Essentials of Visceral Surgery: For Residents and Fellows

Preface
Contents
Contributors
Abbreviations
1: Esophagus, Stomach and Duodenum
1.1 Anatomy and Physiology
1.1.1 Esophagus
1.1.2 Stomach
1.1.3 Duodenum
1.2 Leading Symptoms and Diagnosis
1.2.1 Leading Symptoms
Esophagus
Stomach
Upper GI Bleeding
1.2.2 Diagnosis
Endoscopy
Radiology/Nuclear Medicine
1.2.3 Therapeutic Principles
1.3 Benign Diseases of the Esophagus
1.3.1 Diverticular Diseases of the Esophagus
Etiology
Zenker’s Diverticulum and Epiphrenic Diverticulum (Pulsion Diverticulum)
Midesophageal Diverticulum (Traction Diverticulum)
Forms
Zenker’s Diverticulum (Hypopharynx)
Killian-Jamison Diverticulum
Epiphrenic Diverticulum
Symptoms
Therapy
Zenker-Diverikel
Epiphrenic Diverticulum
1.3.2 Achalasia
Etiology
Pathogenesis
Forms
Primary Achalasia
Secondary Achalasia
Symptoms
Complications
Staging
Diagnosis
Esophagogastroduodenoscopy (EGD)
Manometry
X-Ray (Esophagogram)/Computed Tomography
Therapy
Medical Therapy
Principle
Preparations
Endoscopic Therapy
Pneumatic Dilatation
Endoscopic Injection of Botulinum Toxin
Peroral Endoscopic Myotomy (POEM)
Surgical Therapy
Surgical Therapy Options
Results After Myotomy
1.3.3 Esophageal Perforation
Etiology
Symptoms
Diagnosis
Endoscopy (EGD)
Computed Tomography of the chest
Therapy
Surgical Therapy
Endoscopic Therapy
Conservative Therapy
Prognostic Factors
1.3.4 Hiatal Hernias
Etiology
Types of Hiatal Hernias (. Fig. 1.2)
Cardiofundal Malposition
Axial Sliding Hernia
Paraesophageal Hernia
Mixed Forms
Symptoms
Axial Hernias
Paraesophageal Hernias
Therapy
Symptomatic Therapy
Surgical Therapy
1.3.5 Gastroesophageal Reflux Disease (GERD)
Definition
Etiology
Demographics
Pathophysiology and Risk Factors
Symptoms
Diagnosis
Esophagogastroduodenoscopy (EGD)
24 h pH-Metry/Impedance Measurement
Manometry
Therapy
Conservative Therapy
Surgical Therapy
1.3.6 Guidelines
1.4 Malignant Diseases of the Esophagus
1.4.1 Overview
Esophageal Cancer
Adenocarcinoma of the Gastroesophageal Junction (AEG)
1.4.2 Esophageal Carcinoma (Including AEG)
Definition
Types
Adenocarcinoma
Adenocarcinoma of the Gastroesophageal Junction (AEG)
Squamous Cell Carcinoma
Adenosquamous Carcinomas, Undifferentiated Carcinomas
Epidemiology and Etiology
Occurrence
Risk Factors
Squamous Cell Carcinoma
Adenocarcinoma
Tumor Spread
Continuous Spread
Lymphogenous Spread
Hematogenous Spread
Classification
UICC/AJCC TNM 8 Classification (2017)
UICC Stages According to the TNM Classification 8th Version (2017)
Symptoms
Diagnosis
Esophagogastroduodenoscopy (EGD)
Endosonography
Thoracic CT, Abdominal CT
Bronchoscopy
Panendoscopy
PET-CT, MRI Abdomen
Therapy
Indication
Multimodal Therapy
Principles
Neoadjuvant Radiochemotherapy
Perioperative Chemotherapy
Additive/Palliative Therapy
Principles
Strategy
Operative Therapy Principles
Local Endoscopic Interventional Procedures
Esophagectomy
Prognostic Factors
Follow-Up
Purpose
Implementation
1.5 Benign Diseases of the Stomach
1.5.1 Gastroduodenal Ulcer Disease
Etiology
Appearance
Risk Factors
Symptoms
Diagnosis
Endoscopy (EGD)
Radiology
Further Diagnosis
Complications
Therapy
Conservative Therapy
Interventional Therapy
Surgical Therapy
1.5.2 Guidelines
1.6 Malignant Diseases of the Stomach
1.6.1 Gastric Adenocarcinoma
Definition
Forms
Epidemiology and Etiology
Occurrence
Risk Factors
Tumor Spread
Classification
TNM 7 Classification (2010)
UICC Stages According to the TNM Classification
Symptoms
Diagnosis
Esophagogastroduodenoscopy/Endosonography
Thoracic CT, Abdominal CT
Diagnostic Laparoscopy
PET-CT, MRI Abdomen, Bone Scintigraphy
Therapy
Indication
Multimodal Therapy
Principles
Perioperative Chemotherapy
Adjuvant Radiochemotherapy
Additive/Palliative Therapy
Principles
Strategy
Operative Therapy Principles
Prognosis
Prognostic Factors
Follow-Up
Goals
Implementation
1.6.2 Gastrointestinal Stromal Tumours (GIST)
1.6.3 Guidelines
1.7 Diseases of the Duodenum
1.7.1 Diverticular Disease of the Duodenum
Incidence
Types
Symptoms
Therapy
Complications
1.7.2 Duodenal Cancer
Etiology and Tumor Manifestation
Appearance
Symptoms
Diagnosis and Therapy
Diagnosis
Endoscopic Therapy
Surgical Therapy
Multimodal Therapy
Palliative Therapy
Prognosis
1.7.3 Guidelines
References
2: Small Intestine and Appendix
2.1 Anatomy of the Small Intestine
2.1.1 Measured Values
2.1.2 Limits
2.1.3 Wall Structure of the Small Intestine
2.1.4 Circulation
Arterial Blood Flow
Venous Drainage
Lymphatic Drainage
Mesenteric Base
2.1.5 Innervation
Parasympathetic Component
Sympathetic Component
2.1.6 Small Intestine Functions
Digestion and Nutrient Absorption
Endocrinological Function
Immunological Function
2.2 Diseases of the Small Intestine
2.2.1 Clinical Presentation
General
Inflammatory Bowel Disease
Development
Symptoms
Complications
Neoplastic Intestinal Diseases
Symptoms
GIST (Gastrointestinal Stromal Tumors)/Carcinoid Tumors
2.2.2 Imaging
Radiological Imaging
Conventional Abdominal Radiograph
CT Examination with Contrast Medium
Colon Contrast Enema
CT Enterography/MRI Enterography
Abdominal Sonography
Endoscopic Imaging
Colonoscopy/Esophagogastroduodenoscopy (EGD)
Double Balloon Endoscopy
Capsule Endoscopy
2.2.3 Crohn’s Disease
Pathophysiology
Diagnosis
Differential Diagnosis (= Other Inflammatory Bowel Diseases)
2.2.4 Small Intestinal Neoplasms
Epidemiology
Diagnosis
Histological Classification
Adenomas
Hamartomas
Hemangiomas
Gastrointestinal Stromal Tumors (GIST)
Adenocarcinomas
Lymphomas
Small Intestine NET (Carcinoid Tumors)
Metastatic Lesions
2.2.5 Other Diseases of the Small Intestine
Diverticula and Meckel’s Diverticula
Duodenum Diverticulum
Jejunum and Ileum Diverticula
Meckel’s Diverticulum
Ulcerations and Fistulas
Ulcerations
Enterocutaneous Fistulas
Small Bowel Obstruction/Ileus
Etiology
Classification of Obstruction/Ileus
Clinical Presentation
Complications
Diagnosis
Treatment
2.2.6 Treatment Strategies
Drug Therapy
Crohn’s Disease
Malignant Lesions
GIST/Small Bowel NET (Carcinoid)
Surgical Treatment
General Principles
Segmental Small Bowel Resection + Anastomosis
Laparoscopic Resection
Bypass Procedures
Treatment of CIBD (E.g. Crohn’s Disease)
Indications for Surgical Treatment
Strategy
Treatment of Benign Lesions
Treatment of Malignant Lesions
2.3 Vermiform Appendix
2.3.1 Anatomy of the Vermiform Appendix
Normal Anatomy
Localization Variations (According to Wakeley and Testut & Latarjet)
