkins, 2009.)

www.medicalebookpdf.com

LWBK892_c33_p418-425.indd 419 10/28/11 5:15:56 PM

 420 Part III: The Head and Neck

CLINICAL between the thumb and middle fingers, tive approach, based on findings from vari-
PRESENTATION leaving the index finger free to palpate the ous radiologic and endoscopic studies, has
membranous space between the thyroid replaced this standard. With the advance-
AND DIAGNOSIS and cricoid cartilages. A transverse inci- ments in technology associated with the
As with any injured patient, the principles sion or vertical incision (if landmarks are multislice helical computed tomography
set forth by Advanced Trauma Life Support not absolutely clear) is made at this level (CT) scanner, CT angiography (CTA) has
guide our initial assessment. Important in- and the subcutaneous tissues are separated emerged as the screening modality of choice
formation from the history includes mecha- bluntly with a straight or curved clamp to for penetrating neck wounds in asymptom-
nism of injury and blood loss at the scene. the cricothyroid membrane, which is then atic or stable patients. CTA is easily acces-
Gunshot wounds are associated with a sig- incised with a No. 11 or 15 knife blade for sible, well tolerated with minimal risk, sen-
nificantly higher likelihood of vital structure direct access to the subglottic space. This sitive for defining trajectory, and reliable to
injury than stab wounds. The primary sur- will allow entry of the left index finger for exclude significant arterial injury. Abnor-
vey will identify patients in shock or with control and dilatation or one can use the malities identified on CTA or trajectory sus-
hard signs of vital structure injury such as knife handle or curved clamp to dilate the picious for aerodigestive tract injury should
airway compromise, massive subcutaneous space. A No. 6 endotracheal tube can then be further evaluated with surgical explora-
emphysema, a sucking wound, active hem- be positioned and secured (or No. 5 in a tion, laryngoscopy, tracheobronchoscopy,
orrhage, expanding or pulsatile hematoma, small female). Do not incise too deeply with catheter-based arteriography, esophagos-
carotid bruit or thrill, neurologic defect, or the blade, as this can injure posterior tra- copy, or esophagography as needed. A com-
absent/decreased radial pulse in the ipsilat- chea wall and esophagus. In addition, avoid prehensive literature review by the Practice
eral upper extremity. Immediate surgical cutting or spreading in a vertical axis, as Management Guidelines Committee of the
intervention is indicated when any of these this may injure the cricoid cartilage. Re- Eastern Association for the Surgery of
“hard” signs are appreciated. member that the cricoid cartilage is the Trauma in 2008 concluded that “either con-
Impending airway occlusion can occur only circumferential support for the air- trast esophagography or esophagoscopy
with tracheal or laryngeal injury, with com- way; injury will require repair. When a cri- can be used to rule out an esophageal per-
pression from a large or expanding hema- cothyroidotomy is required it should be foration that requires operative repair.”
toma, or from intraoral hemorrhage. Con- converted to a tracheotomy at the earliest
trol of the airway is a priority in these safe opportunity. PREOPERATIVE PLANNING
patients and may be accomplished by oral Large-bore peripheral venous catheters
endotracheal intubation, cricothyroido- are adequate for circulatory support. How- In the symptomatic patient who requires
tomy, or formal tracheotomy. While blind ever, avoid the ipsilateral upper extremity operation without prior diagnostic testing,
nasotracheal intubation is contraindicated as an access site in patients with zone I zone of entry and likely trajectory are criti-
in this setting, fiberoptic bronchoscopy- (thoracic outlet) entry or trajectory. Pa- cal for planning exposure. The patient
assisted nasotracheal intubation may be tients should have plain radiographs of the should be positioned supine, with arms
helpful when tracheal deviation from large chest to assess for hemopneumothorax or tucked, neck extended, and head deviated
hematoma is present. It is important to rec- missiles and as thorough a neurologic ex- slightly away from the side of injury. A towel
ognize the patient with penetrating neck amination as possible prior to sedation and roll placed transversely beneath the shoul-
injury who has a large hematoma or blood intubation. Active hemorrhage from a der will extend the neck. The sterile prepa-
in the hypopharynx, who needs to be intu- wound in the neck in any zone is best man- ration should include both sides of the neck
bated early but not urgently in the emer- aged by digital compression until the air- from the temporomandibular joint to the
gency department, and who is spontane- way is controlled and surgical access can lower lip down to and including the entire
ously breathing. The initial inclination in be obtained. This digital tamponade may anterior chest to the table laterally and
such a patient is often rapid sequence in- be required until proximal and distal vas- torso distally to the midthighs. Thoraco-
duction with pharmacologic paralysis. This cular control can be obtained in the oper- tomy or median sternotomy may be re-
may convert a patient who was marginally ating room. On occasion, gauze packing or quired for proximal control; this may be the
protecting his airway but breathing to the insertion of a balloon catheter in the oral initial incision with zone I injury (Fig. 3).
patient who now cannot be intubated or cavity to control hemorrhage may be nec- Access to the groins and saphenous veins
ventilated with a bag valve mask. Recogni- essary. must be available. Zone II injuries are best
tion of such patients and control of the Physical examination is unreliable in ex- approached via an oblique incision along
airway with the patient awake, sometimes cluding aerodigestive tract injuries in the the anterior border of the sternocleidomas-
including a surgical airway under local asymptomatic patient with penetrating toid muscle from the angle of the jaw to the
anesthesia, is critical to prevent an avoid- neck wounds deep to the platysma muscle. clavicular head (Fig. 4). With zone I entry,
able disaster. Although some authors have described suc- the surgeon should be prepared to perform
When oral intubation fails or is not fea- cessful observation protocols in patients a median sternotomy for access to and re-
sible, cricothyroidotomy is the quickest without hard signs of vascular injury, such pair of structures in the thoracic outlet or
and most efficient way to access and secure protocols are not appropriate to exclude base of the neck. In this circumstance the
the airway. It is critical to understand that pharynx, esophagus, larynx, or trachea in- ipsilateral arm should be free and prepped
this is a procedure performed basically by jury in the asymptomatic patient. The diag- to the elbow. A horizontal incision along
palpation, not by visualization, of struc- nostic approach to this group of patients the superior aspect of the clavicle will sup-
tures. If right-handed, the operator should has evolved significantly over the past two ply access to the proximal subclavian ves-
be on the patient’s right side and should be- decades. Mandatory surgical exploration of sels and innominate vessels on the right.
gin by palpating the superior and inferior injuries in zone II trades ease and reliability This incision may be independent or
aspects of the thyroid cartilage and by for a high rate of negative and nonthera- can extend an anterior sternocleidomas-
securing this structure with his left hand peutic operation. A more selective opera- toid or median sternotomy incision when

www.medicalebookpdf.com

LWBK892_c33_p418-425.indd 420 10/28/11 5:16:00 PM

 Chapter 33: Penetrating Neck Injury 421

incidence of thrombosis or infection when

compared with the saphenous vein.
Common carotid artery injury is gener-
ally easy to access and repair even when
complex. However, the common carotid ar-
tery may be ligated or shunted in the ex-
treme case in which associated injuries or
severe hemodynamic instability prevent re-
pair. Antegrade flow to the internal carotid
via the external carotid is possible and pa-
tients with adequate collateral cerebral
blood flow (intact circle of Willis) will toler-
ate unilateral common carotid artery oc-
clusion (in 85% to 90% of patients). External
carotid artery injury and injury at the ca-
rotid bifurcation can be repaired when sim-
Fig. 3. Incisions for exposure of penetrating neck injuries. ple. Complicated injury to the external ca-
rotid artery should be ligated as the
collateral supply from the face and scalp is
reliably ample. Injury involving the internal
necessary. Clavicle resection is usually only carotid artery should be repaired when
necessary if access to the axillary artery is TREATMENT simple and the patient’s condition permits,
required. Exposure to the left subclavian ar- especially when patency is preserved. Con-
tery at its origin is difficult through a me- Carotid Artery troversy persists with regard to the treat-
dian sternotomy due to its posterior posi- ment of the injured and occluded internal
tion on the aortic arch. When exposure of Carotid artery injury should generally be re- carotid artery in the face of focal neurologic
the proximal left subclavian artery is re- paired. Primary repair, patch angioplasty, or deficit or coma. The theoretical risk of rein-
quired, it is best obtained via a left anterior interposition grafting are options depending stituting antegrade flow to the brain in the
thoracotomy. Wounds in zone III may re- on the nature of the injury. Small, clean setting of cerebral ischemia is that of hem-
quire a curvilinear posterior extension over wounds (stab wounds ⬍2 cm) that can be ap- orrhage into the ischemic or infracted area,
the mastoid process to allow exposure of proximated without significant narrowing aggravating brain injury. A reasonable ap-
the distal internal carotid artery to the skull should be repaired with a nonabsorbable, proach to this dilemma is to base the deci-
base (see “Surgical Technique”). A horizon- monofilament suture (4-0, 5-0, or 6-0 polypro- sion to repair on the presence or absence of
tal “collar” incision can offer excellent ex- pylene). Saphenous vein or polytetrafluoro- back bleeding from the distal internal ca-
posure to multiple zones when subplatys- ethylene (PTFE) can be used for patch repair rotid. Brisk blood flow from the distal end
mal flaps are developed. This incision is in cases where primary closure would narrow suggests adequate collateral cerebral flow

The Head and Neck

most useful for isolated laryngotracheal in- the vessel or as an interposition conduit when and repair should be safe. Aside from coma,
juries that require a surgical airway or axial segmental resection is required and end-to- which carries a dismal prognosis, neuro-
traverse gunshot wounds that require bilat- end repair is restricted by tension. PTFE as a logic deficits identified in patients with
eral exploration. conduit has not been shown to increase the penetrating neck injury preoperatively are
more likely to improve or remain unchanged
with repair than with ligation.
A heparin bolus, either systemic (5,000
or 10,000 units) or regional (10 to 15 mL or
50 units/mL concentration injected proxi-
mally and distally), should be given when
repair will require vascular occlusion. A
completion angiogram should be obtained
Mastoid following any interposition grafting. Inter-
process
nal shunting will decrease arterial occlu-
sion time and should be considered as an
adjunct during interposition grafting that
includes the internal carotid artery.
Sternocleidomastoid
muscle Preferred Injury to the carotid artery that demon-
incision strates contrast extravasation (pseudoan-
5 eurysm or arteriovenous fistula) on imag-
‘0
RF ing study should undergo surgical repair
H
when accessible (zone II). When the injury
Clavicle is at the skull base or thoracic outlet, endo-
vascular interventions, such as stent place-
ment or embolization, should be consid-
ered. A tear or dissection of the intima that
Fig. 4. Incision for neck exploration is along the anterior border of the sternocleidomastoid muscle. does not limit flow (as with blunt force

www.medicalebookpdf.com

LWBK892_c33_p418-425.indd 421 10/28/11 5:16:00 PM

 422 Part III: The Head and Neck

injury) can be observed with repeat imag- wounds when encountered at initial explo- the internal jugular directly over the carotid
ing after a 2-week interval on anticoagula- ration. Although definitive treatment is usu- bifurcation from the midline (see Fig. 1). Li-
tion. ally deferred, consultation to otolaryngology gation of this vein should be by suture liga-
at the time of exploration is important. ture. The vagus nerve travels between the
carotid and jugular and care must be taken
Internal Jugular Vein when retracting the vein to protect this cra-
Any venous structure in the neck can be
Trachea nial nerve from injury.
safely ligated. Small, simple lacerations to Tracheal injury requires repair. Anterior in- As with any vascular injury, proximal
the internal jugular vein should be repaired jury of appropriate size and location may be and distal control should be obtained prior
with a 4-0 nonabsorbable, monofilament converted to tracheotomy. Unless small and to entering the hematoma. This is often dif-
suture. Larger lacerations can be repaired simply repaired, tracheal injuries should be ficult in the tight confines of the lateral
as well provided the patient’s clinical condi- protected with a tracheotomy. Use an absorb- neck and proximal access alone will fre-
tion permits. When both internal jugular able 3-0 or 4-0 suture, placed transversely, quently suffice along with digital compres-
veins are injured, an attempt at repair of in an interrupted fashion and incorporate sion. Exposure of the proximal common
one should be made. Any vein in the neck the tracheal ring above and below the injury. carotid artery requires release of the inter-
that is ligated should be done so with a su- mediate tendon of the omohyoid muscle
ture ligature to avoid postoperative bleed- Pharynx and Esophagus (separating the superior and inferior bel-
ing from pressure-induced slippage of a lies) along with the enveloping fascial
simple tie. When considering injury to the pharynx or sheath that tethers this muscle like a mes-
cervical esophagus, the importance of early entery to the clavicle below. At a negligible
diagnosis and repair cannot be overstated. cost to patient function, this release allows
Vertebral Artery A delay of several hours can significantly in- a more complete eversion of the sterno-
Vertebral artery injury is much less com- crease the incidence of mediastinitis and cleidomastoid muscle, which can be further
mon than carotid artery injury and the ma- empyema. Injuries should undergo repair enhanced by liberating the sternal head of
jority are diagnosed by angiography (CT or as soon as diagnosed. All repairs should be this muscle (also useful as an interposition
catheter-based) in hemodynamically stable drained with a closed-suction drain that is muscle flap should one be required). This
patients. Optimal treatment is coil or gel– left in place until a contrast esophagram at approach also serves to expose the proxi-
foam occlusion via catheter-based angioem- 1 week shows no extravasation and the pa- mal vertebral artery for ligation when re-
bolization with repeat angiography at tient is tolerating a diet. A leak from a repair quired. To this end, dissection is along the
2 weeks to exclude pseudoaneurysm or ar- can heal without additional surgery, as long lateral border of the jugular vein with re-
teriovenous fistula formation. In the rare as adequate drainage is maintained. En- traction of the bundle medially to encoun-
instance where active hemorrhage and as- teral nutrition can be administered via a ter the supraclavicular fat pad. Careful
sociated shock prevent angiography, hem- soft feeding tube placed during surgery. An- blunt dissection here will yield the first
orrhage control must take place in the oper- tibiotics appropriate for oral flora should stage of the vertebral artery deep in the tho-
ating room. The vertebral artery travels be given perioperatively. racic outlet. Protect the phrenic nerve dur-
within the bony transverse foramen of the ing this dissection. As described earlier,
cervical spine and this portion of the poste- median sternotomy or left anterior thorac-
rior triangle is difficult to expose. If packing
SURGICAL TECHNIQUE otomy may be necessary to control proxi-
the wound can decrease bleeding enough to An incision along the anterior border of the mal vasculature for zone I injuries.
achieve hemodynamic stability, the patient sternocleidomastoid muscle offers the best To expose the internal carotid artery at
may be taken to angiography for emboliza- exposure for a unilateral penetrating injury the skull base, a “hockey stick” extension
tion. Alternatively, control must be obtained to the neck (see Fig. 4). Separate right and curves the superior aspect of the skin inci-
by proximal ligation of the vessel at the tho- left incisions may be made when bilateral sion toward the back of the ear along the
racic outlet (see “Surgical Technique”). How- exploration is required. The skin incision mastoid process. Anatomy in this region is
ever, this should be avoided without distal should begin near the angle of the jaw and dense with cranial nerves, which should be
control of the injury, as angiography and extend down to the sternum. After incising preserved. Protect the marginal mandibu-
embolization will no longer be possible. the platysma muscle, a layer of investing lar branch of the facial nerve (Fig. 5). The
fascia is encountered and taken (in line glossopharyngeal (coursing anteriorly) and
with the skin and platysma incisions) along spinal accessory (coursing posteriorly) nerves
Larynx with two cutaneous nerves (the greater au- depart high, while the hypoglossal nerve, as
When significant enough to compromise ricular and anterior cervical) and the trans- it swings down beneath the occipital branch
the airway, laryngeal injury is typically dis- verse portion of the anterior jugular vein. of the external carotid artery en route to
covered at surgical exploration during the The plane along the anterior border of the the tongue, is most vulnerable. The dissec-
creation of a tracheotomy or during the con- sternocleidomastoid is further developed, tion should begin with division of the poste-
version of a cricothyroidotomy to a formal allowing posterolateral retraction and ac- rior belly of the digastric muscle. The oc-
tracheotomy. Patients with less complex in- cess to the carotid bundle. The internal cipital branch of the external carotid artery
juries found on CT scan or laryngoscopy jugular vein lies most prominently in this and the less important ansa cervicalis (in-
should undergo tracheotomy to protect the space and obscures the carotid artery, nervation to the strap muscles) can be sac-
airway. Laryngeal injuries often need recon- which at this point in the dissection should rificed to preserve the hypoglossal nerve,
struction, internal fixation, or stent place- be easily palpable. Lateral retraction of the which can now be retracted anteriorly. Fur-
ment and are best treated semielectively internal jugular will expose the carotid ar- ther exposure at the skull base can be best
by otolaryngologists. The surgeon should tery and vagus nerve and is facilitated by accomplished via a vertical ramus osteot-
resist the temptation to widely debride these ligation of the facial vein, which courses to omy. Advantages to this procedure over a

www.medicalebookpdf.com

LWBK892_c33_p418-425.indd 422 10/28/11 5:16:00 PM

 Chapter 33: Penetrating Neck Injury 423

External carotid artery

Glossopharyngeal nerve (CN IX)

Posterior belly Anterior belly of digastric Glossopharyngeal—CN IX Vagus—CN X

Facial artery
of digastric Motor: stylopharyngeus, Motor: palate, pharynx,
Occipital artery parotid gland larynx, trachea, bronchial
Mylohyoid Sensory: taste: posterior tree, heart, GI tract to left
Spinal accessory
third of tongue; general colic flexure
nerve (CN XI) Lingual artery
sensation: pharynx, tonsillar Sensory: pharynx, larynx;
Vagus nerve (CN X) Hypoglossal nerve sinus, pharyngotympanic reflex sensory from tracheo-
(CN XII) tube, middle ear cavity bronchial tree, lungs, heart,
Internal carotid artery
GI tract to left colic flexure
Hyoglossus
C2 nerve
Hyoid
Spinal accessory—CN XI Hypoglossal—CN XII
C3 nerve Thyrohyoid
Motor: sternocleidomastoid Motor: all intrinsic and
Inferior root Omohyoid and trapezius extrinsic muscles of tongue
Ansa (excluding palatoglossus—
cervicalis Sternohyoid a palatine muscle)
Superior root
Superior thyroid artery
Common carotid artery
Inferior pharyngeal constrictor

Sternothyroid Carotid
Ansa cervicalis
arteries:
Internal jugular vein
Internal Facial
Lingual
A. Lateral View External
Superior thyroid

Hyoglossus
Posterior belly of digastric Glossopharyngeal nerve (CN IX)

Superior laryngeal nerve Mylohyoid Common

carotid
Hypoglossal nerve (CN XII) Intermediate tendon
of digastric
C
Common trunk
Lingual artery
Anterior belly
of digastric
Greater horn of hyoid Facial
Nerve to

The Head and Neck

External carotid artery thyrohyoid
Facial Lingual
Superior root of Hyoid
ansa cervicalis Lingual
Thyrohyoid
Superior thyroid artery membrane Superior Superior
thyroid thyroid
Common carotid artery Thyrohyoid

External branch of Internal branch of

superior laryngeal nerve superior laryngeal nerve D E
Superior laryngeal artery Lateral Views
B. Lateral View

Fig. 5. Anatomy pertinent to internal carotid artery exposure. (From Agur AMR, Dalley AF. Grant’s atlas of anatomy, 12th ed.
Philadelphia: Lippincott Williams & Wilkins, 2009.)

temporomandibular subluxation have been unrelenting bleeding from the vertebral ar- laryngeal branch of the vagus nerve travels
suggested. tery when proximal ligation is insufficient. in the groove between the esophagus and
Clearly, dissection at the skull base is a Dissection can then proceed or, in the case trachea and is vulnerable to injury during
challenge even when structures are not ob- of hemodynamic instability, the catheter dissection (Fig. 6).
scured by active bleeding or hematoma. A can be left in place, sutured to the vessel Esophageal injury is the most common
more practical approach to exsanguinating and secured at the skin, for 48 to 72 hours. injury missed at neck exploration. Often flat
hemorrhage from injury at this level of the This approach is essentially equivalent to and with a lie off center to the left, the
internal carotid is to place a small throm- ligation of the internal carotid and should esophagus must be evaluated circumferen-
bectomy catheter into the vessel through be reserved for patients in extremis. tially. Necrotic tissue should be debrided
an arteriotomy in the common or proximal Displacement of the entire carotid bun- and healthy tissue approximated with a 3-0
internal carotid artery and inflate the bal- dle laterally will expose the pharynx and or 4-0 suture in one or two layers as needed
loon at various levels until the bleeding is esophagus as well as the larynx, thyroid to establish a watertight closure. The repair
controlled. This technique can also control gland, and trachea inferiorly. The recurrent should then be reinforced with a buttress of

www.medicalebookpdf.com

LWBK892_c33_p418-425.indd 423 10/28/11 5:16:00 PM

 424 Part III: The Head and Neck

Inferior pharyngeal constrictor

External branch of superior laryngeal nerve

Superior thyroid vein

Superior thyroid artery

Thyroid cartilage
Prevertebral fascia

Sympathetic trunk

Cricothyroid Internal jugular vein

Common carotid artery

Cricoid cartilage

Ascending cervical artery

Left lobe Middle cervical ganglion
Thyroid gland
Isthmus Inferior thyroid artery

Vertebral ganglion
Parathyroid glands
Vagus nerve (CN X)
Inferior thyroid vein
Thoracic duct
Esophagus
Trachea

Left recurrent laryngeal nerve

Clavicle

Sternothyroid
Anterior sternoclavicular ligament

Articular disc

A. Anterolateral View

External carotid
artery
Superior thyroid
artery
Thyroid isthmus
Thyroid ima artery
Inferior thyroid Left common
artery carotid artery

Thyrocervical
trunk
Left subclavian
Right subclavian artery
artery
Brachiocephalic Arch of aorta
trunk
Fig. 6. Alimentary layer of the visceral compartment. (From Agur AMR, Dalley AF.
B. Anterior View Grant's atlas of anatomy, 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2009.)

www.medicalebookpdf.com

LWBK892_c33_p418-425.indd 424 10/28/11 5:16:01 PM

 Chapter 33: Penetrating Neck Injury 425

muscle, usually the detached sternal head of for wound exploration. Blood pressure and the American Association for the Surgery of
the sternocleidomastoid muscle. Care must heart rate should be monitored particularly Trauma. J Trauma 2001;50:289–96.
be taken to direct drains away from associ- if there has been dissection or injury near Feliciano DV. Management of penetrating injuries
to carotid artery. World J Surg 2001;25:1028–35.
ated vital structure repairs as salivary en- the carotid bifurcation. A chest radiograph Henry AK. Extensile exposure, 2nd ed. Edinburgh:
zymes are quite corrosive. Occasionally, it is should be obtained to assess for pneu- Churchill Livingstone; 1973.
not possible (extensive tissue injury) or pru- mothorax. Antibiotics in the postoperative Inaba K, Munera F, McKenney M, et al. Prospec-
dent (operative delay) to primarily repair period should be reserved for esophageal tive evaluation of screening multislice helical
the esophagus at the initial operation. In injuries and drains left routinely can be re- computed tomographic angiography in the
this case, the proximal esophagus should be moved after 48 hours if the output is low initial evaluation of penetrating neck injuries.
J Trauma 2006;61:144–9.
exteriorized as an esophagostomy or widely (⬍20 mL). (The exception is with associ- Kumins NH, Tober JC, Larsen PE, et al. Vertical
drained and the distal portion ligated. ated esophageal injury, as discussed ear- ramus osteotomy allows exposure of the distal
lier.) Injuries to the various cranial nerves internal carotid artery to the base of the skull.
POSTOPERATIVE can result in the following predictable defi- Ann Vasc Surg 2001;15:25–31.
MANAGEMENT AND cits: facial droop ( facial), aspiration Osborn TM, Bell RB, Qaisi W, et al. Computed
(glossopharyngeal), dysphagia/dysarthria tomographic angiography as an aid to clinical
COMPLICATIONS (hypoglossal), and vocal cord paralysis (re- decision making in the selective management
of penetrating injuries to the neck: a reduction
Patients who have undergone vascular re- current laryngeal branch of vagus). in the need for operative exploration. J Trauma
pair should be monitored closely for hem- 2008;64:1466–71.
orrhage and neurologic deficit in the imme- Tisherman SA, Bokhari F, Collier B, et al. Clinical
diate postoperative period. Any sign of SUGGESTED READINGS practice guideline: penetrating zone II neck
bleeding or arterial thrombosis should Asensio JA, Chahwan S, Forno W, et al. Penetrat- trauma. J Trauma 2008;64:1392–1405.
prompt rapid return to the operating room ing esophageal injuries: multicenter study of

EDITOR’S COMMENT injuries in Zone II. This is because there were imaging modality with similar accuracy. LeBlang
times when in examination of the area of Zone II and Nunez (Am J Roentgenol 2000;174:1269–78)
following penetrating trauma did not reveal any demonstrated that CTA gives 100% sensitivity
With the war zone that many of our cities have be- severe injury or what seemed a severe injury only in identifying penetrating injury to the cervical
come and with the ready availability of knives and to find that the injury had been missed. While this vessels. Obviously, the use of CTA also results in
guns, and it seems, injuries for the most trivial of was adequate in World War I, in which penetrat- fewer neck explorations in the study by Woo K
altercations, the injuries to the neck, whether by ing neck trauma had a mortality rate of 11%, this et al. (Am Surg 2005;71:754–8).
bullets or certainly by stab wounds, are an impor- dropped in World War II to 7% and in modern ci- Mandatory neck exploration has been
tant part of the contemporary care of trauma. As vilian series, which increasingly resemble various strongly recommended by the authors of a
the authors of every paper quoted here state, the war zones, to 3% to 6%. The first recorded repair large series from South Africa. Over a 20-month
most exposed area is Zone II, which is between of a vascular injury was in 1552 when the French period, Apffelstaedt and Muller (World J Surg
the cricoid and the bottom of Zone III, which is surgeon Ambroise Paré ligated both common ca- 1994;18:917–9) explored all 393 patients present-
from the angle of the mandible to the skull base. rotid arteries and a jugular vein of a soldier who ing with penetrating injuries in Zones I, II, and III.

The Head and Neck

As the chapter states, surgeons favor the Zone had lost a duel. The soldier survived but subse- They stated that clinical signs were highly unreli-
classification because it is useful in consideration quently developed aphasia and hemiparesis. A able because 30% of patients with a vascular in-
of operative access. Zone II is the most “easily” more beneficial outcome was reported in 1803 jury had no clinical signs of vascular injury. Thus,
exposed and repaired, while surgery within Zone when the Scottish surgeon John Gibson Flem- the negative exploration rate was 57% overall; in
I, the thoracic inlet, and Zone III, the skull base, ing successfully ligated a common carotid artery this group, morbidity was 2.2% and mortality 0%.
are far more challenging. Most of the controversy with a good outcome over a 5-month follow-up These expert surgeons were able to report a very
that still exists, although it is being resolved, is period. It should be pointed out that the subjects low morbidity and mortality rate. It is not known
the approach to Zone II and whether it is man- of these ligations were presumed to be young. whether many of these injuries were clinically
datory exploration of all injuries that penetrate As stated earlier, the surgical exploration of relevant. On the other hand, Demetriades et al.
the platysma either by stab wounds or certainly Zones I and III are dealt with when necessary with (Br J Surg 1993;80:1534–6) have been advocating
bullet wounds or other injuries. With respect to a median sternotomy and whatever branching a more selective approach. Routine angiography
the approach to hemorrhagic injuries, Kesser and thoracotomy either a trap door incision or third was performed in 176 stable patients; a vascular
colleagues (Am Surg 2009;75:1–10) support the interspace incision to arrest the bleeding. Zone injury was present in 19%, and of these, only 8%
insertion of a 30-cc Foley catheter into the en- III injuries are more complicated and require a had an injury requiring operation. Thus, both
trance wound that is hemorrhaging and blowing Fogarty balloon at times to gain control. Base of CTA or angiography and Doppler ultrasound have
up the balloon. I wonder whether this is a wise the skull injuries can be most problematic. The excellent sensitivity and specificity; the yield with
approach. It certainly is less dangerous when the complexity of these two zones has resulted in a patients with soft signs is equivocal.
airway is secure with either endotracheal tubes more selective approach in dealing with injuries. Bell et al. ( J Oral Maxillofac Surg 2007;65:691–
or when necessary a tracheostomy but if one There is a temptation to explore Zone III injuries 705) reviewed 134 consecutive patients retrospec-
tamponades a massive bullet wound injury, for with studies because of the ease of vascular con- tively in a Trauma Registry as having sustained
example, or stab wound to the carotid artery, the trol. There are two camps, the first being manda- penetrating neck injuries from 2000 to 2005. The
blood may collect in the interstitial tissues of the tory surgical exploration and the second being usual variables including age, gender, mechanism
neck and thus provide interference of an airway. selective approach to evaluation of the patient of injury, number of associated injuries, Glasgow
Thus, from my way of thinking, the hemorrhage with penetrating neck trauma. The selective Coma Scale, length of hospital stay, disposition,
must be contained either by local pressure or first work-up involves imaging the vessels from the and outcome were recorded. Of these, 120 pa-
by securing the airway and then, if necessary, to aortic arch to the base of the skull, which tradi- tients met the inclusion criteria, and of these,
put in a Foley balloon. I would probably start first tionally is done with angiography, yet ultrasonog- 55 had only superficial injuries that did not pen-
with a 5 or 10 cc in blowing up the Foley balloon. raphy is now more often proposed. More recently, etrate the platysma. The remaining study group
Initially, there was a system that favored the high-quality computed tomography angiograms consisted of 65 patients with more significant
open exploration of most or all penetrating neck (CTAs) have been suggested as a less invasive injuries that entered the platysma. The overall

(continued)

www.medicalebookpdf.com

LWBK892_c33_p418-425.indd 425 10/28/11 5:16:03 PM

 426 Part III: The Head and Neck

mortality for the 65 patients was 3%, or 2 of mendation is usually based on Class I data, outcome. They also suggested the use of CTA
the 65. Complications occurred in seven of the Level II recommendation is usually supported with fewer formal neck explorations and virtual
surviving patients, or 10.7%. Two patients with by Class I and Class II data, and Level III rec- elimination of negative exploration. In my view,
Zone III internal carotid artery injuries devel- ommendation is to be made when scientific this constitutes double publishing, and it was the
oped hemispheric ischemic infarcts and hemi- evidence is lacking but the recommendation is different arena, the one being an ENT journal and
plegia. The use of CTA in clinical decision mak- widely supported by available and “expert opin- the other being a trauma journal, that led to the
ing, say the authors, led to a significant decrease ion.” In 1956, Fogelman and Stewart (Am J Surg acceptance.
in the number of neck explorations performed 1956;91:581–96) recognized that mandatory Ahmed et al. ( J Trauma 2009;67:152–4) exam-
and the virtual elimination of negative neck ex- exploration led to less mortality than observa- ined the radiological aids for penetrating pharyn-
plorations. tion because a significant number of seemingly geal and endoscopic injuries, particularly when
In clinical practice guidelines concerning asymptomatic patients actually have significant patients have severe facial injuries or when they
penetrating Zone II neck trauma, Tisherman injuries. In addition, neck explorations have are obese, intubated, or dynamically unstable.
et al. ( J Trauma 2008;64:1392–1405) attempted little morbidity although the financial cost is They argue that the trauma surgeon should be
to enumerate evidence-based guidelines on vic- significant (in 1981, the cost was $1930, which expert in videoendoscopy, which affords direct
tims of neck-penetrating injuries. Th ey quoted at that time was a lot of money). Consequently, visualization at the bedside and is expeditious.
Bladergroen et al. (Am J Surg 1989;157:483–6) mandatory exploration under general anes- The question was: does a contrast study detect
that mortality for major vascular injuries may thesia for injuries that penetrate the platysma all esophageal injuries, but does it accurately
reach 50%, not including pseudoaneurysms seemed reasonable (Roon AJ & Christensen N, detect hypopharyngeal injuries particular in in-
or arteriovenous fistulas. In this very nice ar- J Trauma 1979;19:391–7, and Walsh MS, Injury tubated patients. The answer seems to be no, but
ticle, which is very well documented, they ask 1994;25:393–5). Continuing in this vein, in this videoendoscopy detected all injuries, hypopha-
the question concerning selective operative paper, there are lists of evidentiary tables of ryngeal, which were largely missed by contrast
management or mandatory exploration. The various studies and the class of evidence they study, and esophageal, in which it was detected
evidence used is Class I, respective random- present as well as a summary of the study, which in intubated and nonintubated patients. Unfor-
ized double-blinded study of which there is one; can be read with profit. tunately, in this paper, the figures did not repro-
Class II, respective randomized, nonblinded Osborn et al. ( J Trauma 2008;64:1466–71) duce well; so while I believe the outcome, I am
trial; or Class III, a meta-analysis of respec- utilized the same data as Bell et al. previously not certain that one can tell from the figures that
tive series. There is only one Class I reference quoted and the same groups of 120 patients with are produced.
out of 112 identified papers. A Level I recom- penetrating injuries to the neck and the same J.E.F.

34 Neurosurgical and Neurological

Emergencies for Surgeons
Ekkehard Kasper, Clark Chen, and Burkhard Kasper

TRAUMATIC AND Every year, ⬃52,000 deaths occur from TBI ■ The head is a rigid compartment filled
NONTRAUMATIC HEAD and it is the leading cause of death and dis- with brain, cerebrospinal fluid (CSF),
ability in children and adults from ages 1 to and blood.
AND BRAIN INJURY 44 years. At least 5.3 million Americans, ■ Cerebral blood flow (CBF) in the healthy
that is, 2% of the U.S. population currently individual is autoregulated for systolic
Traumatic Brain Injury: Blunt live with disabilities resulting from TBI. In blood pressure (SBP) 80 to 160 mm Hg to
Versus Penetrating Trauma addition, moderate and severe head inju- generate an adequate cerebral perfusion
ries are associated with an increased risk of pressure (CPP).
Epidemiology of Traumatic Brain Injury developing Alzheimer’s disease. ■ If autoregulation is intact, CBF is main-
Before we commit ourselves to reviewing Males are about twice as likely as fe- tained constantly via a mean BP adjust-
the management of traumatic brain injury males to experience this and hospitaliza- ment to generate a CPP of 50 to 60 mm
(TBI), we need to understand that this tion rates have increased from 79 per Hg.
problem remains a major public health is- 100,000 in 2002 to 87.9 per 100,000 in 2003. ■ In moderate or severe brain injury cases,
sue in our times. To illustrate this point, I Blasts are a leading cause of TBI among autoregulation is disrupted in a way that
want to reiterate some facts about TBI in active-duty military personnel in war zones CBF varies greatly with mean BP.
the United States as an introduction to the and veterans’ advocates believe that be- ■ The injured brain is more vulnerable to
topic as reported by the Brain Trauma tween 10% and 20% of Iraq veterans, or episodes of hypotension and metabolic
Foundation (www.BTF.org): 150,000 and 300,000 service members, have imbalance which may cause secondary
Brain injuries are most often caused by some level of TBI. Of note, 30% of soldiers brain injury.
motor vehicle crashes, assaults, sports inju- admitted to Walter Reed Army Medical
ries, or even simple falls on the playground, Center have suffered TBIs. Intracranial Pressure
at work, or in the home. An estimated 1.5 Besides hemodynamic parameters and con-
million moderate to severe head injuries Traumatic Head Injury Basics fining metabolic conditions, intracranial
occur every year in the United States and an What are the unique features of brain anat- pressure (ICP) is the single most important
additional estimated 1.6 million to 3.8 mil- omy and physiology, and how do they affect determinant of neurological function of the
lion sports-related TBIs occur each year. patterns of brain injury? brain (Table 1).

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 426 10/29/11 12:15:09 AM

 Chapter 34: Neurosurgical and Neurological Emergencies for Surgeons 427

Normal state - ICP normal

Venus Arterial Brain CSF

volume volume

Compensated state - ICP normal

Venus Arterial Mass Brain CSF

volume volume

Decompensated state - ICP elevated

Venus Arterial Mass Brain CSF

75 mL volume volume 75 mL

Fig. 1. Monro–Kellie doctrine.

Normal ICP is defined as the pressure (in ration, and a correlation with body weight other components, otherwise it will cause an
cm H2O) that is measured within the skull, (obese patient showing higher values). increase in ICP at the expense of the brain.
either in subarachnoid fluid, ventricles, or It must be noted that ICP cannot be pre-

The Head and Neck

parenchyma. It corresponds to the hydro- dicted on the basis of imaging (head CT or ICP Impact
static pressure that must be applied to pre- MRI).
■ In TBI, resulting increased ICP leads to de-
vent the emergence of fluid through a punc- The Monro–Kellie doctrine (Figs. 1 and 2)
creased brain function and poor outcome.
ture needle from the CSF in the horizontal states that the sum of all intracranial volumes
■ Systemic hypotension and low O2-satu-
body position. Normal ICP should reside will remain constant and that any increase in ration adversely affect outcome via poor
below 15 cm H2O. An increase in ICP occurs one of them or adding an intracranial mass CPP and hypoxia (Table 2).
when one of the intracranial compartments will be offset by an equal decrease in one of its
within the rigid skull is increased (1,500 to
1,700 mL total volume, which is made of
around 80% brain parenchyma, 10% CSF, Volume-Pressure Curve
and 10% blood). An acute increase in ICP
above tolerance is fatal. 60
Physiological variations occur and show Herniation
55
age dependence, with children having lower 50
values than adults, fluctuation with each 45
pulse-pressure wave, fluctuation with respi-
ICP (mm Hg)

40
35
30
25 Point of
Table 1 Intracranial Pressure 20 Decompensation

Infants 0.5–2 mm H2O 15

10
Children 2–10 mm H2O Compensation
6–200 mm H2O ⫽ normal 5
Volume of Mass
Adults ⬎200 mm H2O ⫽ abnormal
⬎400 mm H2O ⫽ severe increase Fig. 2. Volume–Pressure curve.

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 427 11/7/11 1:42:45 PM

 428 Part III: The Head and Neck

a possible from bystander accounts. It is

as
Table 2 Cerebral Perfusion Table 4 Causes of Secondary iimportant not to miss the body tempera-
Pressure (CPP) Brain Injury tture in this assessment since hypothermia
CPP (MAP − Edema may depress neurological functions.
m
MAP ICP ICP ⫽ CPP) Change in cerebral blood flow
Normal 90 10 80 Hypercapnia
Acidosis EExamination
Cushing’s 20 80 Altered metabolism ( free radical formation)
100 I may be of vital importance to obtain a de-
It
Response Change in neurotransmitters
Change in receptor activity
sscription of the scenario and vital signs in
Hypotension 50 20 30 aaddition to the first examination at the
Excitotoxicity
Infection/abscess formation sscene. When a patient is “found down,” ask
aabout circumstantial evidence (alcohol,
Primary and Secondary ddrugs, observed blood loss). How long was
the patient unaccounted for? Was there loss
Brain Injuries Secondary injury (Table 4) is delayed of consciousness (LOC), evidence of seizure
Primary and secondary brain injuries are and results indirectly from the impact and activity, or progressive obtundation? Did
the terms to classify brain injury processes. comes via cellular processes as a conse- the patient act abnormally? Did the pa-
In TBI, primary injury occurs during the quence of the trauma. It is a well-known tient develop headache, nausea, vomiting,
initial insult and results from the physical observation that many TBI victims do not blurred vision, hearing loss, altered speech,
impact and energy transfer causing struc- die right away at the scene, but almost half or any other progressive symptom en route?
tural damage to the brain. Secondary injury of the TBI patients deteriorate during their If the patient became unconscious and ar-
is a consequence thereof. Its time course is hospitalization as a result of secondary in- rived with a “blown pupil,” ask when it hap-
more gradual, reflecting the involvement of jury, which ultimately may cause raised ICP pened. If bilaterally, ask which side went up
distinct cellular processes to which both and brain herniation. first and when.
primary and secondary injuries, respec- Since secondary injury occurs over time, As in all other trauma cases, assessment
tively, will contribute. Primary and second- it can be prevented in part by taking mea- of the primary trauma team’s complete sur-
ary injuries occur in other brain insults sures to prevent complications, and re- vey must be conducted first!
such as spontaneous hemorrhage, stroke, searchers are working actively to find drug
■ Observe the primary survey by the
or mass lesions too. therapies to limit or prevent the damage.
trauma team as they gather vital signs
In TBI, primary injury (Table 3) happens
and make sure that all initial measures
from energy transfer at the moment of
trauma and it manifests as concussion (in-
INITIAL DATA EVALUATION to limit secondary brain injury are be-
ing implemented (oxygen administered,
jury without visible correlate on CT), con- It is crucial to obtain as much of the history
adequate ventilation secured, and SBP
tusion (with damage to tissue and vessels), upon arrival of the Emergency Medical Ser-
⬎90 mm Hg maintained at all times).
or diffuse axonal shear injury. Normal phys- vices and particular attention must be paid
■ Check for bradycardia, changes in
iological barriers such as the blood–brain to the mechanism of injury, initial on-scene
breathing frequency, and hypertension
barrier and connective tissue such as the examination, and time course of develop-
(signs for increased ICP and Cushing’s
meninges can be damaged, and cells may ing symptoms of concern.
response).
die in a nonspecific manner. Certain areas Whenever there is significant impact,
■ Make sure that the patient is being treat-
of the brain are more susceptible to injury the index of suspicion of a life-threatening
ed with full spine precautions—a hard
either by location ( fronto-basis and tempo- injury should be very high, even if the pa-
board is used and the cervical spine is
ral tip in head-on collision deceleration in- tient was doing rather well at the scene and
correctly immobilized with a hard col-
juries) or by structural features (myelinated looks good on arrival! Whenever there is
lar or taped to the trauma board. Only
fiber tracts vs. nonmyelinated fibers), and significant injury to the head (e.g., enough
in the setting of hypovolemic systemic
this type of structural injury is thought to to cause a fracture or bleeding), the con-
shock (scalp blood loss can be massive!)
be irreversible. cern for associated cervical spine injury
and in cases of spinal cord injuries with
Since primary injury occurs at the mo- should be high. So, actively search for neck
florid neurogenic shock, you will see hy-
ment of trauma, there is little that can be pain and signs of radiculopathy or myelopa-
potensive responses despite increased
done for it; efforts to reduce disability and thy! If the patient has sustained multisys-
ICP.
death from TBI are thought to be best aimed tem injury, the extent of injury and its
at secondary injury. initial management matters greatly for During the assessment of the trauma
prognostic purposes. team’s survey, get information about medica-
Specific scenarios: In cases of motor ve- tions given during transport (paralytics, nar-
Table 3 Examples of Primary hicle accidents (MVA), questions about
h cotics, sedatives).
Brain Injury in TBI mechanism of injury should include a de-
m Have a quick look at the pupils and
Subarachnoidal hemorrhage ttailed account of vehicle speed (high/low), check for size and reactivity. A side-
Epidural hemorrhage ddirection of impact (head on, rear ended, difference of ⬎1 mm is considered nonphys-
Subdural hemorrhage sside/oblique impact), extend of external iological, unless caused by a preexisting
Parenchymal Hemorrhage ddamage, possible passenger ejection, and condition. Classify the status of the pupils
Concussion ddeath of or injuries to other participants. In since any newly dilated pupil ⬎6 mm defines
Contusion ccases of penetrating or blunt injury, ask a neurosurgical emergency. Rapid acquisi-
Diffuse axonal injury/or aabout the type of assault weapon (e.g., fire- tion of head CT-imaging in this setting (e.g.,
Axonal stretch injury aarm vs. golf club). Get as much information penetrating gunshot wound [GSW] to the

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 428 10/29/11 12:15:09 AM

 Chapter 34: Neurosurgical and Neurological Emergencies for Surgeons 429

Table 5 TBI and GCS Scoring Table

Severity level GCS score
Mild TBI (Concus- GCS 14–15 with LOC
sion) ⬍5 min; Impaired
alertness or
memory
Moderate TBI GCS ⬎9; focal
neurological deficit;
possibly reversible;
some residual
possible
1 2 Severe TBI GCS 5–8
Critical TBI GCS 3–4; poor
Fig. 3. Decorticate posturing. prognosis

head) takes precedence over a detailed sec- open fractures until in the OR and after stimuli are applied to elicit an adequate
ondary trauma survey ! adequate imaging has been obtained. response. Learn to recognize the postur-
Inspect and palpate the globes to assess ing responses to be able to distinguish
Traumatic Brain Injury: The possible rupture. Corneal reflexes can be decerebrate, decorticate, triple-flexion
used to assess CN 5/7 function in the co- withdrawal (Figs. 3 and 4)
Glasgow Coma Scale matose patient. A fundoscopic/ophthal-
In conversant patients also check the
Once the trauma survey has been con- moscopic examination is less valuable
sensation from the head toward the toes
ducted, evaluate the patient rapidly yourself in the adult since ICP increase does not
and mark any possible level that correlates
before other diagnostic studies are done. cause immediate optic nerve pallor and
with a spinal cord injury. Check tactile
Check the patient’s initial Glasgow Coma it is unlikely that one picks up a decrease
stimulation as well as pain. You must per-
Scale (GCS) score to evaluate the patient’s in retinal venous pulsations in this ER
form a rectal examination to assess sphinc-
level of consciousness via motor response, setting. However, in pediatric patients
ter tone; in the comatose patient, this may
eye opening, and verbal response. This and unclear mechanism of injury, evi-
be the only evidence for spinal cord injury.
score has predictive and prognostic value dence of retinal hemorrhage may point
If the bulbocavernosus reflex is missing (re-
(Table 5). to abuse. Pharmacological dilatation
flecting acute myelopathy), the patient may
If the patient is stable and in reasonable must be avoided until ICP elevation has
show signs of spinal shock.
neurological condition, obtain a focused been ruled out. Check the external audi-
Check biceps and patellar reflexes as

The Head and Neck

examination: tory canal (EAC) for hematotympanum
well as plantar responses (Babinski’s reflex).
and otorrhea/liquorrhea. Also inspect
1. Head: Observe the patient for external In acute spinal cord injury, the patient will
the nares for blood or CSF leakage/
signs of trauma (raccoon’s eyes ⫽ perior- rhinorrhea. Lower cranial nerve injury
present with dropped reflexes and mute
bital edema and hematoma, retroauricu- toes. Only in rare cases of brain stem shear
is rare in the acute trauma patients, and
lar hematoma, and ecchymosis ⫽ Battle’s if noticed later during hospitalizations,
injury, one can find hyperreflexia in the
sign indicating a skull base injury). acute setting.
needs attention to assess the risk of
Check head and neck for wounds such Serial neurological examinations and se-
aspiration.
as lacerations, abrasions, and contu- rial imaging are necessary to diagnose de-
2. Body: Check for motor response in all
sions, and palpate for possible fractures. layed neurological status change and deterio-
four extremities; if the patient has de-
Do not probe lacerations concerning for ration from secondary brain injury (Table 6).
creased level of consciousness, painful

Table 6 Classification of
Injury Patterns
■ Concussion or mild TBI
Altered MS with closed head injury
Fully reversible
■ Contusion (e.g., deceleration injury)
Structural changes; mass effect (ME)/
mid line shift (MLS)/swelling
Possibly reversible; some residual
■ Contre-coup injury/second impact
syndrome
■ Diffuse axonal injury (DAI or shear injury)
1 2 microscopic/multiple structural lesions
and LOC severe; poor prognosis
Fig. 4. Decerebrate Posturing.

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 429 11/15/11 10:44:27 PM

 430 Part III: The Head and Neck

INITIAL TREATMENT Table 7 First Set of Conservative TBI Treatment Measures (Before Imaging)
PLAN IN THE ER
■ Optimize positioning: Elevate the head of bed above the level of the heart to improve venous
Since TBI is a rather heterogeneous group return and choose a level of approximately 30 degrees; if the spine is not cleared, tilt the entire
of incidents, it has been extremely difficult bed into reverse Trendelenburg position; make sure the neck is not compressed by tapes from
to gather prospective randomized trial data intubation or tight collars resulting in compromise to jugular venous return. Keep even the
and treatment recommendations from cli- mild TBI patient initially at bedrest until the assessment has been completed
nical studies in this scenario. However, a ■ Administer warm isotonic fluids (ns ⫹ 20 mM KCl) for volume resuscitation and give

few fundamental and basic recommenda- maintenance fluid to avoid secondary injury
tions were derived from detailed analysis of ■ Avoid hypotension (SBP ⬎90 at all times for sufficient CPP)
■ Avoid hypothermia; cover the patient with warm blankets
retrospective data and prospective collec-
■ Intubation in all patients with GCS score of ⬍8 who cannot protect their airway at all times;
tion of data from cohorts that were followed
long term. since facial and skull base fractures may be present, orotracheal intubation is the method of
choice
Some priorities in guidelines are intui- ■ Keep the patient NPO and insert nasogastric tube (NGT) for intubated patients
tive, for example, the systemically unstable ■ Prior to imaging, provide assisted ventilation/hyperventilation
patient needs to be treated first since sys-
If the patient arrives in poor neurological condition and with a high suspicion for increased ICP,
temic hypotension from hypovolemic shock
initiate osmotherapy (100 g mannitol ⫹ 20 mg Lasix) as you go to the CT-scanner as it buys
in the multitrauma patient carries a poor you time
prognosis in neurotrauma. Also, if there are
any concerns for raised ICP or the GCS
score is ⬍9, the patient should have the
treatment initiated imaging is obtained be- stratify the injury into mild, moderate, and
fore, and then the time-consuming diagnos- severe (see Table 6). Strategy in the Trauma Bay:
tic studies are undertaken (see later). Document the morphology: Surface and ■ Early intervention is the goal for all treat-
vault injuries: open versus closed, depressed able conditions
ICP Treatment versus nondepressed, with and without trans- ■ Each patient with a significant impact
After systemic stabilization (make sure located fragments. Basilar injuries: with or or unclear story must be studied with
only isotonic solutions are used), adminis- without CSF leak, with or without cranial imaging.
ter mannitol (around 1 g/kg BW) and nerve palsy. ■ Comatose TBI patients (GCS score of ⱕ8)
furosemide (Lasix) (10 to 20 mg IV) and hy- with normal CT scans may be watched
perventilate the patient (increase fre-
Once a CT of the head as been obtained,
during further workup.
quency and volume for goal pCO2 ⫽ 30) classify the injury pattern into bony and ■ All comatose TBI patients (GCS score of
before you run off to radiology/CT for fur- parenchymal: epidural/subdural/subarach- ⱕ8) with abnormal CT scans should re-
ther studies. noid/intracerebral/focal or diffuse (see later). ceive invasive ICP monitoring.
Upon arrival, the patient will undergo ■ This algorithm helps with earlier
some ER management in the hospital. Here detection of intracranial lesions to prog-
The current existing guidelines for man- are some conservative measures that can nosticate recovery and it improves out-
agement of acute head trauma are con- come.
be initiated quickly and efficiently (Tables 7
tained by a publication of the Brain Trauma and 8).
Foundation and the American Association
of Neurological Surgeons (AANS) and can
be obtained from the AANS or found via
Weblink under: http://www.guideline.gov/ Table 8 Second Set of Conservative TBI Treatment Measures (After Imaging)
content.aspx?id⫽10995.
Some points of interest need to be de- ■ Invasive ICP monitoring is indicated in all patients with a GCS score of ⬍8 and/or signs of
scribed when accepting or signing out a raised ICP on imaging (the only exception being the intoxicated patient with a normal head CT
patient: single versus multiple wounds, who has an obvious reason for depressed mental status and may recover in a short period of
LOC at the scene, GCS score at the scene, time in the ICU under constant observation); each patient should have an immediate repeat
downtime until patient was found and CT after placement of a EVD or ICPB to assess success and/or complications. If the GCS score
is ⬍8 but the patient shows two out of the following three signs: posturing, hypotension, or
treatment was initiated, seizures at the
age ⬎45, monitoring is also recommended
scene, and any accompanying systemic in- ■ Anticonvulsants: Once intracranial imaging has revealed a superficial focus of injury or blood
jury. Then focus on the actual neurological products, load the patient with prophylactic medication such as phosphophenytoin (dilatin
injury: 10 to 15 mg/kg BW) which equals about 1 g per adult load followed by 100 mg TID maintenance
Document the mechanism of injury as dose for a blood serum level of 10 to 20 for a minimum of 10 days. Overall risk of seizures is low,
nonpenetrating blunt trauma in which the even in severe TBI (around 1%), and less in mild TBI (around 0.1%), but their consequences can
bony confinements remain intact (e.g., be dramatic, especially because they can exacerbate secondary damage. Newer data support
strike with a baseball bat) versus penetrat- the use of Leviracetam (Keppra) 1,000 mg p.o. BID, but the drug is still being evaluated.
ing trauma in which the bony integrity has ■ Steroids: Currently there is no indication for routine application of steroid therapy in trauma
been violated (GSW and stabs). It is helpful ■ Antibiotics: In patients with an obvious open scalp injury, provide skin flora coverage (e.g.,
to realize that the energy transfer accounts Cephalosporin: Ancef 1 g Q8 h ⫻ 3). If there is an obvious CSF leak or exposed brain tissue,
provide triple coverage (gram-positive and gram-negative anaerobes; e.g., Vanco/Gent/Flagyl)
for the devastation, so one should specify
■ Analgesics, sedatives, and antiemetics should be prescribed p.r.n.; mind you not to cloud your
“high energy” versus “low energy” injury. On neuroexamination by oversedation. See Table 9 for a guide on dosing
the basis of the initial GCS score, you can

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 430 10/29/11 12:15:11 AM

 Chapter 34: Neurosurgical and Neurological Emergencies for Surgeons 431

Plain XRT films are still acquired in some

Table 9 Dosing Table for Medications t
trauma patients for the initial series and in
Medication Mechanism Dosage Indication Evidence-level
ppatients with possible cervical spine injury,
ppatients presenting with myelopathy or fo-
Mannitol Osmotic 1 g/kg IV GCS score of ⬍9 in patients III ccal spine symptoms, and in all comatose
with a lateralizing motor ppatients if a CT is unavailable. For any pa-
deficit or unequal pupils ttient who is diagnosed with a traumatic
Dilantin Antiepileptic Around 1 g IV Seizure prophylaxis; ⬃100 mg I sspine fracture, a full spine assessment with
TID for serum level CT is mandatory since 15% of patients have
C
Kefzol Antibiotic 1 g Q8 h IV Prophylaxis for G⫹ infections; III oone or multiple associated fractures. In any
scalp lacerations and open ccase of myelopathy with or without ob-
fractures sserved bony abnormality, an immediate MRI
must be arranged to rule out canal compro-
m
mise from, for example, traumatic disc her-
m
niation, hematoma, tumor, or any other
DIAGNOSTIC STUDIES since it is highly specific and sensitive for source.
bony injuries as well as blood and gives a A CT/CTA of the head is recommended
CT of the head is the study of choice in head chance to assess intracranial injuries in a in settings in which the distribution of the
trauma patients. All patients with a GCS timely fashion. (Timely means a significant blood does not match the mechanism of
score of ⬍15 should obtain a CT scan for head injury should be imaged within 15 injury or if the patient has experienced a
proper assessment. Patients who look per- minutes after arrival in the ER.) Most indi- thunderclap headache leading up to the
fect but have a significant mechanism of cations for surgical intervention can be trauma since subarachnoid hemorrhage
injury as well as patients on systemic anti- made on the basis of CT results alone and (SAH) may well be caused by an underly-
coagulation and with syncopal events do not require MRI, which is superior only for ing vascular lesion leading to a syncopal
should also be imaged. In all patients with a prognostic purposes in patients with shear event that then presents secondarily as a
lateralizing or localizing sign, the radio- injuries and diffuse axonal injury (Fig. 5; trauma.
graphic workup must be obtained emergently Tables 10 and 11).

The Head and Neck

A B C

D E F

Fig. 5. Slices of an emergent CT. A: Foramen-Magnum. B: Fourth ventricle. C: Temporal lobe. D: Sylvian fissure. E: Midline/
Ventricles. F: Superficial sulci.

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 431 10/29/11 12:15:11 AM

 432 Part III: The Head and Neck

ccal spinal injuries such as atlantooccipital ■ It subsequently requires a management

Table 10 Checklist for Interpreting ddislocations. protocol written for ICP ⬎20 cm ⬎5 min.
a Trauma Head CT
■ F/u CT is needed immediately after place-
1. Soft tissue windows INDICATIONS FOR ment.
■ Start at the level of the foramen
magnum and work your way up to the SURGICAL INTERVENTION Epidural Hematoma (Fig. 7)
vault
A patient who has a chance of recovery
Any ■ It is characterized by convex, extra-axial,
■ Is the foramen magnum open or
crowded? ffrom TBI, who presents on imaging with a hyperdense mass, confined by sutures.
■ Are the cisterns around the brainstem
ffocal lesion that exerts mass effect, an ex- ■ Incidence among all TBI is about 3%.
visible? ppanding lesion that will predictably cause ■ One-third to one-half of the patients are
■ Is the fourth ventricle visible, open, ffurther damage, or a global injury that raises in coma on admission.
blood filled, and in the midline? IICP or puts the patient at risk quo ad vitam ■ 50% patients present with classic lucid
■ Is there a mass in the posterior fossa or sshould undergo emergent intervention. interval.
cerebellum? Is there a bleed or a stroke? ■ Peak incidence is among patients aged
■ Is the temporal lobe displaced S
Surgical Goals for Craniotomy 20 to 30 years.
medially? (pressing on the third nerve?)
■ Is the Sylvian fissure visible and open?
oor Craniectomy ■ Most frequently from meningeal arteries
or veins, fracture ( fx), or from sinus.
■ Are the ventricles visible and symmetric The surgical goals for craniotomy or craniec- ■ 10% require open surgery.
to the midline (measure shift at the ttomy are as follows:
level of the Foramen Monroi)? ■ Imaging shows incipient mass effect.
■ Is there blood in the ventricles (check ■ Debridement and closure for open ■ Outcome correlates with clot location,
occipital horns in the supine position)? wounds clot thickness, clot volume, and MLS.
■ Is there visible blood around the brain? ■ Evacuation of hematoma and relief of ■ It may be managed conservatively if
■ Are there changes in the brain pressure/midline shift (MLS) the patient is noncomatose, has no fo-
parenchyma ( frontobasal/temporal tip ■ Decompression for edema, that is, cal deficits, clot thickness is⬍15 mm,
contusions)? craniectomy and duroplasty clot volume is ⬍30 cc, and MLS is
■ Does the surface show visible sulci
■ Decrease in ICP ⬍5 mm or in a nontemporal location.
(indicating SAH or assessing ICP)? ■ Indication for surgery is if GCS score
■ Bullet/bone fragment retrieval
2. Bone windows ■ Wound closure for CSF leak is ⬍9 and/or volume is ⬎30 cc.
■ Check for fractures. If at the surface, are ■ Sinus repair ■ Be aware: time from deterioration to
they depressed? How much in mm? Is decompression correlates with out-
there a petrous apex/skull base fracture come!
through the carotid canal (requires PPossible Sources for CSF Leak
CTA)? T
Traumatic CSF leaks occur in around 3% of
■ Check the sinus and whether they are
Clinical Vignette
ppatients with significant head injury and in
air-filled or opacified ( fluid-filled) up to 50% of patients with penetrating inju-
u ■ A 26-year-old female patient s/p MVA with
■ Check for intracranial air indicating a
rries. Two-thirds appear within days of the HA and dizziness and intermittent confu-
CSF leak sion transferred from OSH with initial CT:
■ Check the orbit for fractures rule out
iinsult; 95% manifest within 3 months.
Around two-thirds of leaks stop spontane-
A negative! Repeat imaging for increased
compression of the optic nerve HA about 2 hours later showed a temporal
oously within 72 hours, and most leaks cease
fracture and a new left 12-mm temporal
within 6 months. The incidence of associ-
w
epidural hematoma (EDH) with incipient
ated meningitis is 5% to 10% in closed head mass effect and uncal herniation (Fig. 7).
Other diagnostic studies such as MRI, injuries and its incidence increases with the ■ Emergent L craniotomy for evacuation
conventional angiograms, EMG, EEG, and length of a persisting leak. performed.
nuclear medicine studies are warranted in The treatment recommendation re-
special circumstances only and go beyond mains controversial; we recommend cover-
Subdural Hematoma
the scope of this chapter. The interested age of 72 hours posttrauma to minimize the
risk of meningitis until most leaks close ■ It is characterized as a crescentic, extra-
reader should study publications related to
the definition of brain death and high cervi- spontaneously. axial, hyperdense mass on native head
If a CSF leak persists for ⬎2 weeks, sur- CT (Fig. 9), not confined by suture lines.
gical intervention is indicated. ■ Incidence among severe TBI patient is
about 12% to 30%.
IIllustration of Specific Cases ■ One-third to half of those patients are in
Table 11 Radiological Facts coma on admission.
I
Increased ICP from Global Injury: ■ Rarely patients present with a lucid in-
Approximately 10% of initial head CT scans in Emergent ICP Bolt or EVD Placement
E
patients with severe TBI do NOT show any
terval.
((Fig. 6A–C) ■ Peak incidence lies with patients aged
abnormality
Significant new lesions and increased ICP ■ Indicated in all comatose TBI patients 31 to 47 years, mainly men.
may develop in 40% of patients with an with a GCS score of ⱕ8 and an abnor- ■ Frequently from MVA, falls, fractures,
initially normal head CT mal CT scan. The intracranial pressure assaults.
Approximately 15% of patients with bolt (ICPB) or external ventricular drain ■ 35% to 80% of patients will present with
significant head injury may develop (EVD) is placed in the ER/ICU/OR at GCS score of ⬍9.
delayed deterioration ( from hemorrhage Kocher’s point (10 cm posterior and 3 cm ■ Poor outcome if age ⬎60.
or edema) lateral from the nasion). ■ Imaging shows incipient mass effect.

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 432 10/29/11 12:15:12 AM

 Chapter 34: Neurosurgical and Neurological Emergencies for Surgeons 433

A B C

Fig. 6. A: ICP bolt insertion position on lateral XRT. B: Right frontal EVD placement. C: Postplacement CT scan: the soft tissue
window shows the tip of the catheter at the level of the Foramen Monro.

■ Outcome correlates with clot location, Subarachnoidal Hemorrhage Look carefully at the distribution of the
clot thickness, clot volume, and MLS. It is characterized as diffuse bleeding in blood and especially the basilar cisterns
■ May be managed conservatively if pa- the CSF space (looks like “sugar spilling” of and the Sylvian fissure. If there is any suspi-
tient is noncomatose, without focal extra-axial, hyperdense material on native cion that it could be aneurysmal in nature
deficits, clot thickness ⬍10 mm, clot head CT) not confined by suture lines. It is and the story does not make sense, it is
volume ⬍30 cc, and MLS ⬍5 mm, best visible in the sulci and fissures and mandatory to rule out that the SAH did not
nontemporal location; manage with in the occipital horns of the ventricles precede the TBI.
ICP-bolt. (Fig. 11). Intraparenchymal Hematoma
■ Indication for surgery: GCS score of
⬍9, clot thickness ⬎ 10 mm, MLS ⬎ ■ Incidence among severe TBI patient is ■ Traumatic parenchymal lesions occur in
5 mm, and/or volume ⬎ 30 cc. very high. 10% of all TBI patients and in up to 30%
■ Remember: Time from deterioration ■ Patients may be in coma on admission of severe TBI patients.
to decompression correlates with out- (depends on mechanism of injury and ■ Smaller lesion may not require aggres-
come! impact), but it is very important to get a sive operative treatment, but additive
precise PMH. mass effect may result in secondary

The Head and Neck

Clinical Case Vignette ■ Rarely patients present with a lucid in- brain injury and puts the patient at risk
■ A 42-year-old man s/p fall from standing
terval. for deficit or death (Fig. 12).
prior to admit and had progressive hemi- ■ Frequently from motor vehicle accident ■ All comatose patients with temporal or
paresis; h/o HTN and significant EtOH in- (MVA), falls, fractures, assaults. frontal lesions ⬎20 cc or MLS ⬎5 mm
toxication; imaging revealed a right acute ■ Imaging shows very little mass effect if it or any larger lesions ⬎50 cc should be
SDH (Fig. 10). occurs as an isolated injury. treated surgically.

Fig. 7. Epidural hematoma. Fig. 8. EDH fracture site.

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 433 10/29/11 12:15:12 AM

 434 Part III: The Head and Neck

A B
Fig. 9. Subdural hematoma (SDH).
Fig. 11. A: R traumatic subarrachnoidal hemorrhage filling the sulci over the convexity (green arrows).
B: L frontal traumatic subarrachnoidal hemorrhage from head on collision.

■ Early intervention is advocated with Skull Fracture Indications for surgery: if the depressed
progressive neurological deterioration. bone segment is thicker than the thickness
■ It is characterized by bone destruction
■ The threshold for decompression is a of the overlying skull, they are unstable and
to the skull and possible displacement,
medically refractory ICP increase ⬎ 25 forming an extra-axial mass, not con-
require surgery.
for ⬎5 minutes. fined by sutures (Fig. 14). Gunshot Wounds (GSWs)
■ Incidence among all TBIs is about 6%.
Clinical Case Vignette ■ Because of the high impact, it is associ- ■ GSWs are the most frequent penetrat-
ated with high risk for intracranial hem- ing injuries (other are stabs/nailguns/
■ A 22-year-old man presented s/p snow-
board crash against brick wall; upon ar- orrhage and a significant neurological falls into sharps) and account for one-
rival he had a GCS score of 8 and an R deficit thus causing a poor outcome. third of TBI trauma deaths in patients
third palsy; emergent CT revealed a small ■ Closed fractures can be fixed intraopera- aged ⬍45 years. The overall “proximal
R acute SDH with a nondisplaced skull tively in one setting with craniotomy for mortality” remains ⬎90% (Fig. 15 and
fracture, significant midline shift, and exploration and bone fragment eleva- Table 12).
multiple bilateral hemorrhagic contu- tion and repair.
sions adding up to significant mass ef- Hospital course: CPR is likely to be per-
■ All open fractures require a craniectomy
fect. formed in the field as necessary. Most pa-
with discarding of the bone, followed by tients will arrive per EMS in the hospital
■ Emergent R craniectomy, evacuation of
delayed allograft cranioplasty. Most pa- intubated and sedated. An expeditious
SDH, and temporal lobectomy were per-
formed (Fig. 13). tients have to receive long-term antibi- trauma survey must be performed and ad-
otics. ditional injuries need to be identified and

A B

Fig. 10. Right osteoplastic craniotomy for evacu- Fig. 12. A: Small R SDH with global swelling. B: Right temporal hemorrhagic contusion adding mass
ation of hematoma. effect.

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 434 10/29/11 12:15:13 AM

 Chapter 34: Neurosurgical and Neurological Emergencies for Surgeons 435

A B C

Fig. 13. A: Right hemicraniectomy and evacuation of an SDH. B: R temporal lobectomy performed to create space. C: Second-
stage R cranioplasty performed 8 weeks posttrauma.

treated accordingly. Control bleeding from Outcome: GCS score and LOC (or the main- bral centers. Among the most dangerous
the scalp and other sites. DO NOT PROBE tained level of consciousness) at the scene conditions is brain herniation and its most
WOUNDS. Remember to keep mean arte- and upon arrival in the hospital are the critical final route of brainstem compres-
rial pressure (MAP) high during resuscita- most relevant predictors of outcome. Most sion with consecutive death.
tion and avoid excessive hydration to avoid victims die at the scene. If the patient shows Brain herniation (Fig. 16) occurs when
cerebral edema; standard spine precautions positive LOC at the scene and upon arrival, brain tissue inside the rigid skull is dis-
apply. It is important to describe entrance 94% die and 3% survive with severest dis- placed or shifted by local pressure from its
and exit wounds and unilateral injuries ver- abilities. Suicide attempts are more likely to normal position toward another location
sus bullets crossing midline (very poor be fatal. As in most TBIs, young age and with less pressure. It frequently happens as
prognosis). Get 3D reformats from the CT physical status are advantageous for im- a direct consequence of hemorrhage (sec-
done right away. If you have any chance to proved recovery during rehabilitation, ondary to blood volume) or perifocal brain
save the patient, act proactively and apply which should happen at an experienced TBI edema following ischemic stroke, CNS
mannitol, Lasix, and hyperventilation as center. trauma, infection, or inflammation, but it is
outlined, and get the patient to the OR also commonly seen as vasogenic edema in
swiftly for decompression above. the context of both primary and metastatic
NONTRAUMATIC EMERGENCIES

The Head and Neck

Late complications: If the patient survives CNS tumors. It can also be caused by
the initial insult and finally goes to rehab, a Mass Effect and Herniation “global” problems such as hydrocephalus or
scheduled follow-up with full imaging is generalized edema such as in malignant hy-
necessary to rule out delayed issues such as Background: Irrespective of detailed etiol- pertension.
traumatic aneurysms, hydrocephalus, infec- ogy and pathology, many CNS diseases di- Symptomatology: Any surgeon should
tions, and abscess. Keep the patient on anti- rectly or indirectly threat the patient’s neu- know about the risks of herniation and an-
convulsants until reevaluation to protect rological status and life by exerting force to ticipate and recognize the signs of impending
him from secondary damage from seizures. functionally important and/or vital cere- or incipient herniation that comes with

A B C

Fig. 14. A: L frontal depressed skull fracture from a golf club assault. B: Bone window demonstrating internally displaced frag-
ment. C: Postoperative CT of elevated calvarial fracture, which was repaired and augmented with titanium mesh.

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 435 10/29/11 12:15:14 AM

 436 Part III: The Head and Neck

Fig. 15. A: 1–8: R GSW to the head; extensive bone damage

is visible with translocated fragments and extensive soft tis-
sue injury. B: Surgical decompression via wide hemicraniec-
B tomy and delayed repair.

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 436 10/29/11 12:15:15 AM

 Chapter 34: Neurosurgical and Neurological Emergencies for Surgeons 437

pratentorial mass lesion developing a left

Table 12 TBI from GSW Falls into hemiparesis, Kernohan’s notch pressure
Two Categories: Primary
and Secondary Injuries during incipient herniation is the likely
mechanism. Another traumatic mechanism
Primary injury: Injury to soft tissue (scalp/ leading to secondary damage is hemor-
3
face; bacteria translocation; pressure wave rhage at the site of shearing force (Durette’s
or gas); comminuted fracture to the bone;
cerebral injury from missiles (distinguish:
hemorrhage).
2
direct path/ricochet/fragments/coup and 4
Imaging features: CT and MRI need to be
contrecoup) checked for signs related to early stages of
1 progressive parenchymal shift indicating
Secondary injury: Early: edema (ICP);
cardiac output (MAP); DIC; hemorrhage.
the risk of developing transtentorial hernia-
Late: abscess/infection; traumatic 5 tion.
aneurysms; seizures; migrating fragments 6 Noteworthy are the following: (a) princi-
pal basal cistern narrowing, (b) ipsilateral
ambient cistern widening, (c) contralateral
ambient cistern narrowing, and (d) contral-
CNS disease potentially causing acute or ateral temporal horn widening. Typical com-
Fig. 16. Brain herniation can occur from one plications from herniation syndromes are
delayed mass effect. compartment to another inside the skull. Subfal-
While the attribution of certain clinical usually detected on routine follow-up scans
cine (3), uncal (1), and transtentorial herniation
signs to types and stages of herniation is (2), upward herniation from posterior fossa and include anterior cerebral artery (ACA)
puzzling, key symptoms of brainstem func- (5) through a natural opening (tonsillar hernia- infarction due to transfalcine herniation in
tional impairment in a patient at risk are as tion at the foramen magnum; (6) or through bony case of frontal lobe midline shift or posterior
follows: defects such as the ones created during brain cerebral artery (PCA) infarction due to tran-
surgery (craniectomy sites; 4) or natural defects stentorial herniation (which may also occur
■ Dynamic decrease of the level of conscious- (encephaloceles). from posterior masses). See Figure 17.
ness: somnolence S sopor S coma. Therapy: Intervention for increased ICP is
■ Pupillary changes: especially bilateral either medical or surgical. Goal is to pro-
small pupils, anisocoria, bilateral wide vide treatment that shrinks the brain and
pupils. While often a developing hemiparesis is reduces associated tissue pressures. This
■ Pyramidal signs (especially Babinski). contralateral to the causative lesion (due to includes such measures as improving ve-
■ Abnormal breathing patterns: pausing, axial downward stress to ipsilateral pedun- nous outflow via elevation of the head, hy-
hyperventilation. cular long tracts before their decussation), perventilation for vasoconstriction, osmot-
■ Abnormal body posturing such as decor- an ipsilateral hemiparesis can develop by ica for volume contraction, and steroids to
tication and decerebration (see earlier). displacement of the upper brainstem lead- decrease vasogenic edema in nontraumatic
■ Abnormal motor reaction to painful ing to tentorial force on the contralateral cases.
stimuli. cerebral peduncle (Kernohan’s notch). Thus, Surgical options depend on the scenario

The Head and Neck

■ Development of hemiparesis. in case of a patient with primary left su- and patient eligibility and are aimed at

Fig. 17. Hemorrhage into a left subtotal MCA infarction: Note radiographic signs (points b to d from the above text list) of
transtentorial herniation as mentioned in the text. Note apparent shift of pons and associated changes in perimesencephalic
cisterns.

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 437 10/29/11 12:15:17 AM

 438 Part III: The Head and Neck

(a) eliminating the offending mass that cre- infarction,” for example, ACA occlusion due spect to surgical versus nonsurgical treat-
ates such pressure and (b) forming a space to transfalcine herniation or PCA occlusion ment. According to a pooled analysis of
by creating a skull defect to allow brain ex- due to transtentorial herniation. these trials, the case fatality rate was sig-
pansion to occur and thus significantly low- The primary goal of surgical interven- nificantly reduced comparing decompres-
ering the resulting net tissue pressure and tion is to save the patient’s life and also to sion (29%) versus conservative treatment
reducing midline shift and herniation. limit the functional deficit. Several studies (78%), the absolute risk reduction was 50%,
Neurosurgical strategy, approach, and indicate that decompressive craniectomy and the functional outcome was signifi-
technique for decompression hence depend limits the progressive evolution of effects cantly better. Age appears as most impor-
on the nature of the underlying lesion, the on adjacent areas (e.g., secondary cerebral tant predictor of mortality, disability, and
actual patient systemic status, and relevant ischemia in the penumbra). For supratento- long-term functional dependence.
imaging findings. One classic example is rial strokes it has been shown that early de- Currently there are only limited data re-
decompressing craniectomy for ischemic compressive hemicraniectomy with duro- ported as to the optimal time point for sur-
stroke, which is discussed in detail later. tomy/duroplasty is the most effective gical intervention. More recently available
intervention in such circumstances, ulti- imaging techniques, such as perfusion and
Ischemic Stroke (Malignant mately resulting in interruption of this vi- diffusion MRI, may help determine the time
Media Infarction) cious cycle. It not only reduces mortality course of cerebral ischemia early after
but also improves outcome and reduces in- symptom onset, thereby allowing the clini-
Acute occlusion of any major cerebral ar- farction size. It generates space, decreases cian to decide on indication for surgical in-
tery will result in significant ischemia to ICP, alleviates mass effect, and increases ce- tervention.
the brain secondary to the lack of adequate rebral perfusion to the penumbra, allowing
perfusion given that there is no functional for retrograde perfusion via leptomeningeal Technical Considerations Concerning
collateral circulation. Resulting tissue death collaterals. Metabolically compromised but Hemicraniectomy
leads to the breakdown of the blood–brain viable parenchyma may thus survive. Opti- In order to give the brain parenchyma max-
barrier causing significant edema and mal patient selection remains to be deter-
raised ICP, which may result in herniation. imum space for swelling and allowing for
mined, but preoperative clinical signs and maximum decompression, the primary goal
Among strokes, large middle cerebral artery timing of surgery seem to influence the
(MCA) territory or hemispheric infarction in a standard hemicraniectomy for MCA in-
prognosis. farction is to remove a large bone fragment
is often characterized by early and rapid Many retrospective clinical reports have
clinical deterioration (“malignant MCA in- over one hemisphere (see Fig. 18).
indicated the significant effect of hemi-
farction”) and resulting death unless a life- craniectomy on survival of MCA infarction ■ Trauma flap: fronto-parieto-temporal.
saving intervention is performed. patients, several of them also pointing to ■ Margins:
The clinical picture of total MCA infarc- positive results concerning functional out- ■ Anteriorly: superior border of orbital
tion is characterized by severe sensorimo- come. rim, avoiding frontal sinus
tor hemisymptoms, head and eye deviation Data of three randomized controlled tri- ■ Posteriorly: 2 cm posterior to external
to the side of the lesion, hemi-inattention, als are currently available, that is, DECI- meatus
and global aphasia (dominant hemisphere), MAL, DESTINY, and HAMLET. All of them ■ Medially: 2 cm lateral to midline, avoid-
accompanied by an early deterioration of show significant rates of survival with re- ing superior sagittal sinus
consciousness and need of mechanical ven-
tilation. Main causes are thromboembolic
and atherothrombotic occlusions of proxi- Brain
mal MCA or ICA. Such complete MCA in- Cranium (skull)
farction represents about 1% to 10% of all
supratentorial ischemic strokes and occurs
at an incidence of 10 to 20/1,000,000/year; 1. Pressure from
compared to other stroke types, it tends to Dura mater brain swelling is
affect women more likely and occurs at relieved by
younger ages. It is associated with a signifi- creating more
cant mortality and morbidity rate of up to room.
Skin
80%.
Early diagnosis and initiation of aggres-
sive therapy are determinants of outcome.
In most cases, developing brain edema can- Fat deposits
not be adequately treated by conservative
means alone. Parenchymal edema is mainly
due to ischemia resulting in cytotoxic cellu-
lar reaction. Its effect peaks ⬃1 to 5 days af-
ter the insult. The term “malignant” is used
for such cases when brain swelling is start-
ing early (within 24 to 48 h) and results in
significant mass effect. Extensive edema and
marked elevation of ICP may cause second-
ary brain damage via ischemia of neighbor-
ing brain areas and can lead to “bystander Fig. 18. Hemicraniectomy.

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 438 10/29/11 12:15:17 AM

 Chapter 34: Neurosurgical and Neurological Emergencies for Surgeons 439

■ Inferiorly: just above the ear cartilage, include a definite duration criterion for SE. ance; antiepileptic drug (AED) serum
that is, floor of middle fossa GCSE has often been defined as ⬎30 min- level drop caused by intercurrent dis-
utes’ seizure activity or a series of seizures ease (e.g., gastrointestinal) or pharma-
Mentioned below are the steps involved in without return to full consciousness be- cological interaction (after prescription
hemicraniectomy: tween the individual seizures. Notably, even of an interacting drug); intercurrent
■ Reflect temporal muscle anteriorly a short period of seizure activity may cause infection/febrile disease; and complica-
■ Place several burr holes neuronal injury and self-limitation is really tion acquired during a preceding seizure
■ Store bone fragment in abdominal pouch rare after 5 minutes. (intracranial hemorrhage, CNS trauma).
or cryo-conservated So, do not miss a new acute/subacute
■ Remove sphenoid wing Epidemiology and Etiology cause unrelated to preexisting epilepsy!
■ Tack up dural edges to bony margins SE incidence is estimated to occur in 10 to 20 ■ First manifestation of a idiopathic/cryp-
■ Open dura via stellate or c-shaped inci- cases per 100,000 per year and is increasing togenic seizure disorder.
sion with age. Approximately 50,000 to 200,000 ■ Acute and subacute symptomatic CNS
■ Perform duraplasty (periosteum, tem- cases occur per year in the United States. disease.
poral fascia) Males and females are affected nearly
Notably, any CNS disease may be associated
equally. SE affects all age groups but more
This emergent intervention generates an with the development of acute seizures in-
frequently at the extremes of age (i.e., in
⬃10 cm ⫻ 15 cm calvarial defect with a neonates it is related to hypoxic injury or
cluding SE, which can be the first symptom
lower margin that should be extending ⬍1 metabolic disease and in elderly people it is
also.
cm to the floor of the middle cranial fossa. If Given that such causes might also occur
related to stroke).
the bony opening is too small (⬍8 cm ⫻ 8 Overall mortality rate is as high as 20%
as secondary change (e.g., infarction due to
cm), it can lead to parenchymal injury from vasospasms because of SAH, or intracranial
but may exceed 50% in prolonged SE cases,
persistent pressure at the craniectomy mar- infection after any open surgery, or general-
and death often relates to underlying cause,
gins with subsequent infarction. It must be ized edema due to metabolic derangement
unsuccessful treatment, or SE complica-
emphasized that this type of emergent sur- due to sodium loss because of diuretic treat-
tions.
gery is a dramatic event and justified only ment), any of these scenarios must be con-
Systemic SE complications are (a) ex-
as a life-saving measure. It is to be noted sidered regardless of primary cause of hos-
cessive catecholamine release leading to
that secondary to the significant compro- pitalization.
hypertension, tachycardia, cardiac arrhyth-
mise, from among most of these patients mia, hyperglycemia, and lactic acidosis; (b)
sustained from their TBI, only 55% of the Important Notes
hyperpyrexia promoted by excessive mus-
survivors answered “yes” to the question: cular activity; (c) hypoxia from impaired ■ Classic GCSE is easily recognizable at the
“whether they would have liked the surgery ventilation, pulmonary edema; and (d) bedside by the typical rhythmic tonic–
being performed on them in this setting.” myoglobinemia due to muscular destruc- clonic activity. Rarely, SE presents as
Once the craniectomy has been successfully tion with danger of renal failure. persistent tonic seizure (postural, ver-
performed, one should plan on elective re- Causes of SE may be roughly divided into sive fits).
pair 8 to 12 weeks thereafter to reconstruct three groups (Table 13): ■ Rapid repeated and prolonged extensor

The Head and Neck

the calvarial defect. and/or flexor movements or posturing
■ Exacerbation of a known seizure disorder may be confused with clonic activity but
(irrespective of known or unknown eti- rather characterizes nonepileptic at-
Seizures: Status Epilepticus ology) occurs in up to 50% of the cases. tacks (“psychogenic status”). Typical is
Background Triggering factors include noncompli- the “waxing and waning”—character of
“Status epilepticus (SE)” is a term describ- motor symptoms. EEG is normal during
ing any type of prolonged, sustained, or fast the attack (monitoring!).
repetitive seizure activity and can occur in ■ Suspect persisting SE in any patient not
the setting of TBI or not. It does represent a Table 13 Causes of Status regaining consciousness within the reg-
life-threatening emergency. Most relevant Epilepticus ular timescale after a witnessed grand
status types are as follows: Infection (e.g., meningitis, encephalitis, brain mal seizure (subtle status or NCSE); here
■ Generalized convulsive status epilepticus abscess) EEG is mandatory within 30 minutes
(GCSE; “Grand Mal”-Status). Ischemic stroke (Fig. 19).
Subarachnoid hemorrhage ■ Suspect NCSE in all otherwise unex-
■ Nonconvulsive status epilepticus (NCSE)
and subtle status—SE without major
Neoplastic lesion (primary CNS tumor, plained coma or significant disturbance
metastasis) of consciousness regardless of under-
motor activity; important cause of pro-
longed impairment of consciousness Trauma lying primary cause, especially in the
Systemic disease affecting the CNS, for ICU. NCSE is not rarely the cause of
or unexplained coma; often developing example, eclampsia
out of a GCSE when epileptic activity on unexplained coma, especially in TBI pa-
Toxic etiology (e.g., amphetamines) tients.
EEG outlasts the end of clinical motor Metabolic encephalopathies (e.g., hypona- ■ Repetitive generalized myoclonus in a
activity. tremia, hepatic encephalopathy)
■ Simple partial SE—most frequently as- comatose patient following diffuse hy-
Hypoglycemia poxic brain injury may mimic general-
sociated with certain conditions, for ex- A variety of medications, notably sympath-
ample, chronic focal encephalitis. ized seizures; it poorly responds to AED
omimetics treatment because its pathophysiology
The International League against Epi- Alcohol withdrawal is likely not epileptic; it usually carries a
lepsy (ILAE) classification of SE does not Hypoxic injury poor prognosis.

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 439 10/29/11 12:15:18 AM

 440 Part III: The Head and Neck

Armin SS, Colohan AR, Zhang JH. Traumatic suba-

rachnoid hemorrhage: our current understand-
ing and its evolution over the past half century.
Neurol Res 2006;28(4):445–52.
Benzel E, Day W, Kesterson L. Civilian cranioce-
rebral gun shot wounds. Neurosurgery 1991;
29:67–72.
Berrouschot J, Sterker M, Bettin S, et al. Mortality
of space-occupying (‘malignant’) middle cere-
bral artery infarction under conservative inten-
sive care. Intensive Care Med 1998;24(6):620–3.
Chen CC, Cho DY, Tsai SC. Outcome and prognos-
tic factors of decompressive hemicraniectomy
in malignant middle cerebral artery infarction.
J Chin Med Assoc 2007;70(2):56–60.
Chen C, Smith ER, Ogilvy CS, et al. Decompres-
sive craniectomy: physiologic rationale, clini-
cal indications, and surgical considerations.
In: Schmidek HH, Roberts DW, eds. Schmidek
and Sweet’s operative neurosurgical techniques;
indications, methods, and results, 5th ed., Vol.
1. Philadelphia, PA: Saunders/Elsevier; 2006:
70–80.
Curry WT Jr., Sethi MK, Ogilvy CS, et al. Factors as-
sociated with outcome after hemicraniectomy
for large middle cerebral artery territory infarc-
tion. Neurosurgery 2005;56(4):681–92.
DeLorenzo RJ, Pellock JM, Towne AR, et al. Epide-
miology of status epilepticus. J Clin Neurophy-
siol 1995;12(4):316–25.
Department of Health and Human Services Cen-
Fig. 19. Characteristic rhythmic epileptic EEG activity from a case of NCSE. ters for Disease Control and Prevention. Iraq &
Afghanistan veterans of America. Morb Mortal
Wkly Rep 2007;56:167–70.
Doerfler A, Engelhorn T, Heiland S, et al. Perfusion-
MRI for monitoring of decompress craniecto-
my in experimental hemispheric stroke. Stroke
■ Important seizure and SE-related in- First line Benzodiazepines, especially 1999;30:275.
juries may include severe tongue bites lorazepam ⬎ diazepam ⬎ Doerfler A, Forsting M, Reith W, et al. Decompres-
with the need of surgical therapy, joint midazolam sive craniectomy in a rat model of “malignant”
dislocations and fractures, head and/or Second line Phenytoin/fos-phenytoin
cerebral hemispheric stroke: experimental sup-
facial trauma, rhabdomyolysis with dan- port for an aggressive approach. J Neurosurg
ger of renal failure, and aspiration. Third line Possibly: phenobarbital, 1996;85:853–9.
propofol, valproate, Emery, E. Hidden wounds plague GIs. Denver Post.
Since prolonged GCSE will cause severe levetiracetame April 16, 2007.
CNS damage, it is paramount to diagnose Erban P, Woertgen C, Luerding R, et al. Long-term
Ultima ratio General anesthesia outcome after hemicraniectomy for space oc-
and aggressively treat this condition from
cupying right hemispheric MCA infarction. Clin
the very beginning in the general surgical Guidelines differ among countries and Neurol Neurosurg 2006;108(4):384–7.
population until a root cause has been iden- the United States and Europe. Fandino J, Keller E, Barth A, et al. Decompressive
tified or excluded. craniotomy after middle cerebral artery infarc-
Surgical Treatment tion. Retrospective analysis of patients treated
Treatment in three centres in Switzerland. Swiss Med Wkly
Besides surgical treatment of the primary 2004;134(29–30):423–9.
General Notes cause of SE, if necessary, and AED pharma-
Determine and correct glucose level if nec- Foerch C, Lang JM, Krause J, et al. Functional im-
cotherapy, a surgical intervention can be pairment, disability, and quality of life outcome
essary; substitute thiamine and folate (es- discussed in selected cases of refractory SE, after decompressive hemicraniectomy in ma-
pecially in alcohol withdrawal); optimize for example, in Rasmussen’s encephalitis or lignant middle cerebral artery infarction. J Neu-
supportive care (blood pressure, oxygen); malformation of cortical development. Re- rosurg 2004;101(2):248–54.
establish cardiovascular monitoring; mea- Gennarelli GA, Graham DI. Neuropathology In: Sil-
peatedly, successful surgical SE treatment ver JM, McAllister TW, Yudofsky SC, eds. Text-
sure AED levels in cases of preexisting has been reported, usually from partial epi-
epilepsy prior to acute treatment, perform book of traumatic brain injury. Washington DC:
lepsy with strong semiological imaging and American Psychiatric Association; 2005:27–33.
extensive laboratory testing early and con- electroclinical signs indicating the active Granacher RP. Traumatic brain injury: methods
sider CSF analysis. area. for clinical and forensic neuropsychiatric assess-
ment, 2nd ed. Boca Raton, FL: CRC Press; 2007.
Medical Treatment Gupta R, Connolly ES, Mayer S, et al. Hemicraniec-
It is recommended to establish a specific in- SUGGESTED READINGS tomy for massive middle cerebral artery terri-
house standard algorithm. The general tory infarction: a systematic review. Stroke
Andrews BT. Head injury management. In: 2004;35(2):539–43.
principles of SE drug treatment can be sum- Andrews BT, ed. Intensive care in neurosurgery. Hammeke TA, Gennarelli TA. Traumatic brain
marized as follows: New York: Thieme Medical Publishers; 2003:12. injury. In: Schiffer RB, Rao SM, Fogel BS, eds.

