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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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282
Key procedural steps and anatomy for colonoscopy
Splenic exure Bluish-gray hue
J. Silverstein et al.
Transverse
colon
Hepatic exure Bluish color
Ascending/
cecum colon
Triangular haustra and prominent taenia coli
Short segment coming to a blind end
Thickened taenia
Appendiceal
orice
Small slit in a “whirl” of mucosal folds
9 Endoscopy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Key procedural steps and anatomy for colonoscopy
Thickened fold, may have prolapsing small
bowel mucosa, biliary discharge, or bubbles
283
Ileocecal valve
Terminal ileum: hypertrophic mucosa, villi and
no haustra, Peyer patches (more prominent in
children and young adults)
Intubation (entering): Via direct visualization or
by positioning the endoscope by the appendiceal
orice and withdrawing with the tip angled in
the direction of the valve➔hooking
Pathological ndings
Polyps Inammatory (pseudopolyp): Not true polyps
• Irregular shaped areas of intact mucosa in
areas of localized inammation
• Results from mucosal ulceration and
regeneration
Hamartomatous: Benign tumor-like growths
(non-neoplastic)
Sessile serrated lesions: Heterogenous group
• Hyperplastic: Metaplastic, non-neoplastic
Most common non-neoplastic
<1cm: Low risk of cancer development
• Adenomas: May have dysplasia, can
develop into cancer
Adenomatous: (most common neoplastic)
• Sessile: Base and top have same diameter
• Pedunculated: Narrow base
• Flat: Height less than ½ diameter of lesion
• Depressed: Thickness less than adjacent
mucosa
• Histology: Tubular (80%), villous,
tubulovillous
• Low- or high-grade dysplasia
Diverticulosis Sac-like outpouchings of mucosa and
submucosa through the muscularis propria
Happens at points where arterial vessels
penetrate colon wall
Not true diverticula: Does not contain all layers
Can lead to lower GI bleeding
284
Pathological ndings
Angiodysplasia Tortuous submucosal vessel
Can lead to lower GI bleeding
Engorged vascular cushions that stretch the
mucosa leading to bulging within the lumen
Located within the anal canal
J. Silverstein et al.
Hemorrhoid
Ischemic colitis
Crohn’s Crohn disease is characterized by transmural
Internal: Above dentate line
External: Below dentate line
Can lead to lower GI bleeding
Compromised blood ow and reperfusion
leading to mucosal sloughing with ulcerations
and/or necrosis
➔Ultimately resulting in bleeding
Tends to occur in “watershed” areas of the
arterial blood supply: Distal transverse colon,
splenic exure (Grifth’s point), rectosigmoid
(Sudeck’s point)
inammation of any part of the gastrointestinal
tract, thickening, cobblestoning, and strictures
Cobblestoning: Linear and curvilinear ulcers
Discontinuous lesions: “Skip areas” near normal
tissue
9 Endoscopy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Pathological ndings
Circumferential and continuous inammation
Ulcerative
colitis
Pseudopolyps: Irregular shaped areas of intact
mucosa in areas of localized inammation.
Results from mucosal ulceration and
regeneration
May involve rectum alone (ulcerating proctitis)
or extend proximally to involve various lengths
or all of the colon
Raised yellow or white plaques up to 2cm in
diameter
285
C.Difcile
Neoplasia
Can be scattered with intermittent normal
mucosa or more continuous/circumferential
Mass that is partially or completely obstructing
Can be fungating (ulcerated/necrotic),
exophytic, polypoid, bleeding, friable
286
Complications of colonoscopy and their management
Complication Characteristics Management
J. Silverstein et al.
Anesthetic related Arrhythmias, vasovagal reactions,
myocardial infarction, aspiration
Can result from force against bowel
wall, barotrauma and/or therapeutic
procedure
Perforation
Bleeding
Post polypectomy syndrome
Rate approximately 0.01% to 0.1%
Risk factors: Advanced age, multiple
comorbidities, diverticulosis,
obstruction, polyp resection >1cm
(especially right colon)
Most commonly due to polypectomy
Can be immediate or delayed
Rate of 0.1% to 0.6%
Transmural burn resulting inlocalized
peritonitis due to use of
electrocoagulation
Incidence of 0.003% to 0.1%
Hypoxia: Open airway, supplemental
O2, collapse colon, remove scope
Cardiac: Collapse colon, remove
scope, stop sedation, ACLS protocol
Immediate abdominal radiograph if
suspected➔CT scan if X-ray
negative and high suspicion
NPO, IV uids, IV broad-spectrum
antibiotics
Endoscopic closure by clips, clamps
or suturing
Surgical consultation
Immediate: Coagulation, clipping
Delayed (5–7days): If symptomatic
then repeat colonoscopy with therapy
Does not require surgical intervention
IV hydration, antibiotics, and bowel
rest until symptoms resolve
Infection
Gas explosion
Present 1–5days after colonoscopy:
Fever, localized abdominal pain/
peritoneal signs, and leukocytosis
Transient bacteremia present in about
4% of cases
Signs and symptoms are rare
Likely related to defective equipment or
breaches in protocol
When combustible levels of hydrogen or
methane are present within the lumen
and energy is used (electrocautery or
argon plasma)
Risk factors: Incompletely absorbed
mannitol, lactulose, sorbitol, poor
preparation
No antibiotic prophylaxis needed: No
proven causation
Preventive measure: Use carbon
dioxide
9 Endoscopy
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Diagnostic andTherapeutic Maneuvers
Diagnostic and therapeutic maneuvers
Maneuvers Description
Tissue sampling Tissue sampling: Polypectomy
• Hot (energy) or cold
• Biopsy forceps or snare
Mucosal lesions and/or neoplasms require biopsy
For pedunculated masses, a wire loop with a coagulation current may also be used to
remove suspicious tissue
Hemostasis Argon plasma coagulation, encoclip, epinephrine injection, electrocautery
Stent placement Only uncovered stents in the US
Covered available outside the US
Ideal placement: Middle section traversing obstruction
Maintain soft stool to avoid impaction
Highest success rate in left side lesions
Used for palliation or bridge to surgery
287
Complications: Migration, perforation, occlusion
Dilation Balloon
Strictures
Can be used for stenotic
anastomosis
Complications: Perforation
Endoscopic mucosal resection
(EMR)
Large snares for en bloc
resection or piecemeal
(typically polyp >20mm)
