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Diseases of the Breast

I Anatomy And Physiology A Anatomy Basics 1. Modified sweat glands of ectodermal origin. Develop along the bilateral mammary ridges, where accessory breasts (polymastia) or nipples (polythelia) may be found, if intrauterine reabsorption is incomplete 2. Enveloped by superficial and deep layers of fascia on the anterior chest wall 3. Consist of 15–20 lobules drained by lactiferous ducts that coalesce at the nipple 4. Fibrous septa…

Malignant Pancreas Disease

I Pancreatic Adenocarcinoma A Epidemiology 1. Fourth most common cause of adult cancer mortality in the United States (8th leading cause worldwide) 2. Approximately 50,000 new cases/year nationally with high expected mortality 3. Slight male sex predominance; 1.3:1 male/female ratio 4. Dramatically increases after age 45; peaks in seventh and eighth decades of life 5. Higher incidence in Western and industrialized world 6. Incidence rates are…

Malignant Colorectal and Perianal Disease

I Colorectal Cancer: Epidemiology A Each Year in the United States, 135,000 Cases of Colorectal Cancer will be Diagnosed 1. Colon cancer: 95,000 2. Rectal cancer: 40,000 B Almost 50,000 People Die of Colorectal Cancer Annually in the United States 1. Mortality is steadily decreasing since 1990. 2. Still the third most common cause of cancer death in the United States II Risk Factors 1. Personal…

Small Bowel Malignancy

I Epidemiology A Incidence 1. Although the small intestine comprises 90% of the surface area of the gastrointestinal (GI) tract, less than 3% of primary GI neoplasms occur in this region. Theories for this discrepancy include: a. The dilute and liquid contents of the small bowel cause less mucosal irritation. b. The rapid transit of intestinal contents provides for shorter exposure to carcinogens. c. The lower…

Gastric Malignancy

I Adenocarcinoma of the Stomach A Epidemiology 1. Comprises 95% of all gastric tumors 2. Fourth most common gastrointestinal (GI) malignancy worldwide 3. Second cause of cancer mortality worldwide (behind lung cancer) 4. Approximately 25,000 cases reported in United States in 2015 5. Seventy percent of patients older than 50 (peak in seventh decade of life) 6. Male to female ratio: 2:1 7. Greatest incidence in…

Esophageal Malignancy

I Esophageal Anatomy 1. The esophagus is a muscular pump bordered by two sphincters, the upper esophageal sphincter (UES) and lower esophageal sphincter (LES). Its function is to transport food and liquids in a unidirectional movement, and it possesses no endocrine, exocrine, immunologic, digestive, absorptive, or secretory functions. 2. In contrast to the rest of the gastrointestinal (GI) tract, the esophagus has no serosa, thus reducing…

Head and Neck Malignancy

I Epidemiology 1. Worldwide, it is estimated that 300,000 people are living with oral cavity and pharynx cancer. Approximately 48,000 head and neck cancers are diagnosed in the United States annually, representing nearly 3% of cancers diagnosed in North America and 1.6% of all cancer deaths. The male-to-female ratio is almost 3:1, and the median age of onset is 62 years. The 5-year survival rate is…

Tumor Biology, Syndromes, and Genetic Mutations

I Self-Sufficiency in Growth Signals Mitogens are chemicals that trigger cell mitosis. In contrast with healthy cells, cancer cells have a reduced dependence on mitogens and external growth factors for replication. A Growth Factors 1. Tumor cells and stroma produce factors that may influence tumor growth and stimulate cell environment. 2. Transforming growth factor-beta (TGF-beta) affects angiogenesis, extracellular matrix, and production of cytokines. B Alteration of…

Bariatric Surgery

I Epidemiology of Morbid Obesity A Definitions 1. Overweight—body mass index [(BMI) = weight in kg/height in m 2 ] greater than 25–29.9 2. Obese (Class I)—BMI greater than 30–34.9 3. Severe obesity (Class II)—BMI greater than 35–39.9 4. Morbid obesity (Class III)—BMI ≥40 5. BMI for children differ a. Overweight: BMI greater than 85–95th percentile for age and sex b. Obese: BMI greater than 95th…

Surgical Diseases of the Spleen

The spleen is the largest organ of the reticuloendothelial system, responsible for many filtration and host defense mechanisms; however, it is not well understood. It plays a role in many childhood and adulthood hematologic and immunologic disorders and can cause significant morbidity and mortality in blunt and penetrating trauma. Previous management included simple and straightforward guidelines for splenectomy; the indications for surgical management of splenic disease…