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 440 10/29/11 12:15:18 AM

 Chapter 34: Neurosurgical and Neurological Emergencies for Surgeons 441

Neuropsychiatry. Hagerstown, MD: Lippincott Krieger DW, Demchuk AM, Kasner SE, et al. Park J, Kim E, Kim GJ, et al. External decompres-
Williams & Wilkins; 2003:1150. Early clinical and radiological predictors of sive craniectomy including resection of tem-
Harscher S, Reichart R, Terborg C, et al. Outcome fatal brain swelling in ischemic stroke. Stroke poral muscle and fascia in malignant hemi-
after decompressive craniectomy in patients 1999;30(2):287–92. spheric infarction. J Neurosurg 2009;110(1):
with severe ischemic stroke. Acta Neurochir Kuchta J, Klug N, Ernestus RI. Nonconvulsive sta- 101–5.
2006;148(1):31–7. tus epilepticus as a possible cause of coma in Porth, C. Essentials of pathophysiology: concepts of
Holtkamp M, Othman J, Buchheim K, et al. Pre- neurosurgical intensive care. Current Eur Neu- altered health states, 3rd ed. Hagerstown, MD:
dictors and prognosis of refractory status epi- rosurg 2009;70:176–9. Lippincott Williams & Wilkins; 2010.
lepticus treated in a neurological intensive care Langlois J ScD MPH, Rutland-Brown W MPH; Sauaia A, Moore FA, Moore EE, et al. Epidemiol-
unit. J Neurol Neurosurg Psychiatry 2005;76(4): Wald M. The epidemiology and impact of trau- ogy of trauma deaths: a reassessment. J Trauma
534–9. matic brain injury: a brief overview. Journal of 1995;38(2):185–93.
Huttner HB, Schwab S. Malignant middle cerebral Head Trauma Rehabilitation 2006;21(5):375–8. Scalea TM. Does it matter how head injured pa-
artery infarction: clinical characteristics, treat- LaPlaca MC, Simon CM, Prado GR, et al. CNS trau- tients are resuscitated? In: Valadka AB, An-
ment strategies and future perspectives. Lanc ma. In: Weber JT, Mass AIR, eds. Neurotrauma: drews BT, eds. Neurotrauma: evidence-based
Neurol 2009;8:949–58. new insights into pathology and treatment. El- answers to common questions. Stuttgart/New
Jaramillo A, Góngora-Rivera F, Labreuche J, et al. sevier Science; 2007:13–19. York Thieme; 2005:3–4.
Predictors for malignant middle cerebral artery Lhatoo SH, Alexopoulos AV. The surgical treatment Schwab S, Steiner T, Aschoff A, et al. Early hemi-
infarctions: a postmortem analysis. Neurology of status epilepticus. Epilepsia 2007;48(8):61–5. craniectomy in patients with complete middle
2006 28;66(6):815–20. Lowenstein DH. Status epilepticus: an overview of cerebral artery infarction. Stroke 1998;29(9):
Jüttler E, Schwab S, Schmiedek P, et al. Decom- the clinical problem. Epilepsia 1999;40(1):S3–8. 1888–93.
pressive surgery for the treatment of malignant Lowenstein DH, Bleck T, Macdonald RL. It’s time Spendel M, Lanner G. Operative decompression in
infarction of the middle cerebral artery (DES- to revise the definition of status epilepticus. malignant brain infarction. Neurologia Croatica
TINY): a randomized, controlled trial. Stroke Epilepsia 1999;40(1):120–2. 2007;56(5):21–7.
2007;38(9):2518–25. Marion DW. Pathophysiology and treatment of in- Sullivan PG, Rabchevsky AG, Hicks RR, et al. Dose
Kasper EM, Luedi M, Kasper BS. Gunshot injuries tracranial hypertension. In: Andrews BT, ed. In- response curve and optimal dosing regimen of
to the head. In: Velmahos G, Degiannis E, Doll tensive care in neurosurgery. New York: Thieme cyclosporin A after traumatic brain injury in
D, eds. Penetrating trauma: a practical guide to Medical Publishers; 2003:52–3. rats. Neuroscience 2000;101(2):289–95.
operative technique and perioperative manage- Mayer SA, Claassen J, Lokin J, et al. Refractory status Uhl E. Decompressive hemicraniectomy for space-
ment. Springer; Heidelberg 2011. epilepticus: frequency, risk factors, and impact occupying cerebral infarction. Cen Eur Neuro-
Kaufman HH. Civilian gunshot wounds to the on outcome. Arch Neurol 2002;59(2):205–10. surg 2009;70(4):195–206.
head. Neurosurgery 1993;32: 962–4. Meierkord H, Holtkamp M. Non-convulsive status Vahedi K, Vicaut E, Mateo J, et al. Sequential-de-
Keenan T, Anthony J, Benson D. Non-contiguous epilepticus in adults: clinical forms and treat- sign, multicenter, randomized, controlled trial
spinal fractures. J Trauma 1990;30:489–91. ment. Lancet Neurol 2007;6(4):329–39. of early decompressive craniectomy in malig-
Kellie, G. An account of the appearances observed Merenda A, DeGeorgia M. Craniectomy for acute nant middle cerebral artery infarction (DECI-
in the dissection of two of the three individuals ischemic stroke: how to apply the data to the MAL Trial). Stroke 2007;38(9):2506–17.
presumed to have perished in the storm of the bedside. Curr Opin Neurol 2010;23(1):53–8. Vahedi K, Hofmeijer J, Juettler E, et al. Early de-
3rd, and whose bodies were discovered in the Monro A. Observations on the structure and func- compressive surgery in malignant infarction of
vicinity of Leith on the morning of the 4th No- tions of the nervous system. Edinburgh, Creech the middle cerebral artery: a pooled analysis of
vember 1821 with some reflections on the pa- & Johnson 1823:5. three randomised controlled trials. Lancet Neu-
thology of the brain. Transactions of the Medico- Narayan RK, Michel ME, Ansell B, et al. Clinical trials rol 2007;6(3):215–22.
Chirurgical Society of Edinburg, 1824;1:84–169. in head injury. J Neurotrauma 2002;19(5):503–57. Waterhouse EJ, DeLorenzo RJ. Status epilepticus

The Head and Neck

Kleweno CP, Zampini J, White A, et al. Survival Nkwuo N, Schamban N, Borenstein M. Selected in older patients: epidemiology and treatment
after concurrent traumatic dislocation of the oncologic emergencies. In: Marx JA, ed. Rosen’s options. Drugs Aging 2001;18(2):133–42.
atlanto-occipital and atlanto-axial joints: a emergency medicine: concepts and clinical prac- Teasdale G, Jennet B. Assessment of coma and im-
case report and review of the literature. Spine tice, 6th ed. Philadelphia, PA: Mosby Elsevier; paired consciousness: a practical scale. Lancet
2008;33(18):659–62. 2006. 1974;2:81–4.

EDITOR’S COMMENT As Dr. Kasper writes in the introduction, actual injury to the brain, which results in the
there are ⬃1.5 million moderate to severe head death of a number of areas of brain cells.
injuries in the United States each year, and there
This chapter is not necessarily intended to be are in addition, we are beginning to note, ⬃1.6 to 1. Cerebral blood flow, which is normally auto-
concerned with the isolated brain injury as much 3.8 million sports-related traumatic brain inju- regulated for systemic blood pressure between
as it was to deal with brain injury which com- ries each year as well. Traumatic brain injury is 80 and 160, will give adequate cerebral perfu-
pounded other types of injury. Nonetheless, an the cause of at least 52,000 deaths, and traumatic sion. When hypotension occurs as a result of
essential knowledge, although minimal for the injury is the leading cause of disability in children trauma, autoregulation, which is a major pro-
trauma surgeon with respect to head injury, which and adults from 1 to 44. At least 5.3 million Amer- tective mechanism for the brain, is disrupted,
may either be individual or may complicate other icans currently live with disabilities resulting so that cerebral blood flow, which is autoregu-
more major forms of trauma, seems to be essen- from traumatic brain injuries. It is possible that lated to generate an adequate cerebral perfu-
tial in this society in which we find ourselves with a number of these could have been prevented sion pressure, assumes for the most part the
a significant amount of high-speed trauma in to or the causal after-effects could have been pre- perfusion pressure of a mean blood pressure,
which our injured are placed. It does us little good vented from better-informed treatment of these which may be hypotensive. If the brain is in-
to have a superb resuscitation, arresting of liver traumatic brain injuries. jured, the episodes of hypotension and meta-
bleeding, doing splenectomies, having the ortho- We have learned a great deal from the combat bolic imbalance cause secondary brain injury.
pedic service, repair fractured femurs, etc., only experience of our soldiers in Iraq and Afghani- 2. On the other hand, other than perfusion, the
to lose the patient because of a traumatic head stan, and one-third of the soldiers who are admit- intracranial pressure is perhaps the most
injury that was poorly taken care of. Thus, on Dr. ted to Walter Reed do so because of traumatic damaging. Normal intracranial pressure is
Kasper’s suggestion, I included a chapter on brain brain injury. very low; it is 15 cm of water and below. Since
injuries in an effort to make surgeons aware of There are two main sources of the residual the brain resides in the cranium, and this is a
what they can and cannot do. of traumatic brain injury, and all of them are the rigid compartment, it does not take much to

(continued)

www.medicalebookpdf.com

LWBK892_c34_p426-441.indd 441 10/29/11 12:15:20 AM

 442 Part III: The Head and Neck

disrupt this rather low intracranial pressure. Initially, a patient may look pretty reason- of nine or less is serious and usually involves a
Most of the volume of the skull is made up able when he comes in, and since it is rare that focal neurological deficit, thought of as possibly
of brain parenchyma (80%); 10% is cerebro- either the trauma surgeon or the person taking reversible and some residual possible. A severe
spinal fluid, and remaining 10% is blood. An care of the neurological status is at the scene, a traumatic brain injury results in a Glasgow Coma
acute increase in intracranial pressure is fatal. careful history, if it can be obtained, is critical. A Score of five to eight and a critical traumatic brain
Most of the time, when we are concerned as record of vital signs and first examination should injury results in a Glasgow Coma Score of three
trauma surgeons with traumatic brain injury, be mandatory. Was there any evidence of seizure or four, with few survivors. This is a very detailed
we are concerned with intracranial pressure, activity or progressive obtundation? Was the pa- chapter, and I do not want to burden the reader
monitoring it, and attempting to keep it below tient involved in alcohol or drugs? If the patient with the kind of repetition of what the person tak-
certain levels. was accompanied on the way to the hospital, ing care of the patient needs to know. However,
what was the cause of the evolution of the situ- it is quite important that the trauma surgeons be
We know we cannot alter the events of the trau- ation? If the patient became unconscious and a knowledgeable and know the prognosis and the
matic brain injury. Thus, what is necessary to hap- pupil dilated up, we need to know when that outcomes of the various scores and which type of
pen is that we must keep the patient from deterio- happened. All of these things should be a part of progression neurologically or lack of progression
rating as 50% to 60% do during a hospitalization as trauma Level-I protocol, which hopefully most of will be fatal. Not to do so will jeopardize the pa-
a result of secondary injury. The latter, which may our patients will come in at. As far as the most tient, and one gets into types of priorities, which
ultimately cause increase in intracerebral pressure life-threatening aspect of the patient’s survival, leads to the death of the patient.
and brain herniation, are things which perhaps that is a blown pupil, if it did occur en route, or if
can partially be obviated. The causes for second- A Final Mention of Special Cases: The special case
it were present at the time when the patient was is of the elderly with what seems to be a trivial
ary brain injury are the following: first found, we must know about it; the cause of fall and is on warfarin for chronic atrial fibrilla-
1. Edema; the blown pupil may indicate which side is filling tion. I have spoken out against this for several
2. Change in cerebral blood flow (CBF), usually with a space-occupying lesion, and we need to years, as continued atrial fibrillation need not
decreased; know which side this is happening with. be anticoagulation for ⬎2 years with warfarin as
3. Hypercapnia, which can be controlled by a The Glasgow Coma Scale the presumed clot in the atrial appendage is epi-
ventilator; This is absolutely essential for the people involved thialized. However, the mortality of the elderly on
4. Acidosis, likely to occur with injury, but pos- with trauma or for that matter for anyone else to warfarin with a seemingly trivial injury is 40%. As
sible to forestall; know what type of Glasgow Coma Score is present described in a fine section of Chapter 6, there are
5. Alterations in metabolism, some of which are initially and then upon admission. Each trauma numerous new oral anticoagulants and at least
subtle and cannot be avoided; surgeon should be able to have by heart the way one, apixaban (Pfizer and Bristol-Myers Squibb),
6. Changes in neurotransmitters and receptor in which Glasgow Coma Scores are assigned. It has bested warfarin in a head-to-head clinical
activity, which are likely the result of other probably is easier to have a general range for what trial—perhaps more rapid reversal. Others seem
changes and are really beyond our capacity to the Glasgow Coma Score is. The normal Glasgow to fill the same criteria.
deal with; Coma Score, as we know, is 15, and impaired alert- The high mortality under these circumstances
7. Excitotoxicity; ness or memory leads to a somewhat decrease in seems to have escaped notice.
8. Infection and abscess formation. the Glasgow Coma Score. A Glasgow Coma Score J.E.F.

35 Tracheotomy
Paul F. Castellanos

INTRODUCTION omy, each done as quickly as possible in the have to be taken, ventilator and all, to the
context of an arrest with the single-minded operating room (OR). Concerns about the
The surgical access to the airway has three indication being the preserving of the pa- potential for great and dire complications
spheres, each with different distinct anatom- tient’s life. While the surgical anatomy is have made this sphere slow to evolve and
ical considerations and clinical indications. relevant in the general sense, it is far less of fraught with controversy.
These are the open surgical tracheotomy, the an issue than getting a tube into the airway
emergency tracheotomy or cricothyrotomy, by whatever means as quickly as humanly OPEN SURGICAL
and the percutaneous dilatational tracheot- possible. This, therefore, involves relegating TRACHEOTOMY
omy (PDT). The first two have a wide range of the process of airway protection and reduc-
described techniques each with advocates ing the risk of complications to the surgical General Issues and Indications
and detractors. The indications for a surgical aftermath of the successful emergency pro-
open tracheotomy include: the securing of cedure. The primary indication for tracheotomy is
the airway for its prolonged intubation and PDT is a relatively new sphere of airway the bypassing of the larynx when prolonged
mechanical ventilation; the bypass of the up- surgery generally performed at the bedside intubation is necessary to reduce the risk
per airway for ventilatory protection, per- within the intensive care unit (ICU) with of airway stenosis and secure airway ac-
haps in preparation for major head and neck minimal surgical instrumentation and sim- cess. Apart from these, other indications
surgery; and the establishment of the airway ple surface anatomy guidance. The process include the treatment of airway obstruc-
below a narrowing to enable safe respiration includes, in most circumstances, some tion and the protection of the airway in an-
after the structures above this point have be- means to see into the airway such as a flex- ticipation of head and neck surgery. The
come scarred, most often after prolonged ible or rigid video endoscope to establish timing of when to consider this operation
orotracheal intubation. where you are entering the airway from in the context of prolonged intubation is
Emergency airway access techniques in- within. It is indicated for the critically ill both critical and controversial. There are
clude cricothyrotomy and “slash” tracheot- ventilated patient who would otherwise data that support a 10- to 12-day window

www.medicalebookpdf.com

LWBK892_c35_p442-452.indd 442 10/28/11 5:07:27 PM

 Chapter 35: Tracheotomy 443

of intubation as the target for converting there is essentially no chance they will ever protect the trachea and reduce the stenosis
from orotracheal intubation to tracheot- be decannulated. Examples of such condi- risk (Fig. 2). Leaving one or two undisturbed
omy access. Having performed many bed- tions include huge strokes, extensive brain rings below the cricoid is also beneficial to
side laryngoscopy procedures in the con- injury, or high quadriplegia. The second increase the protection to the cricoid.
text of tracheotomy, I have found a huge scenario is in the care of patients with in- Erosion up toward the larynx is com-
variability in the degree of laryngotracheal tractable aspiration who are being treated mon, particularly in obese patients or those
injury associated with prolonged intuba- by one of a variety of laryngeal closure or with very short necks. These body types
tion. I have developed a strategy for antici- diversion techniques and need a permanent promote the development of stenosis by the
pating the need for conversion to trache- stoma to avoid airway obstruction if the upward displacement of the cannula and
otomy. cannula ever fell out or became plugged the consequent disrupting of the anterior
Younger patients are commonly able to and had to be removed. In both cases, this tracheal wall. The classic surface appear-
tolerate longer intubations. This does not technique allows a low maintenance stoma ance is of a tracheostomy wound with a
apply to children whose airway care is out and the safety of a channel that will remain dense vertical scar beneath it indicating
of the scope of this work. The closed head open for hours to days with no cannula at that the initial entry point into the airway
injury patients, who tend to be younger, are all in many cases. The down side is that if was far lower than it ended up (Fig. 3). A
an exception to this generalization because the clinical assessment is incorrect and the higher cannula placement point can there-
they tend to be constantly fighting to get person’s condition does improve, the stoma fore be justified in these patients to help
the ETT out of their throats, bucking and will have to be closed by a somewhat exten- avoid this. Moving quickly to decannulation
coughing. The pure physical erosion of this sive operation. is more important in this population. They
process is very damaging to the larynx and can be considered to be at a very high risk of
the constant “combat” is intrinsically dan- Open Tracheostomy Techniques post tracheotomy complications.
gerous. They either need to be converted to The technique I advocate for a “mature
a tracheotomy or extubated in a controlled There are innumerable techniques for per- stoma” tracheostomy involves the genera-
way as soon as prudent. This may be within forming a tracheotomy and a tracheostomy tion of laterally based cartilage flaps sewn
the first 2 to 3 days of their care. Conversely, (Fig. 1). The distinction between the two is to the skin by multiple buried absorbable
the comatose patient who needs no seda- of a surgically mature stoma in the latter, sutures (I use 4-0 PDS on a taper needle like
tion and who has some chance of spontane- though both involve an opening or “otomy” an RB-1) (Fig. 4). I use a vertical incision
ous recovery will often have a pristine lar- into the trachea as an intrinsic feature of the through two rings in the midline connected
ynx even after 2 or 3 weeks of OT intubation. operation. Vertical or transverse skin inci- above and below by a generous transverse
They do not cough. They do not swallow. sions are often debated. The vertical is more incision. This is termed an “I” flap by virtue
They just lay there. The other consideration easily made with little risk of needing to li- of the shape of the capital letter “I.” The car-
is to get them out of a unit by converting gate large anterior jugular veins but heals tilage of each flap is supported by lateral
them over to a tracheotomy. This is a care less well than a transverse incision that can axial blood and mucosa, so there is no “ran-
and logistics issue not related to avoiding be put into a skin crease. The deep dissec- dom” feature to the support of this tissue
injury to the larynx. tion often includes the need to either divide that may promote iatrogenic stenosis. All
On the other end of the spectrum is the or reposition the thyroid isthmus. Dividing the suture materials I use in this technique

The Head and Neck

patient with known or suspected extra- it gives a broad access to the trachea but are absorbable so as to avoid the need for
esophageal reflux. Even a couple of days of makes a much bigger wound with a larger suture removal from a difficult to access
intubation in these patients can result in amount of devitalized tissue within it in the area. I also place all of my sutures while the
profound ulcerative laryngitis and edema. form of cauterized or suture-ligated thyroid. patient is still intubated from above through
These patients commonly fail extubation Therefore, this wound is more apt to drain the larynx so that there is no encumbrance
for unclear reasons after having been and become fetid. Conversely, the potential from the respiratory circuit coming through
weaned off the ventilator, but still get a tra- for inadvertent decannulation is lower and the skin while trying to sew the cartilage
cheotomy because additional efforts at ex- the ease of replacing the cannula is far flaps down (Fig. 5; see also Figs. 2 and 4).
tubation also fail. They are a group of pa- greater in the wound with the additional
tients I refer to as having an “at risk” airway. dissection. I personally favor leaving the Complications of Tracheotomy
Apart from their reflux-related throat dis- thyroid isthmus intact to reduce the wound
ease, other factors that can alone or in problems and to support the cartilage in the I have found no technique that enables one
concert produce this increased risk of vicinity of the tracheotomy by the extensive to avoid all of the common complication of
airway edema and vulnerability are: immu- blood supply that the thyroid provides to this procedure. These are: inadvertent decan-
nosuppression; microvascular disease; dia- the trachea. I suture the cannula base to the nulation, or the loss of the airway from the
betes mellitus; and history of recent airway neck to secure it against inadvertent re- separation of the trachea from the airway ap-
instrumentation. In the context of these moval until the track has “formed.” pliance; local infection; stenosis or cicatricial
additional risks, my recommendation is to The type of tracheal incision is also an scarring above, within, or below the airway
proceed with an early tracheotomy to pro- area of great controversy. My recommenda- entry point; cartilaginous or membranous
tect the larynx. The trachea is also at risk tion is to avoid disrupting the circular integ- tracheomalacia; and the potential of injury
from all of these factors. See below in the rity of the trachea as much as you can. Keep- to the critical neighboring structures such as
complications section to address this is- ing the axial blood supply is very beneficial to the esophagus posteriorly and the innomi-
sue. eventual safe decannulation without signifi- nate artery anteriorly. Internal disruption of
The surgically matured tracheostomy is cant stenosis (see section on complications). tissue is the cause of most of these complica-
indicated in a couple of clinical scenarios. A generous transverse incision is preferable tions and is sometimes contributed to by the
The first is in a patient whose neurologic to an inferiorly based (and therefore random) gradual increase in cuff volume used to main-
condition is so poor or so inexorable that cartilage flap known as a “Bjork flap” to tain minute ventilation. This de facto airway

www.medicalebookpdf.com

LWBK892_c35_p442-452.indd 443 10/28/11 5:07:27 PM

 444 Part III: The Head and Neck

Fig. 1. Steps of a typical open tracheotomy. The incision of the thyroid isthmus is a common part of the procedure, though
one I typically avoid if possible. It leaves a lot of tissues to necrose within the tracheotomy wound making the site fetid and
causing malodorous drainage. My preference is to mobilize the isthmus and draw it up or down, whichever is more anatomi-
cally convenient. The hazard is that you will not enter the airway where you want to and that the stoma position may make
for a greater tendency for stenosis of the subglottis by injuring the cricoid cartilage. If necessary, the isthmus can be taken
down sharply and hemostasis can be achieved by focal bipolar cautery and suture ligature. En mass ligation and monopolar
cautery is a much more gross, if not less effective, means for achieving the same end. (Modified from Weissler MC, Couch ME.
Tracheotomy and Intubation. In, Bailey BJ, Johnson JT, Newlands SD, eds. Head and Neck Surgery—Otolaryngology, 4th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2006.)

dilator of the infrastomal airway will eventu- ments like repeated swallowing and cough- mon complication of tracheotomy and tends
ally erode the mucosa and scar the distal tra- ing play a role in this erosive and dilatational to occur early after the procedure has been
chea. This is a very difficult clinical problem process. Because of these host factors, poten- performed and before scar has formed to
to repair. Erosion into the anterior or poste- tially dire complications can occur even un- maintain the trachea in registration with the
rior wall may also occur, thus entering the der the most meticulous attention. As a care- skin incision. This enables the tip of the can-
adjacent structures. Although, in my experi- taker of these complications, I have a list of nula to fall out entirely or to sit within a false
ence, erosion of this type is more likely the recommendation to help avoid them: (a) cuff passage anterior to the tracheal lumen. The
result of the contour and direction of the air- pressure monitoring multiple times per day patient may be able to breath, in the latter
way relative to the cannula design, the angle and (b) keeping track of the total volume in a situation, through the cannula for a short
of the tip of the cannula, the cannula’s flexi- cuff. Changes in cuff pressure and volume time but usually the loss of tidal volumes
bility, and the surface of the patient’s neck will indicate a gradual dilation of the trachea and decreased gas exchange begin to indi-
and chest. Depending on these factors, the and may herald the damage that leads to cate a problem. If the driving pressures are
tip of the tube may be pointing into the “party complications. (c) Endoscopic evaluation of increased or “bag ventilation” is employed
wall” with the esophagus or the anterior tra- the airway through the tracheotomy tube enabling far higher air pressure and volume
chea toward the largest artery of the body can guide appliance choice and its adjust- delivery, a pneumothorax soon follows and a
apart from the aorta (Fig. 6). The dilation that ment to avoid the piercing of the walls in any dire downward spiral can result. The can-
occurs, even in the absence of erosion, can be direction. If done with a “side port” attach- nula can sometimes be replaced by “feel,” if
its own disease in the form of tracheomala- ment, the circuit for ventilation is maintained the problem is caught early and the tracheal
cia. This can make the process of decannula- and the distention of the airway as it is dur- wall is still widely open. If not, manipulating
tion laborious, long, and potentially unsuc- ing normal mechanical ventilation can make the cannula can fully close off the communi-
cessful. Other factors such as the patient’s this assessment more accurate. cation between the skin and the trachea. In-
overall state of nutrition, the ventilatory Inadvertent decannulation warrants spe- tubation from above should be considered
pressures being used, and patient move- cial mention. It is possibly the most com- under such circumstances. If intubation

www.medicalebookpdf.com

LWBK892_c35_p442-452.indd 444 10/28/11 5:07:27 PM

 Chapter 35: Tracheotomy 445

Incision for mature

stoma tracheostomy

Incision for Björk Flap

tracheostomy

Trachea

Suture
Trachea

Neck skin

A B
Fig. 2. A: Generation of the “Björk Flap.” It should be clear to anyone operating on the trachea, that there is no way to main-
tain a vital blood supply to such a long and “random” strip of tissue. The two sides of cartilage at the top of the tracheotomy
are much more prone to lose their curvature if not altogether lose their strength allowing for the generation of the so-called
A-Frame stenosis. I recommend against the use of this technique and present it with the hope of describing why it should be
avoided, even as we continue to advocate it. B: The skin from the neck can be advanced to the trachea instead of the other way
around, if additional security against the dislodgement of the cannula is needed. It takes only a small amount of additional ef-
fort to enable this. In fact, the same maneuver can be extended in the circumference of the tracheotomy to generate an appro-
priately named “tracheostomy” by advancing flaps of skin on the three sides of the opening suturing each to the corresponding
part of the trachea with slowly absorbing buried monofilament sutures. (Modified from Weissler MC, Couch ME. Tracheotomy
and intubation. In: Bailey BJ, Johnson JT, Newlands SD, eds. Head and Neck Surgery—Otolaryngology, 4th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2006.)

The Head and Neck

A B
Fig. 4. Incisions and dissection that are needed
Fig. 3. A: This stoma began at the level of the transverse scar and eroded upward. The jagged edges are for a surgically matured tracheostomy, in the tru-
made up of granulation tissue and cartilage that has lost it circular shape. B: This very old tracheostomy est meaning of the term. The four divided skin seg-
lacks obvious granulation tissue but clearly has eroded up from its original starting point near the tho- ments are sewn down to the airway on each of four
racic inlet up to its ending spot below the larynx. Both patients experienced severe airway complications sides bring them to the mucosa circumferentially.
from the tracheotomies. “A” required a segmental tracheal resection prior to being able to be decan- This promotes the generation of an “ostomy” that
nulated. “B” was able to be decannulated after a series of minimally invasive procedures to widen his will be secure, require little local care, and will have
airway from the inside. to be surgically closed if it is ever no longer needed.

www.medicalebookpdf.com

LWBK892_c35_p442-452.indd 445 10/28/11 5:07:28 PM

 446 Part III: The Head and Neck

A B

Fig. 5. A: Video image of a stoma surgically “matured,” in that skin flaps were sewn to the trachea to accomplish what can
happen to a tracheotomy after it has had a cannula in place for several years depicted in “B.” B: This image, taken during an
endoscopy, provides internal illumination allowing the detection of the granulation tissue evident within the stoma that per-
sists despite the fact that this stoma has been in place for several years. See Figure 4.

from above is not successful or the patient the excellent blood supply and the vigor of not specifically designed for this purpose
has arrested, removal of the existing cannula the immune system built into our design. (Portex Vocalaid Cuffed Blue Line, Smith
and digital exploration of the wound should Nonetheless, tracheotomy sites are often Medical, OH).
be attempted. The anterior tracheal wall oozing with foul mucopurulent secretions Another factor in the generation of a
may be palpated and the opening into the and blood. This indicates a local process particular kind of post-tracheotomy tra-
trachea found. If so, an ETT can be used to that promotes stenosis and can potentially cheal stenosis is the “Bjork Flap” (see Fig. 2).
reintubate the airway and provide for some erode the mucosa within the airway. The This is a random (in vascular terms) carti-
degree of ventilation while chest tubes are most common source of these secretions is lage flap using one or two rings of anterior
being placed. The tracheotomy cannula can the oral cavity pool of saliva and oral flora; tracheal wall to anchor the trachea to the
be passed by Seldinger technique once the but the worst of all bodily fluids able to in- skin and theoretically reduce the risk of in-
situation is stabilized. Depending on why jure the airway are those from the gastroin- advertent decannulation. The problem is
the cannula became dislodged in the first testinal tract. The acid, enzyme, and bile that it can also destabilize the tracheal ring
place, it may be reasonable to introduce an flow from within the central GI tract pro- structure and that in conjunction with the
extra long cannula such as the Shiley XLT vide a perfect mix for injuring the airway to chondritis of the wound in the trachea it-
that comes with a proximal or distal extra a spectacular degree. The solution surely in- self, it promotes a straightening of the two
long segment (Mallinckrodt, St. Louis, MO). cludes avoiding reflux of GI fluids by pos- sides of the tracheal wall that then fall into
Dealing with complications such as tra- tural means, the use of gastrojejunostomy one another. I call this the “A-Frame” steno-
cheoesophageal fistula (TEF) formation technology for post pyloric feeding (the de- sis after this type of house construction (Fig.
and innominate artery fistula (IAF) should tails of which are beyond this work), and 7). Part of the problem with this complica-
be mentioned but cannot be addressed de- vigorous irrigation and suctioning of the tion is that the trachea is not actually
finitively in a work of this scope. The critical aerodigestive tract including the mouth stenotic. No amount of dilation will enlarge
issue is to avoid a tracheostomy in the con- and trachea if at all possible. The “High Low this airway pathology more than for a short
text of a known TEF unless the fistula is Evac” (Mallinckrodt, St. Louis, MO) endo- interval. The posterior wall in the segment
very high and unlikely to be at or below the tracheal tube technology, for example, will of the airway may be fully pliable and will
level of the entry point of the tracheotomy enable the cleansing of the airway above simply stretch open and back to its original
itself. Otherwise, the risk is that the can- the cuff of the tube and has been shown to shape and size afterward. There are some
nula will be placed into the fistula and the decrease infection. In my opinion, this scale transoral techniques that may help but for
esophagus will be intubated. Repositioning of cleansing would also help keep the tra- the symptomatic A-frame stenosis patient,
can be hazardous and ineffective. Dire sce- cheotomy sight healthier, too. Unfortu- a segmental tracheal resection is often all
narios are common in this setting. nately, this technology does not exist in tra- that can be done to repair this complication
The “fetid” tracheotomy wound also cheotomy cannulas to my awareness. There of tracheotomy. In my opinion, the Bjork
bears mention here. Local infection is pos- is a form of tracheotomy cannula that al- Flap is a common and controllable predis-
sible in any wound. The head and neck is lows for the delivery of air into the supras- posing factor to the development of this
famous for tolerating a high degree of con- tomal passage that could be adapted to complication, although it can form in any
tamination without infection because of cleanse the mucosa or to suction, but it is type of tracheotomy. How commonly a Bjork

www.medicalebookpdf.com

LWBK892_c35_p442-452.indd 446 10/28/11 5:07:32 PM

 Chapter 35: Tracheotomy 447

of air continues to flow through the connec- thyrotomy as the only way to go, this is
tion and of necessity maintains its patency. sometimes a very challenging access port,
This should be evaluated endoscopically by not wide enough to put a tube through
an airway clinician through the larynx without the use of the “digital dilator” or the
and through the PTF, if it is wide enough. index finger to enlarge it. The anatomy of
The surgery needed to repair airway steno- the posterior cricoid ring is also unfavor-
sis of the trachea is out of the scope of this able in that it is sloped upward and can
work. Suffice it to say, there are many such sometimes guide your endotracheal tube
options including minimally invasive tech- cephalad rather than down into the tra-
niques that could enable a safe and effective chea. The hallmark of this inadvertent pas-
widening of the airway to restore such a pa- sage is the brisk flow of air out of the mouth.
tient to normalcy. Following such care, the This often baffles the clinicians at the scene
fistula could be closed as described below. and can be confused for a posterior wall in-
Until such surgery is performed, it may be jury. The lost time in getting the airway se-
safest to replace a small cannula through cured can cause dire complications and
the fistula tract to secure the patients air- death. My approach in such circumstances
way. Even a tiny PTF can be dilated under is to turn my blade vertically and bivalve
local anesthesia to accommodate a small the cricoid (Fig. 8). When I teach emergency
metal or cuffless plastic cannula. airway management I include this adage:
A final cause of a PTF is the lack of coop- “anything you bivalve in the service of
eration on the part of the patient to occlude saving someone’s life can be repaired if the
the channel post decannulation with their patient is still alive.” The finest operation in
finger over the wound gauze when speaking the world to gain access to the airway that
or coughing. This is a presumed cause in is clean and well dissected but too slow to
children and head injury/CVA adults who maintain a life is of no value. There is one
are more apt to have this problem. Given goal and one goal only: to sustain life. That
their limited ability to concentrate or even which gets the clinician to that goal fast
understand the need to block the outflow of enough is the right choice.
air through the stoma after removal of the The contribution I offer to this sphere is
Fig. 6. Diagrammatic rendering of the anatomical cannula, it seems reasonable that a persis- of a technique I developed at the University
basis of tracheal erosion through the wall into the tent tract may follow. This may be an unre- of Maryland and the Maryland Shock Trauma
innominate artery. The curved shape of common lated coincidence, of course, since these pa- Center to enable emergency surgical access
tracheotomy cannulas is a common fit for most
tients also tend to have their cannulas in despite the chaos of a typical resuscitation.
patients but not all. Common bleeding may indi-
cate a poor shape match for a given patient. A place for a long period compared to other Getting access to the neck is very challeng-
brisk arterial bleed that stops spontaneously may groups treated as such. ing in someone who is at points being mask
be the so-called sentinel bleed of an innominate If the airway is not narrowed on endo- ventilated, going through repeated efforts at

The Head and Neck

artery fistula. This is commonly a fatal complica- scopic evaluation, the PTF can be closed in intubation, and getting chest compressions.
tion of tracheotomy. (Modified from Weissler MC, a variety of ways. My personal preference is The technique begins with the airway sur-
Couch ME. Tracheotomy and intubation. In: to generate a tube of skin at the base of the geon placing their nondominant hand on
Bailey BJ, Johnson JT, Newlands SD, eds. Head and fistula near the tracheal lumen that can be the neck with the palm under the patient’s
Neck Surgery—Otolaryngology, 4th ed. Philadel- turned into the airway by a Connell stitch chin to extend the head and draw the tra-
phia, PA: Lippincott Williams & Wilkins; 2006.) (a far, near, near, far inverting bowel suture chea out of the chest (Fig. 9). The same hand
technique invented in the late nineteenth is used to stabilize the airway by putting the
century). I then bring the strap muscles to index and third fingers on either side of the
the midline with multiple figure-of-eight trachea/larynx so as to put pressure on the
flap causes stenosis is impossible to deter- absorbable sutures such as Monocryl or paralaryngeal soft tissues and establish the
mine with any accuracy. My impression is Vicryl. I raise the skin above and below the midline of the neck. This also reduces the
that it is still not so common, having sev- PTF with a transversely oriented wound disruptive effect of the compressions on es-
eral colleagues who use this technique that when closed makes the cosmetic out- tablishing as quickly as possible surface
and don’t appear to be having these complica- come very favorable. landmarks of the airway beneath it. Once the
tions to a significant degree. airway is identified, I make a vertical cut to
The last complication of tracheotomy or Emergency Airway Surgery— open the skin. This splays the edges of the
tracheostomy worthy of mention is one that incision because of the pressure of the fin-
follows decannulation. It is known as a per-
Tracheotomy and Cricothyrotomy gers applied to trap the airway. Setting the
sistent tracheocutaneous fistula (PTF). The choice of one technique over the other scalpel down, the dominant hand is used to
When a stoma has been surgically matured is fraught with controversy. I personally will palpate the deeper tissues to verify what was
as described in the technique section above, do a tracheotomy under emergency circum- felt through the skin. The next knife cut is
or when the cannula has been left in place stances if I can. That is to say, if there is into the airway either through the trachea or
for a prolonged period of time, a cutaneous room to approach the trachea for the fenes- the CTM. The channel is palpated and when
tract forms between the surface skin and tration without any delay in the process, performing a tracheotomy, the nondomi-
the trachea that will not spontaneously that is where I will enter. If not, the crico- nant index finger is placed into the airway
close. Other reasons for a PTF include laryn- thyroid membrane (CTM) is an acceptable guiding the tube caudad. If passing the tube
gotracheal stenosis such that a large amount alternative. While some advocate the crico- through the CTM is difficult, a stylet can be

www.medicalebookpdf.com

LWBK892_c35_p442-452.indd 447 10/28/11 5:07:34 PM

 448 Part III: The Head and Neck

A B

Fig. 7. A: Endoscopic view of a patient whose airway was nearly untenable at the time of an intraoperative consult. This initial
view demonstrated no airway at all. On passage of the endotracheal tube, the channel was splayed and the patient resusci-
tated. On dilation, no change in the caliber of the airway was noted, diagnosing the classic “A-Frame” stenosis. B: View after
the first session of laser treatment of this condition by the technique of Dr. Guri Sandu. The patient avoided the need for a
tracheal resection or tracheotomy. The patient was treated with an additional laser procedure and has had a durable benefit.

used to accomplish this. A few additional ing with pressure, pending going to the OR to itself should be bivalved to enable the pas-
pearls: (a) Do not try to place a standard tra- explore and/or revise the wound. (b) An en- sage of the ETT. (d) If the patient has any
cheotomy cannula through an emergency dotracheal tube is the perfect implement means of resisting your efforts to save their
surgical access. These cannulas are not de- and a #6.0 tube fits wherever a typical adult life, wait a little while. (e) Bleeding is a good
signed to enter a small wound or one that index finger can fit. (c) If the wound in the sign that you are not too late. ( f) In my expe-
may be undissected and may become dis- CTM or the trachea is not big enough, en- rience, no one has ever made too large a tra-
rupted. In addition, there is no room to keep large it. The CTM cannot be enlarged in some cheotomy. (g) Anything divided to secure the
your finger in the wound or to control bleed- patients. In these cases, the cricoid airway can be repaired if the patient survives.
(h) Never load your own scalpel blade. (i)
And lastly, imagine your first emergency tra-
cheotomy as often as you think you may have
encountered it to gain a kind of virtual expe-
rience. This comes in very handy when you
first lay knife to skin for the real deal.

Percutaneous Dilatational
Tracheotomy (PDT)
Possible PDT is a technique sphere that is minimally
misdirection invasive and kit based (Fig. 10). It is indi-
of tube cated for nonemergency situations and de-
signed for bedside care in an ICU setting. It
is commonly performed with bronchoscopic
If incision too small, airway lumen visualization through the ex-
Subglottis
turn knife 90 degrees
and cut down
isting endotracheal tube. This approach has
dramatically altered bedside airway care in
Endotracheal tube
many parts of the world and is rapidly gain-
ing popularity in the USA and Asia. Regard-
less of the technique, taking a critically ill
patient to the OR for a tracheotomy not only
removes them from the location where he/
she is best cared for, but also adds additional
Fig. 8. The basics of an emergency cricothyrotomy. The first incision is commonly vertical and deep enough
risks related to the need to transport them
to allow for the palpation of the cricothyroid membrane. The second incision is of the membrane itself,
entering the airway. The vertical rotation illustrated is intended to widen the incision enough to allow for some distance away, rolling their IV pole(s)
the intubation by an endotracheal tube and not a tracheostomy cannula. The latter will not fit through this and their ventilator with them. The costs as-
small aperture and is not intended as an emergency appliance, though such devices do exist. (Modified sociated with OR tracheotomy are very high
from Weissler MC, Couch ME. Tracheotomy and intubation. In: Bailey BJ, Johnson JT, Newlands SD, eds. when OR time is taken into account along
Head and Neck Surgery—Otolaryngology, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.) with the personnel costs of the transport

www.medicalebookpdf.com

LWBK892_c35_p442-452.indd 448 10/28/11 5:07:41 PM

 Chapter 35: Tracheotomy 449

A B

C D

Fig. 9. Emergency airway surgery handhold technique. A: Side view of the neck anatomy with markings indicating the rele-
vant anatomy such as the thyroid notch, the cricoid, and the thoracic inlet. The vertical mark above the thoracic inlet is the
planned skin incision. B: Lateral view of the handhold placed on the airway to stabilize it and isolate the trachea in the context

The Head and Neck

of a resuscitation procedure. C: Oblique view identical to “B.” D: En face view of the procedure as it could be performed with
the scalpel ready to incise the trachea. The left hand could sit over a bag mask being used to ventilate the patient.

team and those in the OR for the surgery by the typical PDT technique or T-PDT, a (SL-PDT) has been introduced to the Oto-
itself. Bedside tracheotomy has the advan- bronchoscope is used to get the existing en- laryngology community (Fig. 11). This tech-
tage of being performed in the ICU obviat- dotracheal tube repositioned so that the tip nique differs from T-PDT in that a suspen-
ing all of the costs unrelated to the proce- of the tube is at or just above the likely entry sion laryngoscopy system is used to secure
dure itself. If done in the ICU by the open point of the trachea as viewed from within the airway such that there is no way for the
technique, there is the disadvantage of the lumen of the airway. This is in reality, a airway to be lost or the patient inadver-
needing to essentially bring the OR to the controlled partial extubation and will limit tently extubated because of the very nature
bedside. With head lights and OR trays, a the minute ventilation of some patients sig- of suspension laryngoscopy. The airway is
cautery device and drapes; tracheotomy nificantly. Most patients with high positive trapped by the orifice of a rigid laryngo-
can be performed in a manner similar to end expiratory pressure (PEEP) needs or scope and elevated with a device designed
that which is performed in the OR itself. Ac- high minute ventilation needs will not tol- to fulcrum the scope against the maxilla
cording to the advocates of this approach, erate this. Inadvertent complete extubation and a second surface, commonly the pa-
this is done in the event that a deep explo- can occur and may be followed by difficulty tient’s tray table. A new foreshortened (cut
ration of the neck is needed to control a in finding the airway and the potential for off at 20 cm) ETT is then passed into the
bleeder that might retract into the sur- dire consequences, even death. While com- airway through the rigid laryngoscope and
rounding tissues. plications on this scale are rare, the poten- the balloon is inflated within the scope and
Kit-based PDT techniques, by contrast, tial for this scale of adverse outcome has the upper larynx so as to seal the airway
are based on the surface incision of skin made the adoption of this otherwise safe within the ventilatory circuit. This enables
with the blunt dissection of the superficial and effective technique slow. This has been the delivery of the requisite tidal flow with
tissues to gain access to the tracheal wall. particularly the case by the one specialty the entire PEEP the patient needs. The in-
The operating clinician navigates through most commonly involved in tracheotomy, ternal view of the airway is accomplished
the procedure by seeing on a video monitor the Otolaryngologists. by a 30 cm ⫻ 5 mm rigid telescope. I prefer
the effect of the manipulation of the soft tis- Recently, a new approach to PDT known the 30 degree angled view to allow for
sues overlying the airway. When performed as suspension laryngoscopy-assisted PDT something of an oblique perspective to the

www.medicalebookpdf.com

LWBK892_c35_p442-452.indd 449 10/28/11 5:07:44 PM

 450 Part III: The Head and Neck

pharynx and so enables the easy placement

of a gastroscope to perform a PEG by the
same or a second care team; (i) the airway is
thoroughly evaluated in the placement of
Bronchoscope the rigid endoscopic access. This last point
warrants further elaboration: the state of
the larynx at the time of tracheotomy can
predict the potential the patient will be able
to undergo decannulation if they recover
Endotracheal
tube (pulled from their critical illness. The presence of
back to glottis) signs of impending TEF or IAF can also be
established and may serve as the basis of
aborting the operation. If necessary, the
airway can also be instrumented to remove
Epiglottis mucous plugs or tissue debris. (j) And
lastly, the basis of a “failed extubation,”
Thyroid cartilage
which is a common indication for trache-
Vocal cords otomy, can be determined such that it may
be possible to avoid a tracheotomy com-
Cricoid cartilage pletely if, for example, a large granuloma is
found to be the basis of this problem. If it
Guidewire is treated at the time of the start of the
Dilator
bedside procedure, a new effort at extuba-
tion can be justified.
Both the T-PDT and the SL-PDT tech-
Fig. 10. Anatomy and instrumentation of the typical or “traditional” percutaneous dilatational trache-
otomy technique with the flexible bronchoscopic image of the inside of the airway, the guide wire enter- niques have a role to play in a comprehen-
ing the airway ahead of the dilator in the area that is transilluminated. (Modified from Weissler MC, sive multispecialty ICU airway program;
Couch ME. Tracheotomy and intubation. In: Bailey BJ, Johnson JT, Newlands SD, eds. Head and Neck T-PDT applying to roughly half of ICU pa-
Surgery—Otolaryngology, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.) tients who need an tracheotomy but have
no special ventilatory needs such as high
PEEPs, have easy to feel landmarks, have an
anterior wall in case I am having any trou- Additional advantages of SL-PDT com- easily accessible segment of trachea, and
ble determining where to enter the airway. pared to T-PDT include: (a) bleeding can be no history of challenging airway anatomy.
Thus, the whole operation can be per- suctioned away with far larger suction ports The remainder of patients, including those
formed with the patient adequately venti- than are typical in a flexible bronchoscope; with high BMIs, poor landmarks, low
lated. There is, therefore, no rush to locate (b) obscure landmarks are not a contraindi- larynges, prior neck surgery, and even neck
the ideal position through which to enter cation since the airway can be found by the tumors, anasarca, or other types of gener-
the airway since there is no significant po- needle probing; (c) the airway itself is lifted alized edema and high/challenging venti-
tential for desaturation. In addition, should in the neck bringing it closer to the surface lator needs can virtually all be offered
the patient become unstable for any rea- and making it more rigid, facilitating the SL-PDT. The contraindications to SL-PDT
son, the procedure can be safely aborted dilatational process; (d) prior tracheal sur- include patients with trismus, uncertain
without any undue risk to the patient. A gery is not a contraindication either, since C-spine disease or kyphoscoliosis, and/or
fresh full-length ETT can simply be placed the additional force of dilation needed to the inability to tolerate a general anes-
into the laryngoscope beyond the airway open the airway can be performed more thetic. Some of these patients can have the
entry point even if the airway has already safely with a clear view of the scarred tis- T-PDT approach. This would leave a tiny
been opened through the skin. The poten- sues seen from within the trachea itself; (e) number who would have to leave the unit
tial for being able to precisely choose the the posterior and anterior walls can be seen for an OR-based tracheotomy.
point of entry warrants emphasis and elab- with ease, often at the same time, decreas- In conclusion, tracheotomy is a very im-
oration. With the clear and controlled view ing the risk of posterior wall penetration portant intervention to protect or establish
that SL-PDT technique gives, the needle and TEF; ( f) obese patients with short the airway and there are many approaches,
placement to begin the dilatational process necks and low laryngeal structures can be each of which has its advantages and risks.
can be precisely chosen. The piercing (and treated, in my opinion, more easily and Open surgery in the OR is the best way to
cracking) of a tracheal ring is all but impos- safely than by open techniques with the fashion a surgically matured tracheal
sible. It is this feature that leads me to be- SL-PDT procedure since the airway is “stoma.” Emergency airway surgery has to
lieve that SL-PDT is the most atraumatic of commonly obliquely oriented and must be be performed as quickly as it is performed
all approaches to tracheotomy. This is in approached at the thoracic inlet with an effectively. The technique presented here is
part because no significant dissection is up–angled approach so as to enter the tra- one that will enable this result. Tracheotomy
needed to gain access to the trachea. This chea at the desired location (a long needle in an ICU patient is best done at the bedside
spares the microvascular support of the is often needed to accomplish this); (g) a with a kit-based system and without leaving
perichondrium on the tracheal cartilage, rigid scope is impervious to needle punc- the unit. ICU patients with contraindica-
thus reducing the risk of chondritis, loss ture, a mishap that in T-PDT can cost US tions to T-PDT can safely have an SL-PDT
of elastic support, and cicatricial scar for- $7,000 or more to repair; (h) the suspension operation and get a thorough airway evalu-
mation. laryngoscopy elevates the larynx in the ation in the process.

www.medicalebookpdf.com

LWBK892_c35_p442-452.indd 450 10/28/11 5:07:47 PM

 Chapter 35: Tracheotomy 451

A B

C D

The Head and Neck

Fig. 11. These images are of a morbidly obese patient, the type of whom who can be treated safely with this technique given
sufficient expertise with the rigid laryngoscopy part of the procedure. This particular male was mechanically ventilated for
several weeks but considered too unstable to be transported to the OR for his tracheotomy. It was performed uneventfully at
bedside using the SL-PDT technique. A: The general view of his body habitus at bedside. B: The Storz Dedo laryngoscope in
place and extending his neck backward and his airway closer to the surface. C: A close up view of the laryngoscope, telescope,
and ventilating endotracheal tube assembly. D: The #8 Shiley XLT Proximal extra length cannula in place ventilating the pa-
tient while the Dedo laryngoscope is still in place to make sure that there is no internal airway bleeding or other problems that
need to be dealt with prior to the conclusion of the procedure.

SUGGESTED READINGS Myers EN, Johnson JT, eds. Tracheotomy: Airway

Management, Communication, and Swallow-
control. Ann Otol Rhinol Laryngol 2009;118(2):
91–8.
Bailey BJ, Johnson JT, Newlands SD, eds. Head and ing, 2nd ed. San Diego, CA: Plural Publishing; White HN, Sharp DB, Castellanos PF. Suspen-
Neck Surgery—Otolaryngology, 4th ed. Philadel- 2008. sion laryngoscopy assisted percutaneous di-
phia, PA: Lippincott Williams & Wilkins; 2006. Sharp DB, Castellanos PF. Clinical outcomes of latational tracheostomy in high risk patients.
Jackson C. The Life of Chevalier Jackson: An Autobi- bedside percutaneous dilatational tracheos- Laryngoscope 2010;120(12):2423–9.
ography. Kessinger Publishing Company; 2008. tomy with suspension laryngoscopy for airway

EDITOR’S COMMENT quickly. It is rare that an emergency tracheostomy Bulfinch 3, where I usually was confronted with
takes place in controlled circumstances. In addi- a gooseneck lamp, a patient with no neck, and a
tion, tracheostomies, at least in the past, were left fourth-year student who was going to help me.
I still think that tracheostomy, especially in an un- to fairly junior members of the team. As an intern That was one of the scariest things I ever had to
controlled situation, is one of the scariest things at Massachusetts General Hospital, I was sent do and then, of course, the student carried with
one ever has to do. One can lose the patient to the so-called medical intensive care unit on him a tray with allegedly all of the instruments

(continued)

www.medicalebookpdf.com

LWBK892_c35_p442-452.indd 451 10/28/11 5:07:48 PM

 452 Part III: The Head and Neck

we needed for an open tracheostomy. Happily, I derwent what they call PDT, using a TED made by airway, whereas emergent procedures were per-
do not remember very many disasters, but they Karl Storz (Tuttlingen, Germany) and Carl Reiner formed on patients with complete airway ob-
easily could have happened. It was in fact a rite (Vienna, Austria). These were patients on long- struction and elective procedures were defined
of passage. term ventilation with orotracheal intubation to as those performed on patients with a secure
The author recognizes the challenging nature within an average of 10 days. There was a kit with airway “with an endotracheal tube or a laryn-
of this procedure and the fact that one can lose a single dilator, and continuous gas monitoring geal mask airway.” I differ with the writer. In any
the patient very quickly. There are a number of was used. Patients were sedated. Heart rate and event, after analyzing 325 patients, 20 examples
pearls offered, by which one can tell he is an ex- rhythm were monitored, as was blood pressure of urgent wide-awake tracheostomies were found
perienced tracheostomist, such as bleeding being and arterial catheterization, and oximetry was in 19 patients. The operation seems to be done in
a good sign that you are not too late, and [num- monitored using a finger probe. The introduction the same fashion as I perform it, including the
ber 6] in my experience no one has ever made too of the TED seems rather complicated and is done cricoid hook being placed into the cricoid or the
large a tracheotomy. I’m not sure whether I agree at right angles. However, the outcome showing first tracheal ring. Since the patient was preoxy-
with the latter one, but I think he’s got the idea. that when one does the percutaneous dilatational genated, oxygen was delivered during the proce-
But the point is to get the patient stabilized and tracheostomy, the incision in the trachea and not dure through a bag mask or nasal cannula or a
to get an airway that cannot be dislodged. out through the back wall seems like a good idea. face mask, it would seem that this is a reasonable
The standard tracheostomy should be carried I have no idea how much this instrument costs, definition of an urgent tracheostomy, since the
out whenever possible in the operating room. and it looks like it is very finely machined, as one patient’s airway is not intubated. Quite honestly,
This is a difficult operation, and there is no point would expect. It is not clear exactly how these pa- I am not entirely certain what the purpose of
in letting the junior person do it except under tients were selected, but the complications with that review, other than that urgent tracheostomy
excellent assistance and supervision. It is best to TEDs were tracheal ring fractures. It remains to could be done safely, but I think we already know
have an anesthesiologist or an anesthetist at the be seen, when this kit is introduced into general that.
head of the table. There needs to be a adequate usage, whether individuals find it helpful or not. Finally, Fikkers BG, et al., from the Depart-
monitoring equipment such as a Pco2 monitor in Kilic D (Ann Thoracic Cardiovasc Surg ment of Intensive Care Medicine in Radboud
order to tell whether you’re in the right place, as 2011;17:29–32) carried out a nonrandomized University Nijmegen Medical Center in Holland,
well as the ability to make certain that all sizes of study with 121 patients, performing surgical reviewed early and late outcomes of single-step
endotracheal tubes are available. Unfortunately, tracheostomy, in other words a standard tra- dilatational tracheostomy (SSDT) versus the
in some situations, such as the patient who has cheostomy, with a U-shaped flap and carried out guidewire dilating forceps (GWDF) technique,
swallowed a foreign body, and of course with the in the operating room between March 2003 and which was a randomized prospective trial in a
patient with no neck or thyroid hyperplasia, it December 2006. In this technique, instead of re- true fashion, such that that 120 patients with 60
gets kind of sticky. moving the tracheal ring, it was used to create a patients in each group were properly randomized
However, it does appear as if the percutane- flap, and the tracheal flap was hung with a suture to two techniques of percutaneous tracheos-
ous tracheostomy is the order of the day, and so from the middle of the second or third cartilage tomy, one the GWDF technique and the second
much of the reading material that one comes rings. At the same time, 85 patients underwent the SSDT technique. Patients were followed up
across in this area is to try and make percuta- the Griggs dilatation technique, which was per- 3 months after decannulation. The complica-
neous tracheostomy, which is challenging in its formed in the intensive care unit. Complication tions in both groups were monitored, yet they
own right, more accurate. Rajajee et al. (Critical rates were similar such that the tracheostomy at were high (58.3% in the GWDF group and 61.7%
Care 2011;15:R67, published online) employed 4.1% had bleeding in two patients, late stenosis in the SSDT group). Nonetheless, they found a
real-time ultrasound-guided percutaneous dila- in two patients, and stomal infection in 1 patient trend toward major perioperative complications
tational tracheostomy as a feasibility study and and percutaneous tracheostomy at 3.6% includ- in GWDF (10% vs. 1.7%). A significant tracheal
found in 13 patients [on the neurosurgical ser- ing bleeding in two patients and pneumothorax stenosis appeared in the SSDT group, but the
vice] that ultrasound actually helped guide the in one patient. The mean operating time was 12 study could not blame the technique since pro-
percutaneous tracheostomy. These were selected minutes for surgical tracheostomy and 8 minutes longed translaryngeal intubation had been car-
patients including three who were morbidly for percutaneous tracheostomy. It is difficult to ried out. Apparently, on follow-up, only 37.5% of
obese, two in cervical spine precautions, one understand how the “staff utilization cost” seems the patients in the GWDF group and 31.8% in the
with a previous tracheostomy. In all 13 patients, like the major advantage of percutaneous tra- SSDT group had no complaints after their percu-
bronchoscopy confirming the guidewire entry cheostomy. Regardless of whether or not there are taneous tracheostomies. The authors concluded
was through the anterior wall and between the similar complication rates, surgical tracheostomy that the SSDT technique appears to have fewer
first and fifth rings, avoiding pneumothorax, tube is necessary and, the authors say, most favorable complaints in the way of major complications
misplacement, posterior-wall injury, significant for select patients with thyroid hyperplasia, short and a comparable long-term outcome.
bleeding or other complication occurred during neck, tracheaomalacia, and obesity neck opera- I am not sure how exactly I view all of these
the procedure. The authors state that percuta- tion history and for pediatric patients. I agree. I different techniques. Clearly, these are patients
neous tracheostomy performed under real-time am not certain that this can be a randomized pro- who are in difficulty and require tracheostomy
ultrasound guidance is not only feasible but also spective trial, because, if you had somebody with assistance. There are a variety of techniques for
appears accurate and safe, and they are contem- a body mass index of 40, it is highly unlikely that carrying this out, which is not surprising, but 5 to
plating a randomized prospective trial. To me you’re going to do a percutaneous tracheostomy. 10 years after the introduction of this technique,
this sounds like a reasonable plan, as one can It is difficult to know how one can actually I suspect, that it would be somewhat uncomfort-
generally use all the help one can get. process urgent tracheostomies. Bobek S, et al. able to have these many techniques up in the air.
An additional aid that might come in handy (J Oral Maxillofac Surg 2011;69:2198–2203, pub- One can only hope that, by the time of the appear-
was described in Laryngoscope (2011;121:1490– lished online) reviewed 327 separate procedures ance of the next edition, the intensive care com-
1494, published online). Nowack A and Klemm E in 325 patients and attempted to distinguish ur- munity thoracic surgeons and general surgeons
described this in the section on how to do it, by gent tracheostomies from elective and emergent as well as intensivists may have come to some
introducing a percutaneous dilatational tracheo- tracheostomies by reading operative reports. I conclusions concerning what the proper tech-
stomy using a tracheotomy endoscope. This is a agree that one can differentiate urgent tracheo- nique for percutaneous tracheostomy is.
discussion of 24 intensive care patients who un- stomies, in which there is an intact unprotected J.E.F.

www.medicalebookpdf.com

LWBK892_c35_p442-452.indd 452 10/28/11 5:07:53 PM

 Endocrine Surgery IV

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 453 10/28/11 8:51:48 PM

 Introduction
000 toChapter
the Parathyroid
Title Section
Josef E. Fischer, MD Author Name

The world of surgery for hyperparathyroid- There are some complicating issues here. neck exploration in which all four parathy-
ism is in transition, and it is not difficult to First, there are the 20% to 22% of patients roids are identified under general endotra-
understand why this is the case. Hyperpara- present with disease that is not the result of cheal anesthesia to something less, either
thyroidism is a protean disease with symp- a single, large hyperfunctioning adenoma, unilateral and/or unilateral or even ambu-
toms that are sometimes difficult to deci- whereas 10% to 12% of patients present latory operation. However, even with the
pher. It is not a rare disease—incidence with the disease are the result of hyperpla- accuracy of Sestamibi scan and ultrasound,
ranges between 1 to 1,000 of the population sia, usually of all four parathyroid glands, the outcome from local directed, unilateral
to 1 to 2,500 of population—and it is also a and the rest are mixed between multiple ad- exploration is between 80% and 90%, as
disease of the elderly that disturbs homeo- enomas and an occasional carcinoma. This compared with the 99% to 100% that bilat-
stasis to the extent that it interferes with does not include those that have multiple eral exploration yields.
quality of life. Furthermore, because the endocrine neoplasia syndromes, which We are very pleased to have Dr. George
number of elderly is increasing, and any op- complicates matters even more. In addition, Irvin, who is essentially the creator and
eration that requires general anesthesia in as a number of authors reviewed in the fol- popularizer of intraoperative measurement
the elderly is fraught with hazard, not only lowing chapters agree, the size of the gland of parathyroid hormone, to put forth his
for the operation itself but in their ultimate does not always equal hyperfunction, and point of view. Dr. Irvin’s argument is very
recovery of their mental faculties, one can microadenoma has been clearly identified. simple: that even with Sestamibi and ultra-
easily understand the great interest in oper- With the number of increasing elderly, sound in the presence of a single adenoma,
ations that can be carried out quickly, effi- including those that are hypercalcemic, I the outcomes do not come close to the out-
ciently, and without full-dress exploration of have had enough experience and have heard comes of bilateral exploration. He proposes
all four parathyroid glands, which remains other stories about the elderly with hyper- that a ⬎50% drop from one of the baseline
the gold standard, with the highest cure rate calcemia to know that I disagree with the values of the quick parathyroid hormone
of 99% to 100%, provided it is carried out in NIH Consensus Conference of 2002. The assay, while increasing the range of success
the hands of an experienced parathyroid symptoms of hyperparathyroidism are so to the range of 93% to 94%, does not ap-
surgeon. Two of the large-series experienced protean and so nonspecific that it is not un- proach the gold standard of bilateral neck
parathyroid surgeons quoted in this section til the hypercalcemia is relieved that one exploration, despite the fact that for a par-
are Dr. Jonathan van Heerden, and his group knows that it was really interfering with ticular elderly patient this may be the way
at the Mayo Clinic in Rochester, and Dr. Orlo their mentation, making them feel poorly, to go. Thus, one has a choice, and the choice
Clark of the University of California in San and resulting in some deleterious cardiac is that of whether to do, for example, a local
Francisco. Both agree that in the hands of symptomatology and hypertension. Thus, anesthetic or cervical block exploration on
an experienced parathyroid surgeon with at least, I believe that unless a good argu- an elderly patient with Sestamibi and ultra-
adequate workup and a diagnostic array, ment as to why the patient should not be sound pointing to the same area, thereby
which is not terribly complicated and agreed operated on can be provided, these patients achieving some degree of success in a pa-
on by most, that the positive outcome of re- deserve operation. That takes us to the ap- tient who might not tolerate a general anes-
lief of hypercalcemia and hyperparathyroid- parent revolution in parathyroid surgery. If thetic as well. It is a good argument, and I
ism should be in the range of 99% to 100%. one can do a focused exploration under cer- am certain the argument will continue. We
Much of this is made possible by newer im- vical block, local anesthesia, or local anes- are very pleased to have the number of ex-
aging techniques, including the Sestamibi thesia with mild sedation, one can convert perts in this field writing these chapters as
scan and real-time ultrasound. the standard operation from a bilateral the debate is very cogent and very timely.

36 Surgical Anatomy of the Thyroid, Parathyroid,

and Adrenal Glands
Clive S. Grant

Success in the surgical management of a ever, if the preoperative process is correctly or pathologists is different from surgical
patient can be conveniently divided into conceived, at least in an elective procedure, anatomy. Because surgeons operate through
three phases: preoperative, intraoperative, a perfectly executed operation guarantees a limited incisions and must preserve func-
and postoperative. Vitally important is the smooth postoperative course in a high per- tion wherever possible, as well as control or
preoperative decision making and plan- centage of patients. The foundation for this prevent bleeding, the “anatomist’s anat-
ning; an expertly performed operation for a operative success is a thorough knowledge omy” must be applied from the surgeon’s
wrong reason is still a bad operation. How- of surgical anatomy. Anatomy to anatomists perspective. An attempt has been made to
454

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 454 10/28/11 8:51:49 PM

 Chapter 36: Surgical Anatomy of the Thyroid, Parathyroid, and Adrenal Glands 455

amalgamate the two forms of anatomy in

the following sections to give a broad per-
spective (the anatomist’s view as well as the
perspective of the surgeon).
The surgical anatomy of the thyroid and
parathyroid glands is so closely interrelated
that much of what is important to one proves
equally important to the other. Because of
this overlap, the overall anatomic relation-
ships of the region are covered in the Thyroid
section, and the differences or additions as
they relate specifically to parathyroid dis-
ease are noted in the Parathyroid section.

THYROID
EMBRYOLOGY
Fig. 1. A: A thyroglossal duct cyst is excised from its usual location just above the thyroid cartilage, in
From a median entodermal diverticulum the midline, overlying or just inferior to the hyoid bone. The central portion of the hyoid bone is excised
on the ventral wall of the pharyngeal gut, in with the specimen, as is a core of muscle tissue encompassing duct tracts that lead to the former fora-
approximately the fourth week of embryo- men cecum at the base of the posterior tongue. B: Lateral view showing the surgeon’s finger through the
logic development, the thyroid descends patient’s mouth positioned to assist excision of the tract at its origin.
from the posterior tongue ( foramen cecum)
in front of the pharynx as a bilobed diver-
ticulum. It initially remains attached to the
pharynx by a hollow tube, the thyroglossal Ectopic normal thyroid tissue or papillary relatively avascular plane. In this plane, the
duct, which attaches to the foramen cecum. thyroid carcinoma can develop in a thyroglos- superior and inferior flaps can be raised
At the end of the second month, the thyroid sal duct cyst or anywhere along the tract of with minimal blood loss. Once the flaps have
reaches its final position in front of the tra- the thyroglossal duct. Lingual thyroid repre- been developed, the strap muscles—the
chea; and the thyroglossal duct tissue, sents a total failure of thyroid descent, in sternohyoid and sternothyroid muscles—are
which has become solid, usually breaks up which the entire thyroid is located at the fora- exposed. The more anterior sternohyoid
and disappears. Distal persistence of the men cecum of the tongue, under the mucosa. muscles lie close together, but the midline
solid duct is represented by the pyramidal Contributing perhaps less than 1% of the between them can be identified as a thin
lobe of the thyroid. If parts of the ductal eventual thyroid mass, yet critically impor- line of fat and avascular fascia. Dissection
epithelium persist, the secretion of the epi- tant in considering thyroid malignancy, are along this line to separate these muscles is
thelium expands the remnant tube, which the lateral thyroid anlagen. Originating facilitated by lifting the muscles anteriorly
is closed at both ends, into a cystic mass from the fourth pharyngeal pouches, corre- so as to avoid the inferior thyroid veins,
filled with colloid-like material—a thyro- sponding to the ultimobranchial bodies, which course just below, running longitudi-
glossal duct cyst. It rarely has a connection they are responsible for production of calci- nally over the trachea. Often bordering the
either to the skin or the tongue unless it has tonin from the parafollicular or C cells. They midline along these muscles are the ante-
been infected and drained or previously fuse with the posterior and medial aspect of rior jugular veins. These veins can be avoided
operated on. Cysts can develop anywhere each thyroid lobe. Medullary thyroid carci- but can be ligated as the need arises.
along the course of the thyroglossal duct nomas evolve from these small parts of the As the sternohyoid muscle is elevated,
but are most typically found overlying the thyroid. the underlying sternothyroid muscles are
hyoid bone in the midline just above the exposed. The fascia between these two
thyroid cartilage. Adjacent to the primary muscles can be dissected for improved
persistent thyroglossal duct remnants, ANATOMY exposure. With the sternohyoid muscles
other smaller duct and mucus-secreting An overall view of the anatomy relevant to retracted, as the sternothyroid muscle is
gland remnants are often found. thyroid and parathyroid operations is dissected from the underlying thyroid lobes,
Endocrine Surgery

To prevent cyst recurrence, the duct and shown in Figure 2. For optimal surgical care is taken to avoid the widely intercon-
remnants can be encompassed in a core of exposure, the patient is positioned with a necting venous network in the thyroid cap-
tissues that should be excised from the cyst small pillow placed between the scapulae, sule. This caution is of particular impor-
through the mylohyoid muscle to the base of and the neck is hyperextended, bringing tance in a larger goiter because the strap
the tongue, the site of the foramen cecum the thyroid gland as far anterior as possible. muscles can be thinned and splayed out
(Fig. 1). In addition, because the hyoid bone The skin incision follows Langer lines trans- across the bulging thyroid lobes and the
fuses in the midline in close proximity to the versely, optimally in a skin crease. large veins are in jeopardy. The insertion of
thyroglossal duct, the duct can pass either the sternothyroid muscle into the thyroid
anterior or posterior, or even course through Dissection of Muscles cartilage can obscure the superior pole of
the bone. The central portion of the hyoid the thyroid gland and can be partially
bone should, therefore, be excised as part of Beneath the skin and subcutaneous tissue is transected for better exposure. Both the
the operation for a thyroglossal duct cyst. the thin platysma muscle, under which is a sternohyoid and sternothyroid muscles (as

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 455 10/28/11 8:51:49 PM

 456 Part IV: Endocrine Surgery

well as the omohyoid muscle) are inner-

vated by the ansa cervicalis, derived from
the hypoglossal nerve and C1 through C3.
These muscles can be partially or com-
pletely removed as necessary for cancer op-
erations without any significant disability.
The cricothyroid muscles run obliquely
from the cricoid cartilage to the thyroid
cartilage and are innervated by the external
branch of the superior laryngeal nerve. This
muscle and nerve should be carefully pre-
served because they serve the important
function of fine-tuning the voice.

VASCULAR ANATOMY
The principal arterial blood supply of the
thyroid gland comes from the paired supe-
rior and inferior thyroid arteries, and, to a
much lesser degree, the thyroidea ima
(Fig. 2). Even when all these arteries are
ligated, remnants of thyroid often survive
from other small branches derived from Fig. 2. Overall anatomic relationships of the thyroid and surrounding structures. Note the course of the
laryngeal and tracheoesophageal arteries. inferior thyroid artery, behind and perpendicular to the carotid artery. The superior thyroid artery and
The superior thyroid artery is the first external branch of the superior laryngeal nerve run in close approximation.
branch of the external carotid artery and
courses inferiorly to reach the superior
pole of the thyroid gland. It often branches
at this point, with the main branch run- and lateral to the ligamentum arteriosum, current laryngeal nerve. Damage to the
ning over the anterior surface of the supe- and ascends in the tracheoesophageal recurrent laryngeal nerve on one side
rior pole of the thyroid and the other groove. Adjacent and mostly anterior to causes vocal cord paralysis and hoarseness
smaller branches entering more posteri- the recurrent laryngeal nerve are the tra- and prevents complete closure of the vocal
orly. The inferior thyroid artery usually cheoesophageal lymph nodes, which are a cords to protect the trachea. This incom-
arises from the thyrocervical trunk, runs common site of metastasis in papillary plete closure results in choking, especially
superiorly behind the carotid artery, and and medullary thyroid carcinoma. Re- when the patient consumes fluids. Bilat-
then arches medially to the thyroid gland, moval of these nodes requires care to pro- eral nerve injury jeopardizes the airway
coursing either perpendicular to or in a tect the recurrent laryngeal nerve; it and usually requires at least a temporary
recurrent path to the thyroid gland. The should preserve not only the inferior para- tracheostomy. When the right subclavian
thyroidea ima artery is encountered in thyroid gland but also its blood supply, artery anomalously originates directly
less than 10% of patients and is almost which usually crosses anterior to the re- from the aortic arch as its fourth branch, it
never a relevant vessel except to ligate.

Dissection of Thyroid Lobe

Once the strap muscles have been dis-
sected laterally, the thyroid gland is ele-
vated anteriorly and medially, opening an
areolar plane overlying the carotid artery
and traversed by one or more small middle
thyroid veins (Fig. 3). These veins are li-
gated and transected, and the space ante-
rior to the carotid from the thyroid carti-
lage inferiorly to the base of the neck can
be dissected safely. This step exposes the
transversely directed inferior thyroid ar-
tery and the obliquely coursing recurrent
laryngeal nerve, a branch of the vagus
nerve, which, on the right, wraps around
the subclavian artery and passes behind Fig. 3. With traction laterally on the strap muscles that have been separated in the midline, but not
the carotid artery to ascend in the trache- transected, and countertraction on the thyroid medially, the middle thyroid vein is exposed. It runs an-
oesophageal groove (Fig. 4). On the left, terior to the carotid artery and should be transected. (From Grant CS, van Heerden JA. Technical aspects
the recurrent laryngeal nerve crosses the of thyroidectomy. In: Donohue JH, van Heerden JA, Monson JRT, eds. Atlas of surgical oncology (pp. 81–6).
arch of the aorta, loops under it, adjacent Cambridge: Blackwell Science, 1995, with permission.)

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 456 10/28/11 8:51:49 PM

 Chapter 36: Surgical Anatomy of the Thyroid, Parathyroid, and Adrenal Glands 457

passes behind the trachea and esophagus.

The right recurrent nerve, therefore, does
not recur around this artery and takes a
direct course from the vagus nerve to the
larynx (Fig. 5). In this instance, although it
emerges posterior to the carotid artery, its
perpendicular course mimics the usual
course of the inferior thyroid artery and
must be distinguished from it.
The inferior thyroid artery is usually the
principal blood supply to both the superior
and inferior parathyroid glands. These feed-
ing vessels are small and fragile, often travel-
ing in a course parallel, if not slightly anterior,
to the parathyroid glands before reaching the
Fig. 4. A non-recurrent, recurrent laryngeal nerve (on the patient’s right side) courses directly from the vascular hila (Fig. 6). As the inferior thyroid
vagus to its insertion at the cricothyroid membrane. artery intersects with the recurrent laryngeal
nerve, it usually branches into superior and

Fig. 5. The right thyroid lobe is retracted anteriorly and medially, and the recurrent
laryngeal nerve is exposed, coursing obliquely in the tracheoesophageal groove and
surrounded by lymph nodes. The thymus lies anterior to the nerve and nodes and can
contain or point to the inferior parathyroid gland. The superior parathyroid gland is not
yet adequately exposed. The intersection of the inferior thyroid artery and the recur-
rent (rec.) laryngeal nerve is marked by branches of the artery, one crossing the nerve
that serves the inferior parathyroid gland. (From Grant CS, van Heerden JA. Technical
aspects of thyroidectomy. In: Donohue JH, van Heerden JA, Monson JRT, eds. Atlas of
surgical oncology. Cambridge: Blackwell Science, 1995, with permission.)

Fig. 6. A: The small vessels feeding the parathy-

roid glands often run at least parallel if not slightly
anterior to the glands. B: The surgeon can usually
Endocrine Surgery

preserve these vessels by gently dissecting them

and the parathyroid glands from the surface of the
thyroid gland. C: Two significant branches of the
inferior thyroid artery (ITA) are routinely present,
one traveling anterior and the other posterior to
the recurrent (rec.) laryngeal nerve. The coales-
cence of the dense posterior thyroid capsule con-
stitutes Berry ligament (lig.), through which the
posterior arterial branch courses. (From Grant CS,
van Heerden JA. Technical aspects of thyroidecto-
my. In: Donohue JH, van Heerden JA, Monson JRT,
eds. Atlas of surgical oncology. Cambridge: Black-
well Science, 1995, with permission.)

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 457 10/28/11 8:51:50 PM

 458 Part IV: Endocrine Surgery

Modified Radical Neck Dissection

Important in the surgical management of
papillary, medullary, and in some Hürthle
cell carcinomas, lymph node metastases to
the lateral internal jugular lymph nodes
will necessitate a lymphadenectomy. De-
pending upon the extent of the dissection,
various descriptive terms have been ap-
plied including regional, functional, selec-
tive, and modified radical neck dissection.
Perhaps more important is the thorough,
en bloc approach, and the neck compart-
ments dissected. The anatomic boundaries
of Compartments I to VI are summarized in
Table 1, and graphically illustrated in Fig-
ure 8. Rarely used in thyroid cancer surgery
is the classic radical neck dissection that
implies sacrifice of the sternocleidomas-
toid muscle (SCM), internal jugular vein
(IJ), and the spinal accessory nerve. Addi-
tionally, the submandibular triangle is vir-
Fig. 7. With traction inferiorly and laterally on the thyroid lobe, the superior thyroid artery (STA) can be tually never dissected for thyroid cancer.
displaced from its closely associated external branch of the superior laryngeal nerve. The artery is there- Whereas in medullary thyroid carcinoma
by transected individually, and the nerve is preserved (inset). (From Grant CS, van Heerden JA. Technical and node-positive Hürthle cell carcinoma,
aspects of thyroidectomy. In: Donohue JH, van Heerden JA, Monson JRT, eds. Atlas of surgical oncology. thorough dissection of Compartment VI is
Cambridge: Blackwell Science, 1995, with permission.) advised, controversy exists as to the extent
and indications for this compartment dis-
section in papillary cancer.
Whether a standard collar incision is ex-
tended vertically along the anterior border
inferior trunks. The superior trunk typically tioned, thyroid cancer often metastasizes to of the SCM, or a separate transverse incision
divides again with one branch anterior and lateral nodes. The routes of spread roughly is made higher in the neck, extensive sub-
another posterior to the recurrent laryngeal follow the venous drainage. Cancers of the platysmal flaps are developed.
nerve. The inferior thyroid veins run verti- upper lobe, in addition to the primary drain-
cally, anterior to the trachea, and are easily age to the supraisthmic nodes, can involve Compartments III, IV, and the Anterior
identified and controlled during the course the midjugular nodes, both anterior and lat- Aspect of Compartment V
of thyroidectomy. Accompanying these veins eral to the internal jugular vein, and occa- The dissection proceeds with dissecting
are the pretracheal lymph nodes, both infra- sionally extend superiorly along the vein to the plane between the SCM and the strap
and supraisthmic (Delphian), which often the base of the skull. Cancers of the mid- muscles exposing the omohyoid muscle
contain metastatic thyroid cancer. and lower thyroid lobes drain initially into that is conveniently sacrificed (Figs. 9 and
The superior thyroid artery and vein, the pretracheal and tracheoesophageal 10). This uncovers the lower aspect of the
which are sacrificed during thyroidectomy, nodes, then to the mid- and lower jugular IJ and adjacent carotid sheath structures
must be separated from the external branch nodes and anterior mediastinal nodes. (carotid artery medially, IJ laterally, and
of the superior laryngeal nerve. Placing in-
ferior and lateral traction on the superior
pole of the thyroid gland usually distracts
the artery away from the nerve, and the ar-
tery can be cleanly isolated and individually Table 1 Compartments of Neck and Levels of Cervical Lymph Nodes
ligated (Fig. 7).
Once the vascular branches to the thy- Level (compartment) Location
roid lobe have been transected and the I (Submandibular triangle) Bounded by anterior and posterior bellies of digastric muscle
nodes cleared, the posterior capsule of the and inferior ramus of mandible.
thyroid is all that remains before the lobe is II (Upper jugular) Extending from base of skull to bifurcation of carotid artery or
completely removed. To re-emphasize, a hyoid bone. The posterior border of IA is the spinal accessory
small vessel regularly courses in this dense nerve (C. XI), and of IB is the sternocleidomastoid muscle.
posterior capsule (Berry ligament), and the Anterior border of compartment is sternohyoid muscle.
recurrent laryngeal nerve is also commonly III (Middle jugular) Inferior border of Level II to omohyoid muscle or cricoid
tethered anteriorly. Gentle dissection will cartilage; anterior borders same as II.
expose the vessel for ligation and push the IV (Lower jugular) Inferior border of Level III to clavicle; anterior and posterior
recurrent laryngeal nerve down and out of borders same as II and III.
danger before the ligament is transected.
V (Posterior triangle) Bounded by clavicle inferiorly, trapezius muscle posteriorly,
In addition to the pretracheal and tra-
sternocleidomastoid anteriorly and medially.
cheoesophageal lymph nodes already men-

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 458 10/28/11 8:51:51 PM

 Chapter 36: Surgical Anatomy of the Thyroid, Parathyroid, and Adrenal Glands 459

down to the floor of the neck onto the pre-

vertebral fascia extending laterally as the
fascia overlying the anterior scalene mus-
cle (Figs. 11 and 12). Running vertically on
the anterior scalene muscle is the phrenic
nerve that is crossed low in the neck by the
transverse cervical artery (Fig. 13A,B), a
branch of the thyrocervical trunk. This ar-
tery may be sacrificed, but care must be
taken to preserve the phrenic nerve. The
lateral border of the IJ may be used as a
guide to dissect inferiorly, but it will join
the subclavian vein, and on the left side,
the thoracic duct. This duct runs adjacent
to the esophagus in the chest, coursing up
behind the carotid sheath structures, and
loops up a short distance from medial to
lateral behind the IJ, and then enters the
subclavian vein near its junction with the
IJ. Nodes near the clear-fluid-containing
duct are commonly involved in thyroid
cancer, and the duct is very vulnerable to
injury. In adults, if injured, the thoracic
duct may be ligated without harm. The dis-
section across the base of Compartment IV
Fig. 8. Anatomic compartments of the neck. at the level of the clavicle is usually safe
with only relatively small veins requiring
control. After releasing the inferior attach-
ments, and with dissection superiorly
along the lateral border of the IJ, and safely
vagus nerve posteriorly between the other IJ anteriorly, and laterally behind the SCM.
elevating the packet of lymph nodes from
two). The lymph nodes to be removed ex- Retracting the IJ anteriorly and medially
the anterior scalene muscle, the packet of
tend from the base of the neck inferiorly, (protecting the adjacent vagus nerve), are-
nodes and soft tissue can be retracted an-
behind the clavicle and slightly behind the olar tissue is easily dissected laterally
teriorly, putting tension on the posterior
attachments behind the SCM. Dissecting
from inferior to superior, the cutaneous
cervical plexus nerves (C 2 to 4) will be en-
countered as substantial nerves coursing
obliquely down behind the SCM (Fig.
14A,B). With care, these nerves can be pre-
served without jeopardizing a good nodal
dissection. Deeply situated at the inferior
and lateral aspect of the dissection, cours-
ing from behind the anterior scalene and
in front of the middle scalene muscles are
the brachial plexus trunks. The superior
border of Compartment III is defined as
the level of the hyoid bone or carotid bifur-
cation. Not infrequently, lymph nodes, lo-
cated anterior to the carotid artery at the
level of the bifurcation, are metastatically
Endocrine Surgery

involved and may be overlooked if not in-

tentionally sought.

Compartment II
Superior to the cervical plexus nerves,
coursing obliquely inferiorly and laterally
from under the posterior belly of the digas-
tric muscle is the spinal accessory nerve
(Nerve XI). If dissection is carefully con-
ducted with low-power cautery, stimula-
Fig. 9. Modified radical neck dissection incision and dissection between sternocleidomastoid muscle tion of the nerve will cause contraction
(SCM) and strap muscles. of the SCM and trapezius muscles with

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 459 10/28/11 8:51:52 PM

 460 Part IV: Endocrine Surgery

posterior belly of the digastric muscle.

These include the carotid sheath struc-
tures, Nerve XI, the sympathetic chain be-
hind the carotid artery, and the hypoglos-
sal nerve (C XII) turning anteriorly, hooking
under the arterial branch to the SCM off of
the occipital artery. If dissection is kept
along the lateral border of the IJ, C XII
should not be encountered. Its descending
branch, the ansa cervicalis (innervating
strap muscles), descends anterior to the
carotid artery and may be identified and
sacrificed lower in the neck (level of the
omohyoid muscle).

PARATHYROID
EMBRYOLOGY
The parathyroid glands develop from Bran-
chial Pouches III and IV. The superior para-
thyroid glands develop from Pouch IV, travel
a shorter distance than the inferior glands,
and are typically located along the posterior
border of the thyroid gland at approxi-
mately 1 cm superior to the entrance of the
Fig. 10. Isolation and resection of omohyoid muscle.
inferior thyroid artery (Fig. 6A). Because of
this location, when the superior glands de-
sudden movement of the shoulder. Further cleared from Compartments IIA (anterior scend further, they almost always remain
dissection with standard instruments will to the nerve) and IIB (posterior to the posterior, in the tracheoesophageal groove
uncover the nerve where it can be traced nerve), if necessary. At this level, several or retroesophageal space (Fig. 15). Even
cephalad and the associated lymph nodes important structures emerge deep to the when located quite low in the posterior su-
perior mediastinum, they can still be re-
trieved through a collar incision.
In conjunction with the thymus, the in-
ferior parathyroid glands develop from
Pouch III and descend to the posterior as-
pects of the lower pole of the thyroid gland.
This long descent gives rise to a much more
variable position for the inferior parathy-
roid than for the superior gland. The loca-
tion of the inferior gland can range from
being high, anterior to the carotid artery
(the so-called undescended parathymus),
to being in the anterior mediastinum within
the thymus, necessitating sternotomy for
retrieval (Fig. 15). Inferior glands associ-
ated with the thyroid gland usually remain
ventral to the recurrent laryngeal nerve,
whereas the superior glands are found dor-
sal to the nerve. The usual home for the in-
ferior glands is on the posterolateral sur-
face of the thyroid gland, just above, at, or
within the attached remnant of the cervical
thymus, the so-called thyrothymic ligament
(Fig. 4). Rarely, this combined descent of
parathyroid and thymus can be trapped
within the carotid sheath, which might
become relevant and evident only when the
parathyroid gland is enlarged and hyper-
Fig. 11. Initial dissection along lateral border of internal jugular vein (IJV) above level of clavicle. CCA, functioning. Moreover, because of the
common carotid artery; SCM, sternocleidomastoid muscle. relationship between the thymus and the

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 460 10/28/11 8:51:55 PM

 Chapter 36: Surgical Anatomy of the Thyroid, Parathyroid, and Adrenal Glands 461

SURGICAL ANATOMY
Virtually everyone has at least four parathy-
roid glands, but at least 13% of the popula-
tion has supernumerary glands. However,
only one-half of these supernumerary glands
are proper glands; the others are tiny, rudi-
mentary bits of parathyroid tissue, usually
located near another normal gland. Supernu-
merary glands become important surgically
in four situations: (a) hyperparathyroidism
caused by multiple endocrine neoplasia, es-
pecially Type 1, and familial hyperparathy-
roidism, when all glands are abnormal;
(b) secondary hyperparathyroidism, most
typically that results from chronic renal fail-
ure, in which all glands are stimulated to
enlarge and hyperfunction; (c) sporadic
cases in which the four usual glands are nor-
mal and only the supernumerary gland is
abnormally enlarged and responsible for hy-
perfunction; and (d) cases in which the su-
pernumerary gland is enlarged in addition
to another normal gland, which represents
a double-adenoma situation.
Fig. 12. Exposure of anterior scalene muscle and phrenic nerve. CCA, common carotid artery; IJV, inter-
nal jugular vein.
Dissection of Parathyroid Glands
There are three important goals in parathy-
developing heart, these aberrant parathy- located on the surface of the thyroid gland, roid surgery: (a) recognition of normal para-
roid glands can be located adjacent to the under the capsule but in clefts of the thy- thyroid glands as well as removal of the ab-
origin of the great vessels from the aorta. roid parenchyma. This location can seem normal glands; (b) safe searches in predictable
In very rare instances, the parathyroid intrathyroidal, particularly during reopera- locations for missing parathyroid glands; and
glands can be found to be completely in- tive parathyroid surgery, when the thyroid (c) the preservation of parathyroid glands
trathyroidal. More commonly, they can be capsule is thickened with scar. during thyroidectomy or the removal of other
abnormal parathyroid glands.
The dissection of parathyroid glands
proceeds similarly to the mobilization of a
thyroid lobe, as described previously. In
contrast, when hyperparathyroidism is the
indication for operation, the arterial supply
of the thyroid is usually preserved. Once the
thyroid gland has been elevated (Fig. 4), the
inferior parathyroid gland is usually sought
first. It usually resides either on the poster-
olateral surface of the lower pole of the thy-
roid gland or at the tip of the cervical
thymus or thyrothymic ligament. In fact,
this ligament can be used to point to the
gland or conceal it within its variably atro-
Endocrine Surgery

phic and fat-replaced thymic substance.

Similar to the superior gland, the inferior
gland is often located in a lobule of fat, from
which it can be distinguished by its reddish-
yellow or yellowish-brown color. Normal
glands are soft, pliable, and virtually non-
palpable, and can be present in differing
shapes depending on whether the fascial
layer that flattens it against the thyroid has
been teased away to yield a more globular
Fig. 13. En bloc dissection of internal jugular vein (IJV) lymph nodes and exposure of floor of neck. CCA, shape. When a tiny biopsy has been taken
common carotid artery. from the nonhilar portion of the gland, the

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 461 10/28/11 8:52:02 PM

 462 Part IV: Endocrine Surgery

Fig. 14. Cervical plexus (CP) and spinal accessory nerve dissection (extending to Level II). IJV, internal jugular vein.

entire parenchymal surface bleeds from firmer, not soft and pliable like normal found in the usual locations, it has almost
pinpoint capillaries (in contrast to fat with parathyroid glands. The thymus can usually universally migrated along an anterior path,
its single bleeding vessel). Thyroid nodules be distinguished by its pale, off-white color. following the course of or located within
and normal or diseased lymph nodes are If an inferior parathyroid adenoma is not the cervical or mediastinal thymus. The se-
quence of searching for inferior glands not
in the usual locations proceeds as follows:
(a) the cervical and mediastinal thymus are
drawn into the wound and searched or ex-
cised for pathologic review; (b) dissection is
carried anterior to the carotid artery at
least to its bifurcation to search for an un-
descended parathymus, as described previ-
ously; (c) the carotid sheath is opened, par-
ticularly if the cervical thymus is seen to
deviate toward it; and (d) the lower pole of
the thyroid is excised to exclude an in-
trathyroidal location.
The superior parathyroid glands are in a
more constant location but are somewhat
more difficult to expose than the inferior
glands. They are usually found within a
globule of fat located along the posterior
border of the thyroid gland, 1 to 2 cm supe-
rior to where the inferior thyroid artery en-
ters the thyroid gland (Fig. 6). Gentle dis-
section to strip thin fascial layers overlying
the gland causes it to pop out directly, or
the surrounding fat can be manipulated to
expose the parathyroid gland. Initially, to
Fig. 15. Owing to their embryologic origins, the parathyroid glands, particularly when enlarged, fol- identify probable locations for this gland,
low different, but often predictable, courses. The superior glands descend posteriorly in the contiguous gentle prodding with an instrument causes
tracheoesophageal groove or retroesophageal space, or into the posterior superior mediastinum. The the fat and contained parathyroid gland to
inferior glands are less predictable but are usually found anteriorly in association with the thymus gland, float within the fascial envelope. They often
either in the neck or in the anterior superior mediastinum. directly overlie the recurrent laryngeal

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 462 10/28/11 8:52:11 PM

 Chapter 36: Surgical Anatomy of the Thyroid, Parathyroid, and Adrenal Glands 463

nerve, although they are separated by a

delicate fascial space. When a superior
gland is not in the usual position, it tends to
migrate posteriorly, behind the inferior thy-
roid artery, drawing its blood supply with
it and descending in the potential space
called the tracheoesophageal groove, which
is almost the same as the retroesophageal
or prevertebral space. Because the recur-
rent laryngeal nerve is closely applied to the
trachea and is located anterior to this dis-
section plane, the retroesophageal space
can be entered and widely dissected from
the level of the larynx superiorly almost to
as low as the tracheal bifurcation inferiorly.
The only critical structure that crosses this
plane is the inferior thyroid artery, which
can be protected as it enters the thyroid
gland or transected. Occasionally, exposure
of the superior gland can be facilitated by
mobilizing the superior pole of the thyroid
gland by transecting the superior thyroid
artery. Very rarely is a superior gland lo-
cated within the thyroid gland. Superior
and inferior glands are remarkably sym-
A
metric in their locations. Even in ectopic
locations, with the exception of an inferior
gland located low in the cervicomediastinal
thymus, symmetry is often preserved.
Although the principal arterial blood
supply to the superior and inferior parathy-
roid glands originates from the inferior thy-
roid arteries, other anastomotic vessels cer-
tainly provide a supplementary supply in
most patients. However, when a total thy-
roidectomy has been performed, these sup-
plementary sources are often interrupted.
As a general rule during a thyroidectomy,
the inferior thyroid artery should be
transected distal to the branches that sup-
ply the parathyroid glands. When an infe-
rior gland is located within the substance of
the thymus, it usually derives a satisfactory
blood supply from thymic vessels.

