The management of thoracic aortic disease is based upon the aortic pathology and anatomy. The thoracic aorta is evaluated in four separate segments: the aortic root, ascending aorta, transverse arch, and descending aorta. In addition to the aortic disease, factors that affect the timing and extent of surgical replacement of the thoracic aorta include the presence of aortic valve pathology, concomitant cardiac disease, and the patient's age and comorbidities. This chapter will review the most common indications for treatment of diseases of the thoracic aorta and the perioperative care of patients undergoing aortic surgery.

The most common indications for surgery on the thoracic aorta, in descending order, are aneurysmal disease, acute aortic syndromes, trauma, and infection. The incidence of thoracic aortic aneurysms is estimated to be 5.9 cases per 100,000 person-years, and replacement of the ascending aorta accounts for the majority of thoracic aorta procedures. The most common causes of thoracic aortic aneurysms (TAAs) are cystic medial necrosis; atherosclerosis; heritable connective tissue disorders (e.g., Marfan syndrome); familial, bicuspid aortic valve disease; and chronic aortic dissection. The presence or absence of symptoms is the most important factor in the management of patients with thoracic aortic aneurysms. Patients with symptomatic TAAs typically experience chest or back pain, depending upon the location of the aneurysm. The sudden onset of pain is considered an ominous warning sign of imminent rupture or dissection, and surgery is indicated for all patients with symptomatic TAAs.

In the late nineteenth and early twentieth century it was taught that vaginal hysterectomy could not be performed if the uterus was enlarged, but uterine size was never quantified. Other suggested contraindications included a ‘narrow vagina’ (pubic arch < 90°) and a diminished bituberous diameter (< 8.0 cm). The bituberous diameter represents the distance between the ischial tuberosities (or sitting bones) which are easily palpated when the patient is in the dorsal lithotomy position. Nulliparity and “a uterus that was too high or did not come down” were also considered as contraindications to the vaginal approach, as were “intra-abdominal conditions” such as endometriosis, adhesions, previous pelvic surgery, previous cesarean section, and chronic pelvic pain.

Hysterectomy became the second most common operation performed in the USA in the middle twentieth century, but the complications related to this operation were not re-evaluated until 1982. The Collaborative Review of Sterilization (CREST) from the CDC studied the complications of abdominal and vaginal hysterectomy. For operative indications that could have been performed by either route, abdominal hysterectomy had a complication rate twice that of the vaginal approach.

Nephrectomy is a common urologic procedure indicated for malignancy, certain benign conditions of the kidney and renal transplantation. Simple, radical, partial and donor nephrectomies and nephroureterectomy all have common surgical steps but have unique complications. Renal tumor ablative interventions are the more commonplace attempts to limit patient morbidity.

Simple nephrectomy is indicated for benign but not trivial conditions. Indications include non-functioning kidneys causing pain (usually from congenital obstruction or urolithiasis), reno-vascular disease causing uncontrollable hypertension, benign symptomatic tumors (angiomyolipomas), trauma, or treatment of infectious diseases (xanthogranulomatous pyelonephritis, chronic or emphysematous pyelonephritis, and tuberculosis). During simple nephrectomy, the kidney is removed within Gerota's fascia along with a small amount of ureter. Nephrectomy for inflammatory conditions can be the most exacting of procedures; medical comorbidities add to the challenge of patient management.

Donor nephrectomy is a simple nephrectomy in which ahealthy kidney (usually the left because of increased veinlength) is removed and transplanted as an allograft in a controlledscheduled situation. These donor patients are allhealthy and have had extensive preoperative evaluations.Transplant nephrectomy is a simple nephrectomy in whichthe renal allograft is removed, usually because of rejectioncomplications.

Radical nephrectomy involves the removal of all structureswithin Gerota’s fascia, which includes the adrenal, kidney, andperi-renal tissue. Adrenal-sparing radical nephrectomy, especiallyfor lower pole tumors, has become commonplacebecause of the low incidence of ipsilateral adrenal invasion ormetastases. Most renal tumors are found incidentally by CT orMRI, or during the process of hematuria screening. Upwardsof 95% of enhancing renal masses are malignant; therefore,needle biopsy or pathologic proof before surgery is not routinelyobtained.