Benign Pancreatic Disease

I Anatomy A Embryology 1. The pancreas begins as dorsal (from duodenum) and ventral (from hepatic diverticulum) budding from the foregut endoderm at approximately the fifth week of gestation. 2. Both the dorsal and ventral portions of the pancreas possess a main duct and fuse when the two pancreatic buds join. However, the portion of the dorsal duct between the anastomosis and the duodenum regresses. The…

Appendix

I Overview A Anatomy 1. The appendix develops as a protuberance of the base of the cecum. a. The base is located at the convergence of the teniae coli, and the tip is variably located (e.g., retrocecal, pelvic). b. Blood supply is via a terminal branch of the ileocolic artery, a branch of the superior mesenteric artery (SMA). B Function 1. The appendix participates in immune…

Benign Colorectal Disease

I Anatomy A Rectum 1. The rectum is 12–15 cm in length and extends from the sacral promontory to the levator ani muscles. 2. The teniae coli splay out at the rectosigmoid junction and fuse to form a contiguous smooth muscle layer. 3. The internal rectum is segmented by three horizontal rectal mucosal folds (valves of Houston) that help to support its contents. 4. The proximal…

Benign Esophageal Disease

I Anatomy A General Description 1. The esophagus is an approximately 30-cm-long, muscular tube that begins 15 cm from the incisors at the cricopharyngeus muscle and ends at the gastroesophageal junction (GEJ) along the cardia of the stomach. There are three normal areas of anatomic narrowing: (1) the cricopharyngeal muscle (the narrowest point of the esophagus), (2) the aortic arch and left main stem bronchus, and…

Inflammatory Bowel Disease

I Inflammatory Bowel Disease A Ulcerative Colitis 1. Diffuse inflammatory disease limited to mucosa of colon and rectum 2. Operative therapy is almost always curative; indicated for refractory disease, toxic distension, or dysplasia B Crohn Disease 1. Chronic, relapsing, transmural, usually segmental, and often granulomatous inflammatory disorder involving any portion of the gastrointestinal (GI) tract from mouth to anus; most common in the terminal ileum 2.…

Peptic Ulcer Disease

If anyone should consider removing half of my good stomach to cure a small ulcer in my duodenum, I would run faster than he. Charles H. Mayo (1865–1939 In the era of Helicobacter pylori doing a gastrectomy for peptic ulcer is like doing a lobectomy for pneumonia. Asher Hirshberg I Occurrence 1. Lifetime risk—10% 2. US prevalence—2% 3. Age a. Duodenal ulcers are more common in…

Intestinal Obstruction

I Terminology A Ileus 1. Mechanical or functional obstruction, usually caused by failure of movement of luminal contents secondary to poor motility B Mechanical Obstruction 1. Partial or complete physical blockage of lumen C Simple Obstruction 1. Occlusion at one area of the bowel D Closed-Loop Obstruction 1. Afferent and efferent bowel limb blockage 2. Occasionally seen with strangulation E Strangulation 1. Ischemic damage to obstructed…

Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding can be characterized and managed by its location. Upper GI bleeding is defined as bleeding originating proximal to the ligament of Treitz, whereas lower GI bleeding occurs distal to the ligament of Treitz. I History History and physical examination can elucidate the cause of GI bleeding. This assessment should be conducted simultaneously with resuscitation. A Characterization of Bleeding 1. Hematemesis (bright red or…

Abdominal Wall Hernias

I Historical Perspective Numerous surgeons and anatomists have participated in the development of the modern-day herniorrhaphy. Several warrant particular interest because of their major contributions to early hernia surgery. A Henry Marcy (1837–1924) 1. Boston surgeon who described anterior approach to hernia repair with high ligation of the hernia sac in 1871 B Edoardo Bassini (1844–1924) 1. In 1887 he wrote “Nuevo Metodo Operativo per la…

Acute Abdomen

The acute abdomen is defined as undiagnosed pain that develops suddenly and is less than 7 days in duration. I Physiology of Abdominal Pain A Visceral Pain Visceral or intestinal contraction, spasm, stretching, distention, or chemical irritation results in visceral afferent nerve fiber stimulation. 1. Location—Pain experienced in the midline corresponds to the embryonic anatomic origin with subsequent descent during organogenesis. a. Foregut —stomach to second…