Ebook NMS surgery (6th edition) Part 2

(BQ) Part 2 book NMS surgery presentation of content: Head and neck surgery, bariatric surgery, minimal access surgery, surgical oncology, trauma and burns, organ transplantation, pediatric surgery, plastic and reconstructive surgery, neurosurgery,...

T e most common neck lesion is a reactive lymph node All adults with a persistent neck mass have

a malignancy until proven otherwise

Most head and neck cancers are squamous cell and are treated with surgery, radiation, or chemotherapy Cosmetic and unctional def cits may be requent

Congenital lesions are abnormal variants o normal structures T yroglossal duct cysts are midline structures that rise and all with swallowing T ey should be resected i symptomatic, a er making sure there is adequate residual thyroid tissue

onsillectomy was once an extremely common operation and is now reserved or those with repeated in ections, as the risk o surgery outweighs the benef ts or most patients

CHAP TER 19

Ba ria tric Surge ry:

Obesity a ects more than one third o Americans and an increasing percentage o children and adolescents Obesity creates metabolic comorbidities and decreases li e span

BMI is the most use ul marker or obesity; people quali y or bariatric surgery with BMI greater than 40 kg/m 2 or 35 kg/m 2 with medical comorbidities

Bariatric procedures are classif ed as primarily restrictive or malabsorptive Roux-en-Y gastric bypass is the most common operation and is a blend o the two Gastric banding and sleeve gastrectomy are restrictive, and the duodenal switch operation is malabsorptive

Postoperative bariatric patients are susceptible to a variety o unique complications, including internal hernia, marginal ulceration, and nutritional def ciencies

achycardia in a postoperative patient is a surgical complication until proven otherwise T e patient must be assessed or anastomotic leak and DV /PE

CHAP TER 20

Minim a l Ac c e s s Surge ry:

Minimally invasive surgery relies on technology to decrease the size o the access incisions; visual cues largely replace tactile ones

T e f rst steps in minimally invasive procedures are establishment o pneumoperitoneum and diagnostic laparoscopy

Pneumoperitoneum is an artif cial state that has a mechanical (pressure) component that can mimic abdominal compartment syndrome T e use o carbon dioxide gas also creates an acidosis

T is does not have a signif cant clinical impact or brie procedures in patients who have minimal physiologic compromise

Surgic a l Onc olo gy:

Oncology is increasingly multidisciplinary Benign and malignant re er to behavior, not outcomes—benign lesions may be atal, and malignant processes may be indolent

Oncogenes drive the cell cycle; tumor suppressor genes provide a natural checkpoint

Dysregulation o either may lead to cancer

Imaging, serum markers, and genomics can all provide diagnosis well in advance o clinical symptoms Screening can reduce mortality in breast, colon, cervical, and prostate cancer

T e NM system provides a common language to group and stage tumors

Fatal hemorrhage occurs in f ve major locations: chest, abdomen, retroperitoneum, thigh, and externally

Hypovolemia is the most common cause o hypotension in trauma and is treated with uid resuscitation However, tension pneumothorax and cardiac tamponade cause hypotension, are not associated with hypovolemia, and are not treated with uid resuscitation T ey should be considered early during resuscitation

FAS exam reliably detects ree uid and can provide an early, sa e means o diagnosing the need

or operation

Initial resuscitation o burn victims may be massive: use 4 mL/kg/% BSA over the f rst 24 hours

Use the rule o 9’s to estimate BSA

Hypothermia may cause coagulopathy and resultant bleeding a er trauma

Simple pneumothorax usually presents with dyspnea and is not emergent, whereas a tension pneumothorax presents with hypotension and requires emergent decompression

CHAP TER 23

Orga n Tra ns pla nta tion:

Calcineurin inhibitors have considerable nephrotoxicity

Organ transplantation is considered or irretrievable end-organ dys unction

T e main complications o immunosuppression are susceptibility to in ections and the development o malignancy

Kidney transplants are the most success ul solid organ transplants Although dialysis is a replacement option, patients live longer with kidney transplants than on dialysis; there ore, all end-stage renal patients are considered transplant candidates Although outcomes are superior with living donors, deceased donors and extended criteria donors have produced acceptable results

Because no alternative exists to replace a dys unctional liver, transplantation remains the only option or severe liver ailure but is raught with complications due to the extent o disease in most

o these patients

Most acute rejection occurs in the f rst year a er transplant and may be related to in ection or inadequate immunosuppression T e cornerstones o immunosuppression are corticosteroids, but immune modulators have been developed that a ect all aspects o -cell unction and di erentiation

Islet cell transplantation may provide the cure o diabetes without the heavy immunosuppression o whole organ transplant o date, results are promising

Pe dia tric Surge ry:

Pediatric surgery represents a separate discipline, since the physiology o children di ers rom that

o adults

Congenital hernias may be associated with other conditions and require care ul assessment be ore repair In general, umbilical hernias are not repaired, as they may close spontaneously Inguinal hernias are repaired with high ligation o the sac Diaphragmatic hernias are repaired but with caution, as pulmonary dys unction may also be present

Many specif c problems can arise within the neonatal GI tract Malrotation and necrotizing enterocolitis may require urgent surgery and may result in long-term problems such as short gut syndrome

Failure to pass meconium in the f rst 24 hours suggests a diagnosis o Hirschsprung disease, which

is conf rmed on rectal biopsy

Projectile vomiting in a 1-month old in ant may represent hypertrophic pyloric stenosis reatment

is a surgical pyloromyotomy a er correction o any metabolic derangements

Wilms tumor and neuroblastoma are the two most common childhood solid tumors

Gastroschisis is an abdominal wall de ect with no sac and has rare associated congenital anomalies

Omphalocele has a sac and has a high association with congenital anomalies

Esophageal atresia is most commonly a proximal esophageal pouch and distal tracheoesophageal ( E) f stula and is associated with cardiac and VAC ERL anomalies

Intestinal malrotation usually presents with bilious vomiting

Duodenal atresia shows an abdominal double-bubble sign, is corrected by duodenoduodenostomy and is commonly associated with other congenital anomalies

Jejunal and more distal bowel atresia occur rom in-utero vascular accidents and have ew associated congenital anomalies

Head and Neck Surgery

Andrea Hebert and Jef rey S Wol

COMP ONENTS OF THE HEAD AND NECK EXAM

Ge ne ra l

I Bre a thing: Note whether the patient is breathing com ortably and the presence o stridor, stertor, or the use o accessory muscles

II Voic e : Note the quality o the patient’s voice (e.g., hoarseness or

mu ed or breathy qualities) and any dysarthria

III Swa llo w: Note i the patient is able to tolerate secretions or i he or

she is drooling

He a d

I Ge ne ra l

A rauma: visible ecchymosis, edema, bony abnormalities, or lacerations

B Masses/lesions: skin lesions, biopsy sites or surgical scars, edema, f rmness, induration, uctuance,

or erythema

II Eye s

A Examination: Be sure to note extraocular motion and pupillary response and to report nystagmus.

B ests

1 Visual acuity: i the patient is complaining o any change in vision

2 Visual f eld test: i the patient is complaining o diplopia

III Ea rs : Standard o ce assessment o hearing includes the Weber and Rinne tests

A Weber test: uning ork is struck and placed on the midline o the patient’s head to determine i the

sound lateralizes and identif es unilateral hearing loss

B Rinne test: involves placing the vibrating tuning ork on

the mastoid process and comparing the perception to that o the sound directly adjacent to the ear; also helps discriminate between conductive and sensorineural hearing loss

C Auricle: Note any de ormity, tenderness to palpation o the

tragus or mastoid, or tenderness with tugging o the pinna

D External auditory canal: Note any canal stenosis, debris, erythema, or otorrhea.

E ympanic membrane: Note whether intact, the presence and characteristics o uid

behind the tympanic membrane, presence o middle ear masses, and whether the membrane retracts

IV Nos e : Per orm anterior rhinoscopy on all patients

A Septum: Examine or deviations or lesions.

B Nasal cavity: Note in erior turbinate hypertrophy, nasal masses or polyps, and the presence o

rhinorrhea

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Stridor is a pitched s ound produced

high-by turbulent f ow through a partially obs tructed upper airway Stertor is lower pitched, snoring-type s ound.

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Per orm a Weber and Rinne exam i the patient has any otologic complaints

V Ora l c a vity/orop ha rynx: Note any masses or lesions and speci y the color, riability, and tenderness

Note any ulceration and palpate with a gloved f nger to determine so ness or f rmness

A eeth: Note the quality o the dentition and the presence o any tenderness.

B Assess: Look or any erythema, edema, palatal asymmetry, or tonsillar deviation Note any uvular

deviation and trismus

VI La rynx: Per orm a laryngeal mirror exam i not per orming f beroptic laryngoscopy

VII Ne c k: Palpate or lymphadenopathy or thyroid masses Note surgical scars, crepitus, or decreased

range o motion

VII Ne urolo gic : Per orm a complete cranial nerve (CN) exam

BENIGN LESIONS OF THE HEAD AND NECK

Wo rkup o r Ac q uire d Le s ions

I De ta ile d his tory: Obtain details about the ollowing

A Family history: malignancy and personal history o cancer

B Risk actors: smoking; alcohol consumption; exposure to

radiation, sawdust, or other potential carcinogens; and exposure

to human papillomavirus (HPV) 16 or 18

C Recent illnesses: upper respiratory in ection (URI), sinusitis, or

tonsillitis; otitis or conjunctivitis; and dental problems

II Phys ic a l e xa m ina tion: See earlier discussion

III La bo ra tory te s ts : may include tuberculin test or tuberculosis,

heterophil titer (monospot test) or mononucleosis, thyroid unction tests or thyroid scan, serologic tests or syphilis, and viral titers (especially or Epstein-Barr virus, which is associated with nasopharyngeal carcinoma and Burkitt lymphoma)

IV Ra diologic s tudie s : may include so tissue radiographs o the

neck, barium swallow, chest x-ray, or scanning procedures such as computed tomography (C ) and magnetic resonance imaging (MRI)

V Endos c opy: indicated i a primary neoplasm is suspected

VI Tre a tm e nt: depends on the f ndings (Fig 18-1)

A Antibiotics: i a bacterial in ection is suspected

B Consultation: may be help ul

1 Dental consultation: i the teeth seem to be a source

2 Dermatology consultation: i skin lesions are present

C Surgical biopsy: may be indicated i a mass does not shrink

signif cantly over 6 weeks and a source o in ection is not ound

1 Fine-needle aspiration (FNA): used with suspected malignancy

2 Excisional biopsy: indicated or persistent cervical adenopathy

NECK ABSCESSES

Typ e s

I Pe ritons illa r a bs c e s s e s (quins y): most common abscesses in the parapharyngeal space ( able 18-1)

A Cause: arise as a complication o acute tonsillitis

B Clinical presentation: Ipsilateral palatal edema, contralateral deviation o the uvula, “hot potato”

voice, trismus, and dysphagia T e patient may have only a low-grade ever or be a ebrile

o neck mas s es : A mas s that has been pres ent or

7 days is inf ammatory;

7 months , malignant; 7 years , congenital

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Scrofula is mycobacterial lymphadenitis

in the neck

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Endos copic biops y and radiologic s tudies s hould precede any open biops y o the neck

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FNA can diagnos e carcinoma but is us ually inadequate to de ne lymphoma

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A patient pres enting with ever and

an erythematous , pain ul,

f uctuant neck mass most probably has an abs ces s

Obs e rve

Re s olve s

Re s olve s Obs e rve

ma s s

Endos copy;

biops y of s us pe cte d prima ry tumor Infla mma tory P hys ica l e xa mina tion

(−)

(+)

(−) (+)

(−) (+)