Surgery has major effects on carbohydrate metabolism and thus presents special risks for patients with diabetes. Surgical mortality rates for patients with diabetes have declined but the successful perioperative care of these patients requires close cooperation between surgeons, anesthesiologists, and primary physicians to prevent complications. There are 25.8 million children and adults in the USA with diabetes – 8.3% of the population [1]. Diabetes is listed as a diagnosis on 23% of hospital discharges [2]. At least half of these patients will require surgery at some point in their lives. In addition to surgical conditions typical of the general population, patients with diabetes have an increased incidence of occlusive vascular disease; cholelithiasis; ophthalmic disease (i.e., cataract extraction, vitrectomy); renal disease; and infection. Three of four patients with diabetes are older than 40 years and are approaching a time of life when surgical indications increase. The presence of diabetes typically is known prior to surgery, although a new diagnosis of diabetes is made in the perioperative period in as many as 12% of cases [3].

Hyperglycemia in the hospital is common and may result from stress, infection, effect of procedures, or is iatrogenic [4]. Previously, glucose levels between 100 and 200 mg/dL were not treated in the perioperative period. This practice was challenged by studies suggesting that more aggressive treatment of elevated glucose levels with insulin reduces infectious complications, decreases mortality, and decreases length of hospital stay [5–7]. Many hospitals developed programs, and started treating both medical and surgical patients with intensive insulin therapy to maintain blood glucose at or below 110 mg/dL, particularly in ICU settings. But, following studies performed in other ICUs, particularly medical ones, failed to reproduce the beneficial effects of intensive insulin therapy. In fact, intensive insulin therapy increased the risk of death [8–11]. One study demonstrated a 2.6% absolute increase in 90-day mortality in patients randomized to tight glucose control [10]. This may have been related to the increased risk for hypoglycemia in the intensive insulin group [12].

Currently, pneumonectomy is often performed for a bulky and centrally located carcinoma of the lung. Occasionally it is indicated for a destroyed lung secondary to chronic infectious disease such as tuberculosis, bronchiectasis, or fungal disease. In general, we favor preservation of pulmonary parenchyma and avoidance of pneumonectomy through the use of bronchial and/or vascular sleeve resections when possible.

All patients require a thorough evaluation to rule out metastatic disease as well as to ascertain their ability to tolerate the operation. Assessment of their cardiac status is carried out as per the American College of Cardiology/American Heart Association guidelines. Evaluation of the pulmonary status includes pulmonary function tests and, in marginal cases, quantitative ventilation/perfusion scans and cardiopulmonary exercise testing.

The operation is performed under general anesthesiaadministered via a double-lumen endotracheal tube.Although potentially feasible thoracoscopically for sometumors, our current approach for a pneumonectomy isthrough a posterolateral thoracotomy. A thoracic epiduralis the cornerstone of pain management in patients undergoinga thoracotomy. The patient is placed in the lateraldecubitus position with the operated side superior; the tableis flexed maximally at the level of the patient’s hips; andcontralateral single lung ventilation is started. Fiberopticbronchoscopy allows confirmation of tube position andhelps to rule out endobronchial disease. Continuous intraoperativemonitoring of vital parameters has increased thesafety of these procedures. A second-generation cephalosporinis administered preoperatively and continued fortwo postoperative doses. Almost all patients are extubatedin the operating suite following surgery.

Early detection and advances in the medical treatment of patients infected with the human immunodeficiency virus (HIV) has moved the care for many patients from acute to chronic care over the last decade. Accordingly, as in any other immunosuppressed patient, there is no strict contraindication to major abdominal surgery in HIV-positive patients. In general, patients with undetected viral load and CD4 T-cell count greater than 200 mm3 undergo emergent laparotomy for the same indications as any other individual (gastrointestinal perforation, refractory hemorrhage, ischemia, and complete bowel obstruction). CD4 count less than 200 mm3 is a predictor for postoperative sepsis and, therefore, additional judgment should be exercised before performing laparotomy because several opportunistic medical infections can mimic peritonitis and potentially can prompt unwarranted exploration. These infections most commonly include mycobacterium avium complex (MAC), cytomegalovirus (CMV), and microsporidia. HIV-positive patients who are immunocompromised are also at increased risk for more uncommon malignancies (non-Hodgkin's lymphoma and Kaposi's sarcoma). HIV-positive patients experience frequent diarrhea (30–60%). Therefore, infectious etiologies for patients with abdominal pain and diarrhea must be investigated to rule them out as causes of acute abdominal pain. Organomegaly may also be a cause of pain in these patients.

One retrospective study has shown that 8% of patients presenting to the emergency room with acute abdominal pain and HIV required abdominal surgery. In the same study, acute abdominal pain in patients with advanced HIV was found to be secondary to opportunistic infections in 10% of the patients. The most common cause of emergency laparotomy in AIDS patients is perforated viscous from CMV. In the absence of a working diagnosis, diagnostic laparoscopy can be considered as an initial means of abdominal exploration to avoid a large laparotomy incision. Common acute abdominal conditions such as appendicitis and cholecystitis should be treated accordingly. In patients with a negative laparotomy result, culture and biopsy of mesenteric lymph nodes is indicated in order to help determine rare infectious etiologies for the development of acute pain.

