1. www.acssurgery.com
WILEY W. SOUBA, MD, ScD, FACS, Editorial Chair DOUGLAS W. WILMORE, MD, FACS, Founding Editor September 2008
THE BEST THIS MONTH’S UPDATES
SURGICAL 2 Head and Neck tissue from the mass is often useful.
The preferred biopsy method is
THINKING 3 Neck Mass
BARRY J. ROSEMAN, MD, FACS
fine needle aspiration. Diagnostic
imaging is indicated if the results are
likely to affect subsequent therapy.
Training in Acute Care Roseman and Budayr, MD, PC Ultrasonography differentiates solid
Maryville, TN masses from cystic ones. CT is also
Surgery: Trauma, Critical useful in this manner and for
Care, and Emergency General ORLO H. CLARK, MD, FACS determining whether a mass is
Surgery, Part 1 Professor, Department of Surgery, within or outside a gland or nodal
University of California San chain. Other imaging tools include
GREGORY J. JURKOVICH, MD, FACS
Francisco, Mount Zion Medical arteriography, angiography,
Professor, Department of Surgery,
Center, San Francisco, CA radiographs, and chest x-rays.
University of Washington School of
Medicine, Chief of Trauma Services,
Harborview Medical Center, Seattle,
DOI 10.2310/7800.S02C03 Management of Head and
WA Various surgical procedures are Neck Masses
reating inflammatory and
DOI 10.2310/7800.2008.NCsep
he practice of trauma care in
required for most masses of the
head and neck; inflammatory and T infectious disorders—cervical
T North America is in evolution,
and the force and rate of this change
infectious disorders are treated
medically.
adenitis (e.g., tonsillitis), subcutaneous
abscesses, various chronic infections,
or chronic inflammatory disorders
are unsettling to many surgeons and valuating any head or neck mass (e.g., sarcoidosis)—is primarily
surgical trainees. The training of
trauma and emergency surgery is
E begins with a careful history. The
physician should check for duration
medical rather than surgical.
Of the possible congenital cystic
deeply rooted in all branches of and growth rate of the mass, lesions, thyroglossal duct cysts
surgery but perhaps is most closely evidence of infection or inflamma- account for about 70% and are
allied with general surgery. The tion, history of trauma, any factors generally surgically removed.
contemporary practice of trauma suggestive of cancer, asymmetry and Branchial cleft cysts are treated by
care at major trauma centers can be skin changes, and origin of the mass, surgical removal of the cyst and the
traced to the city-county hospitals in along with its movement, depth, and sinus tract. Cystic hygromas may be
the 1960s and to the research and a tenderness. A detailed examination continued on page 4
new understanding of resuscitation of the cervical lymph nodes, skin,
strategies that arose from the thyroid gland, major salivary glands,
Vietnam War.1 During the ensuing
two decades, trauma surgery became
oral cavity and oropharynx, larynx In This Issue
and hypopharynx, and the nasal
The Best Surgical Thinking
cavity and nasopharynx should Training in Acute Care Surgery:
Part 2 of this column, which publishes
occur. Trauma, Critical Care, and Emergency
in the October 2008 update of What’s General Surgery, Part 1 1
New in ACS Surgery, will discuss the
response to these social pressures by the 2 Head and Neck
surgical community and the future Neck Mass Diagnosis 3 Neck Mass 1
training paradigms for trauma, critical Through Biopsy and Imaging 5 Gastrointestinal Tract and
care, and emergency general surgery. Abdomen
nitial diagnostic impressions
continued on page 2 I determine the next steps. Sampling
29 Intestinal Anastomosis 4

2. 2 What’s New in ACS Surgery • September 2008 www.acssurgery.com
THE BEST SURGICAL THINKING
continued from page 1
Owned and published by
an attractive career based largely on BC Decker Inc
centers,3 with 84% of the popula-
the mentorship of general surgeons tion within 1 hour of a level I or II EDITORIAL CHAIR:
Wiley W. Souba, MD, SCD, FACS, Columbus, OH
in urban city-county hospitals such trauma center.4 This remarkable
