Surgery Encyclopedia

ammonia signals end-stage liver disease and a high risk jaundice. Such patients should be tested for hepatitis B of hepatic coma. surface antigen (HbsAg) and IgM antibodies to hepatitis B core antigen (anti-HBc IgM), and anti-hepatitis C Albumin is the protein found in the highest concen- virus (anti-HVC) to identify these causes. In addition to Liver function tests tration in blood, making up over half of the protein mass. hepatitis A-E, viral hepatitis may be caused by Epstein- Albumin has a half-life in blood of about three weeks Barr virus (EBV) and cytomegalovirus (CMV) infec- and decreased levels are not seen in the early stages of tions of the liver. Tests for these viruses such as the in- liver disease. A persistently low albumin in liver disease fectious mononucleosis antibody test, anti-viral capsid signals reduced synthetic capacity of the liver and is a antigen test (anti-VCA), and anti-CMV test are useful in sign of progressive liver failure. In the acute stages of diagnosing these infections. liver disease, proteins such as transthyretin (prealbumin) with a shorter half-life may be measured to give an indi- Liver disease may be caused by autoimmune mech- cation of the severity of the disease. anisms in which autoantibodies destroy liver cells. Au- toimmune necrosis is associated with systemic lupus Cholesterol is synthesized by the liver, and choles- erythematosus and chronic viral hepatitis usually caused terol balance is maintained by the liver’s ability to re- by hepatitis B and hepatitis C virus infections. These move cholesterol from lipoproteins, and use it to produce conditions give rise to anti-smooth muscle antibodies bile acids and salts that it excretes into the bile ducts. In and anti-nuclear antibodies, and tests for these are useful obstructive jaundice caused by stones, biliary tract scar- markers for chronic hepatitis. Antibodies to mitochondri- ring, or cancer, the bile cannot be eliminated and choles- al antigens (antimitochondrial antibodies) are found in terol and triglycerides may accumulate in the blood as the blood of more than 90% of persons with primary bil- low-density lipoprotein (LDL) cholesterol. In acute iary cirrhosis, and those with M2 specificity are consid- necrotic liver diseases triglycerides may be elevated due ered specific for this disease. to hepatic lipase deficiency. In liver failure caused by necrosis, the liver’s ability to synthesize cholesterol is re- Preparation duced and blood levels may be low. Patients are asked to fast and to inform clinicians of The liver is responsible for production of the vita- all drugs, even over-the-counter drugs, that they are tak- min K clotting factors. In obstructive liver diseases a de- ing. Many times liver function tests are done on an emer- ficiency of vitamin K-derived clotting factors results gency basis and fasting and obtaining a medical history from failure to absorb vitamin K. In obstructive jaundice, are not possible. intramuscular injection of vitamin K will correct the pro- longed prothrombin time. In severe necrotic disease, the liver cannot synthesize factor I (fibrinogen) or factors II, Aftercare VII, IX, and X from vitamin K. When attributable to he- Patients will have blood drawn into a vacuum tube patic necrosis, an increase in the prothrombin time by and may experience some pain and burning at the site of more than two seconds indicates severe liver disease. injection. A gauze bandage may be placed over the site to prevent further bleeding. If the person is suffering Serum protein electrophoresis patterns will be abnor- from severe liver disease, they may lack clotting factors. mal in both necrotic and obstructive liver diseases. In the The nurse or caregiver should be careful to monitor acute stages of hepatitis, the albumin will be low and the bleeding in these patients after obtaining blood. gamma globulin fraction will be elevated owing to a large increase in the production of antibodies. The alpha-1 globulin and alpha-2 globulin fractions will be elevated Normal results owing to production of acute phase proteins as a response Reference ranges vary from laboratory to laboratory to inflamation. In biliary cirrhosis the beta globulin may and also depend upon the method used. However, normal be elevated owing to an increase in beta lipoprotein. In values are generally framed by the ranges shown below. hepatic cirrhosis the albumin will be greatly decreased, Values for enzymes are based upon measurement at 37°C. and the pattern will show bridging between the beta and • ALT: 5–35 IU/L. (Values for the elderly may be slight- gamma globulins owing to production of IgA. The albu- ly higher, and values also may be higher in men and in min to globulin ratio (A/G) ratio will fall below one. African-Americans.) The most prevalent liver disease is viral hepatitis. • AST: 0–35 IU/L. Tests for this condition include a variety of antigen and • ALP: 30–120 IU/LALP is higher in children, older antibody markers and nucleic acid tests. Acute viral he- adults and pregnant females. patitis is associated initially with 20- to 100-fold increas- es in transaminases and is followed shortly afterward by • GGT: males 2–30 U/L; females 1–24 U/L. GALE ENCYCLOPEDIA OF SURGERY 893

Liver function tests • LDH: 0–4 days old: 290–775 U/L; 4–10 days: Bile acid—A detergent that is made in the liver KEY TERMS 545–2000 U/L; 10 days–24 months: 180–430 U/L; 24 months–12 years: 110–295 U/L; 12–60 years: 100–190 U/L; 60 years: >110–210 U/L. and excreted into the intestine to aid in the ab- • Bilirubin: (Adult, elderly, and child) Total bilirubin: sorption of fats. 0.1–1.0 mg/dL; indirect bilirubin: 0.2–0.8 mg/dL; di- rect bilirubin: 0.0–0.3 mg/dL. (Newborn) Total biliru- bin: 1–12 mg/dL. Note: critical values for adult: greater Biliary—Relating to bile. Cirrhosis—A liver disease where there is a loss of than 1.2 mg/dL. Critical values for newborn (requiring normal liver tissues, replaced by scar tissue. This is immediate treatment): greater than 15 mg/dL. usually caused by chronic alcohol abuse, but also can be caused by blockage of the bile ducts. • Ammonia: 10–70 micrograms per dL (heparinized plas- ma). Normal values for this test vary widely, depending Deamination—Removal of the NH group from 2 upon the age of the patient and the type of specimen. an amino compound, usually by hydrolysis. Detoxification—A process of altering the chemi- • Albumin: 3.2–5.4 g/L. cal structure of a compound to make it less toxic. Abnormal results Hepatitis—Inflammation of the liver. Hepatocyte—Liver cell. ALT: Values are significantly increased in cases of hepatitis, and moderately increased in cirrhosis, liver Isoenzyme—One of a group of enzymes that tumor, obstructive jaundice, and severe burns. Values are brings about the same reactions on the same chem- mildly increased in pancreatitis, heart attack, infectious icals, but are different in their physical properties. mononucleosis, and shock. Most useful when compared Jaundice—Hyperbilirubinemia or too much biliru- with ALP levels. bin in the blood. Bilirubin will be deposited in the skin and the mucosal membranes. The whites of AST: High levels may indicate liver cell damage, hepatitis, heart attack, heart failure, or gall stones. the eyes and the skin appear yellow. Neonatal jaundice—A disorder in newborns ALP: Elevated levels occur in diseases that impair where the liver is too premature to conjugate bile formation (cholestasis). ALP may also be elevated in bilirubin, which builds up in the blood. many other liver disorders, as well as some lung cancers (bronchogenic carcinoma) and Hodgkin’s lymphoma. However, elevated ALP levels may also occur in other- wise healthy people, especially among older