Circulation and Lymphatic Drainage
Histological Features
2.4 Diseases of the Appendix
2.4.1 Appendicitis Vermiformis
Physiopathology
Symptoms
Initial Symptoms
Progressive Symptoms (Due to Inflammation of the Surrounding Structures)
Clinical Presentation: Biochemistry
Clinical Presentation
Biochemistry
Imaging
Ultrasound (US)
Computer Tomography (CT)
Diagnostic Laparoscopy
Differential Diagnosis
Operative Differential Diagnosis
Non-Operative Differential Diagnosis
Gynaecological Differential Diagnosis
Surgical Treatment Modalities
Treatment Strategy
Early Surgical Appendectomy
Antibiotic Treatment
Laparoscopic Appendectomy
Minimally Invasive (Laparoscopic) Appendectomy = Currently the Gold Standard
Controversy with Normal Appearing Appendix at Laparoscopy
Resection Technique
Evidence-Based Approach
Open Appendectomy
McBurney Incision
Median Laparotomy
Drug Therapy
Uncomplicated Appendicitis
Severe Complications (Depicted by Imaging)
Treatment Strategy
2.4.2 Malignant Diseases
Mucocele of the Appendix
Pathophysiology
Epidemiology
Clinical Presentation
Diagnosis
Tumor Marker (Preoperative)
Sonography
CT Abdomen
Colonoscopy
Treatment
Retention Cysts
Appendix Mucoceles
Ruptured Mucocele (= Pseudomyxoma Peritonei/Mucinous Carcinomatosis)
Forecast
Prognostic Factors
Course of the Disease
Survival
Carcinoid Tumors: Neuroendocrine Tumors of the Appendix
Epidemiology
Diagnosis
Non-functional NET
Functional NET
Environment Diagnosis
Treatment (According to Recommendations of the American National Cancer Institute and ENETS)
Aftercare
Noncarcinoid Tumors of the Appendix
Classification According to World Health Organisation (WHO) (. Table 2.2)
Clinical Presentation
Treatment
References
3: Colon
3.1 Anatomy and Physiology
3.1.1 Definition and Limits
3.1.2 Tasks
3.1.3 Location and Classification
3.1.4 Measured Values
3.1.5 Characteristic Features of the Colon
3.1.6 Blood Supply and Drainage
Arteries
Veins
Lymphatic Drainage (. Fig. 3.1)
3.2 Benign Diseases of the Colon
3.2.1 Diverticulosis and Diverticulitis
Definitions
Colon Diverticulum
Diverticular Disease
Diverticulitis (= Pathological)
Epidemiology
Etiology/Pathogenesis
Risk Factors
Complications
Symptoms
Classifications
Diagnosis
Medical History (Medication, Tobacco Consumption)
Clinical Examination
Laboratory Tests
Diagnostic Imaging
Therapy
Prophylaxis of Diverticulitis
Primary Prophylaxis
Secondary Prophylaxis
Conservative Therapy
Asymptomatic Diverticulosis
Complicated Diverticulitis
Surgical Therapy
Surgery Indications
Surgical Strategy
3.2.2 Colonic Polyps
Definition
Epidemiology
Classification (. Table 3.4)
Symptoms
Diagnosis
Therapy
Endoscopic Therapy
Guideline: Polypectomy
Implementation
Postpolypectomy Strategy
Follow-up
Surgical Therapy
Follow-Up Care After Colonoscopic Ablation
3.2.3 Ulcerative Colitis
Definition
Epidemiology
Etiology
Etiopathogenesis
Course
Clinical Presentation
Intestinal Manifestations
Extraintestinal Manifestations (15–20%)
Course
Complications
Diagnosis
Anamnesis
Complete Physical Examination
Lab
Imaging
Endoscopy
Differential Diagnosis
Therapy
Conservative-Medical Therapy
Uncomplicated Ulcerative Colitis
Proctitis
Left-Sided Colitis
Complicated/Severe Ulcerative Colitis
Time-Adapted Approach
Surgical Therapy
Surgery Indications
Standard Surgery: Restorative Proctocolectomy
Follow-Up
Alternative Procedure
Preventive Care (Cancer Prophylaxis)
3.2.4 Chronic Constipation
Definition
Epidemiology
Etiology
Diagnosis
Anamnesis
Physical Examination
Further Diagnosis
Therapy
Step-By-Step Therapy (. Fig. 3.2)
Surgery
3.2.5 Guidelines
3.3 Colon Cancer and Hereditary CRC Syndromes
3.3.1 Colon Carcinoma
Definition
Epidemiology
Etiology and Pathogenesis
Risk Categories
Protective Factors
Pathogenesis
Classification
TNM Classification (2017)
UICC Staging of Colorectal Cancer
Histological Grading
Symptoms
Complications
Diagnosis
Standard Investigations
Guideline-Based Preoperative Diagnostic of Tumor Staging
Colorectal Cancer Screening (in the Asymptomatic Population)
Guideline: Polypectomy
Therapy
Treatment Strategy
Surgical Therapy
Principles of Surgical Therapy
Postoperative Complications
Principles for Specific Situations
Principles in Metastatic Colon Cancer
Adjuvant Chemotherapy
Indications
Contraindications
Standard Chemotherapy = FOLFOX (5-FU/Folinic Acid/Oxaliplatin)
Palliative Chemotherapy
Oncologic Follow-up
Prognosis
3.3.2 HNPCC (Hereditary Non-polyposis Colorectal Cancer): Lynch Syndrome
Definition
Epidemiology
Etiology
Diagnosis
Anamnesis
Test for Mismatch Repair Defect
Prevention
Surgical Therapy
3.3.3 Other Hereditary CRC Syndromes
Familial Adenomatous Polyposis (FAP)
Definition
Etiology
Tumour Spectrum
Prevention
Therapy
Follow-Up
Hamartomatous Polyposis Syndromes
Definition
Prophylaxis
Diagnosis and Therapy
3.3.4 Guidelines
Reference
Suggested Reading
4: Rectum
4.1 Anatomy and Physiology
4.1.1 Definition, Location and Structure
Definition
Location
Limits
4.1.2 Anatomy and Embryology
Topographic Anatomy
Blood Supply and Drainage
Innervation
4.1.3 Physiology
Special Functions of the Rectum
4.2 Benign Diseases
4.2.1 Benign Neoplasms/Malformations
Polyps/Adenomas (Chap. 3)
Schwannomas, Leiomyomas, Angiomyomas
Hirschsprung’s Disease
Infiltrating Endometriosis
4.2.2 Rectal Prolapse
Definition, Classification, Differential Diagnosis, Epidemiology
Definition
Classification
Differential Diagnoses
Epidemiology
Etiology and Pathogenesis
Symptoms and Diagnosis
Symptoms
Diagnosis
Therapy
Non-surgical Therapy
Surgical Therapy
Perineal and Transanal Procedures
Abdominal Procedures
4.3 Malignant Diseases
4.3.1 Histological Tumour Entities
4.3.2 Rectal Cancer
Definition
Forms/Classification
Epidemiology and Etiology
Tumor Spread
Classification
Classification According to Mason (Clinical Staging)
TNM Classification (2017)
Derivation of UICC Stages from TNM Classification
Symptoms
Diagnosis
Rectal Digital Examination
Rigid Rectoscopy
Colonoscopy
Endorectal Ultrasound
MRI Pelvis
Thoracic CT, Abdominal CT
PET-CT
Therapy
Indication
Neoadjuvant Therapy
Long-Term Radiochemotherapy (Preferred in Germany and USA)
Short-Term Therapy (Preferred in the Netherlands, Poland and Scandinavia)
Adjuvant Therapy
Modalities
Results
Additive/Palliative Therapy
Principles
Strategy
Operative Therapy Principles
Local Limited Procedures
Rectal Resection
Abdominoperineal Rectal Extirpation
Prognosis
Prognostic Factors
5-Year Survival Rates
