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  1. 1. WILEY W. SOUBA, MD, ScD, FACS, Editorial Chair DOUGLAS W. WILMORE, MD, FACS, Founding Editor September 2008 THE BEST THIS MONTH’S UPDATES SURGICAL 2 Head and Neck tissue from the mass is often useful. The preferred biopsy method is THINKING 3 Neck Mass BARRY J. ROSEMAN, MD, FACS fine needle aspiration. Diagnostic imaging is indicated if the results are likely to affect subsequent therapy. Training in Acute Care Roseman and Budayr, MD, PC Ultrasonography differentiates solid Maryville, TN masses from cystic ones. CT is also Surgery: Trauma, Critical useful in this manner and for Care, and Emergency General ORLO H. CLARK, MD, FACS determining whether a mass is Surgery, Part 1 Professor, Department of Surgery, within or outside a gland or nodal University of California San chain. Other imaging tools include GREGORY J. JURKOVICH, MD, FACS Francisco, Mount Zion Medical arteriography, angiography, Professor, Department of Surgery, Center, San Francisco, CA radiographs, and chest x-rays. University of Washington School of Medicine, Chief of Trauma Services, Harborview Medical Center, Seattle, DOI 10.2310/7800.S02C03 Management of Head and WA Various surgical procedures are Neck Masses reating inflammatory and DOI 10.2310/7800.2008.NCsep he practice of trauma care in required for most masses of the head and neck; inflammatory and T infectious disorders—cervical T North America is in evolution, and the force and rate of this change infectious disorders are treated medically. adenitis (e.g., tonsillitis), subcutaneous abscesses, various chronic infections, or chronic inflammatory disorders are unsettling to many surgeons and valuating any head or neck mass (e.g., sarcoidosis)—is primarily surgical trainees. The training of trauma and emergency surgery is E begins with a careful history. The physician should check for duration medical rather than surgical. Of the possible congenital cystic deeply rooted in all branches of and growth rate of the mass, lesions, thyroglossal duct cysts surgery but perhaps is most closely evidence of infection or inflamma- account for about 70% and are allied with general surgery. The tion, history of trauma, any factors generally surgically removed. contemporary practice of trauma suggestive of cancer, asymmetry and Branchial cleft cysts are treated by care at major trauma centers can be skin changes, and origin of the mass, surgical removal of the cyst and the traced to the city-county hospitals in along with its movement, depth, and sinus tract. Cystic hygromas may be the 1960s and to the research and a tenderness. A detailed examination continued on page 4 new understanding of resuscitation of the cervical lymph nodes, skin, strategies that arose from the thyroid gland, major salivary glands, Vietnam War.1 During the ensuing two decades, trauma surgery became oral cavity and oropharynx, larynx In This Issue and hypopharynx, and the nasal The Best Surgical Thinking cavity and nasopharynx should Training in Acute Care Surgery: Part 2 of this column, which publishes occur. Trauma, Critical Care, and Emergency in the October 2008 update of What’s General Surgery, Part 1 1 New in ACS Surgery, will discuss the response to these social pressures by the 2 Head and Neck surgical community and the future Neck Mass Diagnosis 3 Neck Mass 1 training paradigms for trauma, critical Through Biopsy and Imaging 5 Gastrointestinal Tract and care, and emergency general surgery. Abdomen nitial diagnostic impressions continued on page 2 I determine the next steps. Sampling 29 Intestinal Anastomosis 4
  2. 2. 2 What’s New in ACS Surgery • September 2008 THE BEST SURGICAL THINKING continued from page 1 Owned and published by an attractive career based largely on BC Decker Inc centers,3 with 84% of the popula- the mentorship of general surgeons tion within 1 hour of a level I or II EDITORIAL CHAIR: Wiley W. Souba, MD, SCD, FACS, Columbus, OH in urban city-county hospitals such trauma center.4 This remarkable FOUNDING EDITOR: as Chicago (Freeark), Dallas, adaptation of regionalized medical Douglas W. Wilmore, MD, FACS, Boston (Shires), and San Francisco (Blais- care is nearly unique to trauma and EDITORIAL BOARD: dell) and was rapidly spread by the has clear evidence of a survival Mitchell P. Fink, md, facs, Pittsburgh Gregory devotees of the charismatic leaders benefit.5 J. Jurkovich, md, facs, Seattle Larry R. Kaiser, md, facs, Houston William H. Pearce, md, facs, of those surgical departments. They But with this success came Chicago John H. Pemberton, md, facs, epitomized the master technician changes in surgical practice. In Rochester, MN Nathaniel J. Soper, md, facs, Chicago who developed an academically community and university hospitals, COUNCIL OF FOUNDING EDITORS: productive career based on the the trauma surgeons were discour- Murray F. Brennan, md, facs, New York physiology of the injured patient. aged, or even banned, from develop- Laurence Y. Cheung, md, facs, Kansas City ing any elective general surgical Alden H. Harken, md, facs, San Francisco These trauma surgeons (although James