Air in soft tissue radiograph

Tre a tm e nt

Airway protection Incision and drainage Antibiotics

II Pa ra pha ryng e a l s pa c e a bs c e s s e s : Arise rom the posterior teeth or tonsils and can a ect the carotid sheath structures and multiple CNs T ey can cause mediastinitis and carotid “blowout”

(i.e., erosion o the artery wall leading to massive hemorrhage)

III Re tropha rynge a l a b s c e s s e s : arise rom in ected

retropharyngeal nodes or extension rom other spaces and can lead

to airway obstruction or mediastinitis

IV Ludwig a ngina : abscess that occupies the sublingual space that

generally arises rom a dental source Can cause death rom airway obstruction, commonly requires tracheostomy

V Be zold a bs c e s s e s : arise rom in ection in the mastoid

CONGENITAL MASSES

Le s io ns o Thyro id Orig in

I Ove rvie w: T yroid gland originates at the oramen cecum and descends centrally to the level o the thyroid and cricoid cartilages ( able 18-2)

A T yroglossal duct: May pass in ront o , through, or behind the hyoid bone; it is generally

obliterated but may persist Solid tumors o thyroglossal duct origin occur almost exclusively within the tongue and above the hyoid bone

B T yroidal primordium: Some may remain at any site in the duct and give rise to cysts, f stulas,

accessory thyroid tissue, and neoplasms

II Thyroglos s a l f s tula s , c ys ts , a nd s inus e s : Occur in the midline; 20% are suprahyoid, 15%

occur at the hyoid, and 65% are in rahyoid

A Fistulas: almost always the result o in ection with spontaneous or surgical drainage

B Cysts: Present by age 10 years in 50% o cases; no sexual predominance exists, but they are most

o en ound in caucasians

1 Size: usually measure 2–4 cm in diameter and gradually

increase in size, although the size may uctuate

2 Behavior: rise and all with the larynx during swallowing

C Sinus tract: may orm as direct connection to the skin and result

in persistent drainage

D reatment: total surgical excision

III Thyroid re s ts : may be lingual or may occur in the neck

A Endotracheal ectopias: may occur

B Palpation: o the normal position o the thyroid o en reveals no evidence o thyroid tissue

C reatment: dictated by the degree o obstruction and by the presence o other thyroid tissue

D T yroid scan: Ensures that unctional thyroid tissue exists in the usual location; 75% o patients

have no other unctional thyroid

Bra nc hia l Cle t Ano m a lie s

I Em bryo log y: In week 4, f ve ridges and grooves appear on the ventrolateral sur ace o the embryonic head that orm the branchial arches and cle s, respectively, and the pharyngeal pouches develop

internally at the same level as the external grooves

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Neck in ections mus t be drained but s hould only be done by thos e amiliar with neck anatomy owing

to the carotid artery, airway, and the cranial nerves

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Abs ces s es in the head and neck can caus e airway compromis e, and intubation or tracheos tomy may be neces s ary.

Type Loc a tion Exa m ina tion Tre a tm e nt

Branchial cleft cyst Preauricular anterior Firm, nontender Surgical excision

D Combinations (o any o the preceding types): can occur

III Ana tom y: Anomalies are generally located along the anterior border

o the sternocleidomastoid (SCM) muscle or deep to it; they can occur anywhere between the external auditory canal and the clavicle

A First cle anomalies: always superior to the hyoid bone

1 Fistula: i present, courses superiorly and end near the

external auditory canal

2 Cyst and tract: may lie in the parotid gland, with a variable

relationship to the acial nerve

B Second cle anomalies: most common type

1 External opening: approximately two thirds down the SCM muscle anteriorly i present

2 Fistula: i present, ascends with the carotid sheath and ends at the tonsillar ossa

C T ird cle anomalies: rare

1 External opening: occurs in the same position as in a second cle f stula

2 ract: ascends along the carotid sheath and opens in the piri orm sinus

D Fourth cle anomalies: have never been seen in their entirety

IV Cha ra c te ris tic s : generally smooth, round, nontender masses

A Size increase: common during URI

B In ected cyst: may abscess or rupture spontaneously to orm a sinus

C Symptoms: determined by size and location o the anomaly

1 Large cysts: may cause dysphagia, stridor, and dyspnea

2 Small cysts: o en undiscovered until adulthood because o

their slow rate o growth and minor symptoms

V Tre a tm e nt: Complete excision without damage to the surrounding vital structures is the def nitive treatment

A iming: Excision is delayed until antibiotic treatment is completed.

B Incision and drainage: avoided, i possible, because it makes subsequent excision more di cult

Te ra to m a s

I De f nition a nd type s : growths that consist o multiple tissues oreign to the part o the body in which they arise

A Epidermoid cysts: most common type; lined by squamous

epithelium and have no adnexa

B Dermoid cysts: epithelium-lined cavities containing skin

appendages (e.g., hair, glandular tissue, and ollicles)

C eratoid cysts (rare in the head and neck): lined with simple

stratif ed squamous or respiratory epithelium and contain cheesy keratinous material

II Ce rvic a l te ra tom a s : most commonly present at birth

A Characteristics: usually 5–12 cm, semicystic, and unilateral

B Symptoms: In ants usually have stridor, apnea, or cyanosis because o tracheal compression, and

dysphagia may also be present Some in ants are asymptomatic at birth but become symptomatic within weeks or months

C Associated anomalies: increased incidence o maternal hydramnios but no increase in associated

in ant anomalies

D reatment: Early excision in in ants is mandatory.

III Ma ligna nt te ra tom a s (o the ne c k): rare; occur exclusively in adults with a very poor prognosis

IV Na s a l de rm oids : commonly apparent shortly a er birth

A Location: Nasal dorsum is the most common site, but they may occur in the tip o the nose or

the columella (the external end o the nasal septum)

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Second brachial cle t anomalies are the mos t common and pres ent with an external opening two thirds

o the way down the anterior border o the SCM mus cle.

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Cons ider a neck mas s to be a branchial cle t anomaly i it is located laterally, increas es in s ize with URIs , and has been pres ent

s ince birth.

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Epidermoid cysts ectoderm; dermoid cysts ectoderm and

mesoderm; teratoid cysts ectoderm, mesoderm, and endoderm

B Characteristics ( able 18-3): male predominance o 2:1; must be di erentiated rom encephaloceles

and gliomas

C reatment: Early removal is important; recurrences secondary to incomplete removal are common.

Va s c ula r Tum o rs

I He m a ng iom a s : Most common tumors o the head and neck in children Girls are more o en

a ected, and lesions are usually solitary

A Capillary hemangiomas: Include nevus ammeus (port-wine stain) and strawberry nevus and are

characteristically ound in the dermis T ey have an early period o evolution, a er which they o en regress T ey may develop suddenly and grow quite large

B Cavernous hemangiomas: More permanent; spontaneous regression is more likely or

hemangiomas present at birth than in those appearing later

C Arteriovenous hemangiomas: occur almost exclusively in adults and have a predilection or the lips

and perioral skin

D Invasive hemangiomas: occur in the deep subcutaneous tissues, deep ascial layers, and muscles

1 Presentation: Present as neck masses, predominantly in children; masseter and trapezius are

the muscles most commonly involved Intramuscular hemangiomas most commonly present in young adults as palpable, mobile, noncompressible masses

2 Characteristics: end to recur a er excision but do not metastasize; they are generally

without thrills, pulsations, or bruits; and pain secondary to compression o other structures

is usually present

E Subglottic hemangiomas: Usually capillary in type Owing to

their location, they o en present at birth with stridor and usually with cutaneous involvement

F reatment

1 Congenital cutaneous hemangiomas: Many lesions regress

spontaneously, but several treatment options exist or those that do not

a Medical: Glucocorticosteroids, inter eron al a, vincristine, and imiquimod have been used or

treatment Propranolol has been shown to induce involution o in antile hemangiomas

b Excision: Laser excision is pre erred in areas with cosmetic or unctional concern

(pulsed dye laser is used) Surgical excision can also be per ormed

2 Subglottic lesions: may require tracheotomy, steroids, propranolol, and, in some cases, laser

excision

3 Extensive lesions: Surgery may be needed.

4 Radiation therapy: Used to suppress tumor growth in areas that are inaccessible surgically;

however, the use o radiation alone is controversial and is known to increase risk o thyroid, breast, and skin cancers

II Cys tic hygro m a s : ound predominantly in the neck and are usually noted at birth

A Location: T ey are more common in the posterior triangle and may extend up into the cheek or

parotid region and down into the mediastinum or axilla

1 Large masses: extend past the SCM muscle into the anterior compartment and may cross

Ca n Be Mid line

As s o c ia te d with

In e c tio ns

o Skin

Me ning itis Ris k

Sinus Tra c t Co m pre s s ible

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When evaluating

a newborn with s tridor, conducting a thorough s kin exam is important.

predilection exists, or right or le side.

1 Small lesions: unilocular and f rm

2 Large tumors: loculated, shi able, and compressible

3 Cyst walls: Usually tense, and because the loculi tend to

communicate, rupture o one locule can cause all o them

to partially collapse

D reatment: Surgery is the mainstay o treatment, but recurrences

are common because resection is o en incomplete

III Ora l a nd p e riora l lym p ha ngio m a s : Relatively common lesions usually ound at birth or soon a er

T ey behave very much like cystic hygromas

ACQUIRED LESIONS

To ns illa r a nd Ad e no id a l Hyp e rtrop hy

I Ob s truc tive hyp e rtrophy: Patients benef ting rom tonsillectomy with adenoidectomy are those with airway obstruction, sleep apnea, dysphagia, or ailure to thrive

II Ade no ide c to m y: per ormed in children with chronic nasal obstruction, especially when they also demonstrate chronic serous otitis media or orthodontic problems

Le uko pla kia , Erythro p la kia , a nd Ke ra to s is

I De f nition: Leukoplakia presents as white lesions that occur on the mucosa o the mouth, pharynx, or

larynx Erythroplakia is a similar red patch.

II Etio log y: T ese lesions are associated with repeated trauma (e.g., rom poorly f tting dentures and decayed teeth), smoking, or use o alcohol

III Tra ns orm a tion: Leukoplakia is precancerous, with a

trans ormation rate ranging rom 11% to 36% Erythroplakia has

a higher trans ormation rate Little correlation exists between the clinical appearance and their histology

IV Dia g nos is : Biopsy, to rule out squamous cell carcinoma, should be per ormed in high-risk patients

(smokers and drinkers) and i the lesion persists a er the removal o an irritative ocus

V Tre a tm e nt: Benign leukoplakic lesions require no treatment but do require continued observation

Pa pillo m a s

I Squa m o us pa pillom a s o the ora l c a vity: usually occur as one lesion but may be multiple and are common on the palate and aucial arches

A Characteristics: usually pedunculated and cauli owerlike in appearance

B Recurrence: rare a er excision

II Na s a l (s c hne ide ria n) pa pillom a s

A Benign lesions o the sinonasal tract: rom the schneiderian mucosa and classif ed into three types:

ungi orm, oncocytic, and inverted

B Inverted papillomas: ypically arise rom the lateral nasal wall

and can invade the sinuses and orbits Grossly, the lesions appear bulky and deep red to gray in color and vary in consistency;

unlike allergic polyps, they are unilateral

1 Characteristics: Patients generally present with nasal

obstruction, a postnasal drip, and headaches T ese lesions occur mainly in men age 50–70 years

2 Malignant trans ormation: Incidence is 10%.

3 reatment: Complete excision that includes the lateral nasal wall and ethmoid sinus Recurrence

is common; there ore, li elong ollow-up is usually recommended

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Leukoplakia and erythroplakia are cons idered precancerous les ions ; biops y and clos e obs ervation are recommended.