FOUNDING EDITOR:
as Chicago (Freeark), Dallas, adaptation of regionalized medical Douglas W. Wilmore, MD, FACS, Boston
(Shires), and San Francisco (Blais- care is nearly unique to trauma and EDITORIAL BOARD:
dell) and was rapidly spread by the has clear evidence of a survival Mitchell P. Fink, md, facs, Pittsburgh Gregory
devotees of the charismatic leaders benefit.5 J. Jurkovich, md, facs, Seattle Larry R. Kaiser,
md, facs, Houston William H. Pearce, md, facs,
of those surgical departments. They But with this success came Chicago John H. Pemberton, md, facs,
epitomized the master technician changes in surgical practice. In Rochester, MN Nathaniel J. Soper, md, facs,
Chicago
who developed an academically community and university hospitals,
COUNCIL OF FOUNDING EDITORS:
productive career based on the the trauma surgeons were discour- Murray F. Brennan, md, facs, New York
physiology of the injured patient. aged, or even banned, from develop- Laurence Y. Cheung, md, facs, Kansas City
ing any elective general surgical Alden H. Harken, md, facs, San Francisco
These trauma surgeons (although James W. Holcroft, md, facs, Sacramento
they did not call themselves that) practice. Advances in diagnostic Jonathan L. Meakins, md, dsc, facs, Oxford
operated confidently and effectively imaging and clinical research PUBLISHER:
in all body cavities and perhaps activities led to the recognition that President, Brian C. Decker
not all cases of blood in the abdo- Vice President, Sales, Rochelle J. Decker
were the last of the “master sur- Vice President and Publisher, Liz Pope
geons” that once were the hallmark men or chest required an operation. Managing Editor, Susan Cooper
of general surgery. Operating Injury prevention strategies began to Director, Journal Sales, Anna King
Manager, Customer Care and Distribution, Marie
primarily in large-volume public, take hold, decreasing the incidence Moore
city-county hospitals, these surgeons of injury from automobiles, falls, Rights and Permissions, Ryan Decker
Director, Digital Publishing, David Love
were also typically referred the most and burns; even the injury incidence Electronic Media Systems Analyst, Jeff Ferguson
challenging surgical problems, not of penetrating trauma violence fell Senior Web/IT Developer, Faisal Shah
only in their own institution but also in all but the most densely popu- ACS Surgery: Principles & Practice (bound
from around the city or region, lated urban areas. Trauma surgery volume: ISBN 978-1-55009-399-5; CD-ROM:
ISBN 978-1-55009-421-3; quarterly CD ROM:
particularly if there was a financial became synonymous with nonopera- ISSN 1538-3210; online: ISSN 1547-1616) is
disincentive to caring for the patient tive care and, with that, a decline in owned and published by BC Decker Inc, 50 King
interest and enthusiasm for this as a St. E., 2nd Floor, PO Box 620, LCD1, Hamilton,
at a private hospital. Consequently, ON L8N 3K7, Canada, Web site: http://www.
the city-county or “safety net” surgical career.6 The extra training bcdecker.com. © 2008 BC Decker Inc. All rights
hospital trauma surgeons developed for added qualifications in surgical reserved. No part of this issue may be reproduced
by any mechanical, photographic, or electronic
an active elective surgical practice critical care became almost a process or in the form of a phonographic
while providing trauma coverage.2 requirement for most trauma recording, nor may it be stored in a retrieval
system, transmitted, or otherwise copied for
Many forces changed that programs and many hospitals, but public or private use without written permission
scenario. The academic success of the accrediting agency demanded of the publisher.
trauma surgeons fostered their that this training be largely devoid Annual subscription rates in Canada and the
incorporation into university of operative experience. The USA: Quarterly CD-ROM: $209 (individual),
$709 (institutional); Online: $189 (individual).
