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Benign Tumors of the Lung

I Overview 1. These tumors account for less than 1% of all resected lung tumors. 2. They may be derived from epithelial, mesodermal, or endodermal cell lines. 3. Hamartomas account for greater than 75% of benign tumors of the lung. 4. Endobronchial tumors present with signs and symptoms related to airway obstruction (most often pneumonia) and bleeding. 5. Peripheral airway and parenchymal tumors usually present as…

The Diabetic Patient

I Definitions A Diabetes 1. Diagnosis of diabetes is made by a random glucose level ≥200 mg/dL with concurrent symptoms of hyperglycemia (blurry vision, thirst, polyuria, weight loss) or any two of the following tests performed on the same day or any one of the following tests performed on different occasions: a. Fasting blood glucose level (after 8-hour fasting) ≥126 mg/dL b. Oral glucose tolerance test…

Dialysis Access

I Introduction 1. In the first quarter of 2014, 671,851 patients were treated for end-stage renal disease (ESRD). 2. In 2013, the number of people on the kidney transplant list was 5 times greater than the number of people who received a transplant. 3. 2006 National Kidney Disease Outcomes Quality Initiative (K/DOQI) a. An initiative that set a goal of arteriovenous (AV) fistula target rate greater…

Mesenteric Ischemia

Mesenteric ischemia is defined by insufficient perfusion to meet the metabolic needs of the end organs (small intestine and colon) supplied by the mesenteric vasculature. Successful treatment requires a high index of suspicion, early recognition of both acute and chronic presentations, and prompt treatment before the onset of irreversible intestinal ischemia and infarction. I Anatomy and Physiology A Vascular Supply Circulation deficits in the gastrointestinal tract…

Carotid Disease

I Background: Stroke 1. Fourth most common cause of death in the United States 2. One million hospital admissions/year 3. Significant neurologic morbidity 4. Risk factors for stroke a. Nonmodifiable (1) Sex (male) (2) Age (>55 years) (3) Race (African American) (4) Family history b. Modifiable (1) Hypertension—preeminent risk factor (2) Smoking (3) Obesity (4) Physical inactivity (5) Diet (6) Diabetes (7) Hypercholesterolemia (8) Alcohol (9)…

Peripheral Vascular Disease

I Definitions 1. Peripheral vascular disease refers to multiple disorders that result from stenotic, occlusive, and aneurysmal diseases of the arteries and veins of the extremities. 2. Peripheral arterial disease (PAD) refers to atherosclerosis involving the aorta, iliac, and lower extremity arteries. II Peripheral Arterial Disease A Epidemiology 1. An estimated 200 million people worldwide live with PAD. 2. In the United States, it is estimated…

Aneurysms

I Epidemiology A General 1. Aneurysm—permanent focal dilation of an artery to at least 1.5 times the normal diameter a. A normal adult male has an aorta that is approximately 2 cm in size (anything >3 cm is considered abnormal). b. Arterial dilation less than 50% increase in diameter = ectasia c. Diffuse enlargement of several arterial segments that are 50% greater than the normal diameter…

Thromboembolic Disease

I Introduction A Epidemiology 1. Deep vein thrombosis (DVT) and pulmonary embolism (PE) are two manifestations of venous thromboembolism (VTE). Despite advances in prevention and treatment of VTE, PE remains the most common preventable cause of hospital death, responsible for approximately 150,000–200,000 deaths per year in the United States. a. Prevention begins before surgery by considering the surgical procedure, its risks, and the patient’s comorbidities. b.…

Neuroendocrine Tumors

I Neuroendocrine Tumors A Demographics 1. Incidence is rising, likely because of increased detection; the majority are found in the gastrointestinal (GI) tract and pancreas. 2. Peak incidence is in sixth to seventh decade of life. B Classification (Multiple Systems and Evolving Terminology) 1. Histologic: well differentiated (previously known as carcinoid tumors) versus poorly differentiated (G3) (previously known as neuroendocrine carcinomas) 2. Well-differentiated neuroendocrine tumors (NETs)…

Adrenal Gland

I Embryology and Anatomy A General 1. Paired, retroperitoneal glands superior and medial to kidney 2. Weight 4–5 g; yellow in color because of high lipid content B Arterial Supply 1. Superior adrenal artery—branch of inferior phrenic artery 2. Middle adrenal artery—branch of aorta 3. Inferior adrenal artery—branch of renal artery C Venous Drainage 1. Single major adrenal vein, 5%–10% of patients with accessory venous drainage…