III La ryng e a l p a p illo m a s : most common laryngeal tumors o childhood and may be ound at any age

A Juvenile type: occurs predominantly in childhood and tends to involute at puberty

1 Etiology: Viral; HPV 6 and 11 are the most common viral strains.

2 Characteristics: Multiple papillomas typically occur and

may involve the airway rom the epiglottis to the bronchi

T e vocal olds are usually involved; hoarseness and obstruction occur late

3 reatment: Laryngoscopic removal, o en by the use o

surgical microdebridement, is the mainstay o therapy

a racheotomy: may be necessary but predisposes to

papilloma seeding

b Recurrence and spread: common

B Adult type: In this orm, the papilloma is generally single.

1 Recurrence: As in the juvenile orm, the papilloma tends to recur ollowing excision.

2 Malignant trans ormation: in recurrent lesions, particularly in patients exposed to radiation

Na s a l Po lyp s

I Inc ide nc e : rare be ore age 5 years and occur more commonly in men

II Etio log y: believed to be an allergic response

A Samter triad: T ey may be associated with asthma and an idiosyncratic reaction to aspirin.

B In children: should prompt a sweat test to rule out cystic f brosis

III Cha ra c te ris tic s : In ammatory polyps are almost always bilateral and may recur; paranasal sinus

involvement is common

IV Tre a tm e nt: Polyps are excised i they obstruct the nasal airways or the sinus drainage pathways;

patients are placed on a topical steroid medication to prevent recurrence, and management o their allergies is vital

Pe rip he ra l Ne rve Tum o rs

I Sc hwa nnom a s : solitary, encapsulated tumors surrounded by a nerve that are primarily located centri ugally and are o en pain ul and tender

II Ac ous tic ne uro m a s : constitute a type o slow-growing schwannoma

A Etiology: arise rom CN VIII, usually within the internal

auditory canal (IAC)

B Signs and symptoms: may include hearing loss, tinnitus,

imbalance, and vertigo

C Evaluation: esting includes an audiogram and MRI with

gadolinium enhancement

D reatment: Because these tumors grow slowly, they can

be observed in the right clinical context Other treatment options are surgical resection or radiation therapy

III Von Re c klingha us e n ne urof brom a tos is (NF I): Neurites (axons) pass through the tumor; lesions

are usually multiple, unencapsulated, located centripetally, and characteristically asymptomatic

A Etiology: Caused by a nerve growth actor gene on chromosome 17q11.2; inheritance is autosomal

dominant

B Malignant trans ormation: 8%

C Signs and symptoms: Ca é au lait spots, vitiligo, gliomas (especially optic), osseous changes, Lisch

nodules (iris hamartomas), meningitis, spina bif da, syndactyly, hemangiomas, axillary or inguinal reckles, NF I in a f rst-degree relative, or retinal and visceral mani estations may be present

IV Ce ntra l ne urof brom a tos is (NF II): Classically, slow-growing, bilateral acoustic neuromas or

neurof bromas cause hearing loss or dizziness and lead to a diagnosis by age 20 years

A Etiology: Chromosomal abnormality involves encoding o a suppressor protein schwannomin

Inheritance is autosomal dominant, but almost 50% o cases are new mutations

B Diagnosis: may also be established by a unilateral CN VIII mass and a relative with NF II or

any two o the ollowing: glioma, juvenile posterior subscapular lenticular opacity, meningioma, neurof broma, or schwannoma

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Laryngeal papilloma,

or respiratory papillomatosis,

is as s ociated with HPV6 and

11 and typically pres ents as hoars eness in a child.

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As ymmetric

s ens orineural hearing los s

is common and requires that acoustic neuroma be ruled out with MRI o the internal auditory canal.

E Gardner type: later onset, slow growth rate; usually bilateral

acoustic neuromas only

V Tre a tm e nt: Most neurogenous tumors o the head and neck can be excised sa ely without sacrif cing nerves

Nonde nta l J a w Le s io ns

I Fibro us dys pla s ia : Developmental anomaly o the bone that mani ests as a de ect in osteoblastic

di erentiation and maturation Any bone(s) in the body can be a ected, including the cranio acial skeleton

A Characteristics: active growth in childhood and stabilization in adulthood

B Signs and symptoms: bone enlargement; the maxilla is more commonly involved than the mandible.

C Radiographs: reveal sclerosis, lytic lesions, or unilocular lesions

D reatment: Obvious de ormity, pain, or inter erence with unction suggests the need or surgery;

conservative resection appears to be the best treatment

E Malignant trans ormation: possible but uncommon

II Torus : Benign bony growth, occurring at the midline o the palate

(maxillary torus) or bilaterally lingual to the bicuspid (mandibular torus) T ey grow slowly and generally have no signif cance except

that they may inter ere with the f tting o dentures

III Os te om a s : Slow-growing, benign tumors in the sinuses, jaws,

or external ear canals T ey may require excision i they produce symptoms

La rynge a l Le s io ns

I La ryng oc e le : Dilatation o the laryngeal saccule, producing an air sac that communicates with the laryngeal ventricle Pressure increases the size o a laryngocele (e.g., coughing, straining, playing a wind instrument)

A Laryngopyocele: in ected laryngocele that can be atal i it results in asphyxia or i the purulent

contents are aspirated

B Location: Laryngoceles may be unilateral or bilateral T ey may also be internal (within the larynx),

external (presenting in the neck), or both (combined)

1 Internal laryngocele: causes bulging o the alse cord and aryepiglottic old

2 External laryngocele: appears as a neck swelling at the level o the hyoid and anterior to the SCM

muscle

C Characteristics

1 Internal laryngoceles: cause hoarseness, breathlessness, and stridor on enlargement

2 External laryngoceles: increase in size with coughing or the Valsalva maneuver; are tympanic to

percussion and may produce hissing as the laryngocele empties air into the larynx when the air pressure is reduced

D Diagnosis: C and MRI scans

E reatment

1 Symptomatic laryngoceles: excised

2 Laryngopyoceles: Incision, drainage, and subsequent excision Antibiotics are also appropriate.

II La ryng e a l we bs

A Characteristics: May be congenital or ollow vocal old trauma When extensive, they present with

stridor, weak phonation, and eeding problems in in ants

B reatment: Excision or division is generally the pre erred treatment, and placement o a stent

or keel is o en required

III Voc a l no dule s : bilateral benign masses that usually occur at the junction o the true vocal olds

A Etiology: associated with vocal abuse

B reatment: Best treated by modi ying the patient’s speaking or singing technique through voice

therapy Surgery is rarely necessary

nerve must be cut at s urgery,

it s hould be generally reanas tomos ed or a nerve gra t s hould be interpos ed.

Quic k Cut

Tori are common benign bony growths that occur on the palate or the mandible.

IV Voc a l polyps

A Characteristics: usually unilateral and o en do not regress with

speech therapy

B reatment: Recommended therapy is care ul excision with

microscopic visualization and avoidance o injury to the underlying lamina propria; in selected cases, the laser may be help ul

V La ryng e a l g ra nulom a s (intuba tion gra nulom a s ): occur over the vocal processes o the arytenoid cartilages

A Etiology: Generally the result o trauma, usually rom an endotracheal tube, and are usually

associated with re ux laryngitis Voice abuse may be a actor

B reatment: Antire ux and speech therapies o en help them regress.

1 Persistent granulomas: best treated by excision a er a period o voice and medical therapy

2 Botulinum toxin: used or selected, recurrent cases

VI Aryte noid dis loc a tio n: generally is the result o endotracheal tube or external trauma

A Characteristics: So , breathy voice a er extubation Flexible f beroptic exam will reveal an

immobile vocal cord

B reatment: Prompt reduction is advisable; otherwise, the arytenoid usually becomes f xed in the

dislocated position However, late reduction (a er months or years) can be success ul

VII Conta c t ulc e rs : mucosal disruptions usually located posteriorly on the vocal olds

A Etiology: sometimes result rom trauma (e.g., rom intubation), occasionally rom vocal abuse, and

o en rom gastric re ux laryngitis or heavy coughing

B reatment: antire ux medication and behavioral changes such as elevation o the head o the bed;

avoidance o ca eine, chocolate, late-night snacks, and atty oods

1 Antacid therapy: usually results in prompt resolution

2 Antibiotics: may be help ul i in ection is present

HEAD AND NECK INFECTIONS

To ns illitis a nd Ad e no to ns illitis

I Tons ille c tom y with a d e noide c tom y: Once the most common operation per ormed in the United States It remains quite prevalent but is now per ormed only or specif c indications

A Obstructive hypertrophy: See earlier discussion.

B Recurrent in ection: Patients with documented recurrent

adenotonsillitis are improved a er tonsillectomy with adenoidectomy

II Pe ritons illa r a bs c e s s : onsillectomy is o en suggested a er treatment or inpatients with a history o previous tonsillitis

Atyp ic a l Myc o b a c te ria In e c tio n

I Cha ra c te ris tic s : Presents as an in amed mass or draining sinus in the head and neck, commonly associated with the parotid

or submandibular glands and is most common in children and adolescents Pulmonary involvement is rare

A Results: Fixation o overlying skin and sinus ormation are common.

B Biopsy: can lead to a chronically draining sinus tract

II Tre a tm e nt: Surgical excision or curettage and drainage Antimycobacterial drug therapy is not indicated because this is not systemic but a localized problem

MALIGNANT LESIONS OF THE HEAD AND NECK

Ove rvie w

I Cha ra c te ris tic s : able 18-4 shows the basic characteristics o head and neck cancer

II Ep ide m iology: Primary malignant neoplasms o the head and neck, excluding skin cancer, account

or 5% o new cancers each year in the United States

A Incidence: Male to emale ratio is 3:1 to 4:1, and most lesions occur in patients older than age

Quic k Cut

Vocal polyps are unilateral and do not improve with s peech therapy; vocal nodules are bilateral and are treated with s peech therapy.

Quic k Cut

Many common

in ections such as ear

in ections (otitis) can be treated with antibiotics alone.

Quic k Cut

A history o three to six episodes o adenotons illitis annually is a relative indication

or tonsillectomy with adenoidectomy.

Nose and sinus Mass Nickel, wood Moderate Nasopharynx Neck mass; serous otitis media Epstein-Barr virus High

B ypes: Approximately 80% o primary head and neck

malignancies are squamous cell carcinomas; the remainder includes thyroid cancers, salivary neoplasms, lymphoma, and other less common tumors

III Ris k a c tors : obacco use, alcohol consumption, and exposure to

radiation are etiologic actors in most squamous cell carcinomas o the head and neck

A Smoking: Approximately 85% o patients with head or neck cancer

smoke or ormerly smoked cigarettes at the time o diagnosis

B HPV: associated with some head and neck squamous cell carcinomas, most commonly strains

16 and 18

Eva lua tio n

I His to ry: Evaluation o the patient starts with a care ul history, especially head or neck malignancy

A Exposure to etiologic agents: such as tobacco, alcohol, sawdust, other toxins, and irradiation

B Associated symptoms: hoarseness or sore throat o more than

3 weeks’ duration, dysphagia, otalgia, dyspnea, nonhealing ulcers, hemoptysis, and neck mass

C Nutritional status

1 Malnourishment: Either because o alcoholism or an

obstructive tumor; some patients may require nutritional supplements

2 Severe malnourishment: Consider re eeding syndrome.

D Family history: critical with inherited actors (i.e., medullary

thyroid cancer)

II Phys ic a l e xa m ina tion: must include an inspection o all the skin and mucosal sur aces o the head and neck

A Intranasal examination and indirect mirror examination:

o the nasopharynx and hypopharynx

B Care ul palpation: o the oral cavity, base o the tongue, and oropharynx

C Fiberoptic examination: o the nose, pharynx, and larynx is indicated in all patients who are being

evaluated or cancer

Tre a tm e nt

I Surge ry (Fig 18-2): Indicated or many patients with head and neck cancer T e e ects o radiation are avoided, and radiation can

be saved or recurrent disease or other primary cancers T e choice

o surgery can be in uenced by many actors

A Malnourishment: can increase the perioperative risk o

Quic k Cut

The number o patients with a s econd primary malignancy o the upper aerodiges tive tract at the time o initial pres entation has been reported to be as high as 17%

be individualized to the needs

o the patient as well as their ability to comply with the treatment plan.