W. Holcroft, md, facs, Sacramento they did not call themselves that) practice. Advances in diagnostic Jonathan L. Meakins, md, dsc, facs, Oxford operated confidently and effectively imaging and clinical research PUBLISHER: in all body cavities and perhaps activities led to the recognition that President, Brian C. Decker not all cases of blood in the abdo- Vice President, Sales, Rochelle J. Decker were the last of the “master sur- Vice President and Publisher, Liz Pope geons” that once were the hallmark men or chest required an operation. Managing Editor, Susan Cooper of general surgery. Operating Injury prevention strategies began to Director, Journal Sales, Anna King Manager, Customer Care and Distribution, Marie primarily in large-volume public, take hold, decreasing the incidence Moore city-county hospitals, these surgeons of injury from automobiles, falls, Rights and Permissions, Ryan Decker Director, Digital Publishing, David Love were also typically referred the most and burns; even the injury incidence Electronic Media Systems Analyst, Jeff Ferguson challenging surgical problems, not of penetrating trauma violence fell Senior Web/IT Developer, Faisal Shah only in their own institution but also in all but the most densely popu- ACS Surgery: Principles & Practice (bound from around the city or region, lated urban areas. Trauma surgery volume: ISBN 978-1-55009-399-5; CD-ROM: ISBN 978-1-55009-421-3; quarterly CD ROM: particularly if there was a financial became synonymous with nonopera- ISSN 1538-3210; online: ISSN 1547-1616) is disincentive to caring for the patient tive care and, with that, a decline in owned and published by BC Decker Inc, 50 King interest and enthusiasm for this as a St. E., 2nd Floor, PO Box 620, LCD1, Hamilton, at a private hospital. Consequently, ON L8N 3K7, Canada, Web site: http://www. the city-county or “safety net” surgical career.6 The extra training © 2008 BC Decker Inc. All rights hospital trauma surgeons developed for added qualifications in surgical reserved. No part of this issue may be reproduced by any mechanical, photographic, or electronic an active elective surgical practice critical care became almost a process or in the form of a phonographic while providing trauma coverage.2 requirement for most trauma recording, nor may it be stored in a retrieval system, transmitted, or otherwise copied for Many forces changed that programs and many hospitals, but public or private use without written permission scenario. The academic success of the accrediting agency demanded of the publisher. trauma surgeons fostered their that this training be largely devoid Annual subscription rates in Canada and the incorporation into university of operative experience. The USA: Quarterly CD-ROM: $209 (individual), $709 (institutional); Online: $189 (individual). hospitals and the economic viability majority of patients cared for by Institutional Web site license pricing available on of civilian blunt trauma care, trauma surgeons have never had an request. Please e-mail abdominal or thoracic operation, Separate shipping and handling apply. All prices particularly in no-fault automobile subject to change without notice and quoted in but most have had an operation by US dollars. insurance states, leading to an another surgical specialist, notably POSTMASTER: Send address changes to BC expansion of trauma programs into Decker Inc, PO Box 758, Lewiston, NY 14092- an orthopedist or neurosurgeon. 0785. private community hospitals. The Residents began to see trauma American College of Surgeons FOR ASSISTANCE WITH YOUR SUBSCRIPTION surgeons as resuscitation doctors contributed to the widespread Please address all inquiries to Fulfillment Department, who surrender the actual operating adoption of trauma programs by the BC Decker Inc, P.O. Box 758, Lewiston, NY 14092- to others. Remuneration for this 0785, or call us at 905-522-7017 or 800-568-7281, or remarkably successful and innova- effort is significantly less than that fax us at 905-522-7839 or 888-311-4987, or email us tive activities of the Committee on received by the operating surgeons, at For change of address, please provide both your new and your old addresses; Trauma, including the hospital particularly considering the time be sure to notify us at least six weeks before you verification program, the Advanced involved.7 Added to this are the expect to move to avoid interruptions in your service. Trauma Life Support course, a largely unrewarding jobs of interdis- YOUR FEEDBACK IS WELCOME national trauma databank, and ciplinary coordination, communica- • E-mail: • Write: BC Decker Inc work with the federal government tion, and discharge planning. This is P.O. Box 620, LCD1 on encouraging inclusive trauma a far cry from the “golden age of Hamilton, ON L8N 3K7 systems in each state. There are Canada trauma surgery,” when trauma currently over 1,100 trauma centers surgeons were considered “master in the United States (of approxi- surgeons” who operated on the mately 6,000 hospitals), including 190 level I centers and 260+ level II continued on page 3