hospitals and the economic viability majority of patients cared for by Institutional Web site license pricing available on
of civilian blunt trauma care, trauma surgeons have never had an request. Please e-mail acssurgery@bcdecker.com.
abdominal or thoracic operation, Separate shipping and handling apply. All prices
particularly in no-fault automobile subject to change without notice and quoted in
but most have had an operation by US dollars.
insurance states, leading to an
another surgical specialist, notably POSTMASTER: Send address changes to BC
expansion of trauma programs into Decker Inc, PO Box 758, Lewiston, NY 14092-
an orthopedist or neurosurgeon. 0785.
private community hospitals. The
Residents began to see trauma
American College of Surgeons FOR ASSISTANCE WITH YOUR SUBSCRIPTION
surgeons as resuscitation doctors
contributed to the widespread Please address all inquiries to Fulfillment Department,
who surrender the actual operating
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remarkably successful and innova- effort is significantly less than that fax us at 905-522-7839 or 888-311-4987, or email us
tive activities of the Committee on received by the operating surgeons,
at acssurgery@bcdecker.com. For change of address,
please provide both your new and your old addresses;
Trauma, including the hospital particularly considering the time be sure to notify us at least six weeks before you
verification program, the Advanced involved.7 Added to this are the expect to move to avoid interruptions in your service.
Trauma Life Support course, a largely unrewarding jobs of interdis- YOUR FEEDBACK IS WELCOME
national trauma databank, and ciplinary coordination, communica- • E-mail: acssurgery@bcdecker.com
• Write: BC Decker Inc
work with the federal government tion, and discharge planning. This is P.O. Box 620, LCD1
on encouraging inclusive trauma a far cry from the “golden age of Hamilton, ON L8N 3K7
systems in each state. There are Canada
trauma surgery,” when trauma
currently over 1,100 trauma centers surgeons were considered “master
in the United States (of approxi- surgeons” who operated on the
mately 6,000 hospitals), including
190 level I centers and 260+ level II continued on page 3 www.acssurgery.com

3. www.acssurgery.com What’s New in ACS Surgery 3
THE BEST SURGICAL THINKING This Month’s CME
continued from page 2 Chapters
neck, chest, abdomen, and any Added to these challenges is the
ACS Surgery offers CME in
injured vessel, and nonoperative evolution (or perhaps revolution) in convenient online format. As
management was unusual.8 surgical training. The halstedian many as 60 AMA PRA Category
Yet now the pendulum appears to pyramidal surgical residency is 1 credits can be earned at
be swinging back once again. largely gone. The mandatory 80- any time during the year. The
Increasingly, trauma centers and hour work week is entrenched, with following chapters are available
trauma surgeons are once again not discussion centered now on reducing for CME credit this month:
simply providing trauma care but this time even further. But perhaps
the most significant influence on 2 Head and Neck
much more broad-based emergency 3 Neck Mass
surgical care of all disciplines. In surgical training has been the change
large part, this has been the result of in the mores and values of current 5 Gastrointestinal Tract and Abdomen
a lack of interest or incentive for trainees and the complexities and 29 Intestinal Anastomosis
sophistication of care that continue
nearly all surgeons to provide “on-
to progress at a dizzying rate and
call” or emergency room coverage.
demand an emphasis on specialized
Declining reimbursement, fear of practices and hence specialized 5. MacKenzie EJ, Rivara FP,
malpractice litigation, disruptive training. The sheer depth and Jurkovich GJ, et al. A national
lifestyle, and conflict with elective breadth of cognitive and technical evaluation of the effect of
practices have all contributed to the knowledge in any one field of trauma-center care on mortal-
problem. Perhaps most contributive, medicine are making it difficult to ity. N Engl J Med 2006;354:
however, has been the continued have expertise in any broad arena. 366–78.
and unabated focus on specialty The era of generalists seems to be 6. Richardson J, Miller F. Will
training. The exodus of general gone or at least largely abandoned future surgeons be interested in
surgery trainees into surgical by most surgical trainees and their trauma care? Results of a
subspecialties has created a void of career plans. Recent analyses show resident survey. J Trauma
surgeons with the broad-based that 70 to 80% of graduates of
1992;32:229–35.