Quic k Cut

Treatment is bas ed

on the s ite and pathology o the primary cancer and the extent o the local, regional, and dis tant dis eas e.

B Coexistent systemic disease: Diabetes, chronic obstructive pulmonary disease, coronary artery

disease, etc increase the surgical risk

C Results: Necessary procedures can be disf guring and can leave the patient with severe unctional

def cits and is best per ormed in institutions that can provide the ull range o rehabilitative services

1 Resection o the larynx: alters communication

2 Surgery on the tongue, oropharynx, hypopharynx, or mandible: can alter or prevent swallowing

D Contraindication: Surgery or a cure is generally contraindicated in patients with distant metastases.

II Ra dia tion the ra p y: Radiation alone is adequate treatment or many early lesions

A Benef ts: It can provide a cure without the unctional or cosmetic def cits associated with surgery,

can treat multiple primary lesions simultaneously, and can prophylactically treat regional nodes that are clinically negative

B Planned postoperative radiation: can signif cantly increase the

survival rate or patients with advanced lesions

C Hyper ractionation (more than one daily treatment) and concomitant chemotherapy: Studies show that these techniques

can enhance the response to radiation therapy, but they increase the risk and severity o local side e ects

D Complications: mucositis, xerostomia, loss o taste, dermal

and so tissue f brosis, dental caries, and bone and so tissue necrosis

III Che m othe ra py: not curative as a single treatment modality in head and neck squamous cell carcinoma

A Neoadjuvant treatment: to reduce the tumor burden be ore radiation or surgery

B Concomitant radiation therapy: to increase response rates in

advanced tumors

C Palliation: in patients with unresectable tumors or distant metastases

IV Re ha bilita tio n: should be planned at the same time as treatment

A Surgical aps: Cosmetic and unctional de ects are reconstructed

at the time o the cancer resection whenever possible

1 Local aps: nasolabial, orehead

2 Distant pedicled skin aps: deltopectoral, omocervical

3 Pedicled myocutaneous aps: pectoralis major, latissimus

dorsi, trapezius

S te rnocle idoma s toid mus cle

Inte rna l jugula r ve in

Quic k Cut

A dental examination and possibly extraction is

required be ore radiotherapy

Dental treatment during and up

to 2 years a ter radiotherapy can be hazardous because

o decreased vascularity and consequent delayed healing.

Quic k Cut

The choice o a surgical f ap depends on the size o the de ect, history o peripheral vascular disease, prior surgeries, or procedures

in the desired donor region and general health and nutritional status o the patient.

E Voice restoration: When the larynx is removed, intensive rehabilitation is required to re-establish

the voice with an electrolarynx that is applied to the neck sur ace, regurgitated air (esophageal speech), or with a prosthesis placed in a tracheoesophageal f stula

F Swallowing training: Many patients who undergo partial laryngectomy, pharyngectomy, or

glossectomy need this to avoid aspiration

NECK CANCER

Ana to m y

I Divis ions : anterior and posterior triangles

A Anterior triangle: Bounded by the midline o the neck, the in erior mandible border, and the

anterior SCM muscle It can be subdivided urther into submandibular, submental, superior carotid, and in erior carotid triangles

B Posterior triangle: Bounded by the posterior border o the SCM muscle, the anterior border o the

trapezius, and the clavicle It is divided urther into supraclavicular and occipital triangles

II Lym pha tic dra ina ge : Fascial planes o the neck enclose the lymphatic system and are important when discussing spread o in ections and malignancy in the head and neck

A Superf cial ascia: subcutaneous and envelops the platysma

B Deep ascia: three parts:

1 Superf cial layer: invests the SCM and trapezius muscles and the parotid and submandibular glands

2 Middle layer: divided into muscular and visceral divisions

a Muscular division: invests the strap muscles and pharyngeal constrictors and buccinators

b Visceral division: also called the pretracheal ascia; envelopes the trachea, esophagus, and

thyroid

3 Deep layer: divided into the alar ascia anteriorly and the prevertebral ascia posteriorly

C Retropharyngeal space: lies anterior to the alar ascia and is an important plane when discussing

spread o malignancy and in ection

D Neck lymph nodes: Many drain specif c areas o the upper aerodigestive tract T ese are divided

into six levels based on location and drainage patterns

1 Deep jugular and spinal accessory chains: where most lymph nodes lie

2 Jugular chain divisions: superior, middle, and in erior groups

Ne c k Ma s s Eva lua tio n in Ad ults with

No Prim a ry Ca nc e r Se e n o n Exa m

I His to ry a nd phys ic a l e xa m ina tion: Care ul history is taken, and the head and neck are examined or evidence o a possible primary cancer

II Dia g nos is : I the primary cancer is not identif ed on the initial examination, the subsequent workup should include the ollowing

A Imaging: Chest x-ray, barium swallow, and C scan o the neck

are indicated in most patients MRI or ultrasound o the neck is guided by f ndings on the history and physical examination

1 MRI: particularly use ul in def ning deeply invasive tongue, pharynx, and larynx tumors

2 C o the sinuses: can be used to search or primary tumors

3 Staging: C or MRI o the chest and abdomen are o en used.

B FNA: should be per ormed to provide a tissue diagnosis

C Panendoscopy: direct laryngoscopy, esophagoscopy, bronchoscopy, and nasopharyngoscopy to

identi y any obvious lesions or biopsy

1 Random biopsies: I the result o the endoscopic survey is negative, biopsy o the nasopharynx

(right, middle, and le ), piri orm sinuses, tongue base, and a tonsillectomy may also be considered

2 Next step: I all biopsies have negative results, proceed with open neck biopsy and rozen section.

Quic k Cut

A workup or malignancy s hould be undertaken in all adults with

a pers is tent neck mas s

Tre a tm e nt

I Typ e s o ne c k d is s e c tion: Figure 18-3

A Radical neck dissection: en bloc dissection o the cervical

lymphatics that includes removal o the SCM muscle, internal jugular vein, or spinal accessory nerve

B Modif ed ( unctional, conservative) neck dissection: removes

the cervical lymphatics within their ascial compartments that spares the SCM muscle, internal jugular vein, and spinal accessory nerve

C Segmental neck dissection: re ers to removal o less than f ve

nodal groups on one side o the neck (e.g., submandibular triangle dissection, supraomohyoid dissection)

II Ele c tive ne c k dis s e c tion: surgical treatment with no known cervical disease; controversial because radiation therapy can provide prophylaxis or metastatic neck disease in many cases

A Choice between surgery and radiation: usually depends on the treatment o the primary tumor

B In general: per ormed or a primary cancer that has at least a 20% chance o occult metastasis

NASAL CAVITY AND PARANASAL SINUS CANCER

Ana to m y a nd Cla s s if c a tio n

I Ba s ic s truc ture : Sinuses are contiguous with the nasal cavity through natural ostia, and the nose and sinuses are lined with a respiratory mucosa, which is pseudostratif ed columnar with goblet cells and cilia

II Lym pha tic dra ina ge : to the parapharyngeal or retropharyngeal nodes

III Lo c a tion: Most tumors (59%) are in the maxillary sinus, 24% are in the nasal cavity, 16% in the

ethmoid, and 1% in the rontal/sphenoid sinuses

Quic k Cut

FNA biops y o a

s olid neck mas s is o ten the rst step in its workup I the les ion is a metas tas is , a ull head and neck exam, in conjunction with imaging, may demons trate the primary tumor

Fig ure 18-3: A: Level o res ection in an en bloc compos ite res ection o the oral cavity, oropharynx,

or both (the clas s ic commando procedure) B: The

s pecimen includes the primary cancer, a s egmental mandibulectomy, and the radical neck dis s ection.

B Adenocarcinomas: including adenoid cystic carcinoma, 10%–14%

Clinic a l Eva lua tio n

I Pre s e nting s ym pto m s : can include nasal obstruction; epistaxis;

localized pain; tooth pain; CN def cits; mass in the ace, palate, or maxillary alveolus; proptosis; and trismus

II Dia g nos is : Extent o the disease is determined by physical examination and radiographic studies

A C scan: use ul or identi ying bony erosions and orbital or

intracranial extension

B MRI: can be used or intraorbital and intracranial invasion

Tre a tm e nt a nd Prog no s is

I Ma xilla ry s inus c a nc e r

A Less advanced cancers: Subtotal or radical maxillectomy Adjuvant radiation may be used.

B Advanced cancers: Usually receive a combination o surgical resection ollowed by chemotherapy

and/or radiotherapy Orbital exenteration and skin resection are per ormed when necessary

II Ethm oid s inus o r na s a l c a vity tum ors : combination o surgical resection and chemotherapy and/

A Overall cure rate: 30%–35%

B 5-year survival rate: less advanced lesions, 70%; decreases to 15%–20% with more advanced disease

NASOPHARYNX CANCER

Ove rvie w

I Ana tom y: Nasopharynx is the most cephalad part o the pharynx; its roo is ormed by the basioccipital and sphenoid bones, and its posterior wall is ormed by the atlas

A Walls: Roo and posterior wall are covered by mucosa, and the adenoid tissue is embedded; the lateral

wall contains the orif ce o the eustachian tube, and, just posterior to that, the ossa o Rosenmüller

B Limits: Choanae def ne the anterior limit, and the ree edge o the so palate provides the in erior

A Elevated Epstein-Barr virus titer: high incidence among persons with nasopharyngeal cancer

B Age: occurs at younger ages than do most solid head and neck tumors

III Cla s s if c a tion: Eighty-f ve percent o nasopharyngeal tumors are epithelial; 7.5% are lymphomas

Epithelial tumors commonly arise in the ossa o Rosenmüller

Clinic a l Eva lua tio n

I Pre s e nting s ym pto m s : Epistaxis, cervical adenopathy, serous otitis media, and nasal obstruction (headache, diplopia, acial numbness, trismus, ptosis, and hoarseness may also be present);

70% o patients will have nodal disease, 40% will have CN involvement

Quic k Cut

Be s us picious or

a malignancy in a patient who pres ents with unilateral nas al obstruction, epis taxis , localized acial pain, or CN

de cits (III, IV, VI, or VII).

and paranasal sinuses.

Quic k Cut

An adult with

a unilateral middle ear

e us ion should have nas opharyngos copy to rule out a nas opharyngeal mas s

II Dia g nos is : conf rmed by biopsy o a metastatic lymph node

A Staging: C and MRI

B Elevated Epstein-Barr virus titer: Monitoring o the titer should show a decrease with success ul

treatment and an increase with recurrences

Tre a tm e nt a nd Prog no s is

I Ra dia tion: Primary treatment or all epithelial nasopharyngeal tumors T e dose is delivered to the nasopharynx and to both sides o the neck Improved responses are possible with combined chemotherapy and radiation in patients who can tolerate the increased toxicity

II Ra dic a l ne c k dis s e c tio n: per ormed or residual nodes i the primary tumor is controlled

III 5-ye a r s urviva l ra te : 40% in patients without positive nodes and 20% in patients with positive nodes

ORAL CAVITY CANCER

Ove rvie w

I Ana tom y: Oral cavity extends rom the lip anteriorly to the aucial arches posteriorly and includes the lips, buccal mucosa, gingivae, retromolar trigones, hard palate, anterior two thirds o the tongue (the oral tongue), and oor o the mouth

II Lym pha tic dra ina ge : to the submental, submandibular, and deep jugular nodes

III Etio log y: Ninety percent o patients are heavy users o tobacco

(either smoking or chewing); 80% o patients are heavy drinkers

Clinic a l Eva lua tio n

I Pre s e nting s ym pto m s : Can include loose teeth, pain ul or nonhealing ulcers, odynophagia, otalgia (with posterior lesions), and cervical adenopathy T e lip is the most common site o carcinoma,

ollowed by the oral tongue and oor o the mouth

II Dia g nos is : Pain, which is a late symptom, occurs a er ulceration develops

A Mandibular radiographs: assess the bony involvement by adjacent tumors

B Nodal metastases: Common, especially in the oor o mouth and oral tongue with more advanced

primary tumors; much are microscopic (occult) disease

C Metastases: uncommon; usually occur late in cancer o the lip or the buccal mucosa

A Surgery: involves an en bloc resection and neck dissection

B echnique: Either a partial mandibulectomy is included or the

tumor is “pulled through” medially to the mandible into the neck (i.e., the tumor is removed en bloc, leaving the mandible intact)

III Tum o rs a tta c he d to the m a ndible : May be removed with a partial thickness o mandible (i.e., the

lingual plate or alveolar process) T e mandibular arch is kept intact when possible

IV Tum o rs d e m ons tra ting bo ny e ros ion in the m a ndible : removed with a ull-thickness portion

o bone

V 5-ye a r s urviva l ra te : overall, or cancer o all oral cavity sites, is 65%

A Lip cancer: Rates as high as 90% have been reported.

