Schwarz / Reutter General and Visceral Surgery Review

1. Auflage 2011
ISBN: 978-3-13-257910-1
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 448 Seiten, ePub

Reihe: Thieme

-- Kevin Helling, MD, University of Iowa Hospitals and Clinics

Covering all the main topics and latest operative techniques, is a compact, highly structured review book designed to maximize your study time for the medical residency board exams. It pinpoints only the information you need to master the exam—enhanced by highlighted key words, summary tables, outline lists, and sidebar notes that make understanding and retention fast and easy.

Features:

• Succinctly covers the major areas in general and visceral surgery—anatomy, etiology,disease patterns, symptoms, diagnosis, and therapy—with a focus on 'what you need to know' for the exam
• Provides nearly 200 instructive surgical descriptions and clear operative illustrations
• Includes state-of-the-art minimally invasive and fast-track surgical techniques
• Breaks topics into concise, digestible chunks of information that facilitate quick memorization
• Offers targeted information that is comprehensive but not excessive—does not overload you with extraneous material

Optimally structured, clearly presented, and packed with helpful study aids, this book is the go-to companion for all students and residents specializing in general and visceral surgery and preparing for the medical residency board exams. It is also useful as a general study aid and a distillation of key points in conjunction with larger, more detailed texts.

Zielgruppe

Ärzte

Autoren/Hrsg.

Schwarz, Nicolas T.

Reutter, Karl-Heinz

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Chirurgie

Inhaltsverzeichnis

1 Perioperative Medicine
Preoperative Phase
Intraoperative Phase
Postoperative Period
Fast-Track Surgery
2 Thyroid
Anatomy
Physiology
General Epidemiology
General Diagnostic Approach
General Treatment Approach
Diseases of the Thyroid
3 Parathyroid
Anatomy
Physiology
Primary Hyperparathyroidism
Secondary Hyperparathyroidism
Tertiary Hyperparathyroidism
Parathyroid Carcinoma
Hypoparathyroidism
4 Thorax (Pleura, Lung)
Anatomy
Pleural Effusion
Pleural Empyema
Chest Trauma: Blunt Chest Injuries
Chest Trauma: Penetrating Chest Injuries
5 Mediastinum
Anatomy
Mediastinoscopy
Subcutaneous Emphysema
Mediastinal Emphysema
Mediastinitis
6 Diaphragm
Anatomy
Diaphragmatic Hernias
Rare Disorders of the Diaphragm
7 Hernias
Inguinal Hernias
Femoral Hernias
Incisional Hernias
Umbilical Hernia
Epigastric Hernia
Internal Hernias
8 Esophagus
Anatomy
Histology
Physiology
Functional Disorders
Esophageal Diverticulum
Gastroesophageal Reflux Disease
Esophageal Carcinoma
Injuries of the Esophagus
9 Stomach and Duodenum
Anatomy
Ulcer
Bleeding from the Stomach and Duodenum
Gastric Carcinoma
MALT Lymphoma
10 Small Intestine
Anatomy
Crohn Disease
Meckel Diverticulum
Jejunal Diverticulum
11 Vermiform Appendix
Anatomy
Acute Appendicitis
Rare Diseases of the Appendix
12 Colon
Anatomy
Anastomosis Techniques
Minimally Invasive Colon Surgery
Diverticulosis and Diverticulitis
Ulcerative Colitis
Polyps of the Colon
Colon Cancer
13 Rectum
Anatomy
Rectal Cancer
Pelvic Floor Insufficiency
14 Anus
Anatomy
Hemorrhoids
Perianal Vein Thrombosis
Anal Fissure
Abscesses and Anal Fistulas
Fecal Incontinence
Anal Carcinoma
15 Intestinal Obstruction
16 Spleen
Anatomy
Physiology
Hypersplenism Syndrome
17 Liver
Anatomy
Benign Liver Tumors
Malignant Liver Tumors
Hydatid Disease of the Liver (Echinococcosis)
Portal Hypertension
Liver Trauma
18 Gallbladder and Biliary Tract
Anatomy
Cholecystolithiasis
Acute Cholecystitis
Gallbladder Carcinoma
Extrahepatic Bile Duct Carcinoma
19 Pancreas
Anatomy
Physiology
Acute Pancreatitis
Chronic Pancreatitis
Pancreatic Pseudocysts
Carcinoma of the Pancreas
Endocrine Pancreatic Tumors
Pancreatic Trauma
20 Transplantation
21 Peritonitis
22 Neuroendocrine Tumors and Gastrointestinal Stromal Tumors
Neuroendocrine Tumors
Gastrointestinal Stromal Tumors
23 Soft-Tissue Tumors
24 Vascular Surgery
Arteries
Veins
25 Emergency and Trauma Surgery
Polytrauma
Head Injury
Fractures
Dislocations
Soft-Tissue Injuries
Bone Infection
Nerve Injury
Tendon Rupture