training and experience who are general surgery training programs
7. Esposito TJ, et al. Perception of
capable of providing the expertise are opting for further specialty
training and a practice that empha- differences between trauma
needed to continue the type of
sizes a more narrow focus.11 Like care and other surgical emer-
practice once common in city-
many social pendulums, this trend gencies: results from a national
county hospitals and in many rural
might be reversed, but current survey of surgeons. J Trauma
communities. This is a reflection of
health care expectations and patient 1994;37:996–1002.
both a demand in surgical staff that
demands are not supportive of the 8. Moore EE, Maier RV, Hoyt
has not yet been addressed and a
model of generalist care by physi- DB, et al. Acute care surgery:
tendency of hospitals and surgical
cians. Further adding to specializa- eraritjaritjaka. J Am Coll Surg
departments to acquiesce to this
tion is evidence of better outcomes 2006;202:698–701.
demand to attract and retain these with the concentration of complex
lucrative and desirable elective 9. Malangoni M. Acute care
problems and procedures and surgery: the general surgeon’s
clinical practices. These individuals remuneration strategies that favor
have completed the same residencies perspective. Surgery 2007;141:
specialized procedure care.12 324–6.
as others who see this as their
responsibility and often have been 10. Committee on the Future of
References Emergency Care in the United
certified in surgery by the American
Board of Surgery.9 Hence, we are 1. Blaisdell FW. Development of States Health System, Board on
the city-county (public) Health Care Services. The
faced with a crisis in access to
hospital. Arch Surg future of emergency care.
emergency surgical care in this
1994;129:760–4. Washington (DC): Institute of
country, a crisis addressed by the
2. Moore EE. Acute care surgery: Medicine of the National
National Academy of Sciences in a the safety-net hospital model.
three-volume analysis entitled The Academies; 2007.
Surgery 2007; 141:297-8.
Future of Emergency Care.10 This 11. Fischer JE. The impending
3. MacKenzie E, Hoyt DB, Sacra
“white paper” includes sections on JC, et al. National inventory of disappearance of the general
hospital-based emergency care, hospital trauma centers. JAMA surgeon. JAMA 2007;298:
emergency medical services, and 2003;289: 1515–22. 2191–3.
pediatric emergency care. This 4. Branas C, MacKenzie EJ, 12. Aucar J, Hicks L. Economic
influential advisory group has Williams JC, et al. Access to modeling comparing trauma
deemed hospital-based emergency trauma centers in the United and general surgery reimburse-
care to be at a breaking point, with States. JAMA 2005;293: ment. Am J Surg 2005;190:
no clear resolution in sight. 2626–33. 932–40.

4. 4 What’s New in ACS Surgery • September 2008 www.acssurgery.com
THIS MONTH’S UPDATES
continued from page 1
treated expectantly, but complete Surgery, Nuffield Department of development of reliable, disposable
surgical excision can be indicated. Surgery, John Radcliffe Hospital, instruments over the past 30 years
Hemangiomas can resolve spontane- Headington, Oxford, UK has changed the surgical practice
ously, and the treatment of choice is dramatically. With modern devices,
generally observation. SHAZAD ASHRAF, MD technical failures are rare, staple
Of the benign neoplasms, salivary Bobby Moore Fellow (CRUK), lines are of more consistent quality,
gland neoplasms should have an University of Oxford and Cancer and anastomoses in difficult
open biopsy, with preparation for and Immunogenetics Lab, locations are easier to construct.