  3. 3. What’s New in ACS Surgery 3 THE BEST SURGICAL THINKING This Month’s CME continued from page 2 Chapters neck, chest, abdomen, and any Added to these challenges is the ACS Surgery offers CME in injured vessel, and nonoperative evolution (or perhaps revolution) in convenient online format. As management was unusual.8 surgical training. The halstedian many as 60 AMA PRA Category Yet now the pendulum appears to pyramidal surgical residency is 1 credits can be earned at be swinging back once again. largely gone. The mandatory 80- any time during the year. The Increasingly, trauma centers and hour work week is entrenched, with following chapters are available trauma surgeons are once again not discussion centered now on reducing for CME credit this month: simply providing trauma care but this time even further. But perhaps the most significant influence on 2 Head and Neck much more broad-based emergency 3 Neck Mass surgical care of all disciplines. In surgical training has been the change large part, this has been the result of in the mores and values of current 5 Gastrointestinal Tract and Abdomen a lack of interest or incentive for trainees and the complexities and 29 Intestinal Anastomosis sophistication of care that continue nearly all surgeons to provide “on- to progress at a dizzying rate and call” or emergency room coverage. demand an emphasis on specialized Declining reimbursement, fear of practices and hence specialized 5. MacKenzie EJ, Rivara FP, malpractice litigation, disruptive training. The sheer depth and Jurkovich GJ, et al. A national lifestyle, and conflict with elective breadth of cognitive and technical evaluation of the effect of practices have all contributed to the knowledge in any one field of trauma-center care on mortal- problem. Perhaps most contributive, medicine are making it difficult to ity. N Engl J Med 2006;354: however, has been the continued have expertise in any broad arena. 366–78. and unabated focus on specialty The era of generalists seems to be 6. Richardson J, Miller F. Will training. The exodus of general gone or at least largely abandoned future surgeons be interested in surgery trainees into surgical by most surgical trainees and their trauma care? Results of a subspecialties has created a void of career plans. Recent analyses show resident survey. J Trauma surgeons with the broad-based that 70 to 80% of graduates of 1992;32:229–35. training and experience who are general surgery training programs 7. Esposito TJ, et al. Perception of capable of providing the expertise are opting for further specialty training and a practice that empha- differences between trauma needed to continue the type of sizes a more narrow focus.11 Like care and other surgical emer- practice once common in city- many social pendulums, this trend gencies: results from a national county hospitals and in many rural might be reversed, but current survey of surgeons. J Trauma communities. This is a reflection of health care expectations and patient 1994;37:996–1002. both a demand in surgical staff that demands are not supportive of the 8. Moore EE, Maier RV, Hoyt has not yet been addressed and a model of generalist care by physi- DB, et al. Acute care surgery: tendency of hospitals and surgical cians. Further adding to specializa- eraritjaritjaka. J Am Coll Surg departments to acquiesce to this tion is evidence of better outcomes 2006;202:698–701. demand to attract and retain these with the concentration of complex lucrative and desirable elective 9. Malangoni M. Acute care problems and procedures and surgery: the general surgeon’s clinical practices. These individuals remuneration strategies that favor have completed the same residencies perspective. Surgery 2007;141: specialized procedure care.12 324–6. as others who see this as their responsibility and often have been 10. Committee on the Future of References Emergency Care in the United certified in surgery by the American Board of Surgery.9 Hence, we are 1. Blaisdell FW. Development of States Health System, Board on the city-county (public) Health Care Services. The faced with a crisis in access to hospital. Arch Surg future of emergency care. emergency surgical care in this 1994;129:760–4. Washington (DC): Institute of country, a crisis addressed by the 2. Moore EE. Acute care surgery: Medicine of the National National Academy of Sciences in a the safety-net hospital model. three-volume analysis entitled The Academies; 2007. Surgery 2007; 141:297-8. Future of Emergency Care.10 This 11. Fischer JE. The impending 3. MacKenzie E, Hoyt DB, Sacra “white paper” includes sections on JC, et al. National inventory of disappearance of the general hospital-based emergency care, hospital trauma centers. JAMA surgeon. JAMA 2007;298: emergency medical services, and 2003;289: 1515–22. 2191–3. pediatric emergency care. This 4. Branas C, MacKenzie EJ, 12. Aucar J, Hicks L. Economic influential advisory group has Williams JC, et al. Access to modeling comparing trauma deemed hospital-based emergency trauma centers in the United and general surgery reimburse- care to be at a breaking point, with States. JAMA 2005;293: ment. Am J Surg 2005;190: no clear resolution in sight. 2626–33. 932–40.