Follow-up
Targets
Time Intervals
Special Features
4.3.3 Guidelines
Further Reading
Suggested Reading
5: Anorectum
5.1 Anatomy and Physiology
5.1.1 Anatomy
5.1.2 Physiology
5.2 Benign Diseases
5.2.1 Hemorrhoidal Disease
Definition
Classification
Epidemiology
Etiology
Symptoms
Diagnosis
Differential Diagnosis
Therapy
Basic Therapy
Conservative and Interventional/Semioperative Therapy
Sclerotherapy (Blond or Blanchard or Bensaude procedures)
Infrared Coagulation
Rubber Ring Ligation (According to Barron)
Doppler-Guided Hemorrhoidal Artery Ligation (HAL)
Recto-Anal Repair
Surgical Therapy
Milligan-Morgan Hemorrhoidectomy
Ferguson Hemorrhoidectomy
Subanodermal Resection (Parks Procedure)
Stapler Hemorrhoidopexy (Longo Procedure)
Therapy Strategy for Grade 4 Hemorrhoids
Complications
5.2.2 Anal Vein Thrombosis
Definition
Epidemiology
Etiology
Triggering Factors
Symptoms
Diagnosis
Differential Diagnosis
Therapy
Conservative Therapy
Surgical Therapy
Complications
5.2.3 Anal Fissure
Definition
Acute Anal Fissure
Chronic Anal Fissure
Epidemiology
Etiology
Main Cause = Heavy Pressing
Other Causes
Symptoms
Diagnosis
Differential Diagnosis
Therapy
Conservative Therapy
Surgical Therapy
Complications
5.2.4 Anorectal Abscess
Definition
Epidemiology
Etiology
Cryptoglandular Origin
Rarer causes
Symptoms
Diagnosis
Differential Diagnosis
Therapy
Conservative Therapy
Surgical Therapy
Complications
5.2.5 Anorectal Fistulas
Definition and Classification
Definition
Classification of Anorectal Fistulas (According to Course)
Epidemiology
Etiology
Cryptoglandular Origin
Rarer Forms of Fistula
Symptoms
Diagnosis
Differential Diagnosis
Therapy
Conservative Therapy
Surgical Therapy
Complications
5.2.6 Pilonidal Sinus
Definition
Epidemiology
Etiology
Risk Factors
Pathophysiology
Symptoms
Asymptomatic Form
Acute Abscessed Form
Chronic Form
Diagnosis
Differential Diagnosis
Therapy
Conservative Therapy
Surgical Therapy
Complications
5.2.7 Fecal Incontinence
Definition
Clinical Classification
Score Classification
Epidemiology
Etiology
Pathophysiology
Risk Factors
Symptoms
Diagnosis
Therapy
Conservative Therapy
Surgical Therapy
Complications
5.2.8 Anorectal Voiding Dysfunction (Outlet Constipation)
Definition
Definition
Classification
Epidemiology (Of All Forms of Constipation)
Etiology
Symptoms
Diagnosis
Therapy
Surgical Therapy
Complications
5.3 Malignant Disease: Anal Carcinoma
5.3.1 Definition
Anal Carcinoma
Classification: TNM Classification
Anal Margin Carcinoma
5.3.2 Epidemiology
5.3.3 Aetiology
5.3.4 Symptomatology
5.3.5 Diagnosis
5.3.6 Differential Diagnosis
5.3.7 Therapy
Conservative Therapy
Surgical Therapy
Complications
5.4 Guidelines
Suggested Reading
6: Endocrine Organs
6.1 Anatomy and Physiology of the Thyroid Gland
6.1.1 Embryology and Anatomy
Macroscopy
Microscopy
Localization
Blood Supply
Development
6.1.2 Physiology
Thyroid Hormones (Thyroxine, T4, and Triiodothyronine, T3)
Control Loop (Negative Feedback)
Calcitonin
6.2 Diseases of the Thyroid Gland
6.2.1 Epidemiology
Goiter and Multinodular Goiter
Hyperthyroidism (Thyroid Autonomy)
Autoimmune Diseases
Thyroid Cancer
6.2.2 General Methods of Investigation
Clinical Examination
Laboratory Thyroid Function Tests
Basic Diagnosis (For Each Patient)
Specific Diagnosis (For Further Clarification)
Imaging Studies
Ultrasound
Computer Tomography (CT)
Magnetic Resonance Imaging (MRI)
Nuclear Medicine Diagnosis
Fine Needle Aspiration Cytology (FNA)
Principle
Interpretation of the Cytological Findings
Diagnostic Strategy
6.2.3 Basics of Surgical Therapy, Complications and Postoperative Care
Preoperative Measures
Basics of Surgical Therapy
Minimally Invasive Surgical Techniques
Cervical Lymphadenectomy (LAD) for Thyroid Cancer
Surgical Anatomy and Classification Systems
Pathophysiology
Sentinel Node Biopsy Technique
Selective LAD (“Berry Picking”)
Compartment-Oriented LAD
Postoperative Complications
Bleeding Needing Revision
Recurrent Laryngeal Nerve Lesion
Parathyroid Hypofunction (= Hypoparathyroidism; . Fig. 6.6)
Thyrotoxic Crisis
Tracheomalacia
Postoperative Care
6.2.4 Benign Thyroid Diseases
Hypothyroidism
Definition
Symptoms
Diagnosis
Therapy
Hyperthyroidism
Definition
Etiology
Symptomatology (. Table 6.2)
Toxic Nodules (= Autonomies)
Definition
Epidemiology
Symptoms
Diagnosis
Therapy
Immunothyreopathy: Graves’ Disease
Definition
Epidemiology
Pathophysiology
Symptoms
Diagnosis
Therapy
Thyroiditis
Acute Thyroiditis
Pathogenesis
Symptoms
Diagnosis
Therapy
Subacute Thyroiditis (De Quervain)
Pathogenesis
Symptoms
Diagnosis
Therapy
Autoimmune Thyroiditis
Symptoms
Diagnosis
Therapy
Special Forms of Thyroiditis
Traumatic Thyroiditis
Drug-Induced Thyroiditis
Goiter and Nodular Goiter
Definition
Goiter
Nodular Goiter
Pathogenesis
Diagnosis
Clinical Examination
Ultrasound
Scintigraphy (7 Sect. 6.2.2)
FNA
Laboratory (Standard Levels, 7 Sect. 6.2.2, Laboratory Thyroid Function Tests)
Therapy
Medical Therapy and Prophylaxis
Surgical Therapy
6.2.5 Malignant Thyroid Diseases
Cancers of the Thyroid Gland
Definition (. Table 6.13)
Papillary Thyroid Cancer (PTC)
Epidemiology
Molecular Pathology BRAF Mutation: Approx. 50% of PTC
Prognosis
Therapy Principles
Follicular Thyroid Cancer (FTC)
Epidemiology
Molecular Pathology
Prognosis
Therapy Principles
Poorly Differentiated Thyroid Cancer
Epidemiology
Molecular Pathology
Prognosis
Therapy Principles
Anaplastic Thyroid Cancer
Epidemiology
Molecular Pathology
Prognosis
Therapy Principles
Medullary Thyroid Cancer (MTC)
Epidemiology
Molecular Pathology
Prognosis
Therapy Principles
Familial Non-Medullary Thyroid Cancer (7 Sect. 6.3)
Rare Thyroid Cancers
Primary Malignant Lymphoma of the Thyroid Gland
Primary Sarcomas of the Thyroid Gland
Metastases in the Thyroid Gland
6.2.6 Workup of a Solitary or Dominant Thyroid Nodule
Epidemiology
Symptoms
Diagnosis
Medical History and Clinical Examination
Laboratory Diagnosis (7 Sect. 6.2.2 Laboratory Thyroid Functuon Tests)
Ultrasound
Scintigraphy
FNA (7 Sect. 6.2.2 Fine Needle Aspiration Cytology) (. Fig. 6.3)
Therapy
Indications for Surgical Therapy
Indications for Conservative Therapy
Operative Therapy Principles
6.2.7 Guidelines
6.3 Familial Malignant Syndromes of the Thyroid Gland
6.3.1 Introduction (. Table 6.14)
Genetics
6.3.2 Hereditary Medullary Thyroid Carcinoma
Medullary Thyroid Carcinoma (MTC)
Clinical Presentation
Diagnosis
Treatment
Multiple Endocrine Neoplasia 2A (MEN 2A)