Minimal-Access Parathyroidectomy
Application of minimal-access techniques
that have swept across all disciplines of sur-
gery have been applied to parathyroidec-
tomy and, to a lesser degree, thyroidectomy.
Endocrine Surgery

B Two distinct methodologies have emerged:

Fig. 16. A: The single “hot spot” is located at the inferior pole of the right lobe of the thyroid and moves
First, an open technique, which uses local
with it in oblique views, indicating a right inferior parathyroid adenoma. B: The “hot spot” is located at anesthesia and a small incision and is di-
the inferior pole of the right lobe of the thyroid, but moves into the midline in the left oblique view, indi- rected by preoperative imaging and some-
cating a right superior parathyroid adenoma (RS, left oblique view). times by intraoperative rapid parathyroid
hormone determination, and second, mi-
croendoscopic techniques. The feasibility of
both techniques has been solidly established
in the hands of experts, and the ultimate use
of either or both awaits the assessment of
the safety, cost-effectiveness, and, perhaps
most important, the demands of patients.

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 463 10/28/11 8:52:16 PM

 464 Part IV: Endocrine Surgery

Although perhaps only two-thirds of pa- location of a tumor (or paraganglioma) is at The left adrenal gland lies on the dia-
tients with hyperparathyroidism are actu- the origin of the inferior mesenteric artery phragm and is covered on its anterior surface
ally suitable for a limited exploration using on either side of the aorta, near the Zucker- by peritoneum superiorly and on its lower
present localization modalities, the surgeon kandl organ. Accessory adrenal tissue can be portion by the nonperitoneally covered pan-
must understand not only the anatomy of found occasionally in the connective tissue creas. The adrenal vein exists near the lower
the parathyroid glands, but also the critical adjacent to the main gland but can also oc- border of the gland, often to join with the
importance of his or her ability to interpret cur near a gonad, either ovary or testis. inferior phrenic vein to empty into the renal
localization studies accurately. vein.

Sestamibi Parathyroid Scan ANATOMY ANATOMY IMPORTANT

Up to 80% of patients with sporadic hyper- Because the adrenal glands are situated TO VARIOUS SURGICAL
parathyroidism are demonstrated by sesta- deeply in the retroperitoneum, and because
primary diseases that require adrenalec-
APPROACHES
mibi scan to have a single “hot spot” that
represents a single enlarged parathyroid tomy are rare, surgeons tend to be less fa-
miliar with the anatomic relationships of
Anterior (Transabdominal)
adenoma. This is probably the single most
effective preoperative localization method these glands (Fig. 17). Additionally, adrenal Right
currently available. Even if the hot spot is tumors can distort these relationships. On After the abdominal incision is made, the
located as far inferior as the lower pole of both sides, they cap the kidneys and derive posterior edge of the liver should be dis-
the thyroid gland, it can still be a superior arterial blood supply from the aorta and the sected from the posterior peritoneum,
parathyroid gland, located posteriorly in inferior phrenic and renal arteries. which allows the liver to be lifted anteriorly
the tracheoesophageal groove. Conversely, On the right, the upper part of the gland and superiorly. This maneuver is also facili-
a hot spot superior to the superior pole of lies partially behind the inferior vena cava, tated by transecting one or two small
the thyroid gland is almost certainly an in- against the bare area of the liver (to which it branches from the anterior surface of the
ferior gland—the undescended parathy- can seem somewhat adherent), and on the inferior vena cava coursing to the caudate
mus. Oblique views should be included in diaphragm. The principal venous drainage lobe of the liver. Neither the hepatic flexure
the scan technique to distinguish an ante- is through the adrenal vein, which is short of the colon nor the duodenum usually
rior hot spot, which is most likely an inferior and wide and which exits the gland just needs to be mobilized unless the tumor is
gland and rotates with the inferior pole of below its apex to enter the inferior vena quite large. The arterial branch from the in-
the thyroid gland (Fig. 16A). A posterior hot cava on its posterior surface and is the only ferior phrenic artery is often located at the
spot—a superior gland—moves to the mid- vein to enter the inferior vena cava posteri- extreme superomedial aspect of the gland,
line in the opposite oblique view (Fig. 16B). orly along its retrohepatic course. higher than the adrenal vein, and requires
Also, the level of the sternal notch should be
noted, as the gland may reside within the
mediastinal thymus in the anterior-superior
mediastinum yet to be easily retrievable
from a cervical incision. These ectopic but
not unusual locations have been recognized
for decades but need to be carefully consid-
ered to place a limited incision properly or
to opt for a standard open exploration.

ADRENAL GLANDS
EMBRYOLOGY
The adrenal glands can be separated into
two distinct areas, both histologically and
physiologically: the cortex and the medulla.
The cortex develops from mesodermic celo-
mic epithelium of the posterior abdominal
wall, at the cranial end of the mesonephros.
The medulla develops from the neural crest
in conjunction with the sympathetic ganglia.
This group of neural cells migrates along the
adrenal vein to invade the cortex and be-
comes the completed adrenal gland. Other
small masses of these cells, which stain
brown with chromic acid (thus the name Fig. 17. Overall anatomic relationships of the adrenal glands. Note the origins of the three main arteries:
chromaffin or pheochrome cells), can persist the inferior phrenic, aortic, and renal branches. Note also the single draining veins (except a small acces-
throughout the life along the sympathetic sory right adrenal vein): the right, located superior and medial; and the left, found inferior and medial.
chain as paraganglia. The most common Ao, aorta; Ce, celiac; IVC, inferior vena cava; LAd, left adrenal gland; RAd, right adrenal gland.

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 464 10/28/11 8:52:23 PM

 Chapter 36: Surgical Anatomy of the Thyroid, Parathyroid, and Adrenal Glands 465

careful control. Once this artery and the ad-

renal vein have been transected and the
posterior peritoneal layer that covers the
superior aspect of the adrenal gland has
been incised, the gland can be retracted lat-
erally as the inferior vena cava is retracted
medially, which separates the plane be-
tween the two (Fig. 18). Control of the ves-
sels from the aorta and renal vessels com-
pletes the dissection. With reasonable
frequency, at least one small but significant
accessory adrenal vein drains from the in-
ferior aspect of the gland (especially impor-
tant when large tumors are present that
enlarge these veins) into the right renal
vein. This situation is easily controlled
when recognized. Care must be taken on
this side as well as on the left to avoid ligat-
ing or injuring a small polar branch of the
renal artery.
Fig. 18. A: Cross section of the anatomic relationships of the adrenal tumor, the inferior vena cava
(IVC), and the right adrenal vein. B: With the liver elevated and the IVC retracted medially, the short, Left
fat, right adrenal vein is exposed, coursing from the adrenal tumor to the posterior surface of the IVC. Access to the left adrenal gland can be
C: The vein has been clipped or ligated and transected, and the minimally vascular areolar tissues be-
tween the tumor and the IVC below the level of the vein are dissected. D: Along the medial inferior
gained by dissecting the omentum from
aspect of the tumor, the aortic and renal arterial branches that need to be controlled are found. (From the colon, elevating the stomach, and dis-
Grant CS, van Heerden JA. Technical aspects of thyroidectomy. In: Donohue JH, van Heerden JA, Monson secting the avascular plane under the pan-
JRT, eds. Atlas of surgical oncology. Cambridge: Blackwell Science, 1995, with permission.) creas to elevate it off the adrenal gland.
The spleen does not need to be mobilized
in this approach, but this exposure is ade-
quate only for small to moderate tumors.
For larger tumors, including adrenal can-
cers, the splenic flexure of the colon can be
dissected and the spleen and pancreas
mobilized from their bed (including liga-
tion of short gastric vessels) to the pa-
tient’s right side (Fig. 19). This step exposes
the adrenal gland or tumor inferomedially
and eventually the most critical area of
dissection on the left side. The adrenal
vein and the arterial branches from the
aorta and renal artery course in this space
(Fig. 20).

Laparoscopic (Transperitoneal)
The laparoscopic approach has rapidly
been adopted as the procedure of choice
for removing all benign tumors, both func-
tioning and nonfunctioning, with the up-
per size limit varying from 6 to 10 cm. Obvi-
Endocrine Surgery

ously, larger tumors require enlarging one

of the trocar sites to accommodate re-
moval, but most tumors “mold” somewhat
into an oblong shape, allowing a much
smaller transabdominal hole than might
be expected. However, at present, most au-
Fig. 19. A: Retracting the spleen medially and inferiorly, the lateral peritoneal attachments are incised.
thors reporting a series of laparoscopic
B: The short gastric vessels are individually transected. C: With omentum dissected from the left trans- adrenalectomies prefer to remove adrenal
verse colon, the spleen and pancreas mobilized from their bed, and the short gastric vessels transected, malignancies using an anterior, open ap-
these organs can be retracted into the patient’s right upper quadrant, exposing a large adrenal tumor. proach.
(From Grant CS, van Heerden JA. Technical aspects of thyroidectomy. In: Donohue JH, van Heerden JA, At least three different laparoscopic ap-
Monson JRT, eds. Atlas of surgical oncology. Cambridge: Blackwell Science, 1995, with permission.) proaches have been described, including

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 465 10/28/11 8:52:24 PM

 466 Part IV: Endocrine Surgery

arterial branches to the adrenal gland but

to protect the arteries coursing to the
underlying kidney. Particularly true of lap-
aroscopic procedures, visualization is
enhanced considerably by traction, and
elevating the adrenal gland to facilitate dis-
section of the posterior attachments is most
helpful. Placement of the adrenal gland into
an endoscopic bag and withdrawal through
one of the trocar sites completes the
operation.

Left Adrenalectomy
Often, only three trocars are necessary for
left adrenalectomy, because once the
spleen is mobilized, it usually does not re-
quire ongoing retraction. Trocar place-
ment is planned in mirror image to the
right side described previously. Before the
third trocar is placed, the splenic flexure
Fig. 20. A: Along the inferomedial aspect of the adrenal tumor, the adrenal vein is identified, somewhat
shorter than usual in the situation depicted. Care must be taken not to injure renal arterial branches
may need mobilization, sometimes exten-
coursing close by the vein as it is transected. B: The adrenal branches from the inferior phrenic and sively, to facilitate not only the placement
aorta can be seen in their typical locations. (From Grant CS, van Heerden JA. Technical aspects of thyroi- of the trocar, but also the “dropping” of
dectomy. In: Donohue JH, van Heerden JA, Monson JRT, eds. Atlas of surgical oncology. Cambridge: Black- the transverse colon to gain exposure to
well Science, 1995, with permission.) the left adrenal vein later. The camera is
usually placed in the lateral cannula (or
3rd cannula if 4 are used—the most lat-
eral to aid in retracting the kidney to ex-
directly anterior with the patient positioned divided to allow retraction of the liver, both pose the medial aspect where the adrenal
supine; retroperitoneal with the patient medially and anteriorly, off the retroperito- vein drains into the left renal vein), but
prone; and, most commonly, transperito- neum. The retroperitoneal attachments to placement can be switched to another
neal with the patient positioned laterally, the liver should be lysed, exposing the infe- trocar as needed for optimal visualiza-
with the side to be operated on elevated. rior vena cava (IVC). The camera is usually tion. A blunt instrument is used to tip the
“Breaking” the operating room table to best placed in the second cannula, and the spleen away from its retroperitoneal
distract and enlarge the distance from the two lateral cannulae are used for dissection attachments; these then are incised rela-
costal margin to the iliac crest allows maxi- and retraction by the surgeon. As the tively close to the spleen coursing superi-
mal space for placement of the trocars. retroperitoneal covering is incised adjacent orly, curving around the superior margin,
Moreover, the most lateral trocar should be to the IVC, lateral retraction is placed on and looking for and protecting the stom-
placed so as to avoid restriction of its infe- the adrenal gland to distract it from the ach as the dissection proceeds medially.
rior rotation by the iliac crest. The anatomic IVC. Although the space between the gland The characteristic “fuzzy” areolar tissue
considerations for a laparoscopic approach and the IVC is limited, the camera magnifi- posterolateral to the spleen that extends
are not substantially different from the cation allows precise cautery dissection of to the pancreas can be opened widely, ex-
open operations, but some deserve special the small vessels proceeding from the infe- posing a variable thickness of fat and the
emphasis. rior border of the gland superiorly. We have adrenal gland. Locating the adrenal gland
not required direct retraction of the IVC. may be the most difficult portion of the
Right Adrenalectomy The incision in the retroperitoneal covering procedure. During an operation for Cush-
is curved laterally above the superior bor- ing adrenal hyperplasia, with consider-
Although the right side is potentially more der of the adrenal gland, which allows fur- able overall obesity but particularly
dangerous of the two sides due to the short ther mobilization. Care must be taken to generous amounts of fat in the retro-
adrenal vein, the exposure is more direct avoid unintentional trauma to the adrenal peritoneum, the marginally enlarged ad-
and often easier than the left side. Four tro- vein or the moderate-sized inferior phrenic renal gland sometimes is engulfed by the
car sites are used, starting a few centime- artery, which can be transected at this fat. Along the medial border of the gland,
ters inferior to the right costal margin, stage. Gentle dissection of the adrenal vein, as noted in the open procedure, the infe-
somewhat medial to the midclavicular line, ensuring circumferential clearance, per- rior phrenic vein may prove to be a valu-
and coursing laterally. As much space as mits safe and precise control with endo- able landmark. We often initially dissect
possible should be allowed between trocar scopic clips. the medial, superior, and lateral borders
sites to prevent the camera and instru- As the dissection is carried around before visualizing and transecting the left
ments inserted through the cannulae from the inferior border of the gland, a thicker adrenal vein, which is longer and gener-
interfering with each other. The most me- layer of fat is commonly encountered, and ally more slender than its right-sided
dial cannula is used for retracting the liver, special attention must be taken, as in the counterpart, and, when dissected, is
and the right triangular ligament should be open operation, to clip and transect the easily clipped.

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 466 10/28/11 8:52:26 PM

 Chapter 36: Surgical Anatomy of the Thyroid, Parathyroid, and Adrenal Glands 467

SUGGESTED READINGS Grant CS, van Heerden JA. Technical aspects of

adrenalectomy. In: Donohue JH, van Heerden
primary hyperparathyroidism. J Endocrinol In-
vest 1997;20:429.
Åkerström G. Anatomy and strategy of parathyroid JA, Monson JRT, eds. Atlas of surgical oncology. Porterfield J, Factor D, Grant C. Operative technique for
operation. In: Åkerström G, Rastad J, Juhlin C, Cambridge: Blackwell Science; 1995. modified radical neck dissection in papillary thy-
eds. Current controversy in parathyroid operation Grant CS, van Heerden JA. Technical aspects of roid carcinoma. Arch Surgery 2009;144(6):567–74.
and reoperation. Austin, TX: R.G. Landes; 1995. thyroidectomy. In: Donohue JS, van Heerden Thompson GB, Grant CS, van Heerden JA, et al.
Åkerström G, Malmaeus J, Bergström R. Surgical JA, Monson JRT, eds. Atlas of surgical oncology. Laparoscopic versus open posterior adrena-
anatomy of human parathyroid glands. Surgery Cambridge: Blackwell Science; 1995:81–86. lectomy: a case-control study of 100 patients.
1984;95:14. Gray SW, Skandalakis JE. Embryology for surgeons. Surgery 1997;122(6):1132–36.
Grant CS. Pheochromocytoma. In: Clark OH, Philadelphia: WB Saunders; 1972. Young WF, Stanson AW, Grant CS, et al. Primary
Duh Q-Y, eds. Textbook of endocrine surgery. Miccoli P, Pinchera A, Cecchini G, et al. Minimally aldosteronism: adrenal venous sampling. Sur-
Philadelphia: WB Saunders; 1997. invasive video-assisted parathyroid surgery for gery 1996;120(6):913–20.

EDITOR’S COMMENT patients 39/58 (68%) served as a control. The one patient underwent only parathyroidectomy
preoperative PAS score in the hyperparathyroid with limited resection of the thyroid gland. The
group was originally 318 and decreased to 177 at en bloc resection with the parathyroid tumor
This is a wonderful chapter written by a very one year and 189 at 10 years (P ⬍ 0.05). Thyroi- was limited to ipsilateral thyroid lobectomy in
experienced surgeon and with a number of very dectomy patients’ preoperative scores were 170, the selected 10 patients. Prophylactic neck dis-
excellent “pearls.” The most important message 190 after one year, and 174 at 10 years. Despite section was performed in eight patients without
concerning thyroid cancer is that this is a real the highly elevated PAS scores in the previously recovering a single metastatic gland. Despite
cancer and that many of the practices that have hyperparathyroid group, there was no difference this, the patients had recurrent disease in the
unfortunately become ingrained in our treat- between the groups (previously hyperparathyroid neck not only in the lymph nodes but also in
ment of this disease are just plain wrong. For vs. thyroidectomy group at one and 10 years). One lung—for one patient in lung and for the other
example, in cancers of the upper lobes—the presumes that the lower PAS scores were reflec- in brain. Of the other three who did not undergo
author states that cancers of the upper lobe, in tive of the patients’ quality of life. This is an im- a lymph node dissection, one had local recur-
addition to the primary drainage into the su- portant paper as there is still slight controversy rence in a regional lymph node. After analyzing
praisthmic neck nodes, can also involve both as to whether the elderly who are hyperparathy- the genetic mutations, the authors suggest that
the anterior and lateral nodes in respect of the roid should be operated on. the HRPT2 mutation may be associated with tu-
jugular vein and extend superiorly along the Another controversy in differentiated or pap- mor recurrence.
veins to the base of the skull. Also despite what illary thyroid cancer is whether a central neck Open adrenalectomy has been the mainstay
various compartments are resected in respect to dissection should be carried out. Shen et al. (Sur- of resection of the adrenals for adrenal cortical
the node dissections are en bloc, and the “berry gery 2010, published online) separated patient carcinoma pheochromocytomas and adrenal
picking” is totally inappropriate. Again this is a undergoing thyroidectomy as to the surgeon metastases. As experience has increased with
real cancer. thought both as a result of preoperative ultra- laparoscopic adrenalectomy, there is of course a
The lower parathyroids as the author states sound and intraoperative inspection and palpa- desire on the part of both patients and surgeons
may very well be in the horns of the upper thy- tion that a central lymph node dissection should to minimize trauma to the patient and have a
mus which can be retrieved through the neck be carried out (Group 1) or that the evidence did quicker postoperative course. Mazzaglia and
with persistence. Another salient point is that not suggest concomitant central lymph node dis- Vezeridis ( J Surg Oncol 2010;101:739–44) have ex-
there may be supernumerary glands in as many section. There were 191 patients in each group. In amined the role of laparoscopy in adrenal resec-
as 13% of patients and these may be troublesome Group I 49 patients had recurrence in the local tion, particularly in incidentalomas which may
and may be the source of the adenoma when all or regional area (12% central neck and 21% lat- be malignant. In the absence of any other clues,
four glands are normal. eral neck) as opposed to only 11 out of 191 (6%) management is directly related to size of lesion,
One very excellent differential and a “pearl” is in group II (3% central neck and 3% lateral neck, with 25% of the tumors greater than 6 cm being
that when one does the biopsy of a parathyroid, P ⬍ 0.05). Finally, 84% of the patients in Group 1 adrenocortical carcinomas. They recommend ob-
“the entire surface bleeds” and not a single vessel, were free of disease at last survey compared with servation for the patients with lesions less than
as fat does. The discussion of the sestamibi scan 94% of the patients in group 2 (P ⬍ 0.05). Tran- 4 cm. For the patients with lesions between 4 and
and where the various hot spots may be should sient hypocalcemia significantly followed central 6 cm, observation between 6 and 12 months is
be especially noted as helpful, especially as a hot lymph node dissection. There was no difference in recommended, and at that time CT scan should
spot which is superior to the superior pole of the disease-specific mortality. The authors concluded be repeated.
thyroid gland is almost certainly an inferior gland that surgeon assessment of the central neck com- Laparoscopy is inappropriate for the lesions
in the “undescended parathymus.” partment with ultrasound and palpation is an in which adrenocortical carcinoma is suspected,
While many of us speak of the symptoma- accurate predictor of which patients with papil- as the cortex may be fragile and split, and in that
tology of undiagnosed hyperparathyroidism lary thyroid cancer will benefit from central neck case, cancer cells may be implanted in the area.
especially in the elderly as being a reason why node dissection and the rest do not need central Open adrenalectomy has been shown to increase
these patients should be operated on, the symp- node dissection. survival in patients with metastatic melanoma
toms of hyperparathyroidism are often vague, so Parathyroid cancer is rare and yet there is and lung cancer from three- to fourfold from an
vague that they had been grouped under “para- some controversy here as to whether en bloc average of 6 to 8 months and not operated pa-
thyroid assessment of symptoms” or PAS scores resection of thyroid gland with the parathyroid tient’s to 20 to 30 months. Port site recurrence
Endocrine Surgery

for hyperparathyroidism. Supposedly, parathy- cancer is appropriate. In addition, somatic and is rare, at least according to some authors (Kim
roidectomy decreases these PAS scores. Pasieka germ line mutations of HRPT2 and MEN 1 were et al. Cancer 1998;82:389–94; Haigh et al., Ann
et al. (Surgery 2009;146:1006–13) studied 122 hy- examined by polymerase chain reaction and au- Surg Oncol 1999;6:633–9; Luketich and Burt Ann
perparathyroid patients, of which 78 (64%) were tomated DNA sequencing. En bloc resections of Thorac Surg 1996;62:1614–6).
available for review 10 years later. Thyroidectomy thyroid tissue were performed in 10 patients and J.E.F.

www.medicalebookpdf.com

LWBK892_c36_p453-467.indd 467 10/28/11 8:52:27 PM

 468 Part IV: Endocrine Surgery

37 Fine Needle Aspiration Biopsy of the Thyroid:

Thyroid Lobectomy and Subtotal and Total
Thyroidectomy
Herbert Chen

ANATOMY cause significant swallowing dysfunction with hypothyroidism. In patients with a

that is relieved with thyroidectomy. suppressed TSH and symptoms/signs of hy-
The thyroid gland lies in the central com- perthyroidism, a thyroid scan is the next
partment of the neck and is made up of a step to determine the etiology. Patients
left and right lobe as well as an isthmus. The Physical Examination with Graves’ disease, which comprise 70%
isthmus is located just below the cricoid Signs of hyperthyroidism include elevated of hyperthyroidism, will have diffuse up-
cartilage (Fig. 1). The thyroid normally pulse, tremor, warm skin, and prominent take, while patients with a toxic thyroid
weighs 14 to 20 g. The arterial supply is from eyes. Signs of hypothyroidism include dry nodule will have a single focus of uptake,
the superior thyroid artery (the first branch skin, nonpitting edema, and coarse hair. and those with Plummer’s disease (multiple
of the external carotid) and the inferior thy- The thyroid gland can be palpated easily by hot thyroid nodules) will have multiple-foci
roid artery from the thyrocervical trunk. standing behind the patient and locating uptake. In the absence of hyperthyroidism,
The venous drainage of the thyroid com- the cricoid cartilage. The isthmus lies just thyroid scans have limited utility in the
prises the superior thyroid vein, which below the cricoid. Asking the patient to workup of thyroid nodules.
drains into the internal jugular vein, the drink water while palpating the neck with The best imaging study for the thyroid is
middle thyroid vein (only present in 50% of both hands will facilitate localization of cervical ultrasound. Findings on ultrasound
individuals), and the inferior thyroid vein, thyroid mass since the thyroid moves up suspicious for thyroid malignancy include
which drains into the innominate/brachio- and down with swallowing. Thyroid nod- microcalcifications, hypoechogenicity, gross
cephalic veins. The thyroid contains 90% of ules are usually quite firm. It is important local invasion, irregular margins, and re-
the body’s iodine. Iodine is oxidized and to also examine the central and lateral neck gional lymphadenopathy. Ultrasound is crit-
binds to tyrosine residues in thyroglobulin lymph nodes for lymphadenopathy. ical for guiding fine needle aspiration (FNA),
(colloid). About 1% of thyroid hormone is which is the procedure of choice for the eval-
released every day. The half-lives of the ac- uation and management of thyroid nodules.
tive forms of thyroid hormone are 7 days for DIAGNOSIS
T4 and 1 to 3 days for T3. The most useful laboratory test for screen-
ing patients with thyroid disease is mea-
FNA Biopsy
CLINICAL PRESENTATION surement of thyroid stimulating hormone FNA is a relatively simple and safe proce-
(TSH), which is suppressed in patients with dure, and it is usually performed in the out-
History hyperthyroidism and elevated in patients patient clinic. The patient is placed in a
When evaluating a patient presenting with
thyroid disease, one should inquire about
symptoms of hyperthyroidism or hypothy-
roidism, risk factors for thyroid cancer, and
symptoms due to enlargement of the gland.
Symptoms of hyperthyroidism include heat
intolerance, weight loss, palpitations, hair
loss, and diarrhea. Symptoms of hypothy-
roid include cold intolerance, fatigue,
weight gain, constipation, and hoarseness.
Thyroid nodules occur in 4% to 7% of the
general population. The vast majority of
these nodules (95%) are benign. Risk fac-
tors for thyroid cancer include hypothy-
roidism, a family history of thyroid cancer
(especially papillary or medullary thyroid
cancer), and a history of head/neck irradia-
tion. Large thyroid nodules or diffusely en-
larged glands can cause compressive symp-
toms involving the esophagus, trachea, and
recurrent laryngeal nerve such as dyspnea,
stridor, orthopnea, dysphagia, or hoarse- HRF ‘06

ness. Recent data suggest that even moder- Fig. 1. FNA biopsy diagram with neck extended, nondominant hand on nodule, and needle in dominant
ately enlarged thyroid gland/nodules can hand.

www.medicalebookpdf.com

LWBK892_c37_p468-478.indd 468 10/28/11 9:14:36 PM

 Chapter 37: Fine Needle Aspiration Biopsy of the Thyroid: Thyroid Lobectomy and Subtotal and Total Thyroidectomy 469

supine position with a pillow or towel roll 2. suspicious/indeterminate: follicular neo- follicular cancers. We generally perform a
placed behind the shoulder to extend the plasm, Hurthle cell neoplasm, suspicious diagnostic thyroid lobectomy in patients
neck and to bring the thyroid closer to the but not diagnostic of papillary thyroid without frozen section. We and others have
surface of the skin (Fig. 1). At our institu- cancer; demonstrated that intraoperative frozen
tion, the patient often has EMLA cream ap- 3. malignant: papillary thyroid cancer, med- section is misleading and does not provide
plied to the skin 20 to 30 minutes prior to ullary thyroid cancer, anaplastic thyroid any additional information ⬎90% of the
the procedure. The skin is then prepped cancer, lymphoma, metastases; and time. Thus, we wait for permanent histology
with alcohol, and 1% lidocaine without epi- 4. inadequate/nondiagnostic. and if positive for cancer perform a comple-
nephrine can be injected into the skin for tion thyroidectomy usually within 5 days or
FNAs in the latter category should be
additional local anesthesia. The thyroid after 2 to 3 months from the original thy-
repeated as up to 80% may be diagnostic on
mass is localized with ultrasound and im- roid lobectomy. For patients with a follicular
the repeat attempt.
mobilized between the fingertips of the neoplasm, we would consider an initial total
nondominant hand. Using the dominant thyroidectomy for the following: contralat-
hand, a 23- or 25-gauge 1.5-in. needle with TREATMENT AND eral nodular disease or Hashimoto’s thy-
an attached 10-mL syringe is advanced into INDICATIONS roiditis, the patient is already taking thyroid
the lesion, with the clinician noting the hormone, or patient preference.
consistency of the nodule upon entering. Malignant FNA Hurthle cell neoplasm. Approximately
We prefer the nonsuction technique be- 70% of Hurthle cell neoplasms or lesions are
cause it results in less trauma and bleeding. Papillary thyroid cancer. For lesions ⬍1 cm, adenoma while 30% are cancer. Similar to
If utilizing the suction technique, the sy- either thyroid lobectomy or total thyro- follicular neoplasms, the presence of capsu-
ringe is pulled back with the thumb once idectomy is acceptable. For lesions 1 cm lar and/or vascular invasion on permanent
the lesion has been entered. A syringe- or greater, total thyroidectomy is recom- histology distinguishes Hurthle cell ade-
holder aspiration device can facilitate this mended. If abnormal lymph nodes are seen nomas from cancers. Likewise, we generally
technique. Once the needle enters the le- intraoperatively or by ultrasound, level 6 cen- perform a diagnostic thyroid lobectomy in
sion, it is rapidly moved back and forth tral lymph node dissection is indicated. In patients without frozen section. If the per-
along a single track for each aspiration until patients with enlarged lateral lymph nodes, manent histology is positive for cancer, we
material is seen with the hub of the needle. FNA should be performed on the lymph node perform a completion thyroidectomy. Many
Suction (if utilized) is released before re- and if positive a compartmentalized lymph studies have shown that the rate of malig-
moval of the needle from the nodule. Firm node dissection often involving levels 2, 3, nancy for Hurthle cell neoplasms is directly
pressure is applied to the puncture site. and 4 lymph nodes should be done. related to the size of the lesion. While can-
Three to six passes are often required to Medullary thyroid cancer. Total thyroi- cer is very uncommon with Hurthle cell
obtain an adequate sample. If a cyst is en- dectomy with bilateral central (level 6) neoplasms less than 2 cm in size, the rate of
countered, the fluid is completely aspirated lymph node dissection is the minimal oper- cancer exceeds 50% in lesions of a greater
and sent for cytologic examination. The re- ation. For patients with abnormal lateral size than 4 cm. Thus, we typically recom-
gion of the cyst is then evaluated by ultra- lymph nodes by ultrasound or computed to- mend a total thyroidectomy for Hurthle cell
sound and any residual solid component mography (CT), or in patients with calci- neoplasms larger than 4 cm. We would also
reaspirated. tonin levels ⬎1000 pg/mL, modified radical consider a total thyroidectomy in patients
The needle is then detached from the sy- neck dissection should be performed. Be- with contralateral nodular disease and
ringe, and the syringe filled with air, reat- cause of the association of medullary thyroid Hashimoto’s thyroiditis, if the patient was
tached, and the contents expelled onto a cancer with multiple endocrine neoplasia already taking thyroid hormone, or patient
glass slide. A second slide is placed on top of type 2 A (MEN 2 A), preoperative evaluation preference.
the first slide and the material is smeared by should include plasma and/or 24 urinary Suspicious, but not diagnostic, of papillary
pulling the slides in opposing horizontal di- metanephrines for pheochromocytoma, CT thyroid cancer. An aspirate “suspicious for
rections. Slides can be either immediately scans of the neck, chest, and abdomen for papillary thyroid cancer” is not the same as
placed into alcohol or sprayed with fixative staging, calcium and parathyroid hormone an aspirate “diagnostic for papillary thyroid
for Papanicolaou’s stain or air-dried for Diff- testing for hyperparathyroidism, and RET cancer” in regard to likelihood of malignancy
Quik (May-Grunwald-Giemsa) staining. The proto-oncogene testing to assess for familial and surgical management. The cytologic cri-
definition of specimen adequacy varies disease. teria for papillary thyroid cancer include
from institution to institution. Usually at Thyroid lymphoma and anaplastic thyroid large monolayer sheets of follicular epithe-
least 6 to 10 clusters of cells on two separate cancer. These types of thyroid malignancies lial cells, enlarged nuclei with powdery chro-
slides are required to make a diagnosis. On- are primarily treated with chemotherapy matin, intranuclear cytoplasmic inclusions
Endocrine Surgery

site evaluation by a cytopathologist can sig- and/or radiation therapy. Occasionally, thy- and grooves, and papillary structures with
nificantly reduce the inadequacy rate. Com- roidectomy is performed for early anaplastic or without tall columnar cells. While FNAs
plications from FNA are extremely rare but cancers, and for palliation of airway com- diagnostic of papillary thyroid cancer have
include bleeding/hematoma (⬍0.5%), tra- promise from thyroid lymphoma. all of these features, those FNAs that have
cheal puncture (rare), nodule infarction some but not all of the features of papillary
(⬍5%), and tumor seeding (⬍0.005%). Suspicious/Indeterminate FNA thyroid cancer are read as “suspicious for
FNAs are usually classified into four cat- papillary thyroid cancer.” Multiple reports
egories: Follicular neoplasm. Approximately 80% of have shown that FNAs suspicious for papil-
follicular neoplasms or lesions are adenoma lary thyroid cancer are malignant 50% to 60%
1. benign: nodular goiter, Hashimoto’s thy- while 20% are cancer. The presence of cap- of the time. Thus, for a thyroid nodule that
roiditis, subacute thyroiditis, cyst, and sular and/or vascular invasion on perma- is suspicious for papillary thyroid cancer, we
colloid nodule; nent histology distinguishes adenomas from would recommend a thyroid lobectomy to

www.medicalebookpdf.com

LWBK892_c37_p468-478.indd 469 10/28/11 9:14:36 PM

 470 Part IV: Endocrine Surgery

resect the nodule, with intraoperative fro- usually consists of clinical follow-up with a Postoperative bleeding and subsequent
zen section analysis. We and others have repeat thyroid ultrasound in 6 months. If hematoma formation is a potential life-
demonstrated that frozen section is ex- the nodule increases in size or becomes threatening complication that must be care-
tremely useful with an FNA suspicious for worrisome in ultrasound appearance dur- fully monitored during the postoperative
papillary thyroid cancer, as it is accurate ing follow-up, repeat FNA is warranted. Our period. This occurs in ⬍1% of cases. Wound
90% of the time. If the frozen section is pos- practice has been to follow small, asymp- infections are uncommon. The most com-
itive for papillary thyroid cancer, we would tomatic thyroid nodules at 6, 18, and 42 mon wound complication is seroma forma-
perform a total thyroidectomy at that time. months. tion that usually resolves spontaneously.
If the frozen section is negative, we would Hyperthyroidism. Kocher developed sub- Patients should be aware that after to-
terminate the operation having performed total thyroidectomy as the treatment for tal or near-total thyroidectomy they will
only a lobectomy and wait for final histo- hyperthyroidism from Graves’ disease, be required to take lifelong thyroid hor-
logic evaluation. which then became the routine form of mone replacement. In patients undergoing
therapy for the disease. After the advent of thyroid lobectomy, the vast majority
Benign FNA radioactive iodine therapy in the 1930s, sur- (⬎85%) will not require thyroid hormone.
gery became less commonly performed as However, we and others have described
The management of a thyroid nodule that the primary treatment. There are still a risk factors that increase the chance of hy-
is “benign” on FNA is dependent upon the number of important indications for surgi- pothyroidism after thyroid lobectomy,
size of the nodule and if the patient has cal treatment of hyperthyroidism such as which include a high-normal TSH, Hashim-
symptoms due to the nodule. Benign nod- age, sex, pregnancy, and lactation, the pres- oto’s thyroiditis, and a low T4 level. When
ules generally do not require surgery un- ence of a thyroid nodule or large goiter patients are stratified into three groups
less they are causing compressive symp- (Plummer’s), and patient preference. These based on their preoperative TSH measure-
toms (airway compromise, dysphagia, factors may guide clinicians to offer surgery ment (ⱕ1.5, 1.51 to 2.5, and ⱖ2.51 μIU/
etc.). Data from multiple investigators as a first-line treatment. For patients with mL), the rate of hypothyroidism after thy-
have shown that thyroidectomy in symp- Graves’ disease or Plummer’s disease, total roid lobectomy increases significantly at
tomatic patients can greatly improve qual- thyroidectomy is the operation of choice each level (13.5%, 20.5%, and 41.3%,
ity of life. Thyroidectomy should also be and has largely replaced subtotal thyroidec- respectively). Thus, preoperative TSH levels
considered in patients with thyroid nod- tomy, which is associated with a much high can be used to predict the likelihood of
ules and a history of head and neck irradi- recurrence rate and similar morbidity. For postoperative hypothyroidism.
ation because of the increased risk of patients with hyperthyroidism due to a sin- Preoperative testing. In all patients un-
developing thyroid cancer. We generally gle hot nodule, unilateral thyroid lobectomy dergoing thyroid surgery, it is our practice
advocate a total thyroidectomy in patients is the best operation. to check the preoperative calcium and
with thyroid nodules and a history of head parathyroid hormone level to rule out hy-
and neck irradiation, irrespective of biopsy PRE- AND PERIOPERATIVE perparathyroidism, and to obtain a base-
findings. line value for comparison. In patients who
Nodule greater or equal to 4 cm in size.
PLANNING are diagnosed with hyperparathyroidism,
While FNA is extremely accurate in delin- Informed consent. As with any operation, the we perform parathyroidectomy at the time
eating most benign from malignant thyroid surgeon should have a thorough discussion of thyroidectomy. If the patient has a hoarse
nodules, several studies have shown that with the patient about the indications, al- voice preoperatively or if has had a previ-
FNA is less reliable with thyroid nodules ⱖ4 ternate treatment options, and potential ous operation that placed the vagus or re-
cm. McCoy and colleagues noted that pre- complications of thyroidectomy. Complica- current laryngeal nerve at risk, he or she
operative FNA results in patients with thy- tions for thyroid lobectomy include injury to should have direct or indirect laryngoscopy
roid nodules ≥4 cm were read incorrectly the recurrent laryngeal nerve, resulting in a preoperatively to assess the status of the
as benign in 13% of patients with cancer; hoarse voice, and external branch of the su- recurrent laryngeal nerves. A paralyzed
when multifocal micropapillary carcinoma perior laryngeal nerve, leading to an inabil- nerve may alter operative plans and should
was included, this false-negative rate for ity to reach the high octaves when singing. I definitely be discussed when obtaining
preoperative FNA reached 16%. In a study typically quote a 5% to 10% rate of tempo- informed consent. A procedure planned
from our group, FNA results reported as be- rary/transient hoarseness and a 1% to 2% on the side contralateral to a nerve injury
nign turned out to be either neoplastic rate of long-term voice complications. risks bilateral nerve injury and the need for
(22/52) or malignant (4/52) on final pathol- The parathyroid glands could also be in- tracheostomy.
ogy. Among patients with nondiagnostic advertently injured. This does not pose a Hyperthyroidism. It is important to re-
FNAs, the risk of malignancy was 27%. problem with a thyroid lobectomy (since store a patient with hyperthyroidism to a
We concluded that in patients with thyroid the contralateral two parathyroids would euthyroid state prior to surgery to avoid the
nodules ⱖ4 cm, FNA results are highly in- be sufficient), but increases the risk of hy- potential of precipitating a thyroid storm
accurate, misclassifying half of all patients poparathyroidism should future thyroid or during surgery. This can be accomplished
with reportedly benign lesions on FNA. Fur- parathyroid surgery be required since the within 6 weeks using an antithyroid drug
thermore, those patients with a nondiag- remaining parathyroid glands would be at such as PTU 100 to 300 mg three times daily
nostic FNA display a very high risk of dif- risk. In patients undergoing a total thyroi- or methimazole 10 to 30 mg three times a
ferentiated thyroid carcinoma. Therefore, we dectomy, a 10% to 20% rate of transient day. Methimazole is usually changed to a
recommend that diagnostic lobectomy, at a hypocalcemia and a 1% to 2% rate of per- single daily dose once a patient is euthyroid
minimum, be performed in patients with manent hypocalcemia required calcitriol since it has a longer duration of action com-
thyroid nodules ⱖ4 cm regardless of FNA supplementation. We and others have pared with PTU. Propranolol in doses of 40
cytology. In patients who are asymptomatic shown that hypoparathyroidism for most to 120 mg four times a day is often added to
and have nodules ⬍4 cm, management patients usually resolves within 1 week. control symptoms of tachycardia, tremor,

www.medicalebookpdf.com

LWBK892_c37_p468-478.indd 470 10/28/11 9:14:36 PM

 Chapter 37: Fine Needle Aspiration Biopsy of the Thyroid: Thyroid Lobectomy and Subtotal and Total Thyroidectomy 471

heat intolerance, and anxiety. Propranolol

is usually initiated simultaneously with the
antithyroid drug, but is continued about
1 week after surgery since the half-life of T4
is 7 days. We administer a saturated solu-
tion of potassium iodide (SSKI) in a dose
of 1 drop two to three times daily or Lugol’s
solution in a dose of 5 to 10 drops two to
three times daily about 10 to 14 days prior
to surgery to decrease the vascularity of the
thyroid gland and facilitate surgical resec-
tion. These agents are discontinued imme-
diately after surgery. When a patient requires
urgent surgery, rapid preparation can be
accomplished within 7 days using a combi-
nation of a corticosteroid (dexamethasone
2 mg every 6 hours), propranolol 40 mg every
8 hours, and sodium iopanoate (500 mg ev-
ery 6 hours). Since both propranolol and
sodium iopanoate have a rapid onset of ac-
tion, it is worth starting these two agents
even in truly emergent cases.
Perioperative considerations. Patients
should urinate immediately preoperatively
so that there is no need for a Foley catheter.
As thyroidectomy is classified as a “clean”
operative procedure, prophylactic antibiot-
ics are not required unless the patient has a
special medical condition warranting their
administration. Compression stockings and
sequential compression devices are used
selectively for deep vein thrombosis (DVT) Fig. 2. Thyroid anatomy illustrating the gland’s relationship to the hyoid bone, thyroid cartilage, cricoid
prophylaxis. Heparin should be used very cartilage, and the trachea.
selectively since recent data suggest that
the risk of postoperative neck hematoma
overweighs the incidence of DVT in pa- rings just caudal to the cricoid cartilage astinum if indicated and can be cosmeti-
tients undergoing thyroidectomy. (Fig. 2). A deflated IV bag is placed under cally unappealing.
the patient’s shoulders to extend the neck In smaller masses, we traditionally begin
SURGICAL TECHNIQUE and support the shoulders and lower cervi- with a 2- to 4-cm centrally placed incision,
cal spine. The bag is then inflated to pro- though lateral extension of this incision
Thyroid lobectomy. Following the induction duce the appropriate amount of neck ex- may be warranted based on the size of the
of general anesthesia, the patient remains tension. The head should be well supported gland. Factors that affect the size of the in-
in the supine position, arms straight and using a head ring. A headlight facilitates cision include gland size, patient body mass
tucked at their sides, and generous padding lighting and exposure through the limited index, extent of planned exploration, and
is placed at the elbows to prevent nerve in- incisions. During the operation, the table is availability of assistants to retract. The skin
jury. The patient’s neck is midline and ex- placed in a beach-chair position to decrease incision should be made with a deliberate
tended. This neck extension is performed the cervical venous pressure. sweep of the scalpel, dividing the skin and
with extreme caution and with the assis- The cricoid cartilage is then palpated subcutaneous tissue simultaneously. He-
tance of the anesthesia team to ensure that and its location noted. The skin incision is mostasis is achieved with electrocautery.
the endotracheal tube is secured and that placed in a skin crease approximately 1 cm The incision is deepened to the areolar tis-
the cervical spine is not overextended or below the cricoid cartilage (Fig. 3). The ori- sue plane just deep to the platysma muscle
Endocrine Surgery

suspended. Preoperative assessment should entation of the incision should be along the where an avascular plane is reached. Once
include asking the patient to fully extend lines of Langer, since crossing the normal the incision is made and deepened through
his or her neck, so that the person position- skin lines may lead to more prominent scar- the platysma, the superior and inferior sub-
ing the patient knows the level of natural ring. It is of paramount importance to place platysmal planes are developed. Using two
neck extension. Hyperextension of the neck the incision in a neck crease whenever pos- Allis clamps, the superior edge of the plat-
may lead to increased postoperative pain sible, as neck creases have the least amount ysma muscle or dermis is grasped and
and a slight risk of spinal cord damage. Per- of tension. An incision made too low will placed under tension (Fig. 4). This permits
fect alignment of the head and body must result in pronounced scar formation, diffi- vertical retraction of the flap while counter-
be ensured to prevent erroneous placement culty in dissecting the superior pole, or per- traction with the surgeon’s finger or Kitner
of the cervical incision. Appropriate posi- haps missing the thyroid entirely. Incisions exposes a natural bloodless plane. Ideally,
tioning ensures that the isthmus of the thy- made too high will make it difficult to re- dissection should proceed within the rela-
roid overlies the second and third tracheal move lymph nodes in the superior medi- tively avascular plane between the platysma

www.medicalebookpdf.com

LWBK892_c37_p468-478.indd 471 10/28/11 9:14:36 PM

 472 Part IV: Endocrine Surgery

Fig. 3. Site of incision in a skin fold about 1 cm below the cricoid. Surface anatomy with
underlying anatomy shown to demonstrate why this location is optimal for thyroid surgery.

muscle fibers and the anterior jugular veins. section should be carried down to the level be taken to avoid injury to these veins, as
Utilizing a combination of blunt and sharp of the suprasternal notch. Care should be active bleeding and danger of air embolus
dissection within this plane—alternatively, taken to not buttonhole the retracted skin have been reported with openings made
electrocautery is acceptable to raise the and to avoid the anterior jugular veins, into the anterior jugular vein. The skin flaps
skin flap—the upper skin flap is freed to the which should remain on the anterior sur- are held apart with a self-retaining Sippel or
level of the thyroid notch. The inferior edge face of the sternothyroid muscle. The ante- spring retractor (Fig. 5).
of the platysma is then grasped and an infe- rior jugular veins symmetrically flank the The sternohyoid muscles are separated
rior flap is created in a similar fashion. Dis- midline raphe of the neck. Special care must in the midline using electrocautery. With

Fig. 4. Creating superior flap—Allis clamps on platysma, counter-

traction with the surgeon’s finger, and electrocautery, also demon-
strating anterior jugular veins.

www.medicalebookpdf.com

LWBK892_c37_p468-478.indd 472 10/28/11 9:14:36 PM

 Chapter 37: Fine Needle Aspiration Biopsy of the Thyroid: Thyroid Lobectomy and Subtotal and Total Thyroidectomy 473

vessels. At the anterior aspect of this medial

dissection, there are often small crossing
blood vessels, which should be divided with
the Ligasure or Focus.
After this anterior dissection is complete
and space permits, a Dietrich clamp is
placed behind the superior thyroid vessels
to allow sealing of the vessels with the Liga-
sure or Focus (Fig. 7). This is repeated with
other vessels or tissue at the superior thy-
roid pole until the entire superior pole is
free. As the superior thyroid lobe is mobi-
lized, care must be taken to avoid injuring
the underlying superior parathyroid gland.
After mobilization and rotation of the up-
per lobe medially, the remaining thyroid
Fig. 5. Dividing the strap muscles with electrocautery. lobe is then mobilized from lateral to me-
dial. To achieve exposure, the gland is re-
tracted anteriorly and medially with the
electrocautery, the cervical fascia investing used to retract both strap muscles laterally surgeon’s index finger and the strap muscles
the paired sternohyoid muscles is then in- (Fig. 6). are held laterally with an Army–Navy re-
cised, separating the strap muscles (ster- Once the thyroid lobe is exposed, our tractor. Blunt dissection with a Kitner clears
nohyoid and sternothyroid). As the length initial step is to divide the superior pole ves- areolar tissue from the lateral aspect of the
of this incision will ultimately determine sels to mobilize the upper lobe. We utilize thyroid lobe. The middle thyroid vein is di-
access to the thyroid gland, the incision thermal sealing instruments such as the Li- vided with the Ligasure, or between clamps
should be placed exactly in the midline of gasure or Focus harmonic scalpel to divide and tied with 2-0 silk sutures (Fig. 8). This
the neck between the sternohyoid muscles, all the thyroid vessels. We have shown that dissection permits full medial rotation of
extending from the thyroid notch to the these energy devices reduce operative time the thyroid lobe. With the lateral and supe-
level of the sternal notch. There are fre- with no increase in morbidity. I rarely uti- rior aspect of the thyroid dissected free, the
quently crossing veins at both the superior lize any sutures to ligate thyroid vessels. The thyroid can now be mobilized medially and
and inferior aspects of the midline and care superior pole vessels are then dissected free anteriorly, out of the operative wound. The
must be taken to avoid bleeding. The ipsi- laterally. An Army–Navy retractor is utilized thyroid lobe is then retracted in this antero-
lateral strap muscles are then grasped with for exposure and similar blunt dissection medial position for the remainder of the
a Babcock clamp and gently dissected off with a Kitner is employed to sweep the are- procedure, and is best held under slight ten-
the thyroid capsule with electrocautery and olar tissue and remaining strap muscle fi- sion with the surgeon’s index finger covered
blunt dissection with a Kitner or a teardrop bers from the lateral superior thyroid pole. with a sponge. With this maneuver, the re-
suction device. This avascular plane be- This pole is then separated from the crico- current laryngeal nerve can now be identi-
tween the strap muscles and the thyroid thyroid muscle medially using a Dietrich fied, as can the parathyroid glands (Fig. 9).
gland can be bluntly dissected until the (curved right angle) clamp (Fig. 6). Extreme About 85% of the parathyroid glands are
internal jugular vein is identified. Develop- care is taken to keep all medial dissection found within 1 cm of where the recurrent
ment of the proper cleavage plane will al- close to the thyroid lobe so as to not place laryngeal nerve crosses the inferior thyroid
low lateral mobilization of the sternohyoid the external branch of the superior laryn- artery, with the superior parathyroid gland
and sternothyroid muscles. This is only per- geal nerve at risk. This nerve can lie on the located posterior to the nerve and the inferior
formed on the side ipsilateral to the lobe to lateral surface of the cricothyroid muscle, in gland located anterior to the nerve (Fig. 9).
be excised. An Army–Navy retractor is then close proximity to the superior pole blood The superior parathyroid gland is more likely
to be in direct contact with the thyroid cap-
sule posteriorly (near the tubercle of Zucker-
kandl at the level of the cricoid cartilage),
and can be identified once the thyroid is re-
tracted medially. After careful dissection to
create a plane between the thyroid capsule
Endocrine Surgery

and superior parathyroid gland, blunt dissec-

tion with a Kitner can push the parathyroid
back on a broad pedicle, safely away from the
operative field. Surgical clips can mark the
parathyroid glands for future identification
and provide hemostasis with minimal ma-
nipulation of the gland’s blood supply.
The recurrent laryngeal nerve should be
always identified during the lobectomy. It
should run directly medial to the superior
parathyroid, and can be visualized after
Fig. 6. Exposure of the superior pole of thyroid and upper pole vessels with retraction. pushing the superior parathyroid gland

www.medicalebookpdf.com

LWBK892_c37_p468-478.indd 473 10/28/11 9:14:36 PM

 474 Part IV: Endocrine Surgery

laterally as described above. I find it easiest

to identify the recurrent nerve medial to
the superior parathyroid, knowing that the
nerve is most consistent in the position
where it enters the larynx on the postero-
lateral aspect of the cricothyroid muscle.
The right recurrent nerve travels laterally
in the lower neck and then travels obliquely
toward the midline at an angle approxi-
mately 30 degrees to the tracheoesopha-
geal groove. During this course, it can pass
behind, between, or anterior to the main
branches of the inferior thyroid artery. The
left nerve, on the other hand, travels in the
Fig. 7. Division of the superior pole vessels with Ligasure. tracheoesophageal groove for its entire
cervical course. The recurrent nerves can
be identified in the inferior aspect of the
operative field if there is associated inflam-
mation or scarring closer to the thyroid.
In order to protect the nerves, only tis-
sue that is transparent and/or definitively
identified to be vascular or lymphatic
‘0 6
RF should be divided. Even after identification
H

of the recurrent nerve, it is still important

Middle thyroid
vein (divided)
to be cautious when dividing tissue as most
recurrent nerves can branch prior to enter-
ing the cricothyroid muscle. An anterior
branch of the nerve can be mistaken for a
vessel easily. Electrocautery should be care-
fully used adjacent to the nerve because it
can arc and thermally injure the nerve
nearby. After identification of the recurrent
nerve along its entire course, the lower
parathyroid is located. The inferior pole
blood vessels are usually under tension at
this point and are divided with the Ligasure
or Focus as close to the thyroid gland as
possible (Fig. 9). Once the vessels are di-
Fig. 8. Medial retraction of thyroid with fingers covered with surgical sponge after division of the middle
thyroid vein. vided, further blunt Kitner dissection can
push the proximal ends of these vessels and
the associated nearby inferior parathyroid
gland away from the thyroid, protecting it
for the remainder of the case.
Note that the inferior pole vessels are the
blood supply to the inferior parathyroid
glands and most superior parathyroid glands,
which is why only the terminal branches di-
rectly entering the thyroid should be divided
(Fig. 9). Branches of the inferior thyroid artery
are divided with the Ligasure or Focus as close
to the thyroid gland as possible to avoid
devascularizing the parathyroids (Fig. 9). The
final dissection off the anterolateral aspect of
the tra-chea, through the remainder of the
ligament of Berry, should be performed care-
fully since this is the area where the nerve is at
greatest risk of injury (Fig. 10). Once on the
anterior aspect of the trachea, this is an avas-
cular plane. The thyroid isthmus is mobilized
off the anterior trachea with electrocautery to
the intersection with the contralateral lobe.
Fig. 9. Anterior/medial retraction of thyroid, showing recurrent laryngeal nerve and parathyroid gland The thyroid isthmus is then divided with the
anatomy. Division of the distal branches of the inferior thyroid artery with Ligasure. Focus or Ligasure at this location (Fig. 11).

www.medicalebookpdf.com

LWBK892_c37_p468-478.indd 474 10/28/11 9:14:36 PM

 Chapter 37: Fine Needle Aspiration Biopsy of the Thyroid: Thyroid Lobectomy and Subtotal and Total Thyroidectomy 475

Small artery erative day. Skin closure is with a 5-0 Prolene

and vein suture with horizontal ½-in. sterile strips.
Subtotal thyroidectomy. In a traditional
subtotal thyroidectomy, 2 to 3 g of thyroid
tissue is left bilaterally. This is no longer
6 recommended by us and others, because
H RF ‘ 0
recurrent disease can occur bilaterally and
reoperation would place both recurrent
laryngeal nerves and all functioning para-
thyroid glands at risk. Instead, a Hartley–
Ligament
Dunhill subtotal thyroidectomy is now rec-
of Berry ommended if residual thyroid tissue is left
in situ. This involves a total lobectomy and
isthmusectomy on the most diseased side
Recurrent and a subtotal resection (leaving approxi-
laryngeal mately 4 g) on the contralateral side. Subto-
nerve tal thyroidectomy should not be performed
for patients with malignant disease as thy-
Fig. 10. Dissection of the ligament of Berry depicting the course of the recurrent laryngeal nerve. roid tissue left in situ on the side of the pri-
mary tumor is at risk for recurrent disease,
higher doses of radioactive iodine (RAI) are
With the specimen excised, it is reexam- roid muscle. The strap muscles are then required after subtotal thyroidectomy, and
ined to ensure that no parathyroid tissue reapproximated in the midline with a run- thyroglobulin assays are less sensitive for
has been inadvertently removed. If a normal ning 2-0 vicryl suture. We then inject 30 cc of predicting tumor recurrence.
parathyroid gland is identified on the ex- 0.25% bupivicaine (Marcaine) for postoper- When a subtotal thyroidectomy is
cised thyroid specimen, it should be auto- ative local anesthesia. The platysma is reap- planned, a thyroid lobectomy should be
transplanted immediately (see “Parathyroid proximated with a running 3-0 vicryl suture. performed on the most diseased lobe, as de-
Implantation”). The operative field is irri- Surgical drains are almost never used. A scribed in the “Thyroid Lobectomy” section.
gated and hemostasis ensured. Surgicel is potential exception is after excision of large On the side of the subtotal resection, the up-
useful when there is minimal bleeding im- substernal goiters, as the resulting cavity per pole vessels and the inferior pole vessels
mediately adjacent to the recurrent laryn- may benefit from a closed suction drain are mobilized and divided with Ligasure or
geal nerve, which is often just as the nerve brought out through the lateral aspect of Focus, as described above. The middle thy-
enters the larynx posterior to the cricothy- the wound and removed on the first postop- roid vein is then divided and the thyroid
lobe is mobilized out of the wound as previ-
ously described. The recurrent nerve is
identified. However, branches of the inferior
thyroid artery are not ligated. The postero-
lateral resection margin through the thyroid
is selected so that an appropriate volume of
thyroid tissue is left in situ, while keeping
the dissection plane safely anterior to the
recurrent laryngeal nerve and the parathy-
roid glands (Fig. 12). Focus or Ligasure is
utilized to transect the thyroid tissue along
this dissection line (Fig. 13). Additional he-
mostasis can be achieved with pressure and
electrocautery, when safe to do so. Keeping
the posterior thyroid capsule intact helps to
protect the nearby recurrent laryngeal nerve
and parathyroid glands, but recall that the
nerve can traverse onto the lateral aspect of
Endocrine Surgery

the thyroid at the level of the cricoid carti-

lage and tubercle of Zuckerkandl, in close
proximity to where the gland will be divided.
I typically put a piece of Surgicel on the cut
edge of the thyroid gland. The incision is
then closed in the same manner as during
a thyroid lobectomy, including 30 mL of
0.25% bupivicaine.
Total thyroidectomy. A total thyroidec-
tomy is the treatment of choice for the ma-
jority of thyroid cancers. A near-total thyroi-
Fig. 11. Dividing the thyroid isthmus with Ligasure during thyroid lobectomy. dectomy leaves less than 1 g (1 cm) of thyroid

www.medicalebookpdf.com

LWBK892_c37_p468-478.indd 475 10/28/11 9:14:37 PM

 476 Part IV: Endocrine Surgery

tissue on one side of the neck. It is performed

when a total thyroidectomy is planned, but a
minute portion of thyroid is purposely left in
situ, in close proximity to the recurrent laryn-
geal nerve or parathyroid gland, when it is
deemed unsafe to do otherwise. A total thy-
roidectomy is essential performing a thyroid
lobectomy on each side, without transecting
the isthmus. One should perform the opera-
tion on the most abnormal side of the thyroid
first, so that if the nerve is inadvertently in-
jured or invaded by thyroid cancer, a less ex-
tensive procedure can be performed on the
Selected plane of
dissection through thyroid opposite side to ensure that the contralateral
nerve is preserved. Bilateral recurrent laryn-
geal nerve palsy should be avoided at all
costs, as this often requires a tracheostomy
to protect the patient’s airway.
My preference is to resect the thyroid as
a single specimen. However, if the underly-
6

ing thyroid condition is benign, the isthmus

HRF ‘0

can be transected. Some surgeons feel that

this creates more room in the operative
field and dissection of the posterior surface
of the thyroid off the trachea enables better
Fig. 12. Diagram of planned dissection across thyroid parenchyma for subtotal thyroidectomy with re- mobilization of the gland anteriorly. If the
current laryngeal nerve and parathyroid glands in diagram. thyroidectomy is being performed for a
proven or potential underlying malignancy,
isthmus division should be avoided and the
entire thyroid excised en bloc. I generally
place a piece of Surgicel in each side of the
neck after a total thyroidectomy. The wound
is closed in a manner similar to a thyroid
lobectomy. If a near-total or total thyroi-
dectomy is being performed as a “comple-
tion” thyroidectomy, it should usually be
performed within 5 days of the original thy-
roid lobectomy or at least 2 to 3 months af-
terward. Operating within this intervening
time period is associated with reactive scar
tissue and more bleeding. This is generally
not a problem when a unilateral procedure
was done at the initial operation.
Parathyroid implantation. To autotrans-
plant a parathyroid gland, confirmation that
it is normal parathyroid tissue should first be
established histologically with a frozen sec-
tion of a small portion of the gland, especially
if the patient has thyroid cancer. While being
evaluated, the remaining parathyroid tissue
should be minced into pieces and placed in
saline solution. Once confirmed to be nor-
mal parathyroid, the minced parathyroid tis-
sue is placed in a pocket created in the ipsi-
lateral sternocleidomastoid muscle and
secured with a 3-0 silk figure-eight suture
that closes the muscle fascia. The site is then
marked with two surgical clips. Any parathy-
roid gland considered to be at risk should be
autotransplanted, regardless of the status of
Fig. 13. Transection of the thyroid with Ligasure for subtotal thyroidectomy. the other glands. Each parathyroid gland
should be treated as if it were the only re-
maining functioning parathyroid tissue.

www.medicalebookpdf.com

LWBK892_c37_p468-478.indd 476 10/28/11 9:14:37 PM

 Chapter 37: Fine Needle Aspiration Biopsy of the Thyroid: Thyroid Lobectomy and Subtotal and Total Thyroidectomy 477

POSTOPERATIVE nerve dysfunction for over 6 months) occurs SUGGESTED READINGS

in 1% or less of cases when an experienced en-
MANAGEMENT docrine surgeon does the operation. The pa- Callcut RA, Selvaggi SM, Mack E, et al. The utility
of frozen section evaluation for follicular thy-
Thyroid lobectomy. The vast majority of pa- tient should be reassessed for ongoing clinical roid lesions. Ann Surg Oncol 2004;11:94–8.
tients in my practice have a thyroid lobec- evidence of nerve injury. If it persists for more Chen H, Nicol TL, Udelsman R. Follicular lesions
tomy as an outpatient; i.e., they are dis- than 6 months, a direct laryngoscopy should of the thyroid. Does frozen section evaluation
charged home after 2 hours of postoperative be arranged to formally assess nerve function. alter operative management? Ann Surg 1995;
observation in the outpatient unit. There is Subtotal or total thyroidectomy. After sub- 222:101–6.
no diet restriction for postoperative pa- total or total thyroidectomy, few patients are Chen H, Zeiger MA, Clark DP, et al. Papillary car-
tients. Most patients progress from clear cinoma of the thyroid: can operative manage-
observed as short-stay 23-hour hospital ment be based solely on fine-needle aspiration?
liquids to solid food within hours after the admission. We have moved to same-day J Am Coll Surg 1997;184:605–10.
operation. Narcotic analgesia is rarely re- discharge in most of these patients. Diet, Chen H, Nicol TL, Zeiger MA, et al. Hurthle cell
quired after the first 24 hours and patients pain management, activity, and wound care neoplasms of the thyroid: are there factors
often require no more than acetaminophen are similar to thyroid lobectomy. One con- predictive of malignancy? Ann Surg 1998;227:
with codeine for pain control. The liberal cern that has limited same-day discharge af- 542–6.
use of Marcaine in the incision prior to clo- ter total thyroidectomy has been postopera- Greenblatt DY, Sippel R, Leverson G, et al. Thyroid
resection improves perception of swallowing
sure reduces postoperative incisional pain tive hypocalcemia or hypoparathyroidism. function in patients with thyroid disease. World
significantly. Nonnarcotic medications such We have developed a protocol to predict and J Surg 2009;33:255–60.
as acetaminophen or ibuprofen should be treat patients at risk for this. All patients are Haymart MR, Greenblatt DY, Elson DF, et al. The
the initial analgesic if the patient’s pain is placed on 2000 mg of calcium daily for the role of intraoperative frozen section if suspi-
only minimal to moderate. This is probably first week after surgery. We obtain a serum cious for papillary thyroid cancer. Thyroid 2008;
more common than after other general sur- PTH: less than 10 pg/mL is concerning for 18:419–23.
Haymart MR, Repplinger DJ, Leverson GE, et al.
gery cases and may be caused by the pro- hypoparathyroidism, and these patients are Higher serum thyroid stimulating hormone
longed neck extension during the operation. placed on 0.25 μg calcitriol twice daily in ad- level in thyroid nodule patients is associated
Again, preventative measures with proper dition to calcium. Patients with PTH levels with greater risks of differentiated thyroid can-
positioning must be stressed. The patient is 10 pg/mL or greater are given calcium only. cer and advanced tumor stage. J Clin Endocrinol
discharged home with Steri-Strips in place. Calcium and PTH levels are obtained at the Metab 2008;93:809–14.
The patient can shower 24 hours postopera- 1-week postoperative visit. If both calcium Musunuru S, Schaefer S, Chen H. The use of the
tively, after which the Steri-Strips should be and PTH are normal, calcium as well as cal- Ligasure for hemostasis during thyroid lobec-
tomy. Am J Surg 2008;195:382–4.
blotted dry. Patients should not drive until citriol is stopped. Patients are also discharged Pinchot SN, Al Wagih H, Schaefer S, et al. Accuracy
they are comfortable doing a complete on thyroid hormone (1.5 μg/kg) starting on of fine-needle aspiration biopsy for predicting
“shoulder check” for parking or changing postoperative day 1. A TSH level is obtained neoplasm or carcinoma in thyroid nodules
lanes. They can resume activities of daily liv- 6 weeks after surgery. Thyroid hormone re- 4 cm or larger. Arch Surg 2009;144:649–54.
ing upon discharge, but should refrain from placement should aim for a TSH level within Roy M, Chen H, Sippel RS. Is DVT prophylaxis
strenuous exercise for about 4 to 5 days. I normal range for patients with benign dis- necessary for thyroidectomy and parathyroi-
dectomy. Surgery 2010;148(6):1163–8.
see patients back in clinic 1 week after sur- ease, within the low-normal range for pa- Stoll SJ, Pitt SC, Liu J, et al. Thyroid hormone
gery to remove their sutures and review the tients requiring a suppressive dose for benign replacement after thyroid lobectomy. Surgery
pathology. No labs are obtained at this visit disease, less than 0.1 mU/L for low-risk pa- 2009;146:554–60.
but after 6 weeks a TSH level is checked to tients with thyroid cancer, and 0.05 mU/L or Youngwirth L, Benavidez J, Sippel R, et al. Parathy-
rule out postoperative hypothyroidism. slightly lower for all other patients with dif- roid hormone deficiency after total thyroidec-
If the patient has a hoarse voice postopera- ferentiated thyroid cancer. If the patient is tomy: incidence and time to resolution. J Surg
Res 2010;163(1):69–71.
tively, it may be due to irritation by the endo- found to have well-differentiated thyroid Zarebczan B, Chen H. A comparison of the liga-
tracheal tube or it could be temporary or per- cancer, and radioactive iodine is planned, we sure and harmonic scalpel in thyroid surgery: a
manent injury to the recurrent laryngeal routinely do not withdraw thyroid hormone single institution review. Ann Surg Oncol 2011;
nerve. Permanent nerve injury (persistent but utilize recombinant TSH (Thyrogen). 18(1):214–18.

EDITOR’S COMMENT The risks of increased malignancy in thyroid nod- reason was that Dr. Cope was very, in a sense,
ules include head and neck radiation therapy and ahead of his time and in particular somewhat un-
Endocrine Surgery

a familiar association of thyroid cancer. usual as far as surgery was concerned. Dr. Cope
The thyroid is a metabolically active gland, in Thyroid cancer is now considered a real can- was very pro-psychiatry. To a certain extent this
which 1% of the stored thyroid hormone is re- cer. This has come a long way from the 1960s, might have been because of his wife, who was a
leased per day. The half-lives of the two thyroid when Dr. Oliver Cope, one of the famous thyroid social worker, a very nice lady, with whom my
hormones that are released are 1 to 3 days for T3 and parathyroid surgeons, did not believe that wife, Karen, a social worker, had an excellent
and 7 days for T4. With an aging population and this was a real cancer and in fact thought that the relationship. Dr. Cope believed, and here he was
ready availability of thyroid ultrasonography, the major therapy for thyroid cancer was psychiatry. ahead of his time, that doing a radical mastec-
number of thyroid nodules in the general popula- To a certain extent one can believe this, for the tomy for breast cancer was mutilating to women,
tion is beginning to be a public health consider- very simple reason that papillary carcinoma of to which everybody agreed, and that it was not
ation, as 4% to 7% of the population has thyroid the thyroid was by far the most common form of necessary to do a complete axillary dissection for
nodules. It is estimated that 95% of these nodules thyroid cancer, and it was rare to see a patient die all breast carcinomas, and he also believed that
are benign and therefore do not require surgery. of papillary carcinoma of the thyroid. The other infiltration of the lymph nodes with lymphocytes

(continued)

www.medicalebookpdf.com

LWBK892_c37_p468-478.indd 477 10/28/11 9:14:37 PM

 478 Part IV: Endocrine Surgery

was a good prognostic sign, for which he might the number of FNAs performed in the later time therefore, of FNA is 95% with a sensitivity of 83%,
have been correct, and a complete axillary dissec- period increased significantly by 250%. Patients a specificity of 92%, and the positive predictive
tion was unnecessary. undergoing FNA were more likely to be female value of 75%. Most authorities agree on this.
Because Dr. Cope felt strongly that carcinoma and were significantly older. With regard to the The critical issue here is the FNA’s suspicious
of the thyroid (and by this he meant papillary car- FNA diagnoses, not surprisingly, benign FNAs (indeterminate) results. Malignant disease means
cinoma of the thyroid) was not a real cancer, no increased whereas the diagnosis of malignancy that FNAs cannot be accurately excluded, and, if
one did a node dissection. The evolution of thyroid decreased in proportion regardless of whether these had been documented as follicular neo-
cancer from that particular time until now has one was dealing with papillary carcinoma of the plasms or suspicious, a diagnostic lobectomy is
been a real sea change. First of all, I think every- thyroid or follicular neoplasms. There also was a probably appropriate despite the fact that many
body believes that thyroid cancer is a real cancer. remarkable increase in the incidence of thyroidi- of them will reveal the nondisease.
Second, total thyroidectomy has become a prin- tis, whatever that is. Looking at Table 2 in this Finally, when can FNA be omitted? In the pres-
cipal operation for this disease, which in fact was article, which comes from Dr. Chen’s unit, group ence of thyroid nodules in patients with the RET
not very often carried out at the time when I was 1 had 905 patients with 1.33 FNA per patient gene mutation, strong family history of thyroid
a resident in the 1960s. Finally, lymph node dissec- whereas group 2 of 1,875 patients had 1.48 FNA cancer, endocrine neoplasia type II, or increased
tion, particularly of the central lymph nodes and per patient. Whether or not this indicates greater basal or stimulated calcitonin levels, or history
perhaps some additional nodes, is now a frequent suspicion is not clear, but in Table 3, ìDistribution of neck radiation, FNA should be omitted and at
part of operations for thyroid cancer, and patients of Diagnoses,î benign FNA diagnoses (certain) least a diagnostic lobectomy undertaken.
with thyroid cancer not only merit something increased from 68% to 76%, which was statisti- With his extensive experience of a type of thy-
close to a total thyroidectomy or at least a unilat- cally significant, whereas the follicular/Hurthle roidectomy does Professor Sakorafas suggest. The
eral lobectomy with an isthmusectomy but could cell neoplasms decreased from 9.1% to 4.1%. The lobectomy plus isthmusectomy at least guards
also undergo a resection of the central nodes. only other significant change between the two against the possibility of injuring both laryngeal
Fine-needle aspiration (FNA) is the staple as groups was papillary thyroid carcinoma, which nerves. However, the significant disadvantage is
far as the further steps taken in the patient who decreased from 6.3% to 3.4%. There are some that there may be a highly significant recurrence
has a thyroid nodule between 1 and 4 cm in size. other differences as well. rate with a normal follow-up. Thus, the diagno-
As I will detail later, FNA is unequivocally benign A very nice and thorough review is offered sis in recurrent disease is something that needs
in 70% of patients. For those patients who have by Dr. George H. Sakorafas from the 4th Depart- to be borne in mind. Nodule recurrence could be
clearly malignant thyroid nodule, for lesions with ment of Surgery at Athens University (Surg Oncol prevented by levothyroxine-suppressive therapy.
papillary carcinoma, with lesions that are smaller 2010;19:e130–e139), who wrote a scholarly and Other alternatives include subtotal thyroidectomy
than 1 cm, either thyroid lobectomy or total thy- erudite article on FNA and its practical consid- and total/near-total thyroidectomy, in the case of
roidectomy is acceptable as far as Dr. Chen is erations, which can be read with great profit. Dr. less than 3 g of residual thyroid. As far as lymph
concerned, and I agree. However, if abnormal Sakorafas points out that FNA is central to the di- node resection is concerned, if one believes that
lymph nodes are seen intraoperatively by ultra- agnosis of thyroid nodules. We know that. He esti- one has a malignancy in station 6 central node, this
sonography, a level 6 central lymph node dissec- mates that 5% of the patients have thyroid nodules should be carried out, and as previously stated, the
tion is indicated. In patients who have enlarged found by palpation and by ultrasonography or station of unilateral node resection is appropriate.
lateral lymph nodes, FNA should be performed autopsy in 50%. The clinical significance of these Frozen section of the nodules and lymph nodes do
on the lymph node, and, if positive, level 2, 3, and nodules remains unknown, since most of them do not yield an appropriate resection. The situation
4 lymph nodes should be dissected on that side. not progress, especially those found at autopsy. He continues in individuals wanting to get a prospec-
Dr. Chen then details the various types of cancer points out that malignant thyroid nodules should tive study with increased accuracy.
and what should be done, especially in associa- be managed aggressively by thyroidectomy and Along these lines, Mathur A, et al. (Surgery
tion with medullary thyroid cancer and multiple that more common benign thyroid nodules should 2010;148:1170–1177), from Clark’s unit in San
endocrine adenoma. I will go into more detail in be managed conservatively. He also points out Francisco, suggest that FNA may be nondiagnos-
discussing some of the articles. that there are very infrequent local compressive tic or indeterminate or suspicious in 20% to 30%
Among follicular neoplasms, 80% are ad- syndrome symptoms or thyroid dysfunction and of cases; in other words, FNA is appropriate and
enomas whereas 20% are cancer. Capsular and therefore the thyroid nodule is significant when it diagnostic in 70% of cases. This group agrees with
vascular invasion differentiates obviously ad- reveals thyroid cancer. Ninety-five percent of these the previous two individuals as to the percentage
enomas from follicular cancers, and a thyroid will be benign or be adenomas. The other inci- of definitive FNAs. They applied a series of mark-
lobectomy is indicated without a frozen section. dence that has increased is when there is a thyroid ers and found that three variables, including BRAF
This is especially true, since the frozen-section nodule that is cancerous, where it is much more V600E, NRAS, and KRAS, were among the six can-
analysis does not provide additional information likely, as Dr. Chen points out in his chapter, to be didate diagnostic markers used for univariate and
and is inaccurate. Among Hurthle cell neoplasms, accompanied by some sort of node dissection. multivariate analyses in 341 patients, but by using
70% are adenomas and 30% are cancers. Since the practice in Dr. Sakorafas’ clinic is NRAS mutation and three variables including the
As far as size is concerned, a lesion smaller frequently accompanied by ultrasonography, he tissue inhibitor of metalloproteinase 1 expression,
than 1 cm with papillary carcinoma does not merit emphasizes that varying the size of needles de- benign from malignant thyroid tumors could be
a total thyroid lobectomy. Hurthle cell neoplasms pending on the vascularity and the blood supply, accurately distinguished in 91% including 67% for
are very uncommon, unless with a lesion smaller and that three to six aspirations per nodule, is the indeterminate and 77% FNA groups.
than 2 cm, but for lesions larger than 2 cm, approx- probably good practice. He also says that it is best Ferraz C, et al., in a special review in J Clin En-
imately half are malignant neoplasms. As for the le- if there is a highly qualified pathologist present to docrinol Metab (2011;96:2016–2026), attempted
sions that are 4 cm or larger, FNA is inaccurate for immediately read the specimen, which is not likely once again to arrive at somatic mutations to re-
the most part and therefore special considerations the practice in most of the United States. The ultra- duce the number of indeterminate fine-needle
exist, and, if one is suspicious enough, a diagnostic sound-guided FNA is recommended for nodules biopsies. Not different from most of the other
lobectomy is undertaken. It is better to undertake larger than 10 mm and only if suspicious clinical or publications, this review of 20 publications gave
a somewhat lesser procedure, where cancer is not ultrasound features are present in nodules that are a mean sensitivity of 63%, which is a little low but
clear, and protect the laryngeal nerve. smaller than 10 mm. The cystic nodules are differ- nothing terribly different.
With the central status FNA of the thyroid oc- ent. They have not been discussed elsewhere, but We are left with FNA biopsy in thyroid nod-
cupies, many of the articles to which I will refer they could represent simple cysts, colloid nodules, ules that generally need to be larger than 1 cm,
are critical to understanding what we undertake hemorrhagic adenomas, or even necrotic papillary but we are warned that for thyroid nodules larger
and what we do not undertake. Coorough N, carcinomas. The malignancy rate within cystic than 4 cm, FNA tends to be unreliable. On the
et al. (J Surg Res 2011:1–4, published online) ana- thyroid nodules is approximately 10%. other hand, it has been honed to a fine skill and
lyzed FNA data from 981 consecutive patients, In his experience, the results of FNA are cat- therefore should be repeated, although with a
who underwent thyroid FNA between 2002 and egorically benign in 70%, categorically malignant number of relative differences and the outcomes,
2009. The early time period of 2002 to 2005 and in 5%, as identified by an experienced cytopathol- perhaps, we are biopsying too much, especially in
the later time period of 2006 to 2009 were di- ogist, suspicious or indeterminate in 10%, and the elderly and in the female.
vided. The data were compared. Not surprisingly, insufficient for diagnosis in 15%. The accuracy, J.E.F.