  4. 4. 4 What’s New in ACS Surgery • September 2008 THIS MONTH’S UPDATES continued from page 1 treated expectantly, but complete Surgery, Nuffield Department of development of reliable, disposable surgical excision can be indicated. Surgery, John Radcliffe Hospital, instruments over the past 30 years Hemangiomas can resolve spontane- Headington, Oxford, UK has changed the surgical practice ously, and the treatment of choice is dramatically. With modern devices, generally observation. SHAZAD ASHRAF, MD technical failures are rare, staple Of the benign neoplasms, salivary Bobby Moore Fellow (CRUK), lines are of more consistent quality, gland neoplasms should have an University of Oxford and Cancer and anastomoses in difficult open biopsy, with preparation for and Immunogenetics Lab, locations are easier to construct. removal if indicated. For benign Weatherall Institute of Molecular thyroid nodules and nodular goiters, Medicine, John Radcliffe Hospital, FNA can ascertain malignancy, Headington, Oxford, UK Factors Contributing to indicating surgery. Managing soft DOI 10.2310/7800.S05C29 Failure of Anastomoses tissue tumors (lipomas, sebaceous nastomosis failure can be cysts) usually involves simple surgical excision. Chemodectomas Intestinal anastomoses, employing either sutures or staples, can have A attributed to an increased incidence of low resections (5 cm (carotid body tumors), neurogenic high success rates as long as good or less from the anal verge) and tumors (neurofibromas, neurilemo- apposition of the edges, without patients who present in the emer- mas), and laryngeal tumors should tension, and an optimal blood gency setting with already compro- generally be removed. supply are present. mised hydration status, sepsis, or Primary malignant neoplasms may he creation of a join between two obstruction. Other factors that can be present. Lymphoma can be treated with radiation therapy, chemotherapy, or both. Thyroid T bowel ends (anastomosis) is an operative procedure of central influence the failure rate include anemia, diabetes mellitus, previous cancer (not benign thyroid disease) irradiation or chemotherapy, importance in a general surgeon’s is generally managed by total or malnutrition with hypoalbumin- practice. To minimize the risk of near-total thyroidectomy. Localized emia, and vitamin deficiencies. potential complications (peritonitis, tumors of the aerodigestive tract can bloodstream infection, further often be cured with surgery alone or surgery, creation of a defunctioning Common Procedures with chemoradiotherapy. Malignant sarcomas are uncommon, but are stoma, and death), it is imperative to Requiring Anastomosis adhere to several well-established here are essential preliminary treated with wide surgical resection. Skin cancers generally require principles. Patients can also influence anastomosis success, as T steps before a bowel anastomosis. First, the patient must be positioned excision with adequate margins. Metastatic tumors often require anastomotic healing mimics that of on the operating table in a manner neck dissection, which can be wound healing elsewhere in the that is appropriate for the planned elective or therapeutic, and compre- body. Thus, success (or failure) can operation. Second, the incision must hensive or selective. Neck dissection be influenced by age (and its be made in such a way as to allow is often the appropriate treatment presence of comorbid conditions, adequate exposure of the operating for metastatic adenocarcinomas. malnutrition, and vitamin field. Finally, the segment of bowel Metastatic melanomas should be deficiency) and poor blood flow. to be removed must be isolated with excised (extent dependent on an adequate resection margin. Three thickness). Managing patients with generic operations involve the small an unknown primary malignancy is Technical Options for and large bowel (and anastomoses). challenging. However, when cervical Fashioning Anastomoses A single-layer sutured extramucosal lymph nodes contain metastatic utures and staples are the most side-to-side enteroenterostomy may squamous cell carcinoma, the primary tumor is in the head and S common materials used. The newer generation of sutures includes be performed when no resection is done, as a bypass procedure; after a neck about 90% of the time. small bowel resection; when there is monofilament and coated braided sutures, and both represent a substantial advance beyond silk and 5 Gastrointestinal Tract and Abdomen other multifilament materials. Presently, there is no advantage of Coming in October continuous versus interrupted 1 Basic Surgical and Perioperative 29 Intestinal Anastomosis sutures, but double-layered anasto- Considerations moses are shown to yield a lower 8 Preparation of the Operating Room NEIL J. MORTENSEN, MD rate of postoperative leakage. 7 Trauma and Thermal Injury Professor of Colorectal Surgery, Surgical stapling devices were 9 Injuries to the Pancreas and Chair, General and Vascular first introduced 1908, but the Duodenum
  5. 5. What’s New in ACS Surgery 5 a discrepancy in the diameter of the segments parallel. In a double-layer coloanal anastomosis is actually a two ends to be anastomosed; or sutured end-to-side enterocolos- resection of the distal sigmoid colon when the anatomy is such that the tomy, the end of the ileum is joined and the rectum, now a more most tension-free position for the to the side of the transverse colon. common procedure after the anastomosis is with the two bowel The double-stapled end-to-end development of circular staplers.