people. Ammonia: Increased levels are seen in primary GGT: Increased levels are diagnostic of hepatitis, liver cell disease, Reye’s syndrome, severe heart failure, cirrhosis, liver tumor or metastasis, as well as injury hemolytic disease of the newborn, and hepatic en- from drugs toxic to the liver. GGT levels may increase cephalopathy. with alcohol ingestion, heart attack, pancreatitis, infec- Albumin: Albumin levels are increased due to dehy- tious mononucleosis, and Reye’s syndrome. dration. They are decreased due to a decrease in synthe- LDH: Elevated LDH is seen with heart attack, kid- sis of the protein which is seen in severe liver failure and ney disease, hemolysis, viral hepatitis, infectious in conditions such as burns or renal disease that cause mononucleosis, Hodgkin’s disease, abdominal and lung loss of albumin from the blood. cancers, germ cell tumors, progressive muscular dystro- phy, and pulmonary embolism. LD is not normally ele- Patient education vated in cirrhosis. Health-care providers should inform the patient of any abnormal results and explain how these values reflect Bilirubin: Increased indirect or total bilirubin levels the status of their liver disease. It is important to guide the can indicate various serious anemias, including hemolyt- patient in ways to stop behaviors such as taking drugs or ic disease of the newborn and transfusion reaction. In- drinking alcohol, if these are the causes of the illness. creased direct bilirubin levels can be diagnostic of bile duct obstruction, gallstones, cirrhosis, or hepatitis. It is Resources important to note that if total bilirubin levels in the new- born reach or exceed critical levels, exchange transfusion BOOKS is necessary to avoid kernicterus, a condition that causes Burtis, Carl A. and Edward R. Ashwood. Tietz Textbook of brain damage from bilirubin in the brain. Clinical Chemistry. Philadelphia: W. B. Saunders, 1999. 894 GALE ENCYCLOPEDIA OF SURGERY

Cahill, Matthew. Handbook of Diagnostic Tests. 2nd ed. sorbed from the intestines, and performs the final stages Springhouse, PA: Springhouse Corporation, 1999. of digestion, converting food into energy and replace- Henry, J. B. Clinical Diagnosis and Management by Laborato- ment parts for the body. The liver also filters the blood of ry Methods. 20th ed. Philadelphia: W. B. Saunders, 2001. all waste products, removes and detoxifies poisons, and Wallach, Jacques. Interpretation of Diagnostic Tests. 7th ed. Liver transplantation excretes many of these into the bile. It further processes Philadelphia: Lippincott Williams & Wilkins, 2000. other chemicals for excretion by the kidneys. The liver is OTHER also an energy storage organ, converting food energy to a Jensen, J. E. Liver Function Tests. [cited April 4, 2003]. <http:// chemical called glycogen that can be rapidly converted www.gastromd.com/lft.html>. to fuel. National Institutes of Health. [cited April 4, 2003]. <http:// www.nlm.nih.gov/medlineplus/encyclopedia.html>. When other medical treatment interferes with the Worman, Howard J. Common Laboratory Tests in Liver Dis- functioning of a damaged liver, a transplant is necessary. ease. [cited April 4, 2003]. <http://www.cpmcnet.columbia. Since 1963, when the first human liver transplant was edu/dept/gi/labtests.html>. performed, thousands more have been performed each year. Cirrhosis, a disease that kills healthy liver cells, re- Jane E. Phillips, Ph.D. placing them with scar tissue, is the most common rea- Mark A. Best, M.D. son for liver transplantation in adults. The most frequent reason for transplantation in children is biliary atresia—a disease in which the ducts that carry bile out of the liver, Liver removal see Hepatectomy are missing or damaged. Included among the many causes of liver failure that bring patients to transplant surgery are: • Progressive hepatitis, mostly due to virus infection, accounts for more than one-third of all liver trans- Liver transplantation plants. Definition • Alcohol damage accounts for approximately 20% of Liver transplantation is a surgery that removes a dis- transplants. eased liver and replaces it with a healthy donor liver. • Scarring, or abnormality of the biliary system, accounts for roughly another 20% of liver transplants. Purpose • The remainder of transplants come from various can- A liver transplant is needed when the liver’s func- cers, uncommon diseases, and a disease known as ful- tion is reduced to the point that the life of the patient is minant liver failure. threatened. Fulminant liver failure most commonly happens during acute viral hepatitis, but is also the result of Demographics mushroom poisoning by Amanita phalloides and toxic reactions to overdose of some medicines, such as aceta- Compared to whites, those with African-American, minophen—a medicine commonly used to relieve pain Asian, Pacific Islander, or Hispanic descent are three and reduce fever. The person who is the victim of mush- times more likely to suffer from end-stage renal disease room poisoning is a special category of candidate for a (ESRD). Both children and adults can suffer from liver liver transplant because of the speed of the disease and failure and require a transplant. the immediate need for treatment. Patients with advanced heart and lung disease, who are human immunodeficiency virus (HIV) positive, and As the liver fails, all of its functions diminish. Nutri- who abuse drugs and alcohol are poor candidates for tion suffers, toxins build, and waste products accumu- liver transplantation. Their ability to survive the surgery late. Scar tissue accumulates on the liver as the disease and the difficult recovery period, as well as their long- progresses. Blood flow is increasingly restricted in the term prognosis, is hindered by their conditions. portal vein, which carries blood from the stomach and abdominal organs to the liver. The resulting high blood pressure (hypertension) causes swelling of and bleeding Description from the blood vessels of the esophagus. Toxins build-up The liver is the body’s principle chemical factory. It in the blood (liver encephalopathy), resulting in severe receives all nutrients, drugs, and toxins, which are ab- jaundice (yellowing of the skin and eyes), fluid accumu- GALE ENCYCLOPEDIA OF SURGERY 895

As of 2003, the availability of organs for transplant Liver transplantation A transplant surgeon will perform the surgery in was in crisis. In October 1997, a national distribution WHO PERFORMS system was established that gives priority to patients THE PROCEDURE AND who are most ill and in closest proximity to the donor WHERE IS IT PERFORMED? livers. Livers, however, are available nationally. It is now possible to preserve a liver out of the body for 10 to 20 hours by flushing it with cooled solutions of special a hospital that has a special unit called a trans- chemicals and nutrients, if necessary. This enables trans- plant center. port cross-country. Description lation in the abdomen (ascites), and deterioration of mental function. Eventually, death occurs. Once a donor liver has been located and the patient is in the operating room and under general anesthesia, There are three types of liver transplantation meth- the patient’s heart and blood pressure are monitored. A ods. They include: long cut is made alongside of the ribs; sometimes, an up- • Orthotopic transplantation, the replacement of a whole wards cut may also be made. When the liver is removed, diseased liver with a healthy donor liver. four blood vessels that connect the liver to the rest of the body are cut and clamped shut. After getting the donor • Heterotrophic transplantation, the addition of a donor liver ready, the transplant surgeon connects these vessels liver at another site, while the