Patients who develop ductal carcinoma or carcinoma of the breast generally require operative treatment of their disease process in conjunction with chemotherapy and/or radiation therapy. Ductal carcinoma in situ (DCIS) is a non-invasive process that most commonly presents as microcalcifications on screening mammography, and accordingly the incidence has increased substantially from the time that screening mammography became widespread. The rates at which DCIS progresses to an invasive process vary, but it is associated with an elevated risk of developing carcinoma and, accordingly, surgical treatment is the current standard of care. Diagnosis is made by an image-guided biopsy in which a core of tissue is interpreted by a histopathologist. DCIS represents a heterogeneous group of pathologic subtypes, with comedo-type necrosis representing cellular features that are associated with aggressive behavior and higher risk of progression to invasive cancer.

While standard treatment of DCIS formerly was mastectomy secondary to a high incidence of multicentric disease, current care for patients with DCIS largely allows for breast conservation techniques in appropriately selected patients. The Van Nuys Prognostic Index (VNPI) looks at three statistically significant predictors of local recurrence: tumor size, margin width, and pathologic classification. Patients who have increased predictors of recurrence undergo lumpectomy followed by radiation treatment rather than mastectomy, while patients with a low VNPI can undergo lumpectomy alone. Of note, a margin less than 1 cm is an independent predictor of recurrence and, accordingly, re-resection rather than radiation treatment is recommended. Although the recommendation for evaluation of the axilla with sentinel node biopsy in patients with DCIS is controversial, those patients with diffuse DCIS or pathologically aggressive features are generally considered appropriate candidates for sentinel lymph node biopsy. Additional adjuvant treatment with tamoxifen, an anti-estrogen drug, should also be considered on an individual basis as it has been shown to reduce both ipsilateral and contralateral breast cancer events.

Introduction

Peptic ulcer disease (PUD) refers to a defect in the gastrointestinal mucosa of the stomach or duodenum that penetrates through the muscularis mucosa. Most studies of PUD have defined an ulcer as requiring a minimum diameter of 5 mm, although this size criterion is arbitrary. Ulcers form when there is a mismatch in protective and damaging gastrointestinal factors, with the most common destructive factors being infection with the bacteria Helicobacter pylori and use of non-steroidal anti-inflammatory drugs (NSAIDs). Without treatment of the primary cause, PUD is typically a relapsing-remitting chronic condition. Symptoms are variable, are often non-specific, and may even be absent. The mainstay of diagnosis of PUD is upper endoscopy. Since PUD is an acid-related condition, treatment includes acid suppression as well as specific treatment aimed at any causative factors identified.

Epidemiology

The worldwide incidence of PUD is approximately 0.1–0.2% and appears to be decreasing [1]. Furthermore, hospitalization rates, need for surgery, and PUD-related mortality are also all decreasing [2,3]. These improvements are likely due to the decreased prevalence of H. pylori, use of increasingly potent acid suppression, and the increased therapeutic role of upper endoscopy. The prevalence of PUD in patients with H. pylori infection is 1–6% [4], and is 11% in patients taking low-dose aspirin [5]; in the absence of H. pylori infection or NSAID use PUD is uncommon [6].

The median sternotomy was first described by Julian in 1957 for use in cardiac surgery. A 5% sternal wound infection rate was reported, and the treatment of choice was debridement and open packing. Since that time, management of sternal wounds has changed drastically. Shumacker and Mandelbaum introduced the closed-chest catheter irrigation system in 1963 and reduced mortality from 50 to 20%. The pedicled omental flap was advocated by Lee et al. in 1976. A few years later, Jurkiewicz et al. revolutionized the treatment algorithm with the introduction of muscle flaps.

Sternal wound infections are divided into superficial (affecting the skin, subcutaneous tissue, and pectoralis fascia only) and deep. It is important to recognize patient risk factors (including, but not limited to): BMI > 30 kg/m2, diabetes mellitus, urgent operation, sepsis/endocarditis after surgery, smoking history within one year, COPD, renal insufficiency, and history of stroke. The most commonly isolated pathogen is coagulase-negative staphylococcus, followed by Staphylococcus aureus, Propioni, Acinetobacter, Enterobacter cloacae, Escherichia coli, and Klebsiella. There is a subset of patients who never grow bacteria; they are deemed to have non-infectious sternal dehiscence.