www.medicalebookpdf.com

LWBK892_c37_p468-478.indd 478 10/28/11 9:14:37 PM

 Chapter 38: Total Thyroidectomy, Lymph Node Dissection for Cancer 479

38 Total Thyroidectomy, Lymph Node

Dissection for Cancer
Thomas W.J. Lennard

ANATOMY nerve and the superior thyroid artery, the what variable and on occasions the glands
most common variable being that the nerve can be within the thyroid, attached to it or
The normal thyroid gland is composed of is some distance from the artery, but on oc- lying along the thyrothymic tract. Preserva-
two symmetrical lobes lying on either side casions it can again weave its way between tion of these glands and their blood supply
of the trachea and joined by an isthmus at the branches of the artery and be very close during thyroidectomy is important and
the level of the second, third, and fourth tra- to the upper pole of the thyroid. Because parathyroid dysfunction following thyroi-
cheal rings. The gland lies underneath the of the close relationship of these two nerves dectomy is the commonest complication of
strap muscles of the neck (the sternothyroid to the blood supply of the thyroid, the tech- thyroidectomy. Structures close to the thy-
and the sternohyoid muscles), each lobe on nique of capsular dissection of the thyroid, roid gland, which become relevant during
either side of the larynx and trachea. The whereby the surgeon stays close to the cap- nodal dissection include the trachea, the
gland is invested by pretracheal fascia, sule of the thyroid, will ensure the greatest esophagus, and the carotid sheath. The lat-
which is responsible for its movement dur- protection for these important nerves. Very ter contains the common carotid artery, the
ing swallowing. In some patients, there is an rarely, there can be an inferior artery of the internal jugular vein, and the vagus nerve. A
upward extension of the gland from the thyroid (the thyroid ima artery), which en- surgeon operating on the thyroid gland for
isthmus called the pyramidal lobe and this ters the lower part of the isthmus directly malignancy will need a good understanding
represents a developmental island of tissue from the brachiocephalic trunk or occa- of the lymph node territories of the neck (see
in the position of the thyroglossal duct. Ac- sionally from the arch of the aorta. Fig. 1).
cessory and separate islands of thyroid tis- The venous return from the thyroid in
sue can be found in the superior mediasti- the upper pole follows the superior thyroid CLINICAL PRESENTATION
num near the hyoid bone and beneath the artery, but for the middle part of the thyroid,
sternomastoid muscle. The thyroid gland a separate, short and wide vein, usually sin- Thyroid cancer presents most commonly as
descends into the neck embryologically, fol- gle but sometimes with several branches, a painless lump within the thyroid gland.
lowing a proliferation of the cells at the drains directly into the internal jugular vein. Such swellings usually will be ⬎1 cm in
junction of the anterior third and posterior During mobilization of the thyroid, this vein size, if clinically palpable. As the tumor
two thirds of the tongue. The importance of or series of veins needs to be secured early growth progresses, compressive symptoms
understanding this developmental pathway before traction is put on the lobe because may occur causing dysphagia or dyspnea,
is essential if a surgeon is trying to remove tearing can cause substantial hemorrhage and the patient may become aware of supr-
the whole of the thyroid tissue and on occa- and make identification of other vital struc- aclavicular swellings in the neck or swell-
sion division of the hyoid bone and tracing tures nearby extremely difficult. The third ings in the posterior triangle of the neck
the thyroglossal duct all the way toward group of veins, the inferior thyroid veins, representing involved lymph nodes. Rarely,
the base of the tongue may be required. In drains the lower poles of the thyroid form- thyroid cancer can present as disseminated
addition, embryologically, the calcitonin- ing a plexus that runs down into the bra- disease most typically with bone, lung, or
producing cells join the thyroid gland hav- chiocephalic veins. Lymphatic drainage of mediastinal tumor deposits. Differentiated
ing migrated from the neural crest. Other the thyroid follows the arteries, but there is thyroid cancers (papillary and follicular)
neural crest tissue forms part of the adrenal considerable crossover of lymphatic flow are nonsecretory tumors, so there are few, if
glands and the parathyroid glands, and this between the neck compartments in the any, systemic symptoms during tumor de-
explains the combination of multiglandular presence of malignant disease. velopment. On the other hand, medullary
disease in the syndromes known as multi- The nerve supply to the thyroid gland is thyroid cancer arising within the C cells se-
ple endocrine neoplasia type II. predominantly from the sympathetic cervi- cretes calcitonin, and this can cause sys-
The thyroid gland obtains its blood sup- cal ganglion, these fibres being vasocon- temic symptoms including blushing and
ply through the superior and the inferior strictor. diarrhoea. Undifferentiated or anaplastic
thyroid arteries. The superior thyroid artery Close to the thyroid gland and intimately thyroid cancer may present as a diffuse rap-
is the first branch from the anterior aspect associated with it and sharing its blood sup- idly growing goiter, with early compressive
of the external carotid artery and it reaches ply are the parathyroid glands. There are symptoms due to the infiltrative nature of
Endocrine Surgery

the gland as a single vessel, usually at the typically four parathyroid glands—two on the disease. If the great vessels of the neck
upper pole of the thyroid. The inferior thy- each side—and in health both glands lie are involved in this process, venous conges-
roid artery, by contrast, divides outside the within 1 cm radius of the inferior thyroid ar- tion may be clinically evident in the region
thyroid gland into four or five branches that tery as they begin to break into its branches of the face and the neck.
pierce the gland supplying the lower pole of to supply the thyroid. The gland situated su- Increasingly, thyroid cancer is being di-
it. The recurrent laryngeal nerve lies usually periorly is called parathyroid four because it agnosed as a result of an incidental finding
behind the inferior thyroid artery, but it can develops from the fourth pharyngeal pouch, as a consequence of a radiological investiga-
on occasions lie in front of it or weave its and that below the lower pole of the thyroid tion unrelated to the thyroid (the so-called
way between the branches of the artery. is called parathyroid three, developing from thyroid incidentaloma). This is further dis-
There is a variable relationship between the the third pharyngeal pouch. The anatomical cussed elsewhere in this chapter. These tu-
external branch of the superior laryngeal position of the parathyroid glands is some- mors are commonly ⬍1 cm in size, although

www.medicalebookpdf.com

LWBK892_c38_p479-485.indd 479 10/28/11 5:03:42 PM

 480 Part IV: Endocrine Surgery

the age of 16 should be checked. Familial

polyposis and Cowden’s syndrome should
be enquired about, the latter being an asso-
ciation between thyroid cancer, macroceph-
aly, and breast cancer. If the patient gives a
history of rapid growth of the thyroid swell-
ing and hoarseness of the voice or symptoms
suggestive of disseminated disease such as
bone pain, then suspicion of thyroid malig-
nancy is raised. Thyroid nodules occurring
in children are more likely to be malignant
than in adults and it should be remembered
that thyroid cancer presents most com-
monly in females around the age of 40.
Physical findings will include the swell-
ing in the neck, a careful search for associ-
II ated lymphadenopathy, an assessment of
I the voice, and the differentiation of a true
thyroid nodule, which moves on swallow-
ing from other nonthyroid swellings in the
neck. Baseline blood tests will include tests
of hemoglobin, renal function, and liver
III function, and specifically for the thyroid,
thyroid function tests (including TSH, T4,
and T3 level) should be performed. A cal-
cium level should also be taken. If the TSH
level is low and below the normal range,
V then a radionuclide thyroid scan should be
performed to see if the thyroid nodule is hy-
VI perfunctioning. If so, further pathological
IV evaluation is not required since hyperfunc-
tioning nodules are very rarely malignant.
However, if the patient has a hyperthyroid
state that is not concordant with a hyper-
functioning nodule on radionuclide scan-
ning then the nodule does require separate
VII evaluation by way of biopsy (see below).
A diagnostic thyroid ultrasound should
be performed in all patients with a thyroid
nodule with the aim of confirming that the
Fig. 1. Nodal levels and their numbered compartments in the neck (I–V). nodule is arising within the thyroid and as-
sessing its size. There are some ultrasound
features of thyroid nodules, which are more
suspicious of malignancy and in addition
on occasions patients may be harboring the lymph nodes in the neck can be assessed
large tumors, which they were unaware of DIAGNOSIS for evidence of metastatic involvement. The
and which are picked up on cross-sectional ultrasound scan can also be used to take a
imaging for other reasons. With the advent The patient presenting with a nodule, guided biopsy, and nodules that were not
of genetic testing for multiple endocrine thought to be arising within the thyroid, will palpable and known about may be seen on
neoplasia type II, patients are now present- clearly need a careful history and examina- the scan and can also be biopsied and as-
ing through a family member having been tion before embarking upon diagnostic sessed. There is no clear evidence that sug-
diagnosed with the disease leading to pre- tests. In the history, care should be taken to gests that calcitonin should be measured in
disposition testing. Depending on the age evaluate whether the patient is hyperthy- every patient with a thyroid nodule and al-
and specific mutation involved, some of roid, hypothyroid, or euthyroid. In thyroid though this is a very specific test for medul-
these patients may be diagnosed before cancer, the patient most commonly will lary thyroid cancer, the measurement of
their medullary thyroid cancer is developed have neither over nor underactivity of the calcitonin as a screening tool is unproven
and is at the stage of C cell hyperplasia. thyroid. A careful family history should be and currently not recommended.
However, when an index case is discovered, sought for diseases associated with the thy- Once a nodule is identified, then a fine-
inevitably some family members are found roid and the development of tumors in can- needle aspiration (FNA) biopsy is required. In
who have the established disease and the didate organs namely adrenal disease and large solitary nodules, this can be performed
presentation is through the family history parathyroid disease in family members. In in the clinic freehand without the use of ul-
rather than a presenting complaint for the addition, a personal history of irradiation or trasound guidance; however, increasingly,
individual concerned. exposure to radiation, particularly under ultrasound guidance of biopsy is employed to

www.medicalebookpdf.com

LWBK892_c38_p479-485.indd 480 10/28/11 5:03:42 PM

 Chapter 38: Total Thyroidectomy, Lymph Node Dissection for Cancer 481

ensure the accurate assessment of the pal- sound and FNA biopsy but subsequently choices and options available to the patient.
pable nodule. Difficulties can arise when turn out to be malignant, follow-up of pa- There is clear evidence that completeness of
multiple nodules are detected by ultrasound, tients with benign thyroid nodules is ad- surgical resection is an important factor in
and deciding which nodule to sample in this vised and repeat biopsy should be consid- securing a successful outcome, and recur-
setting can be challenging for the radiologist ered if the nodule grows in size, either rence within the neck remains the most
and/or clinician. Ultrasound features, which clinically or on ultrasound. There are no common site of recurrence. Nevertheless,
are suggestive of malignancy, include a hy- clear guidelines for thresholds of nodule our understanding of the biology of thyroid
poechoic nodule, increased vascularity, ir- growth or timescales for repeat assess- cancer, particularly in relation to small pri-
regular margins, the presence of microcalci- ments but the American Thyroid Associa- mary tumors and small deposits within the
fications, and hardness of the nodule tion guidelines in 2009 suggest that a 20% lymph nodes, is incomplete. Overtreatment
(elastography). Whilst no one feature is diag- increase in nodule diameter should prompt can result in considerable morbidity with
nostic, an experienced radiologist will often further biopsies. These biopsies should be no gain to the patient and undertreatment
be able to combine the above features into a performed at between 6 and 18 months af- clearly may compromise the final outcome.
sensitive diagnostic probability. When thy- ter the initial FNA biopsy. If a firm diagnosis As already mentioned in the section on
roid abnormalities picked up by cross-sec- of thyroid cancer is made or there is a strong “Diagnosis,” accurate preoperative staging
tional imaging or ultrasound for other rea- suspicion of this (Thy4 and Thy5), then care- of the disease by neck imaging is important.
sons (the incidentaloma) are ⬍1 cm in size, ful ultrasound evaluation of the loco re- However, preoperative ultrasound does not
routine FNA biopsy is not recommended un- gional lymph nodes should be performed. identify all involved lymph nodes and is
less there are features that are suggestive of Biopsy should be undertaken of any con- somewhat operator dependent. Lymph
malignancy including the presence of lymph cerning lymph nodes, which may clarify the nodes in the neck are divided into anatomi-
nodes nearby, which are concerning. If pa- situation in a patient with Thy4 cytology cal compartments (see Fig. 1). The level 1
tients are in a higher risk category (family and will allow appropriate nodal surgery to lymph node compartment is the submental
history, previous radiation) or if the thyroid be planned at the first operation. and submandibular node compartments
nodule was picked up through a positron above the hyoid bone. Levels 2, 3, and 4
emission tomography (PET) scan, then there TREATMENT lymph nodes are aligned along the jugular
will be a greater tendency to perform biopsy veins on each side between the posterior
on subcentimeter nodules than if this was The treatment of thyroid cancer and associ- border of the sterno cleido mastoid muscle
not the case. In experienced hands, either ated involved lymph nodes needs to be care- and the anterior level 6 compartment. The
guided or freehand FNA biopsy of thyroid fully thought through and discussed as part level 5 nodes are in the posterior triangle
nodules has a good specificity and sensitivity. of a multidisciplinary approach. It is a po- lateral to the sterno mastoid muscle and
However, if the cytopathologist does not have tentially lethal disease and must be re- the level 6 nodes are central, running from
enough cellular material to make a diagno- spected as such. The treatment will often be the hyoid bone down to the suprasternal
sis, the FNA should be repeated and it should multimodal including surgery, radio iodine, notch. Superior mediastinal lymph nodes
be remembered that a small number of thy- and TSH suppression with Thyroxine. Care- above the level of the innominate artery
roid nodules (⬍10%), despite repeatedly re- ful plans for the postoperative management and in the upper mediastinum are referred
ported as benign or serial biopsies, will turn and monitoring of the patient, including the to as level 7 nodes. Removal of the thyroid
out to be malignant when resected. Classifi- measurement of thyroglobulin levels, inter- tumor in the neck and associated lymph
cation of thyroid FNA biopsy specimens is mittent scans, and clinical follow-up, will nodes may well be an appropriate treat-
usually based on a scale of 1 to 5. Thy1 sug- all be needed. There are several published ment even in the context of disseminated
gests insufficient cells for a diagnosis, Thy 2 is guidelines regarding the treatment of thy- disease, since once the primary and loco re-
benign, Thy3 indeterminate, Thy4 suspicious roid cancer, including those published by gional nodes have been removed, metasta-
of malignancy with around a 95% specificity, the American thyroid Association (2009), ses are more easily treated with radioactive
and Thy5 a clear case of a malignant diagno- the British Thyroid Association, and the iodine in the absence of other tissue avid for
sis. Whilst FNA biopsy can accurately diag- British Association of Endocrine and Thy- iodine. For goiters limited to the neck, ultra-
nose papillary thyroid cancer, medullary thy- roid Surgeons (2007), together with a re- sound alone is the imaging modality of
roid cancer and sometimes anaplastic cently published evidence-based review of choice in planning treatment, but in retros-
cancer, it will not differentiate nodules that surgery for thyroid cancer published in the ternal goiters or those where medullary thy-
are due to follicular thyroid cancer or lym- World Journal of Surgery (May 2007). roid cancer is thought to be present, CT or
phoma. For the latter (lymphoma), a guided The obvious central strategy for the cross-sectional imaging of the mediastinum
core biopsy will often be sufficient and open treatment of the disease is the complete re- is advised. If the preoperative investigations
surgery is seldom required. For the former, moval of the primary tumor and, wherever have fallen short of a firm diagnosis of
Endocrine Surgery

follicular neoplasms, diagnostic thyroid possible, any extensions out with the thy- established thyroid cancer, then a diagnos-
lobectomy is the only way currently available roid gland, together with the removal of the tic hemithyroidectomy is required on the
to confirm or refute the difference between a relevant involved lymph nodes. Neverthe- affected side. Wherever possible, surgeons
benign follicular adenoma and a follicular less, the execution of this relatively simple should try to remove all the thyroid tissues
carcinoma of the thyroid. sounding strategy becomes somewhat more on the affected side at the time of a diagnos-
The use of molecular markers and PET complicated as the individual variables for tic lobectomy, so that further surgery is not
scanning, whilst seeming promising, to help each patient are considered. Comorbidities required in that compartment. Revisional
in this conundrum is not accurate enough in the patient, precise type of thyroid can- surgery to remove a remnant of thyroid tis-
at the present time to substitute for diag- cer, size of the primary involvement or oth- sue following an incomplete lobectomy is
nostic thyroid lobectomy. Because of the erwise of the lymph nodes, particular sub- dangerous for the patient in terms of risks to
previously stated small number of thyroid type of tumor together with personal and the recurrent laryngeal nerve and parathy-
nodules, which appear benign on ultra- family history will all influence the final roid gland, as well as challenging and

www.medicalebookpdf.com

LWBK892_c38_p479-485.indd 481 10/28/11 5:03:43 PM

 482 Part IV: Endocrine Surgery

difficult for the surgeon. If a patient has a those nodes should be performed at the poor life expectancy. A risk-based strategy
suspicious FNA biopsy and other features, same time as total thyroidectomy. to the operation has been outlined but it is
which make it likely that they have a thyroid In any event, the surgeon should aim to not based upon prospective randomized
cancer in their history, or comorbidities complete the operation without leaving any controlled trials, rather on observational
which would make a second operation dan- macroscopic disease present in the neck. It studies and consensus meetings. Total thy-
gerous if the diagnostic lobectomy prove to should never be assumed that radio iodine roidectomy, whether with or without lymph
be malignant, then a discussion can take treatment will compensate for inadequate node dissection, is generally well tolerated
place with the patient about the validity of surgery and whilst accepting that it may and in experienced hands can be performed
proceeding immediately to a total thyroi- well have a significant role in destroying with minimal morbidity. Surgeons will need
dectomy, even when the diagnosis falls microscopic foci of thyroid cancer, the sur- to consider whether they want to have a
short of confirmed thyroid cancer. This may geon’s duty is without question to remove preoperative vocal cord check to establish
be particularly relevant when the patient all bulky disease, preferably at the first op- the integrity of the recurrent laryngeal
has a multinodular goiter, which in its own eration. Lymph node mapping techniques nerves before embarking upon the opera-
right, even if it is benign, might require total (e.g., sentinel lymph node biopsy), success- tion. Whilst a preoperative cord check will
thyroidectomy. Because of multifocality in ful in the management of other primary tu- not influence the care a surgeon takes dur-
thyroid cancer of all types, if the primary mors such as the breast and melanoma, ing the operation to protect the recurrent
tumor is ⬎1 cm in size, then total thyroi- have not proved accurate ways of directing laryngeal nerve, it can establish accurately
dectomy is the operation of choice. For the surgeon to the relevant lymph node ba- whether or not the nerves are compromised
a small subcentimeter low-risk thyroid sin for resection in the neck, almost cer- before surgery and prevent any debates
cancer with no predisposing risks for fur- tainly due to the considerable crossover of about the role of the operative procedure
ther disease (e.g., radiation or family history) lymphatic channels between the anatomi- itself in causing cord palsy. In a patient with
or evidence of disseminated disease (en- cal compartments of the neck. a history of voice change and/or in cases or
larged lymph nodes on ultrasound), a uni- It can be seen, therefore, that the preop- revisional surgery, preoperative cord checks
lateral lobectomy may be sufficient. Never- erative planning of the thyroidectomy and are advised. Nerve-monitoring devices are
theless, the patient should be counselled lymph node dissection is vital so that the available for use but a large meta-analysis
that although metastasis and multifocality surgeon can advise the patient about the of this technique has not demonstrated a
are unlikely with subcentimeter differenti- reasonable options available and a com- significantly reduced nerve palsy rate in pa-
ated thyroid cancers, follow-up by using bined agreement can be made regarding tients, in whom nerve monitoring was car-
thyroglobulin measurements in patients the extent of primary surgical treatment to- ried out versus those that were not (NICE
with residual thyroid tissue and imaging gether with lymph node resection. This may Guidelines 2008). It is an option, therefore,
the thyroid gland with radionuclide scans is include the need for preoperative vocal cord for the surgeon to consider nerve monitor-
more difficult when a normal lobe or part of checks. A combination of personal factors ing, but it should not be stated that nerve-
a normal lobe has been left in situ. relevant only to a particular patient, biopsy monitoring devices and their use imply a
Whilst the evidence base for dealing results, blood tests, and scan information is more careful surgeon or will lead to a re-
with the primary thyroid tumors is rela- likely to be unique for each person with op- duced risk of nerve palsy. The patient
tively robust, there is less certainty and erable thyroid cancer; hence the impor- should be placed in the supine position
agreement about the optimal treatment for tance of a multidisciplinary approach to with their arms alongside the trunk. Some
the lymph node basin. Lymph node metas- this disease. Thyroid cancer by and large is form of soft object should be placed be-
tases are present in a significant number of a slow-growing cancer. The exception is tween the scapulae behind the vertebral
patients who present with differentiated anaplastic carcinoma of the thyroid, a con- column so that the shoulders can fall away
papillary thyroid cancer; yet, the clinical dition best treated by external beam radio- from the operative field thus exposing the
significance and effect of this on overall therapy, surgery being reserved only for get- neck optimally. In addition, the neck should
survival is less clear. Accepting that, as ting control of the airway. There is, therefore, be extended and the table tilted to 30 de-
stated above, ultrasound does not detect all enough time to make appropriate decisions grees from the horizontal. Before any
involved lymph nodes and nor will palpa- and carry out investigations without the drapes or cleaning of the patient are under-
tion at surgery, a strategy is required to need to rush into an ill-judged and ill- taken, the routine preoperative checks will
achieve accurate staging of the patient’s prepared operation. be made to confirm the site of the lesion to
disease without unnecessary complications be removed and the personal details of the
or morbidity. If the lymph nodes are known SURGICAL TECHNIQUE patient. Care must also be taken to ensure
to be involved by preoperative ultrasound that all anesthetic tubes and lines are se-
and FNA, then a therapeutic central com- Differentiated thyroid carcinoma is an un- cured and cannot be loosened or leaned on
partment dissection should be carried out common condition but its incidence is in- during the operation by the surgical team.
at the time of total thyroidectomy. In antici- creasing. Approximately 30,000 patients The skin of the neck and upper chest will be
pation of the nodes being involved in the will be diagnosed with this in the United prepared with cleansing solutions and ster-
absence of a preoperative staging confirma- States each year, the vast majority will be ile towels draped around the operative
tory test, in large primary tumors (T3 or T4) papillary thyroid cancers (60%) and 20% field. Meticulous attention to hemostasis
the same dissection should be performed. will be follicular thyroid cancers. The re- must be given from the very beginning. A
In follicular thyroid cancer or small primary mainder will be medullary and anaplastic transverse skin incision placed midway be-
thyroid cancers (T1 or T2), prophylactic carcinomas. As mentioned earlier, there is tween the thyroid cartilage and the sternal
central neck dissection may be omitted. If variability in the progression rate of these notch and extending no further than the
the lateral lymph node compartments (lev- cancers, the differentiated tumors being medial border of the sternomastoid on ei-
els 2 to 5) are proven to be involved preop- slow growing, but the anaplastic carcinoma ther side will give adequate exposure to
eratively, then compartmental excision of being a rapidly progressive disease with a most goiters. The skin incision should be

www.medicalebookpdf.com

LWBK892_c38_p479-485.indd 482 10/28/11 5:03:43 PM

 Chapter 38: Total Thyroidectomy, Lymph Node Dissection for Cancer 483

placed in a skin crease if possible and is subclavian artery on the right and comes surgeon will proceed to carry out a comple-
deepened through the subcutaneous tis- off as a direct branch from the vagus nerve. tion thyroidectomy on the remaining lobe.
sues and the platysma muscle. Superior The vascular pedicles to the thyroid gland If there is no tumor in this lobe, this may be
and inferior flaps can then be raised by a (the superior thyroid artery and vein and a more straightforward procedure, but if
variety of surgical techniques, either with the inferior thyroid artery and vein) can be the disease is multifocal then care must be
the knife or electrocautery. Once the flaps identified and cleaned up using a combina- taken to remove entire thyroid and associ-
have been developed, a self-retaining re- tion of pledget dissection and a mosquito ated tumor deposits as with the first side. If
tractor is placed in the wound and the strap clip. Where the vessels branch to enter the the integrity of the parathyroid glands is
muscles are separated in the midline from capsule of the gland they can be divided questionable at the end of the total thyroi-
the thyroid cartilage down to the sternal either with a combination of liga clips and dectomy, then autografting of one or more
notch. Occasionally, it will be necessary to ties or using the harmonic scalpel. The of these can be considered. To achieve this,
divide the strap muscles to gain access to order in which the vessels are taken will the normal parathyroid can either be sliced
the thyroid gland, but more commonly they depend somewhat on the anatomy of the into 1-mm slices and inserted into small
can be easily retracted to allow adequate individual patient, but it is the author’s pockets in the sternomastoid muscle, or al-
exposure of the whole gland and lymph practice to take the superior pole vessels ternatively it can be morselated, suspended
node basin. The side of the neck, which in- first allowing greater mobilization of the in lactate ringers or plasma, and injected
volves the thyroid primary tumor, should lobe before securing the inferior thyroid ar- into the muscle.
be operated on first. If the thyroid tumor is tery and vein at a capsular level, and then,
invading a strap muscle or adherent to last of all, the inferior thyroid veins. Care LYMPH NODE DISSECTION
muscle, then a portion of that muscle can must be taken not to injure the external
be excised to ensure adequate margins branch of the superior laryngeal nerve as This will be appropriate in patients with
around the tumor. Retraction of the thyroid the upper pole vessels are taken. The thy- papillary thyroid cancer and medullary thy-
lobe upwards into the wound and medially roid gland can readily be grasped with a roid cancer. In follicular carcinoma, the tu-
is the first step of the operation and this Babcock type of tissue forceps, which does mor rarely metastasizes to the regional
will allow the middle thyroid vein to be not traumatize the gland or tear it. The last lymph nodes, spread being more commonly
seen. This vessel should be secured and di- bit of dissection of the lobe before it can be hematogenous. As previously stated, if a de-
vided. Techniques to do this include the freed off the front of the trachea involves cision has been taken preoperatively to
placement of ties in continuity or small the division of the Berry ligament. Small carry out a level 6 lymph node dissection,
metal clips. In addition, the use of hemo- vessels run in this ligament and there is a this will require removing all the lymph
static devices such as the harmonic scalpel very close relationship between it and the node basin from the hyoid bone down to
(Johnson & Johnson) can be employed. recurrent laryngeal nerve as the nerve ap- the sternal notch in the craniocaudal plane
Once the lobe has been lifted upwards us- proaches the cricothyroid membrane. and medially to laterally all the lymphoid
ing pledget dissection, the hilum of the Failure to deal with this ligament ade- tissue between the two carotid arteries.
gland can be identified and by sweeping quately leads to bleeding from those vessels Care will need to be taken to preserve the
away the tissue in the region of the hilum of in it, which then retract onto the surface recurrent laryngeal nerves during this dis-
the gland, the inferior thyroid artery can of the nerve and can be troublesome to con- section and also, wherever possible, the
usually be readily identified. This is an im- trol. Great care is therefore required as parathyroid glands. An almost inevitable
portant landmark early in the operation as Berry’s ligament is dissected, not to tear or consequence of increased numbers of level
it has a reasonably constant relationship damage the vessels within it. Its proximity 6 dissections is going to be the uninten-
with the recurrent laryngeal nerve and the to the nerve will often preclude the use of tioned loss of the inferior parathyroid
parathyroid glands all of which need to be cautery or the placement of even mosquito glands in a greater number of patients. If
preserved and protected. Within a 1- to clips around it, so the use of fine liga clips any of the lateral compartments need re-
2-cm radius of the inferior thyroid artery may be the only method of securing this secting, then this should be planned preop-
both parathyroid glands will normally be structure before it is divided. The gland can eratively as a result of risk stratification on
found. In addition, the recurrent laryngeal then be freed from the surface of the tra- the basis of tumor size, lymph node, and
nerve will be running typically behind the chea using cautery and if a single lobectomy FNA assessment. There is no need to resect
inferior thyroid artery from the root of the is to be performed, the isthmus can be di- radically, so structures such as the sterno-
neck laterally, up towards the insertion into vided and sutured or if the harmonic scal- mastoid muscle and the jugular vein can be
the cricothyroid membrane. The recurrent pel is used, no suturing will be needed. Fro- left in situ. It may be necessary to extend
laryngeal nerve is readily identified by the zen section examination of Thy4 lesions is the collar incision in the neck if an exten-
presence of the vasa nervorum, which run carried out in some centers and in certain sive lymph node dissection is planned, for
Endocrine Surgery

on the front of the nerve seen as a fine red circumstances can be helpful. It may be example, to level 5. In medullary thyroid
line. Early identification of the nerve should possible for the pathologist to give a firm cancer, it may be necessary to do a thymec-
be undertaken before any further major diagnosis of papillary thyroid cancer dur- tomy and remove level 7 nodes, particularly
structures are divided. Occasionally, the ing the operation in an indeterminate le- if the preoperative cross-sectional imaging
nerve can divide low in the neck into one or sion, but it is unlikely that a diagnosis of suggests that disease is there. In the course
more branches and these branches can be follicular cancer will ever be achieved by of removing tissues low in the neck, how-
fine and difficult to identify close to the lar- frozen section since careful examination of ever, care must be taken not to damage the
ynx, and therefore full tracing of the nerve the entire nodule capsule and blood vessels thoracic duct on the left and the right lym-
from the neck upwards is helpful. Very is necessary to reach this diagnosis. The phatic duct. The thoracic duct on the left
rarely, there can be anomalous recurrent time available perioperatively for this will arises from the thorax and extends above
laryngeal nerves, the so-called direct laryn- not permit this to be carried out adequately. the left clavicle before inserting into the
geal nerve, which does not loop around the If a total thyroidectomy is performed the internal jugular vein at its junction with the

www.medicalebookpdf.com

LWBK892_c38_p479-485.indd 483 10/28/11 5:03:43 PM

 484 Part IV: Endocrine Surgery

subclavian vein. The duct is thin walled, charged to home on the first postoperative advised. Low-risk patients, by definition, will
flat, and not easily seen and injury to this day. Postoperative bleeding is uncommon, have no local or distant metastasis, complete
structure is usually suspected because of but must be watched for and if it occurs, the resection of the tumor, and a more bland his-
the presence of significant amounts of neck must be reopened immediately to per- tology. Intermediate risk patients will have
white lymph in the operating field. If injury mit relief of laryngeal edema and tracheal evidence of microscopic invasion of tumor
does occur, the duct should be identified compression by blood clot. Cord palsy is outside the thyroid, cervical lymph node me-
and ligated since lymphatic fluid will other- uncommon (⬍1% in most registries and tastasis, aggressive histology, or evidence of
wise continue to drain in the postoperative audits). If it is unilateral, the patient will vascular invasion. High-risk patients are de-
period. Before closing the neck, a careful have a hoarse and less powerful voice; if it is fined as those having macroscopic tumor
check must be made of all the primary vas- bilateral, there may be a need for an urgent invasion of local structures, incomplete tu-
cular pedicles that have been secured, to- tracheostomy to secure the airway. Checks mor resection, distant metastasis, and evi-
gether with a check on the viability of the must be made to detect hypoparathyroid- dence of high markers of persistent thyroid
parathyroid glands and the integrity of the ism. Early symptoms of this include tingling tissue (thyroglobulin or calcitonin).
recurrent laryngeal nerves. If nerve damage around the mouth and in the toes and the The use of radioactive iodine treatment
has occurred, then primary repair should fingers. Muscle cramps can ensue if this is after total thyroidectomy for papillary or
be considered, as the results of this are opti- not promptly treated and it is therefore a follicular cancer is to eliminate any small
mal if carried out at the time of injury. If the routine practice to measure the calcium amount of thyroid tissue that has been left
operating surgeon does not have the neces- level postoperatively for some period of in the neck, though this should be uncom-
sary skills to do this, then he should con- time within 12 hours of completion of the mon if a total thyroidectomy has been per-
sider calling in an experienced colleague. operation. Predicting hypoparathyroidism formed. Alternatively, small deposits of mi-
Typically, 7 or 8-O interrupted nylon sutures and preemptively treating it has occupied croscopic metastasis in lymph nodes will
are used to approximate the ends of the cut many endocrine surgical units over the also take up radio iodine and, especially in
nerve or if a segment of the nerve has been years. A combination of an early drop in the lateral compartment of the neck, can
resected and the ends cannot be approxi- parathyroid hormone level and an early facilitate destruction of all the thyroid tu-
mated, then some form of nerve graft may drop in calcium levels within 6 hours of sur- mor. Radio iodine ablation, therefore, is
be needed. If autotransplantation of the gery predicts the need for calcium supple- recommended for all patients with known
parathyroids has been undertaken and ments. Practice for monitoring hypopara- metastasis, gross extrathyroidal extension
there is parathyroid malfunction, it will thyroidism postoperatively varies around of the tumor or a primary tumor size of ⬎4
take 6 to 8 weeks for the grafts to get their the world; some units starting all patients cm. In smaller thyroid cancers, if there are
blood supply and during this time the pa- on supplements preemptively with the in- proven lymph node metastases or other
tient’s calcium will need to be supported tention of weaning them off in the early high-risk features when the staging criteria
with oral supplements of calcium and/or postoperative period, other units monitor- are assessed, then the selective use of radio
vitamin D. If there is a significant dead ing the levels of calcium and prescribing as iodine ablation should be considered. Small
space, then drainage may be needed, but it needed. In any event, it would appear that primary thyroid cancers ⬍1 cm with no
is the practice of the author not to drain ap- approximately 30% of patients after total risk features do not need radio iodine abla-
proximately 90% of total thyroidectomies. thyroidectomy will develop transient hy- tion and in addition, when there are multi-
Reapproximation of the strap muscles us- pocalcemia and require at least calcium sup- focal changes within the gland but all foci
ing continuous 3-O Vicryl and subcuticular plements. In extreme cases where hypocalce- ⬍1 cm, radio iodine is also not needed. In
closure of the neck skin using 4-O absorb- mia is resistant, intravenous solutions may preparation for radio iodine ablation, pa-
able sutures produces a good cosmetic re- be required to correct it and a check should tients should have adequate TSH stimula-
sult. It is the author’s practice to spray the be made of the patient’s magnesium level, tion to ensure that any thyroid cells present
wound after final suturing with a clear since low magnesium levels can exacerbate are iodine avid. This can be achieved either
transparent wound dressing such as Opsite the effects of hypocalcemia, as can preopera- by withdrawing thyroid hormone supple-
Spray. No bandaging is placed over the neck tive vitamin D deficiency. ments to induce a rise in endogenous TSH
and this allows staff in the recovery unit or by giving recombinant human TSH. Thy-
and in the ward in the early postoperative POSTOPERATIVE roglobulin is a useful marker of persistent
period to see promptly if there is any neck MANAGEMENT or recurrent thyroid disease. However, the
swelling. Before leaving the theater, pa- presence of antithyroglobulin antibodies in
tients who have undergone a total thyroi- Once the surgical pathology specimen is some patients makes this assay difficult to
dectomy should have their thyroid replace- available, accurate staging of the patient by interpret. Early after surgery, the thyroglob-
ment therapy prescribed. If it is anticipated TNM staging or a variety of other classifica- ulin level remains elevated for some weeks.
that the patient will need postoperative ra- tions can be achieved. The importance of So it should not be relied upon in the initial
dio iodine or imaging using radio iodine staging is to enable an accurate prognosis assessment of recurrent disease.
isotopes, then T3 should be prescribed. This for a given patient with differentiated thy- Follow up of patients following treatment
of course will not be applicable to medul- roid cancer and to inform decisions regard- for differentiated thyroid cancer should be
lary thyroid cancer in which radio iodine ing postoperative adjuvant treatment in- lifelong. Patients with a high risk of recur-
has no role to play. These patients can there- cluding radio iodine therapy. Whichever of rence should be monitored more closely be-
fore be started directly on the normal re- the staging systems is used, the vast majority cause the early detection of recurrent dis-
placement dose of T4. of patients will be found to have a low risk ease may offer the opportunity to eradicate
Patients make a rapid recovery follow- of mortality with a need for less intensive that disease. In addition, it is recognized
ing total thyroidectomy and are typically follow-up and treatment. Focusing adjuvant that TSH suppression by the use of exoge-
able to eat and drink on the day of surgery treatments and closer scrutiny on those nous thyroxine is important in minimizing
and are self-caring. They can usually be dis- patients at the highest risk of recurrence is the risks of recurrence and regular checking

www.medicalebookpdf.com

LWBK892_c38_p479-485.indd 484 10/28/11 5:03:43 PM

 Chapter 38: Total Thyroidectomy, Lymph Node Dissection for Cancer 485

of thyroid function tests in the postoperative SUGGESTED READINGS Lim YC, Choi EC, Yoon YH, et al. Central lymph
period to ensure a TSH of ⬍1 ng/mL is im- node metastasis in unilateral papillary micro-
portant. American Thyroid Association Guidelines 2009. carcinoma. Br J Surg 2009;96:253–7.
British Thyroid Association & British Associa- Lundgren CI, Hall P, Dickman PW, Zedenius J. The
The investigation and management of tion of Endocrine Surgeons Guidelines 2007. influence of surgical and post-operative treat-
recurrent disease is beyond the scope of Barbaro D, Boni G. Radio iodine ablation of post ment on survival in differentiated thyroid can-
this chapter, but it will include imaging in surgical thyroid remnants after preparation cer. Br J Surg 2007;94:571–7.
the form of cervical ultrasound, PET scan- with recombinant human TSH, why, how and Machens A, Hauptmann S, Dralle H. Prediction
ning, and biopsy of any suspicious nodules. when. Eur J Surg Oncol 2007;33:535–40. of lateral lymph node metastasis in medullary
Wherever possible, further surgery to resect Evidence based endocrine surgery: Thyroid can- thyroid cancer. Br J Surg 2008;95:586–91.
cer. World J Surg 2007;31(5). Maclen SA. Niccoli-Sire P. Hoegel J, et al. Early
recurrent disease is advisable, even in the Foreman E, Aspinall S, Bliss RD, Lennard TWJ. The malignant progression of hereditary medullary
presence of metastasis, in order to optimize use of the harmonic scalpel in thyroidectomy thyroid cancer. N Engl J Med 2003;349:1517–25.
the subsequent use of radioactive iodine to beyond the learning curve. Ann R Coll Surg Engl National Institute for Clinical Excellence (UK) report
treat those metastases. 2009;91(3):214–16. on the use of nerve monitoring in thyroid surgery.

EDITOR’S COMMENT There is some interest in trying to be more (World J Surg 2007;31[suppl]:877–8). Forty-two
selective as to the role of central compartment papillary and three medullary cancers were
lymphadenectomy and whether one could select found in Group I and 75 papillary, two follicular,
It is interesting to remember that during my such patients who would benefit (Anand SM et al. and 17 medullary cancers were found in Group
resident days at the Massachusetts General Hos- Arch Otolaryngol Head Neck Surg 2009;135:1199– II. Transient hypocalcemia was a more frequent
pital, Dr. Oliver Cope, the resident expert and 204). Sentinel lymph node biopsies in 98 patients problem with 16 patients with bilateral thymec-
well-known thyroid surgeon, talked about and who underwent total thyroidectomy and also un- tomy (Group I, 35.5%) versus 10 (Group II, 10.7%).
believed that differentiated thyroid cancer or derwent sentinel lymph node biopsy by means of They concluded that bilateral thymectomy was
papillary carcinoma of the thyroid was a different methylene blue dye, 1% was injected into the peri- more dangerous than worthwhile.
disease and really did not have to be treated ag- tumor. They then underwent central lymph node With the frequency of metastases now be-
gressively. At one point in his career, he espoused dissection. Fifteen out of 70 patients had metas- coming more widespread, or at least being recog-
psychotherapy for patients with thyroid carci- tasis-positive sentinel lymph node biopsies while nized to a greater extent, radioactive iodine ther-
noma. Lymph node dissection was forbidden— the remaining 55 did not. The take-home message apy is becoming more aggressive. An exhaustive
after all, some of these patients lived for 30 years is that if the sentinel lymph node was negative, approach is given in Best Practices and Research
and were treated with radioactive iodine. 100% of the central compartment nodes were ( J Clin Endocrinol Metab 2008;22:989–1007). Rein-
How the situation has changed! Lymph node negative when they were resected. The authors ers C et al followed up with an exhaustive review
dissection and total thyroidectomy are now be- state that when the sentinel lymph nodes are of the appropriate approach to radiation therapy.
ing routinely carried out for a disease, which was negative, no central lymph node dissection should At the same time, Barbaro D and Boni G (Eur J
thought not to be real cancer. There is a great deal be carried out. Patients can undergo radioactive Surg Oncol 2007;33:535–40) advocate the use of
of activity in the literature, which is complemen- iodine treatment, but dissection is not necessary. recombinative TSH in association with radiation
tary to this very fine chapter. Much of it is an on- A less optimistic viewpoint is expressed by ablation.
going discussion concerning the extent of lymph Koo BS et al. ( J Am Coll Surg 2010;210:895–900), The use of the harmonic scalpel is presented
node dissection, how aggressive it should be, and who analyzed records of 70 papillary thyroid by Prof. Lennard and his group in its use dur-
what we should do with the central lymph nodes carcinoma with total thyroidectomy and com- ing thyroidectomy (Ann R Coll Surg Engl 2009;
under different circumstances: when ipsilateral prehensive neck dissection (central lymph node 91:214–16). They find that after a learning curve,
lymph nodes are positive, when bilateral nodes metastases were present in 82.9%; 34.3% had bi- the use of the harmonic scalpel during thyroidec-
are positive, and deciding whether central lymph lateral and central neck involvement; and 48.6% tomy reduces operative time and postoperative
node dissections should be carried out. These had unilateral, ipsilateral central neck involve- hypocalcemia.
are questions that would not have been asked ment). Isolated contralateral central LN metas- Finally, there is considerable interest in
10 years ago and as time goes on, it appears that tases were not found without ipsilateral central medullary thyroid cancer. One group led by
differentiated thyroid cancer is not looked upon neck involvement. This group, I suspect, would Andreas Machens has tried to use abnormal
any longer as a nice, well-behaved cancer, but is a perform central neck dissection in many cases in carcinoembryonic antigen levels in 150 patients
cancer, which needs to be treated like any other. which others might not. with a diagnosis of medullary thyroid cancer.
Yet, there are variations in the treatment of Another somewhat gloomy prognosis was pre- Although the breakdown of the various levels is
cancer of the thyroid, and these were evaluated by sented by Lim YC et al. (Br J Surg 2009 96;253–7) in detailed, suffice it to say that CEA levels higher
Famakinwa OM et al. (Am J Surg 2010;199:189–98), which 27 of 86 patients with ipsilateral papillary than 30 ng/mL indicate central and ipsilateral
who compared the practices in a total of 52,964 thyroid microcarcinoma had metastatic central lymph node metastases, while CEA levels higher
patients with differentiated thyroid cancer and lymph nodes. Eighteen of these were ipsilateral than 100 ng/mL signify contralateral lymph
whether they were treated in accordance with and nine bilateral. I would suspect that this group node and distant metastases (Arch Surg 2007;
the American Thyroid Association guidelines for would also be much more aggressive in pursuing 142:289–93).
this disease. They found that 71% was treated central compartment node dissection. Khatib ZL Machens A et al. try to clarify the need for
in accordance with the recommendations for et al. (World J Surg 2010;34:1181–6) would extend lymph node dissection in patients with medul-
Endocrine Surgery

surgery: 15% underwent central lymphadenec- the dissection to partial thymectomy in associa- lary thyroid cancers (Ann Surg 2009;250:305–10).
tomy, 31% had radioactive iodine without lymph- tion with central lymph node dissection. Lymph They conclude that in the absence of clinical evi-
adenectomy, and 25% had radioactive iodine and node metastasis on the ipsilateral side of the pri- dence to the contrary, such patients with normal
lymphadenectomy. Patients older than 65, and mary tumor was present in 45 patients in whom bi- basal calcitonin levels may avoid lymph node dis-
especially African-Americans, were at the widest lateral thymectomy was carried out (Group I) and section.
deviation from the guidelines. unilateral thymectomy in 93 patients (Group II) J.E.F.

www.medicalebookpdf.com

LWBK892_c38_p479-485.indd 485 10/28/11 5:03:43 PM

 486 Part IV: Endocrine Surgery

39 Comprehensive Parathyroidectomy for the

Treatment of PHPT
Allan E. Siperstein and Mira Milas

INTRODUCTION dectomy, a term we have designated to mean ation between parathyroids and severe
examination of all parathyroid glands bilat- bone disease was noted, although the origi-
The modern era of parathyroid disease erally with appropriate resection of diseased nal misconception was that osteitis fibrosa
management is characterized by three fun- glands. It is imperative to recognize that cystica caused parathyroid problems, rather
damentally new and important features. “conventional” or “bilateral” parathyroid than the reverse. Felix Mandl performed
First is the evolution of primary hyperpara- procedures are not obsolete but in fact re- the first successful parathyroidectomy in
thyroidism (PHPT) from a rare endocrine main essential. Comprehensive parathyroi- 1925 in Vienna. Oliver Cope and his col-
disorder to the most common cause of hy- dectomy will remain integral to the surgical leagues at the Massachusetts General Hos-
percalcemia in the outpatient population, treatment of PHPT and, for appropriate pa- pital then contributed significantly to the
with estimated prevalence of 1 in 500 tients, is the ideal initial operation. Compre- knowledge of parathyroid anatomical dis-
women and 1 in 2,000 men. A second and hensive parathyroid examination can be tribution and challenges of ectopic and me-
related feature is higher prevalence of as- performed in a minimally invasive way. This diastinal parathyroids. Exemplifying this is
ymptomatic PHPT, where the clear bio- approach requires a thorough understand- the well-known case history of their pa-
chemical diagnosis of parathyroid disease ing of parathyroid gland anatomy and em- tient, Captain Charles Martell, who under-
exists without noticeable symptoms or clin- bryology and of specific indications based went his seventh parathyroid exploration
ically detectable consequences, such as on clinical presentation, parathyroid imag- in 1932. From that time period until about
bone density loss or kidney stones. More ing, and intraoperative findings. In this chap- 2003, bilateral, comprehensive parathyroid
patients are being diagnosed in such an as- ter, we review the key roles of comprehensive exploration was the dominant surgical ap-
ymptomatic phase of the disease because parathyroidectomy as part of the spectrum proach for the treatment of parathyroid
calcium has become a routine component of available parathyroid operations. disease.
of automated chemistry panels, thus lead- The key aspects of parathyroid anatomy
ing to incidental detection of hypercalce- ANATOMY AND and embryology to adapt to comprehensive
mia. Conversely, more practitioners are also parathyroidectomy are illustrated in Figs. 1
recognizing the need to screen patients
EMBRYOLOGY to 3. The appearance of parathyroids can be
with osteoporosis, osteopenia, and kidney There are typically four parathyroid glands variable even when they are biochemically
stones for underlying PHPT utilizing not in most individuals. A large autopsy study functioning normally. When diseased, para-
just calcium, but a panel that includes cal- identified four parathyroid glands in 84% of thyroid glands may display variable mor-
cium, intact parathyroid hormone (PTH), human cadavers, five or more glands in 13%, phological changes in size, shape, texture,
and 25-hydroxyvitamin D levels. and only three parathyroids in 3%. Supranu- and firmness. Abnormal parathyroids are
In response to these evolving presenta- merary parathyroids are most often located generally fuller in all dimensions, have a
tions of parathyroid disease, several multi- in the thymus. The possibility of having an darker brown or reddish-brown color, and
disciplinary publications have offered unusual number or location of parathyroid do not compress easily or are significantly
guidelines for the indications and timing of glands has direct impact on the success of firm when gently probed. They may have an
parathyroid surgery. Despite these guide- parathyroid surgery and the potential need irregular and knobby shape, more promi-
lines, patients with PHPT remain, as a for comprehensive parathyroidectomy. nent vascular pedicles, or a plexus of vascu-
group, underreferred and undertreated sur- A brief survey of the history of parathy- lature. Glands of patients with secondary
gically. Surgical therapy remains the only roid surgery illustrates the importance of and tertiary hyperparathyroidism may be
definite and durable treatment for PHPT. applying the knowledge of parathyroid sclerotic and light in color from this fibro-
What was once designated “conventional,” anatomy and embryology during parathy- sis. In cases of borderline abnormal appear-
“traditional,” or “bilateral” parathyroidec- roidectomy. Normal parathyroid glands are ance, it is helpful to determine in vivo para-
tomy, however, may not be the most suit- approximately 5 to 6 mm in greatest dimen- thyroid weight prior to excision of the
able terminology for present-day and future sion, weigh 15 to 35 mg, and can be incon- parathyroid. This can be readily done by
surgeons. The third important feature of spicuous with their orange-tan color em- measuring parathyroid length (L), width
current surgical management of parathy- bedded or flattened within a surrounding (W), and height (H) using a small ruler or
roid disease is, therefore, that there has yellow fatty tissue envelope. Thus, they were micrometer device without removing the
been a clear paradigm shift toward focused only first identified in a large mammal, the gland. Since most glands are oval, calculat-
parathyroid surgery: the exploration of a Indian Rhinoceros. Following this discov- ing the volume of an ellipsoid using sizes in
single site of suspected parathyroid gland ery by Sir Richard Owen during an autopsy millimeters estimates parathyroid gland
abnormality. Most parathyroid surgeons of the rhinoceros in the London Zoo in 1852 weight in milligrams (weight [mg] ⬇ L ⫻
have adapted this as the favored initial and publication as a minor comment about W ⫻ H ⫻ ½) [mm3]). There is ongoing in-
approach to parathyroid surgery, guided by parathyroids in 1862, it was Swedish medi- terest and some controversy in defining
radiologic studies and intraoperative PTH cal student Ivar Viktor Sandstrom who first what truly constitutes an abnormal para-
measurement. identified parathyroids in man in 1875. In thyroid, and whether this is a matter of
This chapter, however, is devoted to the the early 1900s, biochemical measurement purely morphological form, biochemical
approach of a comprehensive parathyroi- of calcium became possible and the associ- function, or a combination of both.

www.medicalebookpdf.com

LWBK892_c39_p486-495.indd 486 10/28/11 5:02:55 PM

 Chapter 39: Comprehensive Parathyroidectomy for the Treatment of PHPT 487

A B

Fig. 1. Parathyroid anatomy can be variable. Even normal parathyroid glands can assume irregular shapes
(A) that should not be mistaken for adenomas or hyperplasia. Asymmetry or variable degrees of parathyroid
enlargement furthermore exists even in multigland hyperplasia (B). The intraoperative photo illustrates
three variably abnormal parathyroids in morphology; all were histologically hypercellular. Despite the find-
ing of one significantly large parathyroid at first, there can be additional abnormalities in the remaining
parathyroid glands. Average parathyroid gland sizes vary by underlying pathology (C): 700 mg single for
adenomas, 150 mg for each hyperplastic gland in PHPT, and 1,000 mg for each gland in secondary HPT.
C

Embryologically, the upper parathyroids ithyroidal fat posterior to the superior pole roid locations in the left and right sides of
develop from the fourth branchial pouch of the thyroid gland and near the path of the the neck. Additional clues for parathyroid
and migrate caudally with the thyroid, recurrent laryngeal nerve as it enters the location can come from observing the pat-
while the lower parathyroid glands derive cricothyroid muscle. In contrast, the lower terns of vasculature in and around the ex-
from the third branchial pouch and migrate parathyroids are more widespread around pected parathyroid region. Both parathy-
with the thymus. The upper parathyroid the lower pole of the thyroid gland, thyro- roids typically derive some blood supply
glands have a narrow area of distribution thymic ligament, and pretracheal fat. Sym- from the inferior thyroid artery. In relation
and are fairly reliably positioned in the per- metry is usually present between parathy- to the path of the main trunk of this artery as
it nears the thyroid, upper parathyroids are
cranial and deeper, and lower parathyroids
are caudal, anterior, and medial. Unusually
curved or extra branching patterns of the ar-
tery may alert to abnormal parathyroids
found hanging at the ends of those branches,
sometimes several centimeters away from
the thyroid capsule. Within their fatty enve-
lope, a normal parathyroid will have a leaf-
like branching pattern of their vascular pedi-
cle. This is a helpful contrast to lymph nodes,
fat or thymic tissues that have no visible vas-
cular pattern, and abnormal parathyroids
whose vascular pedicle may be exaggerated.
Migratory distribution of the parathy-
roids can lead to ectopic locations within
the thymus, within the sheath encompass-
Endocrine Surgery

ing the carotid artery, jugular vein, and va-

gus nerve even in high cervical locations,
retroesophageally and even intrathyroi-
dally. Some, but not all of these, areas can
be accessed via the usual cervical incision
during comprehensive parathyroid explora-
tion. Recently, novel nomenclature was pro-
posed to further classify cervical parathyroid
adenomas into regions relevant for parathy-
roid exploration (see Suggested Readings).
Fig. 2. Normally expected distribution of upper and lower parathyroid glands (see Ritter and Milas in Ectopic parathyroid locations in the ante-
Suggested Readings for additional references). rior mediastinum, other deeper regions of

www.medicalebookpdf.com

LWBK892_c39_p486-495.indd 487 10/28/11 5:02:56 PM

 488 Part IV: Endocrine Surgery

DIAGNOSIS
Traditionally, the diagnosis of PHPT has
rested on the demonstration of simultane-
ously elevated serum total and/or ionized
calcium with elevated intact PTH, in the
setting of normal or high calcium excre-
tion in the urine. With this combination of
findings, the diagnosis of PHPT is practi-
cally definitive. In part, this is because
modern measurements of PTH detect the
intact molecule, reflecting the entire pro-
tein derived from the parathyroid glands,
and essentially eliminating confounding
diagnoses from ectopic sources of PTH,
such as tumors producing PTH-related
peptide (PTHrp). The rare hereditary con-
dition of benign familial hypercalcemic
hypocalciurea (BFHH) is excluded by the
finding of normal or high levels of calcium
in a 24-hour urine collection.
Approximately 10% of patients will have
unusual biochemical presentations that do
not fit these classical diagnostic criteria,
but are nonetheless found to have PHPT.
There are at least two atypical versions of
the disease. Normocalcemic PHPT mani-
fests with normal total serum calcium but
Fig. 3. Distribution of ectopic parathyroid glands (see Ritter and Milas in Suggested Readings for addi- high PTH and has been relatively well ap-
tional references).
preciated; despite borderline laboratory
values, these patients suffer from kidney
stones, osteoporosis, and bone fractures.
The other form of PHPT has high calcium
the mediastinum, and even pericardium re- femur sites. PTH also increases gastrointes- levels but normal PTH. Diagnosis is some-
quire alternate surgical approaches often in tinal calcium absorption. It upregulates re- what easier if PTH values are “inappropri-
collaboration with thoracic surgeons. nal hydroxylation of 25-hydroxyvitamin D, ately” high-normal for the degree of hyper-
and can thus lead to a serum profile of low calcemia (40 to 60 pg/mL on a scale where
25-hydroxyvitamin D and elevated 1,25-di- 60 pg/mL is maximal reference range), but
CLINICAL PRESENTATION hydroxyvitamin D in some patients. It is in- can be challenging when values are as low
PHPT is a disorder of excessive PTH secre- tuitive from these physiologic derangements as 15 pg/mL. This atypical version has not
tion, derived from single (70% to 90%) or how the clinical presentation of PHPT can been well characterized.
multiple (10% to 30%) benign parathyroid include any or all of the following: kidney Table 1 provides a recommended diag-
tumors in the vast majority of patients and stones; osteopenia, osteoporosis, and bone nostic work-up for PHPT and strategies to
only rarely (⬍1%) from parathyroid carci- fractures; diagnosis of vitamin D deficiency; clarify the diagnosis in challenging scenar-
noma. Only 3% of patients with PHPT have increased urination and thirst; and vague ios. It is advisable to obtain a baseline bone
this in the context of multiple endocrine abdominal aches and constipation. Less density assessment with DXA scan, espe-
neoplasia (MEN) syndromes. clear is the underlying mechanism for the cially if this did not precede referral of the
The excess PTH secretion disbalances spectrum of additional clinical findings in patient to the surgeon. Urinary calcium ex-
multiple aspects of calcium homeostasis, patients with PHPT: neurocognitive changes cretion lower than 50 mg/dL should
ultimately leading to hypercalcemia. A prin- such as depression, poor mentation, inabil- prompt consideration of explanations that
cipal action of PTH targets the kidney to re- ity to focus, and insomnia; musculoskeletal include BFHH, renal disease, and use of
tain calcium and excrete phosphorus and aches and weakness; profound fatigue; and thiazide diuretics, among others.
bicarbonate, thereby elevating serum cal- rare presentation of pancreatitis. Osteitis fi- Although there can be other non-endo-
cium and reducing serum phosphate levels brosa cystica and Brown tumors are almost crine causes of hypercalcemia coexisting
and pH, and causing hypercalciurea and historical clinical findings, rarely encoun- with PHPT, these are exceedingly rare. Sep-
nephrocalcinosis. Chronically high PTH in- tered in such severity at the present time. In arate investigation for these is not war-
creases osteoclast activity, particularly in contrast, incidental diagnosis at an asymp- ranted at the outset in a patient with
cancellous bones, thereby contributing to tomatic stage of PHPT is becoming increas- elevated calcium and intact PTH whose
bone density loss. The effects of PHPT are ingly prevalent, although many reveal subtle medical history does not have pertinent
especially apparent in the distal radius, thus symptoms on closer interrogation. The vast findings, such as hypercalcemia-associated
DXA scans measuring osteopenia and os- majority of patients with PHPT are indeed malignancies. Such investigation may be
teoporosis should include this region in ad- asymptomatic, most often with kidney helpful in atypical presentations. Obtain-
dition to the usual lumbar spine, hip, and stones and bone density loss. ing a thorough family history is important

www.medicalebookpdf.com

LWBK892_c39_p486-495.indd 488 10/28/11 5:02:57 PM

 Chapter 39: Comprehensive Parathyroidectomy for the Treatment of PHPT 489

Table 1 Diagnostic Work-Up for Primary Hyperparathyroidism INDICATIONS FOR

SURGERY
In a patient found to have hypercalcemia or diagnosed with conditions that can be related to PHPT
(osteopenia, osteoporosis, kidney stones) A joint statement in 2005 by national pro-
ffessional associations of endocrine sur-
■ Careful history and physical examination, including symptoms, prior head and neck radiation
treatments, prior neck surgery, medications, prior endocrine disorders in the patient, and
ggeons and endocrinologists stated that op-
patient’s family eerative management is clearly indicated for
■ Initial serum biochemical profile: serum total calcium, serum ionized calcium, intact PTH, aall patients with classic symptoms or com-
serum phosphate, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D. pplications of PHPT. More challenging has
■ If this initial profile is compatible with PHPT, complete the diagnostic work-up with 24-h urine bbeen the perspective of decision making for
collection for measurements of urinary volume, creatinine, and calcium. tthose with apparently asymptomatic PHPT.
■ Diagnosis is confirmed when there is elevated serum total or ionized calcium, or both, in Experts organized by the National Insti-
E
conjunction with elevated or high normal PTH, and elevated or normal 24-h urinary calcium. ttutes of Health in 2002 proposed parathy-
■ Note that imaging studies (ultrasound, 99-Tc sestamibi scan, and 4D-computed tomography) rroidectomy for the following patients: (a)
are not intended for diagnostic purposes, but as localizing studies obtained following tthose ⬍50 years of age, (b) who cannot par-
diagnosis and the decision to proceed with surgery
tticipate in appropriate follow-up, (c) with a
In a patient with normocalcemic hyperparathyroidism sserum calcium level ⬎1.0 mg/dL above the
■ Repeat several serum biochemical profiles. Look for elevation in ionized calcium. normal range, (d) with urinary calcium
n
■ Consider underlying vitamin D deficiency or other causes of secondary hyperparathyroidism ⬎400 mg/24 h, (e) with a 30% decrease in
⬎
and treat appropriately. rrenal function, or ( f) with systemic compli-
■ Consider calculating the patient’s personal upper limit of normal PTH by the formula PTH ccations of PHPT including nephrocalcinosis,
[ULN pg/mL] ⫽ 120 ⫺ (6 ⫻ serum calcium mg/dL) ⫺ (½⫻ 25-hydorxyvitamin D ng/mL) ⫹ oosteoporosis (T-score lower than ⫺2.5 SD at
(¼⫻ patient’s age in years). The measurements of calcium, PTH, and vitamin D should be tthe lumbar spine, hip, or wrist), or a severe
from the same blood draw. If the patient’s measured serum value of PTH is higher than this
calculated ULN PTH, the diagnosis of PHPT would be more likely.
ppsychoneurologic disorder.
It is difficult to predict reliably the devel-
In a patient suspected to have other potential causes of hypercalcemia or an initial biochemical oopment, timing, and progression of disease
profile that shows hypercalcemia with low normal intact PTH, consider screening for iin patients with asymptomatic hyperpara-
■ Bony metastases, sarcoidosis, pulmonary tumors (chest radiograph). tthyroidism. Long-term nonoperative man-
■ Multiple myeloma (serum protein electrophoresis). aagement can be costly. For these reasons,
■ PTH-related peptide-producing tumors (serum PTHrp). oother experts have advised a more liberal
■ Check recent staging for cancer status if history of prior malignancy. aapproach to recommendations of parathy-
In a patient with possible multiple endocrine neoplasia (MEN) type 1 or 2 rroidectomy beyond the NIH criteria, pro-
■ Screen for serum or urinary metanephrines prior to parathyroid surgery. vvided that surgery can be performed safely
■ Complete investigation of endocrinopathies as appropriate for patient’s history. aand with minimal risks for a disease that, in
■ Genetic testing to confirm that MEN1 or 2 is not required prior to parathyroidectomy. ssome patients, may be minimally problem-
aatic at the time of presentation. Thus, for
eexample, parathyroidectomy may be appro-
priate to consider for patients with Os-
to discern possible MEN and, if suspected, ticularly related to osteoporosis and bone teopenia (T-scores ⫺1 to ⫺2.5 SD) and mild
appropriate additional evaluation can be fractures, and neurocognitive issues. A neurocognitive symptoms.
tailored. Routine genetic testing for MEN1 number of surgical techniques have evolved The indications for comprehensive para-
(where 90% manifest parathyroid disease) over the last decade. These include focal thyroidectomy as the initial surgery for
and MEN2 (where parathyroid disease and unilateral exploration guided by intra- PHPT, once a patient has met the criteria
affects, 5% patients) is unwarranted as operative PTH measurement, radioguided indicated above, are listed in Table 2. The
part of initial diagnostic work-up for parathyroid surgery, and videoscopic and guiding principle of comprehensive para-
PHPT. robotically assisted parathyroidectomy. thyroid exploration is that some patients
They all aim to achieve the above goals. have significantly higher risk for multigland
Some patients with PHPT may not be parathyroid disease, such that successfully
TREATMENT suitable candidates for surgery or have achieving the operative goal of normocalce-
other reasons to forego parathyroidectomy. mia is contingent on the evaluation of all
The operative goals for the treatment of Percutaneous ethanol ablation, bisphos- parathyroid glands in their usual anatomi-
Endocrine Surgery

proven PHPT are the following: phonates, and calcimimetic agents have cal locations, and the appropriate resection
been described as nonoperative treatment of those that appear abnormal.
1. Achieve a normocalcemic state and nor-
mal long-term PTH. options. These medications reduce calcium
2. Avoid injury to the laryngeal nerves. and PTH levels while administered, but
3. Engender minimal postoperative mor- their long-term impact on improving sys- PREOPERATIVE
bidity and negligible mortality. temic consequences of hyperparathyroid- PLANNING: PARATHYROID
4. Achieve cosmetic scar appearance ac- ism is unclear. Frequent monitoring of LOCALIZATION STUDIES
ceptable to the patient. changes in laboratory values, recommenda-
tions to avoid dehydration and excess cal- The thoughtful, step-wise assessment of the
Surgery remains the most clearly dem- cium intake, and periodic reassessment for patient to reach a diagnosis of PHPT and
onstrated mechanism for durable cure of surgery are important components of non- identify the need for surgery is the most im-
PHPT and symptomatic improvement, par- operative management. portant part of preoperative planning. The

www.medicalebookpdf.com

LWBK892_c39_p486-495.indd 489 10/28/11 5:02:57 PM

 490 Part IV: Endocrine Surgery

aare localization techniques used for reopera- Most surgeons currently perform parathy-
Table 2 Indications for Compre- ttive rather than initial preoperative evalua- roid surgery with general anesthesia, and
hensive Parathyroidec-
tomy as the Initial Surgery ttion. Neck ultrasound, and particularly sur- some use local anesthetics supplemented
for PHPT: the Systematic ggeon-performed ultrasound, provides the by deep cervical nerve block and sedation.
Examination of all Para- aadded advantage of identifying concomitant No antibiotics are needed except in reoper-
thyroid Glands in their tthyroid disease that may need to be ad- ative cases. Prophylaxis for deep vein
Usual Anatomic Location ddressed during parathyroid surgery. Thyroid thrombosis is left to the judgment of the
and Appropriate Resection n
nodular disease is seen in as many as 30% of surgeon and tailored to patient need, but in
of Diseased Parathyroids ppatients, while 4% will have previously undi- general, sequential compression stockings
aagnosed thyroid cancer detected during have the least of risk of neck hematoma
Absolute indications eevaluation for PHPT. while providing DVT prophylaxis.
Known or suspected multiple endocrine It is valid to consider whether patients Comprehensive parathyroid exploration
neoplasia syndromes sselected for comprehensive parathyroid ex- can also be performed without the use of
Intraoperative PTH fails to drop after pploration require any preoperative imaging. intraoperative adjuncts, although these
resection of suspected single adenoma IIn principle, this imaging is not essential be- may be helpful depending on the complex-
Failure to find diseased gland at location ccause the risk of mediastinal or cervical ecto- ity of surgical findings, assessment of use-
indicated by imaging studies ppic parathyroid disease is rare. It is justifiable fulness by the individual surgeon, or experi-
Finding more than one abnormal parathyroid
during intended focal or unilateral neck
tto conduct comprehensive parathyroidec- ence of the surgeon. Numerous intraop
exploration ttomy without imaging studies, and this strat- erative adjuncts have been described. Most
Negative imaging studies eegy has a decades-long successful track re- notably, intraoperative PTH measurement
Imaging studies suggesting multiple sites of ccord. Conversely, if no preoperative imaging has become a fundamental part of modern
disease sstudies are available or if they are entirely parathyroid surgical practice. It is used to
Coexisting thyroid cancer or bilateral goiter nnegative, comprehensive rather than focal confirm complete excision of hyperfunc-
requiring total thyroidectomy pparathyroid exploration is advisable. Preop- tioning glands and is discussed in detail in
Advisable indications eerative imaging is valuable, nevertheless, the subsequent chapter. Intraoperative
wwith comprehensive parathyroidectomy as it PTH, however, is least accurate in predict-
Discordant parathyroid imaging studies
Unavailability of intraoperative PTH ccan facilitate the conduct and speed of the ing multigland parathyroid hyperplasia.
measurement ooperation by focusing early dissection on the Other adjuncts include frozen section his-
Inability to obtain preoperative imaging rregion of greatest suspected abnormality. tology and needle aspiration of excised tis-
Lithium-induced PHPT sue for measurement of PTH as means of
Non-MEN familial hyperparathyroidism SURGICAL TECHNIQUE distinguishing parathyroid from non-para-
Coexisting thyroid pathology that may thyroid tissue. It is useful to recall that nei-
require operative intervention C
Comprehensive parathyroidectomy can be ther frozen section examination nor per-
Surgeon preference or experience aaccomplished with minimal invasiveness manent histology can distinguish between
aand morbidity, gentle dissection, and the single adenomas, hyperplasia, or various
use of few delicate instruments (Fig. 4). underlying parathyroid disease states

remaining efforts are directed to determin-

ing that a patient is medically fit to undergo
parathyroidectomy safely and to localizing
the site of parathyroid disease.
There is a spectrum of radiologic imaging
studies available for localization of abnormal
parathyroid glands. The most frequently
used modalities are neck ultrasound, 99-Tc
sestamibi scans and computed tomography
(CT) scans, or combinations of these. Normal
parathyroids are not expected to be imaged,
except perhaps with 4D CT scans. 99-Tc ses-
tamibi scans are conducted variably among
radiology departments, and techniques in-
clude two-dimensional planar scans with
initial and delayed imaging, 3D SPECT imag-
ing, use of concomitant CT scanning with or
without intravenous contrast dye, and use of
123-I to subtract the contribution of thyroid
uptake of 99-Tc sestamibi. Surgeons may find
it valuable to be familiar with the technique
used by their radiologists and review images
collaboratively, as reported accuracies of the
various modalities range from 50% to 96%.
Magnetic resonance imaging, selective ve-
nous sampling, and occasionally PET scans Fig. 4. Instrumentation useful for comprehensive parathyroidectomy.

www.medicalebookpdf.com

LWBK892_c39_p486-495.indd 490 10/28/11 5:02:58 PM

 Chapter 39: Comprehensive Parathyroidectomy for the Treatment of PHPT 491

(primary, secondary, or familial hyperpara- this midline and require ligation, although brown) of the parathyroid. A normal para-
thyroidism). Intraoperative gamma probe electrocautery is sufficient for dividing thyroid will appear flattened and have a
has been applied to in vivo localization of most of these tiny branches. The sternothy- leaf-like vascular pattern absent in simple
abnormal parathyroids and ex vivo mea- roid muscle is bluntly separated from the fat or thymus. It can be gently coaxed out of
surement of radiotracer counts as markers undersurface of the sternohyoid muscle for the areolar or fatty covering to determine its
of normal versus abnormal parathyroids. a short distance, again to aid mobility in entire size and that it does not hide an en-
Intraoperative ultrasound has been sug- lateral retraction. The loose areolar tissue larged segment (a “cap of normal” disguis-
gested to facilitate incision placement. between the sternothyroid muscle and thy- ing an underlying parathyroid tumor). An
There is extensive literature on the clinical roid is taken down with cautery at low set- abnormal or enlarged parathyroid will often
efficacy of these adjuncts. Their ultimate tings or blunt dissection. It is important to appear as a mass bulging below thicker tis-
application remains surgeon dependent separate these tissues or any pretracheal fat sue, or have a sliding motion back and forth
and some are more essential for focal rather at the very edge of the sternothyroid mus- beneath a film of thin areolar cover. The ab-
than comprehensive parathyroidectomy. cle, to avoid unintentionally displacing normal parathyroid should also be sepa-
Once anesthetized, the patient is posi- parathyroid tissue laterally. Traction is ex- rated from the encasing thin areolar tissue
tioned with arms tucked at the side and erted on the thyroid lobe by using a peanut so that its only attachment is the vascular
head gently hyperextended, facilitated by or manually with 4 ⫻ 4 sponges, in order to pedicle. This can sometimes be facilitated
placement of a roll or bean bag between the elevate and medially rotate the lobe. This by using a #3 Penfield instrument, whose
scapulae. Care to have vertical alignment of exposes the lateral and posterior thyroid curvature can gently scoop out a parathy-
the patient’s chin, suprasternal notch, and surface, and brings the middle thyroid vein roid. Ideally, the dissection should free the
center of the thyroid cartilage aids a sym- into view. This vein is always above the enlarged parathyroid along its lateral and
metric incision. Likewise, to optimize cos- plane of the carotid artery, which should posterior aspects first, leaving the medially
metic results, it is helpful to mark potential now be visible or palpable. The vein courses located pedicle along the thyroid last.
incision sites while the patient is awake and in a medial to lateral direction, similar and We have designated the search for para-
sitting upright, as this best reveals natural often parallel to the inferior thyroid artery, thyroid glands along the usual anatomical
skin creases, which can move or become which in contrast, is always situated deep distribution of upper and lower parathy-
less visible in supine position. The authors to the carotid artery. The middle thyroid roids as the “primary parathyroid survey.”
prefer chlorhexidine for sterile prep be- vein can be isolated, ligated, and divided to It takes into consideration exploring all
cause it is nonflammable and avoids poten- facilitate exposure. the regions shown in Fig. 2, until the remain-
tial irritation and staining of the face and Comprehensive parathyroid exploration ing three parathyroids have been identified.
neck. begins by identifying the abnormal para- It is useful to develop a systematic order of
A transversely oriented incision is made thyroid gland in the area suggested by pre- exploration and practice it routinely. A con-
according to the optimal site marked. In operative imaging. Very fine instruments venient strategy is to target exposure of the
most patients, this is 1.5 to 2 fingerbreadths are used for these maneuvers and the im- most abnormal parathyroid first, then the
above the suprasternal notch. The length of portance of maintaining a bloodless field ipsilateral parathyroid, and finally explore
the incision varies with surgeon preference, cannot be overemphasized. Blood staining the contralateral side. When all parathyroids
and usually does not need to be longer than discolors the adjacent tissue and can make have been indentified, assessment about the
4 to 6 cm. Comprehensive parathyroid ex- parathyroids less noticeable. If parathyroid disease process (single adenoma, double ad-
ploration can be performed via incisions as imaging is negative, the area of the lower enoma, or hyperplasia) can be made and a
small as 2.5 cm positioned in the midline at parathyroid is exposed first because it is decision about which parathyroids to re-
the thyroid isthmus. The incision is carried more accessible. Exposure of the upper move and in what order can be determined.
down by electrocautery through the plat- parathyroid area requires an even greater Treatment of single adenomas is simple
ysma muscle that is about 2 to 3 mm thick degree of medial rotation of the thyroid excision of the abnormal gland. Multigland
(more visible in men) and relatively free of lobe. The strategy is to identify fatty-appear- hyperplasia is ideally treated with subtotal
blood vessels. Deep to the platysma is an ing tissue along the edges of the thyroid or parathyroidectomy and parathyroid cryo-
avascular plane just above the anterior jug- adjacent to the space where branches of the preservation. If only two or three of the four
ular veins that can be developed to aid ex- inferior and superior thyroid artery enter glands are abnormal, the abnormal para-
posure, using a combination of electrocau- the thyroid gland. Purposeful observation thyroids are excised while the normal para-
tery and blunt dissection. This subplatysmal of the operative field is more effective than thyroids can be left in situ without resec-
plane is developed until the thyroid carti- blind dissection. Care should be taken to tion, marking their location with a clip. If all
lage is palpable superiorly and the sternal stay close to the thyroid to avoid injury to four glands are abnormal, the remnant
notch inferiorly, but can be dissected less in the recurrent laryngeal nerve. The nerve should be fashioned first, resecting all but a
Endocrine Surgery

thin patients. Mobilizing these flaps offers does not have to be exposed or skeletonized segment measuring approximately 6 ⫻ 4
optimal exposure through small incisions by as part of comprehensive parathyroidec- mm or the size of a normal parathyroid
increasing the ease of retraction. Anterior tomy. Its presence in the vicinity and orien- (around 25 mg). This segment remains at-
jugular veins are preserved as a potential tation relative to enlarged parathyroids tached to the vascular pedicle and is marked
source of blood sampling for intraoperative should always be considered, and its path with a clip across the transected surface.
PTH. revealed just enough, if necessary, to ensure Parathyroids with discrete or long vascular
Once the subplatysmal flaps are created, its safety during subsequent dissection. pedicles and those with oval rather than
a self-retaining retractor is placed. The When an area of likely parathyroid ab- globular or knobby shape are easier to fash-
avascular midline raphe of the strap mus- normality is seen, careful blunt dissection is ion into remnants. Inferior parathyroids are
cles is opened vertically along the midline done using a fine curved hemostat to sepa- more suitable to use as remnants because
to separate the muscles and expose the thy- rate the overlying fatty tissue looking for they are easier to approach in event of fu-
roid. Occasionally, small vessels can cross subtle color changes (darker orange to ture reoperation.

www.medicalebookpdf.com

LWBK892_c39_p486-495.indd 491 10/28/11 5:03:05 PM

 492 Part IV: Endocrine Surgery

tially be avoided if preoperative ultrasound

describes a normal thyroid without nod-
ules. Examination of the path along the ca-
rotid artery and jugular vein can be per-
formed as widely as the incision allows. The
skin incision can be enlarged to permit ad-
equate exposure of any of these regions.
Parathyroid gland location is generally
symmetrical and can aid in contralateral
neck exploration. A parathyroid located at
the posterior midpoint of the thyroid lobe
could represent either a lower gland that
sits higher than usual, or an upper gland
that is more inferior than usual. Finding the
other ipsilateral gland should take into ac-
count both possibilities. Double parathy-
roid adenomas, reported in 3% to 15% of
patients, have a nonuniform distribution
that favors enlargement of both upper para-
thyroids (Fig. 7).
After exploration and resection are com-
pleted, the neck is irrigated with sterile wa-
ter, which provides a clearer view of the
surgical field than saline. Hemostasis is
achieved. Each gland or remnant should be
reevaluated for viability. Some mild bruis-
ing and discoloration of the parathyroids is
acceptable. If parathyroid tissue has be-
come completely black from ischemia or
has questionable viability, it can be reim-
planted into the ipsilateral sternocleido-
mastoid muscle. The strap muscles and
platysma are reapproximated with absorb-
able suture, and the skin incision is closed.
Drains are seldom, if ever, necessary. Our
preferred technique uses a 3-0 prolene sub-
cuticular stitch with long tails left in place
until surgical glue is applied and dried.
Once the patient is extubated, the prolene
is easily pulled out, leaving a cosmetic clo-
sure.

Fig. 5. Secondary parathyroid survey examines areas of atypical or ectopic parathyroid location when POSTOPERATIVE
initial exploration fails to reveal all pathologic glands.
MANAGEMENT
Short-term postoperative management
A “secondary parathyroid survey” refers ies (Fig. 6). The secondary survey should varies according to surgeon preference. Fol-
to exploration of cervical regions when not be performed just to locate a normal lowing parathyroidectomy, most surgeons
parathyroid position is more unusual or ec- parathyroid, but a missing pathologic elect to observe their patients for 23 hours,
topic, and when the above primary survey gland. The thymus should be retracted out but many use outpatient care. Long-term
has not led to conclusive findings. Impor- of the mediastinum as far as possible with- management relies on diligent monitoring
tant areas to examine are summarized in out avulsion, carefully examined, palpated, of calcium and PTH levels to observe dura-
Fig. 5. The most commonly missed location and removed. The middle thyroid vein ble cure of hyperparathyroidism. Ideally, a
is a retroesophageal parathyroid that has should be ligated and divided, if not already full biochemical panel that includes cal-
sunken into the deep posterior space be- done, as this provides greater exposure of cium, PTH, and vitamin D should be
hind the tracheoesophageal groove, often the trachea and esophagus. Mobilizing the checked at 2 weeks after surgery during the
lying on the anterior surface of the spine upper thyroid pole as during thyroidectomy first postoperative visit, then at 6 months,
and below the main trunk of the inferior can occasionally disclose ectopic parathy- and then annually for the remainder of the
thyroid artery. This parathyroid is embryo- roids without devascularizing the thyroid patient’s lifetime. The impact of vitamin D
logically derived from the upper gland, al- gland. Thyroid lobectomy on the side of the deficiency in causing transient secondary
though it often appears to have a position missing abnormal parathyroid may be jus- hyperparathyroidism postoperatively in an
more inferior than the actual lower gland, tifiable even when no palpable abnormali- otherwise cured patient is well recognized.
both intraoperatively and on imaging stud- ties exist, but this circumstance can poten- This can be seen in up to 20% to 30% of

www.medicalebookpdf.com

LWBK892_c39_p486-495.indd 492 10/28/11 5:03:05 PM

 Chapter 39: Comprehensive Parathyroidectomy for the Treatment of PHPT 493

Endocrine Surgery

Fig. 6. Preoperative imaging (A) shows a large inferior midline sig-

nal abnormality on the gray-scale 99-Tc sestamibi image. It is more
precisely seen on the color SPECT views to be very posterior in the
tracheoesophageal groove, thus actually representing a right upper
parathyroid. A normal right lower parathyroid is at the tip of the
instrument in panel B. The vascular pedicle of the right upper para-
D
thyroid adenoma is looped in panel C, and the excised specimen
oriented in vivo in panel D.

www.medicalebookpdf.com

LWBK892_c39_p486-495.indd 493 10/28/11 5:03:05 PM

 494 Part IV: Endocrine Surgery

total excision of multigland hyperplasia. A

parathyroid remnant crafted on its native
vascular pedicle is usually less prone to
cause hypocalcemia than total parathyroi-
dectomy with remnant implantation into
muscles of the neck or nondominant
forearm. An additional safeguard against
permanent hypocalcemia can come from
cryopreservation of small parathyroid frag-
ments (each 2 to 3 mm in size), which can
later be autotransplanted into the patient’s
forearm (Fig. 8). In the absence of this capa-
bility, the surgeon should use judgment
about the extent of resection in multigland
A B hyperplasia and can consider leaving a
Fig. 7. A: Double parathyroid adenomas have nonuniform distribution that favors enlargement of both remnant larger than 25 mg. The need to re-
upper glands. B: Only a minority (18%) will have ipsilateral location. implant cryopreserved parathyroid tissue

patients in the first year after surgery and

requires reassurance (of both patient and
referring physicians), treatment, and moni-
toring. It is important to ensure that the
patient receives adequate calcium and vita-
min D supplementation after surgery. Mini-
mal daily calcium carbonate or citrate sup-
plementation is 500 to 600 mg taken two to
three times daily. Depending on the degree
of vitamin D deficiency, some patients may
require over-the-counter supplements of
800 to 2,000 IU daily of vitamin D3 cholecal-
ciferol, while others need a prescription-
level strength such as 50,000 IU ergocalciferol
weekly ( for 25-hydroxyvitamin D⬍20 ng/
mL) and very rarely 0.25 or 0.5 mcg daily of
A
calcitriol ( for 1,25-dihydroxyvitamin D defi-
ciency or significant hypocalcemic symp-
toms). These patients should be reevaluated
with blood tests at 3 months after surgery
to determine need for ongoing vitamin D
supplementation. Durable cure after com-
prehensive parathyroidectomy means 95%
to 98% success rate, with 2% to 5% of pa-
tients at risk to develop recurrent hyper-
parathyroidism.

COMPLICATIONS
Infections occur exceptionally rarely. Neck
hematomas requiring operative evacuation
and permanent hoarseness from recurrent
laryngeal nerve injury should likewise be
minimal (0.5% to 1%). There must be deli-
cate tissue handling to avoid damage to
normal parathyroids or disruption of ab-
normal glands. The actual tissue of these
structures should never be grasped itself;
B
rather, forceps and instruments should
handle the surrounding fatty tissue, filmy Fig. 8. A: Subtotal or near-total parathyroidectomy with parathyroid cryopreservation. B: The small
adventitia, or vessels. Hypocalcemia be- parathyroid fragments are drawn up into the syringe as a convenient way of transportation in sterile
comes a greater risk with subtotal or near- fashion to the cryopreservation facility.

www.medicalebookpdf.com

LWBK892_c39_p486-495.indd 494 10/28/11 5:03:09 PM

 Chapter 39: Comprehensive Parathyroidectomy for the Treatment of PHPT 495

usually becomes evident within 6 months a decade of change. J Am Coll Surg 2009;209: 7. Phitayakorn R, McHenry CR. Parathyroidec-
of surgery if the cervical remnants become 332–43. tomy: overview of the anatomic basis and
nonfunctional. 3. Mazzaglia PJ, Berber E, Kovach A, et al. surgical strategies for parathyroid operations.
The changing presentation of hyperpara- Clin Rev Bone Miner Metab 2007;5:89–102.
The potential for missed ectopic or su- thyroidism over three decades. Arch Surg 8. Ritter H, Milas M. Parathyroidectomy: bilater-
pranumerary parathyroids and persistent 2008;143:260–6. al neck exploration. In: Terris D, ed. Operative
or recurrent hyperparathyroidism should 4. Moalem J, Guerrero M, Kebebew E. Bilat- Techniques in Otolaryngology. St. Louis, MO:
be discussed with patients prior to sur- eral neck exploration in PHPT – when is it se- Elsevier; 2009.
gery to properly inform expectations of lected and how is it performed? World J Surg 9. Siperstein A, Berber E, Barbosa G, et al. Pre-
surgery. 2009;33:2282–91. dicting success of limited exploration for 1°
5. Pasieka JL, Parsons LL, Demeure MJ, et al. hyperparathyroidism using ultrasound, ses-
Patient-based surgical outcome tool demon- tamibi scan, and intraoperative PTH: analysis
SUGGESTED READINGS strating alleviation of symptoms following of 1,055 cases. Ann Surg 2008;248(3):420–8.
parathyroidectomy in patients with PHPT. 10. Yip L, Ogilvie JB, Challinor SM, et al. Identifi-
1. AACE/AAES Task Force on PHPT. Position World J Surg 2002;26(8):942–9. cation of multiple endocrine neoplasia type 1
statement on the diagnosis and management 6. Perrier ND, Edeiken B, Nunez R, et al. A novel in patients with apparent sporadic PHPT. Sur-
of PHPT. Endocr Pract 2005;11:49–54. nomenclature to classify parathyroid ade- gery 2008;144(6):1002–6; discussion 1006–7.
2. Greene A, Mitchell J, Davis R, et al. National nomas. World J Surg 2009;33(3):412–6.
trends in parathyroid surgery from 1997–2007:

EDITOR’S COMMENT and 100%. This is not a merely hypothetical fig- tional parathyroid exploration has become some-
ure; there are real decreases in cognitive function, what rare and only occurs when there is failure
as we shall see in this commentary, especially in of a minimally invasive approach to parathyroi-
As Professor Siperstein states, parathyroidectomy patients who are older than 75 and patients with dectomy, whatever minimally invasive approach
has become one of the most common operations, higher calcium, the more rapid the decline in cog- is, since many individuals do not define what they
particularly as or near an outpatient in the sur- nition, so success is important. A redo explora- do, and then a conventional bilateral neck explo-
geon’s armentarium. While it is tempting to say tion of the neck, in an attempt to find the missing ration parathyroidectomy becomes necessary.
that all groups have the same approach, that is gland, is sometimes a difficult procedure, so it is The field of parathyroid surgery has changed
clearly not so. I believe that Dr. Siperstein uses a best avoided. considerably in the past 5 years, and the contro-
bilateral approach in all cases, and believes that in The minimally invasive parathyroidectomy versy of intraoperative PTH has been somewhat
all cases all four glands, or all normal glands and following the improvement in Tc99m-sestamibi ameliorated since, as one will see in the chapter
all abnormal glands should be identified. I do not scan and ultrasonography has made, as the au- devoted to this by Dr. Solerzano (Chapter 38) is
think that this is the case with Professor Moley, who thors point out, minimally invasive parathyroi- not absolute, but is helpful. It is widely used, but
indicates that the “conventional parathyroidec- dectomy the standard in some, but not all units. not accepted as the absolute sine qua non of suc-
tomy” should only occur in the minority of cases. Unfortunately, however, there is no good defini- cess. Perhaps it should be and perhaps surgeons
A big difference between the two chapters may be tion, at least in the papers I have reviewed, as to should persist until there is a 50% decrease in
the fact that intraoperative parathyroid hormone what a minimally invasive parathyroidectomy is, intraoperative parathyroid assay. The difference
(PTH) measurement is not mentioned by Dr. Siper- unless what it means, as seems likely, that when is that different individuals use a different sam-
stein and therefore it is necessary to have a visual focus is on an enlarged parathyroid gland, which ple technique. When originally described by Dr.
verification of which glands are what. Not that the seems to show increased uptake of the sestamibi George “Bucky” Irvin, the standard was to have a
intraoperative PTH measurement is the sine qua scan or an enlarged single gland on ultrasound preincision figure and then, a sample drawn after
non. In the 5 years between the editions, it would and does not bother to do either a unilateral or the parathyroid gland had been dissected free,
appear as if most parathyroid surgeons believe that a bilateral neck exploration. In addition, it does thereby elevating the level of PTH, and then two
the PTH is helpful in about 60% of the cases, but is appear that the accepted success rate, unfortu- postexcision samples: one variable between 5 and
not the sine qua non. I believe the reason for this nately, in minimally invasive parathyroidectomy 10 minutes and the other at 15 minutes to half an
is that the confusion between the initial samples in the absence of a bilateral neck exploration hour. In this case, the evolution of parathyroidec-
that is preincision and whether or not one also has has yielded an acceptance of 89% to 95% success tomy has been a moving target. Many surgeons
preexcision sample after the offending parathyroid rate in the “cure” of hyperparathyroidism. There ask me whether it is worthwhile doing a new edi-
gland has been identified and dissected out so that does appear to be, and I hope this is not correct; tion approximately every 5 years. The answer is
the PTH measurement immediately before exci- a difference in acceptance of what success is in yes, and as one can see in this volume, not only
sion is perhaps artificially elevated. operation on primary hypercalcemic hyperpara- parathyroid and hernia, but also gastrectomy
There also seems to be a difference in the ap- thyroidism between specialties. In the endocrine and Roux-en-Y, and a number of other areas that
proach to diagnosis. I am not trying to pigeon- surgical groups descended from general surgeons, have been real changes in what various surgeons
hole everybody but it seems to me that in Prof. it does appear that the higher figure of success of around the world think.
Siperstein’s chapter he argues that the surgeon at least 99% to 100% is not only the standard, but In trying to define what the standard is for
should be very much involved in the diagno- is achievable, especially if one pursues finally, parathyroidectomy, there are at least four areas
sis. I do not know what Prof. Moley thinks as to bilateral neck exploration in the failure of, for which we need to be cognizant of. They are the
whether or not someone else does the diagnosis example, intraoperative PTH decreases of 50% following:
and the surgeon passes on it, or whether the sur- or more. However, in the otolaryngological lit-
Endocrine Surgery

geon is actively involved in the diagnosis. erature, several papers of which will be quoted in 1. The appropriate diagnostic procedures.
These may be subtle differences in the two this commentary, it does appear that 95% to 96%, 2. The role of minimally invasive parathyroi-
chapters in a disease that has become very com- is thought of as a good result. I cannot accept this. dectomy, and wherever possible, to define it
mon and in which patients undergo different The cognitive decreases in function, especially in and what it means. It clearly means different
procedures by different individuals all of whom the elderly, as well as the difficulty in redo neck things to different surgeons.
have significant experience in practice and re- exploration, make it imperative that individuals 3. The role of intraoperative PTH measurements:
section. who are performing parathyroid surgery will ac- How and when performed and the interpreta-
In the introduction to the section on parathy- cept no less than a 99% to 100% success rate in tion thereof.
roid surgery in the fifth edition, I made the point the first try in single gland hyperparathyroidism. 4. How strongly does one feel about hyperpara-
that in good units the standard of care, perhaps, is As Professor Moley points out in the first thyroidism in the elderly (over 75 years old),
to “cure” primary hyperthyroidism between 99% paragraph of this very nice chapter, the conven- and should they be operated on.

(continued)

www.medicalebookpdf.com

LWBK892_c39_p486-495.indd 495 10/28/11 5:03:13 PM

 496 Part IV: Endocrine Surgery

Those are at least the minimum expectations tween 2004 and 2008. Unfortunately, the mean plained that the additional benefit of intraopera-
that we should have concerning this disease. Yet, age of the patients was 60, not the group that, I tive parathyroid therapy is marginal, especially
apparently, not all believe that these should be believe, we would be much more interested in, given the longer duration of surgery. I violently
our standards. Ruda JM et al., Otolaryngol Head since that is a group that is still controversial, to disagree with this conclusion. The purpose of the
Neck Surg (2005) 132:359–72 reviewed 20,225 some extent. Their success rate was 99% using a operation is not to set speed records, but to have a
cases of primary hyperparathyroidism (PHPT) re- minimally invasive approach, which they did not successful parathyroidectomy, which ameliorates
ported. Of these, the distribution of the etiology describe, on an ambulatory basis. The difference or cures hypercalcemia and hyperparathyroid-
of the disease was somewhat different than what between the previously, seemingly accepted 95% ism. A success rate of 96% is no longer acceptable.
we had previously been led to believe. There were and 99%, while perhaps, not significantly statis- This, unfortunately, is from another otolaryngol-
single adenomas in 88.9%, multiple gland hyper- tically, is significant, biologically, since 99%, at ogy unit. I hope that they do not believe that a
plasic disease in 5.7% was somewhat lower than least to me, is the standard to which various success rate of 96% is appropriate.
previously, 4.1% in double adenomas, and 0.74% surgeons should aspire. There was a significant From the UK and the Hull Royal Hospital,
of parathyroid carcinomas. The two standard pre- reduction in mood and anxiety symptoms and Charlotte SD et al., in Journal of Laryngology and
operative tests, which were the Tc99m-sestamibi improvement in spatial working memory in Otology, published online, July, quite frankly gave
and ultrasound were 88.4% and 78.79% sensi- patients with PHPT who underwent successful me a pause. Their failure rate in PHPT, they de-
tive, respectively, for single adenoma, and 44.7% parathyroidectomy. However, the elderly were fined in 220 primary procedures over 4.5 years,
and 35% for multiple gland hyperplasic disease not selected out in this group, but Tram MR was 6.4%, thus a success rate of 93.5%. I have not
in 29%, 30%, and 16.2% for double adenomas, et al. (J Am Geriatr Soc 2007;55:1786–92) found read such a low figure for success in a literature
respectively. The results of operation, initially that high serum calcium levels were associated over the past 10 years. Also, one wonders how
offered minimally invasive radioguided parathy- with a rapid decline in cognitive function, espe- careful the recordkeeping was. Of the 220 pa-
roidectomy and the initial operation of unilateral cially for people older than 75 years. This find- tients, apparently, 16 did not have postoperative
exploration, and then finally, bilateral neck explo- ing of improvement in a cognitive function was calcium, and they would not exclude them. The
ration were 96.66%, 95.25%, and 97.69%, respec- present, even if patients with an abnormally high authors do not state what else was not excluded
tively. Intraoperative parathyroid assays were calcium level were excluded from this study. or what was not available. Table 1 is quite reveal-
not considered sine qua non, but “were helpful” Another chapter, which apparently did not ing, in which, of the 13 patients that they group,
in ⬃60% of bilateral neck exploration conver- seem to accept the necessity for a 99% remission the solitary adenoma was missed in four of six of
sion surgeries. They also stated that intraopera- rate in hypercalcemia and hyperparathyroidism Group I, the other two were familial hypercalce-
tive PTH was helpful, but not foolproof adjunct (Bach G et al., published online, 2011 in Head and mic hypocalcuria. In Group 2, undertreated mul-
in parathyroid exploration surgery. However, in Neck), in which a relatively small number of pa- tiglandular hyperplasia was present in four; the
Table 3, the results are given as stated previously tients, 240, were divided in three groups between second adenoma was missed in a fifth; a prob-
with bilateral neck exploration as 97.69%, but bi- January 2002 and January 2006. The first group, able missed adenoma, again, in the sixth; and
lateral neck exploration conversion, when what- 109 patients, underwent Tc99m-sestamibi scan- three adenomas in the seventh patient. Intraoper-
ever the previous minimally invasive parathyroid ning and ultrasonography, and intraoperative ative parathyroid tact only utilized three samples;
technique was unsuccessful, was 99.08%. The parathyroid measurement. The second group of the first, before incision; the second, after removal;
author’s conclusion that these results support a 102 underwent only ultrasonography and sesta- and the third, after 15 minutes. There was no
greater role for the treatment of primary hyper- mibi scanning, and the third group, ultrasonog- preexcision sample, which, it seems to me, is es-
thyroidism using less invasive approaches is not raphy and intraoperative PTH monitoring. The sential, if one is going to use intraoperative PTH
correct in my view, for the above-mentioned rea- technique was not described before the surgery, measurement after a gland has been isolated
sons. One should not accept 96.66% or 95.25%, but intraoperative parathyroid samples were and just before removal. I realize that the gland
or even 97.69%; the only thing that is acceptable four; I assume that one was preincision, one was has been stimulated, and the PTH may be in-
is a 99% success rate for the reasons mentioned preexcision, and then there were two postexci- creased, but that is what most individuals have
above, and if it takes a conversion to a bilateral sion samples, although this is not described. Of practiced.
neck exploration, so be it, unless, of course, the the group that had Tc99m-sestamibi scanning and Taking together, I have to agree with the au-
surgeon is unfamiliar and hesitant about using ultrasound, preoperatively, followed by intraop- thors of some of the papers, particularly Clive
this approach. erative parathyroid determination, the success Grant, John Van Heerdon, and also Robert Udels-
What is the goal of hypercalcemia in the rate increased from 97% to 99%. The ultrasonog- man’s unit at Yale, that the acceptable standard is
cognitive impairment that supposedly occurs in raphy and sestamibi scanning were successful in the 99% to 100% cure rate of PHPT. Anything less
patients with hyperparathyroidism? Roman SA 96% of the cases, and in Group 3, a small group, in may border on practice below the standard. The
et al. (Ann Surg 2011;253:131–7) carried out psy- which there was only ultrasound, the use of intra- acceptance of 96% as a routine is not acceptable
chological evaluations in 212 patients who were operative PTH in these 29 patients increased the in 2011.
referred to a large tertiary referral center be- success rate from 89% to 96%. The authors com- J.E.F.