Parathyroid

I Parathyroid Embryology and Anatomy A Embryology 1. Superior parathyroid glands—derived from fourth branchial pouch (same as thyroid) a. Most common location: posterior aspect of upper and middle thyroid lobes at level of cricoid cartilage (80%) b. Alternative locations: tracheoesophageal groove, paraesophageal or retroesophageal, middle or posterior mediastinum, intrathyroidal, carotid sheath 2. Inferior parathyroid glands—derived from third branchial pouch (same as thymus) a. Most common location:…

Thyroid

I Embryology A Thyroid Development 1. At 3 weeks’ gestation, this is the first endocrine organ to develop. 2. It originates as an outgrowth of the pharyngeal endoderm at the base of the tongue (foramen cecum). 3. Epithelialized endoderm migrates down the middle of the neck anterior to the hyoid bone and larynx. 4. The thyroglossal duct is the tubular tract that forms along the migratory…

Pancreas Transplantation

I General Considerations A History and Epidemiology 1. First pancreas transplant was performed in 1966 at the University of Minnesota. 2. More than 25,000 US and 10,000 worldwide pancreas transplants have taken place since the original operation. 3. Type 2 diabetes mellitus (DM) is associated with an increased risk of blindness (25×), kidney disease (17×), gangrene (20×), heart disease (2×), and stroke (2×) compared with patients…

Liver Transplantation

I General Considerations A History 1. 1967—Starzl performed the first successful liver transplant. 2. 1983—Venovenous bypass was introduced for use during anhepatic phase; cyclosporine was approved for transplant immunosuppression. 3. 1984—Broelsch and associates introduced the reduced-size liver transplantation. 4. 1989—first successful living related transplant 5. 1998—first successful living donor transplant to adult recipient 6. Approximately 7000 liver transplants are currently performed yearly in the United States.…

Renal Transplantation

I General Considerations A History and Epidemiology 1. First kidney transplant performed between identical twins by Joseph Murray in 1954 2. Early transplantation halted by lack of adequate immunosuppression a. Initially attempted total body irradiation and mercaptopurine (6-MP), which had significant toxicity b. Steroids and azathioprine initiated in 1960s opened the door to further efforts due to more acceptable maintenance regimens. B Immunology of Renal Transplantation…

Benign Liver Disease, Cirrhosis, and Portal Hypertension

Cirrhosis is the end-stage of chronic liver disease characterized by degeneration of the normal hepatic architecture and replacement with fibrosis. Clinically these patients present with loss of hepatocellular function, including coagulopathy, encephalopathy, and jaundice. The hepatocellular fibrosis causes increased resistance to transhepatic flow, leading to portal hypertension, ascites, varices, and a number of physiologic syndromes. I Pathophysiology 1. Acute and chronic liver injury leads to generation…

Malignant Gallbladder and Biliary Tree

I Gallbladder Cancer A General Considerations 1. In the United States, 1.2 cases per 100,000 people annually; worldwide, sixth most common gastrointestinal tumor and represents more than 80% of biliary tumors 2. Found in 0.1%–0.5% of all cholecystectomy specimens 3. Associated with gallstones in more than 90% of cases 4. Increased incidence in certain ethnic groups—Alaskan, Native Americans 5. Other factors—porcelain gallbladder, cholecystenteric fistulas, anomalous pancreaticobiliary…

Benign Gallbladder and Biliary Tree

I Anatomy A Gallbladder 1. Pear-shaped sac lying in gallbladder fossa on inferior surface of liver with 30–50-mL capacity, greater than 300-mL capacity when obstructed 2. Divided into four anatomic portions: fundus, corpus, infundibulum, and neck 3. Demarcates anatomic division between left and right hepatic lobes (Cantlie line runs between gallbladder and inferior vena cava [IVC] and divides liver in two lobes) 4. Supplied by the…

Malignant Skin Lesions

I Basal Cell Carcinoma A General 1. Most common skin malignancy 2. Originates from epidermis: basal epithelial cells and hair follicles 3. Clinical presentation a. Waxy or cream-colored b. Classically described with pearly, rolled borders c. Central ulceration common; slow, indolent growth d. 70% occur on face e. Local destruction; rarely metastatic disease 4. Types a. Nodular—classic type b. Superficial—slow growing, scaly, pink plaque c. Sclerosing/morpheaform—rarest…