Epidemiology
Genetics
Clinical Presentation
Diagnosis
Treatment (. Table 6.15)
Multiple Endocrine Neoplasia 2B (MEN 2B)
Epidemiology
Genetics
Clinical Presentation
Diagnosis
Therapy (. Table 6.15)
Familial Medullary Thyroid Carcinoma (FMTC)
Epidemiology
Genetics
Clinical Presentation
Diagnosis
Treatment
6.3.3 Familial Papillary Thyroid Carcinoma (FPTC)
Clinical Presentation
Diagnosis
Screening Recommendations
Treatment
6.3.4 Rare Genetic Syndromes Associated with Thyroid Cancer
Familial Adenomatous Polyposis (FAP)
Epidemiology
Genetics
Clinical Presentation
Diagnosis
Treatment
Gardner Syndrome
Definition and Epidemiology
Genetics
Clinical Presentation
Diagnosis
Treatment
Cowden Syndrome
Epidemiology
Genetics
Clinical Manifestations
Diagnosis
Management
Treatment
Carney Complex I
Epidemiology
Genetics
Presentation
Diagnosis
Treatment
6.3.5 Guidelines
6.4 Anatomy and Physiology of the Parathyroid Gland
6.4.1 Anatomy
Localization
Blood Supply
6.4.2 Physiology (. Fig. 6.4)
Parathormone (PTH)
Calcium (Ca++)
Control Loop (Negative Feedback)
6.5 Diseases of the Parathyroid Gland
6.5.1 Benign Parathyroid Diseases
Primary Hyperparathyroidism (pHPT)
Definition
Forms
Sporadic pHPT
Hereditary pHPT (7 Sect. 6.3)
Epidemiology
Symptoms
Diagnosis
Laboratory Diagnosis (. Fig. 6.5)
Diagnostic Imaging
Genetic Workup
Differential Diagnosis (. Fig. 6.6)
Secondary (sHPT), Tertiary HPT (tHPT) (See Below)
Familial Hypocalciuric Hypercalcemia (FHH)
Milk-Alkali Syndrome
Lithium Therapy
Malignancy-Associated Hypercalcemia
Granulomatous Disease
Endocrinopathies
Drugs
Immobilization, Bed Rest
Therapy
Indications for Medical Therapy
Indications for Surgical Therapy
Operative Therapy Principles
Complications (Section “Postoperative Complications”)
Reoperation
Secondary Hyperparathyroidism (sHPT)
Definition
Etiology (. Table 6.24)
Renal sHPT
Extrarenal sHPT (= Differential Diagnosis) (. Table 6.23)
Symptoms
Diagnosis (. Fig. 6.5)
Therapy
Conservative/Medical = Primary Therapy of sHPT
Surgical Therapy
Postoperative Follow-Up: Like pHPT (See Above “pHPT”)
Tertiary Hyperparathyroidism (tHPT)
Definition
Etiology
Therapy
Hypoparathyroidism
Epidemiology
Symptoms
Diagnosis
Etiology
Therapy
6.5.2 Parathyroid Cancer
Epidemiology
Symptoms
Diagnosis
Therapy
6.5.3 Guidelines
6.6 Anatomy and Physiology of the Adrenal Gland
6.6.1 Embryology
6.6.2 Anatomy
Topographic Anatomy
Location
Blood Supply
Innervation
Histological Anatomy
Adrenal Cortex
Adrenal Medulla
Positional Relationships
6.6.3 Physiology
Steroid Hormones
Glucocorticoids
Effects of Glucocorticoids
Regulation (. Fig. 6.8)
Mineralocorticoids
Effects of Mineralocorticoids
Regulation (. Fig. 6.9)
Adrenal Sexual Steroids
Effects of Adrenal Sexual Steroids
Regulation
Catecholamines
Regulation
Effects of Catecholamines
6.7 Diseases of the Adrenal gland
6.7.1 Primary Hyperaldosteronism (Conn Syndrome)
Definition
Etiopathogenesis
Etiologies
Pathogenesis (7 Sect. 6.6.3)
Clinical Presentation
Diagnosis (See Algorithm . Fig. 6.10)
Laboratory Adrenal Function Tests
Etiological Diagnosis
Diagnostic Imaging
Selective Venous Sampling
Therapy
Medical (Drug) Therapy
Surgical Therapy
Results
6.7.2 Cortisol-Producing Adrenal Adenoma
Definition
Cushing’s Syndrome
Cushing’s Disease
ACTH Syndrome
Epidemiology and Etiology
Clinical Signs
Diagnosis
Laboratory Adrenal Function Tests
Overnight Cortisol Suppression Test
Free Cortisol 24 h Urine Test
48-h Low-Dose Dexamethasone Test
Etiological Diagnosis
ACTH in Plasma
Therapy
Surgical Therapy
Cushing’s Disease
Ectopic ACTH Secretion Syndrome
Cushing’s Syndrome in Adrenal Tumor (Adenoma or Carcinoma)
Medical (Drug) Therapy
6.7.3 Pheochromocytoma
Definition
Epidemiology
Clinical Signs
Arterial Hypertension
Other Symptoms
Diagnosis
Laboratory Function Tests
Etiological Diagnosis = Localisation Diagnosis
CT Scan
MRI
MIBG Scintigraphy
Therapy
Preoperative Preparation
Background
Principle
Surgical Therapy
Strategy
Principles of Surgical Therapy (7 Sect. 6.7.7)
Postoperative Monitoring/Follow-Up
Chemotherapy
Radiotherapy
Palliative Therapy
6.7.4 Adrenocortical Carcinoma
Definition
Epidemiology and Prognosis
Epidemiology
Prognosis
Clinical Signs
Unclear Abdominal Complaints
Symptoms of Overproduction of Adrenocortical Hormones
Diagnosis
Biochemical Screening
Imaging
Therapy
Surgical Therapy
Strategy
Postoperative Follow-Up
Chemotherapy
Radiotherapy
6.7.5 Adrenal Incidentaloma
Definition
Epidemiology
Clinical Evidence
Functional Incidentalomas
Non-functional Incidentalomas
Evaluation Algorithm
Therapy
Indications for Surgical Therapy
Strategy
6.7.6 Adrenal Metastases
Epidemiology
Clinical Signs
Diagnosis
Therapy
Surgical Therapy
6.7.7 Principles of Adrenal Surgery
General (. Fig. 6.13)
Decisive Factors for the Choice of a Procedure
General Rule
Open Adrenalectomy
Indications
Technique
Laparoscopic Adrenalectomy
Advantages (Compared to Open Access)
Good Candidates for Laparoscopic Adrenalectomy
Retroperitoneoscopic Adrenalectomy
Indications
Advantages
Contraindications
6.7.8 Guidelines
References
Further Reading
7: Bariatric and Metabolic Surgery
7.1 Epidemiology
7.1.1 Incidence
7.1.2 Health Economic Consequences
7.2 Pathophysiology and Principle of Action of Bariatric Surgery
7.2.1 Pathophysiology
7.2.2 Working Principle of Bariatric Surgery
Restrictive Methods
Hypoabsorptive Methods
Combined Methods
7.3 Clinical Evidence
7.3.1 Bariatric Surgery: Laparoscopic Versus Open
7.3.2 Bariatric Surgery: Prospective Controlled Studies
7.3.3 Metabolic Consequences of Bariatric Surgery
7.3.4 Mortality: Bariatric Surgery Versus Drug Therapies
7.4 Specific Current Bariatric Interventions
7.4.1 Roux-Y Gastric Bypass “Gastric Bypass”
7.4.2 Banded Gastric Bypass
7.4.3 Laparoscopic Adjustable Gastric Banding (LAGB)
7.4.4 Biliopancreatic Diversion (BPD)
7.4.5 Biliopancreatic Diversion with Duodenal Switch (BPD/ DS)
7.4.6 Gastric Sleeve Resection
7.5 Complications
7.5.1 Mortality
Causes of Mortality
Risk Factors
7.5.2 Gastrointestinal Complications
Nausea and Vomiting
Dumping Syndrome
Deficiency Symptoms
Other Gastrointestinal Complications
7.5.3 Other Complications
Complications in the SOS Study (Sjöström 2013)
7.6 Historical Interventions and Interventions in the Context of Studies
7.6.1 Historical Interventions
Jaw Wiring
Adjustable Gastric Banding (Vertical Banded Gastroplasty)
Jejunoileal Bypass (Intestinal Bypass)
Stomach Partitioning