40 Intraoperative Parathyroid Hormone

Assay–Guided Parathyroidectomy
Carmen C. Solorzano, Denise M. Carneiro-Pla, and John I. Lew

INTRODUCTION is the result of autonomous hypersecretion There are currently two major operative ap-
of PTH by one or more parathyroid glands. proaches: traditional parathyroidectomy
The ability to quickly measure parathyroid Surgical treatment of SPHPT continues to and focused parathyroidectomy. The major-
hormone (PTH) in plasma and tissue has be based on the identification and removal ity of high-volume parathyroid surgeons
changed the understanding and surgical of all hypersecreting parathyroid tissue perform focused parathyroidectomy guided
management of sporadic primary hyper- while preserving normally functioning by preoperative localization studies and in-
parathyroidism (SPHPT). This disease entity glands that maintain calcium homeostasis. traoperative parathyroid monitoring (IPM).

www.medicalebookpdf.com

LWBK892_c40_p496-500.indd 496 10/28/11 5:02:17 PM

 Chapter 40: Intraoperative Parathyroid Hormone Assay–Guided Parathyroidectomy 497

In this chapter, the use of IPM as an adjunct HISTORY OF IPM Currently, hypersecretion of PTH by abnor-
during parathyroidectomy in patients with mal gland(s) is measured by a nonradioac-
SPHPT is discussed. Reiss and Canterbury first described an anti- tive two-site immunochemiluminescent
Traditional parathyroidectomy requires body with good affinity for PTH in humans antibody that captures and quantifies the
bilateral neck exploration (BNE) that in- using an immunoradiometric assay. The util- unknown amount of hormone in a sample
volves the identification of usually four ity of this assay, however, was limited as it of plasma. Rapid results are essential if the
parathyroid glands, and based on the sur- recognized only part of the PTH molecule. In surgeon is to use hormone dynamics to
geon’s judgment, the excision of all grossly 1987, Nussbaum and colleagues described a guide parathyroidectomy. Most intraopera-
enlarged glands. All normal-sized parathy- new method for measuring the intact (1–84) tive assays provide results on an average of
roid glands are left in situ. A problem with PTH molecule by using a two-site antibody 8 to 20 minutes, and the PTH dynamic
this approach is that the size of a parathy- technique that proved more sensitive and changes shown by these rapid assays corre-
roid gland does not always directly correlate specific than previous PTH assays. Since late well with standard diagnostic assays
to its secretory function. If any hypersecret- PTH has a rapid rate of decay (half-life, 3 to 5 with respective normal ranges. Since sur-
ing gland(s) is left behind, hypercalcemia minutes), these authors suggested that in- geons need a short turnaround time, point-
will persist, resulting in a failed parathyroi- traoperative measurement of PTH might of-care capability with the assay equipment
dectomy. Conversely, if too many normally prove useful to the surgeon performing para- placed in, or in close vicinity to, the operat-
functioning parathyroid glands are excised thyroidectomy. The impetus for developing a ing room is of utmost importance.
or their blood supply compromised during quick quantitative method to determine the
extensive dissection, postoperative hy- removal of all abnormal parathyroid tissue HOW IPM IS USED
poparathyroidism with resultant hypocalce- was a hypersecreting parathyroid gland that
mia and tetany may occur. Large series have was missed after excision of a single enlarged IPM only measures the circulating amount of
shown that this operative approach yields gland during BNE. In 1990, Irvin and col- hormone at the time and from the location
success rates of 95% to 99% when performed leagues refined and applied this assay to where the sample is obtained. The surgeon
by experienced parathyroid surgeons. How- routine clinical practice in the surgical man- must be attentive, understand, and direct the
ever, these curative rates may fall to 70% agement of SPHPT at the University of Mi- sampling times related to the stages of the
when traditional parathyroidectomy is per- ami. By heating and shaking the antibodies operative procedure. There are several intra-
formed by inexperienced surgeons. with the patient’s blood sample to speed re- operative criteria published that predict
In the early 1990s, imaging studies were action times using this assay, intraoperative postoperative calcium levels using changes
increasingly being used by surgeons to PTH monitoring (IPM) was shown to predict in hormone dynamics following excision of
localize and guide parathyroidectomy. postoperative normocalcemia in patients hyperfunctioning glands. The initially de-
Unfortunately, these localization studies after parathyroidectomy. With the later scribed criterion used to predict postopera-
frequently missed multiple gland disease transition from radionuclear to immuno- tive eucalcemia in patients with SPHPT is a
(MGD) making them unreliable as the sole chemiluminescent technology, this PTH as- “50% PTH drop” 10 minutes after complete
adjunct to focused parathyroidectomy. say became a practical test for intraopera- resection of all hyperfunctioning tissues
Around this time, IPM was introduced pre- tive, point-of-care use. Since 1996, rapid PTH (Table 1). This protocol developed at the Uni-
cisely to avoid missed MGD and to assure assays have become commercially available versity of Miami by George L. Irvin III requires
complete excision of all hypersecreting for intraoperative use, and such surgical ad- peripheral venous or arterial access for blood
glands before leaving the operating room. juncts are now used worldwide. collection at specific times during parathy-
Since its introduction more than a decade roidectomy. This intravenous access is kept
ago, IPM has transformed the surgical HOW IPM WORKS open with a slow infusion of saline, which
management of SPHPT from traditional must be discarded from the line before any
BNE to a more focused, less invasive para- IPM is used by surgeons to confirm the com- blood sample is measured to prevent dilu-
thyroidectomy requiring minimal neck plete excision of all hyperfunctioning para- tion. During the procedure, the anesthesiolo-
dissection. thyroid tissue. The surgical adjunct also gist collects 4 mL of whole blood in an EDTA
alerts the surgeon of an incomplete removal tube at specific times: (a) a “preincision” level
of abnormal parathyroid tissue, thereby in- before skin incision, (b) a “preexcision” level
CANDIDATES FOR IPM-GUIDED dicating the need for further exploration. collected after dissection and just before
PARATHYROIDECTOMY
Parathyroidectomy should be considered
in a patient with a secure diagnosis of Table 1 Definitions Used to Calculate the Accuracy of the “50% PTH Drop”
SPHPT shown by (a) persistent hypercalce- Criterion in Predicting Postoperative Calcium Levels for at Least
Endocrine Surgery

mia, (b) elevated PTH level, (c) normal re- 6 Months After Parathyroidectomy
nal function, (d) normal or elevated urinary
calcium, and (e) no history of multiple en- 50% PTH drop at 10 Operative success Operative failure
min after parathyroid (normal or low (high calcium  high
docrine neoplasia. Excellent operative suc- PTH 6 mo)
gland excision calcium for 6 mo)
cess can be achieved in most patients with
symptoms associated with hypercalcemia True positive Yes Yes No
or in those patients with no apparent symp- True negative No No Yes
toms and surgical indications as detailed False positive Yes No Yes
by the Summary Statement from the Third
International Workshop on the Manage- False negative No Yes No
ment of Asymptomatic Primary Hyperpara- PTH, parathyroid hormone.
thyroidism in 2008.

www.medicalebookpdf.com

LWBK892_c40_p496-500.indd 497 10/28/11 5:02:17 PM

 498 Part IV: Endocrine Surgery

190 rately calculate the PTH drop and avoid

% drop from the highest
100 unnecessary neck exploration (Fig. 3).
2. A PTH level that has already dropped
significantly from the preincision level
PTH level

79% usually signifies that the abnormal para-

50
95 thyroid gland’s main blood supply was
50 40 already disrupted at the beginning of the
dissection (Fig. 4).
0 3. In some patients, the surgeon may want
Preincision Preexcision 5 min 10 min to wait for a 20-minute level if the crite-
Timed operative blood samples rion was not met 10 minutes after gland
Fig. 1. Demonstration of intraoperative parathyroid hormone (PTH) dynamics after successful excision excision or if the decline dynamics are
of a single hyperfunctioning gland. With a drop at the 10-minute postexcision interval of 79% from the not as expected. In the majority of these
highest PTH level, this hormone dynamic predicts a postoperative return to eucalcemia and successful patients, the IPM criterion is met with
parathyroidectomy. Without further exploration of the remaining glands, the operation is completed. this additional 20-minute level and ac-
Dotted line shows time of gland excision. curately predicts postoperative success.
Ultimately, the surgeon should rely on
his/her best judgment to continue ex-
ploration.
clamping the abnormal gland’s blood supply, random time or in the operating room 4. The site of blood sampling can have po-
(c) a 5-minute level, and (d) 10-minute level when either preincision or preexcision tentially important implications. Jugu-
after excision of the suspected abnormal level is obtained. If only a preincision lar venous sampling during parathy-
gland. When peripheral PTH values drop baseline PTH sample is collected before roidectomy usually results in higher
more than 50% from the highest either prein- neck incision, the surgeon may miss the overall absolute PTH values when
cision or preexcision level 10 minutes after peak of the hormone elevation due to compared to peripheral samples and
the excision of all abnormal parathyroid parathyroid gland manipulation. A “pre- may take longer to fall into the normal
gland(s), this criterion predicts normal or excision” sample collected just before the range leading to potential unnecessary
low calcium levels postoperatively with an gland’s blood supply is ligated will avoid neck explorations for surgeons who
overall accuracy of 98%. After this sufficient missing this peak of PTH level. In other require normal range PTH levels at 10
decrease occurs, the observed hormone dy- words, the PTH level will appear not to minutes to meet curative criteria. Fur-
namic guides the surgeon to terminate the drop sufficiently at 10 minutes (50%) thermore, centrally obtained samples
procedure without further exploration or because it was in fact much higher after are more likely to be spuriously elevat-
identification of the remaining normally se- the preincision blood was drawn. Preinci- ed making interpretation of the results
creting parathyroid glands. An example of sion and preexcision samples should both occasionally difficult and prolonging
IPM used in a patient after excision of a single be obtained in every procedure to accu- the operation.
hypersecreting gland is shown in Figure 1.
With an adequate PTH drop at the 10-minute
postexcision interval from the highest prein- 180
100
cision or preexcision PTH level, this hormone
% drop from the highest PTH level

dynamic predicts a postoperative return to

eucalcemia without further exploration of
the remaining glands. IPM does not predict 77%
115
late recurrence of hyperparathyroidism ( fol- 98 96 99
102 110 100
lowing at least 6 months of eucalcemia), but
only that all currently hypersecreting glands 50
have been excised.
Conversely, if the hormone level fails to
drop at the 10-minute interval following ex- 40
cision of a suspected hyperfunctioning 22
parathyroid gland, the PTH assay signals
that more hypersecreting tissue is likely to 0
be present. Thus, the surgeon is directed to Pre- Pre- 5 min 10 min Pre- 5 min 10 min Pre- 5 min 10 min
incision excision excision excision
continue the exploration with the above de- 1 2 3
scribed protocol applied to each removed Timed operative blood samples
gland. Another example of IPM shows the
hormone dynamics in a patient with multi- Fig. 2. Intraoperative parathyroid hormone (PTH) dynamics during successful parathyroidectomy in a pa-
tient presenting with multiglandular disease (MGD). An intraoperative preincision level of 102 pg/mL, care-
ple gland disease (MGD) in Figure 2.
ful dissection of an abnormal right inferior parathyroid gland led to a rise of PTH level to 180 pg/mL.
After excision of this hypersecreting gland, the PTH assay showed no decrease at 5 minutes (110 pg/mL)
INTRAOPERATIVE PEARLS and 10 minutes (100 pg/mL). Reexploration of the neck revealed two additional abnormal hypersecreting
glands. The fourth gland appeared grossly normal. This graph shows that the expected hormone level did
1. The accuracy of the IPM criterion de- not decrease significantly until excision of the third hyperfunctioning parathyroid gland. With a 77% de-
creases when only one “baseline” sample, crease in the 10-minute sample (22 pg/mL) compared with the third preexcision plasma sample (99 pg/mL),
either outside the operating room at a no remaining hypersecreting parathyroid tissue was present.

www.medicalebookpdf.com

LWBK892_c40_p496-500.indd 498 10/28/11 5:02:17 PM

 Chapter 40: Intraoperative Parathyroid Hormone Assay–Guided Parathyroidectomy 499

300 RESULTS OF IPM-GUIDED

% drop from the highest PTH level
100
PARATHYROIDECTOMY
46% from preincision
Although surgeon judgment and experi-
ence is still essential in determining the
78% from preexcision excision of abnormal parathyroid glands
50 initially, IPM has nevertheless largely sup-
planted subjective evaluation of parathy-
120 140
roid hypersecretion based on observed
gland size and/or histopathology, and has
65
improved the operative success rate of
0 parathyroidectomy. Preoperative imaging
Preincision Preexcision 5 min 10 min
studies also play an important role in these
Timed operative blood samples focused operations by identifying the ana-
Fig. 3. This graph demonstrates the need for a preexcision measurement to achieve an adequate para- tomical location of a hypersecreting and/or
thyroid hormone (PTH) drop to correctly predict operative success. Lack of a preexcision sample in this enlarged gland. The most reliable and fre-
case would lead to unnecessary bilateral neck exploration. Insufficient PTH drop in 10 minutes from the quently used modalities are the sestamibi
preincision level (46%). Dotted line shows time of gland excision. (MIBI) scan and cervical ultrasonography.
When a suspected abnormal gland is local-
ized preoperatively, it allows the surgeon to
perform minimal dissection of the targeted
ADDITIONAL USES FOR IPM venous sampling has been successfully per- area for excision of an abnormal gland. IPM
formed in the office setting for preoperative is then used to determine whether all hy-
Differential Internal Jugular localization of parathyroid glands in pa- persecreting tissue has been removed and
Venous Sampling tients with equivocal localization studies. the need to continue exploration for more
abnormal tissue. When small incisions are
Many surgeons perform standard BNE for
patients with negative preoperative localiza-
Biochemical Fine Needle Aspiration used, and other parathyroid glands are not
routinely visualized, the operating surgeon
tion studies. Differential jugular venous Fine needle aspiration of tissue for PTH depends on IPM for the assurance of com-
sampling has been used in these patients to measurement differentiates parathyroid plete excision of all hypersecreting para-
lateralize the side of the neck harboring glands from other neck structures with thyroid tissue.
the hyperfunctioning parathyroid gland(s). 100% specificity. A 25-gauge needle at- When localization studies are incorrect
When performed intraoperatively, samples tached to a syringe is used to collect the tis- or do not recognize the presence of MGD
from the most inferior portion of each sue sample. The content aspirated in the that can occur in up to 20% of patients, IPM
internal jugular vein, preferably guided by needle is diluted with 1 cc of saline solu- is essential for operative success. If the sur-
ultrasound, are taken before skin incision tion, centrifuged, and the supernatant is geon concentrates on excising only the
for rapid PTH measurement. This technique, used for PTH measurement with the rapid identified abnormality on a nuclear scan or
which can be positive in 70% to 80% of cases, PTH assay. This technique provides quick ultrasound, failure is unavoidable. MIBI
guides the surgeon to the side of the neck tissue identification without frozen section, scans can be completely negative, have a
containing the highest PTH level (10% higher and it can be helpful when gland localiza- single wrong focus, show multiple foci both
than the opposite side), leading to successful tion is challenging, especially when an in- correct and incorrect, and miss multiple
unilateral neck exploration in most patients trathyroidal parathyroid, indeterminate gland involvement. IPM used as an adjunct
when used in conjunction with IPM. Re- exophytic thyroid nodule or enlarged lymph to parathyroidectomy can prevent failure
cently, ultrasound guided differential jugular nodes are also present. when localization studies are incorrect,
which is not always evident until in the op-
erating room or at completion of the proce-
% drop from the highest PTH level

100 dure. Combined MIBI and ultrasound (US)

110 rarely miss MGD leading to operative suc-
cess in nearly 99% of cases, obviating the
7% from preexcision need for IPM. While excellent outcomes in
74% from preincision this subgroup of highly selected patients
Endocrine Surgery

50 with concordant localizing studies can be

30
achieved, this selective approach signifi-
cantly limits the number of eligible patients
for focused parathyroidectomy. Preopera-
25 28
tive MIBI and US have been shown to be
0 concordant only 50% to 60% of the time,
Preincision Preexcision 5 min 10 min thereby leaving a great number of patients
Timed operative blood samples with no definitive or discordant localiza-
Fig. 4. This graph demonstrates the importance of collecting both preincision and preexcision samples tion. Discordance between MIBI and US has
to correctly predict operative success. Lack of a preincision sample would lead to false negative results been reported to be as high as 38% in con-
leading to unnecessary bilateral neck exploration. PTH, parathyroid hormone. Insufficient PTH drop in secutive patients treated by parathyroidec-
10 minutes from preexcision level (7%). Dotted line shows time of gland excision. tomy with an 11% rate of MGD. In such

www.medicalebookpdf.com

LWBK892_c40_p496-500.indd 499 10/28/11 5:02:17 PM

 500 Part IV: Endocrine Surgery

instances where there are discordant stud- leading to unnecessary further neck explo- MGD, and thus operative failure, may actu-
ies, IPM has been shown to minimize missed rations and lowering its overall accuracy. ally be removing various sized, but normally
abnormal parathyroid glands. Complicating the interpretation of IPM functioning, parathyroid glands not con-
Excellent outcomes for focused parathy- results reported in the literature is the ever- tributing to SPHPT.
roidectomy with IPM have been confirmed changing definition of MGD. Surgeons us-
by several studies showing operative suc- ing the least strict intraoperative criterion SUGGESTED READINGS
cess and complication rates comparable to report MGD rates as low as 3% to 5%, which
traditional BNE. In one study of 656 consec- are much lower than the rates reported Berger AC, Libutti SK, Bartlett DL, et al. Het-
erogeneous gland size in sporadic multiple
utive patients over 11 years where 255 un- when surgeons use stricter criteria or bilat- gland parathyroid hyperplasia. J Am Coll Surg
derwent focused parathyroidectomy and eral neck exploration (14% to 30%). This has 1999;188:382.
401 conventional BNE, the cure rates were led to the belief that the “50% PTH drop” Beyer TD, Chen E, Ata A, et al. A prospective evalu-
99% and 97% with complication rates of criterion misses MGD leading to unaccept- ation of the effect of sample collection site on in-
1.2% and 3% respectively. Focused parathy- able operative failure rates as high as 16%. traoperative parathormone monitoring during
roidectomy also had a reduced operating Multiple series of parathyroidectomy guided parathyroidectomy. Surgery 2008;144(4):504.
time (1.3 hours vs. 2.4 hours), and a reduc- by this “50% PTH drop” criterion report Bilezikian JP, Khan AA, Potts JT, et al. Guidelines
for the management of asymptomatic primary
tion in length of hospitalization (0.24 days operative success rates of 97% to 99%, and hyperparathyroidism: summary statement
vs. 1.64 days) when compared to BNE. In an- fail to show these hypothetical high failure from the third international workshop. J Clin
other subsequent study of 718 patients over rates. At the authors’ institution, operative Endocrinol Metab 2009;94:335.
34 years, the cure rates for focused parathy- success was 98% in treated patients with a Carneiro DM, Solorzano CC, Nader MC, et al. Com-
roidectomy and BNE were 97% and 94% re- 2% failure and 3% recurrence rate 10 years parison of intraoperative iPTH assay (QPTH) cri-
spectively. Finally, in a 5-year follow-up of a after undergoing focused parathyroidec- teria in guiding parathyroidectomy: which crite-
rion is the most accurate? Surgery 2003;134:973.
randomized controlled trial, focused para- tomy guided by IPM. This long-term study Carneiro-Pla D. Effectiveness of “office”-based, ultra-
thyroidectomy provided the same long-term indicates that there may be an overestima- sound-guided differential jugular venous sampling
results as traditional BNE in patients with tion of the predicted incidence for MGD; if (DJVS) of parathormone in patients with primary
primary hyperparathyroidism. The afore- such higher rates of missed MGD were cor- hyperparathyroidism. Surgery 2009;146(6):1014.
mentioned studies all concluded that focused rect, a 16% or greater operative failure rate Carneiro-Pla DM, Solorzano CC, Lew JI, et al.
parathyroidectomy was an attractive alter- would have been appreciated. Long-term outcome of patients with intraop-
erative parathyroid level remaining above the
native to BNE for most patients with pri- When stricter criteria are used or bilat- normal range during parathyroidectomy. Sur-
mary hyperparathyroidism. eral neck exploration is performed after the gery 2008;144(6):989.
Parathyroidectomy guided by IPM com- “50% PTH drop” has occurred, additional Fahy BN, Bold RJ, Beckett L, et al. Modern para-
pared to traditional BNE results in less neck enlarged glands may be found as previously thyroid surgery: a cost-benefit analysis of local-
dissection, shorter operative times, smaller described. Proponents of BNE continue to izing strategies. Arch Surg 2002;137:917.
incisions, use of local anesthesia, and out- base the success of their operations on the Irvin GL, Carneiro DM. Management changes in pri-
patient procedures. IPM has been shown to ability to differentiate between normal and mary hyperparathyroidism. JAMA 2000;284:934.
Irvin GL, Carneiro DM, Solorzano CC. Progress in
be cost effective in the United States mainly abnormal glands based on size alone and/ the operative management of sporadic primary
because it allows for ambulatory or outpa- or histopathology. Nevertheless, since op- hyperparathyroidism over 34 years. Ann Surg
tient parathyroidectomy. IPM allows for ap- erative success without the excision of these 2004;239:704.
proximately a 50% decrease in hospital additionally found “enlarged” glands is the Irvin GL, Dembrow VD, Prudhomme DL. Opera-
costs and patient charges when compared same, the answer to this dilemma may rest tive monitoring of parathyroid gland hyper-
to BNE. Other investigators, however, sug- in that grossly enlarged glands may not al- function. Am J Surg 1991;162:299.
Lew JI, Irvin GL. Focused parathyroidectomy guid-
gest that focused parathyroidectomy guided ways be hyperfunctioning. Prior reports ed by intraoperative parathormone monitoring
by IPM is not cost-effective because of the have indicated that parathyroid gland size does not miss multiglandular disease in patients
cost associated with the need of additional and histology does not always correlate with sporadic primary hyperparathyroidism: a
laboratory personnel and expensive local- with parathyroid function. ten year outcome. Surgery 2009;146:1021.
ization studies. In a prospective randomized study of pa- Lew JI, Solorzano CC, Montano RE, et al. Role of
tients that underwent parathyroidectomy intraoperative parathormone monitoring dur-
ing parathyroidectomy in patients with discor-
CURRENT ISSUES WITH IPM determined by gland size during BNE, there dant localization studies. Surgery 2008;144:299.
was a higher 10% incidence of MGD com- Malmeus J, Granberg PG, Halvorsen J, et al. Para-
Over the last few years, surgeons have mod- pared to patients who underwent parathy- thyroid surgery in Scandinavia. Acta Chir Scand
ified the “50% PTH drop” criterion with roidectomy determined by gland function 1988:154:405.
the ultimate goal of minimizing operative with IPM (0%). Despite fewer glands excised Nussbaum SR, Zahradnik RJ, Lavigne JR, et al.
failure and improve its cost-effectiveness. in the IPM group, the operative success for Highly sensitive two-site immunoradiometric
Stricter criteria that have been proposed both groups was similar. The same findings assay of parathyrin, and its clinical utility in
evaluating patients with hypercalcemia. Clin
include a larger PTH level percent drop were reported in another study where there Chem 1987;33:1364.
(65% to 70%) and/or return of the final was a higher incidence of MGD in patients Perrier ND, Ituarte P, Kikuchi S, et al. Intraoperative
PTH to within normal range, or a PTH de- who underwent BNE (16.5%) compared to parathyroid aspiration and parathyroid hormone
crease at 5 minutes after gland excision. those patients who underwent parathyroi- assay as an alternative to frozen section for tis-
There is evidence to suggest that modifica- dectomy guided by IPM (11.1%) despite sue identification. World J Surg 2000;24:1319.
tion of the original and least strict “50% similar surgical success rates. These find- Reiss E, Canterbury JM. A radioimmunoassay for
parathyroid hormone in man. Proc Soc Exp Biol
PTH drop” criterion to stricter require- ings and other mounting evidence suggest Med 1968;128:501.
ments may slightly decrease the number of that surgeons who routinely excise parathy- Udelsman R. 656 consecutive explorations for
operative failures, but will significantly in- roid glands based on size and/or histopa- primary hyperparathyroidism. Ann Surg 2002;
crease the incidence of false negative results thology in an effort to minimize missed 235:665.

www.medicalebookpdf.com

LWBK892_c40_p496-500.indd 500 10/28/11 5:02:17 PM

 Chapter 41: Minimally Invasive Parathyroidectomy 501

EDITOR’S COMMENT follow-up on 383 consecutive patients whose that they, and other authors as well (McHenry
parathyroidectomy was guided by parathyroid CR, et al. Surgery 1990;108:801–7; Kao PC, et al.
hormone assay. Of the patients, 302 had PTH lev- Ann Clin Lab Sci 2002;92:244–51), support 70% as
Dr. Solorzano has written a carefully reasoned els decreased to the normal range (Group I) while a decrease is safer and will result in fewer recur-
and nonmilitant chapter concerning a technique 81 patients had a 50% decrease in PTH levels but rences. This, they suggest, will raise the success
developed by Dr. Bucky Irvin. The use of intra- it did not return to the normal range (Group II). rate to 90% to identify the 10% of patients that
operative parathyroid hormone measurements Recurrent hyperparathyroidism was found in 2% are multiglandular. I suppose this is, as one of my
has swept the world of endocrine surgery. In this (8 of 383 patients) and eucalcemia with elevated mentors told me, a manifestation of the senti-
chapter, a number of questions are asked, and in PTH levels was found in 19% (52/302) of Group ment: “in a biological system, anything that can
the literature that accompanies this commentary, I whereas, in Group II, 27% (22/81) had elevated go wrong will.”
more questions are asked. PTH with normal serum calcium. However, only Kandil E, et al. (Arch Otolaryngol Head Neck
First, a number of endocrine surgeons have 2% (6/302) in Group I and only 2.5% (2/81) in Surg 2009;135:1206–8) review a total of 47/552
questioned whether intraoperative measure- Group II developed hyperparathyroidism. More consecutive patients who were found to have
ments of parathyroid hormone are necessary in importantly, 70.5% (57/81) in Group II were eu- double adenomas and 48 additional patients
first time parathyroidectomy patients (Sebag F, calcemic with normal PTH. Thus, although there who had more than two glands diseased. In all
et al. Surgery 2001;134:1049–55). Second, others is concern about the long-term outlook of Group patients, the intraoperative PTH decreased by
(Agarwal G, et al. Surgery 2001;130:963–70) have II, the initial follow-up after 50 months is reassur- 80% with the removal of both abnormal para-
questioned its cost-effectiveness. Third, still oth- ing. thyroid glands. The cure rate was 98%. The au-
ers have asked whether the technique is also suit- Writing from the Italian experience, Lupoli thors’ conclusion was that double adenomas
able for double adenomas. Fourth, the originators GA, et al. (Med Sci Monit 2009;15:CR111–16) do exist and are not merely a manifestation of
themselves have asked, in an attempt at long- studied 101 patients with sporadic primary hy- hyperplasia.
term follow-up, what happens to the patients per parathyroidism. Samples were obtained Moalem J, et al. (Am J Surg 2009;197:222–6),
while PTH drops more than 50% intraoperatively before manipulation of the parathyroids and 10 writing from Orlo Clark’s unit, bring attention to
and elevated parathyroid hormone remains after minutes after excision. At 3 minutes following a very important issue which may result in either
the operative procedure although the patients excision, the median percentage decrease in PTH false negatives or false positives in the intraop-
are eucalcemic. This, of course, assumes that the was 56.1% and, after 10 minutes, 77.3% respec- erative assay and that is hemolysis, which may
disease of hyperparathyroidism is only a disease tively. In seven patients, the PTH level decreased decrease the level of PTH from 24.5% to 53.8%
of serum calcium, which it may not be. Fifth and very slowly and in patients with double adenoma as compared with nonhemolyzed controls. They
finally, are the results better if the criteria on drop an increase in PTH level occurred, which the au- also provoked hemolysis by the freeze–thaw
of intraoperative PTH are not 50% but a 70% or thors hypothesized occurred because of manipu- method confirming the findings. This should be
80% drop intraoperatively? lation of the second adenoma. Despite a decrease taken into account in all measurements and the
I have always had a problem with the lack of of greater than 50%, multiglandular pathology sample discarded if it is hemolyzed. The overall
precision in the first data point on the intraopera- was identified because a relatively large parathy- impression one gets is that less than a decade
tive PTH measurement. Is it preincision or preex- roid adenoma “masked” the hyperactivity of the after the description of intraoperative measure-
cision, which I have always taken as an attempt other parathyroid glands. The authors conclude ment of parathyroid hormones, the criteria for
to elevate the initial level of the hormone by ma- the evaluation of more than one postexcision successful operation are very much in flux, and
nipulation, making it easier to get a 50% drop in level is necessary if multiglandular disease is that the disease may be much more complicated
the hormone levels postexcision. Carneiro-Pla suspected or there has been “excessive manipu- than we initially imagined.
et al. (Surgery 2008;144:989–94) did a long-term lation,” whatever that means. They also suggest J.E.F.

41 Minimally Invasive Parathyroidectomy

Robert Udelsman and Tobias Carling

BACKGROUND an enlarged and normal gland were found which side to explore was incorrect. Today,
on the initial side, then contralateral cervi- minimally invasive parathyroidectomy (MIP)
Approximately 85% of patients with pri- cal exploration was obviated. Other authors is performed after preoperative parathyroid
mary hyperparathyroidism (pHPT) harbor advocated a similar approach, arguing that localization usually with high-quality ses-
a single adenoma and are cured by excision bilateral exploration increased the risk, tamibi scans, ultrasonography, or four-
of the incident gland. The remaining pa- cost, and morbidity of surgery for pHPT. dimensional parathyroid computed tomog-
tients display double adenomas (3% to 5%) The Lund University surgeons advocated raphy (CT) scans, often under cervical block
Endocrine Surgery

or four-gland hyperplasia (10% to 15%). unilateral parathyroidectomy, which they anesthesia during which a focused explora-
Thus, with accurate preoperative localiza- defined as removal of both an adenoma and tion is performed, and the rapid intraopera-
tion, targeted surgery using unilateral neck ipsilateral normal parathyroid gland. The tive parathyroid hormone assay is employed
exploration under regional or local anes- excised tissue was studied microscopically to confirm an adequate resection.
thesia has been developed; moreover, it has during surgery with oil-red-O, and the deci-
been evaluated over the past decade and sion to stop the operation at this stage was
has become the standard of care in an ever- based on demonstration of a reduction in
INDICATIONS
increasing number of specialized centers. intracytoplasmic fat droplets in the excised The indications for MIP are the same as
Unilateral surgery for pHPT was advocated adenomatous parathyroid tissue. Both tech- those for traditional cervical exploration,
in 1975, and the side to be explored was niques would fail, however, in the setting of a that is, symptomatic patients or those with
chosen based on palpation, esophageal im- double adenoma on the contralateral side asymptomatic pHPT fulfilling the criteria
aging, venography, or arteriography. If both and if the essentially “random” choice of established by the most recent National

www.medicalebookpdf.com

LWBK892_c41_p501-508.indd 501 10/28/11 5:34:18 PM

 502 Part IV: Endocrine Surgery

Institutes of Health (NIH) consensus meet- posterior to the thyroid gland. The overall
ing. In addition, there are now significant sensitivity for localizing adenomas smaller
data to support more liberal use of parathy- than 500 mg varies, from 53% to 92%. A ma-
roidectomy for pHPT, since the disease has jor limitation of sestamibi scans is related to
been associated with a number of “nonclas- the coexistence of thyroid nodules or other
sical” morbidities, some of which seem to metabolically active tissues (e.g., lymph
improve postoperatively. These include neu- nodes, thyroid nodules, and metastatic thy-
rocognitive impairments and cardiovascu- roid cancer) that can mimic parathyroid ad-
lar abnormalities. Patients with persistent enomas, thereby causing false-positive re-
disease (previously failed parathyroidec- sults on sestamibi scans. This limitation can
tomy) as well as other reoperative cases can be overcome in part by using the double-
also be successfully operated on using MIP tracer subtraction technique of sestamibi, in
techniques. Minimally invasive techniques which both thyroid and parathyroid nodular
are rarely employed when preoperative lo- abnormalities can be diagnosed simultane-
calization of the parathyroid tumor was not ously, or in combination with a neck ultra-
performed, is negative, or is consistent with sound to preoperatively distinguish between
multiglandular enlargement. The role of thyroid lesions and parathyroid enlarge-
MIP in the setting of familial hyperparathy- Fig. 1. Sestamibi SPECT imaging in a female with ment. Sestamibi with SPECT does not pro-
roidism (HPT), that is, multiple endocrine pHPT displaying uptake in the left lower position vide detailed anatomical depiction, and can
neoplasia type 1 (MEN1), MEN2A, the after 75 minutes of washout. only detect double adenomas and multig-
hyperparathyroidism–jaw tumor syndrome landular hyperplasia in 25% to 45% of cases.
(HPT-JT), familial isolated hyperparathy- Ultrasound is effective, noninvasive, and
roidism (FIHPT), and HPT occurring in pa- inexpensive, but its limitations include both
tients with an underlying mutation in the tivity, and an absence of p-glycoprotein on operator dependency and its application
calcium sensing receptor (CASR) gene, is the cell membrane. Sestamibi imaging can being limited to the neck because it cannot
evolving. A conventional cervical explora- be performed preoperatively to plan a MIP image mediastinal adenomas. The normal
tion should be performed in the vast major- or on the morning of operation in combina- parathyroid gland is generally too small to
ity of these cases, although MIP may prove tion with the use of a gamma probe in the be visualized sonographically, whereas the
to have a limited role in specific instances operating room to guide the surgeon during parathyroid enlargement seen in pHPT is
of familial HPT. For instance, in HPT associ- the operation. A meta-analysis of the sensi- often identified as a homogeneously hy-
ated with MEN2A, HPT-JT, and FIHPT tivity and specificity of sestamibi scanning in poechoic extrathyroidal ovoid mass (Fig. 2).
where uniglandular uptake is noted on pre- 6,331 cases demonstrated values of 90.7% Parathyroid adenomas are typically vascu-
operative imaging, MIP may be considered. and 98.8%, respectively, and suggested that lar and an arterial branch can often be fol-
Rare cases when parathyroid carcinoma is 87% of the patients with sporadic pHPT lowed to the superior or inferior pole of the
diagnosed or suspected, a radical resection would be candidates for a unilateral explora- lesion. An additional advantage of ultra-
at the initial operation is required for opti- tion. The sensitivity of sestamibi is limited in sound is the ability to perform fine needle
mal results. multiglandular disease. In a large study, scin- aspirates with rapid parathormone (PTH)
tigraphy localized at least one gland in all measurements of the aspirates, especially
PREOPERATIVE IMAGING patients, but only 62% of the total number of in patients undergoing reexploration. By it-
hyperplastic glands. SPECT, which allows lo- self, ultrasound has approximately a 50% to
The development and refinement of parathy- calization of structures in the anterior/pos- 75% true-positive rate, with generally better
roid imaging has been essential for the devel- terior plane, is particularly helpful in detect- rates for larger glands. However, when com-
opment of MIP techniques. Several noninva- ing smaller lesions and adenomas located bined with sestamibi, the true-positive rate
sive preoperative localization methods are
available, including sestamibi–technetium-
99m scintigraphy, ultrasonography, CT,
magnetic resonance imaging (MRI), and
thallium-201–technetium-99m pertechne-
tate scanning. The most commonly used mo-
dality remains sestamibi with single-photon
emission computed tomography (SPECT),
which generates three-dimensional localiza-
tion (Fig. 1). In 1989, it was first reported that
the new agent technetium-99m used for car-
diac imaging was also avidly taken up by
parathyroid tissue. Parathyroid cells have a
large number of mitochondria, which take
up sestamibi/technetium-99m. Sestamibi, a
monovalent lipophilic cation, diffuses pas-
sively across cell membranes, concentrates
in mitochondria, and accumulates in ade- Fig. 2. Corresponding cervical ultrasound from the same patient as in Figure 1, showing a large hy-
nomatous parathyroid tissue because of in- poechoic cystic parathyroid adenoma (PAd). The left thyroid (T), trachea (Tr), and left internal jugular
creased blood supply, higher metabolic ac- vein (IJ) are indicated.

www.medicalebookpdf.com

LWBK892_c41_p501-508.indd 502 10/28/11 5:34:18 PM

 Chapter 41: Minimally Invasive Parathyroidectomy 503

single study that the operating surgeon can

easily interpret. In a recent series, 4DCT dis-
played improved sensitivity (88%) over ses-
tamibi imaging (65%) and ultrasonography
(57%), when the imaging studies were used
to localize (lateralize) hyperfunctioning
parathyroid glands to one side of the neck.
Moreover, when used to localize parathy-
roid tumors to the correct quadrant of the
neck (i.e., right inferior, right superior, left
inferior, or left superior), the sensitivity of
4DCT (70%) was significantly higher than
sestamibi imaging (33%) and ultrasonogra-
phy (29%). In a prospective consecutive
cohort, the results at Yale University are sim-
ilar. Moreover, 4DCT predicted multiglan-
dular disease (Fig. 4) in 85.7% (6/7) patients.
Compared with sestamibi with SPECT, 4DCT
is significantly less expensive but associated
Fig. 3. Four-dimensional parathyroid CT scan displaying a left upper ectopic paraesophageal parathy- with higher exposure to ionizing radiation
roid adenoma (arrow) in a patient with pHPT. The left thyroid (T), trachea (Tr), esophagus (Eso), internal and thus should be used cautiously in chil-
jugular veins (IJ), and common carotid arteries (CCA) are indicated. dren and young adults. Moreover, due to the
use of intravenous contrast it should be
avoided in patients with renal insufficiency
approaches 90%, with few false-positives. mension referring to the changes in perfu- as well as in patients with concomitant well-
The ability of both ultrasound and sesta- sion of contrast over time. Exquisitely differentiated thyroid carcinoma. With the
mibi with SPECT to detect parathyroid ab- detailed, multiplanar images are obtained development of improved CT scanning, MRI
normality is reduced in milder forms of that accentuate the differences in the perfu- is rarely used. However, since it does not in-
pHPT (i.e., only mildly elevated PTH and sion characteristics of hyperfunctioning volve the use of radiation it may be em-
calcium levels) and in obese patients. parathyroid glands (i.e., rapid uptake and ployed in select cases. Parathyroid adenomas
Four-dimensional parathyroid CT scan washout), compared with normal parathy- may appear very intense on T2-weighted
(4DCT) is a promising new parathyroid im- roid glands and other structures in the neck images.
aging technique. Also, 4DCT is similar to CT (Figs. 3 and 4). The images provide both A subset of patients who require reex-
angiography. The term is derived from three- anatomic information and functional infor- ploration will have negative, discordant,
dimensional CT scanning with an added di- mation (based on changes in perfusion) in a or nonconvincing, noninvasive localization
studies. Current guidelines recommend
that these patients undergo invasive local-
ization procedures in the form of selective
venous sampling (SVS) with measurements
of PTH. Rapid PTH measurement is now be-
ing used in the angiography suite, because
results are rapidly available on site, and in-
terventional radiologists can obtain addi-
tional samples from a region in which a
subtle but potentially significant PTH gra-
dient is detected. In a recent study, SVS had
a sensitivity of 83.3% for the correct local-
ization of a parathyroid adenoma or hyper-
plastic parathyroid glands, whereas false-
positive or indeterminate results of SVS
were found in 6% and 2% of cases, respec-
Endocrine Surgery

tively.

REGIONAL BLOCK ANESTHESIA

TECHNIQUE
The majority of parathyroidectomies are
performed under general anesthesia using
either an endotracheal tube (ETT) or laryn-
geal mask airway (LMA). We prefer local
Fig. 4. Four-dimensional parathyroid CT scan displaying bilateral enlarged superior parathyroid glands and regional block anesthesia with moni-
(arrows) in a eutopic position in a patient with familial pHPT. The thyroid (T), trachea (Tr), internal tored anesthesia care (MAC). The regional
jugular veins (IJ), and common carotid arteries (CCA) are indicated. block is performed by the surgeon in the

www.medicalebookpdf.com

LWBK892_c41_p501-508.indd 503 10/28/11 5:34:18 PM

 504 Part IV: Endocrine Surgery

Intravenous sedation is used to minimize

patient anxiety while maintaining an awake,
conscious patient who can phonate. Propo-
fol was thought to possibly interfere with
the PTH assay, but a recent randomized
trial has shown that the PTH assay can be
employed during propofol sedation.
Regional anesthesia avoids complica-
tions associated with general anesthesia, in-
cluding endotracheal intubation, which has
been reported to cause vocal cord changes in
up to 5% of patients. Furthermore, exploring
a conscious patient permits intraoperative
assessment of the superior and recurrent la-
ryngeal nerve functions because the patient
can vocalize during the procedure.
LoGerfo and colleagues have shown that
bilateral neck exploration under regional an-
esthesia can be performed safely and effec-
tively in patients with coexisting thyroid dis-
ease and a nonlocalized adenoma. In a series
of 236 patients undergoing MIP, 62% had a
nonlocalizing sestamibi scan preoperatively
or no scan at all, but only four required con-
Fig. 5. The patient has a large-bore peripheral intravenous line inserted, which is used for medication version to general anesthesia. Twenty-three
and fluid administration as well as sampling for parathormone (PTH) levels. The patient is awake, wear- percent had a simultaneous procedure per-
ing protective eye glasses, and a fan is used to circulate room air gently toward his or her face to mini- formed for thyroid disease, and 85% under-
mize the sensation of claustrophobia. went a bilateral neck exploration. We re-
cently reported in 441 consecutive patients
that 47 (10.6%) required conversion to gen-
operating room, and intravenous supple- travascular administration. We have found eral anesthesia. In all instances, conversion
mentation is administered by the anesthe- that by also infiltrating along the anterior was performed in a controlled fashion using
sia staff (Fig. 5). In most patients, 1% lido- border of the sternocleidomastoid muscle, neuromuscular blockade, endotracheal intu-
caine containing 1:100,000 epinephrine is as well as a local field block, excellent anal- bation, and maintenance of the original sur-
used and supplemented during the opera- gesia is obtained in virtually every case gical field preparation. Table 1 summarized
tion as required. Care is taken to aspirate (Fig. 6). The total cumulative volume of lido- the reasons for conversion from regional
before delivering the anesthetic to avoid in- caine administered is typically 18 to 25 mL. block to general endotracheal anesthesia.

Table 1 Reasons for Conversion to

General Anesthesia from
Cervical Block During
Minimally Invasive
Parathyroid Surgery in 47
(10.6%) of 441 Consecutive
Patients
Indication Number (%)
Concomitant thyroid 16 (34)
pathology
Multiglandular parathyroid 15 (32)
disease
Technical considerations 8 (17)
Patient discomfort 5 (11)
Intraoperative diagnosis of 2 (4)
parathyroid carcinoma
Toxic reaction to lidocaine 1 (2)

A B Data from Carling T, Donovan P, Rinder C, et al.

Minimally invasive parathyroidectomy using cervical
Fig. 6. Cervical block anesthesia. A: A superficial cervical block is administered posterior and deep to
block: reasons for conversion to general anesthesia.
the sternocleidomastoid muscle (SCM) (1). B: Local infiltration is also performed along the anterior Arch Surg 2006;141:401–4.
border of the SCM (2), and a local field block (3) is performed.

www.medicalebookpdf.com

LWBK892_c41_p501-508.indd 504 10/28/11 5:34:18 PM

 Chapter 41: Minimally Invasive Parathyroidectomy 505

SURGICAL TECHNIQUE
AND RESULTS
No preoperative imaging modality will re-
place the need for a well-trained, thoughtful
parathyroid surgeon. Surgeons performing
MIP must understand the embryology and
anatomy of the parathyroid glands. The em-
bryonic development and descent into the Anterior
cervical neck of the parathyroids lead to a jugular vein
highly variable anatomy. Ectopic parathy-
roid tissue is commonly encountered within
the thyroid, thymus, mediastinum, carotid Sternothyoid
sheath and in the tracheoesophageal groove. muscle
Sternothyroid muscle
Nondescended glands can be located along
the carotid bifurcation or along the larynx.
The MIP technique used at our institu- A B
tion is individualized after the parathyroid Fig. 7. (A) An abbreviated Kocher incision is made, the platysma is divided, and (B) the strap muscles
adenoma has been localized. Typically, a are separated.
2.5–3.5 cm abbreviated Kocher incision is
made and limited subplatysmal flaps fol-
lowed by opening of the median raphe. The
thyroid gland is then mobilized antero- Parathyroid surgery is a meticulous pro- tumor extraction. Since the remaining
medially (Figures 7 and 8). Occasionally, the cedure and operative experience correlates normal parathyroid glands are suppressed
middle thyroid vein is ligated to achieve with rates of recurrence and persistence as by the hyperfunctioning parathyroid ade-
this. The parathyroid adenoma is then iden- well as complications. The procedure is noma, a decline (⬎50%) in PTH is usually
tified aided by the preoperative imaging. It guided by intraoperative PTH measure- seen by 5 or 10 minutes, and the patient
is important to handle the parathyroid ade- ments, which is used routinely. requires no additional exploration. Failure
noma gently to avoid rupture of its capsule of the peripheral venous PTH level to ade-
with may spill parathyroid tumor cells. If INTRAOPERATIVE PTH quately decline suggests remaining hyper-
the parathyroid gland has to be grasped, it functioning parathyroid tissue and addi-
is preferable to handle the parathyroid by Intraoperative PTH measurement is em- tional surgery is indicated under either
the fat pad often extending around the ployed since although sestamibi scans are regional or general anesthesia.
gland or its end-arterial blood supply. In ad- very sensitive for single adenomas, they Chapuis in France (1990) and Irvin in Mi-
dition, unnecessary mobilization of the fail to identify 17% of a second (double) ami (1991) independently described the use
parathyroid adenoma may cause an over- adenoma and 55% of hyperplastic glands. of intraoperative PTH monitoring to guide
stimulation in PTH secretion (Figure 9). The The circulating half-life of PTH is 3.5 to the surgeon during parathyroid surgery in
end-arterial blood supply is ligated using 4 minutes and thus PTH levels are ob- patients with successful preoperative imag-
clips or silk ties. The distal ligasure can func- tained prior to and 5 and 10 minutes after ing. These pioneers both concluded that
tion as a handle to elevate the parathyroid
gland from the tracheo-esophageal groove.
Prior to excision of the parathyroid ade-
noma, the recurrent laryngeal nerve is pro-
tected. It is not necessary to dissect the re- Recurrent
current laryngeal nerve in all cases as the laryngeal nerve
dissection by itself may increase the risk of
injury. Rather the surgeon has to be very fa-
miliar with its normal anatomy and ana-
tomical variations. For instance, when re-
moving an anteriorly located inferior Inferior thyroid Common
parathyroid adenoma, a preferable ap- artery branch to carotid artery
Endocrine Surgery

proach is to minimize the dissection of the parathyroid

tracheo-esophageal groove. On the other adenome
Artery clipped
hand, careful dissection of the recurrent la- and divided
ryngeal nerve avoiding the use of electro-
cautery may be required for inferior and su-
perior parathyroid adenomas located in the
Parathyroid
vicinity of the nerve. Thus, details of each adenoma removed
operation should be individualized based
on the location of the parathyroid adenoma
as well as the patient’s anatomy. For the sur-
gical technique in less straight-forward Fig. 8. The parathyroid adenoma is identified, its end-arterial blood supply is ligated, the recurrent
cases, see section “Challenging Patients”. laryngeal nerve is protected, and the adenoma is removed.

www.medicalebookpdf.com

LWBK892_c41_p501-508.indd 505 10/28/11 5:34:19 PM

 506 Part IV: Endocrine Surgery

Although we rely heavily on the intraop-

erative PTH assay, it does not replace clini-
cal judgment and the assay should be inter-
preted in this context.

CHALLENGING PATIENTS
Equivocal Imaging
Although the preoperative imaging of pa-
tients with pHPT has improved, approxi-
mately 10% to 15% of patients still present
with equivocal or negative imaging results.
We do not routinely perform additional im-
aging in the previously unexplored patients;
rather, these patients are explored under
cervical block anesthesia, or if the patients
prefers, general anesthesia. Additional im-
aging techniques using ultrasound guided
Fig. 9. Interpretation of intraoperative PTH measurements. The graph illustrates typical findings in intra- FNA or SVS are reserved for patients under-
operative PTH levels in four different scenarios. Case A shows the typical fall in PTH levels to below 50% of going remedial cervical exploration. Mul-
the preoperative baseline after excision of a single parathyroid adenoma, whereas case B illustrates an ini- tiglandular parathyroid enlargement ap-
tial rise in PTH levels at time 0 minutes after resection, which is due to surgical manipulation. The patient pears to be more common in patients with
in case C has pHPT due to double adenomas. Thus, although there is a slight reduction in PTH levels after negative imaging studies. The intraopera-
removal of the initial parathyroid gland at time 0 minutes, the PTH levels normalize only after excision of
the second adenoma 10 minutes later. Case D shows typical findings of patients with pHPT due to hyper-
tive rapid PTH assay has been validated in
plasia of all four glands, and biochemical cure is not achieved until after subtotal parathyroidectomy. the setting of multiglandular parathyroid
disease in patients with either primary or
secondary HPT.

intraoperative PTH monitoring could be re- more stringent criteria than most, with a
liably used during surgery to influence the greater than 50% reduction from the base-
Static PTH Postexcision
extent of surgery and to determine the need line with an absolute normalization of the In about 85% of the cases the rapid PTH as-
for exploration of the contralateral side of PTH levels (Fig. 9). However, some surgeons say demonstrates a ⬎50% drop in the intact
the neck. At our institution, we have labora- advocate using a greater than 50% reduc- PTH level after excision of a single enlarged
tory personnel and the analytical machine tion after parathyroidectomy, using the parathyroid gland, which is consistent with
in the operating room, providing almost in- higher of either the preincision or the ma- a diagnosis of a single parathyroid ade-
stant feedback to the surgeon. nipulation value. The rationality to use noma. In the remaining patients, failure of
Blood is collected from a peripheral vein, more stringent criteria relates to the fact the PTH to drop suggests additional disease
such as the antecubital vein, as blood sam- that patients may have multiglandular dis- and further exploration is mandatory. Con-
pled from the anterior or inferior jugular ease. We and others have advocated obtain- tinued exploration unilaterally as well as
veins may not yield accurate results, be- ing delayed measurements selectively (20 bilaterally can be done under regional block
cause of their proximity to the parathyroid minutes or more after excision), especially in the vast majority of cases, but conversion
glands. To date, no standardized guidelines in the setting of renal insufficiency, cystic to general anesthesia is sometimes needed.
have been formulated regarding the timing parathyroid tumors, a significant manipu- Since the most advantageous time to cure
and number of PTH levels to measure dur- latory rise in the intact PTH, and multiglan- pHPT is during the first surgical explora-
ing parathyroidectomy. It is important to dular hyperplasia. In the setting of familial tion, it is the obligation of the initial sur-
measure a preincision baseline level as well HPT (especially MEN1), a reduction in PTH geon to perform a meticulous exploration
as an immediate postexcision level, because levels greater than 80% may be advocated evaluating both eutopic and ectopic sites.
frequently there will be a significant in- prior to accepting adequate excision of This exploration includes the retroesopha-
crease in PTH levels during surgical manip- parathyroid tissue. geal space, thymus gland, carotid sheaths,
ulation of the gland. If the manipulation In addition to being a valuable adjunct and submandibular region for undescended
level is not measured, the postexcision val- to confirming the completeness of parathy- glands. If the occult gland is still not identi-
ues may be difficult to interpret. Additional roid resection, the rapid PTH assay has fied, additional intraoperative adjuncts are
PTH levels are measured 5, 10, and occa- been shown to be a useful adjunct to other used, including ultrasound and bilateral in-
sionally 20 or 30 minutes following excision aspects in the treatment of pHPT. We rou- ternal jugular vein sampling, to determine
of the targeted gland, the latter specimen tinely perform, ex vivo, fine needle aspira- if an ipsilateral PTH gradient is present.
being collected only if there is not an appro- tions (FNAs) of tissue excised during para- This technique has guided us to explore up-
priate reduction in PTH levels at 5 and thyroid surgery with measurement of PTH. stream and locate occult undescended or
10 minutes. A positive aspirate will demonstrate PTH partially descended glands. Partial or com-
There is no universally adopted algo- levels greater than 1,000 pg/mL. This has plete thyroid lobectomy can be performed
rithm for interpreting the results of intra- eliminated the need for frozen section anal- depending on the suspected location of
operative PTH measurements. We advocate ysis in the vast majority of cases. the missing gland. We generally do not

www.medicalebookpdf.com

LWBK892_c41_p501-508.indd 506 10/28/11 5:34:20 PM

 Chapter 41: Minimally Invasive Parathyroidectomy 507

recommend sternotomy at the initial explo- Previously Operated Patients mibi scanning, ultrasound, 4DCT, venous
ration unless imaging strongly suggest localization, or ultrasound combined with
mediastinal disease that is not accessible Reoperative parathyroid surgery has haunted FNA of suspected enlarged parathyroid
by less invasive routes. Despite all of these endocrine surgeons following the first glands.
maneuvers, there still remains a subset of successful operation for pHPT performed
patients in whom the elusive parathyroid is by Felix Mandl in Vienna in 1925. Unfortu-
not identified. In this setting, ligation of the nately, the patient (Albert J.) developed
blood supply to the missing parathyroid recurrent disease 6 years postoperatively POSTOPERATIVE
gland is performed. This usually involves and ultimately died of recalcitrant hyper- MANAGEMENT
ligation of the ipsilateral inferior thyroid calcemia. Despite the success rate of para- Approximately 90% of cases are performed
artery but may also involve devasculariza- thyroidectomy in the modern era, surgeons under regional cervical block anesthesia in
tion of other arterial branches. still encounter three groups of patients rep- the ambulatory setting at our institution.
resenting challenging management issues: However, the patients are counseled that an
(a) patients with persistent pHPT having overnight stay is a possibility. The most
Coexistent Thyroid Disease failed initial exploration, (b) patients who common reasons for admission to the hos-
Coexistent thyroid disease is relatively com- develop recurrent pHPT having sustained a pital are multiglandular disease requiring
mon, and may range from benign nodules period of eucalcemia for greater than subtotal parathyroidectomy, significant co-
to thyroid cancer. In patients undergoing a 6 months after their initial operation, and morbidity, advanced age, or the lack of sup-
preoperative ultrasound showing thyroid (c) patients who have undergone previous port at home. The patient is monitored for 1
lesions, appropriate work-up should be neck explorations, particularly total thyroi- to 4 hours postoperatively, mainly to ensure
done prior to parathyroid exploration. In dectomy, who then develop pHPT. In each absence of a neck hematoma. After curative
cases where a preoperative ultrasound has of these settings, remedial cervical explora- parathyroidectomy, the patient is placed on
not been performed, intraoperative recog- tions are associated with decreased success oral calcium carbonate in the immediate
nition of coexistent thyroid disease is some- and increased complication rates. Recently, postoperative period (2 to 4 weeks) to avoid
times encountered. A thyroid lobectomy we reported the experience with remedial symptoms of transient relative hypocalce-
can be performed under regional block, but surgery over the past 15 years in 130 con- mia. Since many patients suffer vitamin
for more extensive thyroid resections con- secutive operations (Fig. 10). The explora- D deficiency as well, they are advised to
version to general anesthesia is sometimes tions were performed under general anes- adhere to current recommendations for
needed. Patients with Hashimoto’s thyroidi- thesia in the majority of patients but MIP calcium/vitamin D supplementation.
tis, Graves’ disease, or sarcoidosis often dis- was employed in 23 patients. The cure rate
play significant cervical lymphadenopathy was similar in the two groups, 94% and
causing difficulty in distinguishing enlarged 96%, respectively. Again, meticulous preop- RESULTS AND
lymph nodes from hypercellular parathy- erative work-up enhances the chance of
roid glands. operative success, and may include sesta- COMPLICATIONS
The success of MIP has been confirmed by
evidence of cure and complication rates
that are at least as good as those achieved
by conventional bilateral exploration. Spe-
cifically, in a series of 656 consecutive para-
thyroidectomies (of which 401 were per-
formed in the standard fashion and 255
were performed with MIP) between 1990
and 2001, there were no significant differ-
ences in complication (3.0% and 1.2%, re-
spectively) or cure rates (97% and 99%, re-
spectively). MIP was associated with an
approximately 50% reduction in operating
time (1.3 hours for MIP vs. 2.4 hours for
standard operation), a sevenfold reduction
in length of hospital stay (0.24 days vs. 1.64
days, respectively), and a mean savings in
Endocrine Surgery

terms of charges of $2,693 per procedure.

This represents a reduction by nearly one-
half in total hospital charges. A prospective
randomized controlled trial comparing
unilateral with bilateral neck exploration
was recently published. In this study of 91
patients, those assigned to preoperative
A B
sestamibi localization and unilateral neck
Fig. 10. Location of enlarged parathyroid glands resected during remedial cervical exploration. Because exploration with the rapid PTH assay were
of overlapping glands, the parathyroid glands are not drawn to scale. Some patients had more than one compared with those assigned to bilateral
enlarged gland. Individual glands are depicted on one illustration only. A: Anteroposterior projection. neck exploration. Patients who underwent
B: Lateral projection. unilateral neck exploration had a lower

www.medicalebookpdf.com

LWBK892_c41_p501-508.indd 507 10/28/11 5:34:20 PM

 508 Part IV: Endocrine Surgery

incidence of early postoperative hypocalce- ization: an analysis of 1000 patients. Surgery Lo CY, Lang BH, Chan WF, et al. A prospective
mia, necessitating calcium supplementa- 2008;144:74–9. evaluation of preoperative localization by tech-
tion. There were no statistical differences Bergenfelz A, Lindblom P, Tibblin S, et al. Unilat- netium-99m sestamibi scintigraphy and ultra-
eral versus bilateral neck exploration for pri- sonography in primary hyperparathyroidism.
with respect to complication rates, costs, mary hyperparathyroidism: a prospective ran- Am J Surg 2007;193:155–9.
and operative time between the two groups. domized controlled trial. Anna Surg 2002;236: Mihai R, Simon D, Hellman P. Imaging for pri-
The study, which was not blinded, was en- 543–51. mary hyperparathyroidism–an evidence-based
cumbered by a high-crossover rate; only Bilezikian J, Potts JJ, Fuleihan G-H, et al. Summary analysis. Langenbecks Arch Surg 2009;394:
62% of patients assigned to unilateral ex- statement from a workshop on asymptomatic 765–84.
ploration actually underwent this opera- primary hyperparathyroidism: a perspective Rodgers SE, Hunter GJ, Hamberg LM, et al. Improved
for the 21st century. J Clin Endocrinol Metab preoperative planning for directed parathyroidec-
tion. This may relate to the relatively low 2002;87:5353–61. tomy with 4-dimensional computed tomography.
sensitivity (71%) of the sestamibi imaging Bilezikian JP, Khan AA, Potts JT Jr. Guidelines for Surgery 2006;140:932–40; discussion 40–1.
in this population. the management of asymptomatic primary hy- Stalberg P, Carling T. Familial parathyroid tu-
The complication rate of MIP is similar perparathyroidism: summary statement from mors: diagnosis and management. World J Surg
or lower to that of the standard cervical ap- the third international workshop. J Clin Endo- 2009.
proach. Recurrent laryngeal nerve injury crinol Metab 2009;94:335–9. Stojadinovic A, Shaha A, Orlikoff R, et al. Pro-
may occur in 0.5% to 1.0% of the cases. The Carling T, Donovan P, Rinder C, et al. Minimally in- spective functional voice assessment in pa-
vasive parathyroidectomy using cervical block: tients undergoing thyroid surgery. Ann Surg
risk of permanent hypoparathyroidism is reasons for conversion to general anesthesia. 2002;236:823–32.
absent if a single gland is explored and re- Arch Surg 2006;141:401–4; discussion 4. Tibblin S, Bondeson AG, Ljungberg O. Unilateral
moved, but always remains a concern in Chen H, Mack E, Starling JR. A comprehensive parathyroidectomy in hyperparathyroidism due
patients undergoing subtotal parathyroi- evaluation of perioperative adjuncts during to single adenoma. Ann Surg 1982;195:245–52.
dectomy for multiglandular disease. minimally invasive parathyroidectomy: which Udelsman R. Six hundred fifty-six consecutive
is most reliable? Ann Surg 2005;242:375–80; dis- explorations for primary hyperparathyroidism.
cussion 80–3. Ann Surg 2002;235:665–70.
Gold JS, Donovan PI, Udelsman R. Partial me- Udelsman R, Donovan PI. Remedial parathyroid
SUGGESTED READINGS dian sternotomy: an attractive approach to surgery: changing trends in 130 consecutive
Barczynski M, Golkowski F, Konturek A, et al. Tech- mediastinal parathyroid disease. World J Surg cases. Ann Surg 2006;244:471–9.
netium-99m–sestamibi subtraction scintigra- 2006;30:1234–9. Udelsman R, Aruny JE, Donovan PI, et al. Rapid
phy vs. ultrasonography combined with a rapid Irvin GL III, Dembrow VD, Prudhomme DL. Op- parathyroid hormone analysis during venous
parathyroid hormone assay in parathyroid aspi- erative monitoring of parathyroid gland hyper- localization. Ann Surg 2003;237:714–9; discus-
rates in preoperative localization of parathyroid function. Am J Surg 1991;162:299–302. sion 9–21.
adenomas and in directing surgical approach. Jaskowiak N, Norton JA, Alexander HR, et al. A pro- Udelsman R, Pasieka JL, Sturgeon C, et al. Surgery
Clin Endocrinol (Oxf) 2006;65:106–13. spective trial evaluating a standard approach to for asymptomatic primary hyperparathyroid-
Berber E, Parikh RT, Ballem N, et al. Factors reoperation for missed parathyroid adenoma. ism: proceedings of the third international work-
contributing to negative parathyroid local- Ann Surg 1996;224:308–20; discussion 20–1. shop. J Clin Endocrinol Metab 2009;94:366–72.

EDITOR’S COMMENT have had endotracheal tubes because of changes An interesting analysis comes from William
in the vocal cord, that these patients, when pos- Beaumont Hospital in Royal Oak, Michigan, by
sible, should not be intubated. Nagar et al. (Am J Surg 2011, published online), in
As our population becomes older and patients The minimally invasive procedure, as ex- which they attempt to determine whether mini-
obviously more frail, we need to worry about the plained by Professor Udelsman, does not mean mally invasive radio-guided parathyroidectomy
patients with real diseases, which should not be the exclusion of other adjunctive procedures that (MIRP) as compared with intraoperative parathy-
neglected but, in fact, be dealt with. Such is the are being used. For example, the SVS or vascular roid-hormone-guided parathyroidectomy have
increasing recognition of hyperparathyroidism in drawback and sampling or the localization of the equivalent intermediate-term outcomes in pri-
the elderly, which 10–15 years ago was dismissed, parathyroid gland with a minimal gradient is a mary hyperparathyroidism. Since they were not
that it is, in fact, at this point recognized as mani- useful adjunct, and an FNA of a parathyroid gland, done concurrently but retrospectively, one ques-
festing in a number of ways including weakness, which could be carried out under ultrasound vi- tion arises, as one reviews this paper, as to whether
loss of energy, and perhaps some neuropsychiat- sualization, may yield elevated parathyroid levels. they really were equivalent. They reviewed the pa-
ric changes. Therefore, in patients who can toler- There is an unfortunate tendency on the part of tients who underwent either MIRP or intraopera-
ate the procedure, it is perfectly worthwhile to individuals, who have not had a long history in tive parathyroid-hormone parathyroidectomies.
render them normocalcemic, hopefully without dealing with hyperparathyroidism, to try and The primary outcome was persistent disease,
doing too much harm. Thus, the movement to minimize the adjuncts that sometimes take place, while conversion to bilateral exploration and
minimally invasive parathyroidectomy is a logi- such as intraoperative parathyroid hormone. One multigland disease were secondary outcomes.
cal progression and is progressing with time. Pa- needs to point out that, in the excellent endocrine As a result of the various operations, one MIRP
tients, especially the elderly, also are reluctant to groups around the country, the average success patient and no intraoperative-parathyroid-
surgery, especially if they have been told that they rate for parathyroidectomy is 99% in the gen- hormone patient had persistent disease—in other
have cardiovascular disease. So it comes without eral surgery and endocrine groups. On reviewing words, the operation failed in the MIRP patient.
surprise that various individuals have argued for many papers on parathyroid disease in writing The intraoperative-parathyroid-hormone group
a minimally invasive procedure, omitting some the commentaries for this sixth edition, it seems had more conversions to a bilateral neck explo-
of the various additional tests, such as those car- to me that 94% to 95% of success rate is accept- ration, 3.7% versus 13% in the intraoperative-
ried out in more and more minimally invasive able in the ENT literature. I am afraid that is “not parathyroid group, and this was statistically sig-
procedures, which may take time, and which are on,” as the British would say. Irrespective of the nificant to 0.02. While seven patients with double
especially difficult on elderly who are merely se- specialty, especially in operations on the elderly, adenomas and six patients with multiglan-
dated but do not have an endotracheal tube and we are required to get the maximum benefit for a dular disease were found in the intraoperative-
full anesthesia. I do agree, since there are voice procedure that is extremely stressful on these peo- parathyroid-hormone group—in other words,
changes in a significant number of patients who ple to avoid reoperation, which is indeed difficult. 13 in all—there were none in the MIRP. Since the

www.medicalebookpdf.com

LWBK892_c41_p501-508.indd 508 10/28/11 5:34:20 PM

 Chapter 42: Secondary and Tertiary Hyperparathyroidism 509

number of patients with double adenomas and and insisting on keeping a minimal invasion in Another wrinkle is a microadenoma, which is
multiglandular disease were within the normal the excision. Likewise, the difference between more difficult to find and has basically elevated
range in the intraoperative-parathyroid group, the two groups is that the incidence of multig- levels of PTH but is significantly lower than in pa-
I can only conclude that the MIRP group was landular disease and of double adenoma was dif- tients with a classic adenoma. As they point out,
carefully selected to avoid any double adenoma ferent, as the patients who were thought to have the calcium and the PTH-serum levels were lower
or multiglandular disease, and the groups were this were not included in the minimally invasive than what they conventionally accepted as being
not comparable. I would disagree with the latter approach solely but had a bilateral conventional essential for primary hyperparathyroidism, that
conclusion, which states, “ioPTH intraoperative neck exploration under general anesthesia, which is, 2.6 mmol/L calcium and 6 pg/mL for PTH. The
parathyroid-hormone facilitates successful mini- is appropriate. That is, I believe, what happened adenoma group had a success rate of 98%, and the
mally invasive parathyroidectomy . . . when com- in the previous paper, except it is not stated in microadenoma group had a success rate of 92%,
pared with MIRP and provides cure rates similar that paper. which, though not statistically different, are not
to BNE bilateral neck exploration.” I would also A third paper by Vaid and Pandelidis was to the same. They are modest in their conclusions,
add that MIRP gives satisfactory results, when review minimally invasive parathyroidectomy for saying that, if they believed that what they are go-
the patients are carefully selected not to have primary hyperthyroidism using preoperative ses- ing to be dealing with at the time of operation is
double adenomas or multiglandular disease. That tamibi scan and intraoperative radio-guidance. It a microadenoma on the basis of mild preopera-
is the real conclusion of this paper. makes a specific statement of the need of mea- tive elevation of calcium and PTH-serum levels,
A paper from the authors’ unit compares a surement of intraoperative parathyroid-hormone they should be prepared to do a bilateral neck
great deal of experience between 1990 and 2009 levels. They wanted to ascertain the outcomes of exploration rather than some variant of MIRP. I
at two separate tertiary-care academic hospi- MIRP performed in a community hospital with- fully agree.
tals. They evaluated (Udelsman R et al., Ann Surg out the expense of measuring parathyroid hor- Finally, Quillo et al. attempted to apply the
2011;253:585–91) 1,650 consecutive patients who mone (PTH) intraoperatively. They carried out a Norman 20% rule to see whether it was valid in
underwent surgery for primary hyperparathy- retrospective medical-record review of patients performing MIRP. The 20% rule means that the
roidism by a single surgeon—I assume this means collected from April 1, 1998, to May 31, 2005, and area of the technician’s sestamibi scan is 20%
Professor Udelsman. Conventional bilateral cervi- reported it in Archives of Surgery (2011;146:876–8). higher than the surroundings and thus guides
cal exploration under general anesthesia was per- Of 188 parathyroidectomies at that time for hy- the surgeon to a successful surgical excision.
formed on 613 patients. Later, I assume, though perparathyroidism by one surgeon (S. P.), there They do not rule out the use of the intraoperative
not concurrent, that MIRP was performed on were 111 patients who underwent MIRP. In this parathyroid hormone assay, which may be used
1,037 patients. Outcomes and total hospital costs series of 111 patients, they found what they called at the time of the procedure to verify that the
were compared. MIRP in the author’s hands is as- 2 recurrences, which, in fact, were failures of the abnormal functioning tissue has been removed.
sociated with an improvement in the cure rate to operation, since the parathyroid-hormone levels In this study, which reviewed their database
99.4%, which is the equivalent of other first-class and the calcium never decreased, thus achieving from January 1, 1999 to December 31, 2007, 216
units; the complication rate was low, 1.45%, com- a success rate of 98%, which is close but not up to MIRP patients with complete radio-guided and
pared to a conventional exploration with a cure what I consider the standard on the basis of the postoperative management data were identified,
rate of 97.1%, slightly below the average, and a literature. As they say, higher preoperative PTH specifically in looking at the ex vivo parathyroid-
complication rate of 3.1%. What is different about levels and gland weights had a direct correlation gland radioactivity compared with the excision
their approach to MIRP is that they also utilized with successful performance of MIRP. I believe site/background. The average percentage was
intraoperative parathyroid-hormone levels to that what they are telling us is that the group may 107% and the range was from 14% to 388%. In
guide them, as there is evidence that there is con- be slightly selected, in that the patients who did 99% of the patients (196/198), radioactivity from
version required to general anesthesia, when the not have large glands and a high PTH level may the excised gland was at least 20% of the radio-
hyperparathyroidism was not thought of as be- have been suggested to undergo a conventional activity from the excision site. Normocalcemia
ing cured, based on the inadequate fall of plasma operation under general anesthesia. I would also postoperatively was documented in 195 of the
PTH (parathyroid hormone) after resection of the suggest to the authors that they get their termi- 198 patients at 12-month follow-up. They con-
image-identified lesion which was thought to be nology straight. When a patient undergoes opera- clude that the 20% rule, while not being the en-
the cause of the hyperparathyroidism. The over- tion and the operation is not successful, it is not tire criterion, may be utilized to get a successful
all conversion rate was 10%, which indicates that a recurrence, but a failure of the operation. In this outcome of parathyroidectomy, although it is not
curing hyperparathyroidism is more important case, two patients who did not have a successful the only criterion that they would wish to use in
for this group, rather than avoiding doing para- parathyroidectomy were not recurrences, but fail- the future.
thyroid hormones and making a limited incision ures, since the values never went back to normal. J.E.F.

42 Secondary and Tertiary Hyperparathyroidism

Kaare J. Weber and Shalini Arora
Endocrine Surgery

INTRODUCTION thyroidism in the setting of chronic renal ETIOLOGY

failure remains a challenge to both neph-
Secondary hyperparathyroidism is a physi- rologists and endocrine surgeons. Previous Calcium regulation responds to both para-
ologic response to a defect in calcium ho- estimates suggested that 5% of the renal thyroid hormone released by the parathy-
meostasis. Causes are broad and can include failure population undergo surgery for roid glands and active vitamin D (1,25-
genetic, gastrointestinal, vitamin D-related, hyperparathyroidism every year; however, dihydroxyvitamin D3) produced by the
and renal-related causes (Table 1). Nearly all with advances in medical management, that kidney. The main target organs of these
patients with chronic renal failure develop number is now thought to be 1% per year, two hormones are the bones, kidneys, and
some degree of secondary hyperparathy- with an overall estimate of 10% eventually intestines. The exact etiology of secondary
roidism. Therefore, secondary hyperpara- undergoing parathyroidectomy. hyperparathyroidism remains unclear but

www.medicalebookpdf.com

LWBK892_c42_p509-514.indd 509 10/28/11 5:33:57 PM

 510 Part IV: Endocrine Surgery

aand normal or elevated serum calcium lev-

Table 1 Differential Diagnosis of eels. Tertiary hyperparathyroidism resem-
Secondary Hyperparathy-
roidism bbles primary hyperparathyroidism because
oof the autonomously functioning parathy-
Gastrointestinal/ Gastric bypass rroid glands from a monoclonal expansion
malabsorption Celiac disease oof adenomatous like tissue. Although it
Cystic fibrosis m most commonly occurs due to hyperplasia
Pancreatic disease oof all four glands, there are reports of single
Calcium deficiency
Liver/biliary disease
aand double glands causing the hyperpara-
tthyroid state in 2.6 to 32% of patients.
Kidney related Chronic kidney disease
Vitamin D Lack of sunlight CLINICAL
deficiency exposure
Inadequate dietary
MANIFESTATIONS
intake S
Secondary hyperparathyroidism can lead
Genetic Pseudohypoparathy- tto a spectrum of bone disease referred to
roidism rrenal osteodystrophy. There are four main Fig. 1. Calciphylaxis right breast/nipple–areolar
ttypes of bone diseases seen in renal failure complex.
ppatients and include osteitis fibrosa cystica,
adynamic bone disease, osteomalacia, and
is thought to be multifactorial. Decreased mixed uremic osteodystrophy in which ele-
active vitamin D production, hypocalcemia, ments of both high and low bone turnover Although most patients with tertiary hy-
and phosphate retention all contribute to are seen. Subclinical changes in mineral perparathyroidism remain asymptomatic,
the development of secondary hyperpara- metabolism and bone structure begin early those presenting with symptoms mirror
thyroidism. As glomerular filtration rate de- in the course of kidney disease but signs that of primary hyperparathyroidism. These
clines, circulating levels of active vitamin D and symptoms of bone disease typically do include nephrolithiasis, peptic ulcer dis-
begin to decrease due to diminished hydrox- not occur until the patient is already on di- ease, pancreatitis, and bone disease. Fol-
ylation of 25-hydroxyvitamin D to the active alysis. Patients can present with weakness, lowing transplant, high parathyroid hor-
1,25-dihydroxyvitamin D. As a result, a de- bone pain, myopathy, and fractures. mone levels stimulate the transplanted
crease in absorption of calcium from the gut In addition to bone disease, uremic pru- kidney to produce activated Vitamin D. This
leads to hypocalcemia. Hypocalcemia com- ritus can be quite debilitating, impacting in turn results in increased bone turnover
bined with hyperphosphatemia due to im- greatly on quality of life. Etiology is multi- and absorption of calcium from the gut
paired excretion by the kidneys, leads to factorial but is thought be due to changes leading to hypercalcemia. In patients who
stimulation of the parathyroid glands to in calcium and phosphate metabolism with remain asymptomatic, calcium levels over
release parathyroid hormone. The result is elevated calcium/phosphate product, in- 12 mg/dL may cause graft deterioration.
hyperplasia of all parathyroid glands due to creased parathyroid hormone, anemia, and
polyclonal cell proliferation and compensa- high aluminum levels.
tory increase of parathyroid hormone in at- Persistent hyperparathyroidism can also
MEDICAL MANAGEMENT
tempts to raise serum calcium levels. Con- lead to calcium phosphate precipitation Medical therapy of secondary hyperpara-
tinued stimulation of the parathyroid glands resulting extraosseous calcification of the thyroidism is based upon knowing the ma-
leads to formation of monoclonal cell prolif- joints, soft tissues, and viscera. High para- jor factors contributing to excess parathy-
eration within the hyperplastic tissue and thyroid hormone levels can induce vascular roid hormone release, including vitamin D
can result in the development of nodular hy- calcifications, including coronary artery deficiency, hypocalcemia, and hyperphos-
perplasia. The parathyroid cells of nodular calcification. phatemia. The current management of sec-
hyperplasia have been shown to have de- Renal hyperparathyroidism is associated ondary hyperparathyroidism involves some
creased expression of both the vitamin D with an increase in cardiovascular morbid- combination of calcium and vitamin D sup-
and calcium-sensing receptors. ity and mortality. Mechanisms are not clear plementation, phosphate binders, and a cal-
Prolonged stimulation of the parathy- but are thought to be due to derangements cimimetic. Calcimimetics have been added
roid glands may result in autonomous pro- in calcium and phosphate metabolism lead- to the nephrologists’ armamentarium more
duction of parathyroid hormone even after ing to accelerated vascular calcification in- recently. They are called “calcimimetic” be-
removal of the physiologic stimulus, lead- creasing adverse cardiovascular events. Hy- cause they mimic the effects of extracellular
ing to tertiary hyperparathyroidism. This perphosphatemia has also been identified calcium on parathyroid glands. They act by
condition occurs in up to 30% of patients as an independent risk factor for decline in occupying the calcium-sensing receptor on
with chronic renal failure after kidney renal function and higher mortality. the parathyroid glands, thus down-regulating
transplantation. It can, however, occur in A rare but life-threatening complication parathyroid hormone release. Cinacalcet
any patient with secondary hyperparathy- of secondary hyperparathyroidism is calci- has been shown to improve parathyroid hor-
roidism with long-standing hypocalcemia, phylaxis. Calciphylaxis is an entity of exces- mone, calcium, and phosphate levels with
and should be suspected in patients with sive calcium deposition in the microvascula- early evidence showing reduced risk of para-
renal hyperparathyroidism who become ture, leading to ischemia and ulcers in atypical thyroidectomy, fracture, and cardiovascular
hypercalcemic. Etiology is thought to be areas of the body (Fig. 1). The ulcers typically events in renal failure patients. Prior to the
due to the loss of calcium-sensing and vita- do not respond to debridement and local introduction of calcimimetics, ⬃5% of the
min D receptors on the parathyroid glands wound care. Often these wounds become su- renal population came to surgery for symp-
resulting in elevated parathyroid hormone per-infected, resulting in sepsis and death. tomatic secondary hyperparathyroidism.

www.medicalebookpdf.com

LWBK892_c42_p509-514.indd 510 10/28/11 5:33:57 PM

 Chapter 42: Secondary and Tertiary Hyperparathyroidism 511

Current estimates suggest that only 1% of a can be confirmed by preoperative aspi-

and
the renal failure population will require Table 3 Indications for Surgery in rration and measurement of parathyroid
Tertiary Hyperparathy-
parathyroidectomy with the introduction of roidism hormone. This can prevent the traditional
h
calcimimetics. hemithyroidectomy that has been advo-
h
Tertiary hyperparathyroidism is charac- Persistent hypercalcemia ccated in the past for unidentified parathy-
terized by hypercalcemia and hypophos- Renal phosphorous wasting rroid glands. Ultrasound can also help iden-
phatemia and therefore does not respond Pruritus ttify thyroid pathology that should be
to the above regimen for secondary hyper- eevaluated preoperatively to avoid having to
parathyroidism. Minimal evidence exists Nephrolithiasis rreturn to the neck for future thyroid sur-
that calcimimetics may benefit patients Severe osteopenia, low bone mineral density ggery. However, ultrasound does not image
suffering from tertiary hyperparathyroid- Parathyroid gland weight ⬎500 mg tthe mediastinum and chest wall. Most me-
ism and therefore calcimimetics are cur- ddiastinal glands are small intrathymic nests
rently not approved for this entity. Surgery oof parathyroid cells and are not imaged
remains the only therapeutic option for well. However, one or more of the parathy-
these patients. roid glands can descend into the chest and
weakness, and itching. Moreover, bone loss, avoid detection during neck exploration.
fractures, and extra-skeletal calcifications Although 99mTc-sestamibi scans can be
INDICATIONS FOR are indications for surgery. tailored to view the chest, the sestamibi is
SURGERY There is an ongoing controversy on the not always taken up well by hyperplastic
approach to calciphylaxis. However, be- parathyroid tissue. MRI or now 4D CT scan
Indications for surgery for secondary hyper- cause mortality rates can be as high as 90%,
parathyroidism can be broken down into with parathyroid protocol may prove to be
calciphylaxis is best managed by control- helpful in localizing ectopic glands in the
both biochemical and clinical indications. ling secondary hyperparathyroidism with
Guidelines have been developed to improve thorax (Fig. 2).
parathyroidectomy. Once the biochemical Most agree that for persistent or recur-
clinical outcomes for patients suffering abnormalities are corrected, the ischemia
from renal hyperparathyroidism. The Kid- rent hyperparathyroidism, preoperative lo-
and ulcers of calciphylaxis are then allowed calization studies in some combination are
ney Disease Outcomes Quality Initiative to heal with ongoing local wound care.
(KDOQI) specifies targets for calcium and useful.
Similar to secondary hyperparathyro-
bone mineral metabolism to slow disease idism, tertiary hyperparathyroidism lacks
progression and minimize complications clear indications for surgery based on ran- SURGICAL METHODS
(Table 2). Surgery is often employed when domized controlled studies. Elevated para-
medical management “failed” to meet these There are three approaches to surgery in
thyroid hormone levels are seen in over 25% this population: subtotal parathyroidec-
guidelines. However, randomized controlled of patients 1 year after kidney transplanta-
trials do not exist indicating when parathy- tomy with three and one half gland removal,
tion; however, up to 5% of posttransplant total parathyroidectomy with transcervical
roidectomy should be performed. Parathy- patients will ultimately need parathyroi-
roidectomy is generally recommended thymectomy and autotransplantation of
dectomy. Proposed indications for surgery parathyroid tissue, and total parathyroidec-
when serum levels of intact parathyroid are also based on biochemical and clinical
hormone are ⬎800 pg/mL in association tomy. All three approaches have tradition-
criteria (Table 3). While the standard delay ally resulted in good outcomes for patients.
with hypercalcemia and/or hyperphos- of surgery is 1 year, surgery can be per-
phatemia. Also a calcium/phosphate prod- No randomized trials exist comparing the
formed at 3 months because most patients three operations. It is important to under-
uct of ⬎55 implies failed medical therapy. should recover normal parathyroid func-
Size of parathyroid glands is a relative stand that surgery for secondary hyper-
tion by this time. parathyroidism is not a cure. This is a tem-
indication for surgery. Glands with an esti-
mated volume of ⬎500 mm3 or diameter porizing procedure to gain control over the
greater than 1 cm on ultrasound are likely PREOPERATIVE pathophysiologic response to renal failure,
and the only hope for cure is a kidney trans-
to have developed nodular hyperplasia. This LOCALIZATION plant.
is based on the belief that nodular hyper-
plasia of secondary hyperparathyroidism Traditionally, preoperative imaging is not All operations utilize a Kocher incision.
has diminished expression of both vitamin obtained for secondary and tertiary hyper- Bloodless technique optimizes the sur-
D and calcium-sensing receptors leading to parathyroidism. Unlike primary hyperpara- geon’s view and should allow for identifica-
a diminished response to medical therapy. thyroidism, these entities are due to multig- tion and preservation of the recurrent
Regardless of absolute laboratory values landular disease and require a bilateral neck laryngeal nerve. If all four glands are not
Endocrine Surgery

or size of the parathyroid glands, surgery is exploration to identify all offending glands. easily identified, then the surgeon should
often indicated with the onset of symptoms. Standard imaging with 99mTc-sestamibi explore the neck “according to the rules of
These include bone and joint pain, muscle and ultrasound have not had reported great surgical anatomy of the parathyroid glands,”
success in identifying all pathologic glands. guided by the knowledge of embryologic
However, because 10% of patients can development of the parathyroids. Care
have supernumerary glands and up to 30%
h should also be taken to preserve the capsule
Table 2 KDOQI Bone Mineral oof patients can have ectopic glands with re- of the individual parathyroid glands during
Metabolism Targets nal hyperparathyroidism, preoperative im-
n exploration to prevent seeding or parathy-
Calcium level 8.4–9.5 mg/dL aaging can aid in localizing the parathyroid roidosis, which could potentially render
Phosphate level 3.5–5.5 mg/dL gglands, particularly mediastinal and in- these patients inoperable in the future.
ttrathyroidal glands. Ultrasound can iden- Subtotal parathyroidectomy involves re-
iPTH level 150–300 pg/mL ttify parathyroid glands within the thyroid moving the three most abnormal appearing

www.medicalebookpdf.com

LWBK892_c42_p509-514.indd 511 10/28/11 5:33:58 PM

 512 Part IV: Endocrine Surgery

Fig. 2. Ectopic mediastinal parathyroid adenoma localized by

4D CT scan. (Courtesy of Dr. Puneet Pawha.)
C

glands, leaving a 50-mg remnant of the tomy with autotransplantation of parathy- A portion of the most normal appearing
most normal appearing gland. The remnant roid tissue. All parathyroid glands including gland is then autotransplanted. Prepara-
must be well vascularized to avoid hy- supernumerary glands are removed at the tion of tissue and site of implantation vary
poparathyroidism. After all glands are iden- initial neck exploration. Because ectopic among surgeons. We mince a 50-mg piece
tified, a biopsy of the most normal appear- glands or even embryologic parathyroid of tissue and place it in a pocket of the bra-
ing gland is taken, leaving behind 50 mg of rests can be within the thymus, the rem- chioradialis muscle of the forearm (Fig. 3).
well-vascularized tissue. This gland should nant thymus is removed transcervically to When possible, the arm containing dialysis
be marked with a nonabsorbable suture minimize recurrence. access is avoided. The muscle fibers are
and/or a clip. Once it is clear that the rem-
nant is well vascularized, the other glands
may be removed completely. In case where
the remnant appears ischemic, a second
gland is chosen as remnant and the proce-
dure is repeated. Generally, superior glands
are chosen as remnant because the blood
supply is more predictable. In addition, the
inferior glands may become devascularized
during thymectomy. One advantage of this
approach is that an additional incision in
the forearm is avoided. Concern with this
approach includes leaving behind too large
a remnant or supernumerary glands result-
ing in persistent or recurrent disease. Reop-
erative surgery in the neck increases poten-
tial morbidity to the patient, particularly
risking injury to the recurrent laryngeal
nerve.
As a result, many surgeons favor a total
parathyroidectomy and transcervical thymec- Fig. 3. Autotransplantation of parathyroid tissue to brachioradialis muscle of forearm.

www.medicalebookpdf.com

LWBK892_c42_p509-514.indd 512 10/28/11 5:33:58 PM

 Chapter 42: Secondary and Tertiary Hyperparathyroidism 513

carefully spread to avoid bleeding and he- The traditional surgical approach to ter- Currently, there are no clear criteria to
matoma formation, which can jeopardize tiary hyperparathyroidism includes explo- help interpret intraoperative parathyroid
the transplant. The fascia is then closed ration of all four glands. A subtotal parathy- hormone levels in secondary hyperparathy-
with clips to allow for future identification roidectomy or a total parathyroidectomy roidism. Compared to primary hyperpara-
of the graft if needed. It is important that with autotransplantation of parathyroid tis- thyroidism, we use more stringent criteria
this tissue be confirmed to be parathyroid sue in the forearm is performed. Ideally, of a 90% drop from baseline as an indication
tissue on frozen section prior to autotrans- parathyroid tissue should be cryopreserved of a successful operation and removal of all
plantation to avoid implantation of thyroid for possible postoperative hypoparathyroid- parathyroid glands. Nephrologists prefer an
tissue, lymph node, or even metastatic ism. Since up to one-third of the patients absolute drop of parathyroid hormone to
lymph node. An advantage to this approach have been reported to have a single or dou- 200 pg/mL or less postoperatively. The util-
is that no parathyroid tissue remains in the ble adenoma, patients requiring surgery for ity of the assay has been questioned by some
neck. If and when a recurrence does occur, tertiary hyperparathyroidism may benefit surgeons since all four glands are explored
the surgeon can stay away from the neck, from a minimally invasive, focused parathy- in hyperplasia. However, given the high in-
avoiding the possibility of recurrent laryn- roidectomy. Increased recurrence rates cidence of supernumerary glands, the assay
geal nerve injury. Surgery for recurrent dis- after less than subtotal parathyroidectomy can be helpful in determining the complete-
ease in patients who have undergone auto- have been reported, and as such, one should ness of surgery. In addition, thymectomy
transplantation to the forearm can be proceed with caution. However, as experi- may not need to be performed in all pa-
performed under local anesthesia with a ence grows with intraoperative parathyroid tients if intraoperative parathyroid hor-
small incision to the arm. hormone monitoring, measurement of mone levels indicate adequate resection.
Total parathyroidectomy and thymec- parathyroid hormone levels in the operat- The assay can be quite helpful in guiding the
tomy without autotransplantation is even ing room for tertiary hyperparathyroidism extent and success of parathyroidectomy in
advocated by some endocrine surgeons. Re- can guide the extent of the resection. This tertiary hyperparathyroidism in selective
markably, long-term follow up shows that approach has led to rates of success that is patients when preoperative imaging indi-
these patients are not aparathyroid and equivalent to the traditional approach. cates single or double adenomas.
have measurable parathyroid hormone
levels. However, concerns exist regarding INTRAOPERATIVE PARATHYROID PERIOPERATIVE MANAGEMENT
permanent hypoparathyroidism requiring
life-long calcium and vitamin D supplemen-
HORMONE MONITORING The perioperative management of these pa-
tation. This can lead to adynamic bone dis- Parathyroid hormone has a serum half-life tients often requires a multidisciplinary ap-
ease with very little bone turnover creating of 2 to 4 minutes. As such, measurement of proach. Patients should undergo dialysis
possibly a worse scenario than the renal intraoperative parathyroid hormone levels 1 day prior to surgery. A successful operation
osteodystrophy of secondary hyperparathy- in primary hyperparathyroidism is rou- would be one in which the parathyroid hor-
roidism. tinely used to determine successful removal mone drops significantly with the resultant
Overall, permanent hypoparathyroidism of diseased parathyroid glands. In primary profound drop in calcium postoperatively.
is found in 10% of all patients undergoing hyperparathyroidism, a drop in the intra- Hypocalcemia after surgery is the intended
surgery for renal hyperparathyroidism, operative parathyroid hormone value of effect and is not a complication of the sur-
regardless of surgical method. Therefore, 50% or more to within normal limits 5 min- gery; however, both the surgeon and the
cryopreservation of parathyroid tissue is utes after excision is indicative of a cure in nephrologist must be prepared to deal with
recommended if available at the operative ⬎95% of patients. This criterion for intra- this possible life-threatening electrolyte im-
institution for all approaches. Patients are operative parathyroid hormone monitoring balance. Patients can require up to 18 or
considered permanently hypoparathyroid is well accepted for primary hyperparathy- even 20 g of IV calcium in a 24-hour period.
after 6 months from the time of initial sur- roidism. There is no absolute value. Calcium must be
gery. Although autotransplantation succeeds However, the interpretation of intraoper- given according to the patient’s needs. Post-
in over 90% of patients who receive fresh ative parathyroid hormone monitoring in operative supplementation should also in-
parathyroid at the time of initial surgery, only secondary hyperparathyroidism is compli- clude oral calcium as well as vitamin D.
half of the cryopreserved autotransplants cated by the clearance of parathyroid hor- Vitamin D can be given in various forms. In
have meaningful function. mone breakdown products in renal failure addition, if both the oral and the intrave-
The approach to recurrence requires a patients. Parathyroid hormone is a single- nous supplementation are not adequate, the
coordinated and meticulous evaluation. chain polypeptide consisting of 84 amino ac- patients can be dialyzed with a high calcium
Imaging with ultrasound, parathyroid scan, ids. The intact parathyroid hormone assay bath to help prevent symptomatic hypocal-
MRI, and now 4D CT scan with parathyroid measures both the 1-84 parathyroid hormone cemia.
Endocrine Surgery

protocol can help identify if there is any tis- and large C-terminal degradation fragments, Platelet dysfunction in renal failure pa-
sue remains in the neck or chest. In addi- which are cleared by the kidneys. These by- tients as well as the need for heparin during
tion, sampling parathyroid hormone from products have a half-life that is 5 to 10 times dialysis postoperatively raises the concern
both arms to determine if a gradient exists longer than that of the 1-84 parathyroid hor- for hematoma formation. Placement in a
can be very helpful in determining if the lo- mone and may interfere with interpretation closely monitored setting postoperatively
cation of recurrence is in the forearm. The of the assay. The newer bioactive assays mea- such as the intensive care unit is prudent.
absence of a gradient implies that there is sure only the active parathyroid hormone Life-threatening hypocalcemia and airway
residual or ectopic tissue in the neck or and not the inactive C-terminal fragments compromise can be identified early and
chest. If imaging studies fail to localize the and may be more specific in patients with avert disaster. Discharge can be considered
gland, selective venous sampling can be renal failure. However, interaction with N- when patients are maintaining their cal-
done to aid in the location of the culprit terminal fragments, which are also cleared cium needs orally without symptoms of hypo-
gland. by the kidneys has been reported. calcemia.

www.medicalebookpdf.com

LWBK892_c42_p509-514.indd 513 10/28/11 5:33:59 PM

 514 Part IV: Endocrine Surgery

SUGGESTED READINGS ary and tertiary hyperparathyroidism. Surgery

2004;136(6):1252–60.
Triponez F, et al. Less-than-subtotal parathyro-
idectomy increases the risk of persistent/re-
Dumasius V, Angelos P. Parathyroid surgery in Nichol PF, et al. Long-term follow-up of patients current hyperparathyroidism after parathyroi-
renal failure patients. Otolaryngol Clin North with tertiary hyperparathyroidism treated by dectomy in tertiary hyperparathyroidism after
Am 2010;43:433–40. resection of a single or double adenoma. Ann renal transplantation. Surgery 2006;140(6):
Fraser WD. Hyperparathyroidism. Lancet 2009; Surg 2002;235(5):673–80. 990–9.
374:145–55. Packman KS, Demeure MJ. Indications for para- Triponez F, et al. Surgical treatment of persistent
Kebebew E, et al. Tertiary hyperparathyroidism. thyroidectomy and extent of treatment for hyperparathyroidism after renal transplanta-
Histologic patterns of disease and results of patients with secondary hyperparathyroidism. tion. Ann Surg 2008;248(1):18–30.
parathyroidectomy. Arch Surg 2004;139:974–7. Surg Clin North Am 1995;75(3):465–82. Weber KJ, et al. Intraoperative PTH monitoring in
Milas M, Weber CJ. Near-total parathyroidec- Tominaga Y, et al. Surgical treatment of renal hyper- parathyroid hyperplasia requires stricter crite-
tomy is beneficial for patients with second- parathyroidism. Semin Surg Oncol 1997;13(2):87–96. ria for success. Surgery 2004;136(6):1154–9.

