(BQ) Part 1 book Essentials of general surgery presents the following contents: Perioperative evaluation and management of surgical patients, fluids; electrolytes and acid base balance; nutrition; surgical bleeding: bleeding disorders, hypercoagulable states, and replacement therapy in the surgical patient; shock -Cell metabolic failure in critical illness; surgical critical care, wounds and wound healing, surgical infections.
Essentials of General Surgery FIFTH EDITION Lawrence_FM.indd i 7/21/2012 6:20:14 PM About the Cover: Portrait of Dr Samuel D Gross (The Gross Clinic) Thomas Eakins Oil on canvas, 1875 feet × feet inches (243.8 × 198.1 cm) Philadelphia Museum of Art: Gift of the Alumni Association to Jefferson Medical College in 1878 and purchased by the Pennsylvania Academy of the Fine Arts and the Philadelphia Museum of Art in 2007 with the generous support of more than 3,600 donors, 2007 Lawrence_FM.indd ii 7/21/2012 6:20:14 PM Essentials of General Surgery FIFTH EDITION Senior Editor Peter F Lawrence, MD Wiley Barker Endowed Chair in Vascular Surgery Director, Gonda (Goldschmied) Vascular Center David Geffen School of Medicine at UCLA Los Angeles, California Editors Richard M Bell, MD Professor of Surgery University of South Carolina School of Medicine Columbia, South Carolina Merril T Dayton, MD Professor and Chairman Department of Surgery State University of New York at Buffalo Buffalo, New York Questions Editor James C Hebert, MD Albert G Mackay and H Gordon Page Professor of Surgery University of Vermont College of Medicine Burlington, Vermont Content Editor Mohammed I Ahmed, MBBS, MS (Surgery) Department of Surgery Affiliated Institute for Medical Education Chicago, Illinois Lawrence_FM.indd iii 7/21/2012 6:20:14 PM Acquisitions Editor: Susan Rhyner Product Manager: Angela Collins Freelance Editor: Catherine Council Marketing Manager: Joy Fisher-Williams Vendor Manager: Bridgett Dougherty Design & Art Direction: Teresa Mallon, Doug Smock Compositor: SPi Global Copyright © 2013, 2006 Lippincott Williams & Wilkins, a Wolters Kluwer business 351 West Camden Street Two Commerce Square Baltimore, MD 21201 2001 Market Street Philadelphia, PA 19103 Printed in China All rights reserved This book is protected by copyright No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright To request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via website at lww.com (products and services) Library of Congress Cataloging-in-Publication Data Essentials of general surgery / [edited by] Peter F Lawrence — 5th ed p ; cm Includes bibliographical references and index ISBN 978-0-7817-8495-5 I Lawrence, Peter F [DNLM: Surgical Procedures, Operative WO 500] 617—dc23 2011051080 DISCLAIMER Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320 International customers should call (301) 223-2300 Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST Lawrence_FM.indd iv 7/21/2012 6:20:14 PM Preface “What all medical students need to know about surgery to be effective clinicians in their chosen fields?” The primary responsibility of medical schools is to educate medical students to become competent clinicians Because most physicians practice medicine in a nonacademic setting, clinical training is paramount The 3rd year of medical school, which focuses on basic clinical training, is the foundation for most physicians’ clinical training These realities not diminish the other critical functions of medical school, including basic science education for MD and PhD candidates, basic and clinical research, and the education of residents and practicing physicians However, the central role of providing clinical education for medical students cannot be overemphasized The education of students, residents, and practicing surgeons should be a continuum, although it may seem fragmented at times to students Because of the length of time needed to completely train surgeons, surgical residents remain “students” for to years beyond medical school As a result of this extensive training period, most medical schools have large numbers of surgical residents, and resident training makes up the bulk of their educational efforts Student education is part of the continuum that starts in the 1st or 2nd year of medical school, continues through residency, and never ends, because continuing education and lifelong learning are essential for all physicians NOT JUST FOR SURGEONS This textbook and its companion volume, Essentials of Surgical Specialties, were produced to start that continuum of education for medical students, and to focus on medical students who are not planning a surgical career We believe that all physicians need to have a fundamental understanding of the options provided by surgery to be competent, so the book asks the question, “What all medical students need to know about surgery to be effective clinicians in their chosen field?” Rather than using traditional textbook-writing techniques to address this question, members of the Association for Surgical Education (ASE), an organization of surgeons dedicated to undergraduate surgical education, have conducted extensive research to define the content and skills needed for an optimal medical education program in surgery Somewhat surprisingly, there has been consensus among practicing surgeons, internists, and even psychiatrists about the knowledge and skills in surgery needed by all physicians The information from this research has become the basis for this textbook The research process also identified technical skills, such as suturing skin, that should be mastered by all physicians and that are best taught by surgeons FIFTH EDITION ENHANCEMENTS The fifth edition of this textbook has continued the approach that has resulted in its use by many medical students in the United States, in Canada, and throughout the world: This edition has been extensively revised to provide the most current and up-to-date information on general surgery Additionally, the entire interior has been refreshed and is now full-color for an even more enjoyable reading experience Our authors are surgeons devoted to teaching medical students and understand the appropriate depth of knowledge for a 3rd-year student to master We not attempt to provide an encyclopedia of surgery We include only information that 