Leseproben

2     Thyroid

B. Thiel

Anatomy

Ontogenic Development

The thyroid develops in the embryo from the floor of the pharynx (foregut) from day 24, initially as the thyroglossal duct. The two lobes of the thyroid arise from this. From week 7 they lie in front of the trachea. The duct often persists as a pyramidal lobe superior to the thyroid gland.

Histology

Follicles consisting of epithelial cells are the central feature. These are arranged in a single layer and produce thyroglobulin, the precursor of the thyroid hormones, in the follicle. The thyroid is surrounded by a capsule of connective tissue (fibrous capsule); connective tissue septa originate from this and divide the organ into individual lobules. Each lobule consists of several follicles. In mammals, the parafollicular C cells are located between the epithelial cells of the follicles and their basement membrane. Around the follicles are reticular fibers and a dense capillary network (blood and lymphatic capillaries).

Fig. 2.1 Arterial and venous supply of the thyroid (from Thieme Atlas of Anatomy, Neck and Internal Organs, © Thieme 2006, Illustration by Karl Wesker).

Arteries (Fig. 2.1)

• Superior thyroid arteries

• Inferior thyroid arteries

• Thyroid ima artery

• Superior thyroid arteries from the external carotid artery

• Inferior thyroid arteries from the thyrocervical trunk (which arises from the subclavian artery)

• Thyroid ima artery: This unpaired artery is found in 10% of the population. It arises from the thyrocervical trunk or aortic arch and approaches the isthmus from below. Within the thyroid there are numerous anastomoses. The thyroid arteries are not end-arteries. There is good collateral circulation from extraglandular arteries, enabling all four thyroid arteries to be ligated without interfering with the nutrition of the gland.

Veins (Fig. 2.1)

• Unpaired thyroid plexus

• Middle thyroid vein

• Superior thyroid vein

• Unpaired thyroid plexus drains into the inferior thyroid vein and brachiocephalic vein (downward)

• Middle thyroid vein (the Kocher vein) drains into the internal jugular vein (laterally)

• Superior thyroid vein drains into the internal jugular vein (upward)

Nerves

• Superior laryngeal nerve

• Internal branch

• Recurrent laryngeal nerve

• Warning: recurrent laryngeal nerve and superior laryngeal nerve are at risk

• Superior laryngeal nerve from the inferior ganglion of the vagus nerve. The external branch innervates the cricothyroid muscle. It is at risk during ligature of vessels at the upper pole.

Fig. 2.2 The external branch of the superior laryngeal nerve runs close to the thyroid in ca. 15% of people and can be spared by ligating the vessels at the upper pole close to the capsule (from Frilling and Weber 2007, see p. 413)
1: Internal branch of superior laryngeal nerve
2: External branch of superior laryngeal nerve
3: Superior thyroid artery

• The internal branch contains mainly sensory fibers and supplies the mucosa of the epiglottis and larynx to below the glottis.

• The recurrent laryngeal nerve runs in the groove between the esophagus and trachea and crosses the inferior thyroid artery variably. It can run in front of, behind, and partially in front of and partially behind the branches of the thyroid artery. It is particularly at risk during ligature of the inferior thyroid artery. The motor branches of the recurrent nerve innervate the laryngeal muscles with the exception of the cricothyroid muscle. Figure 2.2 shows the course of the nerves.