7.6.2 Interventions in the Context of Studies
Laparoscopic Gastric Plication “Gastric Plication”
Endoscopic Sleeve Gastroplasty “Gastric Plication”
Mini Gastric Bypass
Ileal Transposition with/Without Sleeve Gastrectomy
Laparoscopic “Jejunal Sleeve” (On Gastric Bypass/Sleeve)
Laparoscopic Single Anastomosis Duodenal Switch (SADI-S)
Myoelectric Gastric Stimulation
7.7 Metabolic Surgery
7.7.1 Definition
7.7.2 Scientific Basis
7.8 S3 Guidelines (February 2018)
7.8.1 Quality Assurance
7.8.2 Diagnosis and Evaluation
7.8.3 Indication
7.8.4 Choice of Procedure
7.8.5 Technical Aspects and Complications
7.8.6 Aftercare
7.8.7 Guidelines
References
Suggested Reading
8: Liver, Gallbladder and Bile Ducts
8.1 Anatomy and Physiology of the Liver
8.1.1 Definitions
8.1.2 Macroscopic and Microscopic Anatomy
Macroscopic Anatomy
Ligaments and Ligamentous Attachments
Functional Subdivision
Microscopic Anatomy
8.1.3 Tasks of the Liver and Functional Liver Volume
Tasks of the Liver
Blood Formation Site (Embryonic Period)
Protein Biosynthesis and Degradation
Cleavage of Carbohydrates and Glycogen Storage
Central Organ of Lipometabolism
Special Metabolic Services
Detoxification Function (Through Biotransformation)
Central Organ of the Trace Element Metabolism
Immunological Function
Functional Liver Volume After Resection
Functional Liver Volume After Resection (FLR)
FLR Targets
Measurement of FLR
8.1.4 Location
Position Projection
8.1.5 Measured Values
Weight
Linear Readings
8.1.6 Blood Supply and Drainage
Blood Supply and Drainage of the Liver
Arterial Inflow = Hepatic Artery
Portal Venous Inflow = portal vein
Venous Outflow
8.1.7 Terminology of Liver Resections (. Fig. 8.1)
Anatomical (= Typical) Liver Resections
Atypical Liver Resections
8.2 Diseases of the Liver
8.2.1 Benign Diseases
Hepatocellular Adenomas
Definition and Subtypes
Definition
Subtypes
Epidemiology and Risk Factors
Epidemiology
Risk Factors
Symptoms and Complications
Diagnosis
Surgery Indication
Focal Nodular Hyperplasia (FNH)
Definition
Epidemiology
Diagnosis
Complications
Therapy
Conservative Approach: Generally
Surgical Therapy
Hemangiomas
Definition
Epidemiology
Clinical Presentation and Complications
Clinical Presentation
Complications
Diagnosis
Therapy
Conservative Therapy
Surgical Therapy
Echinococcosis
Definition
Clinical Presentation
E. granulosus (Cysticus, Unilocularis), Dog Tapeworm
E. multilocularis (alveolaris), Fox Tapeworm
Diagnosis
Therapy
Surgical Therapy
8.2.2 Malignant Diseases of the Liver
Primary Tumors
Hepatocellular Carcinoma (HCC)
Epidemiology and Risk Factors
Early Detection
Special Forms
Clinical presentation and Classification
Diagnosis
Surgical Therapy
Intrahepatic Cholangiocarcinoma: CCC
Definition
Epidemiology
Symptoms and Classification
Diagnosis
Therapy
CCC of the Common Hepatic Duct Bifurcation: Klatskin Tumors
Definition
Epidemiology
Symptoms and Classification
Prognosis
Therapy
Liver Metastases
Indications
Therapy
8.2.3 Technique of Liver Resection
Planning of the Resection
Technical Conditions
Parenchyma Conditions
Caution
Strategy of Resection
Resection Type
Minor Resection (<3 Segments)
Major Resection
Technology
Possible Complications
8.3 Liver Transplantation
8.3.1 General and Legal Basis
(National) Legal Basis
Definition
Indication and Listing
Indication for Liver Transplantation
Listing
Organ Allocation
Eurotransplant
Principles of Organ Allocation
8.3.2 Evaluation and Follow-Up of Liver Function
Clinical Follow-Up
Laboratory Parameters of Liver Synthesis and Excretion
Hepatocellular Integrity
Biliary Integrity
Synthesis Performance of the Liver
Excretory Capacity of the Liver
Scoring Systems for Liver Function and Prognosis
Child-Pugh Score (. Table 8.1)
MELD Score
8.3.3 Indications for Liver Transplantation: Relevant Underlying Diseases in Adults
Chronic Liver Disease
Underlying Disease for Liver Cirrhosis
Cholestatic Liver Disease
Chronic Drug Toxicity
Metabolic Diseases/Genetic Diseases
Other Diseases
Acute Liver Disease
Malignant Diseases of the Liver
Hepatocellular Carcinoma (HCC)
Cholangiocarcinoma (CCC)
Epithelioid Hemangioendothelioma
8.3.4 Contraindications for Liver Transplantation
Lack of Patient Adherence/Psychosocial Problems
High Age
Cardiovascular and Pulmonary Concomitant Diseases
Infections
Extrahepatic Metastases
8.3.5 Surgical Principles
Patient Positioning
Laparotomy
Recipient Hepatectomy
Machine Perfusion of the liver
Implantation
Vena Cava Anastomosis
Portal Vein Anastomosis
Reperfusion
Portal vein
Hepatic artery
Bile Duct
Postoperative Phase
8.4 Anatomy and Physiology of the Gallbladder and Bile Ducts
8.4.1 Gallbladder (Vesica Biliaris)
8.4.2 Bile Ducts
8.4.3 Blood Supply and Drainage of the Gallbladder and Bile Ducts
Blood Supply of the Extrahepatic Bile Ducts + Gallbladder
Blood Supply of the Intrahepatic Bile Ducts
8.5 Diseases of the Gallbladder and Bile Ducts
8.5.1 Benign Diseases of the Gallbladder
Cholecystolithiasis
Definition
Epidemiology
Classification
Symptoms
Complications
Diagnosis
Clinical Presentation
Lab Chemistry
Imaging Non-Invasive Procedures
Imaging Invasive Procedures
Further Etiological Clarification
Therapy
Conservative Therapy
Surgical Therapy
Gallbladder Polyps
Definition
Epidemiology
Clinical Presentation
Diagnosis
Therapy
Surgical Therapy
Conservative Therapy
Acute Cholecystitis
Definition
Pathophysiology
Course
Other Risk Factors
Symptoms
Symptoms
Complications of Acute Cholecystitis
Diagnosis
Clinical Presentation
Lab
Sonography
Therapy
Indication
OP Procedure
8.5.2 Benign Diseases of the Bile Ducts
Choledocholithiasis
Definition
Epidemiology
Clinical Presentation
Therapy
Indication
Choledochal Cysts
Definition
Epidemiology
Pathogenesis
Clinical Presentation
Diagnosis
Therapy
8.5.3 Gallbladder Carcinoma
Epidemiology
Symptoms
Diagnosis
Sonography
CT Abdomen and Thorax
Alternative MRI with Magnetic Resonance Cholangiopancreatography (MRCP)
TNM Classification and Staging (UICC 2010)
TNM Classification
Therapy
Surgical Therapy
OP Indication/Strategy
Adjuvant Therapy
References
Further Reading
Suggested reading
9: Pancreas
9.1 Anatomy and Physiology
9.1.1 Definition, Location and Structure
9.1.2 Anatomy and Embryology
Embryology (. Fig. 9.1)
Anatomy
9.1.3 Physiology
Exocrine Function
Endocrine Function
Control of the Functions
9.2 Benign Diseases
9.2.1 Acute Pancreatitis
Definition
Forms
Acute Edematous Pancreatitis