diseased liver is left in- to the donor vessels. A connection is made from the bile tact. duct (a tube that drains the bile from the liver) of the • Reduced-size liver transplantation, the replacement of a donor liver to the bile duct of the liver of the patient’s whole diseased liver with a portion of a healthy donor bile duct. In some cases, a small piece of the intestine is liver. Reduced-size liver transplants are most often per- connected to the new donor bile duct. This connection is formed on children. called Roux-en-Y. The operation usually takes between six and eight hours; another two hours is spent preparing When an orthotropic transplantation is performed, a the patient for surgery. Therefore, a patient will likely be segment of the inferior vena cava (the body’s main vein in the operating room for eight to 10 hours. to the heart) attached to the liver is taken from the donor, as well. The same parts are removed from the recipient The United Network for Organ Sharing (UNOS) and replaced by connecting the inferior vena cava, the data indicates that patients in need of organ transplants hepatic artery, the portal vein, and the bile ducts. outnumber available organs three to one. When there is a possibility that the afflicted liver may recover, a heterotypic transplantation is performed. Diagnosis/Preparation The donor liver is placed in a different site, but it still has The liver starts to fail only when more than half of it to have the same connections. It is usually attached very is damaged. Thus, once a person demonstrates symp- close to the patient’s original liver; if the original liver toms of liver failure, there is not much liver function left. recovers, the donor liver will wither away. If the patient’s Signs and symptoms of liver failure include: original liver does not recover, that liver will dry up, leaving the donor in place. • jaundice • muscle wasting (loss of muscle) Reduced-size liver transplantation puts part of a donor liver into a patient. A liver can actually be divided • forgetfulness, confusion, or coma into eight pieces—each supplied by a different set of • fatigue blood vessels. In the past, just two of these sections have • itching been enough to save a patient suffering from liver fail- ure, especially if it is a child. It is possible, therefore, to • poor blood clotting transplant one liver into at least two patients and to trans- • build-up of fluid in the stomach (ascites) plant part of a liver from a living donor—and for both • infections the donor and recipients to survive. Liver tissue grows to • bleeding in the stomach accommodate its job provided that the organ is large enough initially. Patients have survived with only A doctor will diagnose liver disease; a liver special- 15–20% of their original liver intact, assuming that that ist, a transplant surgeon, and other doctors will have to portion was healthy from the beginning. be consulted, as well, before a patient can be considered 896 GALE ENCYCLOPEDIA OF SURGERY

for a liver transplant. Before transplantation takes place, the patient is first determined to be a good candidate for QUESTIONS transplantation by going through a rigorous medical ex- TO ASK THE DOCTOR amination. Blood tests, consultations, and x rays will be Liver transplantation needed to determine if the patient is a good candidate. • What should I do to prepare for this opera- Other tests that may be conducted are: computed tomog- tion? raphy (CAT or CT) scan, magnetic resonance image • Who will tell me about the transplant process? (MRI), ultrasound, routine chest x ray, endoscopy, scle- • Can I tour the transplant center? rotherapy and rubber-band ligation, transjugular intra- hepatic portosystemic shunt (TIPS), creatinine clearance, • Who are the members of the transplant team cardiac testing (echocardiogram [ECHO]) and/or elec- and what are their jobs? trocardiogram [EKG or ECG]), and pulmonary function • Is there a special nursing unit for transplant test [PFTs]), liver biopsy, and nutritional evaluation. A patients? dietitian will evaluate the patient’s nutritional needs and • How many attending surgeons are available design an eating plan. Since a patient’s emotional state is to do my type of transplant? as important as their physical state, a psychosocial evalu- • Does the hospital do living donor trans- ation will be administered. plants? Once test results are reviewed and given to the liver • Is a living donor transplant a choice in my transplant selection committee, the patient will be assessed case? If so, where will the living donor evalu- for whether he or she is an appropriate candidate. Some pa- ation be done? tients are deemed too healthy for a transplant and will be followed and retested at a later date if their liver gets • What is the organ recovery cost if I have a worse. Other patients are determined to be too sick to sur- living donor? vive a transplant. The committee will not approve a trans- • Will I also need to change my lifestyle? plant for these patients. Once a patient is approved, they • How long will I have to stay in the hospital? will be placed on a waiting list for a donor liver. When • Why is recovery such a slow process? placed on the waiting list, a patient will be given a score based on the results of the blood tests. The higher a pa- tient’s score, the sicker the patient is. This results in the pa- tient earning a higher place on the waiting list. tube will be inserted into the windpipe to facilitate Suitable candidates boost their nutritional intakes to breathing. It is removed when the patient is fully awake ensure that they are as healthy as possible before surgery. and strong enough to breathe on his or her own. There Drugs are administered that will decrease organ rejection may be other tubes that are removed as the patient re- after surgery. The medical committee consults with the covers. When safe to leave the SICU, the patient is patient and family, if available, to explain the surgery moved to the transplant floor. Walking and eating will and any potential complications. Many problems can become the primary focus. Physical therapy may be arise during the waiting period. Medicines should be started to help the patient become active, as it is an im- changed as needed, and blood tests should be done to as- portant part of recovery. When the patient begins to feel sure a patient is in the best possible health for the trans- hungry and the bowels are working, regular food that is plant surgery. Psychological counseling during this peri- low in salt will be given. od is recommended, as well. A patient should expect to spend about 10 to 14 days in When a donor is found, it is important that the trans- the hospital, although some stays may be shorter or longer. plant team be able to contact the patient. The patient Before leaving the hospital, a patient will be advised of: awaiting the organ must not eat or drink anything from signs of infection or rejection, how to take medications and the moment the hospital calls. On the other hand, the change dressings, and how to understand general health liver may not be good enough for transplantation. Then, problems. Infection can be a real danger, because the med- the operation will be cancelled, although this does not ications taken compromise the body’s defense systems. The happen often. doctors will conduct blood tests, ultrasounds, and x rays to ensure that the patient is doing well. Aftercare The first three months after transplant are the most Following surgery, the patient will wake up in the risky for getting such infections as the flu, so patients surgical intensive care unit (SICU). During this time, a should follow these precautions: GALE ENCYCLOPEDIA OF SURGERY 897