EDITOR’S COMMENT the normal governing stimuli in these patients. a difference in graft survival rate between those
It can also occur in patients with secondary hy- patients who underwent parathyroidectomy and
perparathyroidism with long-standing hypocal- those who did not, with those who did not have
One of the nice things about reading this chapter cemia and should be suspected in patients with superior survival rate. An attempt to bring about
and having the ability to comment on it is that 2HPT or renal hyperparathyroidism who become a statistical significance to these numbers is un-
it may be that I finally understand what second- hypocalcemic. The receptors controlling calcium derpowered and P ⫽ 0.06 is an indication of how
ary hyperparathyroidism is thought to be and the sensing and vitamin D sensing on the parathyroid close it really is, and at this rate, with double the
difference between secondary and tertiary hyper- glands result in elevated parathyroid hormone number of patients in the study, in other words
parathyroidism. Also, I have a pretty reasonable and/or normal or elevated serum calcium level. 49 patients being 100 patients, there would be a
understanding of what one does for each one of Tertiary hyperparathyroidism rather than renal statistical difference in graft survival rate. If one
these disease states. hyperparathyroidism more resembles primary adopts this point of view, one must challenge the
On the basis of this excellent chapter written hyperparathyroidism because it is due to autono- conclusion of this study which states “parathyroi-
by Kaare Weber and the various papers I have mously function parathyroid glands and which dectomy in renal transplant recipients seems to
read in association with in writing this com- histologically shows in monoclonal expansion be a safe and effective therapy for persistent ter-
mentary, this confusing entity of secondary and of adenomatous like tissue. Although it usually tiary hyperparathyroidism. Parathyroidectomy
tertiary hyperparathyroidism is related first of all occurs with hyperplasia of all the four glands, as may be associated with worsening glomerular
to renal failure. Secondary or renal hyperparathy- we see with the rest of the papers that I quote, filtration rate but it may not be associated with
roidism occurs in almost all patients with renal tertiary hyperparathyroidism may result from significantly decreased long-term graft sur-
failure who develop some degree of secondary the hyperplasia and growth of just one and two vival.” I would take issue with the last sentence.
hyperparathyroidism or 2HPT, as the abbrevia- glands and this has led to a somewhat different That leaves us with an interesting quandary as
tion is, or “renal hyperparathyroidism.” It remains approach in some centers, resulting in excision whether or not the current system of treating ter-
a challenge to both nephrologists and endocrine of one or two glands instead of total excision of tiary hyperparathyroidism, which is referred to in
surgeons. Previously, it was thought that 5% of the all the four enlarged glands and the reimplanta- this article perhaps total parathyroidectomy and
renal failure population undergoes surgery for hy- tion of diced parathyroid tissue in the forearm. If implant because of the fact the glomerular hyper-
perparathyroidism every year for 2HPT. Medical one adapts this point of view, then the remain- filtration is reversed by total parathyroidectomy
management has advanced and the number has ing glands in tertiary hyperparathyroidism in the glomerular filtration, may deteriorate acutely.
thought to have decreased to 1% a year with the subtotal removal should be the upper glands be- While theoretically the authors believe that
overall estimate of 10% eventually undergoing cause they have a better blood supply. this should reverse the disease of tertiary hy-
surgical intervention. What is the exact percentage of tertiary, that perparathyroidism, parathyroidectomy that is
As Dr. Weber cogently states in a brief review, is, autonomous hyperparathyroidism, in pa- complete and implantation in the forearm, for
calcium regulation is partially controlled by both tients with renal failure who have undergone a example, which was a previous standard, may
parathyroid hormone release by parathyroid renal transplant? (Kendal E. et al. Am J Med Sci acutely decrease glomerular filtration rate. In the
glands and the production of active Vitamin D 2010;239(5):420–24) tracked 794 renal transplants long term, therefore, parathyroidectomy of all the
(1,25-dihydroxy Vitamin D sub3.) by the kidney. in the Department of Surgery in Tulane Univer- four parathyroids may result in decreasing graft
In the control of calcium metabolism, the main sity School of Medicine that had at least 3 years survival rate or may in fact be just hinted at by
target organs are the bones with their vast stores follow-up to examine the effect of parathyroi- the current data.
of calcium, and kidneys with their exchange for dectomy on renal function and graft survival. As Several groups that have previously argued for
calcium and intestines with absorption of cal- many as 49 of the 794 renal transplant recipients total parathyroidectomy in tertiary hyperparathy-
cium. Secondary hyperparathyroidism is not well were diagnosed with hyperparathyroidism that is roidism have now, it appears, reversed course per-
understood but is thought to be multi-factorial secondary or renal hyperparathyroidism (2HPT) haps because of this and consequently only carry
which is a nice dodge for when you do not know before transplant. Further, 19 of the 49 patients out limited parathyroidectomy leaving two para-
something. “Decreased active vitamin D produc- had persistent independent hyperparathyroid- thyroids intact in 3HPT. Pitt et al. writing from
tion, hypocalcaemia, and phosphate retention ism and underwent parathyroidectomy after kid- Madison (Surgery 2009;146:1130–37) reviewed 140
all contribute to the development of secondary ney transplant. As the authors of this nice paper patients with 3HPT or tertiary hyperparathyroid-
hyperparathyroidism” according to the author. state, “Hypocalcemia usually gradually resolves ism who underwent either limited parathyroidec-
(The rest of the initial introduction to the chap- within the first year after kidney transplantation” tomy versus total or subtotal parathyroidectomy.
ter can be read with great profit if one wants to (D’ Alessandro, A.M., Surgery 1989;106:1049–55 The limited parathyroidectomy consisted of 29 pa-
understand 2HPT and 3HPT.) Upon transplant, and discussion 1055–56; PubMed 2588112). tients who underwent the resection of one n ⫽ 12,
most renal hyperparathyroidism or secondary While patients with hyperparathyroidism or 2, or n ⫽ 17 parathyroids. Of the other 111, they
hyperparathyroidism goes away. However, pro- and normal parathyroid function had similar underwent subtotal parathyroidectomy (104 with
longed stimulation of parathyroid glands may 3-year graft survival rate (88 vs. 84, P ⫽ not sig- 3 glands removed and/or reoperative parathy-
result in autonomous production of parathyroid nificant), parathyroidectomy was associated roidectomy in 12 patients). Follow-up was for 5
hormone even after the relief and removal of the with decreased glomerular filtration rate after 3 years, and 94% of the patients were eucalcemic.
physiological stimulus. This occurs in perhaps years (44.7 ⫾ 20.0 vs. 57.7 ⫾ 23.7 mL/min, P ⫽ All patients with persistent hypocalcemia had
5% of all patients and by definition is tertiary ⫺0.04). However, there was no statistical differ- undergone subtotal parathyroidectomy. The in-
hyperparathyroidism, that is the parathyroids ence in 3- year graft survival rate (71% vs. 88%, cidence of permanent hypocalcemia was 7% after
now are out of control and do not respond to P ⫽ 0.06). I would surmise that there probably is subtotal or total parathyroidectomy and 0% after

www.medicalebookpdf.com

LWBK892_c42_p509-514.indd 514 10/28/11 5:33:59 PM

 Chapter 43: Transsternal, Transcervical, and Thoracoscopic Thymectomy for Benign and Malignant Disease 515

limited resection and although this is not statisti- was near 0%. Of note, the hospital stay was 4.3 parathyroid hormones into quintiles and utilized
cally significant, I would bet that an imaginative and 6.5 days whether it was minimally invasive the second quintile as the reference but there was
statistician could get this to a statistical signifi- or openly carried out. no association of the intact parathyroid hormone
cance because of the presence of 0%. The authors In a paper from Amsterdam, Kievit et al. values and achievement of the hemoglobin goals.
conclude: “Therefore a strategy of limited para- (World J Surg 2010;34:993–1000) reviewed a group The only data which seemed to be correlative was
thyroid dissection seems appropriate for patients of 64 adults and 8 children and adolescents treated serum albumin being >3.5 g/dL with the Bromo-
with 3HPT when the disease is limited to one or for secondary or tertiary hyperparathyroidism. cresol Green assay method being associated with
two glands.” On the basis of current evidence, that This was a retrospective study and the blood pa- meeting the hemoglobin goal. While I would not
may be a modest statement. rameters consisting of parathyroid hormone and ascribe the better outcome as far as hemoglobin
Another approach of Sun et al. (World J Surg calcium levels were obtained and compared with to the albumin levels are considered, one should
2009;33:1674–79) who, in the absence of renal all currently available articles on children with remind oneself that the level of serum albumin
dialysis at Nanjing Medical University, reviewed secondary or tertiary hyperparathyroidism. It is is inversely related to the extravascular albu-
34 secondary hyperparathyroid patients who difficult to translate their data which is in pico- min usually related to edema and thus children
underwent endoscopic total parathyroidec- moles for the hormone and millimoles for serum who were edematous had a higher destruction
tomy with autotransplantation among the first calcium. However, suffice it to say that the ef- of albumin and hence a lower serum albumin
67 cases at the Department of Minimally In- fectiveness of parathyroidectomy was 75% of the may had some correlation to the hemoglobin.
vasive Surgery over a 3-year period. The other total parathyroidectomy and forearm implants They did not deal with parathyroidectomy and
33 patients of the total of 67 cases underwent and did not significantly differ between children its effect on either albumin or hemoglobin but
traditional total parathyroidectomy with auto- and adults. It is likely that in the future more and noted that many of the patients with tertiary hy-
transplantation. Autotransplantation, therefore, more units will be utilizing subtotal parathyroi- perparathyroidism remained anemic even after
was used in both groups and does not answer dectomy based on the enlarged one or two glands parathyroidectomy.
the question of whether subtotal parathyroi- and careful follow-up. It does seem as if progress is being made in
dectomy on secondary hyperparathyroidism is In a final commentary paper, Smith et al. (Am this previously mysterious syndrome of second-
better for renal function or not. They are more J Kidney Dis 2010;55:326) investigate the anemia ary and tertiary hyperparathyroidism and its ef-
interested in us declaring that the minimally associated with renal failure and hyperparathy- fect both on serum calcium perhaps, glomerular
invasive approach is appropriate under these roidism in children in dialysis centers totaling filtration rate perhaps, renal graft survival, and
circumstances with a low morbidity and mortal- 588 patients followed in the center for Medicare perhaps serum albumin.
ity and shorter hospital stay. The recurrence rate Services of CMS. They stratified the level of intact J.E.F.

43 Transsternal, Transcervical, and Thoracoscopic

Thymectomy for Benign and Malignant Disease
Including Radical Mediastinal Dissection
Malcolm M. DeCamp and Alberto De Hoyos

Thymectomy is one of the most common me- acter characterized by soul, spirit, courage, The finding of thymic tumors in autop-
diastinal procedures performed by thoracic power, will, heart, and anger, it is also related sies in 1889 by Oppenheim and in 1901 by
surgeons. Myasthenia gravis (MG), an auto- to the herb thyme and to the thyme flower. Weigert first suggested an interrelation be-
immune disease characterized by weakness Rufus (98 to 117 CE), who lived in Ephesus, a tween the thymus and MG. Contemporane-
and fatigability following repetitive exer- center of learning on the western shore of ous invention of X-rays by Wilhelm Roent-
cise, is the most common indication for modern-day Turkey, is acknowledged as the gen in 1895 allowed diagnostic imaging of
thymectomy. Regardless of the etiology, first person to refer to the thymus gland in enlarged mediastinal structures. The first
malignant, benign, or autoimmune, com- humans. thymectomy for MG was performed in 1911
plete resection of all thymic tissue is the key The thymus gland gained clinical im- by Ernst Ferdinand Sauerbruch from Zur-
to state-of-the-art thymectomy. Thymec- portance once it was linked by the Swiss ich. He used a radiogram to diagnose thy-
tomy can be performed via a variety of op- physician Platter in 1614 to the sudden mic enlargement, associated it with the pa-
erative approaches. The purpose of this death of a 5-month-old boy from suffoca- tient’s MG symptoms, and performed a
Endocrine Surgery

chapter is to analyze the pathophysiology tion. An autopsy was performed at the re- successful transcervical thymectomy on a
of thymic diseases, the indications for sur- quest of the father as two other sons had 19-year-old woman.
gery in their treatment, and the available died similarly. This revealed a highly vascu- In 1936, Alfred Blalock became the first
techniques of resection to achieve accept- lar mass compressing the mediastinal person to perform a transsternal thymec-
able and durable outcomes. structures. This condition was subse- tomy in a 19-year-old woman with persis-
quently called “mors thymica or thymic tent, severe MG and an anterior–superior
HISTORY OF SURGERY OF THE death.” More than two centuries later, Sir mediastinal tumor that had only partially
Astley Cooper in 1832 described the death responded to three courses of radiotherapy.
THYMUS GLAND of a 19-year-old woman from a malignant Beginning with this case, and encouraged
The word thymus originates from the Greek thymic tumor invading the major veins of by the neurologist Ford, Blalock also dem-
word thymos, which has dual meaning. Al- superior mediastinum and compressing onstrated the relation between MG and
though it is synonymous with heroic char- the trachea. nonthymomatous thymus glands.

www.medicalebookpdf.com

LWBK892_c43_p515-527.indd Sec1:515 10/28/11 8:53:00 PM

 516 Part IV: Endocrine Surgery

Sir Geoffrey Keynes followed Blalock in

1942 when he performed a thymectomy
and completion thyroidectomy on one of
his previous patients with severe MG and
recurrent thyrotoxicosis 12 years after re-
moval of a goiter. The subsequent smooth
postoperative period encouraged Keynes,
who reported a series of 281 thymectomies
by 1956. His contributions to the evolution
of thymectomy included the separate evalu-
ation of the operative results of patients
with thymomatous and nonthymomatous
glands, and the precise documentation of
surgical thymic anatomy.
The transsternal approach remained the
“gold standard” for thymectomy until the
early 1960s. After Carlens described medi- Fig. 1. Embryologic development of the thymus and parathyroid glands from the third and fourth pha-
astinoscopy in 1959, Crile in 1964 and ryngeal pouches.
Akakura in 1965 reported their experience
with 24 cases of transcervical thymectomy.
In addition to MG, the indications for
thymectomy were extended to resection of
thymic cysts or suppression of rejection in ventral portion, which is destined to be-
renal transplant recipients. In 1969, Kirsch- come a thymic lobe. The entire third pouch ANATOMY
ner reported on 21 cases with only 1 death, separates from the pharynx during the 7th
and suggested that transcervical thymec- week. These thymic primordia migrate in a In the newborn, the thymus weighs 10 to
tomy be adopted as the preferred approach caudal and medial direction. Originally 12 g and continues to grow until puberty.
to resection, exclusive of thymomas. hollow, thymic primordia rapidly become Steinmann reported an average weight of
Other clinicians remained skeptical solid epithelial bars, and during the 8th 27.3 g with a standard deviation of 16.4 g
regarding completeness of transcervical week, the caudal ends of the paired compo- within the 1st year of life. At puberty, the
thymectomy. Reported clinical failures fol- nents of the thymus fuse together to form gland reaches its maximum weight of 20 to
lowing cervical excisions, in some cases what is generally a four-lobed gland that 50 g. Thereafter it enters a gradual involu-
necessitating a reresection, fueled the on- attaches to the anterior pericardium. The tion state, decreasing in mass to only 5 to
going debate of the optimal approach to organ, then being attached to the growing 15 g in the elderly. At this time, the paren-
thymectomy for MG. These discussions be- pericardium, descends into the mediasti- chyma is mostly replaced by fibrofatty
came more complicated after the reports num behind the sternum and anterior to tissue.
of Masaoka et al. in 1975 and Jaretzki in the great vessels. Incomplete migration The thymus is a bilobed glandular struc-
1988 demonstrating the presence of extrag- may potentially leave islands of thymus ture; however, its two lobes are rarely
landular thymic tissue in 74% of the cases. anywhere along the course of the primor- symmetrical. The thymus is located pre-
Investigators at the University of Pennsyl- dia. The lower capsule tends to be less dis- dominantly in the anterior–superior medi-
vania have reported comparable results tinct, and thymic corpuscles, as well as astinum, where it anteriorly covers the great
with transcervical thymectomy to trans- abundant lymphocytes, trail off into the vessels, pericardium, and the base of the
sternal thymectomy after using a specially surrounding mediastinal fat and nodal tis- heart. It is also in close proximity with the
designed sternal retractor that allowed ex- sue. Because of either premature arrest of anterior surface of the innominate vein as it
tended dissection through the limited cer- migration or deviation from its natural runs obliquely across the superior mediasti-
vical incision. With this report, the scale tract, the thymus gland itself may be found num to join the right brachiocephalic vein to
again tipped in favor of less-invasive sur- anywhere between the hyoid bone crani- form the superior vena cava (SVC; Fig. 2).
gery in the debate of thymectomy for MG. ally and the xiphoid process of sternum The thymus may sometimes lie adjacent to
caudally. either SVC on the right or the pulmonary
Although the thyroid, parathyroid, and artery on the left. One or both lobes may
EMBRYOLOGY thymus glands arise from the pouches of the also lie behind the left innominate vein
The thymus gland, together with the infe- same primordial pharynx, they separate in instead of in front of it. The two thymic
rior parathyroid glands, arises from the later stages of embryonic life. As the thymus lobes are fused in the midline, giving the
third pair of pharyngeal pouches (Fig. 1). descends caudally, the parathyroid glands gland its H-shaped configuration. The up-
Although the fourth pharyngeal pouches normally remain settled at the same level with per poles of each lobe reach into the neck
also give rise to a small amount of thymic and posterior to the lower poles of thyroid. where they join the thyroid gland by the
tissue, these are usually vestigial masses The parathyroid glands are also called para- thyrothymic ligaments on both sides. The
and these latter primordia in humans are thymic glands. In autopsy studies, as many as lower poles lie on the pericardium anterior
usually either absent or rudimentary. In 20% of inferior parathyroid glands are found to the heart.
the 6th week of gestation, epithelium of the within the thymic capsule in the neck or in The arterial supply of the thymus is
third pouch proliferates to form a dorsal the mediastinum. Although more common chiefly derived from the internal tho-
bulbar component, later becoming the in- for parathyroid tissue, thyroid tissue may also racic arteries, although it receives bran-
ferior parathyroid gland, and an elongated be present within the thymus gland. ches from inferior thyroid arteries and

www.medicalebookpdf.com

LWBK892_c43_p515-527.indd Sec1:516 10/28/11 8:53:00 PM

 Chapter 43: Transsternal, Transcervical, and Thoracoscopic Thymectomy for Benign and Malignant Disease 517

Fig. 2. Anatomy of the thymus gland. A: Lateral view, showing the relationship to the left brachiocephalic vein, the inferior
aspect of the thyroid gland, and the phrenic and recurrent laryngeal nerves. B: Anterior view, showing the relationship to the
pericardium and great vessels. The major arterial supply originates from the internal thoracic (internal mammary) arteries,
and the major venous drainage empties posteriorly into the left brachiocephalic vein.

pericardiophrenic arteries as well. There of cases in 1991. Jaretzki documented the The proper function of the immune sys-
may be small draining veins traveling with variations of extraglandular thymic tissue tem depends on the normal simultaneous
the arteries from any of the three sources. found in different mediastinal locations in development of cellular and humoral com-
However, the main venous drainage is 1997. These publications form the basis ponents, and normal interaction between
through one or two major trunks, formed for the ongoing debate on completeness them. Although thymus-centered T-cell
by convergence of multiple tributaries from and adequacy of thymectomy via various population is responsible for differentiating
both lobes, running posteriorly between the incisions. self-antigens from intruders and producing
lobes and draining into the anterior surface cell-mediated immune reactions, as seen in
of the innominate vein. Although it is a ma- PHYSIOLOGY AND delayed hypersensitivity reactions, the
jor lymphatic tissue, unlike a lymph node, bursa-dependent system, formed by the
the thymus gland lacks afferent lymph
PATHOPHYSIOLOGY bursa, lymphoid follicles, and plasma cells,
channels. There are efferent lymph chan- The thymus is a complex organ with epithe- is responsible for the production of immu-
nels, which only drain the capsule and fi- lial and lymphoid components. During in- noglobulins (A, G, and M) and specific anti-
brous septa of the gland and drain into fancy, the thymus is essential for the devel- bodies. Any disturbance in development of
anterior mediastinal, pulmonary hilar, and opment of cellular immunity. It is the main either system may lead to one of the various
internal mammary lymph nodes. Both sym- site for maturation of null lymphocytes into immunologic deficiency syndromes. Inter-
Endocrine Surgery

pathetic and parasympathetic nerve fibers T cells. The majority of cells in the thymus estingly, some of these syndromes have
are found in the thymus. are T lymphocytes and epithelial cells. These been associated with various neoplasms of
Numerous islets of thymic tissue, both cells comprise the two main structural lay- the thymus as well as with congenital thy-
macroscopic and microscopic, may be ers of the gland, the cortex and the medulla, mic hypoplasias and agenesis. Some mor-
found in the neck, middle mediastinum, respectively. Occasional lymphoid follicles phologic changes that the thymus can dis-
both pulmonary hili, aortopulmonic win- with B cells and germinal centers can also play have also been linked to hyperplasia,
dow, retrocarinal fat, diaphragm, and even be found. Although rare, myoid cells may be abnormal development, and infections.
within the pulmonary parenchyma. Masaoka a part of histologic picture in the thymus. Symptoms related to thymic disease are
et al. reported 72% of extracapsular micro- These cells act like skeletal muscle cells, in- categorized as the ones arising directly from
scopic collections of thymic tissue in the cluding expression of the acetylcholine re- the thymic lesion by either compression or
anterior mediastinum in 1975, and Fukai et ceptors (AChRs), and may be involved in invasion, symptoms associated with a pre-
al. came up with the same findings in 51.8% the pathophysiology of MG. viously described clinical syndrome (i.e.,

www.medicalebookpdf.com

LWBK892_c43_p515-527.indd Sec1:517 10/28/11 8:53:00 PM

 518 Part IV: Endocrine Surgery

MG, red cell aplasia, or hypogammaglobu- slow-growing tumors; however, they exhibit Hermelink proposed a classification system
linemia), or nonspecific systemic symptoms malignant potential as some demonstrate based on the origin of the cells more than
such as anorexia and fatigue. Developmen- local invasion, pleural dissemination, and the cell type (i.e., cortical, medullary, or
tal anomalies can involve the location of the systemic metastases without overt cyto- mixed subtypes). They differentiated the
thymus or its development. Failure of the logic features of malignancy. They are more origin of epithelial cells found in the thy-
thymus to descend into the anterior medi- common between ages 40 to 60 and do not moma according to their resemblance to
astinum might account for cervical thymic show predilection for either sex. the normal epithelial cells in other parts of
tissue, which can be mistaken for neoplasm, The clinical presentation of thymoma is the thymic lobule and classified the tumor
lymphadenopathy, or an enlarged parathy- extremely varied. In up to 50% of instances, accordingly. In cortical thymomas, the epi-
roid. This aberrant tissue can cause compres- these neoplasms are entirely asymptomatic, thelial cells are large and round or polygo-
sive symptoms such as stridor or dysphagia. discovered incidentally on chest imaging or nal, with clear round nuclei, conspicuous
Lymphocyte count and tests of immunologic at autopsy. Approximately 30% of patients nucleoli, and poorly defined cytoplasm. In
capacity may be diminished by thymectomy; present with local symptoms related to contrast, the epithelial cells of medullary
however, no particular clinical problems pressure or direct invasion. In 20% to 70% of thymomas are smaller and spindle-shaped
have developed to correlate with these labo- patients, thymoma is associated with with irregular or fusiform nuclei and incon-
ratory observations. systemic disorders that are primarily of spicuous nucleoli. The histologic features of
autoimmune origin. When present, these cortical thymomas suggest a more malig-
THYMIC NEOPLASMS concomitant diseases worsen the progno- nant phenotype, and indeed they are more
sis. The most common autoimmune disease aggressive. This classification was suggested
The epithelial subset of thymic neoplasms, associated with thymoma is MG. However, to have independent prognostic implica-
namely, thymoma, is the most common tu- up to 28% of thymoma patients will present tions. In their 80-patient series in 1990,
mor of the anterior mediastinum. It is fun- with an immune disorder other than MG. Pescarmona and colleagues found that the
damental in oncology that a successful The most common disorders include pure Müller-Hermelink (M-H) classification reli-
therapeutic approach to a neoplasm be red cell aplasia, lupus erythematosus, poly- ably predicted prognosis. Medullary thymo-
based on a definitive and prognostically re- myositis, and hypogammaglobulinemia. mas tended to be more encapsulated and
producible classification and staging sys- All thymomas originate from the thymic clinically acted benign, but cortical ones
tem. However, the classification of thymic epithelial cells; however, only about 4% of were invasive and malignant in nature.
tumors has been one of the most debated them consist of a pure population of epithe- When a modification of the Bernatz classi-
subjects of modern thoracic surgery and lial cells. Most have mixed populations of fication was used in the same 80-patient
oncology. There have been several classifica- lymphoid cells, to a varying extent. There series, there was no correlation found
tion proposals, focusing on one or more of have been two major approaches to histo- between the subtypes and their prognosis.
histology, embryology, and biology of the tu- logic classification of thymomas. In 1961, Wilkins (1995) also confirmed the M-H re-
mors, in an attempt to establish an agreed-on Bernatz et al., from Mayo Clinic, divided sults, as he noted only a few recurrences in
nomenclature. Although lymphomas are far thymomas into lymphocytic, epithelial, patients with medullary or mixed tumors,
more common than thymomas in children mixed, and spindle subtypes according to whereas the recurrence rate was much
and adolescents, the only role for surgery in the lymphocyte-to-epithelial cell ratio in higher in cortical tumors.
their treatment is for diagnostic and staging tumors. At that time, thymic carcinomas The World Health Organization’s (WHO)
purposes. Mesenchymal and germ cell tu- were not distinctly segregated, but grouped “Histological Typing of Tumors of the Thy-
mors of the thymus are uncommon. The with thymomas. In 1978, Levine and Rosai mus,” reported by Rosai in 1999, reflected
most common type is teratoma. Seminomas proposed a new classification, which proved the consensus of the pathologists special-
and nonseminomatous germ cell tumors to be of high clinical relevance. In this re- izing in thymic tumors (Table 1). The cellu-
also occur in the thymus, almost exclusively port, they divided the thymomas into be- lar origins of the various neoplasms are
in men. Thymic carcinoids are extremely nign (circumscribed) and malignant (inva- emphasized in this classification, which is
rare, often associated with endocrinopa- sive) types. Malignant thymomas were further a successful synthesis of the most widely
thies such as Cushing syndrome or inappro- divided into type I (invasive thymoma with used classifications and resembles more
priate secretion of the antidiuretic hormone. minimal atypia) and type II (showing mod- the M-H classification. Currently, the WHO
They are typically invasive, often recur, are erate to marked atypia). In this system, type classification appears to be the preferred
associated with extrathoracic metastases, II malignant thymomas correspond to thy- classification method in thymic neoplasms.
and have a poor prognosis. The thymus can mic carcinomas. Wick et al., in 1982, and In this classification, type A represents atro-
rarely be a site for metastasis as well. Lewis et al., in 1987, proposed the separa- phic adult-life thymic cells that are spindle
tion of thymic epithelial cell neoplasms or oval in shape, and type B represents bio-
Thymoma into thymomas and thymic carcinomas, active thymic cells, of fetus and infants,
which is now well accepted. Mixed thy- with dendritic or epithelioid appearance.
Thymomas are rare tumors. Despite this, moma cases with islets of thymic carci- Type B thymomas are further divided into
they account for 20% of all mediastinal neo- noma behave clinically like typical thymo- B1, B2, and B3 on the basis of increasing
plasms and comprise half of all primary tu- mas more than like thymic carcinomas. epithelial-to-lymphoid ratio and the emer-
mors found in the anterior compartment. These findings support the theory that thy- gence of atypia of the epithelial cells. Type
They may also be encountered in other ar- momas carry the potential for malignant AB thymomas display the common features
eas of the neck and the thorax, such as, but transformation into malignant thymic of type A and type B lesions. Type C tumors
not limited to, along the pleura, inside the carcinoma. are frankly malignant cells, and these le-
pericardial sac, over the diaphragm, within The Bernatz system remained the main- sions correspond to thymic carcinomas.
the lung parenchyma, and even as a poly- stay of thymoma classification until the There are at least nine subtypes of type C
poid lesion in the trachea. Thymomas are mid-1980s. In 1985, Marino and Müller- tumors, and they may be further subdivided

www.medicalebookpdf.com

LWBK892_c43_p515-527.indd Sec1:518 10/28/11 8:53:02 PM

 Chapter 43: Transsternal, Transcervical, and Thoracoscopic Thymectomy for Benign and Malignant Disease 519

Table 1 World
| Health Organization (WHO) Classification of Thymomas MYASTHENIA GRAVIS
M
and Carcinomas of the Thymus The original description of MG dates back
WHO histologic type Previous corresponding terminology tto the case report of the physiologist Sir
A Medullary thymomas; spindle cell thymoma Thomas Willis in 1672. The real recognition
of
o the clinical syndrome came after the re-
AB Mixed thymoma
port
p by Wilks in 1877, in which he described
B1 Predominantly cortical thymoma; organoid thymoma; lymphocyte- a young woman who died of a respiratory
predominant thymoma; lymphocytic thymoma paralysis.
p Autopsy did not reveal any cen-
B2 Cortical thymoma tral
t nervous system pathology that would
B3 Well-differentiated thymic carcinoma; epithelial; predominant explain
e the problem. In 1895, Jolly described
epithelial; squamoid thymoma the
t test now bearing his name, disclosing
the
t easy fatigability in the affected muscle
C Thymic carcinoma (with nine subtypes)
following
f repetitive stimuli. He then pro-
posed
p the name myasthenia gravis pseudop-
aralytica for the disease. In 1899, the Berlin
Society for Neurology and Psychiatry short-
into low-grade and high-grade malignant As part of the WHO thymoma classifica- ened the name to myasthenia gravis. How-
tumors. tion effort, it was suggested that a ever, only during the last two decades has
Besides the efforts of classifying the thy- TNM scheme be used in staging of all malig- the pathophysiology of this disorder be-
momas according to their histologic or nant thymomas and thymic carcinomas come well elucidated as the experiments
morphologic features, Masaoka et al. (1981) (Table 4). Because there has been so much revealed the microstructure, physiology,
proposed an anatomic classification based controversy regarding tumor classification and molecular composition of the nicotinic
on the presence or absence of gross or mi- during the past four decades, no authorized AChR.
croscopic invasion of the tumor capsule as TNM system has been adopted. The proposed The prevalence of MG has been esti-
well as its metastatic status (Table 2). Med- WHO TNM schema remains tentative, pend- mated at 43 to 64 per million population. It
ullary and mixed histology tumors are usu- ing validation of its reliability, reproducibil- has a predilection for females with a ratio of
ally not invasive and therefore correspond ity, and predictive power. 3:2. Its peak age is 20 to 30 in women and
to Masaoka stages I or II, whereas cortical To further enhance our understanding more than 50 years in men. The disease is
thymomas are more commonly invasive of thymic malignancies and provide sup- usually nonfamilial. The common present-
and more likely to be Masaoka stages of III port to patients and families with thymic ing symptom of the disease is an insidious
or IV. Later modifications of the Masaoka cancer, the Foundation for Thymic Cancer onset of generalized weakness. This is seen
classification, as suggested by Koga et al. Research (FTCR) organized meetings of in- in 85% of the patients. It is usually symmet-
(1994) and Nakagawa et al. (2003), have ternational leaders in the field, resulting in rical and becomes more intense at the end
been more widely adopted (Table 3). These collaborative initiatives. These include sev- of the day. Muscles innervated by cranial
incorporated microscopic incomplete cap- eral published meta-analyses as well as nerves are often the first to be affected;
sular invasion into stage I, leaving only National Comprehensive Cancer Network however, any striated muscle in the body
transcapsular invasion in stage II. (NCCN) guidelines for the management of may be involved. Some patients may pres-
thymic malignancies. The FTCR partnered ent with external ocular symptoms only,
with the National Cancer Institute to orga- such as ptosis and diplopia. These symp-
n the first International Conference on
nize toms may either spread to other muscle
Thymic Malignancies in 2009 (www.thymic. groups or remain confined to the eye, and
Table 2 Masaoka Clinical Staging
of Thymomas o As a result of these efforts, the Interna-
org). may be so subtle that patients may go
t
tional Thymic Malignancy Interest Group through several eyeglass prescriptions be-
Masaoka
stage Diagnostic criteria
(
(www.itmig.org) was created with broad in- fore they are diagnosed with MG. The worst
t
ternational and multidisciplinary represen- type of disease occurs when the bulbar
I Macroscopically, completely t
tation and held its inaugural meeting in muscles are involved. The symptoms may
encapsulated and, M 2010.
May include dysarthria with nasal tones caused
microscopically, no
capsular invasion
II Macroscopic invasion into
surrounding fatty tissue or
d i SSurgery

mediastinal pleura; or Table 3 |Modified Masaoka Clinical Staging of Thymomasa

g

microscopic invasion into

I Fully encapsulated tumor (a thymoma completely surrounded by a fibrous capsule of
Endocrine

capsule
varying thickness that is not infiltrated by tumor growth in its full thickness)
III Macroscopic invasion into
II Tumor infiltrates beyond the capsule into the thymus or mediastinal fatty tissue.
neighboring organ (i.e.,
E

Adhesion to the mediastinal pleura may be present

pericardium, great vessels,
or lung) III Macroscopic invasion into neighboring organs (i.e., pericardium, great vessels, or lung)
IVa Pleural of pericardial IVa Pleural of pericardial dissemination
dissemination IVb Lymphogenous or hematogenous metastasis
IVb Lymphogenous or hematog-
a
enous metastasis As used by Koga et al. (1994) and Nakagawa et al. (2003).

www.medicalebookpdf.com

LWBK892_c43_p515-527.indd Sec1:519 10/30/11 3:12:19 PM

 520 Part IV: Endocrine Surgery

ccules diffuse across the synaptic cleft and

Table 4 Tentative TNM Staging System by the World Health Organizationa bbind to postsynaptic ACh receptors on the
T factor endplate
e of the muscle cell. In MG patients,
tthis mechanism is blocked by an antibody-
TX Primary tumor cannot be assessed mediated
m attack on nicotinic AChRs on the
T0 No evidence of primary tumors muscle endplate. Clinically and physiolo-
m
T1 Macroscopically, completely encapsulated and, microscopically, no capsular invasion gically,
g MG should be differentiated from
tthe “myasthenic syndrome,” which is also
T2 Macroscopically, adhesion or invasion into surrounding fatty tissue or mediastinal
pleura, or microscopic invasion into capsule
kknown as the Eaton–Lambert syndrome. It
iis a rare defect of neuromuscular transmis-
T3 Invasion into neighboring organs, such as pericardium, great vessels, and lung sion
s and is usually associated with bron-
T4 Pleural or pericardial dissemination cchogenic carcinoma. It is characterized by
N factor weakness and easy fatigability of proximal
w
muscles of the extremities, with minimal
m
NX Regional lymph nodes cannot be assessed or
o no bulbar symptoms and decreased or
N0 No lymph node metastasis aabsent deep tendon reflexes.
N1 Metastasis to anterior mediastinal lymph nodes The autoimmune attack on the AChRs
aappears to involve both cellular and hu-
N2 Metastasis to intrathoracic lymph nodes except anterior mediastinal lymph nodes
moral
m immune systems. Approximately
N3 Metastasis to extrathoracic lymph nodes 880% to 90% of MG patients have serum anti-
M factor bbodies to the AChR. B lymphocytes, which
ssecrete anti-AChR immunoglobulin G, have
MX Distant metastasis cannot be assessed
been
b found in circulating blood as well as
M0 No hematogenous metastasis iintrathymic germinal centers. Anti-AChR
M1 Hematogenous metastasis aantibody and AChR interaction may occur
Stage grouping iin one of three ways: by accelerating the
degradation
d of AChR through a cross-linking
Stage I T1 N0 M0 pphenomenon, by directly blocking the re-
Stage II T2 N0 M0 cceptor site, or by complement-mediated
Stage III T1 N1 M0 ddegradation of the receptor sites. Besides
the
t amplified production of B cells in MG,
T2 N1 M0
aantigen-specific T-helper cells are increased
T3 N0,1 M0 aas well. AChR-specific T cells accumulate in
Stage IV T4 Any N M0 myasthenic thymus glands regardless of the
m
presence
p or absence of thymomas. The pe-
Any T N2, 3 M0
rripheral blood of myasthenic patients con-
Any T Any N M1 ttains an increased amount of these autore-
a
aactive T cells, which in turn activate AChR-
Based on Yamakawa’s proposed tumor–node–metastasis classification of thymoma with stage grouping as
detailed by Hasserjian et al. (2005). reactive
r B cells stimulating the anti-AChR
aantibody production.
Treatment is aimed at decreasing the
circulating antibody levels, using either im-
munosuppression or plasmapheresis. This
by palatal paresis, diminished voice, and classification (Table 6). Postoperative as- will result in clinical improvement in af-
dysphonia. Often, patients can bite on the sessment can be monitored again in a stan- fected individuals as long as the treatment
food but as they continue to eat, the masti- dardized schema by following the De Filippi continues. In appropriately selected patients,
cation muscles weaken until they can no classification (Table 7). the treatment that offers the best chance of
longer chew or close their jaws. Dysphagia Approximately 75% of patients with MG complete remission is thymectomy. In this
may be associated with nasal regurgitation have thymic abnormalities; the majority way, the source of autoimmunization is re-
of liquids. Weakening of neck and back having thymic hyperplasia. Although thy- moved, depleting the specific T-helper cell
muscles may necessitate manual support of momas are present in 10% to 25% of MG population and normalizing T-cell function.
the head. Pelvic weakness may result in patients, a higher proportion (30% to 60%) B cells and helper T cells primed before
waddling gait. The most dreaded complica- of patients with thymoma manifest some thymectomy would theoretically remain in
tion, however, is respiratory involvement. features of MG. circulation, thus accounting for incomplete
Weakness of respiratory muscles with pare- recovery in many patients who have under-
sis of intercostal muscles and the dia- Pathophysiology of gone thymectomy as well as the relatively
phragm may necessitate emergent medical prolonged period (up to 2 years) between
attention. The Osserman and Genkins clas-
Myasthenia Gravis operation and remission in many patients.
sification of MG is still very useful and The process of neuromuscular transmis- The ideal patient for thymectomy is young
widely adopted (Table 5). Standardized pre- sion in synapses is initiated with influx of with a short duration of symptoms and with
operative clinical staging has been recom- calcium into the motor neuron, which in significant disability and poor control with
mended by applying the Myasthenia Gravis turn leads to release of acetylcholine (ACh) anticholinesterase medications. Conversely,
Foundation of America (MGFA) clinical into the synaptic space. These ACh mole- elderly patients with nonthymomatous MG

www.medicalebookpdf.com

LWBK892_c43_p515-527.indd Sec1:520 10/28/11 8:53:02 PM

 Chapter 43: Transsternal, Transcervical, and Thoracoscopic Thymectomy for Benign and Malignant Disease 521

Table 5 Osserman and Genkins Classification System of Myasthenia Gravis (MG) Table 7 De Filippi Postoperative
Classification
I. Pediatric MG Class Description
A. Neonatal MG (1%)
Seen in offspring of myasthenic mothers Class 1 Complete remission, no medication
Self-limited (⬍6 weeks) Class 2 Asymptomatic, decreased
Caused by transplacental transfer of circulating AChR antibodies medication
Progression to juvenile or adult form is rare Class 3 Improved, decreased symptoms or
B. Juvenile MG (9%) decreased medication
Onset any time between birth and puberty Class 4 No change
Tends to be permanent
Nonmyasthenic mother Class 5 Worsening symptoms
MG disability is classified as in adult MG
Familial involvement
II. Adult MG
Group I: Ocular MG (20%)
Disease limited to ocular muscles a generally not helped by thymectomy. In
are
40% ultimately develop clinically generalized disease ggeneral, patients with mere ocular symp-
Electromyographic results may be positive in peripheral muscles ttoms, or those whose condition is well
Rarely progresses after 2 years of isolated ocular symptoms ccontrolled with acceptable medical treat-
Group IIA: Mild generalized disease (30%) ment, are usually not first-line candidates for
m
Initial ocular symptoms progress gradually to generalized symptoms and involve tthymectomy. On the other hand, Shrager
cranial, limb, and truncal muscles eet al. reported an actual 50% complete remis-
Respiratory muscles are spared ssion, with a 5-year Kaplan–Meier estimate of
Good response to medical therapy, with low mortality ccomplete remission of 57%, in patients with
Group IIB: Moderately generalized disease (20%) ppure ocular MG. They also noted that as
More severe generalized involvement m
many as 50% of pure ocular MG patients his-
Bulbar symptoms are common, such as dysarthria, dysphagia, feeding problems ttorically deteriorate or develop generalized
Relative sparing of respiratory muscles M
MG. In their ocular myasthenic patient group
Less responsive to medical therapy tthat had undergone thymectomy, the inci-
Group III: Acute fulminating MG (11%)
ddence of MG progression was zero.
Rapid onset of severe generalized weakness MG is unusual in childhood; however,
Prominent respiratory symptoms oone would expect the thymus to have a crit-
Severe bulbar, limb, and truncal weakness iical role in immunologic development. Al-
Poor response to therapy tthough no deleterious effects of thymec-
High association with thymoma ttomy have been shown in children older
High mortality rate tthan 3 years of age, it is usually advisable to
Group IV: Late severe MG (9%) ppostpone pediatric thymectomies until pu-
Patients with severe symptoms developing ⬎2 years after onset of ocular or mild MG bberty. In patients with MG and thymoma,
High incidence of thymoma tthe clinical course is influenced favorably
Poor response to therapy bby smaller tumor size.

SURGICAL TECHNIQUE
Thymectomy
Thymectomy is performed for benign and
Table 6 |Myasthenia Gravis Foundation of America Clinical Classification malignant thymic pathology. Thymectomy
m
Class Description ffor MG, with or without thymoma, must be
ccomplete in order to obtain drug-free re-
Class I Any ocular muscle weakness, other muscle strength normal
Endocrine Surgery

mission or at least significant improvement.

m
Class II (IIa, IIb) Mild muscle weakness affecting limb, axial, oropharyngeal or This principle has fueled the endless debate
respiratory muscles; any degree of ocular muscle weakness bbetween the enthusiastic proponents of the
Class III (IIIa, IIIb) Moderate muscle weakness affecting limb, axial, oropharyngeal or most extensive thymus and mediastinal fat
m
respiratory muscles; any degree of ocular muscle weakness rresection and the defenders of thymic
Class IV (Iva, IVb) Severe muscle weakness affecting limb, axial, oropharyngeal or rresection through a minimal incision. The
respiratory muscles; any degree of ocular muscle weakness MGFA Thymectomy Classification was pro-
M
pposed in an attempt to apply objectivity and
Class V Defined by intubation, with or without mechanical ventilation, except when
cconsistency in reporting the various ap-
employed during routine postoperative management
pproaches and techniques employed when
Adapted from Jaretzki A, Barohn R, Ernstoff RM, et al. Myasthenia gravis: recommendations for clinical research rremoving the thymus in patients with MG
standards. Ann Thorac Surg 2000;70:327–34. ((Table 8). There is evidence of superior

www.medicalebookpdf.com

LWBK892_c43_p515-527.indd Sec1:521 10/28/11 8:53:02 PM

 522 Part IV: Endocrine Surgery

vvital capacity, maximum expiratory force tibody levels. Plasmapheresis is also advis-
Table 8 Myasthenia Gravis Founda- should
s be measured, both before and af- able prior to thymectomy in patients with
tion Association Thymec- tter application of cholinergic inhibitors.
tomy Classification bulbar symptoms even if they are well con-
Maximum expiratory force is a good way of
M trolled on their current medical regimen.
T-1 Transcervical Thymectomy ppredicting an efficacious cough, and a mea- Three to five plasma exchanges, typically
(a) Basic surement
s of less than 40 to 50 cm H2O performed every other day, provide good
iindicates a higher risk of postoperative re- preoperative preparation. As plasmaphere-
(b) Extended
sspiratory complications. Vital capacity less sis is a nonspecific plasma exchange, other
T-2 Videoscopic Thymectomy tthan 2 L is another indicator of possible serum proteins such as clotting factors are
(a) Classic vventilatory compromise. depleted. To allow sufficient time for their
Every myasthenic candidate for thymec- resynthesis, surgery should be scheduled 2
(b) VATET ttomy should undergo a preoperative to 3 days after the final pheresis session.
T-3 Transsternal Thymectomy contrast-enhanced
c computerized tomo- Anticholinesterase agents (pyridostig-
ggraphic (CT) scan of mediastinum to rule out mine) should be discontinued 8 hours before
(a) Standard
a thymoma and to accurately assess vascular the surgery. If these medications are discon-
(b) Extended rrelationships. CT defines the anatomic loca- tinued any earlier, especially in severe cases,
T-4 Transcervical and Transsternal tion, t size, density, and extent of mediastinal it may result in a myasthenic crisis. On the
Thymectomy tumors, t identifies pulmonary and/or pleu- other hand, continuing the medications up
ral-based r metastases, and evaluates the sta- until the time of surgery, especially in patients
VATET, Video-Assisted Thoracoscopic Extended tus t of contiguous mediastinal lymph nodes.
Thymectomy.
with mild symptoms, may cause a postopera-
Multidetector
M CT with multiplanar recon- tive cholinergic crisis. Premedication in the
structive s capability may suggest local inva- operating room is usually minimal, consist-
results with the T-3b and T-4 techniques, sion of other mediastinal structures such as ing of atropine and a mild sedative. Long-
with proponents arguing that these ap- the chest wall, heart, pericardium, great ves- acting muscle relaxants are avoided and deep
proaches ensure maximal exposure and thus sels, central airways, or diaphragm and as- anesthesia is maintained by inhalational
more complete removal of all thymic tissue. sists in surgical planning. Most centers agree agents and short-acting narcotics. Use of suc-
Development of fiberoptic surgical tools, that magnetic resonance imaging rarely cinylcholine at induction is controversial. If
video applications in mediastinal and tho- adds much additional information to an op- possible, it is better to avoid it, but one should
racic surgery, and specially designed sternal timally performed and reformatted contrast- not hesitate to use it in case of a difficult intu-
elevators improved direct mediastinal enhanced CT. The utility of positron emission bation. First-generation cephalosporins are
vision and the completeness of removed thy- tomography in thymoma management is optimal for perioperative antibiotic prophy-
mus from a small cervical incision. This in unknown. In the presence of clinical and ra- laxis. Aminoglycosides are to be avoided as
turn allowed the proponents of limited- diologic evidence for a resectable thymoma, they may increase neuromuscular blockade.
incision approaches to improve the scope of the surgical approach should be a full me-
their resections and report outcomes that dian sternotomy in order to obtain complete
had remission rates comparable with those resection. A preoperative tissue biopsy is un-
TRANSSTERNAL THYMECTOMY
of open extended or maximal thymectomies. necessary and likely contraindicated because
The 1990s saw the advent of video-assisted of the risk of seeding the ipsilateral pleural
Standard Thymectomy
thoracic surgery and yet another approach space. There are however, reports of video- A standard thymectomy can be accom-
to thymic surgery. Given the absence of com- assisted thoracoscopic surgery (VATS) ap- plished via either a full or partial sterno-
parative studies, each of these approaches is proaches to resection of small thymomas tomy. For nonthymomatous MG, a partial
in use today and will be discussed here. (stage I and II). The goal of surgery remains a sternotomy provides sufficient exposure. If
complete (R0) resection with inclusion en a partial sternotomy is chosen, a T-shaped
Preoperative Evaluation bloc of any adjacent structures involved by sternal incision through the fourth inter-
tumor such as pericardium, pleura, lung, or costal space facilitates excision of the
and Preparation major vessels. Margins of resection include inferior thymic poles. There is consensus
Patients undergoing thymectomy for MG the thyroid gland superiorly, diaphragm infe- regarding performing full sternotomy in
should not be rushed into the operating riorly, and both phrenic nerves laterally. Mi- any patient with suspected thymoma, or
room until their medical condition is opti- croscopic (R1) and macroscopic (R2) incom- conversion of incision to full sternotomy in
mized. MG surgery is usually safe and well plete resections are to be avoided but if case of intraoperative finding of thymoma.
tolerated provided that a systematic, unavoidable should be treated with adjuvant The detailed technique of surgical dis-
meticulous preoperative evaluation and radiotherapy with consideration of chemo- section will be described here. The tech-
preparation is performed. A team approach therapy as indicated by the NCCN guidelines nique used in standard thymectomy is the
involving the anesthesiologist, neurologist, (www.nccn.org). Fit patients who present same as for extended thymectomy except
pulmonologist, respiratory therapist, inten- with localized but marginal or unresectable that there is a limitation in reaching cau-
sivist, and thoracic surgeon is mandatory to disease should undergo core needle biopsy dally to the lower-most part of the anterior
minimize risk and achieve the desired out- to confirm the histology followed by induc- mediastinum and above the diaphragm be-
come. The primary neurologist is charged tion chemoradiotherapy in an attempt to al- cause of the intact lower sternum.
with establishing an optimal medical regi- low subsequent resection.
men of anticholinesterases and immune- If the MG patient is unstable and/or Extended Thymectomy
modulating drugs including corticoster- symptoms are poorly controlled despite
oids. A preoperative spirometric workup is maximal maintenance therapy, intravenous Extended transsternal thymectomy in-
essential to forecast possible perioperative immunoglobulin infusion or plasmapheresis volves a full median sternotomy through
respiratory complications. In addition to is performed to diminish the circulating an- either a midline or transverse submammary

www.medicalebookpdf.com

LWBK892_c43_p515-527.indd Sec1:522 10/28/11 8:53:03 PM

 Chapter 43: Transsternal, Transcervical, and Thoracoscopic Thymectomy for Benign and Malignant Disease 523

skin incision. It is planned to overcome the roid use and in the presence of abundant identified and safely divided as the inferior
shortcomings of standard thymectomy in mediastinal fat. En bloc resection of all medi- lobes are elevated. Once the dissection is
removing all of the thymic tissue beginning astinal fat tissue, including both mediastinal completed on both sides up to the anterior
at the diaphragm and extending cranially pleural sheets, will ensure the inclusion of borders of phrenic nerves, and the speci-
together with complete anterior mediasti- all of the thymic remnants in the resected men is separated from the anterior surface
nal fat exenteration. It only lacks the acces- specimen. Initially, both pleural spaces are of the innominate vein, the only attachment
sory cervical incision from the transsternal– opened and the phrenic nerves identified. that remains would be the superior horns of
transcervical (maximal) thymectomy. Then, by using sharp and blunt dissection, the gland. This part of the dissection is car-
the overlying mediastinal pleurae are ried out cautiously to avoid premature dis-
Surgical Technique pushed to the sides to bring the thymus and ruption as the superior horns may be very
left innominate vein into view. Once the an- delicate and extend well up into the cervi-
The patient is positioned supine with a terior surface of the gland is exposed, the cal planes. Inferior parathyroid glands
transverse shoulder roll behind the scapulae mobilization starts at the diaphragm. The should be avoided and left with their blood
and with the head in extension. A standard mediastinal fat, including the anterior peri- supply intact if they are visualized. Venous
midline incision is made starting from one cardiophrenic fat pad, is elevated bilater- tributaries between the thymic horns and
fingerbreadth below the suprasternal notch, ally and continued superiorly with the inferior thyroid plexus should be ligated
extending down to below the xiphoid pro- lower lobes of the thymus. The phrenic and divided. The fatty tissue between the
cess. In case of standard thymectomy, the nerves should always be kept under direct SVC and aorta is swept anteriorly toward
incision is prematurely ended at the level of vision to avoid injury. The lymph nodes and the mobilized thymus. Similarly, the lymph
the fourth intercostal space. Because many fat that course along the nerves are also areolar tissue within the aortopulmonary
of the patients are young women, a trans- separated and included with the specimen. window deep under the innominate vein is
verse submammary incision might be cos- As the dissection moves cranially, the spec- included with the specimen, completing
metically preferable (Fig. 3). The presternal imen should be elevated off the pericar- the excision. Extra caution is needed during
soft tissue and the fascia overlying the ster- dium and sharp dissection should be car- this radical anterior mediastinal lymph node
num are cut in the midline with electrocau- ried strictly on the pericardium. dissection to avoid the left phrenic, vagus,
tery. Once the cleido-cleido ligament is di- The arterial blood supply to the thymus and recurrent laryngeal nerves within the
vided with caution to avoid the vascular gland is laterally from the internal thoracic aortopulmonary window and along the left
structures that may lie posterior to it, the arteries. These branches are isolated and upper part of the dissection as such an in-
space posterior to the manubrium is devel- ligated appropriately. Once these anchoring jury would be devastating for a myasthenic
oped from the mediastinal tissues with blunt vascular structures are divided, the gland patient.
finger dissection. Similar digital dissection can be rotated upward, exposing its poste- The presence of a thymoma mandates a
is carried out inferiorly behind the xiphoid rior surface (Fig. 4). The thymic veins drain- thorough evaluation of resectability prior
process and the lower end of the sternum. ing into the innominate vein are easily to embarking on thymectomy. The surgeon’s
The sternum is vertically split in the midline
with a reciprocating or oscillating saw.
Because of its involution and since it is
mostly filled with fibrofatty tissue, the thy-
mus gland is often hard to distinguish from
mediastinal fat in the adult. This is espe-
cially true in patients with long-term ste-

Endocrine Surgery

Fig. 3. The Y-shaped skin incision, with a ce-

phalad skin/subcutaneous flap, allows access to
the entire sternum for midline sternotomy while Fig. 4. A: Division of the branches from the internal thoracic arteries allows the en bloc specimen to be
maintaining cosmesis (especially in females) of rotated upward, exposing the undersurface of the gland and the draining veins. B: The brachiocephalic
the upper chest area. vein is exposed and the thymic veins are isolated and divided between ligatures or clips.

www.medicalebookpdf.com

LWBK892_c43_p515-527.indd Sec1:523 10/28/11 8:53:03 PM

 524 Part IV: Endocrine Surgery

assessment of local invasion is critical in thymomatous patient group. Although the ryngeal nerves and the inferior parathyroid
defining the precise Masaoka stage (Tables majority of myasthenic patients who glands are usually identified and preserved. If
2 and 3), which in turn influences decisions underwent thymectomy experienced sig- it becomes difficult to differentiate inferior
regarding adjuvant treatments. A complete nificant improvement in their symptoms, parathyroid glands from the thymus tissue,
exploration includes inspection and palpa- drug-free remission was achieved predomi- or the ectopic thymus tissue, a frozen section
tion of both pleural spaces, the lung paren- nantly in patients with earlier Osserman can be sent for analysis and confirmation.
chyma, and the diaphragmatic and pericar- classes. This observation supports the rec- Following the true cervical portion of the
dial surfaces. Any tissue or organ involved ommendation for early thymectomy, as pro- dissection, the cleido-cleido ligament is cut
by direct invasion with the thymoma should gression of symptoms was associated with vertically and the prethymic plane is sepa-
be included in the en bloc resection. Dense an incomplete response to thymectomy. rated from posterior sternal plate by blunt
adherence of a thymoma to the pericardium finger dissection. The gland is palpated for
requires that a portion of the parietal peri- nodular or invasive characteristics. A special
cardium be included with the specimen.
TRANSCERVICAL THYMECTOMY narrow right-angled retractor is placed be-
Direct invasion of the myocardium is rare. The original transcervical thymectomy de- hind the sternum and attached to a self-re-
Droplet metastases along the pericardium scribed in the early 1970s involved removal taining apparatus for upward traction. With
and/or pleura should also be excised. In an of only the intracapsular thymus gland. Such the help of headlight illumination, the ante-
adult, one but not both phrenic nerves can a technique will not suffice as acceptable rior mediastinum is then well visualized. The
be resected if necessary. If the patient also therapy for MG. In recurrent cases following already mobilized upper half of the gland is
suffers from MG, every effort to preserve basic transcervical thymectomy, transsternal lifted up and dissection is carried down pos-
diaphragmatic innervation should be made. reoperations revealed 2 to 60 g of retained terior to the thymus until the innominate
Invasion of the innominate vein or SVC may thymic tissue, including thymomas. With vein is exposed and the thymic venous
require local resection. When possible, de- specialized retraction, improved instrumen- branches isolated where they drain into in-
fects in these low-pressure vessels should tation, and illumination, the technique used nominate vein. These branches are ligated
be reconstructed with autologous tissue in selected patients with thymic hyperplasia and divided under direct vision. After this is
patches, transposition of the SVC or innom- only has achieved results comparable with accomplished, the remaining attachments of
inate vein to the right atrial appendage, or those of transsternal approaches. Moreover, the gland and pericardial fat pad are dissected
interposition native vein or prosthetic proponents argued that patients with MG caudally with the combination of sharp and
grafts. If the right brachiocephalic to the may choose transcervical removal of the thy- blunt dissection, as well as cranial traction,
SVC connection and the left jugulo-subcla- mus earlier in the course of their disease ow- off of the pericardium and bilateral pleural
vian confluence remain intact, then an iso- ing to its superior cosmetic results and lower surfaces. Although the dissection technique
lated resection of the innominate vein can morbidity. Because the duration of symptoms is almost identical to that of transsternal
be left unreconstructed. has an adverse effect on the MG response to thymectomy, the major difference is the in-
Following resection of the gland, metic- thymectomy, an earlier commitment to sur- ability to keep the phrenic nerves under direct
ulous hemostasis is performed. Patients gery could provide better outcomes. vision at all times. Therefore, utmost care
who underwent plasmapheresis prior to Following the same preoperative prepara- should be paid to the anatomic landmarks
surgery may tend to bleed more postopera- tion as for transsternal thymectomy, the pa- and to staying away from the possible course
tively. A chest tube placed from the right tient is positioned supine on the operating of the phrenic nerves. If there is any invasion
inframammary chest wall, across the medi- table, with a roll behind the shoulders and of pleura, it should be resected en bloc with
astinum, and extended to the contralateral the neck extended. Anesthesia equipment is the specimen and may necessitate conver-
apex usually provides adequate postopera- positioned laterally in relation to the patient’s sion to a sternotomy or VATS approach.
tive drainage. For more extensive resec- head as the surgeon is seated at the head of After removal of the specimen, the ante-
tions, the pleural spaces can be drained the bed. As there is always the possibility to rior mediastinum should carefully be in-
separately. The sternum is reapproximated convert to an open sternotomy in case of an spected for satisfactory hemostasis. Unless
with stainless-steel wires and the soft tis- emergency or unexpected finding (thy- the pleural spaces are opened, no chest
sues with absorbable sutures in layers. Post- moma), the surgical field should be wide tube is required. A red rubber catheter is
operatively, the patient is extubated in the enough to expose such anatomic landmarks placed into the mediastinum through the
operating room, the recovery room, or in- to allow this surgical conversion. The inci- incision during closure of the layers. Once
tensive care unit and is closely followed by sion is a transverse curvilinear incision ap- the strap muscles and platysma layers are
the surgery, anesthesia, and neurology teams proximately 2 cm above the sternal notch. approximated with absorbable sutures, and
for signs of myasthenic crisis. Patients are After the skin incision, the platysma is cut the lungs are fully expanded, the red rubber
usually maintained on their preoperative and both superior and inferior skin flaps are catheter is placed on suction and removed.
medications as MG response to thymec- raised by electrocautery dissection. The strap The skin is closed with a running absorb-
tomy is usually slow to evolve. muscles are separated and retracted laterally able subcuticular suture.
Following transsternal thymectomy, on both sides. The upper poles of the thymus Major contraindications to transcervical
Scott and Detterbeck reported 78% of pa- gland are usually located at this tissue plane thymectomy are suspicion of thymoma and
tients had improved by at least one modi- lying superficial to inferior thyroid vessels. the patient’s inability to fully extend the
fied Osserman class and 69% had complete Initially, the upper portion of the thymus neck. Previous sternotomy or mediastinal
remission in Osserman classes I, II, and III. gland and surrounding fat tissue is dissected surgery also preclude the transcervical ap-
Masaoka reported a 46% remission rate at off of the trachea, thyroid gland up to its isth- proach. The most important criticism
5 years, 67% at 15 years, and 90% overall pal- mus, and inferiorly to the sternal notch. Ecto- against transcervical thymectomy is the
liation for the nonthymomatous group. The pic thymus tissue should always be expected higher likelihood of incomplete resection of
same investigators noted only a 32% remis- and searched for, deep to and superior to the the thymus tissue and, accordingly, a lower
sion rate and 82% palliation rate for their upper horns on both sides. The recurrent la- rate of complete remission. Cooper et al., in

www.medicalebookpdf.com

LWBK892_c43_p515-527.indd Sec1:524 10/28/11 8:53:04 PM

 Chapter 43: Transsternal, Transcervical, and Thoracoscopic Thymectomy for Benign and Malignant Disease 525

three different reports, have presented com- in the anterior axillary line. If needed, an- Kong retrospectively compared their results
plete remission rates of 52% at 3.6-year fol- other posterior port can be placed for lung with those of a patient population that was
low-up, 35% at 5 years, and 44% in 8.4 years. retraction. The entire hemithorax is care- previously treated by the same surgical
In the report by Shrager et al., the actuarial fully examined for metastatic disease or for team using a transsternal approach. Al-
complete remission rate was 43% at 4.6 direct mediastinal pleural involvement. In though the operative time was significantly
years. These results were comparable with case of a thymoma or invasive disease, con- longer, the hospital stay and postoperative
the 50% actuarial complete remission rate version to open sternotomy is recom- parenteral narcotic requirements were sig-
in Jaretzki’s report of combined, maximal mended. The mediastinal incision starts nificantly less in their VAT thymectomy
transcervical–transsternal thymectomies. from just anterior to the SVC, which is group.
the cardinal landmark in the right chest.
Once the pleura are opened longitudinally, Technique for Left-Sided
VIDEO-ASSISTED the thymus is exposed. The plane between VAT Thymectomy
the anterior surface of the thymus and me-
THORACOSCOPIC THYMECTOMY diastinal fat pad and the posterior table of Under general anesthesia via a double-lu-
Thymectomy can be accomplished using the sternum is dissected across the medi- men endotracheal tube, the patient is ro-
video-assisted thoracoscopy (VAT) using a astinum to the contralateral side. The right tated 45 degrees toward the right lateral
variety of approaches. These include right- inferior horn of the thymus is identified and decubitus position. Typically, three or four
or left-sided VAT thymectomy, bilateral VAT dissected off the pericardium and aorta, be- thoracoscopic ports are used. The ports are
thymectomy, bilateral VAT combined with ginning at the diaphragm inferiorly and ex- located in the fourth intercostal space along
a cervical approach for extended thymec- tending cranially to the innominate vein. the midclavicular line, a camera port in the
tomy (video-assisted thoracoscopic extended Often, simple blunt dissection with anterior fifth intercostal space at the anterior axil-
thymectomy (VATET), Table 8), bilateral and cephalad retraction of the gland is suf- lary line, and the other working ports in the
VAT combined with a subxiphoid approach, ficient. The thymic venous branches drain- fourth intercostal space approximately
and VAT thymectomy with sternal and an- ing into the innominate vein are isolated, 2 cm lateral to the anterior axillary line, and
terior chest wall elevation. Both right- and doubly clipped, and divided. The left infe- in the sixth intercostal space between the
left-sided approaches have their advantages rior horn is dissected free using the same anterior axillary and the midclavicular
and limitations. In left video-assisted tho- gentle combination of blunt dissection and lines. The entire left hemithorax is exam-
racic thymectomy, it is easier to mobilize cephalad retraction. ined to locate the important structures,
the left inferior pole and pericardial fat tis- Once the two inferior poles are freed up such as aorta, subclavian artery, and phrenic
sue lying laterally along the left ventricle. to the isthmus and venous branches are di- nerve, and to look for tumor or thymic de-
The aortopulmonic window is also more di- vided, traction is applied anteriorly and in- posits on pericardial, pleural, and diaphrag-
rectly visualized. On the other hand, dissec- feriorly to allow the dissection of superior matic surfaces. If an invasive thymoma is
tion along the innominate vein and visual- horns from the surrounding mediastinal found, the procedure is converted to a me-
ization of the SVC can be quite challenging. and cervical tissue. If one or both superior dian sternotomy.
The proponents of right-sided VAT thymec- horn(s) of the thymus gland pass behind the The dissection begins with left inferior
tomy use the SVC as a helpful landmark, innominate vein, it/they should be carefully horn and the pericardial fat pad, which is
and can more easily identify the innomi- dissected off the vein before they can be separated from the diaphragm inferiorly.
nate vein. Combinations of transcervical, freed safely from the neck. The descending The mediastinal pleura is incised along the
subxiphoid, and bilateral VAT thymectomy blood supply within the inferior thyroid course of the left phrenic nerve, leaving
may allow for more extended thymic resec- plexus may require clips for adequate he- 1 cm of margin anteriorly. The adjuvant use
tion. Despite this, the complexity of multi- mostasis. Cautery should be avoided here of pneumomediastinum performed preop-
ple incisions is cumbersome, associated to prevent injury to the recurrent laryngeal eratively or low-level (5 to 10 cm H2O) CO2
with postoperative pain similar to that fol- nerves. Once the thymus gland is com- insufflation intraoperatively has been re-
lowing sternotomy, and lacks any evidence pletely free, it is removed in an endo bag ported to facilitate separation of the gland
for therapeutic benefit. Currently, only right through the most anterior trocar incision, from the pericardium and posterior ster-
or left VAT approaches to thymectomy are as this is usually the widest intercostal num. The dissection is then continued ce-
performed with significant frequency to space. phalad bluntly with pledget dissectors to
warrant a detailed description. In case of a clinical stage I or II thymoma, the level of the innominate vein. Before pro-
the dissection may be modified according ceeding above the innominate vein, it is
Technique for Right-Sided to its size and location. If it is located to the advisable to dissect the thymus off the
VAT Thymectomy left of the midline and is large, a left VAT sternum anteriorly and complete the mobi-
Endocrine Surgery

thymectomy may also be performed. How- lization of the right lower horn. Utmost care
Following the initiation of general anesthe- ever, VAT thymectomy for thymoma is sug- should be given to avoid an injury to the
sia with a double-lumen endotracheal tube, gested only for stage I thymomas. After re- contralateral phrenic nerve or to opening
the patient is positioned in full left lateral moval of the specimen, the bed is closely the opposite pleural space. The thymic veins
decubitus position with the bed rotated 30 examined for bleeding and completeness of draining into the innominate vein are
degrees to the right to allow the lung to fall the resection. The brachiocephalic veins are then isolated, clipped, and divided. This
away posteriorly. The port for a 0-degree or skeletonized, and the junction where they is followed by the dissection of the
a 30-degree telescope is made at the fifth form the SVC is clearly visualized. The pleu- superior horns up to the level of fascial
intercostal space along the posterior axil- ral space is drained with a small chest tube attachments to the thyroid gland low
lary line. The remaining working ports are or silastic drain and the port incisions are within the neck. The intact thymus gland is
located at the third intercostal space in the closed in layers. In their early experience extracted from the chest in an endo bag
midaxillary line and fifth intercostal space with VAT thymectomy, Yim et al. from Hong through the most anterior access port. The

www.medicalebookpdf.com

LWBK892_c43_p515-527.indd Sec1:525 10/28/11 8:53:04 PM

 526 Part IV: Endocrine Surgery

surgical field is policed for bleeding and any Technique of Robotic Thymectomy ized and the underlying lung identified. The
extra pericardial fat tissue is removed from pleura is gently incised and entry to the
the pericardiophrenic angles, aortopulmo- RATS thymectomy can be performed contralateral pleural space is achieved. At
nary window, and aortocaval groove. Once through a right- or left-sided approach. Ad- this point, the dissection moves toward the
the dissection is complete, the junction of vantages of the left-sided approach include thoracic inlet and the fat covering the in-
both brachiocephalic veins where they form better access to the aortopulmonary win- nominate vein is dissected. The left innomi-
the SVC should be clearly visualized. The dow and lower possibility of phrenic nerve nate vein is identified and the dissection
pleural space is appropriately drained injury. The left-sided approach may allow a continues along the border of the vein to
and the port incisions are closed in simple more extensive resection of ectopic thymic the point where the thymic veins are identi-
layers. tissue than the right-sided approach and fied. These veins can be controlled and di-
Regardless of which VAT approach to gives remission rates similar to maximal vided with electrocautery or clipped and
thymectomy is used, there are shared ben- thymectomy in an early, highly selected clin- divided. The left superior thymic horn is
efits such as less postoperative discomfort, ical review. Advantages of the right-sided then identified and dissection performed
a shorter hospital stay, superior cosmesis, approach include easier identification of by applying traction and gentle electrocau-
and acceptance of surgery by the patient the innominate vein and a larger operative tery until the entire horn is dissected from
earlier in the disease course. The thoraco- space for improved maneuverability of the the thyroid attachments. Care is taken to
scopic procedure is generally more time- instruments. avoid injury to the innominate vein or
consuming and requires additional techni- Placement of the incisions is, however, avulsing thymic venous branches. The right
cal expertise. The patient must be able to similar for both approaches. The patient is thymic horn is dissected in a similar fash-
tolerate single-lung ventilation for a pro- intubated with a double-lumen endotra- ion. The plane of dissection in the right
longed period of time. Although the re- cheal tube for selective single-lung ventila- hemithorax is then carried cephalad until
sponse rates reported with VAT approaches tion. For a left RATS thymectomy, the pa- the innominate vein is reached at the con-
are comparable with the results of more in- tient is positioned left side up at a 30-degree fluence with the SVC. The right phrenic
vasive approaches, the complete remission angle with a bean bag or with a roll along nerve is usually protected by the SVC and
rates are still somewhat lower, likely be- the left paraspinal area. The camera port for care should be taken not to pull the nerve
cause of shorter follow-up and limited ac- the 0-degree stereo endoscope is introduced into the field of dissection. The entire thy-
crual in reported series. The variety of through a 15-mm incision in the fifth inter- mus gland, fatty mediastinal tissue, and the
approaches to resection and inconsistent costal space on the midaxillary line. CO2 cervical extensions are resected and the
use of adjunctive measures, such as pneu- insufflation is utilized to aid with exposure specimen is placed in a bag. Following ex-
momediastinum or CO2 insufflation, has (6 to 10 mm Hg). Two additional ports are traction of the specimen and complete he-
hindered adoption of a standard approach placed: one in the third intercostal space on mostasis, a 24F or 28F chest tube is inserted
to VAT thymectomy. the midaxillary region and another in the through the lower port and directed trans-
fifth intercostal space on the midclavicular mediastinally so that the tip of the tube is in
line. Two arms of the robotic system are the right pleural space. The lung is rein-
ROBOTIC THYMECTOMY then attached to the two access ports and a flated and the incisions closed. The patient
Incorporation of robotic surgical systems third arm is attached to the endoscope. The is extubated in the operating room and af-
has been proposed by some to enhance ma- left arm controls an instrument for grasp- ter a period of observation in the recovery
neuverability of instruments and precision ing of the thymus and the right arm has an room, the patient is admitted to a regular
of surgical dissection of the thymus when endoscopic dissection device with electro- surgical floor. The chest tube is typically re-
compared with conventional VATS thymec- cautery function (cautery hook). The dis- moved the following day and the patient
tomy. While the feasibility and safety of section starts inferiorly at the left pericar- discharged on postoperative day 1 to 3.
robotic-assisted thoracoscopic surgery diophrenic angle and continues along the
(RATS) thymectomy has been proven, no anterior border of the phrenic nerve. Care is POSTOPERATIVE
additional benefits have been demonstrated taken to avoid current injury to the phrenic
over the VATS approach. Proponents of nerve by staying several millimeters away
MANAGEMENT
RATS suggest that robotic surgery is more from the nerve. The dissection is continued Following thymectomy, the majority of the
suitable than VATS for either complete or cephalad toward the thoracic inlet at the patients can be extubated in the operating
extended thymectomy because of easier point where the phrenic nerve crosses over room or in the recovery area within a few
dissection of the upper horns, better con- the innominate vein. The thymic tissue is hours. Frequent evaluations of the myas-
trol of the upper thymic veins, and improved dissected from the pericardium by grasping thenic patient by the anesthesiologist, sur-
unilateral access to the entire anterior me- the thymus and dividing the areolar tissue geon, and/or neurologist with periodical
diastinum. Disadvantages of RATS include with electrocautery from the phrenic nerve measurements of negative inspiratory force
the initial expense of the equipment, lack of toward the retrosternal area. At this point, and forced vital capacity may allow the
formal training, and a steep learning curve. the retrosternal plane of dissection is estab- extubated patient to be cared for on a stan-
Several groups have reported their experi- lished by gently grasping the thymus down- dard postsurgical ward. Some authors
ence with RATS, mostly for MG. The median ward and electrocautery is utilized to incise strongly recommend that these patients be
operating time for the entire group of ap- the mediastinal pleura away from the inter- followed in an intensive care setting for at
proximately 200 patients was 2 hours, with nal mammary vessels. This plane of dissec- least 24 hours. Postoperative analgesia is
a range from 1 to 5.2 hours. The mortality tion is carried from the midsternum toward maintained by administering small doses
for the group was 0%, the morbidity was 2% the thoracic inlet until the prior plane of of intravenous morphine or by patient-
to 10%, and the length of stay was a median dissection is reached if front of the innomi- controlled analgesia. It is advisable to start
of 2 to 5 days. RATS has also been utilized nate vein. Retrosternal dissection is contin- oral intake cautiously and slowly. Once the
for resection of small thymomas. ued until the contralateral pleura is visual- patient tolerates liquids without symptoms

www.medicalebookpdf.com

LWBK892_c43_p515-527.indd Sec1:526 10/28/11 8:53:04 PM

 Chapter 43: Transsternal, Transcervical, and Thoracoscopic Thymectomy for Benign and Malignant Disease 527

of choking, cough, or aspiration, the diet tory failure such as phrenic nerve injury. Castle SL, Kernstine KH. Robotic assisted thymec-
can be advanced. Following drain removal, The latter can be suspected by the presence tomy. Semin Thorac Cardiovasc Surg 2008;20:
parenteral analgesia is converted to an oral of an elevated diaphragmatic contour in full 326–31.
Fukai I, Funato Y, Mizuno T, et al. Distribution of
agent. Most patients are able to return to inspiration on an upright chest radiograph. thymic tissue in the mediastinal adipose tissue.
normal activity and work within 2 to 4 Phrenic nerve conduction studies or fluoro- J Thorac Cardiovasc Surg 1991;101:1099.
weeks following transsternal thymectomy scopic or ultrasound evaluation of diaphrag- Jaretzki A III. Thymectomy for myasthenia gravis: an
and 1 to 2 weeks following transcervical or matic movements may confirm isolated analysis of the controversies regarding technique
video-assisted thoracic thymectomy. phrenic dysfunction. In the absence of some and results. Neurology 1997;48(suppl 5):S52.
The care of a myasthenic patient requires anatomic explanation for ventilator depen- Kirschner PA. The history of surgery of the thymus
gland. Chest Surg Clin N Am 2000;10:153.
teamwork, with an experienced neurologist dence, and if reinitiation of cholinesterase Levine G, Rosai J. Thymic hyperplasia and neopla-
involved throughout the perioperative pe- inhibitors and stress dose steroids does not sia: a review of current concepts. Hum Pathol
riod. Immunosuppressive medications, such stabilize the patient, plasmapheresis should 1978;9:495.
as azathioprine, mycophenolate, or cy- be instituted and continued daily. Proper Masaoka A, Mondem Y, Nakahara K, et al. Follow-
closporin, are usually continued in the post- preoperative preparation of MG patients, up study of thymoma with special reference to
operative period; however, the continuation especially those with bulbar symptoms, their clinical stages. Cancer 1981; 48:2485.
of corticosteroids is controversial. In some coupled with meticulous surgical and anes- Masaoka A, Yamakawa Y, Niwa H, et al. Extended
thymectomy for myasthenia gravis patients: a
centers, it is preferred to discontinue the thetic management has vastly reduced the 20-year review. Ann Thorac Surg 1996;62:853.
steroids after surgery, whereas they may be incidence of myasthenic crisis following Mineo TC, Pompeo E, Lerut TE, et al. Thoraco-
given and weaned over varying durations in thymectomy. When it does occur, consider- scopic thymectomy in autoimmune myas-
others. Most patients will not be completely ation of early tracheostomy is appropriate. thenia: results from left-sided approach. Ann
asymptomatic soon after surgery. Typically, Thorac Surg 2000;69:1537.
weaning of MG medications happens over Müller-Hermelink H, Engel P, Harris N, et al. Tu-
SUGGESTED READINGS mors of the thymus. In: Travis W, Brambilla E,
time through close outpatient follow-up by Müller-Hermelink H, et al., eds. Pathology and
a neurologist, and, for some patients, this Bernatz PE, Harrison EG, Clagett OT. Thymoma:
a clinicopathologic study. J Thorac Cardiovasc genetics of tumours of the lung, thymus and
may require years. Surg 1961;42:424. heart. Lyon, France: IARC Press; 2004:145.
The most feared complication after Blalock A. Thymectomy in the treatment of myas- Osserman KE, Genkins F. Studies in myasthenia
thymectomy is myasthenic crisis with acute thenia gravis: report of twenty cases. J Thorac gravis: review of a twenty year experience in
respiratory failure. It may be caused by Surg 1944;13:316. over 1200 patients. Mt Sinai J Med 1971;38:497.
Blumberg D, Port JL, Weksler B, et al. Thymoma: a Shrager JB, Deeb ME, Mick R, et al. Transcervical
weakness and fatigability of the respiratory thymectomy for myasthenia gravis achieves
muscles limiting ventilation or from oropha- multivariate analysis of factors predicting sur-
vival. Ann Thorac Surg 1995;60:908. results comparable to thymectomy by sterno-
ryngeal muscle dysfunction with inability to tomy. Ann Thorac Surg 2002;74:320.
Calhoun RF, Ritter JH, Guthrie TJ, et al. Results of
maintain an open airway free of secretions. transcervical thymectomy for myasthenia grav- Yim APC, Kay LC, Izzat MB, et al. Video-assisted
Myasthenic crisis should be differentiated is in 100 consecutive patients. Ann Surg 1999; thoracoscopic thymectomy for myasthenia grav-
from other postoperative causes of respira- 230:555. is. Semin Thorac Cardiovasc Surg 1999;11:65.

EDITOR’S COMMENT tion of this disease have side effects which can measured surgical time, estimated blood loss,
be fatal, such as steroids, mestinon, and some and chest tube output which was similar in
of the immunosuppressive agents. My own bias both groups. The average hospital stay for
This chapter concerns various approaches to which will become obvious is that while I un- minimally invasive thymectomy was 2.4 days
thymectomy, including radical mediastinal derstand the reason why people want to do compared with 4.3 days. Narcotic pain medi-
dissection. Dr. DeCamp and Dr. De Hoyos set VATS or transcervical thymectomy for myas- cation over 2 weeks was six in the open group
out the rational for extensive and radical medi- thenia gravis, I do not believe that the reason- and one in the minimally invasive group. What
astinal dissection well. The thymus gland, with ing that goes into the papers which I quote has is interesting about this paper is that there
the inferior parathyroid glands, arise from the any validity in a disease which is chronic and were no reports of results (unless I missed it) as
third pair of pharyngeal pouches, although the from which people die. A length of stay of two far as medication, tapering from medication,
fourth pharyngeal pouches also give rise to a days and decreased pain medication over two and the recovery of patients from their my-
small amount of thymic tissue, these are “usu- weeks really, to me, have no relevance in trying asthenic syndrome. It would seem to me that
ally vestigial masses and these latter primordial to put these patients into total drug free remis- this would be an essential part of any report of
in humans are usually either absent or rudi- sion. As I show you after quoting these various thymectomy.
mentary.” The authors also point out the classic papers with minimally invasive and robotic Pennathur et al. (J Thorac Cardiovasc Surg
papers by Jaretzki in 1988, preceding Masaoka thymectomy and while I appreciate the skill 2011;141:694–701) reviewed 40 patients who
et al. in 1975, demonstrating the presence of with which these operations are done it does underwent surgical resection of early stage thy-
Endocrine Surgery

extraglandular thymic tissue (rests) in 74% of not appear as if the results are as good as, for momas over a 12-year period. Of the 40, 14 un-
the cases. These extrathymic thymic rests, as it example, I quote from my own personal series derwent thymectomy for stage I and 26 for stage
were, contain thymic tissue because of the long of radical mediastinal dissection through full II. Women, who tend to do better following re-
descent of the thymus from the neck of the em- sternotomy. section, numbered 21 and were a mean age of
bryo. Since no one knows how much thymic tis- Youssef et al. (Am J Surg 2010;199:589–93) 64 years old. As many as 22 patients underwent
sue is required to cause myasthenia gravis, the reviewed thymectomies performed via sterno- open thymectomy, whatever that means; the
authors argue that a complete dissection from tomy to those performed through minimally results were not impressive. Myasthenia gravis
phrenic nerve laterally to phrenic nerve down invasive thymectomy between 2005 and 2009. symptoms improved in 9 of the 11 patients, un-
to the diaphragm and up to the thyroid is the There were eight patients in each group. They changed in 1, and exacerbated in 1. The Osser-
appropriate of taking care of these complicated were not strictly comparable, there was one man score was 2 preoperatively and had declined
patients. This is basically a fatal disease and perioperative death “unrelated to the surgi- 2 points from the preoperative score at the last fol-
the medications that are required for ameliora- cal procedure and no morbidity.” The authors low-up assessment. There were no differences in

(continued)

www.medicalebookpdf.com

LWBK892_c43_p515-527.indd Sec1:527 10/28/11 8:53:04 PM

 528 Part IV: Endocrine Surgery

the two surgical approaches. The discussion fol- were symptomatic. Interestingly, both the as- subcutaneously and to carry out a sternotomy
lowing presentation is quite interesting because ymptomatic and the symptomatic patients had comfortably, getting a complete dissection
of the rather vehement criticism of this paper. a high rate of pathologic diagnosis that should from phrenic nerve to phrenic nerve, from
For some reason, the authors thought that this have caused, rightly so, a resection. If one re- diaphragm to thyroid, and complete excision
was not a randomized study and wanted to know views what symptomatic meant, chest discom- of the thymus, of course. In these patients,
how the patients were selected. In this regard, Dr. fort, pain, shortness of breath, cough, fullness, the mean age of onset was 36 years and the
Thomas Rice of the Cleveland Clinic, asked: are fatigue, dysplasia, and hoarseness, were those patients underwent duration of symptoms of
these comparable groups other than the fact that that caused operations. It was difficult to de- 3.3 years before operation was undertaken. The
there was a short-follow and the few events? Dr. termine whether any of these patients had my- patients were followed up 6.8 years following
Rice did not think that it was a fair comparison asthenia gravis despite the fact that there was operation. There was no mortality. Drug-free
of the two small groups. From the numerous dis- hyperplasia and thymoma as well as lymphoma remission was obtained in 50% of the patients
cussions I doubt that this paper convinced very in some of these patients. and symptoms were absent or improved in 77%
many people, despite the fact that there were 13 Finally Goldstein, SD and Yang, SC from the of the patients. Those patients who were fol-
authors. Johns Hopkins Medical Institutions (Ann Tho- lowed up for greater than 10 years achieved the
Joseph Shrager from the Department of Car- rac Surg 2010;89:1080–86) reported on robotic greatest remission rate of 71% and symptom-
diothoracic Surgery at Stanford (Ann Thorac Surg thymectomy for myasthenia gravis between atic improvement of 86%. The dosage of Pred-
2010;89:S2128–34) advertised “Extended Tran- 2003 and 2008. The most common intraopera- nisone and Mestinon decreased by 70% and
scervical Thymectomy: The Ultimate Minimally tive complication was desaturation after sin- 59%, respectively in those patients who do not
Invasive Approach.” Transcervical thymectomy gle lung ventilation. There were 5 thymomas undergo complete remission. While I know that
in his hands revealed complete stable remission among these 26 patients and follow-up was surgeons are concerned about pain, morbidity,
rates of 33% and 35%, slightly higher including 26 months. There was a physically, statistical length of stay, and the use of pain medicine,
patients remaining on single-drug immuno- decrease in symptoms but the average daily nonetheless, in this particular disease associ-
suppression. However, 33% as compared with dose of cholinesterase inhibitor decreased by ated with myasthenia gravis the sine qua non
a number of other series including my own is 63% postoperatively. Further, 82% of the pa- is drug-free remission. I do not know what the
somewhat low. Again, I would point out that tients improved, however, it is not clear how volume of the thymus rests are in 75% to 85% of
the purpose of thymectomy is to put people many patients not require either immunosup- the patients some place in the fat of the medi-
in complete remission. More about this point pressive or anticholinesterase treatment. One astinum is needed to cause symptoms of myas-
later. assumes that there were few complete remis- thenia gravis. I do not believe that a complete
An interesting paper by Singla et al. ( J Thorac sions although in the verbiage, I may have resection is obtained by minimally invasive or
Cardiovasc Surg 2010;140:977–83) reviewed 117 missed this. robotic means. While a sternal split is painful,
patients undergoing thymectomy, out of which My own personal series (Stern LE et al. it is painful for about a week to two weeks at
109 had complete data. Thirty-six underwent Surgery 2001;130:774–79) included 56 patients the most. The operation essentially has less to
operation because the gland was thought to be who underwent radical extended thymectomy no mortality. This seems to be a small price to
diffusely enlarged, and 73 had a discrete mass. through a transsternal incision. The incision pay for a complete remission in the majority of
Of the 36 diffusely enlarged thymus glands, 9 was cosmetic in the sense that it was approxi- the patients.
had no symptoms referable to the thymus. Of mately 4 or 5 cm below the sternum notch J.E.F.
the 73 patients with discrete masses 45, or 62%, and I mobilized the skin, especially in women,

44 Adrenalectomy—Open and Minimally Invasive

L. Michael Brunt and Arthur Rawlings

Tumors of the adrenal gland may present in should undergo adequate preoperative prep- superiorly and posteriorly by the dia-
a variety of clinical manifestations depend- aration to minimize intraoperative compli- phragm, anteriorly by the tail of the pan-
ing on the underlying pathophysiology. Sur- cations. Proper selection of patients for op- creas, and medially by the spleen and aorta.
gical resection is the preferred treatment eration, a thorough knowledge of adrenal The right adrenal gland is bordered inferiorly
for a primary adrenal mass that is hormon- anatomy, and a meticulous and hemostatic by the right kidney; superiorly, posteriorly,
ally functional or malignant. Accurate diag- extra-adrenal dissection technique are im- and laterally by the diaphragm; anteriorly by
nosis and localization through a systematic perative to optimize outcomes, especially the liver; and medially by the inferior vena
approach with biochemical testing and im- in the minimally invasive setting. cava (IVC; Fig. 1).
aging techniques are essential in selecting The arterial blood supply to the adrenal
patients for operation. Several open and gland is derived mainly from the inferior
laparoscopic approaches are available to
ANATOMY phrenic and renal arteries as well as directly
remove the adrenal gland, each with its own The adrenal glands are retroperitoneal or- off the aorta. Occasionally, intercostal and
advantages in terms of exposure, degree of gans immediately superior to the kidneys. ovarian vessels may contribute as well.
invasiveness, ability to explore the entire These glands are slightly nodular with a Rather than one or two main arteries, the
abdomen, and patient outcomes. Tumor firm texture and are surrounded by a layer distribution is primarily one of multiple
size, functionality, bilaterality or extra- of areolar connective tissue. Each gland small branches that enter the superior, me-
adrenal location, malignant potential, indi- weighs approximately 4 to 5 g in the adult dial, and inferior aspects of the gland (Fig. 2).
vidual patient characteristics, and surgeon and has a golden yellow-orange color dis- Venous drainage of the left adrenal is via
experience all play an important role in de- tinct from the pale yellow retroperitoneal the left adrenal vein, which arises from the
termining the type of procedure utilized. fat. The left adrenal gland is bordered inferi- inferomedial aspect of the gland and emp-
Patients with hormonally functional tumors orly by the left kidney and left renal vein, ties into the left renal vein. The inferior

www.medicalebookpdf.com

LWBK892_c44_p528-540.indd 528 10/28/11 5:32:15 PM

 Chapter 44: Adrenalectomy—Open and Minimally Invasive 529

Liver Duodenum which is important during resection of a

malignant tumor.
The adrenal gland is divided into two
distinct components: the cortex and the
medulla. The adrenal cortex is the site of
production of mineralocorticoids (aldos-
terone), glucocorticoids (cortisone), and
sex steroids. The medulla contains chroma-
ffin cells, which secrete the catecholamines
Adrenal epinephrine and norepinephrine and also
dopamine.
Right
kidney
CLINICAL PRESENTATION
Adrenal tumors may come to attention be-
cause of clinical signs and symptoms of hor-
Colon mone hypersecretion, because of local
symptoms of pain due to a large mass, or as
a lesion discovered incidentally during
cross-sectional imaging done for other
reasons. Appropriate diagnosis and local-
ization are imperative for successful opera-
A tive planning and treatment. The various
indications for adrenalectomy are given in
Spleen Table 1. Algorithms for biochemical testing
as well as radiographic imaging are available
for differentiating the various causes of adre-
nal lesions including aldosteronoma, Cush-
ing syndrome, pheochromocytoma, adrenal
cortical carcinoma, metastatic disease of
the adrenal glands, and adrenal incidenta-
loma. A summary of the biochemical evalu-
ation and preoperative preparation used for
the treatment of these adrenal lesions is de-
Stomach scribed in Table 2.
Adrenal

Aldosteronoma
Left
kidney Primary hyperaldosteronism is the most
common cause of secondary hypertension
and has a much higher prevalence rate in
Pancreas the population than previously appreciated,
occurring in 8% to 12% of hypertensive pa-
tients. Although the classic findings in pri-
mary hyperaldosteronism are hypertension
and hypokalemia, many patients with this
diagnosis have a normal serum potassium
level. Therefore, any patient who has hyper-
Colon tension with an early age of onset that is dif-
ficult to control or refractory to medical
management should be considered for this
Endocrine Surgery

diagnosis, regardless of the serum potas-

sium level. Because endogenous hyperal-
B dosteronism suppresses renin secretion,
Fig. 1. Anatomic relationships of the adrenal glands to surrounding structures. biochemical screening entails simultane-
ous measurement of both plasma aldoster-
one and renin levels. A plasma aldosterone
concentration (PAC)–to–plasma renin ac-
phrenic vein usually joins the left adrenal pect of the gland. Accessory adrenal veins tivity (PRA) ratio greater than 20:25 in the
vein above its entry into the renal vein. entering the vena cava or hepatic veins may setting of an absolute PAC greater than 15
Blood from the right adrenal gland empties be present on the right side. Lymphatic ng/dL is consistent with this diagnosis and
directly into the IVC via the short central drainage from the adrenal gland is into adja- should be evaluated further. Confirmatory
adrenal vein that arises from the medial as- cent pericaval and periaortic lymph nodes, testing consists of demonstrating elevated

www.medicalebookpdf.com

LWBK892_c44_p528-540.indd 529 10/28/11 5:32:15 PM

 530 Part IV: Endocrine Surgery

Right adrenal hyperplasia is treated medically with the al-

artery dosterone antagonist spironolactone. Adre-
Right inferior nal cross-sectional imaging with thin-cut
phrenic artery Left superior
(3-mm image slices) computed tomography
adrenal artery
(CT) is indicated once primary aldosteronism
Left inferior
has been confirmed biochemically. Younger
adrenal artery
patients (under age 40 to 50) with a discrete
unilateral macroadenoma (⬎1 cm) and a
Right inferior pole
adrenal artery Left normal contralateral adrenal may undergo
adrenal adrenalectomy without further testing. All
vein other patients should undergo adrenal vein
sampling for cortisol and aldosterone to de-
termine if there is a lateralizing source of in-
creased aldosterone production.
Most aldosteronomas are small, less than
or equal to 1 to 2 cm in size, with a golden
orange color. These tumors are rarely malig-
nant and are ideally suited for laparoscopic
excision. Spironolactone may be given pre-
operatively to control hypertension but
should not be administered until the bio-
chemical evaluation, including adrenal vein
sampling, is complete. Patients should also
Fig. 2. Blood supply to the adrenals.
have potassium levels repleted and, in long-
standing cases, assessment of cardiac func-
tion and renal insufficiency prior to surgery.
24-hour urine aldosterone levels (⬎12 ␮g/24 The most common causes of primary hy-
h) while on a high-sodium diet or after intra- peraldosteronism are aldosterone-produc-
Cushing Syndrome
venous saline loading. Other biochemical ing adenoma (65%) and idiopathic cortical Cushing syndrome results from excessive
findings include an elevated urinary potas- adrenal hyperplasia (35%). Aldosterone- cortisol secretion from a variety of patho-
sium excretion rate (⬎30 mEq/24 h). secreting adrenal carcinomas are rare. Differ- logic processes that is not controlled by
entiation of these causes is critical in direct- normal regulatory mechanisms. Overpro-
ing therapy since the preferred treatment of duction of glucocorticoids may lead to de-
aan aldosteronoma is adrenalectomy, whereas velopment of characteristic features such
Table 1 Indications for Adrenalec- iidiopathic hyperaldosteronism from cortical as truncal obesity, moon facies, plethora,
tomy
Unilateral Adrenalectomy
Aldosteronoma
Table 2 Diagnosis and Preoperative Preparation of Common Adrenal Tumors
Cortisol-secreting adenoma (Cushing
syndrome or subclinical Cushing’s) Tumor type Biochemical diagnosis Preoperative preparation
Unilateral pheochromocytoma (sporadic or Pheochromocytoma Plasma fractionated Alpha-receptor blockade; hydration;
familial) metanephrines and/or beta-blockade only if persistent
Virilizing or feminizing tumors 24-hour urinary tachycardia or epinephrine-secreting
catecholamines and tumor
Nonfunctioning unilateral tumor metanephrines
Size ⬎4–5 cm
Aldosteronoma PAC and PRA; urinary Replete hypokalemia, control
Imaging features atypical for adenoma,
aldosterone and hypertension
myelolipoma, or cyst
potassium (on high-
Adrenocortical carcinomas salt diet)
Solitary unilateral adrenal metastasis Cushing syndrome 24-hour urine-free cortisol; Perioperative stress steroids
Bilateral adrenalectomy from cortical overnight low-dose
adenoma DMST; plasma ACTH
Bilateral pheochromocytomas
Adrenal cortical 24-hour urine cortisol, None unless tumor is cortisol secreting
Cushing syndrome from carcinoma plasma DHEA level
Bilateral nodular adrenal hyperplasia
Ectopic ACTH-producing tumor unrespon- Incidentaloma Low-dose DMST, plasma None unless biochemical screen positive
sive to primary therapy fractionated metanephrines or urine catecholamines
and metanephrines; PAC and PRA if
Cushing disease (pituitary tumor) unsuccess- hypertensive or hypokalemic
fully treated by surgery or radiation
ACTH, adrenocorticotropic hormone; DHEA, dehydroepiandrosterone; DMST, dexamethasone suppression test;
ACTH, adrenocorticotropic hormone. PAC, plasma aldosterone concentration; PRA, plasma renin activity.