Surgically Relevant Groups of Lymph Nodes

• Four compartments are defined when the locoregional groups of lymph nodes and the anatomical boundaries are classified (Table 2.1). In the majority of differentiated thyroid carcinomas, lymph node metastases can be expected mainly in the central cervical (44%) and ipsilateral lateral cervical (34%) compartments (Fig. 2.3).

Table 2.1 Locoregional lymph nodes (LNs) and lymphatic drainage pathways

Three locoregional lymph node stations

Four surgically relevant compartments

Central cervical LN station

Central cervical compartment right and left (1a and 1b)

Lateral cervical LN station

Ipsilateral lateral cervical compartment (2) Contralateral lateral cervical compartment (3)

Upper mediastinal LN station

Mediastinal infrabrachiocephalic compartment right and left (4a and 4b)

Fig. 2.3 Diagram of the lymph node compartments: central cervical (1a, 1b), lateral cervical (2, 3) and mediastinal (4a, 4b) with the percentages of the incidence of LN metastases (from Frilling and Weber 2007, see p. 413).

Physiology

• Hormones: thyroxine (T4), triiodothyronine (T3), and calcitonin

• Mode of action of T3 and T4: energy metabolism ?

• Mode of action of calcitonin: calcium level ?

• Feedback loop: TRH ? ? TSH ? ? T4 and T3 ? ?TSH ? ? TRH ?

• The hormones produced by the thyroid gland are thyroxine (T4), triiodothyronine (T3), and calcitonin. T3 and T4 are produced by the epithelial cells of the follicles. Thyroglobulin, their precursor, is released into the follicle cavity, where it takes up iodine (iodination) and divides to form the hormones thyroxine and triiodothyronine. The parafollicular C cells produce calcitonin.

• The thyroid hormones thyroxine and triiodothyronine act on nearly all the cells in the body and stimulate energy metabolism. They are necessary for growth and differentiation. Other effects include, for example, vasodilatation, a rise in body temperature, and a rise in blood pressure and pulse rate. Calcitonin reduces the calcium level in the blood and is thus an antagonist of parathyroid hormone (PTH), which regulates the extracellular calcium level.

• To regulate the degree of secretion of thyroid hormones, the body possesses a hormonal feedback control mechanism.

When there is a lack of thyroid hormones, the thyroid hormone level in the blood falls.

The hypothalamus releases more thyroliberin (TRH, thyroid releasing hormone).

TRH in turn causes the pituitary to release more thyrotropin (TSH, thyroid stimulating hormone) into the blood.

The TSH reaches the thyroid via the circulation. There it stimulates production of the thyroid hormones T3 and T4.

Negative feedback: high concentrations of T3 and T4 inhibit secretion of TSH and TRH.

T3 and T4 deficiency increases the secretion of TRH and TSH.

• The aim of this feedback control system is to keep the concentrations of free T3 and T4 constant. Persistent TSH secretion leads to hyperplasia of the thyroid (goiter).

General Epidemiology

• Up to two out of three Germans are affected, women and men equally.

• Studies have shown that in Europe one in three people has a pathologically altered thyroid as a result of iodine deficiency.

• Women and men are affected equally, and over the age of 45 years, one in two persons is affected in Germany.

General Diagnostic Approach

Clinical Examination

• Diagnosis starts with the medical history and physical examination (Fig. 2.4). The size and consistency of the thyroid and its movement on swallowing are palpated.

• In the history, attention is paid to the most varied symptoms, which are described below with the respective thyroid disorders.

Fig. 2.4 Investigation of an incidentally discovered nodule (DD: differential diagnosis).

Laboratory Tests

Baseline Tests

• Thyroid disease can be present despite a euthyroid metabolic state, for example, thyroid carcinoma or a compensated adenoma.

• Basal TSH: normal range = 0.27–4.2 µIU/mL. Regulation of TSH secretion is sensitive and specific, even in borderline hypothyroidism or hyperthyroidism.

• A normal TSH level rules out overt hyperthyroidism and hypothyroidism.

• The most important parameters for monitoring treatment with T4 medication:

Normal TSH with replacement therapy (e.g., in hypothyroidism)

Low TSH with suppression therapy (e.g., in goiter)

Do not suppress...