Liver transplantation Acetaminophen—A common pain reliever (e.g., with proliferation of small bile ducts unless these KEY TERMS are also atretic; giant cell transformation of hepatic Tylenol). cells also occurs. Anesthesia—A safe and effective means of alleviat- ing pain during a medical procedure. Antibody—An antibody is a protein complex used Biliary system—The tree of tubes that carries bile. Cirrhosis—A disease in which healthy liver cells by the immune system to identify and neutralize are killed and replaced with scar tissue. Cirrhosis is foreign objects, such as like bacteria and viruses. the most common reason for liver transplantation Each antibody recognizes a specific antigen in adults and is often a result of alcoholism. unique to its target Computed tomography (CT or CAT) scan—A radi- Antigen—Any chemical that provokes an immune ologic imaging modality that uses computer pro- response. cessing to generate an image of the tissue density in Ascites—A build-up of fluid in the stomach as a re- a “slice” as thin as 1–10 mm in thickness through sult of liver failure. the patient’s body. These images are spaced at inter- vals of 0.5 cm–1 cm. Cross-sectional anatomy can Bile ducts—Tubes carrying bile from the liver to be reconstructed in several planes without expos- the intestines. ing the patient to additional radiation. Called also Biliary atresia—A disease in which the ducts that computerized axial tomography (CAT) and comput- carry bile out of the liver are missing or damaged is erized transaxial tomography (CTAT). the most frequent reason for transplantation in children. Biliary atresia of the major bile ducts Electrocardiogram (EKG)—A graphic record show- causes cholestasis and jaundice, which does not ing the electrical activity of the heart. become apparent until several days after birth; Endoscopy—An instrument (endoscope) used to periportal fibrosis develops and leads to cirrhosis, visualize a hollow organ’s interior. • Avoid people who are ill. transplant, so what a patient eats after the transplant is very important. • Wash hands frequently. • Tell the doctor if you are exposed to any disease. Medications needed following liver • Tell the doctor if a cold sore, rash, or water blister ap- transplantation pears on the body or spots appear in the throat or on the Successfully receiving a transplanted liver is only the tongue. beginning of a lifelong process. Patients with transplant- • Stay out of crowds and rooms with poor circulation. ed livers have to stay on immunosuppressant drugs for the rest of their lives to prevent organ rejection. Although • Do not swim in lakes or community pools during the many patients can reduce the dosage after the initial few three months following transplant. months, virtually none can discontinue drugs altogether. • Eat meats that are well-cooked. For adolescent transplant recipients, post transplantation • Stay away from soil, including those in which house- is a particularly difficult time, as they must learn to take plants are grown, and gardens, during the three months responsibility for their own behavior and medication, as following transplant. well as balance their developing sexuality in a body that has been transformed by the adverse effects of immuno- • Take all medications as directed. suppression. Long-term outcome and tailoring of im- • Learn to report the early symptoms of infection. munosuppression is of great importance. To ensure that the transplant is successful and that Cyclosporine has long been the drug of experimenta- the patient has a long and healthy life, a patient must get tion in the immunosuppression regimen, and has been good medical care, prevent and treat complications, keep well-tolerated and effective. Hypertension, nephrotoxicity, in touch with doctors and nurses, and follow their ad- and posttransplant lymphoproliferative disease (PTLD) are vice. Nutrition plays a big part in the success of a liver some of the long-term adverse effects. Tacrolimus has been 898 GALE ENCYCLOPEDIA OF SURGERY

KEY TERMS (contd.) Hepatic artery—The blood vessel supplying arteri- the body—in the lymph nodes, spleen, thymus, Liver transplantation al blood to the liver. tonsils, Peyer patches, and sometimes in bone mar- Heterotrophic transplantation—The addition of a row), and in normal adults, comprising approxi- donor liver at another site, while the diseased liver mately 22%–28% of the total number of leuko- is left intact. cytes in the circulating blood. Magnetic resonance imaging (MRI)—A test that Interleukin-2 (IL-2)—A cytokine derived from T provides pictures of organs and structures inside helper lymphocytes that causes proliferation of T- the body by using a magnetic field and pulses of lymphocytes and activated B lymphocytes. radio wave energy to detect tumors, infection, and Immunosuppression—A disorder or condition other types of tissue disease or damage, and helps where the immune response is reduced or absent. to diagnose conditions that affect blood flow. The Inferior vena cava—The biggest vein in the body, area of the body being studied is positioned inside returning blood to the heart from the lower half of a strong magnetic field. the body. Nephrotoxicity—The quality or state of being toxic Jaundice—Yellowing of the skin and eyes caused to kidney cells. by a buildup of bile or excessive breakdown of red Orthotopic transplantation—The replacement of a blood cells. whole diseased liver with a healthy donor liver. Leukemia—A cancer of the white blood cells Portal vein—The blood vessel carrying venous (WBCs). blood from the abdominal organs to the liver. Lymphoma—A cancer of lymphatic tissue. Receptor—A structural protein molecule on the Lymphoproliferative—An increase in the number cell surface or within the cytoplasm that binds to a of lymphocytes. Lymphocytes are a white blood specific factor, such as a drug, hormone, antigen, cell (WBC) formed in lymphatic tissue throughout or neurotransmitter. developed more recently, and has improved the cosmetic Risks adverse effects of cyclosporine, but has similar rates of hy- Early failure of the transplant occurs in every one in pertension and nephrotoxicity, and possibly a higher rate of four surgeries and has to be repeated. Some transplants PTLD. Prednisone, azathioprine, and tacrolimus are often never work, some patients succumb to infection, and combined with cyclosporine for better results. Newer im- some suffer immune rejection. Primary failure is appar- munosuppressive agents promise even better results. ent within one or two days. Rejection usually starts at the There has been a recent, welcome development in end of the first week. There may be problems like bleed- renal sparing drugs, such as mycophenolate mofetil, ing of the bile duct after surgery, or blood vessels of the which has no cosmetic adverse effects, does not require liver may become too narrow. The surgery itself may drug level monitoring, and is thus particularly attractive need revision because of narrowing, leaking, or blood to teenagers. If started prior to irreversible renal dysfunc- clots at the connections. These issues may be solved with tion, recent research demonstrates recovery of renal or without more surgery depending on the severity. function with mycophenolate mofetil. There is little pub- lished data on the use of sirolimus (rapamycin) in the pe- Infections are a constant risk while on immunosup- diatric population, but preliminary studies suggest that pressive agents, because the immune system is supposed the future use of interleukin-2 receptor antibodies may to prevent them. A method has not yet been devised to be beneficial for immediate post-transplant induction of control rejection without hampering immune defenses immunosuppression. When planning immunosuppres- against infections. Not only do ordinary infections pose sion for adolescents, it is important to consider the ef- a threat, but because of the impaired immunity, trans- fects of drug therapy on both males and females in order plant patients are susceptible to the same opportunistic to maintain fertility and to ensure safety in pregnancy. infections (OIs) that threaten acquired immune deficien- Adequate practical measures and support should reduce cy syndrome (AIDS) patients—pneumocystis pneumo- noncompliance in this age group, and allow good, long- nia, herpes and cytomegalovirus (CMV) infections, term function of the transplanted liver. fungi, and a host of bacteria. GALE ENCYCLOPEDIA OF SURGERY 899