Facial plastic surgery is conceptually divided into aesthetic and reconstructive disciplines. Indications for aesthetic surgery include the sequelae of facial aging: rhytidosis, facial and cervical skin laxity and redundancy, brow ptosis, dermatochalasis and generalized periorbital aging, and cervical fat excess. Additional indications include refinement of nasal, ear, or chin deformities as well as cheekbone and lip enhancement. Reconstructive procedures are indicated for correction of nasal airway obstruction, deformities following facial trauma or cancer resection, and birth defects. Surgical interventions vary in complexity and duration based on the indications and goals of the procedure. Regardless of the indication, facial plastic surgery is most often an elective procedure done to improve the patient's quality of life. Knowledge of relevant complications and sequelae is essential to enlighten the patient so that an informed decision can be made. Realistic expectations including surgical limitations should be thoroughly addressed with each patient preoperatively to avoid postoperative psychological distress and dissatisfaction.

The choice of anesthetic techniques for these procedures is evenly divided between general anesthesia and a combination of local anesthesia with intravenous sedation. Patient preference, surgical expertise, and expected procedure duration should all be considered in the choice of anesthesia. Blood loss from facial plastic and reconstructive procedures is usually minimal and cases requiring transfusions are the rare exception.

Introduction

Advances in medical care have led to increasing numbers of complex, high-risk, obstetric patients. With assisted reproductive technology, women at older maternal ages with medical comorbidities are able to conceive. Internists are often consulted to assist or even primarily manage pregnant women with preexisting medical disease or conditions that develop during pregnancy. This chapter will focus on several of the most common conditions that are unique to pregnancy or that occur due to the physiologic changes during the gestational period.

Cardiovascular

Cardiovascular changes in pregnancy occur predominantly in the first trimester, plateau in the second trimester, and then peak again around the time of labor and delivery. One of the earliest changes seen is a fall in systemic vascular resistance (SVR), reaching its nadir at 14–24 weeks of gestation, and then rising at term [1]. The early fall in SVR relates to peripheral arterial vasodilation, mediated by progesterone and perhaps nitric oxide [2]. In response to falling SVR, the heart rate rises, up to 20% by the third trimester [3]. An increase in heart rate leads to decreased time for diastolic filling and can lead to reduced cardiac output (CO) and perfusion pressures. In the first trimester CO rises and peaks by the end of the second trimester at approximately 30–50% over non-pregnant values. It rises again at the onset of labor, and declines rapidly after delivery [1]. Finally, blood pressure (a product of CO and SVR) falls by approximately 10% in early pregnancy, returning to normal pre-pregnancy values around term [4].

Refractive surgery is performed to reduce dependence on glasses or contact lenses. Refractive surgical techniques reshape the cornea using incisions, heat, various forms of laser, or implantation of intraocular lenses to decrease myopia (nearsightedness), astigmatism, or hyperopia (farsightedness). The excimer laser is currently the technology of choice for keratorefractive surgeons. The laser can reshape the cornea by ablating the anterior corneal surface in procedures such as photorefractive keratectomy (PRK), and more commonly in laser-assisted in situ keratomileusis (LASIK). In LASIK, the surgeon performs corneal stromal ablation using the excimer laser directed to the corneal tissue under a thin lamellar flap. This flap is created by either a microkeratome or a laser.

In order to select the best candidates for refractive surgery, a thorough preoperative history, assessment, and complete eye exam is required. Parameters such as corneal topography, central corneal thickness, degree of refractive error, ocular surface health and patient expectations are all carefully considered in order to determine whether the individual is a good refractive surgical candidate, as well as for selecting the most appropriate procedure. Absolute contraindications to laser vision correction include diagnoses of keratoconus or ectatic corneal dystrophies. Relative systemic contraindications include poorly controlled rheumatoid arthritis and diabetes, pregnancy, and AIDS.

Removal of an eye or the contents of an orbit may be indicated when the eye is affected by neoplasia or a severe infectious process, or when an end-stage ocular disease in a blind eye causes pain. These ophthalmic interventions are usually classified as:

1. Enucleation: the removal of the entire globe, including the sclera, intraocular contents, and the cornea. The stump of the optic nerve as well as the extraocular muscles are left behind.

2. Evisceration: the removal of intraocular contents including the lens, uvea, retina, vitreous humor, and in some cases the cornea. Only the sclera and extraocular muscles remain intact.

3. Exenteration: the removal of the globe and all of the orbital contents. This procedure may include removal of selective sections of orbital bone.