removal if indicated. For benign Weatherall Institute of Molecular
thyroid nodules and nodular goiters, Medicine, John Radcliffe Hospital,
FNA can ascertain malignancy, Headington, Oxford, UK Factors Contributing to
indicating surgery. Managing soft
DOI 10.2310/7800.S05C29
Failure of Anastomoses
tissue tumors (lipomas, sebaceous nastomosis failure can be
cysts) usually involves simple
surgical excision. Chemodectomas
Intestinal anastomoses, employing
either sutures or staples, can have
A attributed to an increased
incidence of low resections (5 cm
(carotid body tumors), neurogenic high success rates as long as good or less from the anal verge) and
tumors (neurofibromas, neurilemo- apposition of the edges, without patients who present in the emer-
mas), and laryngeal tumors should tension, and an optimal blood gency setting with already compro-
generally be removed.
supply are present. mised hydration status, sepsis, or
Primary malignant neoplasms may
he creation of a join between two obstruction. Other factors that can
be present. Lymphoma can be
treated with radiation therapy,
chemotherapy, or both. Thyroid
T bowel ends (anastomosis) is an
operative procedure of central
influence the failure rate include
anemia, diabetes mellitus, previous
cancer (not benign thyroid disease) irradiation or chemotherapy,
importance in a general surgeon’s
is generally managed by total or malnutrition with hypoalbumin-
practice. To minimize the risk of
near-total thyroidectomy. Localized emia, and vitamin deficiencies.
potential complications (peritonitis,
tumors of the aerodigestive tract can bloodstream infection, further
often be cured with surgery alone or surgery, creation of a defunctioning Common Procedures
with chemoradiotherapy. Malignant
sarcomas are uncommon, but are
stoma, and death), it is imperative to Requiring Anastomosis
adhere to several well-established here are essential preliminary
treated with wide surgical resection.
Skin cancers generally require principles. Patients can also
influence anastomosis success, as
T steps before a bowel anastomosis.
First, the patient must be positioned
excision with adequate margins.
Metastatic tumors often require anastomotic healing mimics that of on the operating table in a manner
neck dissection, which can be wound healing elsewhere in the that is appropriate for the planned
elective or therapeutic, and compre- body. Thus, success (or failure) can operation. Second, the incision must
hensive or selective. Neck dissection be influenced by age (and its be made in such a way as to allow
is often the appropriate treatment presence of comorbid conditions, adequate exposure of the operating
for metastatic adenocarcinomas. malnutrition, and vitamin field. Finally, the segment of bowel
Metastatic melanomas should be deficiency) and poor blood flow. to be removed must be isolated with
excised (extent dependent on an adequate resection margin. Three
thickness). Managing patients with generic operations involve the small
an unknown primary malignancy is Technical Options for and large bowel (and anastomoses).
challenging. However, when cervical Fashioning Anastomoses A single-layer sutured extramucosal
lymph nodes contain metastatic utures and staples are the most side-to-side enteroenterostomy may
squamous cell carcinoma, the
primary tumor is in the head and
S common materials used. The
newer generation of sutures includes
be performed when no resection is
done, as a bypass procedure; after a
neck about 90% of the time. small bowel resection; when there is
monofilament and coated braided
sutures, and both represent a
substantial advance beyond silk and
5 Gastrointestinal Tract and
Abdomen
other multifilament materials.
Presently, there is no advantage of Coming in October
continuous versus interrupted 1 Basic Surgical and Perioperative
29 Intestinal Anastomosis sutures, but double-layered anasto- Considerations
moses are shown to yield a lower 8 Preparation of the Operating Room
NEIL J. MORTENSEN, MD rate of postoperative leakage. 7 Trauma and Thermal Injury
Professor of Colorectal Surgery, Surgical stapling devices were 9 Injuries to the Pancreas and
Chair, General and Vascular first introduced 1908, but the Duodenum

5. www.acssurgery.com What’s New in ACS Surgery 5
a discrepancy in the diameter of the segments parallel. In a double-layer coloanal anastomosis is actually a
two ends to be anastomosed; or sutured end-to-side enterocolos- resection of the distal sigmoid colon
when the anatomy is such that the tomy, the end of the ileum is joined and the rectum, now a more
most tension-free position for the to the side of the transverse colon. common procedure after the
anastomosis is with the two bowel The double-stapled end-to-end development of circular staplers.