Drug reactions are also a continuing threat. Every Liver transplantation drug used to suppress the immune system has potential tions are apparent in about 22% of recipient patients (and 6% of donors), and vascular complications occur in problems. As previously stated, hypertension, nephrotox- 9.8% of recipient patients. Other complications in donors include re-operation (4.5%) and death (0.2%). icity, and PTLD are some of the long-term adverse ef- fects with immunosupressive drugs like cyclosporine. There are potential social, economic, and psycho- Immunosuppressants also hinder the body’s ability to re- logical problems, and a vast array of possible medical sist cancer. All drugs used to prevent rejection increase and surgical complications. Close medical surveillance the risk of leukemias and lymphomas. must continue for the rest of the patient’s life. There is also a risk of the original disease returning. In the case of hepatitis C, reoccurrence is a risk factor for orthotropic liver transplants. Newer antiviral drugs hold Alternatives out promise for dealing with hepatitis. In alcoholics, the There is no treatment that can help the liver with all urge to drink alcohol will still be a problem. Alcoholics of its functions; thus, when a person reaches a certain Anonymous (AA) is the most effective treatment known stage of liver disease, a liver transplant may be the only for alcoholism. way to save the patient’s life. Transplant recipients can get high blood pressure, diabetes, high cholesterol, thinning of the bones, and can Resources become obese. Close medical care is needed to prevent BOOKS these conditions. Abhinav, Humar, M.D., I. Hertz Marshall, M.D., Laura J., Blakemore, M.D., eds. Manual of Liver Transplant Med- Normal results ical Care. Minneapolis, MN: Fairview Press, 2002. Beauchamp, Daniel R., M.D., Mark B. Evers, M.D., Kenneth For a successful transplant, good medical care is im- L. Mattox, M.D., Courtney M. Townsend, and David C. portant. Patients and families must stay in touch with Sabiston, eds. Sabiston Textbook of Surgery: The Biologi- their medical teams and drugs must be taken as advised cal Basis of Modern Surgical Practice, 16th ed. London: to prevent infection and rejection of the new organ. W. B. Saunders Co., 2001. However, sometimes because of the way it is preserved, Lawrence, Peter F., Richard M. Bell, and Merril T. Dayton, the new liver doesn’t function as it should, and a patient eds. Essentials of General Surgery, 3rd ed. Philadelphia, may have to go back on to the waiting list to receive a PA: Lippincott, Williams & Wilkins, 2000. new liver. PERIODICALS Brown, R.S., Jr., M. W. Russo, M. Lai, M. L. Shiffman, M. C. Morbidity and mortality Richardson, J. E. Everhart, et al. “A survey of liver trans- plantation from living adult donors in the United States.” Twenty-five million or one in 10 Americans are or New England Journal of Medicine 348, no. 9 (February, have been afflicted with liver or biliary diseases. As of 2003):818–25. June 2003, there were 17,239 patients on the UNOS Goldstein, M. J., E. Salame, S. Kapur, M. Kinkhabwala, D. La- National Transplant Waiting List who were waiting for Pointe-Rudow, N. P. P. Harren, et al. “Analysis of failure a liver transplantation. For the previous year (July 1, in living donor liver transplantation: differential outcomes 2001 to June 30, 2002), there were a total of 5,261 in children and adults.” World Journal of Surgery 27, no. 3 liver transplants performed. Of those, 4,785 were ca- (2003):356–64. daver donors (already deceased) and 476 living Kelly, D. A. “Strategies for optimizing immunosuppression in donors. For liver transplants performed from July 1, adolescent transplant recipients: a focus on liver trans- 1999 to June 30, 2001, the one-year survival rate was plantation.” Paediatric Drugs 5, no. 3 (2003):177–83. Longheval, G., P. Vereerstraeten, P. Thiry, M. Delhaye, O. Le 86% for adults; 1,861 patients died while on the Moine, J. Deviere, et al. “Predictive models of short- and UNOS waiting list for the year ending June 30, 2002. long-term survival in patients with nonbiliary cirrhosis.” More than 80% of children survive transplantation to Liver Transplantation: Official Publication of the Ameri- adolescence and adulthood. can Association for the Study of Liver Diseases and the Since the introduction of cyclosporine and tacro- International Liver Transplantation Society 9, no. 3 limus (drugs that suppress the immune response and keep (March, 2003):260–7. it from attacking and damaging the new liver), success Neff, G. W., A. Bonham, A. G. Tzakis, M. Ragni, D. Jayaweera, E. R. Schiff, et al. “Orthotopic liver transplan- rates for liver transplantation have reached 80–90%. tation in patients with human immunodeficiency virus and Infections occur in about half of transplant patients end-stage liver disease.” Liver Transplantation: official and often appear during the first week. Biliary complica- publication of the American Association for the Study of 900 GALE ENCYCLOPEDIA OF SURGERY

Liver Diseases and the International Liver Transplanta- Purpose tion Society 9, no. 3 (March, 2003):239–47. Papatheodoridis, G. V., V. Sevastianos, and A. K. Burrouhs. Advanced medical directives are legal mechanisms Living will “Prevention of and treatment for hepatitis B virus infec- to assure that patients’ wishes with respect to a number tion after liver transplantation in the nucleoside analogues of medical procedures are carried out in their final days era.” American Journal of Transplantation 3, no. 3 or when they are incapacitated. The documents reflect (March, 2003):250–8. patients’ rights of consent and medical choice under con- Rudow, D. L., M. W. Russo, S. Haflige, J. C. Emond, and R. S. ditions whereby patients can no longer choose for them- Brown, Jr. “Clinical and ethnic differences in candidates selves what medical interventions they wish to undergo. listed for liver transplantation with and without potential living donors.” Liver Transplantation: Official Publication In 1990, recognizing the importance of patient treat- of the American Association for the Study of Liver Dis- ment wishes at the end of life, Congress enacted the Pa- eases and the International Liver Transplantation Society tient Self-Determination Act (PSDA). This federal law 9, no. 3 (March, 2003):254–9. ensures that patients admitted to hospitals, nursing Wong, F. “Liver and kidney diseases.” Clinics in Liver Disease homes, home health agencies, HMOs, and hospices be 6, no. 4 (November, 2002):981–1011. informed of their rights under state law to prepare ad- ORGANIZATIONS vance health care directives and have the documents en- tered into their medical record. Each state has different American Liver Foundation. 75 Maiden Lane, Suite 603, New York, NY. 10038. (800) 465-4837 or (888) 443-7872. Fax: requirements for the living will and the power of attor- (212) 483.8179. [email protected]. <http://www. ney. It is important to research medical directives before liverfoundation.org>. an accident or illness make that an impossibility. Living Hepatitis Foundation International (HFI). 