Following enucleations and eviscerations, an orbital implant is used to replace the globe and restore the lost orbital volume. The implant or sphere serves to maintain the structure of the orbit and to provide motility to the overlying prosthesis. For children, it additionally serves to maintain more normal growth of the surrounding orbital bones. In cases of exenteration, an osseointegrated prosthesis may be attached within the orbit, secured with metal support elements or magnets that are attached to bone.

The meningeal layers covering the brain consist of an outermost layer (the dura mater), a middle layer (the arachnoid membrane), and an inner layer (the pia mater). Between these layers are potential spaces where fluid can collect. Hemorrhage above the dura is called an epidural hematoma. Hemorrhage below the dura is called a subdural hematoma (SDH), and hemorrhage below the arachnoid membrane is called subarachnoid hemorrhage. Bleeding within brain tissue itself is called intraparenchymal hemorrhage, and bleeding into the ventricles is intraventricular hemorrhage. The prognosis and management of these findings are different, so misnomers such as “head bleed” should be avoided when describing an intracranial hemorrhage. Subdural hematomas can grossly be divided into acute, subacute, and chronic. The duration of an acute hematoma is less than 3 days; that of subacute hematoma is from 3–20 days. A chronic hematoma persists for more than 21 days.

Acute subdural hematoma

Historically, the occurrence of acute SDH has been posited to be due to tearing of the bridging veins. This condition can often result from the direct extension of bleeding from a lacerated or contused brain. The most common reported causes of acute SDH are motor vehicle collisions, falls, and assault. This type of injury is seen 3–5 times more often in males than in females; median age is generally in the 40s. As compared with patients with epidural hematoma, patients with acute subdural hematoma are more likely to have associated parenchymal damage and a higher morbidity and mortality. An important category of subdural hematoma patients are those on anti-coagulation therapy. Patients taking anti-coagulants are at risk for intracranial hemorrhage following low-impact injuries such as ground level fall or low-velocity motor vehicle collision. Furthermore, in this patient population, SDH often develops spontaneously and without evidence of antecedent trauma.

Common bile duct exploration is indicated for radiologically confirmed or manually palpable gallstones in the common bile duct (choledocholithiasis). These stones can be asymptomatic or causing obstructive jaundice, gallstone pancreatitis, or ascending cholangitis. It is also indicated to diagnose and treat obstructive jaundice from a benign or malignant stricture; to diagnose and treat stenosis of the sphincter of Oddi; or to repair an injury caused by operation or trauma. Choledochotomy is also appropriate when there are no other alternatives to decompress the common bile duct.

When a stone is identified preoperatively, it is most effective to perform a preoperative ERCP (endoscopic retrograde cholangiopancreatogram) with sphincterotomy to allow extraction of, or access to, common bile duct stones. Patients with resolved cholangitis, persistent jaundice, unresolving pancreatitis, or common bile duct stones documented by other tests are ideal candidates for preoperative ERCP. For stable patients, ERCP may also be performed after cholecystectomy is performed. With the availability of ERCP, the need for open or laparoscopic exploration of the common bile duct has decreased significantly in recent years.

Parathyroidectomy is performed most commonly in patients with primary hyperparathyroidism and those who are dialysis-dependent and have symptomatic secondary hyperparathyroidism. In patients who have hypercalcemia on dialysis or after renal transplantation (tertiary hyperparathyroidism), operation is also indicated. A physical examination, chest radiograph, and intact parathormone assay distinguish between primary hyperparathyroidism and the hypercalcemia of sarcoidosis, metastases, or a paraneoplastic syndrome. A 24-hour urinary calcium test is occasionally indicated to rule out familial hypocalciuric hypercalcemia. Currently, virtually all preoperative patients undergo localization studies such as cervical ultrasonography, computed tomography with intravenous contrast or radionuclide scanning after the intravenous injection of 99mtechnetium-labeled sestamibi in order to allow for shortened operations through limited incisions. A curative parathyroidectomy not only results in improvements in serum calcium but also improvements in bone density, neuropsychiatric symptoms, calciphylaxis, nephrocalcinosis, nephrolithiasis, and cardiovascular risk.

Preoperative therapy to lower extraordinarily elevated serum calcium levels in patients with parathyroid comas or suspected carcinomas should include saline infusions, furosemide, bisphosphonates and, occasionally, calcitonin. Parathyroidectomy is usually performed under general anesthesia through a low collar incision, although local anesthesia is appropriate for elderly and high-risk patients as well as those undergoing minimally radio-guided parathyroidectomy or image-guided focal exploration.