B ongue lesions: Prognosis is worse i the lesion is posterior.

1 Anterior (mobile) tongue lesions: O en diagnosed when they are small; overall 5-year survival

rate is more than 65%

2 Posterior lesions: less than 40%

Quic k Cut

The s even s ubs ites

o the oral cavity are the lips , buccal mucos a, gingivae, retromolar trigone, hard palate, oral tongue, and the

f oor o the mouth.

Quic k Cut

Most malignancies

o the oral cavity are treated with s urgery, with or without radiation.

A Boundaries: ree edge o the so palate superiorly, the tip o the epiglottis in eriorly, and the anterior

tonsillar pillar anteriorly

B Contents: so palate, tonsillar ossae and aucial tonsils, lateral and posterior pharyngeal walls, and

base o the tongue

C Parapharyngeal space: directly lateral to the oropharynx; contains the glossopharyngeal, lingual, and

in erior alveolar nerves; pterygoid muscles; internal maxillary artery; and carotid sheath and is a site

o early extension o an oropharyngeal tumor that also provides a pathway or the tumor to spread to the base o the skull

D Lymphatic drainage: Primarily to the jugulodigastric (tonsillar)

nodes; tumors o the so palate, lateral wall, and tongue base also spread to the retropharyngeal and parapharyngeal nodes

II Etio log y: Alcohol and tobacco use are commonly ound together

in patients with oropharyngeal cancer

A HPV strains 16 and 18: associated with squamous cell cancer o

the oropharynx with increasing incidence

B Local mucosal irritation, malnutrition, and immune de ects:

also implicated

Clinic a l Eva lua tio n

I Pre s e nting s ym ptom s : Most common is a persistent sore throat, which is requently accompanied by ipsilateral otalgia (re erred

pain via the tympanic branch o the glossopharyngeal nerve), vague sensation o throat irritation, restriction o tongue motion (“hot potato voice”), odynophagia, and bleeding

A Malnourishment: Most patients are signif cantly malnourished.

B Cervical adenopathy: Nodal metastases are ound in 70% o patients with cancer o the base o

the tongue and in 60%–80% o patients with tonsillar cancer; most o these nodes are palpable

II Initia l e xa m ina tion: Must include care ul palpation o the base o the tongue Many small tumors are

di cult to see but may be palpated easily

III Dia g nos is : O en made late in the course; many patients are asymptomatic until tumors are large;

others are treated conservatively or incorrectly diagnosed lesions

A Endoscopy under general anesthesia: or all lesions be ore treatment is chosen

B C and MRI: use ul in determining tumor extension

Tre a tm e nt a nd Prog no s is

I Sm a ll le s ions : most commonly treated with radiotherapy

II La rge le s ions : Combined therapy o ers improved survival rates and is indicated when nodal metastasis is present

III Com p os ite re s e c tion (the ja w-ne c k or c om m a ndo proc e d ure ): most commonly used to

resect large lesions o the oropharynx and involves a neck dissection and a partial mandibulectomy in conjunction with excision o the tumor (Fig 18-3) and reconstruction (Fig 18-4)

A racheotomy: routine treatment

B otal glossectomy: Occasionally, the larynx is spared a er in young and otherwise healthy patients.

C Laryngectomy: per ormed when either the tumor invades the pre-epiglottic space or the entire

tongue base and both hypoglossal nerves are removed

IV Tra ns ora l ro botic s urge ry (TORS): now used at some centers or surgical resection o

oropharyngeal tumors

A Reduced morbidity: due to ability to resect the tumor without splitting the mandible

B Decreased need or eeding tubes ollowing resection: demonstrated by some studies

V Pro gno s is : Related to the HPV status o the tumor; patients who have HPV tumors generally have a better prognosis than those who have HPV– tumors

Quic k Cut

Tobacco, alcohol

us e, and HPV 16 and 18 expos ures are ris k actors or oropharyngeal s quamous cell carcinoma.

Quic k Cut

A s ynergis tic e ect

s eems to exis t between alcohol and tobacco in oropharynx cancer, but it has not been de ned.

HYP OPHARYNX AND CERVICAL ESOP HAGUS CANCER

Ove rvie w

I Ana tom y

A Boundaries: Hypopharynx extends rom the pharyngoepiglottic old to the in erior border o the

cricoid area, excluding the larynx

B Contents: includes the piri orm sinuses, the postcricoid area, and the posterior pharyngeal wall

C Lymphatic drainage: Hypopharynx has a rich lymphatic network.

1 Piri orm sinuses: drain to jugulocarotid and midjugular nodes

2 Posterior pharyngeal wall: drains primarily to retropharyngeal nodes

3 Lower hypopharyngeal areas: drain to paratracheal and low jugular nodes

4 Cervical esophagus: drained by mediastinal nodes

II Cla s s if c a tion: Ninety-f ve percent o the tumors in this region are epithelial cancers; 60%–75%

arise in the piri orm sinuses and 20%–25% on the posterior pharyngeal wall; tumors rarely arise in the postcricoid area

III Etio log y: as with other head and neck tumors, related to heavy use o alcohol and tobacco

Clinic a l Eva lua tio n

I Pre s e nting s ym pto m s : riad o throat pain, re erred otalgia, and dysphagia is present in more than 50% o patients

II Hoa rs e ne s s a nd a irwa y ob s truc tion: indicate laryngeal involvement

III Sm a ll p os tc ric oid tum o rs : o en present with mild symptoms o sore throat, globus (a “lump in the

throat”), and throat clearing

IV Ce rvic a l lym ph node m e ta s ta s e s : ound in 75% o patients with piri orm sinus cancers (41%

occult) and in 83% o patients with pharyngeal wall tumors (66% occult)

V Dia g nos is : C scan o the neck with contrast and endoscopy with biopsy complete the workup

Fig ure 18-4: Recons truction o a circum erential pharyngeal de ect with a jejunal ree gra t The vas cular pedicle has been anas tomos ed to branches o the

external carotid artery and internal jugular vein.

III Sm a ll tum ors : can be treated by radiation therapy alone or by surgical resection via a lateral

pharyngotomy

IV Ce rvic a l e s op ha gus c a nc e r: can require removal o the pharynx, esophagus, and larynx

V Pro gno s is : poor because o extensive submucosal spread and the high incidence o cervical metastasis

A Overall 5-year survival rate: 30%

B I eligible or supraglottic laryngectomy: Five-year survival rate rises to 50%.

VI Che m othe ra py with ra d ia tion the ra py: in organ-sparing protocols

LARYNX CANCER

Ove rvie w

I Ana tom y

A Divisions: three regions

1 Supraglottis: extends rom the tip o the epiglottis to include the alse vocal olds and roo o the

ventricle

2 Glottis: extends rom the depth o the ventricle to 1 cm below the ree edge o the true vocal old

3 Subglottis: extends rom 1 cm below the ree edge o the true vocal old to the in erior border o

the cricoid cartilage

B Lymphatic drainage

1 Supraglottis: rich network that crosses the midline and drains to the deep jugular nodes

2 Glottis: poorly developed sparse lymphatics

3 Subglottis: drains through the cricothyroid membrane to the prelaryngeal (delphian) and

pretracheal nodes

II Etio log y: More than 90% o patients have a signif cant history o smoking, and heavy alcohol consumption is a common but not def nite etiologic actor

III Cla s s if c a tion

A Squamous cell carcinomas: account or 95%–98% o the tumors

B Verrucous carcinoma: variant o squamous cell carcinoma that is locally invasive but almost never

metastasizes

Clinic a l Eva lua tio n

I Pre s e nting s ym pto m s : Most common symptom is hoarseness

A Other: Stridor, cough, hemoptysis, odynophagia, otalgia,

dysphagia, and aspiration also occur

B Neck masses: uncommon at the time o presentation

II Diagnos is : All patients require direct laryngoscopy and biopsy; barium swallow, stroboscopic laryngoscopy, and C scan may be help ul

Tre a tm e nt a nd Prog no s is

I Ca rc inom a in s itu: excision o the involved vocal old mucosa and close monitoring

II Ea rly-s tage les ions : Many are treated with radiation because the resultant voice is usually o better quality than the one a er surgical excision (at least initially) However, surgery is still indicated or many patients

A Removal o the involved vocal old: by traditional techniques or by carbon dioxide laser yields

equivalent local control

B Hemilaryngectomy (vertical laryngectomy): or some glottic lesions that involve the anterior

commissure because o the increased risk o cartilage involvement

C Limited surgical resection: or some small lesions o the tip o the epiglottis

III La rge s upra g lottic tum o rs : Supraglottic (horizontal) laryngectomy spares the true vocal olds but

removes the epiglottis, aryepiglottic olds, and alse vocal olds

Quic k Cut

Glottic cancers are

us ually diagnos ed relatively early compared to other cancers o the head and neck due to the pres enting

s ymptom o hoars enes s

B

Fig ure 18-5: A: Total laryngectomy s pecimen ready or removal, attached only to the tongue bas e B: Pharyngeal de ect ollowing total laryngectomy Clos ure is us ually accomplis hed in layers in a T as hion.

che mothe ra py Sta ge s III a nd IV ca nce r

(−)

(−)

(+) (+)

Fig ure 18-6: Example o organ-s paring neoadjuvant chemotherapy protocol.

IV Tra ns glottic tum ors : For supraglottic tumors that spread to a true vocal old, a

suprahemilaryngectomy may be considered Neck dissection, radiation, or both are o en necessary

V Adva nc e d tum ors : Usually require a total laryngectomy, o en combined with neck dissection (Fig 18-5) Postoperative radiotherapy is usually indicated

VI Ve rruc ous c a rc inom a : Conservation laryngectomy, when possible T ere is no need or elective

neck dissection, and the use o radiotherapy is controversial

VII Conc urre nt c he m ora diothe ra py protoc ols : achieve cure rates comparable to those or

traditional combined surgical therapy and allow some patients to avoid total laryngectomy (Fig 18-6)

VIII Pro gno s is : better than with cancer o other head and neck sites

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Skin cancer is the mos t common cancer in the United States , with more than 1 million new cas es diagnos ed each year and more than 10,000 deaths

it allows removal o a margin.