www.medicalebookpdf.com

LWBK892_c44_p528-540.indd 530 10/28/11 5:32:18 PM

 Chapter 44: Adrenalectomy—Open and Minimally Invasive 531

hirsutism, abdominal striae, acne, and the loss of the diurnal variation in cortisol se- uncomplicated pheochromocytomas that are
presence of a “buffalo hump.” Hypertension cretion, low or suppressed plasma ACTH localized on CT or MRI, as it is expensive and
and diabetes are also commonly present. levels, and a blunted response of ACTH to rarely alters treatment in this setting.
Causes of Cushing syndrome can be di- corticotrophin-releasing hormone. Eleva- Once the diagnosis of a pheochromocy-
vided into those that are adrenocorticotro- tion of 24-hour urine-free cortisol levels is toma is made, the patient should be placed
pic hormone (ACTH) dependent and those seen in up to 50% of patients with SCS but on alpha-blockade with phenoxybenzamine
that are ACTH independent. Most ACTH- the degree of elevation is usually mild. Al- to control hypertension and dilate the in-
dependent cases are related to Cushing dis- though patients with subclinical Cushing travascular space, and should be instructed
ease (due to excessive pituitary production have a higher incidence of hypertension, to drink ample fluids. Beta-blockade may
of ACTH), while other cases may result from obesity, and diabetes than controls, the be added if the patient develops tachycar-
ectopic production of ACTH by other tu- natural history is not well characterized. In dia on phenoxybenzamine or has a pre-
mors. ACTH-independent causes include one study, progression to overt Cushing dominately epinephrine-secreting tumor.
primary adrenocortical diseases such as syndrome at 1-year follow-up was 12.5%. For further details, see the section on Pa-
cortisol-producing adenoma, adrenocorti- Adrenalectomy is indicated for patients tient Preparation below.
cal carcinoma, and adrenal hyperplasia. with this condition who are an acceptable
Suspected Cushing syndrome should be risk for surgery. SCS is important to recog- Adrenocortical Carcinoma
evaluated with measurement of 24-hour nize in the setting of adrenal incidentaloma
Adrenocortical carcinoma is a rare malig-
urine-free cortisol levels. A single-dose dex- as these patients may develop adrenal in-
nancy with an annual incidence of less than
amethasone test can also be used to screen sufficiency after adrenalectomy if glucocor-
two cases per million individuals. It carries
for Cushing syndrome. In this test, 1 mg of ticoid replacement is not administered.
a poor prognosis, as many patients (up to
dexamethasone is given at 11:00 pm, and a
40%) have advanced or metastatic disease
morning (8:00 am) cortisol level is obtained.
Normal individuals are able to suppress
Pheochromocytoma at the time of presentation. Adrenocortical
cancers are usually large tumors with an
plasma cortisol to less than 3 μg/dL, whereas Pheochromocytomas are rare tumors that
average diameter of around 12 cm and may
patients with Cushing syndrome fail to sup- arise from the chromaffin cells of the adrenal
be functional or nonfunctional. Malignancy
press. Late-night (11:00 pm) salivary cortisol medulla. Approximately 10% of tumors in
should be suspected in any adrenal cortical
levels are also highly sensitive and specific adults (up to 35% in children) arise in extra-
tumor greater than 6 cm in diameter, as the
in screening for Cushing syndrome and are adrenal locations such as the organ of Zuck-
incidence of malignancy increases with
increasingly being used by some groups. erkandl, bladder, renal hilum, or rarely else-
increasing tumor size. Nonfunctional tu-
Once Cushing syndrome is confirmed where along the sympathetic chain. While
mors may present as abdominal or back
biochemically, plasma ACTH levels should be most pheochromocytomas are unilateral and
pain, weight loss, malaise, or hematuria. A
measured to differentiate ACTH-dependent benign, approximately 10% are bilateral in
majority of adrenal cancers (approximately
from ACTH-independent causes. A low location (seen more commonly in hereditary
60%) are functional, however, with symp-
plasma ACTH suggests adrenocortical dis- endocrine syndromes) and up to 10% may be
toms of Cushing syndrome, virilization, or
ease and should be evaluated further with malignant. These tumors are generally func-
both.
CT. Patients with normal or elevated plasma tional and secrete excessive catecholamines
Preoperative considerations and prepa-
ACTH levels should have pituitary imaging including epinephrine, norepinephrine, and
ration are similar to those for other func-
(pituitary magnetic resonance imaging dopamine. Patients often present with symp-
tioning adrenal tumors. CT scanning or
(MRI), inferior petrosal sinus sampling) to toms of episodic spells consisting of head-
MRI is necessary to fully evaluate the ex-
evaluate for Cushing disease as the cause aches, diaphoresis, and palpitations in asso-
tent of disease as well as possible involve-
and to localize the tumor. Adrenalectomy is ciation with marked hypertension.
ment of major vascular structures and
the treatment for Cushing syndrome from Screening for pheochromocytoma consists
regional or distant metastases. Surgical re-
an adrenocortical tumor. Patients with of measurement of either plasma fractionated
section remains the only potentially cura-
Cushing disease who fail treatment of the metanephrines or 24-hour urinary metaneph-
tive treatment.
pituitary lesion may benefit from bilateral rines and catecholamines (epinephrine, nor-
adrenalectomy. It is important to adminis- epinephrine, and dopamine). Indications for Adrenal Incidentaloma
ter stress doses of steroids to these patients screening for pheochromocytoma include re-
in the preoperative period since they may fractory or accelerated hypertension, labile The most common adrenal mass encoun-
not be physiologically capable of respond- hypertension, hypertensive paroxysms during tered by the clinician is the adrenal incidenta-
ing to stress with endogenous glucocorti- anesthesia or sedation, adrenal incidenta- loma discovered during abdominal imaging
coids. Patients undergoing bilateral adrena- loma, paradoxic hypertension in response to for a non–adrenal-related workup. The inci-
Endocrine Surgery

lectomy should also be given replacement beta-blockers, and familial screening for he- dence of finding an adrenal mass on ab-
mineralocorticoids postoperatively. reditary endocrinopathies. Patients with bio- dominal CT scanning ranges from 0.4% to
chemical evidence suggestive of pheochro- 4.4%. The key factors in evaluating an adre-
Subclinical Cushing Syndrome mocytoma should undergo cross-sectional nal incidentaloma are to characterize its
Subclinical Cushing syndrome (SCS) is a imaging. T2-weighted MRI sequences often size, functionality, and risk of malignancy.
condition is which there is autonomous se- show a bright appearance of the tumor that is Functional masses should be removed re-
cretion of cortisol but without the typical characteristic for pheochromocytoma (adre- gardless of size. Nonfunctional tumors 4 to
clinical signs of classic Cushing syndrome. nal mass/liver image intensity ratio ⬎3.0). 123I- 5 cm or larger should be removed, as should
SCS is most commonly identified in the set- metaiodobenzylguanidine (MIBG) scanning lesions in which the imaging characteris-
ting of an adrenal incidentaloma. Labora- may occasionally be useful in localizing func- tics are atypical for an adenoma. The bio-
tory findings include lack of suppressibility tional, extra-adrenal, or metastatic tumors. chemical evaluation of the adrenal incidenta-
123
of cortisol secretion with dexamethasone, I-MIBG is not warranted in patients with loma should include measurement of plasma

www.medicalebookpdf.com

LWBK892_c44_p528-540.indd 531 10/28/11 5:32:19 PM

 532 Part IV: Endocrine Surgery

fractionated metanephrines or 24-hour urine of 40 to 60 mg/d is sufficient to block most adrenalectomy. Late complications such as
metanephrines and catecholamines to ex- patients. Intraoperatively, patients with va- incisional hernia and chronic incisional
clude a pheochromocytoma and a single low- soactive pheochromocytomas should have pain are also less common with the laparo-
dose (1-mg) dexamethasone test to evaluate continuous blood pressure monitoring via scopic approach.
for subclinical hypercortisolism. Plasma al- an arterial line. Intraoperative fluid resusci- Currently, the presence of local tumor
dosterone and renin levels should be done tation is crucial to avoid hypotension after invasiveness is the only absolute contrain-
only if the patient is hypertensive or hy- the tumor has been removed. dication to laparoscopic adrenalectomy
pokalemic. Patients with Cushing syndrome should (Table 3). Large tumors greater than 8 to
The most common adrenal lesion dis- receive intravenous steroids perioperatively 10 cm in size are more difficult to manipu-
covered as an incidentaloma is a nonfunc- and will require maintenance doses of ste- late and remove laparoscopically and are
tioning cortical adenoma. Adrenal myeloli- roids for 6 months or longer postopera- associated with an increased rate of conver-
pomas are benign lesions composed of fat tively. Mechanical bowel cleansing is not sion to an open operation. Large pheochro-
and bone marrow elements that can be di- routinely given prior to adrenalectomy. mocytomas are often benign and may be
agnosed by their typical radiographic ap- resected laparoscopically by highly experi-
pearance. They do not need to be removed SELECTION OF OPERATIVE enced adrenal surgeons. In contrast, adrenal
unless they are enlarging or become symp- cortical tumors larger than 6 to 7 cm are
tomatic, such as from hemorrhage into the
APPROACH likely to be adrenal cortical cancers and
lesion. Nonfunctioning tumors less than The retroperitoneal location of the adrenals should be approached with great caution as
4 cm should be followed with serial imaging makes them accessible via a variety of sur- some groups have reported higher local re-
at 4 and 12 months. gical approaches: transabdominal, retro- currence rates after laparoscopic excision.
Occasionally other primary tumors such peritoneal, or through the flank, and using However, since the vast majority of patients
as lung cancer, breast cancer, renal cell car- either laparoscopic or open techniques. The with adrenal tumors have lesions that are
cinoma, and melanomas metastasize to the choice of surgical approach in a given pa- less than 6 cm in size and have low malig-
adrenal glands. In addition to CT or MRI, tient depends on the size and functionality nant potential, open adrenalectomy is not
positron emission tomography (PET) should of the lesion, the degree of exposure needed, indicated often. Prior major upper abdomi-
be done in potentially resectable cases to the likelihood that the tumor is malignant, nal surgery on the planned side of the
exclude metastatic disease in other sites. and the surgeon’s experience (Table 3). For adrenalectomy, such as previous splenec-
Surgical resection may be indicated for most patients with an adrenal tumor, lap- tomy, liver resection, or renal procedures,
selected patients with an isolated adrenal aroscopic adrenalectomy is appropriate does not contraindicate a laparoscopic ap-
metastasis. Percutaneous biopsy of sus- and has become preferred over the various proach but does make the procedure more
pected adrenal metastases should be re- open approaches. This approach has been difficult. Laparoscopic adrenalectomy may
served for patients who are not candidates associated with less pain, a shorter hospi- also be more difficult in patients with large
for surgical resection and in whom the re- talization, faster return to unrestricted pheochromocytomas because of the bulk
sults of biopsy will impact therapy. activities, and less morbidity than open and vascularity of these tumors and in pa-
tients who have significant obesity, includ-
ing those with Cushing syndrome.
PATIENT PREPARATION The most common approach to laparo-
Prior to adrenalectomy, patients should Table 3 Indications for Various sscopic adrenalectomy is the transabdomi-
have electrolyte abnormalities such as hy- Surgical Approaches to nal lateral flank approach described by
n
pokalemia corrected. Hypertension should Adrenalectomy Gagner in 1992. Other laparoscopic ap-
G
be controlled medically and patients with Laparoscopic pproaches that have been utilized include
pheochromocytomas should receive 7 to 10 Nonmalignant primary unilateral or bilateral tthe anterior transabdominal and retroperi-
days of preoperative alpha-receptor block- adrenal tumors ⬍8–10 cm in size ttoneal endoscopic approaches. The anterior
ade with phenoxybenzamine to avoid hy- Solitary unilateral adrenal metastasisa ttransabdominal approach provides a view
pertensive exacerbations intraoperatively. Small adrenocortical carcinomasa m
most familiar to laparoscopic surgeons, but
Phenoxybenzamine is typically started in a Open Anterior n
necessitates additional port placement and
dose of 10 mg twice daily and the dose is in- Any tumor with extra-adrenal extension or rrequires more effort to retract abdominal
creased by 10 to 20 mg/d every 2 to 3 days local invasion oorgans to expose the adrenals. A potential
until the blood pressure is well controlled Tumors with suspected regional lymph node aadvantage of this technique is that it may
and the patient is mildly orthostatic. Some metastases oobviate the need for patient repositioning
patients with symptomatic pheochromocy- Large tumors ⬎8–10 cm ffor bilateral adrenalectomy. The retroperi-
tomas in hypertensive crisis will need to be Open Posterior ttoneal approach is the most direct route to
blocked while in the hospital, but for many Small (⬍5 cm) unilateral tumor not tthe adrenals and is gaining in popularity. It
patients the blockade can be managed on amenable to a laparoscopic approach aavoids entry into the abdominal cavity but
an outpatient basis. During this time, pa- Extensive prior upper abdominal surgery on h
has a smaller working space, which can
tients should be instructed to drink ample side of tumor (e.g., major liver resection) ppresent difficulties in patients with large tu-
fluids to allow volume expansion as the Thoracoabdominal m
mors or significant amounts of retroperito-
alpha-blockade proceeds. Our practice has Large tumor with major vascular invasion n
neal fat. It may also be more difficult to
been to admit patients to the hospital the (e.g., inferior vena cava) that cannot be llearn and to maintain orientation in the
day before the scheduled adrenalectomy to controlled intra-abdominally rretroperitoneal space. The transabdominal
increase the blockade and allow monitor- a
Controversial; depends on imaging features and lap- llateral flank approach carries several ad-
ing of orthostatic vital signs and urinary aroscopic surgical experience. vvantages, including good exposure and ac-
output. A total dose of phenoxybenzamine ccess to the superior retroperitoneum and a

www.medicalebookpdf.com

LWBK892_c44_p528-540.indd 532 10/28/11 5:32:19 PM

 Chapter 44: Adrenalectomy—Open and Minimally Invasive 533

large working space. Because this approach

is transperitoneal, the adjacent organs and
anatomic landmarks are clearly identifiable
even though the patient is in a lateral posi-
tion. The transabdominal lateral approach
is the technique preferred by the majority of
centers performing this operation, includ-
ing our group, and will be described in
detail.
Open adrenalectomy may be carried out
via one of four approaches: anterior trans-
abdominal, dorsal or posterior retroperito-
neal, lateral flank, and thoracoabdominal
approach. The anterior approach can be
performed through a bilateral, subcostal, or
midline incision. The benefit of this tech-
nique is that it allows for complete explora-
tion of the abdomen and en bloc resection
of the adrenal and contiguous structures in
patients with large adrenal malignancies.
The posterior approach gives more direct
access to the adrenals, and although it has
been associated with low morbidity, this
approach has been supplanted by laparo-
scopic techniques. The flank approach pro-
vides reasonable exposure and access to
major vessels, but it may be difficult to re-
move larger tumors or to perform en bloc
cancer resections, and is also not com-
monly utilized. The thoracoabdominal ap-
proach provides the greatest exposure for Fig. 3. Patient position for laparoscopic adrenalectomy, left side.
difficult cases and large tumors. However, it
potentially carries additional morbidity and
increased patient discomfort; it is the rare
tumor that cannot be resected via an ab-
dominal incision. A 5-mm incision is placed somewhat Care should be taken in determining port
medial to the anterior axillary line, two fin- placement to allow enough spacing so that
gerbreadths below the costal margin. Initial the instruments can move without imped-
Laparoscopic Adrenalectomy access to create the pneumoperitoneum ance from the other port sites.
Patient Positioning and Setup can be achieved with a closed technique us-
The patient is placed supine on the operat- ing a Veress needle through this incision or Right Adrenalectomy
ing table on a padded beanbag mattress. under direct vision via a larger open inci- For right adrenalectomy, the patient is
After general anesthesia is induced, an oro- sion with a Hasson-type cannula. Our pref- placed in the lateral decubitus position
gastric tube is placed for gastric decom- erence is to use the closed Veress needle with the right side upward. The surgeon
pression. A urinary catheter is often used technique since open access through the stands facing the patient’s back (right side
but may be unnecessary for uncomplicated overlapping muscle layers in the flank is of the table) and the assistant and laparo-
cases and patients with small tumors. The more cumbersome. After establishing ade- scopic camera operator stand on the oppo-
patient is then turned into the lateral decu- quate pneumoperitoneum, a 5-mm optical site side of the table. The sequential steps in
bitus position with the affected side facing trocar to directly visualize the insertion is the dissection are illustrated in Figure 5. Af-
upward. The torso, the extremities, all pres- placed at this site. The 5-mm laparoscope is ter placement of all laparoscopic ports, the
sure points, and the head are well padded inserted through this port to inspect the liver is first mobilized by incising the right
Endocrine Surgery

and the patient is secured with safety straps underlying viscera. The remaining ports are triangular ligament. The hepatic flexure of
and the beanbag mattress. The table is then then placed under direct laparoscopic visu- the colon does not typically need to be mo-
placed in reverse Trendelenburg position to alization at 5- to 7-cm intervals across the bilized or retracted. It is key that the entire
allow abdominal contents to fall away from subcostal and flank region (Fig. 4). We gen- length of the triangular ligament be divided
the upper abdomen, and is flexed at the erally use four ports for both right and left from the inferior border of the liver all the
waist to lengthen the space between adrenalectomy, but the left side can be done way to the diaphragm.
the costal margin and the iliac crest (Fig. 3). with only three ports if the operating sur- Once the liver has been mobilized, it is
The patient is prepped and draped with the geon is experienced. One 12-mm port is retracted medially with a 5-mm instrument
midline of the abdomen exposed so that used for insertion of a clip applier and for placed through the most medial port. The
conversion to an open procedure can be specimen extraction. The remaining ports adrenal gland and IVC should be visible at
performed if necessary. Monitors are placed can all be 5 mm in size. Additional ports this point in the dissection (Fig. 5). The
at both sides of the head of the table. may be added if needed for difficult cases. plane between the adrenal and IVC is then

www.medicalebookpdf.com

LWBK892_c44_p528-540.indd 533 10/28/11 5:32:19 PM

 534 Part IV: Endocrine Surgery

developed by incising the overlying perito-

neum at the lateral border of the vena cava
with an L-hook electrocautery. After identi-
fication of the gland, it is gently dissected
away from the vena cava beginning along
the medial border of the adrenal and con-
tinuing superiorly and inferiorly. Most of
the arterial branches that enter the supe-
rior, medial, and inferior aspects of the ad-
A renal are small and can be cauterized, but
there are often two or three larger branches
P that should be clipped. Alternatively, these
vessels along with the remaining attach-
ments can be taken with an ultrasonic or
bipolar coagulating device.
The right adrenal vein is usually identifi-
able early in the dissection and is typically
located at about the midportion of the ad-
renal; it enters the posterolateral aspect of
the IVC. This vein should be carefully iso-
lated with blunt dissection and a right-
angle instrument and should be doubly li-
gated with clips. Alternatively, if the vein is
large or if the tumor encroaches on it, a vas-
cular stapler can be used to divide the vein
Fig. 4. Port site placement for laparoscopic left adrenalectomy. The dashed lines indicate the anterior and
taking the lateral “shoulder” of the IVC. Ex-
posterior axillary lines and costal margin. The initial Veress needle access is usually achieved just medial cessive traction on the adrenal vein is to be
to the anterior axillary line about two fingerbreadths below the costal margin. In most cases, a fourth port avoided as it may tear along the vena cava
placed medial to the anterior axillary line is also used. A, anterior axillary line; P, posterior axillary line. with resultant brisk hemorrhage. If there is

A B
Fig. 5. Sequential steps in laparoscopic right adrenalectomy. A: Mobilization of the right triangular ligament of the liver. A
hook cautery is used to divide this ligament. B: Dissection of the plane between the adrenal and vena cava. The adrenal vein
is ligated with clips and divided.

www.medicalebookpdf.com

LWBK892_c44_p528-540.indd 534 10/28/11 5:32:19 PM

 Chapter 44: Adrenalectomy—Open and Minimally Invasive 535

and metastases intact for complete patho-

logic assessment. Finally, after the speci-
men is out, the abdomen is reinflated and
the operative bed is reinspected. The ex-
traction site is then closed in two layers of
0-gauge absorbable suture for the fascia
and an absorbable subcuticular layer for
the skin. Steri-strip tapes are sufficient to
approximate the other incision sites.

Left Adrenalectomy
For left adrenalectomy, the patient is
placed in the lateral decubitus position
with the left side facing upward. The sur-
geon and laparoscope camera operator
both stand on the side of the table facing
the patient’s abdomen and the assistant
stands on the opposite side. The landmarks
used for port placement are the same as
for the right side. The key steps in left
adrenalectomy are illustrated in Figure 7.
After port placement, the splenic flexure of
the colon is taken down from its lateral re-
C
flection to the inferior pole of the spleen to
Fig. 5. (Continued ) C: Dissection of the inferior and posterior attachments of the adrenal. Note the ex-
allow it to fall away inferiorly. This step
posure of the superior pole of the kidney. may be carried out with endoscopic scis-
sors but an ultrasonic coagulator or bipo-
lar device is faster and more hemostatic
and is preferred for most of the dissection
major or uncontrolled bleeding from the blood from obscuring the visual field of dis- on the left side. It is usually necessary to
vena cava, the patient should be immedi- section. Once the gland is free, it is placed mobilize the splenic flexure before the
ately converted to an open procedure. Once into an impermeable bag for removal from most dorsal fourth port is placed. The
the vein has been ligated and divided, the the abdomen and the retroperitoneum length of the splenorenal ligament can
adrenal can be retracted away from the (Fig. 6) is irrigated and inspected for hemo- then be divided to the diaphragm using an
vena cava and all remaining medial attach- stasis and for security of the clipped vein ultrasonic coagulator or electrocautery.
ments and small vessels can be divided. At pedicle on the vena cava. The gland is then This allows the spleen to be rotated medi-
this point, the diaphragm should be visible removed at the 12-mm port incision, which ally with gravity using minimal retraction.
posteriorly and the dissection should stay usually will need to be enlarged somewhat. A key step at this stage is to develop the
on top of that plane. The dissection then For large pheochromocytomas and other plane between the tail of the pancreas and
continues along the inferomedial border of large noncortical tumors, the specimen the left kidney using blunt dissection and
the adrenal and out laterally along the su- may be morcellated within the entrapment cautery or an ultrasonic coagulator. The
perior pole of the kidney. Some arterial bag to facilitate extraction. However, it is splenic artery and vein should be visible at
branches are encountered here that may re- preferable to extract most cortical tumors this point as should the salmon-colored
quire ligation with clips. The dissection
should not extend too low into the area of
the renal hilum because of the risk of injur- Grasper holding up
ing a superior polar renal artery. Finally, the the periadrenal fat Adrenal and
tumor
relatively avascular posterior and lateral
attachments are divided.
Care should be taken throughout the
dissection to handle the adrenal and sur-
Endocrine Surgery

rounding tissue in a gentle fashion, as ag-

gressive retraction and blunt dissection can
lead to bleeding or trauma to the adrenal
gland or tumor with risk of tumor spillage.
Direct grasping of the adrenal and tumor
should also be avoided, but one can grasp
the periadrenal fat and use that to elevate
and move the gland around. Minimizing
any retraction or pressure on the tumor
may also serve to limit the release of cate- Entrapment
bag
cholamines by a pheochromocytoma. Me-
ticulous hemostasis is important to prevent Fig. 6. Specimen removal. The adrenal is placed in a secure entrapment bag for removal.

www.medicalebookpdf.com

LWBK892_c44_p528-540.indd 535 10/28/11 5:32:25 PM

 536 Part IV: Endocrine Surgery

Liver

Adrenal
tumor
Spleen

Left Liver
kidney

Pancreas

Spleen

Splenic Left
artery kidney

Pancreas

A B

C D
Fig. 7. Sequential steps in laparoscopic left adrenalectomy. A: The splenic flexure of the colon is taken down and the spleno-
renal ligament is divided (dashed line) B: The plane between the tail of the pancreas and kidney is developed to expose the
adrenal gland. C: The medial, inferior, and lateral borders of the adrenal are dissected to expose the adrenal vein, which is
clipped and divided. D: The posterior and superior attachments are divided to free the gland.

www.medicalebookpdf.com

LWBK892_c44_p528-540.indd 536 10/28/11 5:32:26 PM

 Chapter 44: Adrenalectomy—Open and Minimally Invasive 537

pancreas to the left side of the operative may be of value in selected cases of adrena- the 12th rib. The incision is extended
field. This maneuver should lead directly to lectomy. Another benefit of this approach is through the muscle layers by blunt dissec-
the adrenal gland, which is found in the that it greatly facilitates extraction of larger tion with scissors into the retroperitoneal
perinephric fat in close proximity to the tumor specimens. space and this space is further developed
superior pole of the kidney, just superior with blunt finger dissection. A second tro-
and lateral to the pancreas and splenic ves- Retroperitoneal Endoscopic car is placed under direct finger guidance 4
sels and cephalad to the renal vessels. It is Approach to 5 cm laterally below the 11th rib and a
important to positively identify the pan- third trocar is placed 5 cm medially to the
creas at this stage in order to avoid mistak- The retroperitoneal approach to adrenalec- first port about 3 cm below the 12th rib
ing it for the adrenal. tomy is the most direct route to the adrenal (Fig. 8). A blunt balloon-tipped trocar is
In patients with small tumors or with glands and is becoming more popular for a used at the open insertion site and the
large amounts of retroperitoneal fat, the number of reasons. Its advantages include other ports may be 5 mm in size. Retro-
left adrenal can sometimes be difficult to avoiding intraperitoneal adhesions from pneumoperitoneum of 20 to 25 mm Hg is
find. In such cases, laparoscopic ultra- prior operations, eliminating manipulation achieved, which increases the working
sound can be useful to image the adrenal or retraction of intra-abdominal organs, space and decreases bleeding. The retro-
and to identify its relationship to the kid- and diminished bleeding due to the higher peritoneal fat beneath the diaphragm is
ney and renal vessels. The dissection starts CO2 pressures used. With experience, this pushed down bluntly to expose the upper
along the medial and lateral borders to de- approach can result in faster operating times; pole of the kidney. The dissection should
fine those limits of the adrenal and then Walz has reported 560 adrenalectomies proceed lateral to medially to expose the
progresses inferiorly to locate the adrenal with this technique with average operating adrenal gland. Laparoscopic ultrasonogra-
vein (Fig. 7C). The hook cautery is our pre- times of only 67 minutes.. With the prone phy can be used if there is difficulty locat-
ferred method for this part of the dissec- position, bilateral adrenalectomy can be ing the kidney and adrenal, but with
tion. On the left side, arterial branches en- performed without the need to reposition experience, this is rarely necessary. Th e di-
ter the gland at the lateral–inferior aspect the patient between sides. The disadvan- aphragmatic and medial arterial branches
along the superior pole of the kidney, and tage of this approach includes a smaller are ligated with an ultrasonic or bipolar
also medially. The inferior border of the ad- working space, which makes removal of energy device as encountered during dis-
renal often sits adjacent to the renal vein tumors ⬎5 cm more difficult; also, the section. For right adrenalectomy, the vena
and should be carefully dissected away working space can be compromised if the cava is identified and dissected off the ad-
from that structure. The left adrenal vein peritoneum is opened. In addition, this ap- renal to expose the adrenal vein, which is
courses along the inferomedial aspect of proach can be more difficult to learn ini- ligated. For left adrenalectomy, the adrenal
the gland to drain into the left renal vein tially because the anatomic landmarks and is elevated to expose the inferomedial as-
and should be doubly ligated. The inferior orientation are unfamiliar to most abdomi- pect of the gland where the vein is identi-
phrenic vein empties into the adrenal vein nal surgeons. fied and ligated. One should keep in mind
just above this and may need to be ligated The retroperitoneal approach is carried that the orientation of the surgeon to the
separately. Once the vein has been divided, out with the patient in a prone jackknife major vessels and the adrenal vein relative
the inferior border of the gland is elevated position although a lateral decubitus ap- to the tumor are reversed compared with
and the posterior attachments and remain- proach has also been described. In the the conventional anterior approach (i.e.,
ing lateral and superior attachments are prone jackknife position, the patient is ly- the right adrenal vein will be coming off
divided, usually with an ultrasonic coagu- ing on a rectangular support, which allows the surgeon’s left-handed view of the adre-
lator. Care must be taken to avoid injury to the abdominal wall to hang freely to open nal to enter the posterolateral vena cava).
the superior pole renal arterial branches, up the retroperitoneal space (Fig. 8). Initial After the vein is taken, the adrenal gland
which run cephalad to the renal vein and access to the retroperitoneal space is by is retracted caudally and the remaining
at the lateral aspect of the adrenal. The direct visualization just below the tip of attachments are divided. The gland is
gland is then placed in an impermeable sac
and removed as described for right adrena-
lectomy.

Hand-Assisted Laparoscopic
Adrenalectomy
A hand-assisted laparoscopic approach to
adrenalectomy may be considered for cases
Endocrine Surgery

of large tumors or those in which there are

intraoperative difficulties such as bleeding
or failure to progress with the laparoscopic
dissection. Access for hand port placement
is usually carried out in the subcostal re-
gion or upper midline medial to the other
ports. The hand port often replaces the
most medial 5-mm port depending on
where the incision is located. Although ex-
perience with this technique in patients
with adrenal tumors is limited, its use in
difficult splenectomy cases suggests that it Fig. 8. Patient position and port site placement for the retroperitoneal approach to adrenalectomy.

www.medicalebookpdf.com

LWBK892_c44_p528-540.indd 537 10/28/11 5:32:32 PM

 538 Part IV: Endocrine Surgery

extracted and the incisions closed in the cera, which is often necessary for very large After entering the abdomen, the liver
usual manner. (⬎10 cm) or invasive tumors. This incision and peritoneal surfaces are inspected for
also provides the exposure needed to per- the presence of metastatic disease. On the
form periaortic lymph node dissection and right side, the liver is fully mobilized by
Open Adrenalectomy en bloc resection of contiguous structures dividing the triangular ligament as for the
Anterior Approach in patients with adrenocortical carcinoma. laparoscopic approach. With a large tumor
Open adrenalectomy is most commonly Exposure for this approach may be facili- it may be necessary to mobilize the hepatic
carried out using an extended subcostal in- tated by elevating the right flank somewhat flexure of the colon and retract it inferiorly.
cision. This incision can also be extended and by placing a roll under the right side The duodenum is also mobilized using a
cephalad in the midline up to the xiphoid to (Fig. 9). A midline incision is an option for Kocher maneuver to expose the IVC (Fig. 9B).
allow better exposure for mobilization of the occasional patient who requires bilat- Inferior traction on the kidney exposes
the liver and other upper abdominal vis- eral open adrenalectomy. the adrenal gland. The dissection begins

Liver

Stomach
Adrenal
tumor

Spleen

Stomach

Adrenal
tumor

Left
kidney

IVC

B Pancreas C
Fig. 9. Incision and exposure for open adrenalectomy. A: Incision location. The incision can be extended into a bilateral
subcostal incision or superiorly in the midline to improve exposure. B: Exposure for right adrenalectomy. C: Exposure for left
adrenalectomy. IVC, inferior vena cava. ((B) and (C) modified from Scott HW Jr. Anatomy of the adrenal glands and bilateral
adrenalectomy. In: Nyhus LM, Baker RJ, eds. Mastery of Surgery. Boston, MA: Little, Brown and Co., 1992:1374.)

www.medicalebookpdf.com

LWBK892_c44_p528-540.indd 538 10/28/11 5:32:33 PM

 Chapter 44: Adrenalectomy—Open and Minimally Invasive 539

medially to develop the plane between the margin of retroperitoneal fat and Gerota’s ously described for the endoscopic retro-
tumor and the vena cava and to assess re- fascia. In cases of primary adrenal cortical peritoneal approach. Once the adrenal is
sectability. Periaortic lymph nodes should malignancies, periaortic lymph nodes me- free, the wound is closed in layers with ab-
be assessed for involvement as well. The dial to the adrenal should be removed along sorbable sutures, with care to avoid the
right adrenal vein is ligated and the tumor with the tumor. neurovascular bundles of the ribs. If a pleu-
is dissected away from the vena cava. A por- ral opening is created during the dissec-
tion of the lateral wall of the vena cava may Posterior Approach tion, it can be treated by closing the inci-
be taken along with the tumor if it appears The posterior approach is rarely used today sion over a small red rubber catheter
involved. Once the medial side of the adre- because there are few patients in whom placed in the pleural space and removing
nal and the tumor are free, the dissection this approach would be indicated who are the tube as positive pressure ventilation is
proceeds as described for the laparoscopic not also candidates for laparoscopic delivered after the space has been closed. A
approach. For adrenocortical carcinomas adrenalectomy. chest radiograph is obtained postopera-
that have invaded the kidney or liver, it may In the past, this approach was used pri- tively to ensure that there is no residual
be necessary to perform an en bloc resec- marily for bilateral adrenalectomy for pneumothorax.
tion of the tumor along with these struc- Cushing disease or for small unilateral tu-
tures. mors. The patient is placed prone on two Thoracoabdominal Approach
On the left side, the open operative ap- chest rolls with a pillow or roll under the The thoracoabdominal approach is re-
proach is as described for the laparoscopic hips and pillows under the legs and the ta- served for advanced adrenal malignancy
technique. The splenic flexure of the colon ble is flexed. A hockey stick–shaped inci- with major vessel involvement (e.g., IVC)
is mobilized from its attachments and the sion is made from the 10th rib extending that requires exposure of the supradia-
splenorenal ligament is divided. The tail of first inferiorly and then laterally to the iliac phragmatic vena cava. The options for ac-
the pancreas and spleen are together re- crest (Fig. 10). The latissimus dorsi muscle cess to the chest are to extend the bilateral
flected medially to expose the adrenal (Fig. is divided and the 12th rib is resected, pre- subcostal incision in the midline into a me-
9C). If the spleen and pancreas cannot be serving the intercostal nerve. Next the dia- dian sternotomy or to make a classic thora-
mobilized away from the adrenal because phragm with the pleura along its superior coabdominal incision. For the latter, the
of tumor involvement, then the lesser sac surface is exposed. The pleura is dissected patient is placed supine and a roll is placed
should be opened and the pancreas and off the diaphragm and reflected superiorly under the thorax to be incised. Either a
splenic hilum accessed anteriorly. Large and the diaphragm is incised to expose the midline or subcostal abdominal incision
malignant tumors on the left may require Gerota’s fascia. The adrenal gland is ex- can be carried onto the chest for this ap-
en bloc resection of the spleen, tail of the posed by bluntly reflecting the fat away proach. The thoracic portion of the incision
pancreas, and even the kidney. These tumors and retracting the kidney inferiorly. The re- is made along the 9th or 10th rib. The cos-
should be removed along with a generous mainder of the dissection is then as previ- tal margin is divided and a portion of the
costal cartilage is excised to prevent the
costal margin edges from rubbing together
after the incision is closed. The chest is en-
tered through the eighth or ninth inter-
space and the diaphragm is incised as the
lung is retracted superiorly. Exposure of
the vena cava above and below the tumor
as well as the hepatic veins should be car-
ried out. The dissection then proceeds as
described above.

POSTOPERATIVE
MANAGEMENT AND
COMPLICATIONS
A principal benefit of the laparoscopic ap-
proach compared with open adrenalectomy
has been a reduction in the incidence of
adrenalectomy-related complications. This
Endocrine Surgery

12th rib lower complication rate has primarily been

a result of fewer wound, pulmonary, and in-
fectious complications with the laparo-
Kidney
scopic approach. Although several compli-
cations can occur as a result of adrenalectomy,
many of these can be avoided with careful
dissection principles, good hemostasis, and
thorough knowledge of the surgical anatomy
in this region. The most common operative
complication is hemorrhage, which can oc-
cur from the adrenal vein, small arteries to
Fig. 10. Schematic of incision placement for open posterior adrenalectomy. the adrenal, the adrenal gland or tumor,

www.medicalebookpdf.com

LWBK892_c44_p528-540.indd 539 10/28/11 5:32:35 PM

 540 Part IV: Endocrine Surgery

hepatic veins, renal vessels, and the IVC or mentation with both glucocorticoid and Brunt LM. Minimal access adrenal surgery. Surg
adjacent solid organs (spleen, pancreas, kid- mineralocorticoid replacement. Endosc 2006;20:351–61.
ney, liver). Bleeding has also been the most Following resection of a pheochromocy- Brunt LM, Moley JF. Adrenal incidentaloma. In:
Cameron JL, ed. Cameron’s current surgical ther-
common reason for conversion from the toma, additional intravenous fluids may be apy, 9th ed. Philadelphia, PA, Mosby Elsevier;
laparoscopic approach to open adrenalec- required postoperatively due to intravascular 2008:597–602.
tomy. Minor bleeding during the procedure volume expansion from phenoxybenzamine. Gagner M, Pomp A, Heniford BT, et al. Laparo-
can usually be managed with tamponade of These patients may also become hypoglyce- scopic adrenalectomy: lessons learned from
the area and then direct control of the bleed- mic postoperatively due to loss of inhibition of 100 consecutive patients. Ann Surg 1997;226:
ing site with cautery or clips. Prompt con- insulin secretion by high levels of circulating 238.
Goldfarb DA. Contemporary evaluation and man-
version to an open procedure should be car- catecholamines. Plasma-fractionated meta- agement of Cushing’s syndrome. World J Urol
ried out if the bleeding is from a major vessel nephrines or 24-hour urinary catecholamine 1999;17:22.
that cannot be immediately controlled. In levels should be checked at follow-up and on Gonzalez RJ, Shapiro S, Sarlis N, et al. Laparo-
addition to hemorrhage, vascular occlusion a yearly basis to evaluate for recurrence. Close scopic resection of adrenal cortical carci-
can also occur by inadvertent ligation of a follow-up is also required for patients with noma: a cautionary note. Surgery 2005;138:
renal artery branch or other visceral vessels. adrenocortical malignancy including periodic 1078–86.
Other organs and structures in the vicinity measurement of hormone levels and imaging Guerrero M, Schreinemakers JMJ, Vriens MR, et al.
Clinical spectrum of pheochromocytoma. J Am
of the dissection that may be injured (by with CT or MRI. Local recurrences or solitary Coll Surg 2009;209:727–32.
cautery, clips, or retraction) include the co- metastases may be treated with surgical re- Kebebew E, Siperstein AE, Clark OH, et al. Results
lon, spleen, pancreas, liver, stomach, kidney, section in select cases. of laparoscopic adrenalectomy for suspected
and ureter, and these should be inspected Patients undergoing laparoscopic adre- and unsuspected malignant adrenal neoplasms.
carefully prior to closure. If there is any con- nalectomy usually require minimal paren- Arch Surg 2002;137:948.
cern that the pancreatic parenchyma has teral analgesia and are often on oral pain Kebebew E, Reiff E, Duh Q-Y, et al. Extent of dis-
ease at presentation and outcome for adreno-
been injured, a closed-suction drain should medication on the first postoperative day, cortical carcinoma: have we made progress?
be placed. The diaphragm and pleura can whereas patients undergoing an open pro- World J Surg 2006;30:872–8.
also be injured with any of the various ap- cedure have a greater parenteral analgesia Perrier ND, Kennamer DL, Bao R, et al. Posterior
proaches, although this complication is less requirement often lasting more than 48 retroperitoneoscopic adrenalectomy: preferred
common with the laparoscopic approach. hours. Laparoscopic patients are started on technique for removal of benign tumors and
The patient with a pheochromocytoma a liquid diet early postoperatively and often isolated metastases. Ann Surg 2008;248:666.
Sippel RS, Chen H. Subclinical Cushing’s syndrome
is at risk for intraoperative hypertensive can be discharged within 24 hours unless a in adrenal incidentaloma. Surg Clin North Am
crisis and arrhythmias if there has not been longer period of observation is needed for 2004;84:875–85.
adequate preparation pharmacologically blood pressure management or hormone Stowasser M. Update in primary aldosteronism.
for surgery. Patients with an adrenal tumor replacement. Most patients can return to J Clin Endocrinol Metab 2009;94:3623–30.
causing Cushing syndrome should receive unrestricted activity within 7 to 14 days of Tessier, DJ, Iglesias R, Chapman WC, et al. Previ-
glucocorticoids as a stress dose in the peri- operation. ously unreported high grade complications of
operative period, which can then tapered to adrenalectomy. Surg Endosc 2009;23:97–102.
Vaughan ED. Surgical options for open adrenalec-
an oral maintenance steroid dose until their SUGGESTED READINGS tomy. World J Surg 1999;23:40.
hypothalamic–pituitary–adrenal axis has Berber E, Tellioglu G, Harvey A, et al. Comparison Walz MK, Alesina PF, Wenger FA, et al. Posterior
recovered, which may take up to 12 to 18 of laparoscopic transabdominal lateral versus retroperitoneoscopic adrenalectomy—results
months. Patients undergoing bilateral posterior retroperitoneal adrenalectomy. Sur- of 560 procedures in 520 patients. Surgery 2006;
adrenalectomy will require lifelong supple- gery 2009;146:621. 140:943.

EDITOR’S COMMENT cally identifiable adrenal tumor in the 3 to 4 cm zation of the colon, spleen, and pancreas can be
range. performed in the near bloodless fashion if strict
This chapter emphasizes that the resection attention to the dissection planes is adhered to.
Doctors Brunt and Rawlings have developed a of the right and left adrenal glands must really be The epiphrenic vein on the diaphragm can com-
thorough description of the anatomy, workup, considered two separate operations. The authors monly be followed all the way down to the me-
indications, and techniques of open and laparo- have carefully described their preferred approach dial border of the adrenal gland thus guiding the
scopic adrenalectomy. The authors note that in to these operations of lateral transabdominal surgeon to the extent that the pancreas must be
the workup for pheochromocytoma the charac- adrenalectomy. This has the advantage of using mobilized in the lateral to medial fashion. This
teristic signal of neuroendocrine tumors is seen gravity to assist in the retraction of nearby organs, splenopancreatic mobilization is facilitated by
on T2-weighted MRI. This can be particularly but this also has the potential disadvantage of an preserving a rim of peritoneum on the spleen to
useful for identifying extra-adrenal neuroendo- unfamiliar (lateral or flank) approach to the ab- be used as a handle. This creates “the opening of a
crine lesions occasionally missed on computed domen in the event of the need to convert to open book” approach with the pancreas/spleen on the
tomography. As the authors point out, adrenal surgery for the less experienced. A few additional left and the kidney/adrenal on the right. The spine
“incidentaloma” remains one of the most com- comments for the laparoscopic approach are of the book will be the epiphrenic vein along the
mon indications for surgical evaluation. The NIH noteworthy. Potential port placement should be medial adrenal gland. The dissection of the right
state-of-the-science statement on management made prior to insufflation of the abdomen. Most adrenal gland highlights one of the true beauties
of the clinically unapparent adrenal mass (NIH trocar sites should be on a line that can be con- of the lateral approach. No gastrointestinal mo-
Consens State Sci Statements 2002;19(2):1–25) verted to a single incision should the need arise. bilization is needed. Reider et al. point out that
documents our true lack of understanding of the This placement is impossible to judge once pneu- their operative time in 163 laparoscopic adrena-
natural history of these lesions and the psycho- moperitoneum has been initiated. The dissection lectomies was 31 minutes shorter on the right
logical impact on the patient of the radiographi- of the left adrenal gland which requires mobili- side which is probably due to the more extensive

www.medicalebookpdf.com

LWBK892_c44_p528-540.indd 540 10/28/11 5:32:35 PM

 Chapter 45: Pancreatic Endocrine Tumors 541

exposure required for left adrenalectomy ( JSLS neal approach may be ideal for patients with Surg Oncol 2011;May 5. [Epub ahead of print]).
2010;14(3):369–373). A more important advan- prior intraabdominal procedures ( J Am Coll Surg Their group has also reported on the impact of
tage to the lateral approach on the right is the 2011;212(4):659–665; discussion 665–667). Both obesity resulting in increased operative time and
fact that the short central adrenal vein empties the anterior and retroperitoneal approaches have wound complication rate in the morbidly obese
into the posterior and lateral inferior vena cava. been performed using single incision techniques, population (World J Surg 2011;35(6):1287–1295).
By rotating the patient from the supine position the advantages of which may be debatable. Fi- Incidental and small lesion (except pheo-
to the lateral position the vein is moved from nally, where there is a laparoscopic procedure, chromocytoma) patients can be managed with
underneath the vena cava to a far more acces- there seems to be a robotic approach waiting relatively short hospitalizations. Ramirez-Plaza
sible lateral position. I agree completely with the to take place. Giulianotti reported a series of 41 et al. recently reported a series where 19 to 48
authors that a thorough understanding of the robotic-assisted adrenalectomies (Int J Med Ro- patients undergoing laparoscopic adrenalec-
anatomic relationships is critical to safe adrenal bot 2011;7(1):27–32), with a 2.4% mortality rate tomy were managed on a true outpatient basis
resection. (which is actually higher than most recent series and discharged directly from the recovery room
There is little debate today that minimally of conventional minimally invasive adrenalec- in a less than 8 hours. Using strict criteria of
invasive adrenal resection represents the gold tomy). The rationale for the robotic approach and younger, smaller lesion, healthy patients who
standard when compared with open techniques. the associated additional inherent expense isn’t were operated upon as the first case of the day
The reduction of length of stay, postoperative clear since unmet needs have not been identified and who lived no more than 30 minutes from the
pain and wound complications, the most notable which are improved with robotic assistance such hospital, they successfully managed this popula-
of which is that very difficult to repair flank her- as the need for suturing. tion without complication. All indications other
nia, is dramatic. The current controversy centers The postoperative management of the than pheochromocytoma were considered for
around which of the minimally invasive options adrenalectomy patient varies on the basis of this approach. Clearly, the pheochromocytoma
is most suitable for gland resection. Majority of the initial indication for resection. Most large patients require careful postoperative monitor-
laparoscopic adrenalectomies are performed via series today report nearly no mortality from lap- ing. A recent publication from the University of
the lateral transabdominal approach. There has aroscopic adrenalectomy (e.g., Kercher Am Surg California, San Francisco, by Shen et al. (Arch
been recent interest in the last few years in the 2011;77(5):592–596) especially in healthy patients. Surg 2010;145(9):893–897) noted a 7% incidence
laparoscopic retroperitoneal approach. In non- Two groups merit more careful consideration; the of clinically evident pulmonary emboli in their
randomized series, some authors such as Linos elderly and the obese. Kazaure, whose group re- pheochromocytoma cohort postoperatively. This
found it preferable with shorter length of stay viewed the ACS-NSQIP database, noted a nearly should alert the surgeon to the possibility of a
and decreased pain scores (Surg Endosc 2011; threefold increase in mortality when adrenalec- more aggressive deep venous thrombosis prophy-
June 3. [Epub ahead of print]). Dickson cited tomy was performed in patients older than 70 laxis regimen in these patients.
the additional advantage that the retroperito- years, particularly in low-volume centers (Ann S.D.S.

45 Pancreatic Endocrine Tumors

Jeffrey A. Norton and Yijun Chen

Pancreatic endocrine tumors (PETs) are Cancer Data Base have demonstrated that suspected hormonal syndrome should be
rare pancreatic neoplasms with an annual surgical resection of primary tumor and established. Further, every patient should
incidence of 1 to 1.5 per 100,000 population, metastases in patients with PETs is associ- be carefully assessed for family history of
resulting in approximately 2,500 cases per ated with improved survival. endocrine tumors, especially MEN-1. For
year in the United States. They account for The majority of PETs are sporadic, but endocrinally functional tumors, control of
1% to 2% of all pancreatic neoplasms. PETs PETs may also be associated with genetic the hormonal syndrome should be done to
are clinically classified into two groups: syndromes such as MEN-1 (5% to 10% of pa- prepare the patient for surgery. When plan-
functional and nonfunctional. Functional tients), von Hippel–Lindau (VHL) disease, ning surgical treatment, complete extirpa-
PETs secrete biologically active peptides neurofibromatosis 1 (NF-1), and tuberous tion of tumor should be the goal, but it must
causing one of the previously well-described sclerosis (TSC). Most authors believe that be tailored to the severity and natural course
syndromes including insulinoma, gastri- the cells of PETs are from the embryonic of the disease, the general condition of the
noma, VIPoma, glucagonoma, somatostati- endodermal cells that later give rise to the patient, and the possible complications.
noma, and other exceedingly rare neoplasms. islet cells of Langerhans. It is important to
Nonfunctional PETs are not associated with differentiate PETs from exocrine tumors of
Endocrine Surgery

a specific hormonal syndrome. They ac- pancreas (pancreatic adenocarcinomas),

count for 15% to 30% of all PETs. Insulinoma because PETs have a much better progno- INSULINOMA
is the most common islet cell tumor, while sis. From the National Cancer Data Base, for
gastrinoma and pancreatic polypeptide 3,851 patients who underwent surgical re- The incidence of insulinoma is approxi-
(PP)-oma are the most common malignant section of PETs, the 5-year overall survival mately 0.5 to 1 in a million population. They
islet tumor. With the exception of insulino- was 59.3%, and the 10-year survival was account for about 30% to 45% of all func-
mas, that is usually benign, most PETs are 37.7%. However, the 5-year survival for sim- tional PETs. They are the most common
potentially malignant. However, although ilar patients with pancreatic adenocarci- functional PET. Insulinomas are generally
many of the PETs are malignant, they usu- noma is generally between 5% and 20%. solitary, except in MEN-1 when they may be
ally have slow growth and aggressive surgi- There are several important general multiple throughout the pancreas. About
cal resection should benefit most patients. principles in managing patients with PETs. 90% of insulinomas are benign. They are
Data from many centers and the National Unequivocal biochemical diagnosis for small and uniformly distributed.

www.medicalebookpdf.com

LWBK892_c45_p541-552.indd 541 10/28/11 5:29:58 PM

 542 Part IV: Endocrine Surgery

symptoms (confusion, slurred speech, and Since about 20% to 50% of patients
PATIENT PRESENTATIONS visual changes) mark the end of the fast. Se- have small (⬍2 cm) insulinomas that are
rum glucose and insulin concentrations are not detected by noninvasive imaging, a
Patients with insulinoma usually present measured every 6 hours and when the pa- few more sensitive invasive tests have
with symptoms related to episodic hypogly- tient develops neuroglycopenic symptoms. evolved to localize these tumors preopera-
cemia caused by uncontrolled secretion of The fast is concluded when the patient has tively. Endoscopic ultrasound (EUS) uses
insulin. Common symptoms are neurogly- symptoms and the plasma glucose level a high-frequency ultrasound probe (5 to
copenic (personality changes, blurred vi- drops to less than 45 mg/dL. At that time, 10 mHz) that is placed endoscopically in
sion, fatigue, and seizures) and neurogenic blood insulin levels, C-peptide levels, and close proximity to the pancreas. The pan-
(hunger, sweating, anxiety, tremor, and pal- proinsulin levels are measured and glucose creatic head and duodenum are scanned
pitations due to activation of the autonomic is administered. Urine sulfonylurea prod- with the probe positioned in the duode-
nervous system). Symptoms commonly ucts levels are also checked to exclude ad- num. The body and tail are imaged through
occur during the early morning hours, when ministration of oral hypoglycemic drugs. the stomach. EUS may be the best preop-
glucose reserves are low after a period of The patient is given IV glucose to relieve erative imaging study to localize the insu-
overnight fasting and tumor insulin pro- symptoms. A positive test is defined as hy- linoma. The detection rate is highest in
duction remains elevated. Symptoms may poglycemia (45 mg/dL) with elevated insu- the head of the pancreas (83% to 100%)
also occur during exercise when glycogen lin levels (⬎5 ␮U/mL). Some tumors make because the head can be viewed from three
stores are low. large amounts of proinsulin (⬎25%) that do angles ( from the third portion of the duo-
The majority (60% to 75%) of patients not lower blood glucose level as much as denum, through the bulb of the duode-
are women and some may have undergone regular insulin. Insulinoma patients should num, and through the stomach). It is lower
extensive psychiatric evaluation. Delay in also have elevated C-peptide levels. (37% to 60%) in the body and tail, which
diagnosis is common. Because insulinoma In the pediatric population, insulinoma can only be viewed through the stomach.
is rare and neuroglycopenic symptoms are must be distinguished from nesidioblasto- However, false positives may occur, espe-
relatively nonspecific, a high index of suspi- sis, a congenital islet cell dysmaturation, or cially with accessory spleens. It is best to
cion for insulinoma is necessary when other malregulation that occurs primarily in in- ask for an EUS-guided biopsy. If that is
explanations for these symptoms are not fants and causes hyperinsulinemic hypogly- positive, it is unequivocal.
evident. cemia. Age at the time of presentation is the If both noninvasive imaging and EUS
most important distinguishing factor, as fail to localize the tumor, calcium arte-
DIAGNOSIS nesidioblastosis occurs most commonly in riography can be used. The calcium arte-
children under the age of 18 months. Ap- riogram has largely replaced portal venous
In the workup of a patient with any PET, proximately half of infants with nesidio- sampling (PVS). It is the most informative
multiple endocrine neoplasia type 1 (MEN-1) blastosis require a spleen-preserving near- preoperative test for localizing occult in-
must be excluded. This should be done by total pancreatectomy, in which 95% of the sulinomas. Arteries that perfuse the pan-
carefully checking family history of mani- pancreas is removed, because this disorder creatic head (gastroduodenal artery and
festations of MEN-1 (prolactinoma, primary affects the entire pancreas diffusely. Some superior mesenteric artery) and the body/
hyperparathyroidism, low blood glucose, have been successfully managed with oct- tail (splenic artery) are selectively cathe-
secretory diarrhea, PET, kidney stone, and reotide, and patients outgrow hypoglyce- terized sequentially, and a small amount
multiple lipomas seen on physical examina- mia. Adult nesidioblastosis is very infre- of calcium gluconate (0.025 mEq Ca2⫹/kg
tion). Biochemical studies to exclude other quent. Hypoglycemia has been associated bodyweight) is injected into each artery
MEN-1 tumors should be done when there with gastric bypass surgery, but this can during different runs. A catheter posi-
is suspicion of prolactin, ionized calcium, usually be managed with octreotide instead tioned in the right hepatic vein is used
parathyroid hormone (PTH), gastrin, and of pancreatectomy. to collect blood for measurement of insu-
PP. In any patient with the possibility of lin concentrations. A positive result re-
MEN-1, the MEN-1 gene can be sequenced. quires twofold increase in the hepatic vein
The Whipple’s triad consists of symp-
LOCALIZATION OF INSULINOMA insulin concentration. It localizes the tu-
toms of hypoglycemia during a fast, a con- Since insulinomas are small, accurate pre- mor to the area of the pancreas being per-
comitant blood glucose concentration less operative and intraoperative tumor local- fused by the injected artery. In this way,
than 45 mg/dL, and relief of the hypoglyce- ization is critical. Modern radiologic imag- calcium arteriography helps to identify
mic symptoms after glucose administra- ing facilitates the localization of the tumor, the region of the pancreas containing the
tion. The diagnosis of insulinoma is made avoiding the need for a “blind” pancreatic tumor (head, body, or tail). The arterio-
by the presence of low blood glucose levels resection. Computed tomography (CT) and gram portion of the study may also show
(⬍45 mg/dL) and falsely elevated serum in- magnetic resonance imaging (MRI) are able the tumor as a vascular blush. The sensi-
sulin levels (⬎5 ␮U/mL). Factitious or sur- to identify pancreatic tumors as small as tivity of calcium angiogram is between
reptitious hypoglycemia must be excluded. 1 cm in diameter. Pancreatic protocol CT 88% and 94%. If during surgical explora-
The 72-hour fast is the gold standard for with arterial contrast and thin cuts is our tion, palpation and ultrasound fail to
diagnosis of insulinoma. It is done in the imaging modality of choice. However, the identify the tumor, calcium angiogram–
hospital with appropriate biochemical sensitivity of CT is the same as that of MRI. guided resection may be indicated. How-
measurements and close observation. During Few false positives occur. Somatostatin-re- ever, recently, with improved localization
this test, patients should have intravenous ceptor scintigraphy (SRS), which has a ma- methods, the utilization of this study has
(IV) access, and are allowed to have only jor role in imaging other PETs, is not useful declined.
noncaloric liquids. The fast may last as long in locating insulinomas, as they have a low For patients who have clear clinical and
as 72 hours, although most patients develop density of somatostatin subtype-2 cell- biochemical evidence for insulinoma, but
symptoms in 24 hours. Neuroglycopenic surface receptor. extensive preoperative workup fails to

www.medicalebookpdf.com

LWBK892_c45_p541-552.indd 542 10/28/11 5:29:58 PM

 Chapter 45: Pancreatic Endocrine Tumors 543

localize the tumor, surgical exploration is OPERATIVE MANAGEMENT sected using an endo-stapler. The spleen
still indicated. Studies have demonstrated should be preserved if possible. After tu-
that even in this situation most patients Surgery is the only curative therapy for in- mor removal, a frozen section of PET is
will have successful surgery. The single best sulinoma. With the use of IOUS, blind pan- performed and blood glucose levels usually
modality for localizing insulinoma is intra- creatic resection is no longer indicated. increase. Fibrin glue sealant and a closed-
operative ultrasound (IOUS) (⬎95%). Sur- Enucleation is indicated for most small and suction drains are used to control pancre-
gical exploration with exposure and palpa- benign tumors that are less than 2 cm. Pre- atic exocrine secretion. Laparoscopic re-
tion of the pancreas combined with the operative localized tumors can be removed moval of insulinoma with enucleation or
use of IOUS is accepted as the most cost- with laparoscopic techniques. The gold distal pancreatectomy has been applied in
effective approach for primary insulino- standard of tumor localization is IOUS and many centers, and has been associated
mas, even when other preoperative studies palpation. Even in occult insulinoma pa- with markedly reduced hospital stay, re-
are negative. tients, adequate mobilization of the pan- duced pain, and smaller incisions.
creas with the use of IOUS results in suc- For open procedures, bilateral subcostal
MEDICAL MANAGEMENT cessful identification and resection of the incision is recommended to give adequate
insulinoma in nearly all cases. exposure of the pancreas. Access to the
OF HYPOGLYCEMIA Laparoscopic approaches to insulinoma pancreas is most typically gained through
The aim of medical management is to avoid should be done for well-localized solitary the lesser sac by dividing the gastrocolic
life-threatening hypoglycemia. Euglycemia tumors. In general, a 30-degree camera is omentum. An extended Kocher maneuver
is maintained initially with frequent feeds used and four ports are placed. The specific of the duodenum is done to lift the head of
of a high-carbohydrate diet, including a area of the pancreas with tumor is exposed the pancreas out of the retroperitoneum.
night meal. Cornstarch may be added to by either doing a Kocher maneuver or The separation of the transverse mesocolon
food for prolonged absorption. Diazoxide, opening the gastrocolic ligament. IOUS is from the inferior border of the pancreas al-
which inhibits insulin release, is used for used to identify the tumor and guide the lows for complete mobilization of the pan-
patients who continue to become hypogly- dissection. The relationship of the tumor to creas (Fig. 1). Since almost all insulinomas
cemic between feedings. Diazoxide should vital structures like the superior mesenteric are located within the pancreas and are
be discontinued 1 week prior to surgery to vein (SMV), portal vein, common bile duct, uniformly distributed throughout the en-
avoid intraoperative hypotension. Calcium- and pancreatic duct is clarified with ultra- tire gland, the entire pancreas should be
channel blockers or phenytoin may also sound. Tumors in the head and body are visually inspected and bimanually palpated
suppress insulin production in some pa- enucleated with ultrasound guidance using to identify the presence of tumors after
tients. the harmonic scalpel. Tumors in tail are re- complete mobilization. Insulinomas are

Endocrine Surgery

C D
Fig. 1. Operative maneuvers to identify insulinoma. The pancreas is completely exposed by opening the lesser sac and elevat-
ing the pancreas from its retroperitoneal position. The gland is thus optimally positioned for bimanual palpation, as well as
IOUS, to identify small tumors within the pancreatic parenchyma. A: While an upper midline incision that may extend below
the umbilicus is used by some surgeons, most prefer bilateral subcostal incision for insulinoma. B: After an extended Kocher
maneuver, the head of the pancreas is elevated to allow thorough palpation and ultrasound. C: The lesser sac is opened by
dividing the gastrocolic ligament. D: The inferior border of the pancreas (avascular) is incised, allowing a hand to be placed
underneath the pancreas for palpation and ultrasound.

www.medicalebookpdf.com

LWBK892_c45_p541-552.indd 543 10/28/11 5:29:58 PM

 544 Part IV: Endocrine Surgery

A B

Fig. 2. CT scan (A) and IOUS (B) of an insulinoma (arrows). The insulinoma appears hypervascular compared with the pan-
creas following IV contrast (A) and sonolucent compared with more echodense pancreas on IOUS (B). This procedure was
done laparoscopically and the tumor (1.5 cm in diameter) was enucleated with the guidance of IOUS.

typically small, solitary, encapsulated, and Most insulinomas are amenable to enu- safely. About 10% insulinoma patients have
reddish-brown. The tumor feels like a firm, cleation, which excise only the adenoma MEN-1, and a more aggressive approach is
nodular, and discrete mass. Approximately with minimal normal pancreatic tissue warranted in those patients. Most have
65% of insulinomas may be identified by the loss. Tumor size, location, and surround- multiple pancreatic tumors throughout
traditional operative maneuvers of inspec- ing anatomy determine whether enucle- the pancreas and thus may require a distal
tion and palpation. IOUS is critical during ation or pancreatic resection is performed. pancreatectomy and enucleation of any
surgery for insulinomas because it not only IOUS allows a precise, safe tumor enucle- palpable or ultrasonographically detected
facilitates identification of these tumors, ation and helps plan the shortest, most lesions in the head of the gland. The goal of
but also helps to define the relationship of direct route to the tumor while avoiding surgery is to ameliorate the hypoglycemia
the tumor to the common bile duct, pancre- the pancreatic duct (Fig. 3). The indication by eliminating the source of insulin. Usu-
atic duct, portal vein, and adjacent blood for distal or subtotal pancreatectomy in- ally a dominant large tumor (⬎3 cm) is
vessels. On IOUS, an insulinoma appears as cludes large tumors, malignant tumors, responsible for secreting the excessive
a sonolucent mass with margins distinct proximity to the ductal structure, and the insulin.
from the uniform, more echodense pancre- inability to get a clear margin between For patients with malignant insulinoma,
atic parenchyma (Fig. 2). In experienced normal pancreas and the tumor. In rare the procedure should be planned to attempt
hands, the sensitivity for detecting insuli- cases, pancreaticoduodenectomy is indi- to remove all tumors. This may require major
nomas using IOUS is approximately 95%. cated if enucleation cannot be performed pancreatic resection and/or combined liver
resection. Radiofrequency ablation (RFA)
can also be used to eliminate unresectable
lesions in the liver. If most of the insulin-
producing tumor can be removed, then this
will benefit the patient in terms of long-term
symptomatic control of the glucose level.

OUTCOME
Most patients with sporadic insulinoma are
cured of hypoglycemia. They have a normal
long-term survival. However, for MEN-1
patients, persistent or recurrent hypoglyce-
A B mia owing to multiple insulinomas or meta-
Fig. 3. Enucleation of insulinoma from the pancreas. A: IOUS is extremely helpful in locating the tumor static tumor is not uncommon. With the use
and defining the relationship of tumor to adjacent vessels and the pancreatic duct. Tumors are generally of IOUS, the pancreatic surgery for insuli-
well circumscribed with very clear borders. B: Enucleation of insulinoma is generally done under the noma should have a low morbidity and mor-
guidance of IOUS. The site must be thoroughly drained with closed-suction drains to manage a postop- tality rate. Potential complications include
erative pancreatic leak. fistula, pseudocyst, pancreatitis, and abscess.

www.medicalebookpdf.com

LWBK892_c45_p541-552.indd 544 10/28/11 5:29:59 PM

 Chapter 45: Pancreatic Endocrine Tumors 545

GASTRINOMA PREOPERATIVE TUMOR symptoms associated with acid hypersecre-

LOCALIZATION tion. The usual dose of omeprazole is 40 mg
PO BID. With current medications, it is pos-
In 1955, Zollinger and Ellison described a Noninvasive imaging studies are initially sible to control the gastric acid output in ev-
syndrome of upper jejunal ulceration, gas- used to assess the location of tumor and ery patient with gastrinoma. Although ZES
tric acid hypersecretion, and tumors of the the extent of metastases. Abdominal CT patients typically require two to five times
endocrine pancreas. Later, gastrin was detects approximately 50% of gastrinomas the usual dose of PPIs to keep the BAO
identified as the hormone responsible for overall, but sensitivity depends greatly on ⬍10 mEq/h, BAO should be measured and
the Zollinger–Ellison syndrome (ZES). The tumor size, tumor location, and the pres- be ⬍10 mEq/h prior to the next dose of PPI.
incidence of gastrinoma is about 0.1 to ence of metastases. Gastrinomas ⬎3 cm If the patient has GERD, it should be
3 people per million population. It is the in diameter are reliably detected by CT, ⬍5 mEq/h. Acid hypersecretion may persist
second most common PET. In contrast to whereas tumors ⬍1 cm in diameter are after complete resection of gastrinoma due to
insulinomas, 16% to 35% of gastrinomas are rarely detected. Abdominal MRI has a low hypertrophy of parietal cell mass. PPIs should
associated with MEN-1. Most tumors arise sensitivity (25%) in localizing primary gas- be continued after surgery. They can be ti-
in the duodenum, and about 60% of the pa- trinomas but is the study of choice to show trated with measurements of acid output ap-
tients are diagnosed with malignant dis- hepatic metastases. SRS is the imaging test proximately 3 to 4 months postoperatively.
ease. In the context of MEN-1, the most of choice for localizing primary and meta-
common functional pancreatic PET is gas- static gastrinomas. The sensitivity of SRS
trinoma. Gastrinomas occur in 0.1% of all is about 80% to 90% and the specificity
SURGERY FOR GASTRINOMA
patients with peptic ulcer disease and in 2% approaches 100%. SRS is especially useful With the use of effective PPIs, there is no
of patients with recurrent ulcer disease. The in evaluating the extent of metastases. longer a need for total gastrectomy to re-
mean age at diagnosis is 50 years, and the Because the majority of gastrinomas are duce acid output in patients with ZES. The
mean time from symptoms to diagnosis is 8 located in the duodenum and not the goal of surgery is to remove the primary tu-
years, suggesting that a delay in diagnosis is pancreas, the use of EUS is limited. mor and metastases for potential cure and
common. Invasive localization tests such as selec- prevention of malignancy. Surgical resec-
tive angiography with or without the intra- tion offers the only chance for long-term
PATIENT PRESENTATION arterial injection of secretin and PVS for disease-free survival or cure of ZES. It has
gastrin have been largely supplanted by been shown to improve survival. The deter-
The classic symptoms of gastrinoma are SRS. If all imaging studies are negative and minants of long-term survival are the
those of peptic ulcer disease. Patients have duodenal gastrinomas are suspected, we growth of the tumor and metastases.
epigastric abdominal pain, diarrhea, and would take the approach to explore the du- About 85% of gastrinomas arise in the
esophagitis. Symptoms are caused by gas- odenum with the assumption that most gastrinoma triangle, defined by the junc-
tric acid hypersecretion. Diarrhea occurs in likely the tumors are there. tions of the cystic and common ducts, the
20% of patients, while esophagitis with or second and third portion of the duodenum,
without stricture can also occur. Patients TREATMENT/ACID- and the neck and body of the pancreas
with severe peptic ulcer disease that require (Fig. 4). Duodenal gastrinomas are the most
surgery, recurrent ulceration after adequate SUPPRESSION THERAPY common primary location site. Duodenal
PPI treatment, or multiple ulcerations in Once the diagnosis of gastrinoma is tumors are approximately three times more
multiple locations or unusual locations confirmed, proton pump inhibitors (PPIs) common than pancreatic tumors. Because
should be screened for gastrinoma. should be started immediately to control gastrinomas are often occult and lymph

DIAGNOSIS
ZES is diagnosed by elevated fasting se-
rum level of gastrin and elevated basal
acid output (BAO). Patients must discon-
tinue all antacid medications (PPIs and
H2 receptor antagonists) for 1 week, be-
cause these medications can cause a false
elevation of gastrin. An increased fasting
serum gastrin concentration (⬎1000 pg/
Endocrine Surgery

mL) and an abnormally elevated BAO

(⬎15 mEq/L) establish the diagnosis of
ZES. If the diagnosis is uncertain in pa-
tients with minimally increased fasting
serum gastrin concentrations (100 to 1,000
pg/mL), the secretin stimulation test is
the provocative test of choice. A 200 pg/
mL increase of gastrin concentration
above baseline following secretin stimula-
tion is consistent with ZES. However, only
approximately 80% of patients with ZES Fig. 4. About 85% of gastrinomas arise in the gastrinoma triangle, defined by the junction of the cystic and
have a positive test. common ducts, the second and third portion of the duodenum, and the neck and body of the pancreas.

www.medicalebookpdf.com

LWBK892_c45_p541-552.indd 545 10/28/11 5:30:01 PM

 546 Part IV: Endocrine Surgery

nodes metastasis are common, open rather

than laparoscopic exploration is indicated.
An upper abdominal incision that provides
adequate exposure for exploration of the
entire pancreas, regional lymph nodes, and
liver is necessary. The peritoneal surfaces
and liver are carefully inspected to check
for metastases or implants. Next, the sur-
geon opens the lesser sac widely by dividing
the gastrocolic ligament from the hepatic
flexure to the splenic flexure, thereby ex-
posing the entire neck, body, and tail of the
pancreas. The next maneuver involves an
extended Kocher maneuver by mobilizing
the entire right colon and the proximal as
well as the distal duodenum; this allows Fig. 5. A complete lymphadenectomy for gastrinoma starts at the hepatoduodenal ligament. Then
palpation of the head of the pancreas and, lymph nodes from the porta hepatis, celiac axis, and retroperitoneum, as well as the nodes from both the
equally important, the wall of the duode- anterior and posterior border of the head of the pancreas, are excised.
num. Intraoperative ultrasonography is
performed in a systematic fashion to help
identify small tumors in the pancreas. Gas-
trinomas within the head and neck of the Patients with both ZES and MEN-1 are immediately after surgery, 40% at 5 years,
pancreas are enucleated with palpation or unique because they may have multiple PETs and 34% at 10 years. For those patients with
via ultrasonographic control, while distal in the pancreas and multiple gastrinomas in liver metastases at presentation, the overall
pancreatectomy is indicated for gastrino- the duodenum. The cure rate is low. The ap- survival is only 20% to 38%. Surgery to re-
mas in the tail of pancreas. propriate extent of surgical resection in these move gastrinoma has been shown to im-
Sporadic gastrinomas are usually soli- patients is controversial. We recommend prove survival in patients with sporadic
tary and often (⬃50%) metastasize to lymph surgical exploration only for those patients ZES and patients with MEN-1/ZES who
nodes. This makes it imperative to perform with ZES/MEN-1 and an imageable tumor have tumor⬎2.5 cm. Surgery for gastri-
an extensive lymphadenectomy. We usually ⬎2 cm. The indication in this case is to pre- noma has also been demonstrated to result
start with a lymphadenectomy of the hepa- vent metastatic spread of tumor to the liver, in a lower rate of liver metastasis (5% vs.
toduodenal ligament. Then lymph nodes not to cure ZES. If a patient also has primary 29%) and a lower rate of disease-related
from the porta hepatis, celiac axis, and ret- hyperparathyroidism and ZES, do the para- death (1% vs. 23%), translating into a 15-
roperitoneum, as well as the nodes from thyroid operation first as this may amelio- year survival difference of 93% versus 73%.
both the anterior and posterior border of rate the clinical manifestations of ZES. Therefore we recommend surgical explora-
the head of the pancreas, are excised In sporadic gastrinoma patients, more tion for all patients with sporadic ZES, and
(Fig. 5). Primary lymph node gastrinomas than 90% of the tumors can be found during all patients with MEN-1/ZES who have a tu-
have been reported. Although it is still con- surgery. The postoperative cure rate is 60% mor larger than 2.5 cm.
troversial whether or not tumors can truly
originate in lymph nodes, patients may be
cured with lymphadenectomy alone.
For some patients, intraoperative en-
doscopy can help find the small duodenal
tumors either by direct vision or by transil-
lumination (Figs. 6 and 7). The most fre-
quently missed gastrinomas are those within
the duodenum, and thus opening the duo-
denum (duodenotomy) for transmural
palpation and examination is critical for
duodenal tumor operative detection. For
all patients without an identified primary
tumor, the duodenum is opened. Because
the neoplasm arises in the submucosa and
invades into the mucosa, the gastrinoma
is excised via a full-thickness specimen
with a rim of normal duodenal wall around
the tumor. Do not confuse the ampulla of
Vater or the entrance of the minor pancre-
atic duct with a gastrinoma. If isolated
liver metastases are found and the lesions
are resectable, a synchronous liver resec-
tion can be done after the removal of the
primary tumor. Fig. 6. Endoscopic view of a gastrinoma in the duodenum. This tumor is located in the submucosa.

www.medicalebookpdf.com

LWBK892_c45_p541-552.indd 546 10/28/11 5:30:01 PM

 Chapter 45: Pancreatic Endocrine Tumors 547

this syndrome have glucagon levels above

1000 pg/mL. Patients are generally mal-
nourished and treated with preoperative nu-
tritional support such as TPN. The rash can
be managed with somatostatin ana-
logueoctreotide.
Glucagonomas are usually easily image-
able on CT (size 5 to 10 cm). They are malig-
nant. Most patients have lymph node and
liver metastases. The cure rate is low. How-
ever, even with unresectable metastatic dis-
ease, the progression of the tumor is slow.
Many patients live for years.

SOMATOSTATINOMA
Somatostatinoma is a rare PET that arises
in either the pancreas or the duodenum.
Duodenal tumors are typically near the am-
pulla and small. The somatostatinoma syn-
drome includes steatorrhea, cholelithiasis,
type 2 diabetes mellitus, and hypochlorhy-
Fig. 7. Transillumination of the duodenum using intraoperative endoscopy showing a duodenal wall
gastrinoma. During transillumination duodenal wall tumors appear as a focal light opacity. dria. The diagnosis is made by biological
measurement of somatostatin-like activity
and the presence of tumor. Imaging with CT
scan and SRS are effective for identifying
Patients may also have stomatitis, glossitis, the extent of disease (Fig. 9). Most patients
GLUCAGONOMA cheilosis, and hypoaminoacidemia. All the have unresectable metastatic tumor at time
skin manifestations appear to be a conse- of diagnosis.
Glucagonoma is a rare PET that usually quence of malnutrition. These resolve with
presents during the fifth or sixth decade of treatment using total parenteral nutrition
life. Patients classically present with a rash (TPN). VASOACTIVE INTESTINAL
called necrolytic migratory erythema; they The hormonal diagnosis of glucagonoma
also have type 2 diabetes and a tendency is made by an elevated plasma level of glu-
POLYPEPTIDE TUMOR
toward deep venous thrombosis (Fig. 8). cagon (⬎500 pg/mL). Most patients with
The vasoactive intestinal polypeptide tu-
mor (VIPoma) syndrome is associated with
severe diarrhea, hypokalemia, hypercalce-
mia, and achlorhydria. Patients have severe
watery secretory diarrhea. Secretory or
hormonal diarrhea means that the diarrhea
persists even when the patient is not eating.
It is therefore referred to as the pancreatic
cholera syndrome, the endocrine cholera
syndrome, or the WDHA (watery diarrhea,
hypokalemia, and achlorhydria) syndrome.
The diagnosis of VIPoma is made by an
elevated plasma vasoactive intestinal poly-
peptide (VIP) level (500 pg/mL) and the pres-
ence of secretory diarrhea. The volume of the
Endocrine Surgery

diarrhea is typically 5 to 10 L per day. Be-

cause these patients are often severely de-
hydrated with electrolyte abnormalities, IV
fluid therapy is necessary. The somatostatin
analogue (octreotide) is very effective in
preoperative management of the VIPoma
syndrome. It stops the diarrhea and allows
effective electrolyte replacement.
A B
VIPomas are generally large and can be
imaged by CT scan. SRS is useful to confirm
Fig. 8. Skin manifestation characteristic of necrolytic migratory erythema (NME) rash in a patient with the nature of the CT abnormality as well as
glucagonoma. The patient had NME on both his face (A) and groin (B). to evaluate for metastatic disease. Although

www.medicalebookpdf.com

LWBK892_c45_p541-552.indd 547 10/28/11 5:30:02 PM

 548 Part IV: Endocrine Surgery

Fig. 9. SRS and CT scan of a patient with a large somatostatinoma in the head of the pancreas. The patient had a hypervascu-
lar lesion on CT scan (A) and increased signal on SRS (B).

VIPomas are malignant, surgery is often mones produced by NF-PETs are either func- have become the primary source of morbid-
effective. In addition, at the time of surgery, tionally inert or too small in quantity. ity and mortality for PETs. Malignancy is
each patient should have a cholecystectomy NF-PETs may be identified by imaging for clearly established with histological evidence
to facilitate later treatment with the soma- other indications like PET scan or CT scan. of tumor remote from the primary lesion,
tostatin analog that can cause gallstones. In that setting they are often small and usually in peripancreatic lymph nodes or the
asymptomatic. However, they may also be liver. Recent studies also indicate that low
large at presentation. Clinical presentation histological grade, high mitotic index, and
OTHER RARE PETS generally relates to symptoms including high Ki-67 are all associated with increased
abdominal pain, obstruction, and jaundice. metastatic potential and poor survival.
Other rare PETs include growth hormone– Because aggressive surgical management in- Somatostatin receptor scintigraphy
releasing factor (GRF)-oma, adrenocortico- cluding resection of mesenteric vessels and (octreoscan) SRS is the single best imaging
tropic hormone (ACTH)-oma, parathyroid localized liver metastases is indicated for study to evaluate the extent of disease if the
hormone–related protein (PTH-RP)-oma, NF-PET, it is important to distinguish these tumor binds to the isotope. CT, MRI, and
and neurotensinoma (Table 1). These neo- tumors from other lesions, particularly the bone scan are all useful to monitor disease
plasms occur in less than 0.2 persons per more common pancreatic ductal adenocar- progression and spread. Unnecessary surgi-
million per year. These tumors are mostly cinoma. CT, MRI, and SRS are all useful in this cal procedures are avoided when miliary or
malignant. The hormones, symptoms and regard. EUS with biopsy can provide patho- extensive bilobar hepatic disease and dis-
signs, diagnostic tests and criteria, sites of logical diagnosis and is valuable in differenti- tant metastases are found.
occurrence, and proportions malignant for ating these two pancreatic tumors. With the If multiple PETs are found in a patient,
each tumor are given in Table 1. CT scan and increasing frequency of axial imaging, then MEN-1 should be suspected. Since
SRS are good imaging studies to evaluate the NF-PETs may also be diagnosed as an inci- PETs have a better prognosis than adeno-
primary tumor as well as the metastases. dental pancreatic mass and should be re- carcinoma of the exocrine pancreas, ag-
sected because of potential for malignancy. gressive surgery is indicated even in the
As in functional PETs, development of liver presence of limited metastatic disease. The
NONFUNCTIONAL PETS metastases is the most important determi- purpose of the aggressive surgery is to de-
nant of survival, and preventing liver metas- crease tumor bulk, reduce the hormonal
Nonfunctioning PETs (NF-PETs) are the most tases is the primary goal of surgical resection. syndromes, relieve symptoms of mass ef-
common PET. They do not cause clinical fect, and/or to eliminate cancerous tissue
symptoms of hormone excess. However, and improve disease-free or overall survival.
these tumors may actually produce multiple MALIGNANT PETS Resection of advanced disease, including
hormones and peptides, including neuro- vascular reconstruction, has been done
tensin, PP, chromogranin A, and neuron- Because of the rarity and nonspecific and in- safely and is suggested to improve survival.
specific enolase. Plasma levels of chromogr- termittent nature of their symptoms, delay in Even incomplete tumor resection may im-
anin A are elevated in 60% to 100% of patients diagnosis in PETs is very common. As such, prove the ability to control the hormonal
with NF-PETs and may be used in individual patients with PETs may have metastatic dis- syndrome medically. For metastatic insuli-
patients to follow disease progression, ease at presentation, most commonly in the noma patients, surgical resection of the pri-
relapse, and response to therapy. The hor- liver and, infrequently, in bone. Metastases mary tumor, and aggressive resection of

www.medicalebookpdf.com

LWBK892_c45_p541-552.indd 548 10/28/11 5:30:05 PM

 Chapter 45: Pancreatic Endocrine Tumors 549

Table 1 Features of PETs

Incidence
(people/
million/ Hormone Signs or Malignant
Tumor year) secreted symptoms Diagnostic studies Diagnostic criteria Locations (%)
Gastrinoma 0.1–3 Gastrin Ulcer pain, Serum gastrin, BAO Fasting serum gastrin Pancreas, 60–90
diarrhea, ⬎100 pg/mL, BAO duodenum
esophagitis ⬎15 mEq/h
Insulinoma 0.8 Insulin Hypoglycemia Supervised 72-h fast Glucose ⬍ 45 mg/dL Pancreas 5
and insulin ⬎5 ␮U/
mL
VIPoma VIP Watery diarrhea, Fasting plasma VIP Pancreas, 60
hypokalemia, ⬎250 pg/h (bronchi, colon,
hypochlorhy- adrenal, liver,
dria sympathetic
ganglia)a
Gluca- Glucagon Rash, weight loss, Fasting plasma Fasting plasma glucagon Pancreas 70
gonoma malnutrition, glucagon ⬎500 pg/h
diabetes
Somatosta- Somatostatin Diabetes, Fasting plasma Increased fasting Pancreas, 70
tinoma cholelithiasis, somatostatin plasma somatostatin duodenum,
steatorrhea concentration small bowel,
ampulla
GRFoma 0.2 GRF Acromegaly Fasting plasma GRF Increased fasting Lung, pancreas, 30
plasma GRF jejunum,
concentration adrenal
ACTHoma ACTH Cushing’s Urinary free cortisol, 24-hour urinary free Pancreas 100
syndrome plasma ACTH, cortisol ⬎100 ␮g,
dexamethasone plasma ACTH ⬎50
suppression test pg/h, no dexametha-
sone suppression, no
CRH suppression
PTH-RPoma PTH-RP Hypercalcaemia, Serum calcium, Serum calcium ⬎11 Pancreas 100
bone pain serum PTH, mg/dL, serum PTH
serum PTH- undetectable,
related peptide increased serum
PTH-like factor
Neurotensi- Neurotensin Tachycardia, Fasting plasma Increased fasting Pancreas ⬎80
noma hypotension, neurotension plasma neurotensin
hypokalemia concentration
NF-PETs PP, chromogra- Pain, bleeding None, pancreatic Increased plasma Pancreas ⬎60
nin A, mass polypeptide, concentration of PP,
neurone- chromogranin A chromogranin A or
specific neuron-specific
enolase enolase
a
Rare.
Endocrine Surgery

liver metastases are both associated with vation with CT scans. In patients with hor- control can be performed if more than 90%
prolonged survival and about 50% of pa- monally active tumors, rapidly progressing of the tumor can be excised safely. For pa-
tients have complete biochemical remission tumors, uncontrolled pain, and mass effect, tients with inoperable metastatic liver dis-
after surgery. Although disease-free survival intervention is required. Surgical resection ease, hepatic artery chemoembolization,
is prolonged in most patients, many eventu- remains the mainstay of treatment for cura- laparoscopic radio frequency ablation (RFA)
ally develop recurrent tumor. tive and palliative intent, although hepatic and orthotopic liver transplantation are al-
Several treatment options have developed resection for cure is possible in less than 10% ternatives to surgical debulking. Recently in
over time for the treatment of the liver me- of affected patients. Curative surgery is pos- some centers, resection of the primary pan-
tastasis from PETs. Because of the indolent sible for patients with unilobar metastases creatic tumor even in the setting of unresect-
nature of neuroendocrine tumors, asymp- that occupy less than 75% of the liver paren- able but limited hepatic metastases has been
tomatic patients may undergo serial obser- chyma; palliative resection for symptomatic reported with encouraging results.

www.medicalebookpdf.com

LWBK892_c45_p541-552.indd 549 10/28/11 5:30:06 PM

 550 Part IV: Endocrine Surgery

Symptoms from extensive metastases in patients with primary hyperparathyroid-

may respond to chemotherapy or octreotide. ism and nephrolithiasis or a positive family CONCLUSION
Combination chemotherapy with strepto- history.
zotocin and 5-fluorouracil is the most effec- MEN-1 PETs become symptomatic most PETs comprise a group of less common
tive regimen for metastatic insulinoma, pro- frequently in the fourth or fifth decade; pancreatic tumors that are more indolent.
ducing at least a partial response in 60% of however, the biochemical abnormalities of- Surgery is the mainstay of treatment. The
patients. A few centers have reported prom- ten develop in the third decade. The most management of PETs should consider the
ising new trials using different chemothera- common type is the NF-PET. Among pa- natural course of the disease, endocrinopa-
peutic drugs in combination with antian- tients with functional PETs, 54% have gas- thy, potential for cure, and association of
giogenesis antibodies, mammalian target of trinomas, 20% to 30% have insulinomas, MEN-1. Complete surgical resection of both
rapamycin (mTOR) pathway inhibitors, and and less than 15% have glucagonoma, so- primary disease and limited metastases is
tyrosine kinase inhibitors to control the matostatinoma, or other PETs. Recent stud- indicated. Evolving medical treatment, liver
growth and progression of PETs. Treatment ies have identified significant mortality as- directed therapy, and molecular therapy
with octreotide (Sandostatin LAR) has sociated with PETs as approximately 45% of may offer further improvements in disease
shown antiproliferation activity, with stable MEN-1 gene carriers died of PET-related control and quality of life to patients with
or decreased tumor growth in some patients causes. unresectable tumors.
with PETs. However, the results are unpre- The management of MEN-1 patients
dictable and some patients do not respond must be individualized for each patient
to octreotide. The addition of interferon-␣ based on the pattern of disease. It is still
SUGGESTED READINGS
to octreotide therapy may benefit a sub- controversial about the timing and aggres- Brandi ML, Gagel RF, Angeli A, et al. Guidelines for
group of patients with advanced metastatic siveness of surgery for these patients. For diagnosis and therapy of MEN type 1 and type 2.
disease that is unresponsive to octreotide MEN-1 patients with ZES, surgery to correct J Clin Endocrinol Metab 2001;86:5658.
Chandrasekharappa SC, Guru SC, Manickam P, et al.
monotherapy. Octreotide may ameliorate the manifestation of primary hyperparathy- Positional cloning of the gene for multiple en-
symptoms, especially in patients with ma- roidism (HPT) (3.5 gland parathyroidec- docrine neoplasia-type 1. Science 1997;276:404.
lignant VIPoma, and when symptoms are tomy) will clearly improve the signs and Doherty GM, Doppman JL, Shawker TH et al.
adequately controlled, patients can live symptoms of ZES. So for those patients, sur- Results of a prospective strategy to diagnose,
comfortably and productively for many years gery for HPT should precede the surgery for localize and resect insulinomas. Surgery 1991;
with metastatic disease. gastrinoma. The surgery to resect the gastri- 110:989.
nomas itself is rarely curative because they Fraker DL, Norton JA, Alexander HR, et al. Surgery
in Zollinger–Ellison syndrome alters the natural
have multiple tumors. We recommend sur- history of gastrinoma. Ann Surg 1994;220:320.
MEN-1 SYNDROME gical resection for larger tumors (⬎2 cm) to Hiramoto JS, Feldstein VA, LaBerge JM, et al.
remove any potentially malignant tumors. Intraoperative ultrasound and preoperative
MEN-1 is an autosomal dominant inherited For patients with MEN-1 and insulinoma, localization detects all occult insulinomas.
syndrome first reported by Wermer in 1963. surgery is recommended for almost all Arch Surg 2001;136:1020.
patients because the secreting insulinoma Lamberts SW, Bakker WH, Reubi JC, et al. Soma-
MEN-1 has a wide range of pathology in- tostatin receptor imaging in the localization of
cluding hyperplasia of parathyroid glands, is usually visible as a dominant tumor on endocrine tumors. N Engl J Med 1990;323:1246.
PETs, and pituitary adenomas. It is now the CT scan. This principle also applies Norton JA, Fraker DL, Alexander HR et al. Surgery
known that other tissues are also involved, to MEN-1 associated glucagonoma and to cure the Zollinger–Ellison syndrome. N Engl
including thymus and bronchi (carcinoids), VIPoma. However, in NF-PETs, surgery is J Med 1999;341:635.
subcutaneous fat (lipomas), thyroid gland, indicated for larger tumors that are clearly Norton JA, Kivlen M, Li M, et al. Morbidity and
visible (⬎2 cm) or cause symptoms such as mortality of aggressive resection in patients
adrenal glands, and skin. It has nearly com- with advanced neuroendocrine tumors. Arch
plete penetrance and variable expressivity. obstruction or bleeding. The MEN-1 syn- Surg 2003;138:859.
The mutated gene in MEN-1 has been found drome is a disease that can only be man- Norton JA, Fraker DL, Alexander HR et al. Surgery
to be menin that maps to the long arm of aged, but not cured. Continued surveillance increases survival in patients with gastrinoma.
chromosome 11. Genetic tests are commer- is a very important part of the whole man- Ann Surg 2006;244:410.
cially available now. Approximately 80% of agement for patients. Patients should be fol- Rosch T, Lightdale CJ, Botet JF, et al. Localization
lowed annually to assess whether or not of pancreatic endocrine tumors by endoscopic
patients with MEN-1 have associated PETs; ultrasonography. N Engl J Med 1992;326:1721.
only 5% to 25% of the patients with PETs there is progression of disease. Biochemical
Roy PK, Venzon DJ, Shojamanesh H, et al. Zollinger–
have MEN-1. In all patients diagnosed with hormonal screening and imaging with CT Ellison syndrome. Clinical presentation in 261
PETs, MEN-1 should be excluded, especially scan, SRS, and EUS may be used. patients. Medicine 2000;79:379.