Acute Necrotizing Pancreatitis
Epidemiology
Incidence
Etiology
Symptoms
Diagnosis
Laboratory Diagnosis
Diagnostic Imaging
Risk Assessment (. Table 9.1)
Differential Diagnosis
Therapy
Etiology-Oriented Therapy
Conservative Therapy
Step-Up Approach
Operative Therapy Principles
Prognosis
9.2.2 Chronic Pancreatitis
Definition
Forms
Complications
Epidemiology
Etiology
Alcohol Abuse (75–90%)
Nicotine Abuse
Hyperparathyroidism (with Ca2+ Elevation)
Hereditary
Autoimmunological (IgG-4 and Lymphoplasmocytic Infiltrates)
Symptoms
Abdominal Pain
Symptoms Associated with Loss of Function
Diagnosis
Genetic Examination
Laboratory Diagnosis (. Table 9.2)
Diagnostic Imaging
Sonography
Endosonography
CT/MRI/Magnetic Resonance Cholangiopancreaticography (MRCP)
ERCP
Differential Diagnosis
Therapy
Treatment Strategy
Indications for Conservative Therapy
Indications for Interventional or Surgical Therapy
Operative Therapy: Principles
Division: Resecting/Draining Procedures
Surgical Strategy
Monitoring and Follow-Up
9.2.3 Guidelines
9.3 Malignant Diseases
9.3.1 Pancreatic Carcinoma
Definition
Epidemiology
Etiology
Underlying Genetic Defects
Hereditary Syndromes
Forms
Symptoms
Diagnosis (. Fig. 9.6)
Patient History + Clinical Examination
Imaging Techniques
Therapy
Curative Therapy
Preoperative Therapy
Operation
Pathology
Postoperative Complications
Postoperative Treatment: Adjuvant Chemotherapy
Palliative Therapy
Indications
Therapy Regime
9.3.2 Guidelines
9.4 Cystic Neoplasms
9.4.1 Intraductal Papillary Mucinous Neoplasia (IPMN)
Definition
Epidemiology (. Table 9.6)
Etiology
Symptoms
Diagnosis
CT or MRI
Imaging Signs
Therapy (. Fig. 9.10)
Surgical Therapy of MD-IPMN
Indication for Surgery
Aim of the Operation
Principle
Postoperative Management After Pancreatectomy
Surgical Therapy of BD (“Branch-Duct”)-IPMN
Postoperative Follow-Up
Conservative Therapy of MD-IPMN (5–9 mm Main Duct) and BD-IPMN
9.4.2 Serous Cystic Neoplasms (SCN)
Definition
Epidemiology (. Table 9.6)
Symptoms
Diagnosis
Therapy
Surgical Therapy
Conservative Therapy + Monitoring
9.4.3 Mucinous Cystic Neoplasia (MCN)
Definition
Epidemiology (. Table 9.6)
Symptoms
Diagnosis
Therapy
9.4.4 Solid Pseudopapillary Neoplasia (SPN)
Definition
Epidemiology (. Table 9.6)
Symptoms
Diagnosis
Therapy
Always Operative
Principles
9.4.5 Guidelines
9.5 Endocrine Neoplasms
9.5.1 Definition
9.5.2 Epidemiology
9.5.3 Symptoms
Insulinoma
Gastrinoma (Zollinger-Ellison Syndrome)
VIPom
Glucagonom
Somatostatinoma
Pancreatic Carcinoid Syndrome
Non-Functional NET (95%)
9.5.4 Diagnosis
Laboratory Diagnosis
Chromogranin A
Gastrin
Fast Test
Insulin, Plasma Glucose
5-Hydroxyindoleacetic Acid
Imaging Techniques
Contrast Enhanced Ultrasound
Endosonography
Multidetector CT
9.5.5 Therapy
Benign Solitary NET with Local Resection Option (>2 cm)
NET Without Local Resection Option
Local Recurrences or Metastases of NET
Diffuse Metastasized NET
9.5.6 Guidelines
References
10: Kidney Transplantation
10.1 Introduction
10.1.1 Legal Framework
10.1.2 Structure in Germany
German Foundation for Organ Transplantation
Eurotransplant
Transplant Centers
10.2 Indication for Transplantation and Preparation of the Recipient
10.2.1 Indication for Transplantation
Indication = ESRD [End-Stage Renal Disease]
Contraindications
Causes of End-Stage Renal Disease
10.2.2 Recipient Preparation
Detailed Information—Medical Aspects
Medical Evaluation
Diagnostic Procedure
Detailed Anamnesis and Clinical Examination
Laboratory Tests
Apparative Examination
Screening
Evaluation by Specialist
Vaccinations
10.2.3 Registration in the Waiting List
Indication/Registration
Urgency Status
10.3 Deceased Organ Donation
10.3.1 Organ Donation and Donor Selection
Organ Donation
Donor Selection
Ischemia Times of Organs
10.3.2 Organ Allocation
Allocation Programs
10.3.3 Organ Retrieval
Principle
10.4 Living Kidney Donation
10.4.1 Prerequisites
10.4.2 Legal Limits in Germany
10.4.3 Advantages of Living Kidney Donation
10.4.4 Donor Evaluation [Preparation and Diagnosis]
Initial Interview with the Potential Donor
Detailed Medical Examination (Often Inpatient)
Presentation to an Ethics Committee
10.4.5 Donor Operation
OP Procedure
Open Surgery
Laparoscopic/Retroperitoneoscopic
10.4.6 Risks and Complications
Mortality
Morbidity
Long-Term Risks
10.4.7 Donor Aftercare
10.5 Kidney Transplantation
10.5.1 Back-Table Preparation of the Kidney
10.5.2 Surgical Technique of Transplantation
Implantation Site
Immunosuppression
10.5.3 En Bloc Renal Transplantation
Principle
Advantages
Disadvantages
10.5.4 Surgical Complications
Vascular System (Incidence <5%)
Postoperative Bleeding/Haematoma
Arterial Thrombosis
Graft Vein Thrombosis
Renal Artery Stenosis
Urological Complications (Incidence 2–10%)
Urinary Leakage
Ureteral Stenosis
Ureteral Necrosis
Lymphatic Complications (Incidence 2–18%)
Lymphocele
10.6 Postoperative Treatment
10.6.1 Inpatient Stay
Content
Delayed Graft Function (DGF)/Acute Tubular Necrosis (ATN)
10.6.2 Immunosuppression
Immunosuppressive Therapy
Standard Triple Therapy
Immunological Risk Factors
Immunosuppressive Agents
ABO-Incompatible Transplantation (Living Donation)
10.6.3 Organ Rejection
Hyperacute Rejection
Acute Rejection
Chronic Rejection
10.6.4 Infections
Bacterial Infections
Opportunistic Infections
10.6.5 Aftercare
10.7 Results
11: Spleen
11.1 Spleen: Generalities
11.1.1 Embryology and Developmental Disorders
Embryology
Developmental Disabilities
11.1.2 Anatomy
Structure
Definition (. Fig. 11.1)
Form
Variations
Measurements
Measurements for Adults
Location
Vessels and Innervation
Vessels
Innervation
11.1.3 Physiology
Filter Function
Filter/Degradation Organ of the Altered Erythrocytes
Storage/Degradation Organ of Platelets (and Clotting Products)
Lymphatic Defense Organ
11.2 Spleen Diseases
11.2.1 Benign Haematological Diseases
Idiopathic Thrombocytopenic Purpura (ITP)
Definition
Mechanism
Epidemiology
Clinical Examination
Diagnosis
Therapy
Strategy
Splenectomy
Hereditary Spherocytosis
Definition
Mechanism
Clinical Examination
Diagnosis
Therapy
Hemolytic Anemia Due to Erythrocyte Enzyme Defect
Definition
Clinical Examination
Therapy
Haemoglobinopathies
Definition
Clinical Examination
Therapy
11.2.2 Other Benign Diseases
Splenic Cysts
Classification
Clinical Examination
Epidemiology
Therapy
Splenic Abscess
Risk Factors
Clinical Examination
Diagnosis
Therapy
11.2.3 Malignant Diseases
Lymphomas
Leukemia