3rd- and 4th-year students need to know—and explain it well We intentionally limit the length of each section, so that it can reasonably be read during the clerkship Through problem solving, clinical cases, and sample exam questions, we provide numerous opportunities to practice and test new knowledge and skills, as well as features to aid in review and retention We believe that this approach best prepares students to score high on the National Board of Medical Examiners surgery shelf exam and also prepares them for residency training PEDAGOGICAL FEATURES • • • • • Learning objectives Full-color art program New and updated tables, algorithms, and charts New Appendix including 40 four-color burn figures Sample questions, answers, and rationales for every chapter MORE TOOLS ONLINE • • • • • Bonus chapters Question bank Patient management problems and oral exam questions Glossary Fully searchable e-book v Lawrence_FM.indd v 7/21/2012 6:20:14 PM vi PREFACE • Chapter outlines • Image bank COMPANION TEXTBOOK A companion textbook on the surgical specialties, Essentials of Surgical Specialties, is based on an approach similar to that of Essentials of General Surgery and trains you in specialty and subspecialty fields of surgery This text is separate from Essentials of General Surgery because some medical schools teach the specialties in the 3rd year and others teach them in the 4th year Students who complete both the general surgery Lawrence_FM.indd vi and specialty programs and practice oral and multiple-choice questions will acquire the essential surgical knowledge and problem-solving skills that all physicians need SUCCESS! You are entering the most exciting and dynamic phase of your professional life This educational package is designed to help you achieve your goal of becoming an adept clinician and developing lifelong learning skills It will also help you get into the residency of your choice Best wishes for success in your endeavor 7/21/2012 6:20:14 PM Acknowledgments Many members of the Association for Surgical Education (ASE) provided advice and expertise in starting the first edition of this project nearly 25 years ago Since that time, ASE members have volunteered to assist in writing chapters and editing the textbook At its annual meetings, the ASE provides an excellent forum to discuss and test ideas about the content of the surgical curriculum and methods to teach and evaluate what has been learned We would like to thank our student editors, Tamera Beam and Jason Rogers, who reviewed many of the chapters and provided valuable student perspective on the material presented We would like to extend our thanks to Cathy Council, our editor in Salt Lake City, who coordinated all components of this project I also would like to thank our editors at Lippincott Williams & Wilkins, Susan Rhyner, Jennifer Verbiar, and Angela Collins vii Lawrence_FM.indd vii 7/21/2012 6:20:14 PM Lawrence_FM.indd viii 7/21/2012 6:20:15 PM 259 CHAPTER 13 / STOMACH AND DUODENUM TABLE 13-2 Relative Incidence of Recurrence and Operative Mortality Rate Expressed as Percentages Recurrence Rate (%) Operative Mortality Rate (%) Early Late Afferent Loop Syndrome Dumping Blind Loop Syndrome Alkaline Reflux Gastritis Metabolic Sequelae Vagotomy/pyloroplasty 5–10 1–2 2+ 2+ 0 1+ 1+ Vagotomy/antrectomy Billroth I 1–2 1–4 2+ 2+ 0 1+ 1+ Vagotomy/antrectomy Billroth II 1–3 1–4 3+ 3+ 2+ 2+ 2+ 2+ Selective vagotomy 5–10 1–2 2+ 2+ 0 1+ 0 0 0 3+ 2+ 0 2+ Proximal gastric vagotomy Total gastrectomy 10–15 2–5 These numbers are averages taken from the larger series published in the literature The relative incidences of the postgastrectomy syndromes are expressed on a scale of to 4+, with indicating relative absence of symptoms and 4+ indicating frequent profound symptoms MALIGNANT DUODENAL DISEASE Zollinger-Ellison Syndrome Although very rare, Zollinger-Ellison syndrome is perhaps the most well-known endocrine tumor disorder It is the direct result of a gastrin-producing neoplasm (gastrinoma) The resultant hypergastrinemia causes near maximal stimulation of the parietal cell mass HCl is constantly secreted, leading to the well-described clinical manifestations of the syndrome Over two-thirds of these tumors are located in the gastrinoma triangle, an anatomic triangle whose apices include the junction of the cystic duct with the common bile duct, the junction of the second and third portion of the duodenum, and the neck of the pancreas Gastrinomas can occur sporadically or as part of an inherited familial disorder A strong association exists with the multiple endocrine neoplasia type (MEN-1) syndrome This disorder is characterized by the clinical constellation of pituitary adenomas, hyperparathyroidism, and pancreatic islet cell tumors (of which gastrinomas are the most common) Approximately 60% of all gastrinomas are malignant Unfortunately, about half of the patients with the malignant variant of the disease die within years of diagnosis Because of its slow growth pattern, however, long-term survival up to 15 years is seen in some patients Clinical Presentation and Evaluation A high degree of suspicion is necessary to identify patients with Zollinger-Ellison syndrome Often, the diagnosis is suggested by unusual clinical presentations One such manifestation is the patient complaining of ulcer-like symptoms with concomitant chronic or severe diarrhea Additionally, patients may present with extremely virulent ulcer diathesis In such cases, they will have multiple duodenal ulcers or ulceration in atypical locations (jejunum or ileum) Finally, patients may report a personal or family history of refractory PUD or endocrine disease Evaluation begins with a thorough history and physical examination focused on establishing the presence of any of the above-mentioned associations In particular, a personal or family history of MEN-1 diseases is sought Diagnosis rests on establishing the presence of hypergastrinemia with hypersecretion of acid A fasting serum gastrin level is therefore necessary Care, however, must be taken to make sure that the patient has discontinued any PPIs for at least week prior Lawrence_Chap13.indd 259 to testing PPI use increases gastrin levels The presence of elevated gastrin levels above 1,000 pg/mL is often considered diagnostic Abnormal values