EDITOR’S COMMENT more than 2,500 papers, which are written about syndrome are dead within 5 years, and we will
pancreatic endocrine tumors (PETs). The most discuss this later, as to whether the advent of
notorious is the Zollinger-Ellison syndrome, in PPIs (proton-pump inhibitors) has made it diffi-
This is a very nice, densely written chapter about which it has been stated that, for a while at least, cult to convince both physician and patient that
a fairly complicated area, in which, as we get more there were many more papers written about it this really is a tumor and needs to be treated as a
knowledgeable, there are probably more papers than there were tumors (1,000 at that time). It is, malignancy.
written than there are cases. There are no more as the author indicates, a real tumor, and there The author raises the question as to whether
than 2,500 cases annually, and these are fascinat- are any number of malignant tumors. Twenty- or not Zollinger-Ellison syndrome can arise in
ing to clinicians. I believe that there are probably five percent of patients with Zollinger-Ellison lymph nodes. I believe I had such a patient once,

www.medicalebookpdf.com

LWBK892_c45_p541-552.indd 550 10/28/11 5:30:06 PM

 Chapter 45: Pancreatic Endocrine Tumors 551

who actually perforated an ulcer over the week- 2011;146(6):724–732). This is an important paper, to a Whipple resection,” with which I agree—or
end, and on exploring him—and he had been because PETs sometimes have preoperative to- patients with multiple nonfunctioning PETs with
advertised as having a Zollinger-Ellison syn- mographic evidence of major vascular involve- MEN1 syndrome to a total pancreatectomy—
drome—I found that he had a lesion in a rather ment. Given the tendency of most endocrinolo- because these surgeries are extensive and destruc-
large lymph node, which came off the pancreas gists to believe that the endocrine tumors really tive. However, I do believe that patients who are
with a small connection, and on resecting it he are not dangerous, and, even if they are, they not necessarily going to have that much destruc-
was no longer hyperacidic. I am certain that these should not be operated on, this is an important tion should not be allowed to have an attempt at
things happen, and I thought that that was one paper. Involvement of major blood vessels with resection, including liver resection, especially in
such case. PETs included the portal vein (n ⫽ 20), the supe- gastrinomas that are resectable. Otherwise, the
I agree entirely that, if the patient has a hy- rior mesenteric vein or superior mesenteric ar- outcome is clear, and they will die.
perparathyroidism as part of an MEN-1, then the tery (n ⫽ 16), inferior vena cava (n ⫽ 4), splenic There are two papers that go into the genetic
parathyroids should be dealt with first, and these vein (n ⫽ 4), and heart (n ⫽ 2). Forty-two of these expression in well-differentiated PETs with gas-
may very well be parathyroid hyperplasia, but 46 patients had a PET removed, 12 or 27% the trointestinal and pulmonary carcinoid tumors.
the ordinary one large adenoma in hyperpara- primary only, 30 (68%) with lymph nodes, and 18 The first, by Long KB, et al. (Am J Surg Pathol
thyroidism does not always occur. First one does (41%) with liver metastases. The means of resec- 2010;34:723–729) dealt with the PAX genes that
the parathyroidectomy, and then one turns to the tion were given in the paper including the liver re- encode a family of transcription factors that regu-
Zollinger-Ellison syndrome, the thought being sections, of which 10 were wedge and 8 anatomic. late organogenesis and cell-lineage specification.
that hypercalcemia probably makes acid secre- Vascular reconstruction was carried out in nine “PAX proteins play a critical role in islet cell dif-
tion worse. patients including reconstruction of the superior ferentiation. We recently observed that islet cells
As far as the metastases are concerned, I agree mesenteric vein and portal vein, and one of these show strong, diffuse staining for PAX8 by immu-
entirely that radio-frequency ablation, especially had concomitant reconstruction of the superior nohistochemistry.” They analyzed 190 tumors in-
for multiple liver metastases, if not too numer- mesenteric artery. There were no deaths in the cluding 63 PETs, 31 ileal, 34 liver metastases, and
ous, is essential. However, the laparoscopic radio- group, but 12 patients had complications. Forty- so forth. They noted that PAX8-negative tumors
frequency ablation needs to be done open or lap- one percent of the patients were immediately dis- were more frequently associated with liver me-
aroscopically, because the results of eradication ease-free, but 5 recurred, leaving 13 disease-free tastases, and PAX8 expression was not associated
of the tumor are really significantly better. long-term. The 10-year overall survival was 60%. with patient age, gender, MIB1 index, or lymph
The staging and histopathological grading Not surprisingly, functional tumors had a bet- node metastases. None of the pulmonary me-
for prognosis still is something which has not yet ter overall survival, and, not surprisingly again, tastases and only 20% of the gastric metastases
been completely clarified. Scarpa A., et al. from liver metastases decreased overall survival. The expressed PAX8; however, 5 of 5 gastric but 0 of
the University of Verona and the Center for Ap- conclusion was that these findings suggest that 31 duodenal and 11 of 13 rectal tumors expressed
plied Research on Cancer, a very formidable or- surgical resection of PETs with vascular abut- it. PAX8 was positive in 50% of the metastatic
ganization, in Mod Pathol 2010; 23:824–833, have ment/invasion and nodal or disease metastases masses of the PETs but none of the carcinomas.
come up with a TNM (tumor-node-metastasis) “is indicated.” I agree. The authors believe that these data show that
grading of 274 patients with histologically diag- A lovely review of gastrointestinal neuroen- PAX8 is expressed in normal islet cells and in a
nosed PETs operated on from 1991 to 2005, with docrine tumors was done by David C. Metz and high proportion of primary and metastatic PETs
a last follow-up in 2007. Two hundred forty-six Robert T. Jensen from the University of Pennsyl- in the pancreas, especially the metastatic PETs.
were well-differentiated neoplasms, of which 51 vania in Philadelphia and the digestive-disease They also believe that PAX8 may be a prognostic
were benign, 56 were uncertain, and 139 were branch of the NIH. This is an extensive review of marker in PETs, and that loss of expression is as-
clearly carcinomas, and 28 were poorly differen- PETs and their acknowledged fascination with sociated malignant behavior.
tiated carcinomas. Ki67 immunohistochemistry these various diseases. Unabashedly it is written Another paper on PETs and expression pro-
was the basis of the grading. They also high- from a medical point of view, and they show, for filing for the AKT-mTOR pathway was writ-
lighted the absence of nodal and distal metasta- example, that gastrinomas treated with PPIs have ten by Missiaglia E, et al. (J Clin Oncol 2010;28:
ses, infiltration and tumor dimensions over 4 cm a remarkably decreased referral pattern, because, 245–255) in which they analyzed 72 primary PETs,
as having prognostic significance, and T param- I am afraid, gastroenterologists believe that the 7 matched metastases, and 10 normal pancreatic
eters were then appropriately modified “to reflect only problem is the acid hypersecretion, and, samples. They were examining somatostatin re-
this weakness.” The 5-year survival for modified since PPIs deal with that, then “we certainly need ceptor 2, which was absent or very low in insu-
TNM stages I, II, III, and IV was 100%, 93%, 65%, not pay attention.” On the other hand, most of lomas compared with nonfunctioning tumors.
and 35%, respectively. Independent predictors of the data are given to medical management of the Expression in metastases was significantly as-
death were partially dependent on Ki67 grading. hormonal-excess state, and Iím sorry to say that, sociated with shorter disease-free survival. They
The author concludes that this means of grading when it comes to surgical therapy for cure, I had strongly support in their research a role for the
patients has an excellent way of dealing with the difficulty, especially for gastrinomas, determin- PI3K/Akt/mTOR pathways in neuroendocrine
carcinoma and the prognosis. ing how aggressive the authors in this excellently tumors, and this may give some role to mTOR in-
The author and his coworkers recently au- written paper want to be. I will quote: “At present, hibitors that are now in phase-III trials. The other
thored an article in which they argued that most authorities do not recommend subjecting finding is that FGF13 may be a new prognostic
vascular involvement did not render a pa- patients with MEN1/ZES [multiple endocrine marker that predicts poorer outcome in patients
tient inoperable (Norton JA, et al., Arch Surg neoplasia, type 1/Zollinger-Ellison syndrome] who were clinically considered free from disease.
J.E.F.
Endocrine Surgery

www.medicalebookpdf.com

LWBK892_c45_p541-552.indd 551 10/28/11 5:30:06 PM

 www.medicalebookpdf.com

LWBK892_c45_p541-552.indd 552 10/28/11 5:30:06 PM

 The Breast, Chest, and Mediastinum V

www.medicalebookpdf.com

LWBK892_c46_p553-562.indd 553 10/28/11 11:48:34 PM

 46 Anatomy of the Breast
Kirby I. Bland

Breast tissue is embryologically derived and the gland and extends as septa between the canal. Most structures that course between
anatomically matures as a modified sweat lobes and lobules, providing longitudinal the neck and the upper extremity enter this
gland. Mammary tissues represent a unique and gravitational support to the glandular anatomic passage, which is bounded ante-
feature of the mammalian species. Embryo- elements. The deep layers of the superficial riorly by the clavicle, medially by the first
logically, the paired mammary glands con- fascia that lie upon the posterior surface of rib, and posteriorly by the scapula. The an-
gruently develop within the “milk line,” the breast fuse with the deep (pectoral) fas- terior wall of the axilla is composed of the
which extends between the limb buds from cia of the chest wall. A distinct space, the pectoralis major and minor muscles and
the primordial axilla distally to the inguinal retromammary bursa, can be identified an- their associated fasciae. The posterior wall
area. The number of paired glands varies atomically on the posterior aspect of the is formed primarily of the subscapularis
widely among the various mammalian spe- breast and resides between the deep layer of muscle, located on the anterior surface of
cies, but in humans and most primates, the superficial fascia and the deep investing the scapula, and to a lesser extent by the
only one pair of glands normally develops fascia of the pectoralis major and the con- teres major and latissimus dorsi muscles.
in the pectoral region, one gland on each tiguous muscles of the thoracic wall (Fig. 1). The lateral wall of the axilla is the bicipital
side. In approximately 1% of the female The retromammary bursa contributes to groove, a thin strip of condensed muscular
population, supernumerary breasts (poly- the mobility of the breast on the chest wall. tissue between the insertion of the muscu-
mastia) or nipples (polythelia) may develop. Fibrous thickenings of supportive connec- lature of the anterior and posterior com-
Supernumerary appendages principally de- tive tissue interdigitate between the paren- partments. The medial wall is composed of
velop along the milk lines. While there is chymal tissue of the breast and extend from the serratus anterior muscle.
normally minimal additional development the deep layer of the superficial fascia to at- The fascia of the pectoralis major and
of the mammary gland during postnatal life tach to the dermis of the skin. These fibrous minor muscles are evident in two distinct
in the male, in the female extensive growth suspensory structures, known as Cooper planes: The superficial layer, called the pec-
and development are evident. Evident post- ligaments, located perpendicular to the deli- toral fascia, invests the pectoralis major
natal development of the female mammary cate superficial fascial layers of the dermis, muscle, whereas the deep layer, called the
gland is related to age and is primarily regu- allow remarkable mobility of the gland while clavipectoral or costocoracoid fascia, extends
lated by hormones (estrogens) that influ- providing structural support and breast from the clavicle to the axillary fascia in the
ence reproductive function. The greatest contour. floor of the axilla and encloses the subclavius
development of the breast is attained by the The fully mature female breast extends and the pectoralis minor muscle (Fig. 3).
age of 20 years, and atrophy begins pre- from the level of the second or third rib in- The costocoracoid membrane repre-
menopausally at approximately the age of feriorly to the inframammary fold that is sents the upper portion of the clavipectoral
40 years. During pregnancy and lactation, located at the level of the sixth or seventh fascia and is pierced by the cephalic vein,
striking variants occur in both the amount rib. Laterally, the breast extends from the the lateral pectoral nerve, and branches of
(volume) of glandular tissue and the func- lateral border of the sternum to the ante- the thoracoacromial trunk. The medial pec-
tional activity of the breast. Structural rior or midaxillary line. Breast parenchyma toral nerve does not penetrate the costoco-
changes are also observed during menstrual extends commonly into the anterior axil- racoid membrane, but enters the deep sur-
cycles that result from variations in ovarian lary fold as the axillary tail of Spence. The face of the pectoralis minor and passes
hormone levels. During menopause, with upper half of the breast, particularly the up- through the anterior investing fascia of the
the changes occurring in the hormonal se- per outer quadrant, contains the greater pectoralis minor to innervate the pectoralis
cretory activity of ovarian function, the volume of glandular tissue than the remain- major muscle. Caudad portions of the clavi-
mammary gland undergoes involution and der of the breast. The posterior or deep sur- pectoral fascia, which are anatomically in-
is replaced by fat and connective tissue, and faces of the breast rest upon portions of the ferior to the pectoralis minor, are some-
thereafter, diminishes its structural volume, fasciae of the pectoralis major, serratus an- times referred to as the suspensory ligament
form, and contour. terior, and external oblique muscles; the of the axilla or the coracoaxillary fascia.
gland also resides on upper portions of the Many surgeons refer to this anatomic land-
FUNCTIONAL ANATOMY anterior rectus sheath. mark as Halsted’s ligament, which repre-
sents a dense condensation of the clavipec-
OF THE BREAST toral fascia that extends from the medial
ANATOMY OF THE AXILLA aspect of the clavicle, attaches to the first
The glands of the breast are located within
the superficial fascial compartment of the The anatomical boundaries of the axilla rib, and invests the subclavian artery and
anterior chest wall. This organ consists of 15 represent a pyramidal compartment lo- vein as each traverse the first rib.
to 20 lobes of tubuloalveolar glandular tis- cated between the upper extremity and the Within the axilla are the great vessels and
sue, fibrous connective tissue that supports thoracic wall; this structure has four bound- nerves of the upper extremity, which, to-
its lobes, and the adipose tissue that resides aries inclusive of a base and an apex (Fig. 2). gether with the other axillary contents, are
in parenchyma between the lobes. Subcuta- The curved oblong base consists of axillary encircled by loose connective tissue. These
neous connective tissue typically does not fascia. The apex of the axilla represents vessels and nerves are anatomically contigu-
possess a distinctive capsule around breast an aperture that extends into the posterior ous and are enclosed within an investing
components; rather, this tissue surrounds triangle of the neck via the cervicoaxillary layer of fascia referred to as the axillary
554

www.medicalebookpdf.com

LWBK892_c46_p553-562.indd 554 10/28/11 11:48:36 PM

 Chapter 46: Anatomy of the Breast 555

The Breast, Chest, and Mediastinum

Fig. 1. A tangential view of the breast on the chest wall and a sectional (sagittal) view of the breast and associated chest
wall. The breast lies in the superficial fascia just deep to the dermis. It is attached to the skin by the suspensory ligaments
of Cooper and is separated from the investing fascia of the pectoralis major muscle by the retromammary bursa. Cooper’s
ligaments form fibrosepta in the stroma that provide support for the breast parenchyma. From 15 to 20 lactiferous ducts
extend from lobules comprising the glandular epithelium to openings located on the nipple. A dilation of the duct, the
lactiferous sinus, is present near the opening of the duct in the subareolar tissue. Subcutaneous fat and adipose tissue
distributed around the lobules of the gland give the breast its smooth contour and, in the nonlactating breast, account
for most of its mass. Lymphatic vessels pass through the stroma surrounding the lobules of the gland and convey lymph
to collecting ducts. Lymphatic channels ending in the internal mammary (or parasternal) lymph nodes are shown. The
pectoralis major muscle lies adjacent to the ribs and intercostal muscles. The parietal pleura, attached to the endotho-
racic fascia, and the visceral pleura, covering the surface of the lung, are shown. (From Romrell LJ, Bland KI. Anatomy of
the breast, axilla, chest wall, and related metastatic sites. In: Bland KI, Copeland EM III, eds. The breast: comprehensive
management of benign and malignant diseases, 4th ed. Philadelphia, PA: Saunders Elsevier, 2009:21–38.)

Fig. 2. The anterior chest illustrating the structure of the chest wall, breast, and ax-
illa. See text for details of the structure of the axilla and a description of its contents.
On the right side, the pectoralis major muscle has been cut lateral to the breast and
reflected laterally to its insertion into the crest of the greater tubercle of the humerus.
This exposes the underlying pectoralis minor muscle and the other muscles forming
the walls of the axilla. The contents of the axilla, including the axillary artery and vein,
components of the brachial plexus, and axillary lymph node groups and lymphatic
channels, are exposed. On the left side, the breast is cut to expose its structure in sag-
ittal view. The lactiferous ducts and sinuses can be seen. Lymphatic channels passing
to parasternal lymph nodes are also shown. (From Romrell LJ, Bland KI. Anatomy of
the breast, axilla, chest wall, and related metastatic sites. In: Bland KI, Copeland EM
III, eds. The breast: comprehensive management of benign and malignant diseases, 4th
ed. Philadelphia, PA: Saunders Elsevier, 2009:21–38.)

www.medicalebookpdf.com

LWBK892_c46_p553-562.indd 555 10/28/11 11:48:36 PM

 556 Part V: The Breast, Chest, and Mediastinum

A B
Fig. 3. Sagittal sections of the chest wall in the axillary region. A: The anterior wall of the axilla. The clavicle and three mus-
cles inferior to it are shown. B: Section through the chest wall illustrating the relationship of the axillary artery and medial
and lateral pectoral nerves to the clavipectoral fascia. The clavipectoral fascia is a strong sheet of connective tissue that is
attached superiorly to the clavicle and envelops the subclavius and pectoralis minor muscles. The fascia extends from the
lower border of the pectoralis minor to become continuous with the axillary fascia in the floor of the axilla. (From Romrell LJ,
Bland KI. Anatomy of the breast, axilla, chest wall, and related metastatic sites. In: Bland KI, Copeland EM III, eds. The breast:
comprehensive management of benign and malignant diseases, 4th ed. Philadelphia, PA: Saunders Elsevier, 2009:21–38.)

sheath. The axillary artery can be divided Tributaries of the axillary vein follow the innervates the laterally placed latissimus
into three anatomical segments within the course of the branches of the axillary artery, dorsi muscle. Injury or division is inconse-
axilla proper: usually in the form of venae comitantes, quential to primary shoulder function; how-
paired veins that follow the course of the ar- ever, preservation of this nerve is essential
1. Located medial to the pectoralis minor tery. The cephalic vein passes in the groove to provide transfer survival and motor func-
muscle, the first segment gives rise to one between the deltoid and pectoralis major tion preservation for the myocutaneous flap
branch, the supreme thoracic, which sup- muscles, and thereafter enters the axillary used for the latissimus dorsi musculocuta-
plies the upper thoracic wall inclusive of vein after piercing the clavipectoral fascia. neous reconstruction. The intercostobrachial
the first and second intercostal spaces. Anatomically, the axillary artery is con- nerve is formed by the merging of the lateral
2. The second segment of this artery, lo- tiguous with various portions of the bra- cutaneous branch of the second intercostal
cated immediately posterior to the pec- chial plexus throughout its course in the nerve with the medial cutaneous nerve of
toralis minor, gives rise to two branches, axilla. The cords of the brachial plexus are the arm; this nerve provides sensory inner-
the thoracoacromial trunk and the lat- named according to their structural and vation of the skin of the apex and lateral
eral thoracic artery. Pectoral branches positional relationship with the axillary axilla and the upper medial and inner aspect
of the thoracoacromial and lateral tho- artery—medial, lateral, and posterior— of the arm. A second intercostobrachial
racic arteries supply the pectoralis ma- rather than their anatomic position in the nerve may sometimes form an anterior
jor and minor muscles. Identification of axilla or on the chest wall. branch of the third lateral cutaneous nerve.
these vessels during surgical dissection These are three nerves of principal inter-
of the axilla is imperative to provide safe est to surgeons that are located in the axilla. BLOOD SUPPLY OF THE BREAST
conduct of the procedure. The lateral The long thoracic nerve, located on the me-
thoracic artery gives origin to the lateral dial wall of the axilla, arises in the neck from Blood supply to the mammary gland is
mammary branches. the fifth, sixth, and seventh cervical roots derived from perforating branches of the
3. The third segment of this vessel, located (C5, C6, and C7) with entry in the axilla via internal mammary artery, lateral branches
lateral to the pectoralis minor muscle, the cervicoaxillary canal. This medially of the posterior intercostal arteries, and sev-
gives rise to three branches. These in- placed nerve lies on the lateralmost surface eral branches of the axillary artery. The latter
clude the anterior and posterior humeral of the serratus anterior muscle and is in- vessels include the highest thoracic, lateral
circumflex arteries that supply the up- vested by the serratus fascia such that it thoracic, and pectoral branches of the thora-
per arm, and the subscapular artery, might be accidentally divided together with coacromial artery (Figs. 4 and 5). Branches
which is the largest branch within the resection of the fascia during surgical dis- from the second, third, and fourth anterior
axilla. After a short course, the subscap- section (sampling) of lymphatics of the ax- perforating arteries pass to the breast as me-
ular artery gives origin to its terminal illa. The long thoracic nerve, although di- dial mammary arteries.
branches, the subscapular circumflex minutive in size, courses a considerable The lateral thoracic artery branches allow
and the thoracodorsal arteries. The tho- anatomic distance to supply the serratus an- perfusion to the serratus anterior muscle,
racodorsal artery, which courses with its terior muscle; injury or division of this nerve both the pectoralis muscles, and the sub-
corresponding nerve and vein, crosses results in the “winged scapula” deformity scapularis muscle, and also supply the axil-
the subscapularis muscle, providing its with denervation of the muscle group and lary lymphatics and supporting fatty tissues.
substantial blood supply, as well as that the inability to provide shoulder fixation. The posterior intercostal arteries give rise
of the serratus anterior and latissimus The thoracodorsal nerve takes origin from to mammary branches in the second, third,
dorsi muscles. the posterior cord of the brachial plexus and and fourth intercostal spaces.

www.medicalebookpdf.com

LWBK892_c46_p553-562.indd 556 10/28/11 11:48:37 PM

 Chapter 46: Anatomy of the Breast 557

evident through the overlying skin. Circum-

scribing the nipple, superficial veins form an
anastomotic circle, the circulus venosus.

The Breast, Chest, and Mediastinum

Veins from this circle and from deeper as-
pects of the gland converge to drain blood to
the periphery of the breast, and thereafter
into vessels that terminate in the internal
mammary, axillary, and internal jugular
veins.
Venous return from the gland is derived
from three principal groups of veins provid-
ing drainage of the breast and the thoracic
wall and include (a) perforating branches of
the internal mammary vein, (b) tributaries
of the axillary vein, and (c) perforating
branches of posterior intercostal veins. The
posterior intercostal veins lie in direct con-
tinuity with the vertebral plexus of veins
(Batson’s plexus) that surround the verte-
brae and extend from the base of the skull
Fig. 4. Arterial distribution of blood to the breast, axilla, and chest wall. The breast receives its blood to the sacrum. Clinically, this plexus may
supply via three major arterial routes: (a) medially from anterior perforating intercostal branches arising
provide an important pathway for hematog-
from the internal thoracic artery, (b) laterally from either pectoral branches of the thoracoacromial
trunk or branches of the lateral thoracic artery (the thoracoacromial trunk and the lateral thoracic arter- enous dissemination of breast cancer, and
ies are branches of the axillary artery), and (c) from lateral cutaneous branches of the intercostals arter- may physiologically account for metastases
ies that are associated with the overlying breast. The arteries indicated with a dashed line lie deep to the to the skull, vertebrae, pelvic bones, and en-
muscles of the thoracic wall and axilla. Many of the arteries must pass through these muscles before teral nervous system in the absence of pul-
reaching the breast. (From Romrell LJ, Bland KI. Anatomy of the breast, axilla, chest wall, and related monary metastases.
metastatic sites. In: Bland KI, Copeland EM III, eds. The breast: comprehensive management of benign and
malignant diseases, 4th ed. Philadelphia, PA: Saunders Elsevier, 2009:21–38.)
INNERVATION OF THE BREAST
Neurosensory innervation of the gland is
Although the thoracodorsal branch of the to control can result when penetrating primarily supplied by the lateral and ante-
subscapular artery does not contribute to branches of this vessel are severed. rior cutaneous branches of the second
the primary blood supply of the breast Principal venous outflow of the gland has through the sixth intercostal nerves (Fig. 5).
per se, this vessel is intimately associated preferential directional flow toward the ax- These sensory nerves of the breast originate
with the central and scapular lymph node illa, with the veins principally paralleling the principally from the fourth, fifth, and sixth
groups of the axilla. This fact should be path of the arterial distribution. The superfi- intercostal nerves, although the second and
taken into consideration during axillary cial venous plexus of mammary parenchyma third intercostal nerves may provide cuta-
node dissection, as bleeding that is difficult has extensive anastomoses that may be neous branches to the superior aspect of

Posterior
intercostal vein,
artery, & nerve Azygos vein
Innermost
Fig. 5. A segment of the body wall illustrating the relationship of structures to intercostal m.
the ribs. Two ribs are shown as they extend from the vertebrae to attach to the
sternum. The orientation of the muscle and connective tissue fibers is shown.
Aorta
The external intercostal muscle extends downward and forward. The muscle layer
extends forward from the rib tubercle to the costochondral junction, where the Lateral
muscle is replaced by the aponeurosis, called the external intercostal membrane. Collateral
cutaneous branches
The internal intercostal muscle fibers with the opposite orientation can be seen branches,
through this layer. The innermost intercostal muscle fibers are present along the Internal thoracic
intercostal artery artery &
lateral half of the intercostal space. The intercostal nerve and vessels pass through & nerve vein Sternum
the intercostal space in the plane between the internal and innermost (or intima
of the internal) intercostal muscle layers. Anterior intercostal arteries arise from Anterior
the internal thoracic artery; anterior intercostal veins join the internal thoracic intercostal
vein. Posterior intercostal arteries arise from the aorta; posterior intercostal veins vein, artery, &
join the azygos venous system on the right and the hemiazygos system on the nerve
left. Lymphatics follow the path of the blood vessels. Anteriorly, lymphatics pass
to parasternal (or internal mammary) nodes that are located along the internal External intercostal m.
mammary vessels; posteriorly, they pass to intercostal nodes located in the inter- Internal Perforating
costal space near the vertebral bodies. (From Romrell LJ, Bland KI. Anatomy of the intercostal m. artery & nerve
breast, axilla, chest wall, and related metastatic sites. In: Bland KI, Copeland EM and external
III, eds. The breast: comprehensive management of benign and malignant diseases, intercostal
4th ed. Philadelphia, PA: Saunders Elsevier, 2009:21–38.) membrane

www.medicalebookpdf.com

LWBK892_c46_p553-562.indd 557 10/28/11 11:48:37 PM

 558 Part V: The Breast, Chest, and Mediastinum

the breast. Nerves arising from the cervical prolonged hypoesthesia and/or paresthesia lie lateral and posterior to the axillary
plexus, specifically the anterior or medial can be expected. vein. This group is well identified at the
branches of the supraclavicular nerve, sup- The anterior branches of the intercostal anatomic confluence of the lateral vein
ply a limited region of the skin of the upper nerves exit the intercostal space near the with the latissimus dorsi. These nodes
portion of the breast. Collectively, these lateral border of the sternum to allow receive the majority of lymphatic con-
nerves convey sympathetic fibers for inner- arborization of branches medially and lat- tents from the upper extremity and ipsi-
vation to the breast and the overlying skin. erally over the thoracic wall. The branches lateral back with the exception of lymph
The lateral branches of the intercostal that course laterally innervate the medial that drains into the deltopectoral lymph
nerves exit the intercostal space via the at- aspect of the breast and are referred to as nodes, a group also referred to as the
tachment sites of the slips of the serratus medial mammary branches. infraclavicular nodes (Fig. 7).
anterior muscle. These nerves divide into 2. The external mammary group, usually
anterior and posterior branches as they exit identified by anatomists as the anterior
the muscle. Anterior branches of the inter- LYMPHATIC DRAINAGE or pectoral group, consists of four or five
costal also supply the anterolateral thoracic OF THE BREAST lymph nodes positioned along the lower
wall. The third through the sixth branches, and lateral border of the pectoralis mi-
The major route of lymphatic drainage of
known as the lateral mammary branches, nor muscle contiguous in association
the breast is via the axillary lymph node
supply the majority of the surface of the with the lateral thoracic vessels. These
groups (Fig. 6). There have been consider-
breast. As noted above, the intercostal bra- nodes receive the principal volume of
able variations in nomenclature for the
chial nerve, a large and constant sensory lymph drainage from the breast paren-
lymph node groups of the axilla as the
nerve, takes origin from the lateral branch chyma. From these nodes, lymph drains
boundaries of these nodal groups are not
of the second intercostal nerve. The inter- primarily into the central lymph nodes
well demarcated. These variations are par-
costal brachial nerve courses through the (see below). However, lymph may pass
ticularly evident in level I nodal groups.
fascia of the floor of the axilla to commonly directly from the external mammary
Historically, anatomists have described four
join the medial cutaneous nerve of the arm. nodes to the subclavicular lymph nodes.
principal levels (groups) of axillary lymph
This nerve is of little functional significance; 3. The scapular group, usually identified by
nodes, whereas surgeons typically identify
however, with injury to the intercostal bra- anatomists as the posterior or subscapu-
six groups at three anatomic levels. The most
chial nerve during axillary dissection, the lar group, consists of six or seven lymph
commonly used terms to describe the axil-
principal consequence for the patient is nodes positioned near the posterior wall
lary nodes are as follows:
modest loss of cutaneous sensation in the of the axilla in juxtaposition to the lat-
upper medial aspect of the arm and axilla. 1. The axillary vein group, usually identi- eral border of the scapula and contigu-
No motor loss is evident after injury or divi- fied by anatomists as the lateral group, ous with the subscapular vessels near
sion of the intercostal brachial nerve but consists of four to six lymph nodes that the “axillary floor.” These nodes receive
lymph primarily from the lower aspects
of the neck, the posterior skin and sub-
cutaneous tissues of the trunk (as low as
the iliac crest), and posterior portions
of the shoulder region. Lymph from the
scapular nodes drains into the central
and subclavicular nodes.
4. The central group, considered to be cen-
trally positioned by both anatomists
and surgeons, consists of three or four
large lymph nodes that are embedded in
the fat of the axilla, usually behind the
pectoralis minor muscle. These nodes
receive lymph from the preceding nodal
groups (axillary, external mammary, and
scapular nodal sites) and may also re-
ceive afferent lymphatic vessels directly
from the breast. Lymph from the central
group, which may lie directly upon the
ventral and anterior aspects of the axil-
lary vein, drains directly to the subclavic-
ular (apical, level III) nodes. This group
is often placed superficially beneath the
skin and the fascia of the midaxilla, and
Fig. 6. Schematic drawing of the breast identifying the position of lymph nodes relative to the breast
and illustrating routes of lymphatic drainage. The clavicle is indicated as a reference point. See the text
it is centrally located between the pos-
and Figure 8 to identify the group or level to which the lymph nodes belong. Level I lymph nodes include terior and anterior axillary folds. This
the external mammary (or anterior), axillary vein (or lateral), and scapular (or posterior) groups; level II, nodal group is the most palpable and
the central group; and level III, the subclavicular (or apical). The arrows indicate the routes of lymphatic numerous of axillary lymphatics, and
drainage (see text). (From Romrell LJ, Bland KI. Anatomy of the breast, axilla, chest wall, and related because of its superficial position may
metastatic sites. In: Bland KI, Copeland EM III, eds. The breast: comprehensive management of benign and provide accurate clinical assessment of
malignant diseases, 4th ed. Philadelphia, PA: Saunders Elsevier, 2009:21–38.) metastatic disease.

www.medicalebookpdf.com

LWBK892_c46_p553-562.indd 558 10/28/11 11:48:37 PM

 Chapter 46: Anatomy of the Breast 559

6. The interpectoral or Rotter group, usually

identified by surgeons but not by anato-
mists, consists of one to four small lymph

The Breast, Chest, and Mediastinum

nodes located between the pectoralis
major and minor muscles. This group
is contiguous with pectoral branches
of the thoracoacromial vessels. Lymph
from these nodes enters the central and
subclavicular nodes.
Axillary lymphatics are also divided accord-
ing to their lateral and medial (surgical) ana-
tomic relationships with the pectoralis mi-
nor muscle into three distinct levels and are
identified as levels I through III (Figs. 8 and 9).
Level I nodes are located lateral to or below
the inferior border of the pectoralis minor;
this level includes the external mammary,
the lateral axillary vein, and the scapular
lymph node groups. Level II nodes are located
deep in or behind the pectoralis minor and
include the central lymph node group and
possibly some of the subclavicular lymph
node group. Level III nodes are located su-
peromedial to the upper margin of the pec-
toralis minor and include the subclavicular
(apical) lymph node group (Fig. 6).
W. Sampson Handley is credited with the
recognition of metastatic spread of breast
carcinoma to the internal mammary nodes
as a primary route of lymphatic dissemina-
tion. This British surgeon and anatomist
provided extensive clinical and anatomic
research to confirm that central and medial
breast lymphatics pass medially, parallel the
course of major blood vessels, to perforate
the pectoralis major muscle, and terminate
in the internal mammary nodal chain.
Fig. 7. Schematic drawing illustrating the route of lymphatic drainage in the upper extremity. The relation- Internal mammary nodes are located
ship of this drainage to the major axillary lymph node groups is indicated by the arrows. All the lymph within the retrosternal interspaces between
vessels of the upper extremity drain directly or indirectly through outlying lymph node groups into the
the costal cartilages approximately 2 to 3 cm
axillary lymph nodes. The outlying lymph nodes are few in number and are organized into three groups: (a)
supratrochlear lymph nodes (one or two, located above the medial epicondyle of the humerus adjacent to within the sternal margin (Figs. 7 and 8). This
the basilic vein), (b) deltopectoral lymph nodes (one or two, located beside the cephalic vein where it lies nodal group traverses and parallels the in-
between the pectoralis major and deltoid muscle just below the clavicle), and (c) variable small isolated ternal mammary vasculature and is invested
lymph nodes ( few and variable in number; may be located in the cubital fossa or along the medial side of by endothoracic fascia. The internal mam-
the brachial vessels). Note that the deltopectoral lymph node group drains directly into the subclavicular, mary lymphatic trunks terminate in the sub-
or apical, lymph nodes of the axillary group. (From Romrell LJ, Bland KI. Anatomy of the breast, axilla, clavicular nodal groups (Figs. 6 and 9). The
chest wall, and related metastatic sites. In: Bland KI, Copeland EM III, eds. The breast: comprehensive man- right internal mammary nodal group drains
agement of benign and malignant diseases, 4th ed. Philadelphia, PA: Saunders Elsevier, 2009:21–38.) into the right lymphatic duct, whereas the
left enters the main thoracic duct (Fig. 10).
There are three interconnecting groups of
lymphatic vessels that drain the breast:
5. The subclavicular group, identified by the subclavian trunk. The course of the
anatomists as the apical group, consists subclavian trunk is highly variable ana- 1. A primary set of vessels originate as
of 6 to 12 lymph nodes that are located tomically. It may join and directly enter channels within the gland in the inter-
in part posterior and partially above the the internal jugular vein or the subcla- lobular spaces and parallel the robust
upper border of the pectoralis minor vian vein, or their junction. On the right accumulation of lactiferous ducts of the
muscle. This nodal group extends into side of the subclavian trunk, the right breast parenchyma.
the apex of the axilla along the medial lymphatic duct may enter this structure, 2. The vessels draining the glandular tis-
aspect of the axillary vein. These nodes whereas on the left side confluence with sue and the overlying skin of the central
receive lymph from all the other axillary the thoracic duct is common. Efferent part of the gland pass directly into the
lymph node groups. Thereafter, these vessels from the subclavicular lymph subareolar plexus, an interconnecting
efferent lymphatic vessels from the sub- nodes may also pass to the deep cervical network of vessels located beneath the
clavicular lymph nodes unite to form lymph nodes. areola.

www.medicalebookpdf.com

LWBK892_c46_p553-562.indd 559 10/28/11 11:48:38 PM

 560 Part V: The Breast, Chest, and Mediastinum

3. The rich lymphatic plexus lies upon the

deep surface of the breast to communi-
cate with minute vessels that parallel
the deep fascia underlying the breast.
Along the medial border of the breast,
lymphatic vessels within the substance
of the gland anastomose with vessels
that pass to parasternal nodes.

Lymphatic flow in this organ is multidirec-

tional; however, greater than 75% of lymph
flow directly enters the axillary lymph
nodes. The majority of the residual lymph
egresses to parasternal nodes. This ana-
tomic feature provides support for the ra-
tionale of the sentinel lymph node biopsy
(sampling) of the axilla, popularized and
scientifically advanced by Donald Morton,
to determine the (accurate) histologic sta-
tus of these nodes and, hence, valid patho-
logic staging. Although some authorities
have suggested that the parasternal nodes
receive lymph primarily from the medial
part of the breast, others report that both
the axillary and the parasternal lymph node
groups receive lymph from all quadrants of
Fig. 8. Lymphatic drainage of the breast. The pectoralis major and minor muscles, which contribute to the breast, with no definitive probability for
the anterior wall of the axilla, have been cut and reflected. This exposes the medial and posterior walls of
any quadrant to drain medially or laterally.
the axilla, as well as the basic contents of the axilla. The lymph node groups of the axilla and the internal
mammary nodes are depicted. Also shown is the location of the long thoracic nerve on the surface of This observation allows surgeons to use
the serratus anterior muscle (on the medial wall of the axilla). The scapular lymph node group is closely sentinel nodes procured in the axilla to be
associated with the thoracodorsal nerve and vessels. The roman numerals indicate lymph node groups the principal determinate of pathologic
defined in Figure 9. M, metastases; T, tumor. (From Romrell LJ, Bland KI. Anatomy of the breast, axilla, staging, regardless of the quadrant of ana-
chest wall, and related metastatic sites. In: Bland KI, Copeland EM III, eds. The breast: comprehensive tomic presentation of the index tumor. The
management of benign and malignant diseases, 4th ed. Philadelphia, PA: Saunders Elsevier, 2009:21–38.) skin of the breast also drains via the super-
ficial lymphatic vessels to the axillary lymph
nodes. The anterolateral chest and the up-
per abdominal wall cephalad to the umbili-
cus show a striking unidirectional flow of
lymph toward the axilla. Lymphatic vessels
near the lateral margin of the sternum pass
through intercostal spaces to the paraster-
nal lymph nodes that course with the inter-
nal thoracic vessels. In the upper pectoral
region, small numbers of lymphatic vessels
pass over the clavicle to inferior deep cervi-
cal lymph nodes.
Within the fascial and muscular struc-
tures of the thoracic wall, lymphatics drain
primarily into three groups of lymph nodes:
the parasternal, intercostal, and diaphrag-
matic lymphatics. The parasternal (internal
thoracic) lymph nodes are a group of smaller
lymphatics positioned approximately 1 cm
lateral to the sternal border in the intercos-
tal spaces along the internal mammary ves-
Fig. 9. Schematic drawing illustrating the major lymph node groups associated with the lymphatic sels. These nodes reside in the areolar tissue
drainage of the breast. The roman numerals indicate three levels or groups of lymph nodes that are just beneath the endothoracic fascia bor-
defined by their location relative to the pectoralis minor. Level I includes lymph nodes located lateral dering the space between the adjacent cos-
to the pectoralis minor; level II, lymph nodes located deep to the muscle; and level III, lymph nodes
located medial to the muscle. The arrows indicate the general direction of lymph flow. The axillary vein
tal cartilages.
and its major tributaries associated with the pectoralis minor are included. (From Romrell LJ, Bland The intercostal lymph nodes represent a
KI. Anatomy of the breast, axilla, chest wall, and related metastatic sites. In: Bland KI, Copeland EM III, small group located in the posterior por-
eds. The breast: comprehensive management of benign and malignant diseases, 4th ed. Philadelphia, PA: tion of the thoracic cavity within the inter-
Saunders Elsevier, 2009:21–38.) costal spaces near the origin of the ribs.

www.medicalebookpdf.com

LWBK892_c46_p553-562.indd 560 10/28/11 11:48:38 PM

 Chapter 46: Anatomy of the Breast 561

parenchyma and attach to the cutis reticu-

laris of the dermis are termed the suspen-
sory ligaments of Cooper. These tubuloalveo-

The Breast, Chest, and Mediastinum

lar glands lie within the subcutaneous
tissues. Each lobe of the primary gland ter-
minates in the lactiferous duct, 2 to 4 mm
in diameter, and empties into the subareo-
lar ampulla via a constricted orifice at the
terminus of the nipple (Fig. 1). Beneath the
areola at the termination of each duct is a
dilated portion that is termed the lactifer-
ous sinus. These lactiferous ducts are popu-
lated near their openings with stratified
squamous epithelium. The epithelial lining
of the duct has evidence of gradual transi-
tion to two layers of cuboidal cells in the
lactiferous sinus, thereafter becoming a
single layer of columnar or cuboidal cells
distributed throughout the remainder of
the ductal system.
Morphology of the secretory portion of
the mammary gland varies significantly
with patient age and has physiologic and
anatomic variance with pregnancy and lac-
tation. The glandular component of the
breast is sparse in the inactive (nonpreg-
nant) premenopausal gland and consists
Fig. 10. Schematic of the major lymphatic vessels of the thorax and the root of the neck. The thoracic predominantly of duct elements. The inac-
duct begins at the cisterna chyli, a dilated sac that receives drainage from the lower extremities and the tive organ undergoes slight cyclical changes
abdominal and pelvic cavities via the lumbar and intestinal trunks. Lymph enters the systemic circula-
throughout the menstrual cycle. During
tion via channels that join the great veins of the neck and superior mediastinum. The lymphatic vessels
demonstrate considerable variation as to their number and pattern of branching. A typical pattern is il- pregnancy, the gland is altered in size and
lustrated here. Most of the major trunks, including the thoracic and right lymphatic ducts, end at or near secretory function with dramatic prolifera-
the confluence of the internal jugular with the subclavian veins. (From Romrell LJ, Bland KI. Anatomy of tion inclusive of cellular hypertrophy, lac-
the breast, axilla, chest wall, and related metastatic sites. In: Bland KI, Copeland EM III, eds. The breast: tation, and development. These physiologi-
comprehensive management of benign and malignant diseases, 4th ed. Philadelphia, PA: Saunders Elsevier, cal events are accompanied by relative
2009:21–38.) diminution in the volume of connective
and adipose tissue. With pregnancy, the
epidermis of the nipple and areola becomes
deeply pigmented and somewhat corru-
One or more nodes are found in each inter- the diaphragm, adjacent to the pericardial gated. It is covered thereafter with kerati-
costal space with contiguous relationship sac, where the phrenic nerve innervates nized, stratified squamous epithelium. The
to the intercostal vessels. These nodes re- the diaphragm. These nodes lie near the areola contains sebaceous glands, sweat
ceive deep lymphatics from the posterolat- vena cava on the right side and near the glands, and accessory areolar glands of
eral thoracic wall, including lymphatic esophageal hiatus on the left. The poste- Montgomery, which are intermediate be-
channels from the breast. Upper efferent rior set of diaphragmatic nodes consists tween true mammary glands and sweat
lymphatics from the intercostal lymph of a few lymph nodes located near the glands in their structure. These accessory
nodes on the right side terminate in the crura of the diaphragm. These nodes re- areolar glands present as small elevations
right lymphatic duct, whereas the efferent ceive lymph from the posterior aspect of on the surface of the areola. Sebaceous and
lymphatics from the corresponding nodes the diaphragm and convey the same to sweat glands are distributed along the
on the left side terminate in the thoracic posterior mediastinal and lateral aortic margin of the areola. The apex of the nipple
duct. nodes. contains numerous free sensory nerve end-
The diaphragmatic lymph nodes consist ings and Meissner (tactile) corpuscles in
of three groups of small lymph nodes lo- MICROSCOPIC ANATOMY the dermal papillae, whereas the areola
cated upon the thoracic surface on the di- OF THE BREAST contains few of these terminal sensory
aphragm. The anterior group includes two structures. Neuronal plexuses are also pres-
or three small lymph nodes, also known as Embryologically, the parenchyma of the ent around hair follicles in the skin periph-
prepericardial nodes, located behind the mature mammary gland is composed of 15 eral to the areola; Pacinian (pressure) cor-
sternum at the base of the xiphoid pro- to 20 irregular lobes of branched tubuloal- puscles are present in the dermis and in
cess. The efferent lymphatics from the an- veolar glands. These lobes, separated by the glandular tissue. Anatomically and
terior diaphragmatic nodes pass to the fibrous bands of connective tissue, radiate functionally, the rich sensory innervation
parasternal nodes. The lateral set of dia- from the mammary papilla (or nipple) and of the nipple–areolar complex is of great
phragmatic lymph nodes is composed of are further subdivided into multiple lob- significance to allow lactation and breast
two or three small nodes on each side of ules. The fibrous bands that support the feeding.

www.medicalebookpdf.com

LWBK892_c46_p553-562.indd 561 10/28/11 11:48:39 PM

 562 Part V: The Breast, Chest, and Mediastinum

SUGGESTED READINGS Gray H. The lymphatic system. In: Clemente

CD, ed. Anatomy of the human body, 30th ed.
KI, Copeland EM III, eds. The breast: comprehensive
management of benign and malignant diseases, 4th
Anson BJ, McVay CB. Thoracic walls: breast or Philadelphia, PA: Lea & Febiger; 1985:866–932. ed. Philadelphia, PA: Saunders Elsevier; 2009:21–38.
mammary region. In: Anson BJ, McVay CB, Haagensen CD. Anatomy of the mammary glands. Sakki S. Angiography of the female breast. Ann
eds. Surgical anatomy, 6th ed. Philadelphia, PA: In: Haagensen CD, ed. Diseases of the breast, 3rd Clin Res 1974;6(Suppl 12):1–47.
Saunders; 1984:352–65. ed. Philadelphia, PA: Saunders; 1986:1–46. Sykes PA. The nerve supply of the human nipple.
Batson OV. The function of the vertebral veins and Henriques C. The veins of the vertebral column J Anat 1969;105(Pt 1):201.
their role in the spread of the metastases. Ann and their role in the spread of cancer. Ann R Coll Tan MP. Breast lymphatic anatomy and implica-
Surg 1940;112(1):138–49. Surg Engl 1962;31:1–22. tions for sentinel lymph node biopsy. Ann Surg
Copeland EM III, Bland KI. The breast. In: Sabiston Hunt KK, Newman LA, Copeland EM III, et al. The Oncol 2008;15(8):2345–6.
DC, ed. Essentials of surgery. Philadelphia, PA: breast. In: Brunicardi C, ed. Schwartz’s princi- Turner-Warwick RT. The lymphatics of the breast.
Saunders; 1987:288–326. ples of surgery, 7th ed. New York: McGraw-Hill; Br J Surg 1959;46:574–82.
Cunningham L. The anatomy of the arteries 2005:423–74. van Deventer PV, Page BJ, Graewe FR. Vascular
and veins of the breast. J Surg Oncol 1977;9: Romrell LJ, Bland KI. Anatomy of the breast, axilla, anatomy of the breast and nipple–areola com-
71–85. chest wall, and related metastatic sites. In: Bland plex. Plast Reconstr Surg 2008;121(5):1860–1.

EDITOR’S COMMENT the time and nearly 10% were juxtaposed but not of the lymphatics will be greater, being precisely
involving the SLN. Some ARM lymphatics are as why an ALND has migrated from a Level I, II, and
large as 6 mm. Variations from the traditionally III dissection to a Level I and II dissection. If arm
No one is better at describing anatomy than taught position just below the vein were seen as lymphedema is caused by cutting lymphatics,
Dr. Bland as he does so well in this chapter on a lateral or medial apron (Variations 3 and 4). knowledge of the significant variation of the lym-
the anatomy of the breast and the axilla. Recent Another variation was a complex of smaller lym- phatic drainage within the arm and the ability to
surgical developments have stemmed directly phatics entwined as a cord (Variation 5). Major identify that drainage would represent the first
from anatomical lessons. Conventional wisdom lymphatics of the arm can also bypass the ax- surgical procedure designed to preserve them.
teaches that the lymphatics draining the arm illa proper and go directly to the thoracic duct. The other lesson comes from knowing the
reside juxtaposed to the vein draining into the Further congenital hypoplasia of lymphatics can anatomy of the nipple areolar complex nicely
lateral group of nodes sitting posterior to the vein predispose patients to surgical lymphedema. described by Dr. Bland. It has been traditionally
at the level of the latissimus. If the surgeon can Crossover of the blue ARM lymphatics with the taboo to leave the nipple areolar complex. Be-
avoid skeletonizing the vein, then the risk of lym- radioactive SLN was seen in 3% to 4% of pa- cause the epithelial lining of the duct extends for
phedema could be minimized or avoided. If this tients much less than we initially anticipated. about 7 mm below the skin surface at which time
was the case, then sentinel lymph node biopsy Of course, this is going to be much greater with the cuboidal lining of the true ductal structure
should have eliminated the problem of surgical traditional Level III nodes where the confluence starts, it may be safe to save the skin overlying
lymphedema. In fact, lymphatics with this loca- the nipple areolar complex. This has been given
tion are usually not recognized at the time of sur- various terms such as total skin sparing mastec-
gery. Therefore, we believe that lymphedema is re- tomy or nipple skin sparing mastectomy and is in
lated to disruption of the significant variation in direct contradistinction to nipple sparing or sub-
arm lymphatic drainage that we have described. cutaneous mastectomy where the nipple areolar
Foldi and others have carefully catalogued the complex is retained. Multiple preliminary studies
drainage of the various parts of the arm, but once show that this may be safe.4
identified as a lymph node in the axilla, lymph V.S.K
nodes are categorized only as an axillary lymph
node not distinguished from where it drains but
by where it is positioned in the axillary bed.1 Tra-
ditional lymphatic drainage of the arm is based 1
Foldi M. Remarks concerning the consensus docu-
on extensive lymphatic mapping of the arm but ment (CD) of the International Society of Lymphol-
not within the axilla. ogy The diagnosis and treatment of peripheral lym-
We developed the concept of axillary reverse phedema. Lymphology 2004;37(4):168–173.
mapping (ARM) that uses a simple method–-blue 2
Thompson M, Korourian S, Henry-Tillman R, et al.
dye injected into the upper inner volar subcuta- Axillary reverse mapping (ARM): a new concept to
neous tissue of the arm to map the lymphatic Fig. 1. Variations in axillary reverse mapping. identify and enhance lymphatic preservation. Ann
drainage of the arm.2–3 This determines the in vivo The diagram demonstrates the anatomical vari- Surg Onc 2007;14:1890–1895.
anatomical variation in the axillary lymphatics, ations in ARM drainage. 1. Tradition teaching of
3
Bland K, Klimberg VS, eds. Master techniques in
providing a road map to preserving them (Fig. 1). general surgery: breast surgery, 1st ed. Philadelphia:
We have identified multiple variations of the arm the lymphatics from the arm running juxtaposed Lippincott; 2010.
lymphatics with some being as much as 4 cm be- to the axillary vein either above or below; 2. 4
Boneti C, Yuen J, Santiago C, et al. Oncologic safety
low the vein in a sling type pattern (Variation 2, Sling low in the axilla; 3. Lateral apron; 4. Medial of nipple skin-sparing or total skin-sparing mastec-
Fig. 1). In fact, from a sentinel lymph node biopsy apron, the later two usual consisting of multiple tomies with immediate reconstruction. J Am Coll
incision one can see blue dye in the axilla 40% of blue nodes; 5. Entwined cord of lymphatics. Surg 2011;212(4):686–693; discussion, 693–695.

www.medicalebookpdf.com

LWBK892_c46_p553-562.indd 562 10/28/11 11:48:40 PM

 Chapter 47: Diagnostic Approach to Breast Abnormalities 563

47 Diagnostic Approach to Breast Abnormalities

The Breast, Chest, and Mediastinum

Helen Krontiras, Heidi Umphrey, and Kirby I. Bland

Breast cancer accounts for 26% of all female inherited factors, and previous breast dis- observed and compared with the patient
cancers (excluding nonmelanoma skin can- ease. Female gender is the most common upright for any obvious masses, asymme-
cer and in situ cancers). More than 182,960 risk factor for breast cancer. Male breast tries, and skin changes. The nipples are in-
women were diagnosed with invasive breast cancer accounts for less than 1% of all breast spected for the presence of retraction, in-
cancer in 2008 alone, and despite significant cancer. A patient’s risk for developing breast version, or excoriation. The patient is then
strides in the treatment of breast cancer, cancer increases with age. A woman in the asked to lift her arms for a more careful in-
more than 40,000 women die of the disease sixth decade has a 1 in 24 chance of develop- spection of the lower half of the breasts.
each year. The public has become increas- ing breast cancer, compared with 1 in 257 This maneuver also highlights any subtle
ingly aware of breast cancer and its preva- for a woman in her third decade. Endocrine retraction that is not readily visible with the
lence and, as a result, women presenting risk factors for breast cancer include endog- arms relaxed. Palpation of the regional
with breast complaints are anxious about enous estrogen exposure and exogenous ex- nodes should follow to include the cervical,
the possibility of being diagnosed with breast posure to estrogen and progesterone. Early supraclavicular, infraclavicular, and axillary
cancer. Clinicians evaluating women with menarche, late menopause, late parity, and nodal basins. Finally, the breast is palpated
breast complaints should provide a compre- nulliparity all increase exposure to endoge- in a systematic manner with the patient up-
hensive, efficient, and timely consultation so nous estrogen. In women who have had hys- right with arms relaxed and supine with the
that anxiety can be relieved by a benign diag- terectomy, whether or not the ovaries have ipsilateral arm raised above the head.
nosis or a treatment plan can be instituted been removed should be documented. It A dominant mass is defined as being
promptly should a cancer be diagnosed. may be difficult to accurately determine the three-dimensional, distinct from surrounding
date of menopause, and often questions
HISTORY AND PHYSICAL about menopausal symptoms may be help-
ful. Recent studies have indicated that long-
EXAMINATION term hormone replacement therapy with Table 1 Pathologic Classification
A thorough history and physical examina- estrogen and progesterone can increase risk of Benign Breast Disease
tion are essential components of the diag- for breast cancer. and the Risk Associated
nostic evaluation of a breast abnormality. Previous personal history of breast can- With Each Category
Key features of the history include details cer increases risk for subsequent breast Lesion Relative risk
about the presenting symptom, history of cancer by approximately 0.7% per year. Hav-
Nonproliferative breast
previous breast disease, and risk factors for ing had a breast biopsy also increases risk disease
breast cancer including a menstrual history to a much smaller extent, and this risk is
and other contributing past medical history. further elevated if the pathologic results re- No increased risk No increased risk
Initial questions should focus on the pre- turned atypical hyperplasia or lobular car- Cysts and apocrine
senting symptom, whether it be a mass, cinoma in situ. Table 1 lists the pathologic metaplasia
nipple discharge, palpable adenopathy, pain, classification of benign breast disease and Duct ectasia
or abnormal imaging. Questions should be the risk associated with each category. A
Mild ductal epithelial
asked regarding the length of time the ab- family history of breast or ovarian cancer hyperplasia
normality has been present, associated pain, consistent with genetic or inherited breast
change in size or texture of the breast over cancer significantly increases risk. A history Calcifications
time, and the relationship of the pain or of prior thoracic irradiation in women in Fibroadenoma
change in size of the breast or mass to the their second and third decades of life car- Proliferative breast
menstrual cycle. Additionally, it is impor- ries a risk of subsequent breast cancer of disease
tant to ascertain whether the patient has approximately 35% by age 40. A summary of
Mild increased risk 1.5- to 2.0-fold
noticed any associated nipple discharge, risk factors is listed in Table 2. It is impor-
nipple changes, axillary adenopathy, or skin tant to note, however, that 60% of women Sclerosing adenosis
changes. If the patient reports nipple dis- with newly diagnosed breast cancer have Radial and complex
charge, it is important to inquire about no identifiable risk factors. Thus, the deci- sclerosing lesions
whether the discharge is spontaneous or sion to evaluate a breast abnormality should Florid ductal hyperplasia
happens only with manipulation. A patient not depend on the presence or absence of
may notice staining of spontaneous dis- risk factors. Moreover, the presence or ab- Intraductal papillomas
charge on her bra or bedclothes. sence of risk factors does not influence the Proliferative disease
Identification of risk factors responsible probability that a breast abnormality is ma- with atypia
for increasing a woman’s likelihood of devel- lignant. Moderate increased risk Fourfold
oping breast cancer is important in the daily The physical examination should be per- Atypical ductal
practice of clinicians caring for women. Risk formed with respect for patient privacy and hyperplasia
factors for developing breast cancer can be comfort without compromising the com-
divided into several categories: gender, age, plete evaluation. The examination begins Atypical lobular
hyperplasia
endocrine factors, family history, genetic or with inspection. The breasts are visually

www.medicalebookpdf.com

LWBK892_c47_p563-574.indd 563 10/28/11 5:28:24 PM

 564 Part V: The Breast, Chest, and Mediastinum

ttion at a different point in the menstrual cycle images should be performed as necessary
Table 2 Risk Factors for m may clarify the issue. depending on the specific complaint.
Breast Cancer
In patients who present with nipple dis-
Gender ccharge, the nipple discharge is often elicited
Age dduring palpation of the breast. The charac- Mammography
Genetic risk factors tter, color, and location of the discharging Screening mammography is used to detect
BRCA1 or 2 dduct or ducts should be documented. If the cancer in asymptomatic women when can-
Ataxia–telangiectasia ddischarge is not grossly bloody, a Hemoc- cer is not suspected. Diagnostic mammogra-
Li–Fraumeni ccult test may be used to detect occult blood. phy is used to evaluate patients with breast
Cowden syndrome P Pathologic discharge, which is defined as symptoms or complaints, such as nipple dis-
Family history of breast cancer u unilateral, uniduct, spontaneous, and/or charge or a palpable mass; patients who have
bbloody discharge, should be evaluated with had abnormal results on screening mam-
Personal history of breast cancer ssurgical duct excision. mography; or patients who have had breast
Previous breast biopsy Breast cancer is very uncommon in men, cancer treated with breast conservation ther-
Proliferative breast disease without atypia aaccounting for less than 1% of all breast apy. The diagnostic examination is tailored to
Atypical hyperplasia ccancers. The most common breast problem the individual patient’s specific abnormality.
Lobular carcinoma in situ iin men is gynecomastia. Gynecomastia is a The radiologist is present on site during per-
Previous thoracic radiation bbenign hypertrophy of breast tissue. In formance of diagnostic mammography to fa-
Endocrine risk factors oolder men, the hypertrophy is often unilat- cilitate the problem-solving process.
Early menarche eeral. The patient usually presents with a Screening or diagnostic mammography
Late menopause ddiscoid mass symmetrically placed beneath consists of at least two standard views: cran-
Late parity tthe areola, which may be tender to palpa- iocaudal and mediolateral oblique (Fig. 1).
Nulliparity ttion. There are myriad benign causes of gy- These views demonstrate fibroglandular
Long-term hormone replacement with n necomastia. Many medications are associ- breast tissue. Right and left views are exam-
estrogen and progesterone aated with gynecomastia. Gynecomastia is ined side by side so that asymmetries can be
Lifestyle factors eeasily distinguished from breast cancer in observed. The images are also examined for
Alcohol tthat breast cancer is asymmetrically lo- areas of microcalcifications. A magnifying
Obesity ccated beneath or next to the areola, and glass may be necessary for a thorough eval-
mmay be fixed to the overlying dermis or the uation. The description of the location of the
ppectoral fascia. If breast cancer is sus- abnormalities should be indicated based on
pected, imaging followed by biopsy should a quadrant or clock face (with the physician
tissues, and asymmetric relative to the other be pursued. facing the patient) (Fig. 2).
breast. True masses will persist throughout After analyzing the mammographic im-
the menstrual cycle. If a dominant mass is IMAGING ages, radiologists classify findings into a
identified, it should be measured, and its lo- final assessment category. The Breast Im-
cation, mobility, and character should be Patients referred from another facility aging Reporting and Data System (BIRADS)
documented in the medical record. Diagnosis should provide the actual radiographic im- final assessment classification was devel-
should not be delayed. If uncertainty remains ages so that the consulting surgeon may oped by the American College of Radiology
regarding the significance of an area of nodu- examine the films as part of the complete to standardize mammographic reporting.
larity in the absence of a dominant mass in a patient evaluation. Films of inadequate The BIRADS classification is listed in Table
premenopausal woman, a repeat examina- quality should be repeated. Additional 3. Follow-up recommendations are made

A B

Fig. 1. Standard mammogram views. Mediolateral oblique (A) and craniocaudal (B) views show normal breasts and proper
labeling; the laterality (right or left side) and projection are placed near the axilla.

www.medicalebookpdf.com

LWBK892_c47_p563-574.indd 564 10/28/11 5:28:25 PM

 Chapter 47: Diagnostic Approach to Breast Abnormalities 565

Table 3 Breast Imaging Reporting and Data System Classification: Final

Assessment Categories

andd Mediastinum
diastiinum
Assessment Category Recommendation
0 Need additional imaging evaluation Add views or ultrasound

Medi
1 Negative Annual mammography

Chest, and
2 Benign finding Annual mammography

Chest
3 Probably benign finding—short Unilateral mammography 6 months and
Fig. 2. Schematic of “clock face” and quadrant

Breast Ch
interval follow-up suggested bilateral examinations 12 and 24
methods of describing locations within the breast.

Thee Breast,
months after initial examination
RUO, right upper outer; RUI, right upper inner;
RLI, right lower inner; RLO, right lower outer; LUI, 4 Suspicious abnormality Biopsy should be considered
left upper inner; LUO; left upper outer; LLO, left

Th
5 Highly suggestive of malignancy— Biopsy
lower outer; LLI, left lower inner. appropriate action should be taken
6 Known carcinoma

Reprinted with permission of the American College of Radiology. No other representation of this material is autho-
based on the final assessment category. rized without expressed, written permission from the American College of Radiology.
BIRADS 0 or “incomplete” final assess-
ments require additional imaging to re-
solve or define an abnormality seen on
screening examinations. Additional views 90% of all breast cancers. A mass is a space- Masses that are irregular imply a greater
may include any number of alternate an- occupying lesion that can be detected in two probability of malignancy. Lobulated masses
gles or positions. Spot compression may be projections. If a finding is only seen on one suggest an infiltrative growth pattern that
used to differentiate an area of summated projection, it is referred to as a density. A den- may be suggestive of malignancy. Similarly,
breast tissue from an abnormal lesion. sity may or may not prove to be a real finding margin assessment is important because of
Magnification views may be used to more after directed diagnostic imaging. Masses are the infiltrative nature of most breast can-
clearly evaluate microcalcifications. These characterized by their shape, margin, density, cers. Margins can be described as circum-
techniques may also be used together. and associated microcalcifications to deter- scribed, microlobulated, obscured, indis-
Most mammographically visible cancers mine the probability of malignancy. tinct, or spiculated. A circumscribed margin
present as masses, calcifications, architec- The shape of a mass can be described as that sharply delineates a mass from the sur-
tural distortion, or a combination of the three. round, oval, lobulated, or irregular (Fig. 3). rounding tissue is commonly a benign find-
Masses and calcifications account for about Round or oval masses are usually benign. ing, as seen in a fibroadenoma or a cyst. A

Margins
Shape

Circumscribed

Round

Microlobulated

Oval

Obscured

Lobular
Ill-defined

Irregular Spiculated

A B
Fig. 3. A: Standardized terminology for the shape of masses. B: Standardized terminology for the margins of masses. Repro-
duced from Bland KI, Copeland EW. The Breast. 4th ed. Philadelphia, PA: Saunders, 2009.

www.medicalebookpdf.com

LWBK892_c47_p563-574.indd 565 10/28/11 5:28:26 PM

 566 Part V: The Breast, Chest, and Mediastinum

enable a directed excision of the presumed

abnormality causing the discharge. A nega-
tive ductogram does not obviate the need
for surgical excision of pathologic discharge
(Fig. 8).

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is being
used with increasing frequency for the
screening and diagnosis of breast cancer.
While mammography remains the “gold
standard,” MRI is emerging as an important
modality for evaluating breast diseases.
MRI has several advantages. There is no
ionizing radiation to the patient with MRI.
MRI is not limited by breast density and is
an excellent tool for the screening of young
women with increased risk for inherited
breast cancer. In patients with indetermi-
nate mammographic or ultrasonographic
findings, MRI may be used for problem solv-
ing or clarifying the imaging but should not
replace biopsy for clinically suspicious le-
A B sions. Disadvantages of MRI are cost, lim-
ited availability, and decreased sensitivity
Fig. 4. Invasive ductal carcinoma. Mammogram demonstrates an irregular, hyperdense mass with spicu-
for premalignant lesions. Patients with MRI-
lated margins in the left upper outer breast with associated pleomorphic calcifications. A: Craniocaudal
view. B: Mediolateral oblique view. incompatible implantable devices, metallic
clips, or prostheses cannot undergo MRI.
MRI should be performed in a breast imag-
ing center with a 1.5-Tesla magnet or
greater. Patients lie prone with the breasts
mass with spiculated or stellate margins is The patient is positioned so that the depth suspended in a dedicated breast coil. Pa-
suspicious for malignancy (Fig. 4). of tissue penetration needed for imaging by tients who are claustrophobic may require
Calcifications are a common mammo- the ultrasound beam is minimized. sedation prior to examination. Images are
graphic finding. Most calcifications are not Cystic masses are readily identified with obtained before and after the administra-
associated with malignancy. When found, ultrasound. Cysts are anechoic, oval, or tion of gadolinium, an MRI contrast agent.
the shape or morphology, location, number, round lesions with well-circumscribed mar- The images are then evaluated for areas of
and distribution of the calcifications should gins. Because the cyst contents will transmit enhancement and the morphology of the
be noted. Malignant-appearing calcifica- the ultrasound wave, posterior acoustic en- enhancement curve is noted. Lesions suspi-
tions are usually less than 0.5 mm, pleomor- hancement is visualized. When the above cious for cancer will display postcontrast
phic or heterogeneous, and grouped. They features are present, the diagnostic accuracy enhancement with malignant morphologic
can also be fine, linear, and branching, indi- of ultrasound in evaluating a simple cyst ap- features (Fig. 9).
cating an intraductal process (Fig. 5). proximates 100% (Fig. 6). Solid masses may
have benign or malignant features. Malig-
nant features of a solid mass on ultrasound DIAGNOSTIC BIOPSY
Ultrasound are irregular margins, hypoechoic to the
Ultrasound was initially used to differenti- surrounding tissue, with posterior acoustic
Nonpalpable Lesions
ate solid masses from cystic masses, but it shadowing. Malignant-appearing masses The widespread use of mammography and
has become an important adjunct to mam- usually have a vertical growth appearance other breast imaging has resulted in the de-
mography and is an excellent method for (“taller than wide”) (Fig. 7). Benign features tection of increasing numbers of suspicious
guiding certain interventional procedures. include ellipsoid shape, hyperechogenicity but clinically occult lesions of the breast.
Ultrasound is not a breast screening tool. or hypoechogenicity, and smooth, well- Such lesions represent more than half of
Accurate breast ultrasonography requires circumscribed margins. the detected cancers in screening clinics
high-resolution real-time ultrasound equip- and account for a substantial proportion
ment that is properly maintained and cali- of breast tumors investigated with biopsy.
brated. A 7-MHz linear array transducer is
Ductography Nonpalpable breast lesions are generally
the minimum frequency that can be used Ductography is the injection of contrast discovered on routine screening mammog-
for ultrasound of the breast, although 10- to into a discharging duct to identify a filling raphy, or incidentally with computed to-
13-MHz linear transducers may be prefera- defect or other irregularity. It can be useful mography or MRI performed for other rea-
ble. Operators should be trained in breast in those presenting with nipple discharge sons. Biopsy of these nonpalpable lesions
anatomy and pathology, as well as basic ul- without an underlying mass or imaging ab- can be performed utilizing a variety of
trasound technology and mammography. normality. If an abnormality is found, it may imaging-guided methods.

www.medicalebookpdf.com

LWBK892_c47_p563-574.indd 566 10/28/11 5:28:27 PM

 Chapter 47: Diagnostic Approach to Breast Abnormalities 567

Aspiration be virtually confirmed and the fluid may amination or by imaging localization as
be discarded. Follow-up is necessary histologic sampling is usually required in
A simple cyst is a common finding and is within 4 to 6 weeks to ensure that the cyst this situation. Complex cysts, as defined

The Breast, Chest, and Mediastinum

thought to arise from dilation of the ter- has not recurred. Biopsy may be indicated by septations, debris within the cyst, or a
minal duct lobular units. Simple cysts di- if the cyst recurs. If the fluid aspirated is mural nodule, should be evaluated further
agnosed with ultrasound need not be aspi- bloody, cytologic analysis should be per- with aspiration for cytology or histologic
rated unless the cyst causes the patient formed to rule out malignancy, which oc- biopsy. A solid component may indicate a
pain or she is anxious regarding the find- curs in a very small percentage of cases. papillary neoplasm. In addition, a simple
ing. If the fluid aspirated is greenish or Cysts that yield bloody fluid should not be cyst that does not resolve with aspiration
yellow-brown and the mass resolves ultra- aspirated completely as the cyst may be necessitates a histologic biopsy for defini-
sonographically, a benign diagnosis can difficult to localize either by physical ex- tive diagnosis.

Aa

Ab

Ac

Ad

Ae Af

Fig. 5. Calcifications. Shape: A: Typically benign: (a) lucent centered (skin); (b) vascular; (c) coarse or popcorn-like; (d) large
rod-like; (e) round; ( f) punctate; (continued)

www.medicalebookpdf.com

LWBK892_c47_p563-574.indd 567 10/28/11 5:28:27 PM

 568 Part V: The Breast, Chest, and Mediastinum

Ag Ah

Ai Ba

Bb Ca

Fig. 5. (Continued) (g) milk of calcium; (h) “eggshell” or “rim”; (i) dystro-
phic. B: Intermediate concern: (a) amorphous or indistinct; (b) coarse
Cb heterogeneous. C: Higher probability of malignancy: (a) pleomorphic;
(b) fine linear and fine linear branching.

www.medicalebookpdf.com

LWBK892_c47_p563-574.indd 568 10/28/11 5:28:28 PM

 Chapter 47: Diagnostic Approach to Breast Abnormalities 569

The Breast, Chest, and Mediastinum

Fig. 6. Simple cyst. Features of a simple cyst by ultrasound: Smooth, well-defined
margins; anechoic internal content (no echoes); and posterior acoustic enhancement
(increased through transmission).

Fig. 7. Invasive ductal carcinoma: Features of a malignant-appearing mass by ultra-

sound: Indistinct margins; hypoechoic, heterogeneous echotexture; taller than wide;
and posterior acoustic shadowing.

Fig. 8. This ductogram demonstrates multiple filling defects, caliber changes,

pruning, and cutoffs, all of which are suspicious for a ductal cancer.

Fig. 9. Invasive ductal carcinoma. Axial T1 fat-suppressed postcontrast image dem-

onstrates a large irregular enhancing mass with speculated margins.

www.medicalebookpdf.com

LWBK892_c47_p563-574.indd 569 10/28/11 5:28:30 PM

 570 Part V: The Breast, Chest, and Mediastinum

A B

Fig. 10. FNA cytology. A: Ductal carcinoma showing cellular aspirate with numerous cohesive groups and single atypical cells
(Papanicolaou stain, ⫻40). B: Ductal carcinoma showing cohesive groups and single epithelial cells. Individual cells show nu-
clear enlargement, increased nuclear-to-cytoplasmic ratio, and occasional nucleoli (modified Romanosky stain, ⫻200).

Fine Needle Aspiration Biopsy breast suspended through an opening in used to obtain several cores of breast tis-
the table. The breast is compressed within sue. Stereotactic biopsies performed for
Cytologic analysis of a solid mass by fine the mammographic unit beneath the table calcifications should be evaluated with a
needle aspiration (FNA) biopsy can be ob- (Fig. 11). Two images are obtained and dis- specimen radiograph of the cores obtained
tained rapidly, and often the patient can be played on a digital monitor. The views ob- to confirm the presence of the calcifica-
informed of the results the same day. The tained are taken at ⫹15-degree and –15- tion within the lesion (Fig. 12). A biopsy
technique can be performed using imaging degree angles from the plane perpendicular clip is then placed at the biopsy site via a
guidance or by palpation. The technique of to the image receptor. These views are hollow biopsy needle to facilitate locating
FNA of a palpable mass is described in de- evaluated by the radiologist and the lesion the area should all of the visible abnormal-
tail in the following discussion of palpable is marked in both views. The needle is cali- ity be removed with the biopsy. Patients
mass biopsy. The diagnostic accuracy of brated to the coordinates determined by who cannot lie prone or cannot tolerate
FNA biopsy of breast masses approximates the computer. The skin of the breast is breast compression are not candidates for
80%. When the specimen is properly pre- sterilized, and the skin and underlying soft stereotactic breast biopsy. In addition, if
pared and reviewed by an experienced cyto- tissue are anesthetized with lidocaine. A the breast compresses to less than 4 cm as
pathologist, the false-positive result is rare small puncture is made in the skin using in women with very thin breasts, stereot-
(Fig. 10). False-negative results occur in ap- an 11-knife blade. An 11-blade scalpel vac- actic biopsy should be avoided because of
proximately 15% of cases and thus a lesion uum-assisted needle or a 14-gauge spring- the possibility of piercing the opposite
that is suspicious clinically or by imaging loaded automated large core biopsy gun is edge of the tissue with the needle. The
must be further investigated with core bi-
opsy or surgical excision. When physical
examination, imaging, and FNA yield be-
nign concordant results, the probability of a
lesion being benign approaches 95%.

Core Needle Biopsy

Core biopsy is the preferred method of eval-
uating an indeterminate or suspicious solid
mass. Core biopsy obtains several pieces of
tissue for histologic evaluation. This can be
performed using a variety of image-guided
techniques or by palpation.

Stereotactic Core Biopsy

Stereotactic mammographic devices use
the principle of triangulation, which al-
lows precise location of the breast lesion
to be determined in three dimensions. The
procedure consists of placing the patient
prone on the stereotactic table with the Fig. 11. Stereotactic core biopsy table (Mammo Test Select, Fischer Imaging, Denver, CO).

www.medicalebookpdf.com

LWBK892_c47_p563-574.indd 570 10/28/11 5:28:31 PM

 Chapter 47: Diagnostic Approach to Breast Abnormalities 571

ued surveillance is acceptable. If the result

is indeterminate or image-discordant, surgi-
cal excision is indicated to rule out malig-

The Breast, Chest, and Mediastinum

nancy. In addition, surgical excision is indi-
cated for a core biopsy that demonstrates
atypical hyperplasia (and some advocate for
lobular carcinoma in situ as well) as the inci-
dence of coexisting ductal carcinoma in situ
or invasive carcinoma may be as high as 50%
because of potential undersampling.

Needle Localization Biopsy

Despite the frequency and simplicity of
mammographic identification of suspicious
lesions, intraoperative localization with
subsequent adequate excision presents
challenging technical problems because
the shape and position of the breast during
compression mammography may be quite
different from that seen by the surgeon in
Fig. 12. Specimen radiograph: Dense white microcalcifications in multiple tissue cores. the operating room. This has led to the de-
velopment of several methods for preopera-
tive localization of nonpalpable lesions. The
complication rate is quite low and most with a 11-blade scalpel and the needle is in- aim of these methods is to facilitate com-
patients tolerate the procedure quite well. serted into or abutting the lesion. The posi- plete removal of the lesion at first attempt
Most procedures can be completed within tion of the needle is visualized by ultra- at excision while simultaneously minimiz-
30 minutes. sound (Fig. 13). Once again, a handheld ing the size of the resected specimen and
11- or 8-gauge vacuum-assisted needle or a shortening the duration of anesthesia. Ra-
14-gauge spring-loaded automated large- diologically guided, invasive preoperative
Ultrasound-guided Biopsy core biopsy gun is used to remove several localization of nonpalpable lesions is a safe,
Ultrasound-directed biopsy is performed cores of tissue and in some instances com- simple, and established procedure that al-
for those lesions that are seen with ultra- pletely remove the lesion. lows for accurate and expeditious biopsy. A
sound. Ultrasound-guided core biopsy is MRI-directed biopsy allows those lesions specimen radiograph is mandatory to doc-
technically easier than stereotactic-guided that are seen only with MRI to be biopsied ument the removal of the suspected area
biopsy as real-time imaging allows the sur- under MRI guidance usually with vacuum and to facilitate histologic examination be-
geon or radiologist to visualize the biopsy assistance (Fig. 14). cause often these lesions remain nonpalpa-
as it occurs. Using sterile technique and lo- If the core biopsy result is benign and is ble even upon examination of the resected
cal anesthesia, a small puncture is made concordant with imaging findings, contin- specimen.
The self-retaining wire localization was
first described by Frank, Hall, and Steer.
This technique utilizes a flexible, hooked
wire within the localizing needle. The hook
lodges, ideally, within or adjacent to the
suspicious lesion. The hook prevents dis-
lodgement of wire within the breast prior to
excision. The wire may be placed in most
circumstances using mammography or ul-
trasound guidance, although MR-guided
wire localization can also be performed.
Mammographic images are obtained with
the wire in place and are transported with
the patient to the operating room for surgi-
cal excision (Fig. 15). The incision should be
placed over the imaging abnormality re-
gardless of where the entry site of the wire
is positioned. Tunneling through breast tis-
sue should be avoided. Recommended loca-
tions of incision for performing needle
localization are described in Figure 16.
Utilizing the mammographic images, the
Fig. 13. Ultrasound-guided core biopsy. Ultrasonogram demonstrates automated needle deployment surgeon begins the dissection. Some wires
through the suspicious mass. are labeled with regard to length or possess

www.medicalebookpdf.com

LWBK892_c47_p563-574.indd 571 10/28/11 5:28:36 PM

 572 Part V: The Breast, Chest, and Mediastinum

A B

Fig. 14. MR-guided core biopsy of invasive lobular carcinoma. A: Axial T1 fat-suppressed postcontrast image demonstrates an
enhancing lobular mass in the left posterior breast. B: Axial T1 fat-suppressed postcontrast image shows successful position-
ing of core biopsy needle for vacuum-assisted biopsy.

a change in caliber to direct the excision. Once the specimen is removed, it should Palpable Masses
The direction of the dissection and dimen- be oriented for the pathologist. A variety of Ultrasound evaluation is the preferred
sions of the specimen are determined by orienting techniques can be used, including method of evaluation of a palpable mass,
the lesion size and the relative proximity of sutures or indelible ink (paint). The speci- but practitioners without ultrasound readily
the wire to the lesion. If the incision does men is then sent for specimen radiograph available may use aspiration to distinguish a
not pass though the entry site of the wire, it to conclusively confirm full excision of the solid mass from a benign cystic lesion. De-
is necessary to identify the shaft of the wire suspicious/malignant lesion. The presence tails of cyst aspiration were discussed previ-
proximal to the lesion and retract it into the of the lesion within the specimen is docu- ously. If a solid mass is confirmed, FNA bi-
wound (Fig. 17). Resection then proceeds to mented mammographically and immedi- opsy may be performed to obtain a cytologic
encompass a volume of tissue with at least ately relayed to the surgeon (Fig. 15B). The diagnosis. Once cleansed, the skin overlying
1 cm of normal-appearing tissue outside of specimen should then be sent for patho- the palpable lesion is infiltrated with a local
the mammographic abnormality. logic analysis. anesthetic. The breast mass is immobilized

A B

Fig. 15. Needle localized lumpectomy. A. Right craniocaudal view demonstrating wire localization needle in excellent position
for targeting biopsy clip and mass. The write is deployed through the needle and post wire placement craniocaudal and lateral
views marked for the surgeon. B. Specimen radiograph demonstrates successful excision of biopsy clip and mass targeted for
removal and retrieval of localization wire.

www.medicalebookpdf.com

LWBK892_c47_p563-574.indd 572 10/28/11 5:28:36 PM

 Chapter 47: Diagnostic Approach to Breast Abnormalities 573

The Breast, Chest, and Mediastinum

Fig. 16. Recommended locations of incisions for performing needle localization lumpec-
tomy. The most cosmetically acceptable scars result from incisions that follow the con-
tour of Langer lines. (Reproduced with permission from Bland KI, Edward M. The Breast:
Comprehensive Management of Benign and Malignant Diseases, 4th ed. Philadelphia, PA:
WB Saunders, 2009.)

A B C

D E
Fig. 17. Operative technique for needle localization biopsy of a deep subareolar lesion: The suspicious lesion is “localized” on
the mammogram immediately before surgery. A: During the operation, the needle serves as a guide for the surgeon to perform
the biopsy. B: Development of tissue planes parallel to the localization wire. C: Deeply localized, suspicious lesion approached
via a circumareolar incision. D: Wire is repositioned from the percutaneous localized position and retracted into the wound.
E: Dissection completed parallel to wire. (Reproduced with permission from Bland KI, Edward M. The Breast: Comprehensive
Management of Benign and Malignant Diseases, 3rd ed. Philadelphia, PA: WB Saunders, 2004.)

www.medicalebookpdf.com

LWBK892_c47_p563-574.indd 573 10/28/11 5:28:37 PM

 574 Part V: The Breast, Chest, and Mediastinum

dermal lymphatics is pathognomonic for

inflammatory breast cancer. In patients
who present with skin changes, including
erythema and/or peau d’orange, a 3- to
5-mm punch biopsy can be performed in
the office using local anesthesia. The biopsy
should be full thickness through the most
suspicious area. Most inflammatory breast
cancers do not present with a palpable
mass, but if present, a core biopsy can then
be obtained through the punch biopsy site
to provide more tissue for receptor assays.

SUGGESTED READINGS
American College of Radiology (ACR). ACR
BIRADS®—mammography. In: ACR Breast Im-
Fig. 18. Technique for FNA of a breast mass. (Reproduced with permission from Bland KI, Edward M. aging Reporting and Data System, breast imaging
The Breast: Comprehensive Management of Benign and Malignant Diseases, 3rd ed. Philadelphia, PA: WB atlas, 4th ed. Reston, VA: American College of
Saunders, 2004.) Radiology.
Bassett L, Winchester DP, Caplan RB, et al. Ste-
reotactic core-needle biopsy of the breast: a
report of the Joint Task Force of the American
College of Radiology, American College of Sur-
by the practitioner using one hand to gently outpatient basis. Anesthetic choices include geons, and College of American Pathologists.
but firmly stabilize the quadrant containing local anesthesia, local anesthesia with seda- CA Cancer J Clin 1997;47(3):171.
the mass (Fig. 18). FNA can be facilitated us- tion, or general anesthesia, depending on Bland KI, Copeland EM. The Breast: Comprehensive
ing an “aspiration gun” to allow the operator patient preference and comorbidity or phy- Management of Benign and Malignant Disorders
to apply suction while maintaining the posi- sician preference. As with surgical biopsy of the Breast, 3rd ed. Philadelphia, PA: WB Saun-
tion of the needle in the mass. The proce- with imaging guidance, incisions should be ders; 2004.
Fine RE, Staren ED. Updates in breast ultrasound.
dure uses a 10- to 20-mL syringe and a 22- or cosmetically placed over the breast mass Surg Clin North Am 2004;84(4):1001,v.
25-gauge needle. The needle is inserted into using the natural skin lines, or Langer lines. Harness JK, Wisher DB. Ultrasound in Clinical
the anesthetized skin and suction is applied For lesions where there is a high probabil- Practice: Basic Principles and Clinical Practice.
to the syringe. Moving the needle into the ity of malignancy, obtaining a core biopsy New York: Wiley-Liss; 2001.
suspect lesion at various angles allows prior to proceeding to the operating room Hughes LE, Mansel RE, Webster DJT. Benign Dis-
clumps of cells to be dislodged, aspirated may allow better planning of the cancer treat- orders and Diseases of the Breast: Concepts and
Clinical Management. Philadelphia, PA: WB
into the syringe, and submitted for cytologic ment. An FNA does not distinguish between Saunders; 2000.
evaluation. in situ and invasive disease. If the core biopsy Jackson VP. Diagnostic mammography. Radiol
Palpable masses can be biopsied by exci- result is not concordant with the prebiopsy Clin North Am 2004;42(5):853, vi.
sion without imaging localization. As the findings, an excisional biopsy should ensue. Lee CH. Problem solving MR imaging of the breast.
terminology implies, excisional biopsy of a Radiol Clin North Am 2004;42(5):919, vi.
breast mass removes the entire lesion and Liberman L. Percutaneous image-guided core breast
generally includes a margin of normal breast
Punch Biopsy biopsy. Radiol Clin North Am 2002;40(3):483, vi.
National Comprehensive Cancer Network. The
tissue surrounding the lesion. Excisional While the diagnosis of inflammatory breast complete library of NCCN clinical practice
breast biopsy is best performed in the surgi- cancer is made largely clinically, histologic guidelines in oncology. Jenkintown, PA: Nation-
cal suite, in most circumstances on an confirmation of cancer cells within the al Comprehensive Cancer Network; 2004.

EDITOR’S COMMENT via the hematoma produced at the biopsy site. quire excisional breast biopsy are discordant le-
Hematoma-directed ultrasound (US)-guided bi- sions, atypia, papillomas with atypia (ductal or
opsy obviates the need for barbaric needle local- lobular), and large fibroadenomas. Ductography as
Obtaining a preoperative diagnosis of cancer ization procedures because intraoperative US lo- an imaging tool is not particularly helpful because
allows for a single definitive cancer operation calization is all that is needed and is ultilized only more than 80% of these studies are abnormal,
(including axillary staging) in 75% to 100% of after the patient has gone to sleep (Klimberg VS. adding really no value, while excision is not only
cases, compared with 25% to 40% of patients in Excisional breast biopsy of palpable or nonpalpa- diagnostic but therapeutic. The so-called triple
whom the diagnosis has not been established ble lesions. In: VS Klimberg (Ed.), Atlas of Breast negative test was developed to identify patients
before excisional breast biopsy. It is the standard Surgical Techniques (p. 60–71). Philadelphia, PA: with probably benign-appearing lesions that could
by the National Comprehensive Cancer Network Saunders; 2010). In our hands, it also allows for forgo a formal excisional breast biopsy (Vetto J
(NCCN) and the American Society of Breast Sur- better clearance of cancerous margins (Arentz C et et al. Diagnosis of palpable beast lesions in younger
gery guidelines as well as one of the standards set al. Ten-year experience with hematoma-directed women by the modified triple test is accurate and
by the National Accreditation Program for Breast ultrasound-guided (HUG) breast lumpectomy. cost-effective. Arch Surg 1996;131:967–974). This
Centers. A preoperative needle core biopsy in Ann Surg Oncol 2010;17(Suppl 3):378–83). refers to a combination of results from physical
mammographic-only detected lesions also allows Lesions diagnosed on core biopsy that may examination, imaging (mammography and/or
such lesions to then be visualized by ultrasound have a significant risk of eventual cancer and re- US), and pathology ( fine needle aspiration [FNA]

www.medicalebookpdf.com

LWBK892_c47_p563-574.indd 574 10/28/11 5:28:37 PM

 Chapter 48: Breast-Conserving Surgery 575

or core) in lesions less than 1 cm. When all three essary to pay attention to a cyst if it is causing placed down the biopsy tract under US/Doppler
modalities indicate a benign lesion, the probabil- anxiety to the patient through its palpability or guidance for internal tamponade. This can be re-

The Breast, Chest, and Mediastinum

ity of a diagnostic error is less than 1%. That said, pain. In this case, because of the high likelihood moved after about an hour and works quite well
in lesions less than or equal to 2 cm, we prefer to of recurrent cyst formation, we simply remove for stereotactic biopsy sites.
perform what is termed percutaneous excisional the cyst with a vacuum-assisted device, taking As technology progresses, devices are avail-
breast biopsy using one of several devices avail- a sample of the wall for definitive diagnosis and able that can diagnosis and remove small sus-
able that cannot only sample the lesions but also thus preventing the ability to reaccumulate. picious lesions at one time including vacuum-
remove the fibroadenoma in its entirety in one Worrisome complex cysts can be treated in the assisted core biopsy and large intact sample
setting (Johnson AT et al. Percutaneous excisional same way. devices that use radiofrequency ablati