B Basal cell carcinomas: O the nasolabial olds, medial and lateral

canthi, or postauricular regions are especially aggressive T ey can invade multiple tissue planes and, there ore, require an extensive surgical resection

C Mohs surgery: involves the precise mapping and rozen-section control o the entire resection bed

D Radiation therapy: usually reserved or advanced lesions in areas where surgical excision leaves a

cosmetically unacceptable de ect (e.g., the nose, eyelid, and lip)

E All positive nodes: should be treated with neck dissection or radiotherapy

Ma lig na nt Me la no m a

I Ep ide m iology: Accounts or 1% o all cancers; incidence is increasing by 5%–7% each year

II Etiolo gy: Sun exposure and heredity play important roles

III Pa thologic va ria nts : lentigo maligna melanoma, superf cial

spreading melanoma, and nodular melanoma

IV Sta ging: depth o primary lesion, see part VII Chapter Cuts and

Caveats

V Tre a tm e nt: wide excision with treatment o nodal basins or deeper melanomas

A Sentinel node biopsy: or intermediate depth o invasion to

assess or nodal disease

1 Lymphoscintigraphy: Radiotracer is injected intradermally

around the melanoma lesion Lymphatic imaging is then per ormed a er injection to conf rm appropriate uptake o the radiotracer

2 echnique: Blue dye and radiotracer are injected

intradermally at the site o the lesion T e dye is visible and

a gamma probe is used to identi y radiotracer activity and an incision is made in the area

3 Neck dissection: per ormed or positive nodes

4 Parotidectomy: added or lesions o the anterior scalp,

eyelids, auricles, and cheeks because the f rst-level lymphatic drainage is to the periparotid nodes

B Radiation therapy: usually reserved or palliative treatment o recurrent disease

C Chemotherapy: used or disseminated melanoma

VI Pro gno s is : Survival rate is related to the tumor staging; the prognosis in patients with mucosal

melanoma is extremely poor

HEAD AND NECK LYMPHOMA

Ove rvie w

I Ep ide m iology: Eighty percent o all malignant lymphomas arise rom nodes, many o which are in the head and neck

A Hodgkin lymphoma: Seventy percent o patients have cervical lymph node involvement.

B Extranodal presentation: rare in Hodgkin disease but occurs in 20% o patients with non-Hodgkin

lymphoma

II Cla s s if c a tion

A Non-Hodgkin lymphoma: really a group o diseases, which are classif ed into avorable and

un avorable types on the basis o therapeutic response

B Hodgkin lymphoma: Histology in uences the prognosis.

s quamous cell carcinoma accounts or 16%

When des cribing

s kin les ions concerning or melanoma, us e the ABCD

s ys tem: a s ymmetry, b order irregularity, c olor (uneven color pattern), and d iameter greater than 6 mm.

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A s entinel node

is the rs t node involved

in lymphatic s pread o a malignancy.

Clinic a l Eva lua tio n

I Pre s e nting s ym pto m s : Usually a single, enlarged cervical node; most lymphomatous nodes are f rm and rubbery

A Non-Hodgkin lymphoma: typically presents in upper cervical nodes

B Hodgkin disease: discovered in nodes throughout the cervical chain

C Sites o extranodal involvement in non-Hodgkin lymphoma: Head and neck, particularly in

Waldeyer tonsillar ring Other sites include the nasal cavity, paranasal sinuses, orbit, and salivary glands

D Systemic symptoms: Approximately 40% o patients with Hodgkin lymphoma have ever, sweats,

weight loss, and malaise

II Dia g nos is : Usually made by excisional biopsy o a lymph node; one o the largest nodes should be removed in its entirety

A FNA o the lymph node and endoscopy: should be per ormed to rule out squamous cell carcinoma

B I a possible extranodal source has been discovered: Biopsy f rst.

C Frozen-section diagnosis: o little value except to exclude squamous cell carcinoma

D Additional workup aids in staging: Chest radiograph, C scan o the abdomen, and bone marrow

biopsy are recommended

Tre a tm e nt a nd Prog no s is

I Tre a tm e nt: Combination o chemotherapy agents and radiation therapy are used depending on the stage and pathology

II Pro gno s is

A Hodgkin disease: Favorable prognostic actors include localized

disease, limited number o anatomic sites, absence o massive disease, and a avorable histology

B Survival rates: Patients with limited disease have 5-year, relapse- ree rates o 80%–90%; the rate alls

to 60%–80% in patients with advanced disease treated with combined therapy; and rates as low as 30% occur in advanced disease

C Non-Hodgkin lymphoma survival: Radiation therapy or limited disease yields 50%–70% cure rates.

1 With more advanced lesions: Patients with a avorable histology can have a 60%–70% 5-year

survival rate and a 30% cure rate

2 Patients with an un avorable histology: ace a 24%–40% 5-year survival rate with little chance

or a cure

UNUSUAL TUMORS

Ca ro tid Bo d y Tum ors

I Cha ra c te ris tic s : Usually present as slow-growing, painless neck masses; 3% are bilateral (increasing

to 26% in patients with a amilial tendency or paragangliomas) T e mass may be pulsatile and may have a bruit

II La rge tum ors : can cause dysphagia, airway obstruction, and CN palsies

III Dia g nos is : Angiography shows a tumor blush at the carotid bi urcation that splays the internal and

A Fascial sheath: Encloses the gland; the tightness o this ascia is responsible or the severe pain that

accompanies acute swelling o the gland (acute parotitis)

B Lobes: Classically, the parotid gland was thought to have two lobes, superf cial and deep, which is

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Treatment or lymphoma is generally not

s urgical.

III Ste ns e n duc t: Drains saliva; this duct exits anteriorly, pierces the buccinator muscle, and enters the

oral cavity opposite the second upper molar T e opening is marked by the parotid papilla, which may

be elt by the tongue or a f nger

IV Inne rva tio n (Fig 18-7): Facial nerve enters the posterior part o the gland immediately a er

emerging rom the stylomastoid oramen

A Divisions (two): Facial nerve divides within the substance o the

gland into two parts (zygomatico acial and cervico acial) at the pes anserinus or goose’s oot

B Major branches (f ve): temporal, zygomatic, buccal, mandibular,

and cervical

C Facial nerve and its branches: separate the superf cial and deep

portions o the gland (Fig 18-8)

D Muscles o expression: supplied by the acial nerve on the ipsilateral side o the ace

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Generations o

s tudents have us ed the mnemonic “To Zanzibar By Motor Car” to remember the branches o the acial nerve.

bra nch

Zygoma tic branche s

Pa rotid gla nd

Bucca l bra nche s

Ma rgina l

ma ndibula r bra nch

Ce rvica l bra nch

Ma in trunk

of fa cial ne rve

e me rging from

s tyloma s toid fora me n

Figure 18-7: Facial nerve branches pas s through the parotid gland.

Zygoma ticofa cia l divis ion of fa cia l ne rve

De e p lobe

Is thmus

S upe rficia l lobe

EVALUATION AND MANAGEMENT OF PAROTID MASSES

Ove rvie w

I His to ry a nd phys ic a l e xa m ina tion: can o en di erentiate among benign, malignant, and

in ammatory processes

A Slowly enlarging, distinct mass: can be a benign or malignant neoplasm

B Malignancy: Rapidly enlarging, f rm distinct masses associated with f rm, ipsilateral adenopathy,

and masses associated with pain or acial nerve paralysis usually indicate a malignancy

C In ammatory process: acute, pain ul swelling in one or both glands, associated with ever or

systemic symptoms

D Sialadenitis: Intermittent pain and swelling in the gland; a stone may occasionally be palpable on

intraoral examination

E Parotid mass: Metastatic disease in a parotid lymph node (drainage rom the upper two thirds o

the ace and the anterior scalp) may present as a mass

II Dia g nos tic s tudie s : may provide in ormation that dictates the extent o surgery required, thus permitting better counseling o the patient preoperatively

A Radiologic studies

1 MRI: Can establish i superf cial or deep lobes are involved,

suspicious lymphadenopathy, or acial nerve invasion It may also help to di erentiate individual histologic lesions

2 C scans: discern many o the same structural details but are

not nearly as success ul in di erentiating histologic lesions

B Invasive tests

1 FNA: provides tissue diagnosis

2 Core-needle biopsy or open biopsy: carries the risk o spreading tumor cells and generally is not

B Neck dissection: indicated or high-grade lesions

C Postoperative radiation therapy: may be used or un avorable high-grade lesions or in cases where

a limited dissection was per ormed

PAROTID NEOP LASMS

Be nig n

I Ge ne ra l: Eighty percent o parotid tumors are benign T e most common presenting eature o these tumors is a painless mass, and acial paralysis is rare Very care ul identif cation and surgical treatment, which consists o excision that includes a margin o normal gland, are required

II Ple om orphic a de nom a s (m ixe d tum ors ): So named because they contain both stromal and epithelial components; they are the most common benign salivary tumors (60% o all parotid tumors and are slow growing but may be quite large at the time o presentation)

III Pa pilla ry a de no c ys tom a (c ys ta de nom a ) lym p hom a tos um (Wa rthin tum ors ): consist o

both epithelial and lymphoid elements

A Presentation: T ey are so (cystic) when palpated and contain mucoid material that may appear

purulent T ey are neoplastic and nonin ammatory

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MRI with and without contras t is generally the imaging s tudy o choice when examining parotid les ions

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Be highly s us picious

or malignancy i there is a parotid mas s and the patient has acial weaknes s

Characterized by slowly progressive lymphoid inf ltration o the gland; care must be taken not to con use this lesion with a lymphoma It is associated with HIV.

IV Oxyphil a de nom a s : consist o acidophilic cells called oncocytes, occur most requently in elderly

patients, grow slowly, and do not usually grow larger than 5 cm

V Mis c e lla ne o us le s ions : For example, hemangiomas and lymphangiomas also occur Hemangiomas that do not regress are treated by resection

Ma lig na nt

I Muc oe pid e rm o id c a rc inom a : Arises rom the ducts o the gland It is the most common parotid malignancy and constitutes 9% o all parotid tumors

A ypes

1 Low-grade tumors: more common orm and are the tumors

seen most requently during childhood

a Presentation: T ey generally eel so when palpated and

appear encapsulated at surgery

b reatment: excision, with preservation o acial nerve branches that are not directly involved

by the lesion

c Prognosis: When treated properly, 5-year survival rate is 95%.

2 High-grade tumors: extremely aggressive, unencapsulated tumors that invade the gland widely

a reatment: otal parotidectomy plus neck dissection (even without palpable nodes); surgery

is usually supplemented by postoperative radiation

b Prognosis: Five-year survival rate is 42% with optimal treatment.

II Ma ligna nt m ixe d tum ors (c a rc inom a e x ple om orphic a de nom a , c a rc inos a rc o m a ):

Second most common type o malignancy and responsible or 8% o all parotid tumors T e treatment

is total parotidectomy; a neck dissection is also done or either palpable adenopathy or a high-grade tumor

III Squa m ous c e ll c a rc inom a : Rare in the parotid gland; it is important to di erentiate this lesion

rom a metastasis arising rom a primary tumor elsewhere in the head and neck such as a skin cancer

A Presentation: hard on palpation and accompanied by pain and nerve paralysis

B Prognosis: Five-year survival rate is 20%.

IV Othe r le s ions : include adenoid cystic carcinoma (cylindroma), acinic cell adenocarcinoma, and

adenocarcinoma

A reatment: otal parotidectomy; neck dissection is added when obvious nodal disease is present.

B High-grade, recurrent, and inoperable tumors: treated with radiation

V Ma lig na nt lym phom a : May arise as a primary tumor in the gland T e treatment is the same as or other lymphomas

PAROTID TRAUMA

La c e ra tio ns a nd Fo re ig n Bo d ie s

I Pa re nc hym a l da m a ge : usually heals spontaneously i Stensen’s duct is not injured

II Ste ns e n duc t: the conduit or saliva rom the parotid to the mouth, near the upper second molar

I lacerated or transected, it should be repaired over a small catheter, which will remain in place until the duct heals

III Fa c ia l ne rve injurie s : May recover spontaneously i only an anterior aspect o a distal branch is

injured I a main trunk is injured, it requires repair by primary anastomosis or nerve gra ing

IV Fo re ign bodie s (e g., bulle ts ): should be removed

multicentric.