504 Blick Drive, Sil- wills have become customary in many parts of the coun- ver Spring, MD. 20904-2901. (800) 891-0707 or (301) try and are broadly respected by health care providers. 622-4200. Fax: (301) 622-4702. [email protected]. However, a high percentage of Americans do not have a <http://www.hepfi.org> living will and/or a power of attorney to ensure its com- National Digestive Diseases, Information Clearinghouse. 2 In- pliance. formation Way, Bethesda, MD. 20892-3570. [email protected]. National Institutes of Health, 9000 Rockville Pike, Bethesda, Description Maryland. 20892. (301) 496-4000. NIHInfo@OD. The living will can be a very broad or a very narrow NIH.GOV. <http://www.nih.gov.> document, according to the wishes of the patient. It is the United Network for Organ Sharing. 500-1100 Boulders Park- way, P.O. Box 13770. Richmond, VA. 23225. (888) 894- patient’s declaration, a written statement of what he or she 6361 or (804) 330-8500. <http://www.unos.org> wants to occur in the event of serious accident or illness. It is primarily directed to medical personnel about the type OTHER of care the patient wishes to have, or wishes not to have, U.S. National Library of Medicine and the National Institutes under situations of terminal illness or incapacitation. of Health. Liver Transplantation. 2003 [cited March 13, 2003]. < www.nlm.nih.gov/medlineplus/livertransplanta The document commonly includes the kinds of tion.html>. medical procedures that are usually administered to pa- tients who are seriously ill. These may include: J. Ricker Polsdorfer, M.D. • transfusions of blood and blood products Crystal H. Kaczkowski, M.Sc. • cardiopulmonary resuscitation (CPR) • diagnostic tests • dialysis • administration of drugs Living will • tissue and organ donation Definition • use of a respirator • surgery A living will is a legal document in which patients instruct health-care providers about their wishes with re- The living will declaration can also include issues of spect to medical procedures should they become inca- pain medication, food, and water. Most states recognize pacitated. The living will and the durable medical power that relief from pain and discomfort are procedures that of attorney are two federally mandated parts of what is most people wish to have and these are not considered known as advanced medical directives. life-prolonging treatments. In some states, however, food GALE ENCYCLOPEDIA OF SURGERY 901

Lobectomy, pulmonary and water may be considered life prolonging. and the Durable medical power of attorney—A legal doc- KEY TERMS consideration to forego them may fall within the rights of the patient to refuse. What may be included in the liv- ing will depends upon the state. ument that empowers a person to make medical The living will—in some states called instructions, decisions for the patient should the patient be un- directive to physicians, or declaration—does not require able to make the decisions. a surrogate (an appointed person) to make decisions for the patient. Most states include these types of instruc- a declaration of wishes pertaining to medical tions in their medical durable power of attorney forms. Medical directives—Legal documents that include Not all states, however, recognize separate living wills as treatment (living will) and the stipulation of a legally binding; California, for instance, does not. proxy decision maker (power of attorney). Patient Self-Determination Act (PSDA)—Federal Preparation law that ensures that medical providers offer the option of medical directives to patients and in- The living will should be given careful thought, and clude documents in their medical records. be talked about with the patient’s family, physician, and Surrogate—A person who represents the wishes care providers. It is highly recommended that discussion of the patient, chosen by the patient and stipulat- of patient wishes occurs before medical treatment is nec- ed by a legal document as power of attorney. essary, because the living will involves both the patient’s family and loved ones, who are expected to assist in its implementation. It should be researched for the state in which the patient is most likely to receive medical care, Resources and be dated and signed before two witnesses. PERIODICALS The living will may be drafted on standardized Matousek, M. “Start the Conversation: The Modern Maturity forms, with or without the assistance of an attorney. The Guide to End-of-Life Care.” “The Last Taboo.” Modern document may be revoked in writing, or orally, by either Maturity (September-October 2000). the patient (the person making the advance directive) or ORGANIZATIONS by a designated proxy (a surrogate) at any time. If the Partnership for Caring. 1620 Eye St., NW, Suite 202, Washing- patient does not specify in the living will a particular ele- ton, DC 20006. (202) 296-8071. Fax: (202) 296-8352. Toll- ment of treatment or treatment withdrawal, then it is not free hotline: (800) 989-9455 <www.partnershipfor included. It is very important that living wills be as spe- caring.org/>. cific and detailed as possible. U.S. Living Will Registry. 523 Westfield Ave., P.O. Box 2789, Westfield, NJ 07091-2789. Toll-free: (800) LIV-WILL or Most hospitals offer a medical directives resource, (800) 548-9455). <www.uslivingwillregistry.com/>. commonly in the religious office attached to the hospital. OTHER Coupled with a durable medical power of attorney (a person chosen to make medical decisions on the patient’s Living Wills And Other Advance Directives. <wwww.inteli health.com>. behalf if the patient cannot make his or her own deci- What You Can Cover in Your Healthcare Directives. Nolo Law sions), the living will ensures in advance that patient for All. <wwww.nolo.com/lawcenter/ency> wishes about the quality of death are respected. Nancy McKenzie, PhD Normal results The living will, whether prepared prior to hospital- ization or prepared once the patient is admitted, is placed Lobectomy, hepatic see Hepatectomy in the patient’s medical chart along with other docu- ments such as the medical power of attorney declaration. Providers are required by federal law to honor this decla- ration of the patient’s wishes. The document serves as a statement of intentions on the part of the patient and can Lobectomy, pulmonary be very important to family members, health care providers, and patient proxy during a very distressful and Definition disconcerting time. A lobectomy is the removal of a lobe, or section, of See also Do not resuscitate order. the lung. 902 GALE ENCYCLOPEDIA OF SURGERY