Mucosal resection
Prior to resection inject solution
into submucosa to raise it
Consider tattooing
Complications: Bleeding,
perforation
288
J. Silverstein et al.
Quality Indicators forEndoscopy
Quality indicators
Cecal intubation Proceduralist should have success of:
• ≥90% overall
• ≥95% for screening cases
Adenoma detection rate Rate of at least 25% in those over the age of 50 for screening cases
Withdrawal time
Chronic diarrhea Must obtain biopsies
Biopsy distribution for IBD Four biopsies per 10cm of involved colon
Polypectomy Mucosally based pedunculated and sessile polyps <2cm are
Perforation Rates cannot exceed 1/500 overall and 1/1000 for screening
Post polypectomy bleeding Should be less than 1%
≥6min
resected
Unresectability must be documented
Should be managed non- operatively in ≥90% of cases
Breast andOncology
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
SawyerCimaroliWimann, CarolineE.Williams,
AmberGuth, andJenniferWhittington
10
S. C. Wimann (*)
NYU Long Island School of Medicine General
Surgery Residency, Nyu Langone—Long Island
Hospital, Mineola, NY, USA
e-mail: Sawyer.Cimaroliwimann@Nyulangone.Org
C. E. Williams
General Surgery Residency, University of Central
Florida/HCA Healthcare, Pensacola, FL, USA
e-mail: caroline.williams2@ucf.edu
A. Guth
Department of Surgery at NYU Grossman School of
Medicine, Nyu Langone Hospital,
New York, NY, USA
e-mail: amber.guth@nyulangone.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. Ajouz et al. (eds.), The ABSITE Blueprints, https://doi.org/10.1007/978-3-031-32643-1_10
J. Whittington
Department of Surgery at NYU Long Island School
of Medicine, NYU Langone—Long Island Hospital,
Mineola, NY, USA
e-mail: Jennifer.whittington@nyulangone.org
289
290
development
Pre-puberty
Puberty
Pregnancy
Anatomy andPhysiology
Embryology Pre-puberty Puberty Pregnancy
S. C. Wimann et al.
Aging and
menopause
Breast formed from ectoderm
milk streak
Ectoderm
4 weeks
Blood supply and
lymphatic drainage
Blood supply
From internal
mammary/thoracic
artery (IM); lateral
thoracic artery (LT);
and intercostal arteries
(IC)
Lactiferous ducts
formed at birth
Lobules remain
underdeveloped until
puberty
Axillary artery
Estrogen➔ duct
development
Progesterone ➔
lobular development
Prolactin ➔synergize
estrogen and
progesterone
Progesterone and
prolactin induce
maturation of
breast
Pregnant
Protactin
Lateral Thoracic artery
Acromiothoracic
artery
Lobular and
ductal atrophy
Stroma
decreases
Adipose tissue
increases
Subclavian artery
Internal
Thoracic
artery
Anterior
intercostal
arteries
Supraclavicular
Lo
y
10 Breast andOncology
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Blood supply and
lymphatic drainage
291
Lymphatic drainage
97% drain to axillary
lymph nodes
2% drain to internal
mammary nodes
3 levels of axillary
lymph nodes
Level I: Lateral to
pectoralis minor
Level II: Deep to
pectoralis minor and
inferior to clavicle
Level III: Medial to
pectoralis minor and
inferior to clavicle
Subclavicular Nodes
are continuous with
supraclavicular nodes
in the neck
Rotter’s nodes: Nodes
between pectoralis
major and minor
muscles
High Axillary, apical
Level III
Mid-Axillary,
Level II
Axillary
Vein
Internal
mammar
w Axillary,
Level I
Pectoralis minor
muscle
Nerve Anatomy Innervation Injury Surgical anatomy
Long thoracic
nerve
Thoracodorsal
nerve
Course close to
the chest wall
on the medial
side of the
axilla
Runs parallel to
the chest wall
Crosses axilla
to the medial
surface of the
latissimus dorsi
muscle
Serratus anterior Winged
scapula
Latissimus dorsi Weak arm
pull ups/
adduction
Axillary
Musculocutaneous
artery
Thoracodorsal
nerve
Latissimus dorsi
muscle
Long thoracic
nerve
nerve
Brachial
plexus
Thoracodorsal neurovascular bundle runs in mid
axilla just inferior to the axillary vein and
includes the thoracodorsal nerve and
thoracoepigastric vein ➔this neurovascular
bundle is a key landmark for axillary
dissection and should be preserved
Anterior scalene
muscle
Dorsal nerve
Lateral pectoral
nerve
Medial pectoral
nerve
Medial Mammary
branches of
anterior cutaneous
branch of ICN
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