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Malignant tumors cons titute 20% o all parotid neoplas ms They are o ten characterized by pain and acial nerve paralys is

INFLAMMATORY DISORDERS

Ac ute Sup p ura tive Pa ro titis

I Etiology: usually ound in patients who are debilitated and dehydrated and who have poor oral hygiene

II Ca us a l orga nis m : usually Staphylococcus aureus, which most likely enters the gland rom the mouth via Stensen duct

A Dehydration: Patient whose salivary glands are not secreting actively is susceptible to rapid growth

o the organism in this avorable environment

B Bacterial proli eration: leads to an intense in ammatory reaction in the gland, with edema and

severe pain

III Initia l tre a tm e nt: includes hydration, antibiotics, and measures to promote salivation, such as

occasionally sucking on a lemon

A Cultures: taken rom Stensen duct

B Antibiotics: initially directed against S aureus and are later adjusted as indicated by the results o

the cultures

IV Surgic a l dra ina g e : required i the process is not arrested by the preceding measures

Ca lc ulo us Sia la d e nitis

I Ove rvie w: Condition caused by stones in the salivary ducts I obstruction o the duct occurs,

in ammation and intermittent pain ul swelling o the gland ollow

II Dia gnos is : Radiographs may show the stones In the parotid gland, only 60% o stones are radiopaque

III Surge ry: should be postponed i there is an acute in ection present

A Location: When the stone is near the end o the duct, it can be removed transorally; i it is deep in

the gland, it can be removed by an external incision

B Multiple stones and pain recurrence: Remove the entire gland.

C Sialoendoscopy (endoscopy o the ducts o the salivary glands): has become an increasingly

common way to diagnose and treat non-neoplastic disorders o the salivary gland, including calculi, strictures, and intraductal masses

IV Va ria nts : Sialadenitis can occur without stones I symptoms persist, surgery may be necessary to

remove the gland

Bariatric Surgery

Mark D Kligman

BACKGROUND

Ob e s ity

I Cla s s if c a tio n a nd c om orbidity

A able 19-1: classif es obesity

B able 19-2: shows the risk o obesity-related comorbidities rising with increasing body mass index (BMI)

II Pre va le nc e

A Incidence: In the United States, obesity a ects 35% o adults;

17% o children and adolescents (ages 2–19 years) are also

a ected

B Demographics

1 Ethnicity: Prevalence o obesity is increased in A rican Americans and Hispanics

2 Socioeconomics: Poverty and poor education are also associated with an increased risk o obesity

B Nonsurgical weight management programs: documented ailure

C Surgical: acceptable operative risk and adequate mental capacity

to actively participate in pre- and postoperative care

D Other: absence o current alcohol or illicit drug abuse and o

poorly controlled psychosis or depression

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Obes ity comorbidities have broad

e ects on both the a ected individual and s ociety by limiting daily unction, reducing li e expectancy, and increas ing health care cos ts

Ta ble 19-1: Cla s s if c a tio n o Ob e s ity

Ca rd io va s c ula r Coronary artery disease Congestive heart ailure Hypertension

Dyslipidemia Venous stasis disease Pulm ona ry

Obstructive sleep apnea Obesity hypoventilation syndrome Asthma

End o c rine Insulin resistance Type 2 diabetes mellitus Polycystic ovarian syndrome

Ga s tro inte s tina l Gastroesophageal ref ux disease Nonalcoholic atty liver disease Gallstones

Mus c ulo s ke le ta l Osteoarthritis

Ge nito urina ry Stress urinary incontinence Gyne c o lo g ic

In ertility

He m a to p o ie tic Deep venous thrombosis Pulmonary embolism

Ne uro lo g ic Pseudotumor cerebri Stroke

II Spe c ia l pop ula tions

A Adolescent patients: Bariatric surgery has been demonstrated to be both sa e and e ective in

adolescents

1 Surgery is currently reserved or high-BMI patients (typically, BMI 50 kg/m 2 ) with major comorbidities (e.g., diabetes mellitus [DM], obstructive sleep apnea)

2 Patients must reach bone maturity prior to surgery to avoid growth retardation

3 Family counseling is thought to improve compliance and is mandatory in most programs

B Elderly patients: Care ul consideration o the current health

status and desired goals/results must be undertaken in patients age older than 65 years

C Class I obesity: Early data is very promising or extending the

indications or bariatric surgery to class I obesity (especially

or DM treatment), but the practice is not yet considered the standard o care

III Pa tie nt e va lua tion: done by a multidisciplinary team that

typically includes nutritionists, mental health pro essionals, and exercise physiologists

A Medical subspecialists (most commonly endocrinology, cardiology, or pulmonary medicine):

Consultation is based on specif c patient needs

B Studies: Laboratory testing, radiologic evaluation, endoscopy, cardiac evaluation, and other studies

are also based on specif c needs

SURGICAL TREATMENT OF OBESITY

Ba ria tric Op e ra tio n Cla s s if c a tio n Sys te m

I Re s tric tive o pe ra tions : procedures that limit oral intake

A Adjustable gastric banding (Fig 19-1): Proprietary

silastic band is placed around the stomach just below the gastroesophageal junction (GEJ), orming the outlet o a small gastric pouch

1 Mechanism: Balloon attached to the band’s inner sur ace is

connected via tubing to a subcutaneous port; when sterile water is injected into the port, the balloon in ates, which narrows the outlet and thus limits ood intake

2 Advantage: T is operation is easily reversed

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Bariatric s urgery may improve diabetes , even when per ormed in patients with normal BMI.

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Bariatric operations are categorized as res trictive, malabs orptive, or both.

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There is a hormonal component to weight

management, which is poorly unders tood The bes t s tudied

o thes e hormones is ghrelin.

B Sleeve gastrectomy (Fig 19-2): creates a narrow tube rom the lesser curvature o the stomach by

resection o the greater curvature o the gastric body and undus

1 Mechanism: Sleeve reduces ood intake by impeding its transit through the stomach

2 Disadvantage: T is procedure is not reversible

II Ma la b s orptive ope ra tio ns : procedures that limit nutrient absorption

A Biliopancreatic diversion (Fig 19-3): eatures a 200–500-mL gastric pouch created rom the

proximal stomach by resection o the gastric antrum and distal gastric body

1 Mechanism: T e small intestine is divided 200–300 cm proximal to the ileocecal valve to orm

the alimentary limb (a combination o the Roux limb and common channel), which is used to drain the gastric pouch T e biliopancreatic limb is composed o the remaining small intestine and is anastomosed to the alimentary limb 50–150 cm

proximal to the ileocecal valve, providing drainage or hepatic and pancreatic secretions

2 Complication: commonly causes dumping syndrome

B Biliopancreatic diversion with duodenal switch (Fig 19-4):

Gastric sleeve is used as the gastric pouch, thereby preserving the pylorus and eliminating the risk o dumping syndrome as a complication

e ective weight los s and ris k

o complications

III Com b ine d re s tric tio n a nd m a la b s orption (Fig 19-5):

Gastric bypass is essentially a restrictive operation with limited

malabsorption in which the volume o the gastric pouch is reduced

to 15–30 mL, and the size o the pouch outlet is also limited

A Mechanism: Alimentary limb is ormed rom the entire small

intestine except or the 40–75 cm required to provide drainage

or hepatic and pancreatic secretions

B Advantages: Compared to malabsorptive operations, gastric

bypass has similar weight loss with ewer nutritional complications

Po s to p e ra tive Cons id e ra tio ns

I Vita m in a nd m ine ra l s upple m e nta tio n: Begins preoperatively and continues li elong Supplements commonly include

multivitamins, vitamin B 12 , vitamin D, calcium, and iron

II Me dic a l ollow-up: necessary to adjust medications and to assess nutritional status

A Frequency: at least our times in the f rst postoperative year and annually therea er

B Gastric band patients: additionally assessed or weight loss rate and the band is adjusted as appropriate

III Multidis c iplina ry o llow-up: includes nutritional, exercise, and mental health counseling and

educates patients or optimal results

Gas tric pouch (200–500 mL)

Re s e cte d s toma ch

Biliopa ncre a tic limb

Roux limb (150–250 cm)

Common cha nnel

Ga s tric pouch (100–200 mL)

Common cha nne l (50–100 cm)

Fig ure 19-4: Biliopancreatic divers ion with duodenal s witch

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Bariatric s urgery may be per ormed by laparos copic or open techniques Laparos copic gas tric bypas s reduces abdominal wall complications (wound in ections and

hernias ) at the expens e o increas ed ris k o perioperative

GI hemorrhage, anas tomotic

s tricture, and bowel obs truction

Ga s tric pouch (15–30 mL) Bypa s s e d portion

of s toma ch

Biliopa ncre a tic limb (40–75 cm)

Roux limb (75–150 cm)

Common cha nne l

Fig ure 19-5: Roux-en-Y gas tric bypas s

Outc o m e s

I We ight los s : usually reported as percentage o excess weight loss (EWL)

A EWL: calculated as (current weight ideal body weight)/

(preoperative weight ideal body weight) 100%

B Average weight loss: in uenced by the choice o operation

1 Adjustable gastric band: 40%–50%

III Surviva l: Bariatric surgery reduces the overall 10-year risk o death

rom disease by 50%

P OSTOP ERATIVE MORTALITY AND COMP LICATIONS

Mo rta lity

I Ra te : Overall mortality rate is 0.2%

II Ris k: varies by type o operation (malabsorptive combined restrictive)

III Ca us e s : Most common are sepsis, cardiac complications, and pulmonary embolism (PE)

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Procedures can be compared by the EWL marker

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In the s everely obes e, weight los s by any means , including s urgical, will improve survival.

Com p lic a tio ns

I Ga s tric ba nding

A Early complications (within 30 days o surgery)

1 T romboembolism

a Incidence: deep vein thrombosis and PE 0.15% or less,

much lower than or any other bariatric procedure

b Diagnosis and treatment: as in non-obese patients

c Prevention: Pharmacologic perioperative prophylaxis is

controversial given the rate o thromboembolic events;

however, mechanical prophylaxis should be considered in all patients

2 Per oration (o esophagus/stomach during band placement): rare

3 Device-related complications: May occur at any time in

the patient’s postoperative course and commonly require operative repair Diagnosis and treatment is based on the specif c type o complication T e more commonly occurring device-related complications include the ollowing

a Band penetration (into the gastric lumen): may present as epigastric pain, port site in ection,

loss o restriction, or (rarely) GI hemorrhage

(1) Diagnosis: established by upper endoscopy, upper GI series, or by abdominal computed

tomography (C ) scan

(2) reatment: initially involves antibiotic therapy and band removal

b Band slip (band displacement more distally on to the stomach): may present with vomiting

due to pouch outlet distortion

(1) Diagnosis: conf rmed using plain abdominal f lms, upper GI series, or abdominal C

scan

(2) reatment: initially involves uid removal rom the band to relieve symptoms, ollowed

by surgical revision o the band

c Port in ection: may be caused by direct contamination during band f lls or, secondarily, due to

band penetration

(1) Evaluation: Abdominal C scan and upper endoscopy are required to rule out band

penetration

(2) reatment: initially involves antibiotic therapy and port removal

(a) T e band and its tubing are le in the peritoneal cavity, and the skin overlying the

port is le to heal secondarily

(b) T e tubing is later retrieved and connected to a new port, completing band salvage

B Late complications (more than 30 days a er surgery)

1 Device-related complications: (see above)

2 Nutritional def ciencies: rare

II Sle e ve ga s tre c tom y

A Early complications (within 30 days o surgery)

1 Bleeding

a Incidence: less than 1%

b Site: Bleeding can be intraluminal rom the staple line or rom an intraperitoneal source

c Diagnosis (1) History: Intraluminal bleeding o en presents with hematemesis

(2) Physical examination: O en unremarkable; however, signif cant bleeding can cause

hemorrhagic shock

d reatment (1) Initial therapy: may include resuscitation with uids and blood products and

hemodynamic and urinary output monitoring

(2) Def nitive treatment

(a) Intraluminal bleeding: Controlled using endoscopic techniques; surgical exploration

is reserved or ailed endoscopic therapy

(b) Intraperitoneal bleeding: requires surgical exploration to control hemorrhage site