Purpose WHO PERFORMS Lobectomies are performed to prevent the spread of THE PROCEDURE AND cancer to other parts of the lung or other parts of the WHERE IS IT PERFORMED? body, as well as to treat patients with such noncancerous Lobectomy, pulmonary diseases as chronic obstructive pulmonary disease Lobectomies are performed in a hospital by a (COPD). COPD includes emphysema and chronic bron- thoracic surgeon, who is a physician who spe- chitis, which cause airway obstruction. cializes in chest, heart, and lung surgery. Tho- racic surgeons may further specialize in one Demographics area, such as heart surgery or lung surgery. They are board-certified through the Board of Lung cancer Thoracic Surgery, which is recognized by the Lung cancer is the leading cause of cancer-related American Board of Medical Specialties. A doc- deaths in the United States. It is expected to claim nearly tor becomes board certified by completing 157,200 lives in 2003. Lung cancer kills more people training in a specialty area and passing a rigor- than cancers of the breast, prostate, colon, and pancreas ous examination. combined. Cigarette smoking accounts for nearly 90% of cases of lung cancer in the United States. Lung cancer is the second most common cancer • shortness of breath that grows worse even at lower lev- among both men and women and is the leading cause of els of activity death from cancer in both sexes. In addition to the use of tobacco as a major cause of lung cancer among smokers, • a family history of early COPD (before age 45) second-hand smoke contributes to the development of lung cancer among nonsmokers. Exposure to asbestos Description and other hazardous substances is also known to cause lung cancer. Air pollution is also a probable cause, but Lobectomies of the lung are also called pulmonary makes a relatively small contribution to incidence and lobectomies. The lungs are a pair of cone-shaped breath- mortality rates. Indoor exposure to radon may also make ing organs within the chest. The function of the lungs is a small contribution to the total incidence of lung cancer to draw oxygen into the body and release carbon diox- in certain geographic areas of the United States. ide, which is a waste product of the body’s cells. The right lung has three lobes: a superior lobe, a middle lobe, In each of the major racial/ethnic groups in the Unit- and an inferior lobe. The left lung has only two, a superi- ed States, the rates of lung cancer among men are about or and an inferior lobe. Some lobes exchange more oxy- two to three times greater than the rates among women. gen than others. The lungs are covered by a thin mem- Among men, age-adjusted lung cancer incidence rates brane called the pleura. The bronchi are two tubes which (per 100,000) range from a low of about 14 among Na- lead from the trachea (windpipe) to the right and left tive Americans to a high of 117 among African Ameri- lungs. Inside the lungs are tiny air sacs called alveoli and cans, an eight-fold difference. For women, the rates small tubes called bronchioles. Lung cancer sometimes range from approximately 15 per 100,000 among Japan- involves the bronchi. ese Americans to nearly 51 among Native Alaskans, only a three-fold difference. To perform a lobectomy, the surgeon makes an inci- sion (thoracotomy) between the ribs to expose the lung Chronic obstructive pulmonary disease while the patient is under general anesthesia. The chest cavity is examined and the diseased lung tissue is re- The following are risk factors for COPD: moved. A drainage tube (chest tube) is then inserted to • current smoking or a long-term history of heavy smoking drain air, fluid, and blood out of the chest cavity. The • employment that requires working around dust and irri- ribs and chest incision are then closed. tating fumes Lung surgery may be recommended for the follow- • long-term exposure to second-hand smoke at home or ing reasons: in the workplace • presence of tumors • a productive cough (with phlegm or sputum) most of • small areas of long-term infection (such as highly lo- the time calized pulmonary tuberculosis or mycobacterial infec- • shortness of breath during vigorous activity tion) GALE ENCYCLOPEDIA OF SURGERY 903

Lobectomy, pulmonary • What benefits can I expect from a lobectomy? consult their physician about discontinuing any blood- thinning medications such as Coumadin (warfarin). The QUESTIONS night before surgery, patients should not eat or drink TO ASK THE DOCTOR anything after midnight. Aftercare • What are the risks of this operation? If no complications arise, the patient is transferred • What are the normal results? from the surgical intensive care unit (ICU) to a regular • How long will my recovery take? hospital room within one to two days. Patients may need • Are there any alternatives to this surgery? to be hospitalized for seven to 10 days after a lobectomy. A tube in the chest to drain fluid will probably be re- quired, as well as a mechanical ventilator to help the pa- tient breathe. The chest tube normally remains in place • lung cancer until the lung has fully re-expanded. Oxygen may also • abscesses be required, either on a temporary or permanent basis. A • permanently enlarged (dilated) airways (bronchiectasis) respiratory therapist will visit the patient to teach him or her deep breathing exercises. It is important for the pa- • permanently dilated section of lung (lobar emphysema) tient to perform these exercises in order to re-expand the • injuries associated with lung collapse (atelectasis, lung and lower the risk of pneumonia or other infections. pneumothorax, or hemothorax) The patient will be given medications to control postop- • a permanently collapsed lung (atelectasis) erative pain. The typical recovery period for a lobectomy is one to three months following surgery. Diagnosis/Preparation Risks Diagnosis The specific risks of a lobectomy vary depending on In some cases, the diagnosis of a lung disorder is the specific reason for the procedure and the general state made when the patient consults a physician about chest of the patient’s health; they should be discussed with the pains or other symptoms. The symptoms of lung cancer surgeon. In general, the risks for any surgery requiring a vary somewhat according to the location of the tumor; general anesthetic include reactions to medications and they may include persistent coughing, coughing up breathing problems. As previously mentioned, patients blood, wheezing, fever, and weight loss. Patients with a having part of a lung removed may have difficulty breath- lung abscess often have symptoms resembling those of ing and may require the use of oxygen. Excessive bleed- pneumonia, including a high fever, loss of appetite, gen- ing, wound infections, and pneumonia are possible com- eral weakness, and putrid sputum. The doctor will first plications of a lobectomy. The chest will hurt for some take a careful history and listen to the patient’s breathing time after surgery, as the surgeon must cut through the with a stethoscope. Imaging studies include x ray stud- patient’s ribs to expose the lung. Patients with COPD ies of the chest and CT scans. If lung cancer is suspect- may experience shortness of breath after surgery. ed, the doctor will obtain a tissue sample for a biopsy. If a lung abscess is suspected, the doctor will send a sam- Normal results ple of the sputum to a laboratory for culture and analysis. The outcome of lobectomies depends on the general For patients with lungs that have been damaged by condition of the patient’s lung. This variability is related emphysema or chronic bronchitis, pulmonary function to the fact that lung tissue does not regenerate after it is tests are conducted prior to surgery to determine whether removed. Therefore, removal of a large portion of the the patient will have enough healthy lung tissue remain- lung may require a person to need oxygen or ventilator ing after surgery. A test may be used before surgery to support for the rest of his or her life. On the other hand, help determine how much of the lung can safely be re- removal of only a small portion of the lung may result in moved. This test is called a quantitative ventilation/per- very little change to the patient’s quality of life. fusion scan, or a quantitative V/Q scan. Preparation Morbidity and mortality rates Patients should not take aspirin or ibuprofen for A small percentage of patients undergoing lung seven to 10 days before surgery. Patients should also lobectomy die during or soon after the surgery. This per- 904 GALE ENCYCLOPEDIA OF SURGERY