Non-hematological Malignant Tumors
11.2.4 Spleen Trauma
Epidemiology
Pathophysiology
Diagnosis
Anamnesis
Clinical Examination
Ultrasound Examination
Therapy
11.2.5 Post-splenectomy Morbidity
Asplenia: Pathophysiology
Prophylactic Therapy in Asplenia Patients
References
Further Reading
12: Peritoneum
12.1 Anatomy and Physiology of the Peritoneum
12.1.1 General Anatomy
Definition
Structure (Histology)
Division
12.1.2 Physiology (Tasks) of the Peritoneum
Organ Mobility
Resorption
Immunological Tasks (= Defence)
12.2 Benign Diseases of the Peritoneum
12.2.1 Peritonitis
Definition
Etiology
Primary Peritonitis (Without Previous Abdominal Disease)
Secondary Peritonitis
Spontaneous Bacterial Peritonitis (e.g. in Ascites, Liver Cirrhosis)
Special Form: Peritonitis After CAPD Catheter Insertion
Classification
Symptoms
Diagnosis
Therapy
Surgical Therapy
Conservative Therapy
12.2.2 Peritoneal Adhesions
Epidemiology
Clinical Presentation
Diagnostic Imaging
Therapy
12.3 Pseudomyxoma Peritonei
12.3.1 Definition
12.3.2 Classification
12.3.3 Aetiology
12.3.4 Clinical Presentation
12.3.5 Therapy
12.3.6 Prognosis
12.4 Malignant Diseases of the Peritoneum
12.4.1 Mesothelioma
Definition
Epidemiology
Clinical Presentation
Prognosis
Therapy
12.4.2 Peritoneal Carcinomatosis
Epidemiology
Clinical Presentation
Diagnosis
Imaging Techniques
Staging Laparoscopy
Therapy
Systemic Chemotherapy
12.5 Cytoreductive Surgery (CRS) and HIPEC
12.5.1 Curative CRS and HIPEC
Theoretical Approach
Concept and Goals
Indication
Risk-Benefit Analysis
12.5.2 Prophylactic/Adjuvant CRS and HIPEC
Indications
Evidence
Learning Curve
12.5.3 Palliative Therapeutic Concepts for Ascites
12.5.4 Complications
Most Common Complications
Strategies to Minimize Complications
12.5.5 Results
12.5.6 PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy)
12.5.7 Guidelines
References
Suggested Reading
13: Hernia
13.1 Anatomy and Classification
13.1.1 Hernia Anatomy
13.1.2 Epidemiology
Hernia Incidence
Hernia Distribution
13.1.3 Pathogenesis and Classification
Pathogenesis
Hernia Classification
13.1.4 Hernia-Specific Complications
Intestinal Incarceration
Hernia
Mains Clamping
13.2 General Diagnosis and Therapy Principles
13.2.1 Diagnosis
Physical Examination
Sonography
Further Investigations
13.2.2 Therapy Principles
Procedure for Surgical Therapy
13.3 Incisional Hernia
13.3.1 Definition
13.3.2 Incidence
13.3.3 Aetiology
13.3.4 Clinical Presentation
13.3.5 Diagnosis
Clinical Examination
Sonography
CT or MRI
13.3.6 Surgical Therapy
Open Procedures
Suture Procedure
Sublay Technique
Abdominal Wall Replacement
Laparoscopic Procedures
Special Procedures
Component Separation According to Ramirez
13.3.7 Guidelines
13.4 Inguinal and Femoral Hernia
13.4.1 Anatomy, Definition and Classification
Anatomy
Definition
Division
13.4.2 Epidemiology
Inguinal Hernia
Femoral Hernia
13.4.3 Pathophysiology
13.4.4 Clinical Presentation
Asymptomatic Small Inguinal Hernia
Symptomatic Inguinal Hernia
Complications
Femoral Hernia
13.4.5 Diagnostic Procedures
Palpation of the Inguinal Canal
Sonography
CT/MRI Examination
13.4.6 Therapeutic Principles
Evidence-Based Strategy (. Fig. 13.3)
EHS (European Hernia Society) Recommendation
Principles
Complications
Intraoperative EHS Classification (2007)
Surgical Technology
Inguinal Hernia
Operative Procedure
Shouldice Herniotomy
Aftercare
13.4.7 Guidelines
13.5 Umbilical and Epigastric Hernia
13.5.1 Umbilical Hernia
Definition
Division
13.5.2 Epigastric Hernia
Definition
13.5.3 Clinical presentation
13.5.4 Diagnosis
13.5.5 Therapy
13.5.6 Guideline
13.5.7 Differential Diagnosis: Rectus Diastasis
Definition
Etiology and Pathogenesis
Clinical Presentation
Therapy
13.6 Parastomal Hernia
13.6.1 Definition
13.6.2 Epidemiology
13.6.3 Risk Factors and Prevention
Risk Factors
Prevention
13.6.4 Clinical Presentation
13.6.5 Relevant Complications
13.6.6 Therapy
Open Procedures
Minimally Invasive Procedures
13.6.7 Guidelines
13.7 Other Rare Hernias
13.7.1 Spieghel’s Hernia (Hernia Lineae Semilunaris)
13.7.2 Hernia Obturatoria
13.7.3 Hernia Ischiadica
13.7.4 Hernia Perinealis
13.7.5 Lumbar Hernia
References
Further Reading
14: Gastrointestinal Stromal Tumors and Sarcomas
14.1 Gastrointestinal Stromal Tumours (GIST)
14.1.1 Definition
14.1.2 Epidemiology and Tumour Localisation
Epidemiology
Localization
Tumor Biology
Risk Factors
14.1.3 Clinical Presentation
Manifestation
Symptoms
Prognosis at Diagnosis
14.1.4 Pathology
Conventional Histology
Immune Phenotype
Mutation Detection
14.1.5 Diagnosis
Diagnostic Imaging
Tissue Biopsy
14.1.6 Therapy
Surgical Therapy
Indication
General Principles
GIST of the Stomach
Adjuvant Treatment
Antibodies (Ab) Against the Tyrosine Kinase Receptor
Second-Line Therapy
Neoadjuvant Treatment
Goals
Indications/Target Organs
Multimodal Therapy
Results of Neoadjuvant Therapy
Assessment of the Therapeutic Success in Imaging
Computer Tomography (CT scan)
Positron Emission Tomography (PET)
14.1.7 Guidelines
14.2 Soft Tissue Tumours of the Extremities
14.2.1 General: Classification
Epidemiology
General Information
STS Body-Distribution Pattern
Rare Hereditary Risk Factors
Acquired Risk Factors
14.2.2 Clinical Presentation
Anamnesis
Investigation
14.2.3 Diagnosis
Local Diagnosis
Ultrasound (Unclear Swelling of the Extremity)
Native X-Ray Imaging in 2 Planes
Magnetic Resonance Imaging (MRI): Gold Standard
Fluorodeoxyglucose (FDG)-PET
Diagnosis of Local and General Spread
Pathophysiology
Diagnosis
Biopsy
General
Excisional Biopsy
Open Incisional Biopsy
Punch Biopsy
14.2.4 Classification
Histological Classification
Most Common Entities
Staging and Grading
Staging
Grading
UICC Stages According to the TNM Classification
14.2.5 Prognosis
Main Prognostic Determinants for Non-Metastatic Tumours
5-Year Survival for Patients with STS of the Extremities
14.2.6 Therapeutic Principles
Sarcoma Centre: Tumour Board—Interdisciplinary, Multimodal Therapy
Surgery
Oncosurgical Resective Surgery
Wide Excision
Compartment Resection
Limb Amputation
Reconstructive Surgery
Surface Restoration
Functional Restoration
Tumor Recurrence Surgery
Tumor Metastases Surgery
Radiotherapy
Principle
Application
Neoadjuvant Radiotherapy
Intraoperative Radiotherapy
Chemotherapy
Hyperthermia/Isolated Limb Perfusion
Tumor Follow-up
Local Tumor Follow-up
Systemic Tumor Follow-up
14.2.7 Guidelines
14.3 Retroperitoneal Sarcomas
14.3.1 Epidemiology and Prognosis