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Malabs orptive operations have the highes t mortality rates , res trictive operations have the lowes t mortality rates , and combined operations have intermediate mortality rates

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Minor complications are common with adjus table band s urgery

c Diagnosis (1) Physical examination (abdominal): Unreliable;

peritonitis is a late f nding

(2) Abdominal C : best diagnostic modality or stable

patients

(3) Surgical exploration: def nitive diagnostic tool and

mandatory or di use peritonitis

d reatment: uid resuscitation, broad-spectrum antibiotics,

and nutritional support

(1) Wide peritoneal drainage o the leak site: surgically or percutaneously with image

guidance; f rst-line treatment

(2) Direct repair o the leak site: occasionally success ul

and used in conjunction with wide drainage

(3) Endoscopic techniques: used to seal leaks, typically in

conjunction with drainage

B Late complications (more than 30 days a er surgery)

1 Gastric sleeve stricture: rom postoperative scarring or a

technical error in sleeve construction

a Incidence: 0.5%

b Clinical presentation: Most common symptoms are nausea and vomiting; typically, patients

tolerate uids better than solids

c Diagnosis (1) Physical examination: Usually unremarkable Epigastric pain, i present, is mild

(2) Radiologic evaluation: abdominal C , upper GI series, and upper endoscopy

d reatment (1) Endoscopic stenting and surgical stricturoplasty: success ul in some cases (2) Conversion to gastric bypass: usually the best option

III Ga s tric bypa s s

A Early complications (within 30 days o surgery)

1 Bleeding

a Incidence: 4%

b Site: can be intraluminal, rom an anastomosis or staple line, or intraperitoneal

c Diagnosis (1) History: Hematemesis, hematochezia, or melena suggests an intraluminal source

(2) Physical examination: O en unremarkable; however, signif cant bleeding can cause

hemorrhagic shock

d reatment (1) Initial therapy: may include resuscitation with uids and blood products and

hemodynamic and urinary output monitoring

(1) Def nitive treatment: determined by hemorrhage site

(a) Intraluminal bleeding: O en controllable endoscopically; surgical exploration is

reserved or ailed endoscopic therapy, endoscopically inaccessible bleeding sites, or

or unstable patients

(b) Intraperitoneal bleeding: o en requires surgical

exploration to control hemorrhage site

2 Anastomotic leak

a Incidence: less than 4%

b Etiology: Most leaks occur 5–14 days rom surgery and are

related to tissue ischemia; earlier leaks are usually due to technical error

c Clinical presentation: Most common presenting signs are

those o early sepsis—tachycardia and tachypnea—and patients may appear anxious

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The mos t common pres enting s igns o leak a ter bariatric surgery are thos e o early s epsis —tachycardia and tachypnea

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Direct s uture repair

o a GI leak may s ound appealing, but the s utures will not hold in the s etting o peritonitis and inf ammation

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Anas tomotic leak

is the most eared early complication o bariatric

s urgery Reoperation may be the bes t means o diagnos is

d Diagnosis (1) Physical examination (abdominal): Unreliable; peritonitis is a late f nding

(2) Abdominal C : best diagnostic modality or stable patients (3) Surgical exploration: def nitive diagnostic tool and mandatory or di use peritonitis

e reatment: uid resuscitation, broad-spectrum antibiotics, and nutritional support (1) Uncontained leak: Surgical drainage is o en the only necessary intervention; direct repair

(or resection) is rarely success ul

(2) Contained leaks: can o en be drained percutaneously under imaging guidance

2 Venous thromboembolism

a Incidence (o DV and PE): each less than 1%

b Diagnosis and treatment: beyond chapter scope

c Prevention: Perioperative prophylaxis should ollow

American College o Chest Physicians (ACCP) recommendations or high-risk general surgery patients

(1) Pharmacologic agents (un ractionated heparin or

low-molecular-weight heparin) may be combined with leg compression devices

(2) Prophylactic placement o in erior vena cava f lters is controversial

B Late complications (more than 30 days a er surgery)

1 Dumping syndrome

a Incidence: Up to 85% o patients experience dumping syndrome at some point in their

postoperative course

b Etiology: usually related to poor ood choices, specif cally oods containing ref ned sugars

(e.g., high- ructose corn syrup) or high- at concentrations (especially ried oods)

c Clinical presentation: ollows two patterns (1) Early dumping syndrome: ypically begins 20–30 minutes a er meals and is triggered

by the rapid passage o ood with high osmolality into the small intestine T e hypertonic intraluminal load induces a rapid shi o extracellular uid into the intestinal lumen, producing either GI symptoms (e.g., nausea and vomiting, epigastric ullness, cramping abdominal pain, and diarrhea) or cardiovascular symptoms (e.g., ushing, dizziness, diaphoresis, palpitations, tachycardia, and syncope)

(2) Late dumping syndrome: Begins 1–3 hours

a er meals and is triggered by rapid passage o carbohydrates into the small intestine, which produces a hyperglycemic spike T e insulin released in response is excessive in relation to the total carbohydrate load, subsequently causing hypoglycemia that leads to catecholamine release rom the adrenal gland Symptoms include tremulousness, diaphoresis, light-headedness, tachycardia, and (rarely) con usion

d Diagnosis: Care ul history is usually diagnostic

e reatment (1) Avoid ref ned sugars and atty oods

(2) Somatostatin analogues or acarbose may be help ul or those patients with persistent

symptoms o late dumping syndrome despite dietary changes

2 Anastomotic stricture: occurs almost exclusively at the gastrojejunostomy and may be associated

with marginal ulceration

a Incidence: 1%–15%

b Clinical presentation: ypically involves persistent nausea and vomiting; patients o en

progressively limit their diet to oods that are able to traverse the stricture (i.e., so oods or liquids)

c Diagnosis (1) Physical examination: o en unremarkable (2) Upper endoscopy: best diagnostic tool

d reatment (1) Endoscopic balloon dilation: highly e ective in providing permanent symptomatic relie (2) Surgical revision: required rarely

Quic k Cut

PE accounts or 50% o all pos toperative deaths ollowing gas tric bypas s

Quic k Cut

Dumping s yndrome may occur a ter any

gas trojejunos tomy

c Clinical presentation: most commonly epigastric pain associated with postprandial nausea

and vomiting

d Diagnosis (1) Physical examination: Patients usually have ocal epigastric tenderness

(2) Upper endoscopy: best method or patients with the typical pain pattern (3) Upper GI series or abdominal C scan: sometimes use ul

(4) H pylori testing

e reatment (1) Uncomplicated ulcers: First-line treatment is medical therapy with cytoprotective agents

(sucral ate), proton pump inhibitors, and antibiotics (i H pylori present); patients should avoid NSAID use and smoking

(2) Nonhealing ulcers: surgical revision o the gastrojejunostomy Complications: include upper GI hemorrhage and per oration

4 Internal hernia (Fig 19-6): results rom small intestine trapped in mesenteric de ects created

during gastric bypass construction

a Sites (three): Petersen space, transverse mesocolic, or small bowel mesenteric de ects are possible

tenderness Peritoneal f ndings or rank peritonitis suggest intestinal strangulation

(2) Radiologic evaluation: identif es 80%

(a) Abdominal C : test o choice (b) Upper GI series: sometimes help ul (3) Surgical exploration: consider or patients with persistent unexplained abdominal pain

despite thorough evaluation

e Di erential diagnosis: adhesive bowel obstruction reatment: requires surgical exploration with reduction o herniated intestine, resection o

nonviable intestine, and closure o all potential hernia sites

A

C B

Figure 19-6: Sites or internal hernia ollowing gas tric bypas s include ( A ) the trans vers e

mes ocolic de ect, ( B ) Peters en s pace, and ( C ) the s mall bowel mes enteric de ect

eliminates the possibility o symptomatic gallbladder disease

(2) Only patients with symptomatic cholelithiasis have cholecystectomy at the time o

gastric bypass: All other patients receive a 6-month course o ursodiol (300 mg by mouth

twice daily) T is approach reduces the incidence o subsequent symptomatic gallbladder disease to 2%

6 Nutritional def ciencies: relatively uncommon in patients

who are compliant with postoperative vitamin and mineral supplementation

a Vitamin B 12 def ciency: due to both an overall reduction

in intrinsic actor production and rom bypass o the site o vitamin B 12 production within the stomach

b Calcium and iron def ciency: result rom bypass o the

duodenum and proximal jejunum where divalent cations are most e ciently absorbed

c Fat-soluble vitamin def ciency (especially vitamins D and A): due to reduced at absorption

in the jejunum and ileum

d Vitamin B 1 def ciency (bariatric beriberi): although

uncommon, can occur with prolonged episodes o vomiting; may present with neuropsychiatric abnormalities (Wernicke encephalopathy) composed o con usion, ataxia, ophthalmoplegia, nystagmus, and impaired short-term

memory or with cardiac f ndings including peripheral edema, dyspnea with exertion, paroxysmal nocturnal dyspnea, and tachycardia

IV Biliop a nc re a tic dive rs io n with or without duo de na l s witc h: similar to gastric bypass

Minimal Access Surgery

Daniel Medina, Hugo Bonatti, and Stephen M Kavic

HISTORY

Te c hnic a l Ad va nc e s

I Ce lios c o py: Kelling was the f rst person to per orm peritoneal “celioscopy” in a canine model with a cystoscope and air insu ation in 1901 In 1910, Jacobaeus used the same technique in humans

II Im a ge re s olution: Fiberoptic light sources replaced incandescent lights in the 1960s, and the addition

o digital cameras greatly improved resolution o images More recent developments include def nition three-dimensional cameras and exible camera heads

high-III Sta pling a nd intra c orpore a l e ne rgy de vic e de ve lopm e nt:

based on ultrasound and electricity; allow more e ective division o tissue, hemostasis, and anastomoses

IV Ha nd po rts : 5-cm incisions and a gelcap through which one hand

can be passed while keeping the abdomen air-sealed

V Single a c c e s s s urg e ry: relies on a 3-cm incision and an occluding device with multiple ports through which all instruments can be introduced

VI Rob otic te c hno log y: Independently developed by the National Aeronautics and Space

Administration and other institutions; the surgeon remotely and precisely operates various arms that hold modif ed laparoscopic instruments

VII Hybrid proc e d ure s : per ormed with cooperation o a minimal access surgeon and an interventionist,

such as a radiologist or gastroenterologist

VIII Na tura l orif c e a c c e s s s urge ry: Instruments are introduced through the stomach, rectum, or vagina;

reduces scars, but is not yet the standard o care or most procedures

Op e ra tive Mile s to ne s

I La pa ro s c opic a ppe nde c tom y: pioneered by Semm (1982);

improved diagnosis o pelvic pathology in emale patients

II La pa ros c opic c hole c ys te c tom y: First per ormed by Erich Muhe (1985) in Germany, then by Dubois, Mouret, and Perrisat (1987)

in France T e procedure was introduced and popularized in the United States by McKernan and Saye, and Reddick in the late 1980s

III Othe r: By the early 1990s, the technical easibility o a laparoscopic approach was demonstrated or

virtually all major abdominal surgical procedures

GENERAL PRINCIPLES

Di e re nc e s be twe e n Minim a l Ac c e s s a nd Op e n Surg e ry

I Ope ra tive f e ld: Unlike open surgery in which the operative f eld is exposed through a lengthy skin incision, minimal access surgery depends on accessing a natural or created cavity through small incisions

Currently, all s urgical

s ubs pecialties including urology, orthopedics , cardiothoracic, endocrine, and trans plant employ minimal acces s approaches