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Ultrasonographic Diagnosis of Anorectal Disease

Endorectal and endoanal ultrasound (ERUS and EAUS, respectively) examinations are used to diagnose benign and malignant abnormalities of the rectum and anus. ERUS has been used extensively for local staging of rectal cancer and continues to have a significant role in preoperative staging of rectal tumors. Ultrasound plays less of a role in the evaluation of tumors after chemoradiation. One of the main uses of EAUS…

Magnetic Resonance Imaging Staging of Rectal Cancer

The management of rectal cancer has changed dramatically in the last 5 years. Review of national databases has clearly outlined the wide variations in overall survival rates, rates of local recurrence, and rates of permanent colostomies. Championed by many in Western Europe, most notably by Drs. Quirk, Heald, and Brown, the multidisciplinary treatment of rectal cancer has been shown to result in significant improvement in all…

Diagnostic and Therapeutic Colonoscopy

Since its acceptance for clinical use in 1970, colonoscopy has become the mainstay in the prevention, diagnosis, and treatment of colonic pathology. Even with the development of new diagnostic technologies, such as computed tomography (CT) colonography, only colonoscopy allows for direct visualization of the colonic mucosa combined with the potential for tissue biopsy, removal, or destruction. Colonoscopy also is used to diagnose and treat lower gastrointestinal…

Physiology of the Colon and Its Measurement

The human colon serves to absorb water and electrolytes, store intraluminal contents until elimination is socially convenient, and salvage nutrients after bacterial metabolism of carbohydrates that have not been absorbed in the small intestine. These functions are dependent on the colon's ability to control the distal progression of contents; in healthy adults, colonic transit normally requires several hours to almost 3 days for completion. There are…

Operative Anatomy of the Colon, Rectum, and Anus

Knowledge of the developmental anatomy of the digestive tract is the first step in understanding operative anatomy of the colon, rectum, and anus. The surgical approach to removing portions of the digestive tract requires an understanding of the anatomical planes of the abdomen. The digestive tract begins its development around the fourth week of pregnancy as an outpouching of the pharynx and stomach forming the primitive…

Cysts and Tumors of the Spleen

Cysts and tumors of the spleen are uncommonly encountered in clinical practice and continue to present challenges in both surgical work-up and treatment. Perhaps the continuing evolution of surgical traditions associated with splenic maladies can be partly explained by the relative rarity of these conditions. Literature references provide benchmarks to the myriad of supposed functions and attributes of the spleen as our experience and understanding of…

Splenectomy for Conditions Other Than Trauma

Splenectomy for nontraumatic disorders demands careful risk-benefit analysis and surgical planning. Crucial factors considered include the nature of the underlying disease, the severity of symptoms, alternative therapeutic options, the operative risk, and the success rate of splenectomy. During the past decade, the underlying diseases have become better understood; more and effective medical therapies have become available, specifically immunomodulatory/immunosuppressive regimens; laparoscopic techniques have expanded and decreased operative…

Splenic Trauma in Children

Abdominal injury occurs in approximately 10% to 15% of pediatric trauma patients, with the spleen being the most commonly injured intraabdominal organ, accounting for a significant proportion of the management expenses incurred with blunt traumatic injuries. Historically the initial management of splenic injury was emergent splenectomy. However, as the immunologic importance of the spleen became evident with the recognition of postsplenectomy sepsis, spleen-preserving strategies were implemented,…

Management of Splenic Trauma in Adults

The spleen, an important component of the reticuloendothelial system in normal adults, is a highly vascular solid organ that arises as a mass of differentiated mesenchymal tissue during early embryonic development. The normal adult spleen weighs between 75 and 100 g and receives an average blood flow of 300 mL It functions as the primary filter of the reticuloendothelial system by sequestering and removing antigens, bacteria, and senescent…

Minimally Invasive Surgical and Image-Guided Interventional Approaches to the Spleen

The treatment of spleen disorders in modern surgery requires an extensive knowledge of traditional “open” surgical approaches, minimally invasive surgical procedures, and image-guided interventional techniques that can be tailored to the specific disease. The two sections of this chapter will focus on minimally invasive and image-guided interventional approaches to the spleen. Minimally invasive approaches to the spleen were crafted upon the rapid expansion of laparoscopic surgery…