Epidemiology
Prognosis and Prognostic Factors
14.3.2 Pathology
14.3.3 Classification
AJCC/UICC
TNM Classification
UICC Stages According to the TNM Classification
14.3.4 Molecular Genetics
14.3.5 Clinical Presentation
Early Symptoms
Clinical Symptoms (If Present)
14.3.6 Diagnosis
Medical History and Clinical Examination
Radiology
Multiphase Spiral CT scan
MRI
PET/PET-CT
Renal Scintigraphy
Biopsy
NCCN Guidelines
14.3.7 Therapy
Surgical Therapy
En Bloc Organ Resection
Principle En Bloc Resection
Morbidity and Mortality
Independent Predictive Factors Associated with a Lower Locoregional Tumor Recurrence Rate
Radiotherapy
Preoperative Radiotherapy (PrR)
Main Objectives of the PrR
Theoretical Advantages of PrR (Nussbaum et al. 2014)
Intraoperative Radiotherapy (IORT)
Principle
Limits of the IORT
Postoperative Radiotherapy (PostR)
Chemotherapy
Preoperative Chemotherapy
Adjuvant Chemotherapy
14.3.8 Management of Recurrences
Incidence
Treatment of the Recurrence
14.3.9 Follow up
Evidence
Strategy
14.3.10 Guidelines
References
15: Perioperative Medicine
15.1 Preoperative Phase
15.1.1 Risk Stratification
Identification of Patient-Related Risks
Systemic Diseases with High Postoperative Risk
Perioperative Risk (. Table 15.2)
Intubation Conditions
15.1.2 Laboratory and Blood Products
Blood Management
Laboratory Diagnosis
15.1.3 Additional Investigations
ECG
Chest X-Ray
Pulmonary Function Diagnosis
15.1.4 Perioperative Anticoagulation
Coronary Artery Disease and Stent Implantation
Perioperative Thrombosis Prophylaxis
New Oral Anticoagulants (NOACs/DOACs)
15.1.5 Medication Management
Continue
Convert
Discontinue
Endocarditis Prophylaxis
15.1.6 Information from the Anaesthetist’s Point of View
Legal Situation (Germany)
Prerequisite
Requirement
Elements of Consent
Outpatient Interventions
Living Will or Health Care Proxy
15.2 Intraoperative Phase
15.2.1 Intraoperative Monitoring According to AAGBI and BDA Guidelines
15.2.2 Volume Management
15.2.3 Hemodynamics
Pathophysiology
Risk Factors for Hypotension
Principles/Goals
15.2.4 Heat Retention
15.2.5 Perioperative Antibiotic Therapy
Incidence of SSI (“Surgical Site Infection”)
Risk Factors
Pathogen Spectrum
Prevention
Perioperative Antibiotic Prophylaxis (PAP)
15.3 Postoperative Phase
15.3.1 Analgesia
Pathophysiology
Evidence-Based Analgesia
Pain Measurement
Principles
15.3.2 Postoperative Nausea and Vomiting (PONV)
Forecasting Systems
Prophylaxis
Therapy
15.3.3 Delirium/Postoperative Cognitive Deficit (POCD)
Epidemiology
Division
Preoperative Evaluation of Risk Factors
Prevention
Early Screening
Therapy
15.3.4 Recovery Room (PACU)
15.3.5 Intensive Care Unit (ICU)/Intermediate Care (IMC)
15.4 Fast Track Surgery
15.4.1 Definition
15.4.2 Preoperative Management
15.4.3 Intraoperative Management
15.4.4 Postoperative Management
Analgesia
Early Mobilization
Optimized Diet
15.4.5 Guidelines
Reference
16: Emergency Surgery
16.1 Polytrauma: Abdominal Trauma
16.1.1 Anatomy of the Abdomen
External Divisions
Anterior Abdominal Wall
Lateral Abdominal Wall (= Flank)
Quadrant/Sector Breakdown
Internal Divisions
Abdominal Cavity
Pelvis
16.1.2 Injury Mechanisms (Aetiology and Pathophysiology)
Blunt Abdominal Trauma
Deceleration Trauma
Crush Injury
Compression Injury
Penetrating Abdominal Trauma
Stab Wound
Gunshot Wound
Impalement Injury (Due to Accidents)
16.1.3 Management and Diagnosis
Primary Management
Anamnesis
Clinical Presentation
Laboratory Tests
Diagnostic Imaging
X-ray
Ultrasound Examination
Computer Tomography
16.1.4 Therapeutic Procedure
Conservative Therapy
Blunt Abdominal Trauma
Penetrating Abdominal Trauma
Surgical Therapy
Circulatory Instability
Circulatory Stability
Major Visceral Trauma/Complex Surgery
16.1.5 Guidelines
16.2 Ileus/Obstruction
16.2.1 Definition—Classification
Definition
Classification
16.2.2 Epidemiology
16.2.3 Pathophysiology
“Circulus Vitiosus” of Ileus
Intestinal Distention
16.2.4 Diagnosis
Medical History and Symptoms
Clinical Examination: Status Survey
Lab
Quantity/Quality of Gastrointestinal Contents Discharged
Imaging
Ultrasound
Conventional Abdominal Radiograph
Contrast-Enhanced (Gastrographin) Conventional X-Ray
Computer Tomography (CT scan)
16.2.5 Mechanical Ileus (Mechanical Obstruction)
Etiology and Pathogenesis
Etiology (. Table 16.1)
Pathogenesis
Specific Symptoms
High Small Bowel Ileus
Low Small Bowel Ileus
Large Bowel Obstruction
Complications
16.2.6 Paralytic Ileus/Functional Obstruction
Etiology and Pathogenesis
Etiology (. Table 16.2)
Pathogenesis
Specific Symptoms
16.2.7 Therapy
Conservative Therapy
General Measures
Antibiotic Therapy
Drug Stimulation in Paralytic Ileus
Surgical Therapy
Goals
Emergency Indications
Relative Indications
16.2.8 Specific Therapy for Certain Types of Ileus
Paralytic Ileus
Conservative Therapy
Surgical/Endoscopic Therapy
Vascular Ileus
Strangulation Ileus
Postoperative Ileus
Ogilvie’s Syndrome
Large Bowel Obstruction Due to Colon Cancer
Conservative Therapy
Bridge-to-Surgery
Primary Resection
Gallstone Ileus
Volvulus
16.3 Abdominal Compartment Syndrome
16.3.1 Definitions
Intra-Abdominal Pressure (IAP)
Abdominal Perfusion Pressure (APP)
Intra-Abdominal Hypertension (IAH)
Abdominal Compartment Syndrome (ACS)
16.3.2 Aetiology
Classification of Abdominal Compartment Syndrome (ACS, . Table 16.3)
Pathophysiology
16.3.3 Clinical presentation
Risk Factors
Symptoms
16.3.4 Diagnosis
Bladder Pressure Measurement (Gold Standard)
Clinical Presentation
Imaging
16.3.5 Therapy
General Principles of Therapy
WSACS Guidelines
Supportive Measures
Goals
Conservative Measures
Improvement of Abdominal Wall Compliance
Decrease in Intra-Abdominal Volume
Surgical Measures
Decompressive Laparotomy
New Alternatives
Temporary Abdominal Closure
Definitive Abdominal Closure
16.3.6 Guidelines
16.4 Intestinal Ischemia
16.4.1 General
16.4.2 Acute Intestinal Ischaemia
Epidemiology
Etiology and Pathogenesis
Clinical Presentation
Non-Specific Clinical Presentation
3-Phase Clinical Course (Rarely Detectable)
Diagnosis
Anamnesis
Laboratory Tests
Diagnostic Imaging
Therapy
Stabilization
Acute Mesenteric Artery Embolism
Acute Mesenteric Artery Thrombosis
Acute Mesenteric Vein Thrombosis
Ischemic Colitis and Nonocclusive Mesenteric Ischemia (NOMI)
16.4.3 Chronic Mesenteric Ischaemia (CMI)
Etiology and Pathogenesis
Etiology
Pathogenesis (= Atherosclerosis)
Clinical Presentation
Diagnosis
Therapy
16.4.4 Guidelines