Technique of Splenectomy

Since 1991 when it was first described by Delaitre, the laparoscopic approach has become the standard technique for most cases of elective splenectomy. An increased technical skill among surgeons has extended the application for laparoscopic splenectomy to safely include patients with massive splenomegaly. Some limitations to the laparoscopic approach remain for patients with splenomegaly, splenic trauma, and serious medical conditions. Hematologic diseases, such as idiopathic thrombocytopenic…

Anatomy and Physiology of the Spleen

The spleen has been a source of intrigue and mystery since ancient times, and its anatomy and function have been contemplated by ancient Egyptians and Chinese as far back as 1550 bc . The spleen was variably thought to be associated with emotions, and both ill temper and glee have been thought to arise from the spleen. Across centuries the true significance of the spleen was…

Management of Portal Hypertension

Portal venous hypertension is an entity that is defined by the presence of elevated hydrostatic pressure in the hepatic portal veins greater than 8 mm Hg. In practice it is understood as the constellation of clinical consequences from an abnormally high pressure gradient between hepatic inflow and outflow venous systems. The wide spectrum of clinical manifestations and syndromes, including variceal bleeding, ascites, liver failure, encephalopathy, hepatopulmonary syndrome…

Management of Secondary Hepatic Neoplasms

Secondary hepatic neoplasms refer to a heterogeneous collection of tumors that metastasize to the liver. By definition, these cancers develop from other organ sites but share a common metastatic pathway. Tumors that hematogenously disseminate to the liver include carcinomas (e.g., colorectal, pancreatic, gastric, breast, lung), neuroendocrine cancers, and certain types of retroperitoneal sarcomas and gastrointestinal stromal tumors. Systemic chemotherapy may be associated with improved survival compared…

Management of Primary Malignant Hepatic Neoplasms Other Than Hepatocellular Cancer

Primary hepatic malignancies consist of a diverse spectrum of tumors that arise from an equally diverse population of cells that constitute this complex organ. In addition to hepatocytes, the liver is made of cholangiocytes, neuroendocrine cells, hepatic progenitors, myofibroblastic mesenchymal cells, and vascular endothelial cells. Hepatocellular carcinoma (HCC) represents the vast majority (80% to 90%) of primary liver cancers. All other primary liver neoplasms, including cholangiocarcinoma,…

Hepatocellular Carcinoma

Epidemiology and Etiology Hepatocellular carcinoma (HCC) is the sixth most common malignancy in the world and the fastest growing cause of cancer-related death. This is in part due to endemic viral hepatitis in developing countries and the epidemic of obesity in the Western world. Currently, 84% of patients with HCC live in Asia and Africa, but the incidence of HCC in the United States has been…

Benign Hepatic Neoplasms

The widespread use and progress in modern imaging modalities have led to an increase in the incidental finding of asymptomatic benign hepatic lesions, including cystic and solid tumors. In contrast to most cystic lesions, the latter group is composed of tumors that often harbor true neoplastic characteristics. The most frequent benign solid lesions are hemangioma and focal nodular hyperplasia (FNH), which only rarely require treatment or…

Drug-Induced Liver Injury

Drug-induced liver injury (DILI) is a frequent cause of liver injury. It is the most frequent reason for withdrawal from the market of an approved drug and accounts for one-third to one-half of the cases of acute liver failure in this country. It can mimic both acute and chronic forms of liver disease and often represents an important diagnostic and therapeutic challenge for the treating physician.…

Vascular Diseases of the Liver

The topic vascular diseases of the liver encompasses an array of disparate clinicopathologic entities, with the common thread that they specifically affect the hepatic vasculature. They can be arbitrarily classified into those that involve the hepatic artery and its branches, those that involve the portal vein, and those that involve the hepatic veins. The topics portal hypertension and portal vein thrombosis are addressed separately in Chapter…

Acute Liver Failure and Bioartificial Liver Support

The failing liver represents a syndrome with profound morbidity and mortality. The morbidity of liver failure is secondary to the tremendous decline in metabolic and synthetic functions inherent to the liver. With the decline in metabolic activity, accumulation of toxic substances occurs. The most notable of these toxins is ammonia. Cerebral edema (the most feared complication) is strongly associated with elevated levels of ammonia. In addition…