centage varies from about 3–6% depending on the amount of lung tissue removed. Of cancer patients with KEY TERMS completely removable stage-1 non-small cell cancer of the lung (a disease in which malignant cancer cells form Bronchodilator—A drug that relaxes the bronchial in the tissues of the lung), 50% survive five years after muscles, resulting in expansion of the bronchial Lobectomy, pulmonary the procedure. air passages. Corticosteroids—Any of various adrenal-cortex Alternatives steroids used as anti-inflammatory agents. Emphysema—A chronic disease characterized by Lung cancer loss of elasticity and abnormal accumulation of The treatment options for lung cancer are surgery, air in lung tissue. radiation therapy, and chemotherapy, either alone or in Mycobacterium—Any of a genus of nonmotile, combination, depending on the stage of the cancer. aerobic, acid-fast bacteria that include numerous After the cancer is found and staged, the cancer care saprophytes and the pathogens causing tuberculo- team discusses the treatment options with the patient. In sis and leprosy. choosing a treatment plan, the most significant factors to Perfusion scan—A lung scan in which a tracer is consider are the type of lung cancer (small cell or non- injected into a vein in the arm. It travels through small cell) and the stage of the cancer. It is very impor- the bloodstream and into the lungs to show areas tant that the doctor order all the tests needed to deter- of the lungs that are not receiving enough air or mine the stage of the cancer. Other factors to consider in- that retain too much air. clude the patient’s overall physical health; the likely side Pulmonary rehabilitation—A program to treat effects of the treatment; and the probability of curing the COPD, which generally includes education and disease, extending the patient’s life, or relieving his or counseling, exercise, nutritional guidance, tech- her symptoms. niques to improve breathing, and emotional sup- port. Chronic obstructive pulmonary disease Ventilation scan—A lung scan in which a tracer gas is inhaled into the lungs to show the quantity Although surgery is rarely used to treat COPD, it may be considered for people who have severe symp- of air that different areas of the lungs are receiving. toms that have not improved with medication therapy. A V/Q scan—A test in which both a perfusion scan significant number of patients with advanced COPD face and ventilation scan are done (separately or to- a miserable existence and are at high risk of death, de- gether) to show the quantity of air that different spite advances in medical technology. This group in- areas of the lungs are receiving. cludes patients who remain symptomatic despite the fol- lowing: • smoking cessation • Lung volume reduction surgery. In this procedure, the • use of inhaled bronchodilators surgeon removes a portion of one or both lungs, making room for the remaining lung tissue to work more effi- • treatment with antibiotics for acute bacterial infec- ciently. Its use is considered experimental, although it has tions, and inhaled or oral corticosteroids been used in selected patients with severe emphysema. • use of supplemental oxygen with rest or exertion • Lung transplant. In this procedure a healthy lung from • pulmonary rehabilitation a donor who has recently died is given to a person with After the severity of the patient’s airflow obstruction COPD. has been evaluated, and the foregoing interventions im- plemented, a pulmonary disease specialist should exam- Resources ine him or her, with consideration given to surgical treat- BOOKS ment. Braunwald, Eugene, M. D., Anthony S. Fauci, M. D., Dennis Surgical options for treating COPD include laser L. Kasper, M. D., et al., eds. Harrison’s Principles of In- therapy or the following procedures: ternal Medicine, 15th ed. New York: McGraw-Hill Profes- sional, 2001. • Bullectomy. This procedure removes the part of the Henschke, Claudia I., Peggy McCarthy, and Sarah Wernick. lung that has been damaged by the formation of large Lung Cancer: Myths, Facts, Choices—And Hope, 1st ed. air-filled sacs called bullae. New York, NY: W. W. Norton & Company, Inc., 2002. GALE ENCYCLOPEDIA OF SURGERY 905

Long-term care insurance Johnston, Lorraine. Lung Cancer: Making Sense of Diagnosis, son’s care in cases of chronic illness or disability. Poli- Long-term care insurance Treatment, and Options. Sebastopol, CA: O’Reilly & As- sociates, 2001. Definition Pass, H., M. D., D. Johnson, M. D., James B. Mitchell, PhD., et al., eds. Lung Cancer: Principles and Practice, 2nd ed. Long-term care (LTC) insurance provides for a per- Philadelphia, PA: Lippincott Williams & Wilkins, 2000. Tierney, Lawrence M., Stephen J. McPhee, and Maxine A. Pa- cies for LTC provide insurance coverage for times when padakis, eds. Current Medical Diagnosis & Treatment an individual cannot independently manage the essential 2003, 42nd ed. New York, NY: McGraw-Hill/Appleton & activities of daily living (ADLs). These are universally Lange, 2002. known as feeding, dressing, bathing, toileting, and walk- PERIODICALS ing, as well as moving oneself from a bed to a chair Crystal, Ronald G. “Research Opportunities and Advances in (transferring). However, disabilities are not confined to Lung Disease.” Journal of the American Medical Associa- these physical situations; they can be mental as well. The tion 285 (2001): 612-618. key element is that they limit the individual’s ability to Grann, Victor R., and Alfred I. Neugut. “Lung Cancer Screen- perform any of these functions. ing at Any Price?” Journal of the American Medical Asso- ciation 289 (2003): 357-358. Mahadevia, Parthiv J., Lee A. Fleisher, Kevin D. Frick, et al. Purpose “Lung Cancer Screening with Helical Computed Tomog- The purpose of LTC insurance is to provide cover- raphy in Older Adult Smokers: A Decision and Cost-Ef- age for a succession of caregiving services for the elder- fectiveness Analysis.” Journal of the American Medical ly, the chronically ill, the disabled, or the seriously in- Association 289 (2003): 313-322. jured. This care may be provided in a skilled nursing fa- Pope III, C. Arden, Richard T. Burnett, Michael J. Thun, et al. “Lung Cancer, Cardiopulmonary Mortality, and Long- cility (SNF); a nursing home; a mental hospital; in a per- Term Exposure to Fine Particulate Air pollution.” Journal son’s home with a registered nurse (RN), a licensed of the American Medical Association 287 (2002): 1132- practical nurse (LPN), or nurse’s aide; or even in an as- 1141. sisted living facility (ALF). It is important to note the so- cietal changes responsible for the increased need for pro- ORGANIZATIONS fessional services to care for our loved ones. Although American Cancer Society. 1599 Clifton Road, N.E., Atlanta, today’s families are smaller and a number of women are GA 30329-4251. (800) 227-2345. <www.cancer.org>. working outside the home, the majority of LTC contin- American Lung Association, National Office. 1740 Broadway, ues to be provided by unpaid, informal caregivers—fam- New York, NY 10019. (800) LUNG-USA. <www.lung ily members and friends. usa.org>. National Cancer Institute (NCI), Building 31, Room 10A03, 31 In 2003, more than 24 million households in the Center Drive, Bethesda, MD 20892-2580. Phone: (800) 4- United States included a caregiver who was 50 years of CANCER. (301) 435-3848. <www.nci.nih.gov>. age or older. About 73% of unpaid caregivers were National Comprehensive Cancer Network. 50 Huntingdon women—and one-third of them are more than 65 years Pike, Suite 200, Rockledge, PA 19046. (215) 728-4788. old. Many caregivers, especially women, balance multi- Fax: (215) 728-3877. <www.nccn.org/>. ple roles by providing care for both their parents and National Heart, Lung and Blood Institute (NHLBI). 6701 their children. Caring for a loved one full-time can over- Rockledge Drive, P.O. Box 30105, Bethesda, MD 20824- whelm even the most devoted family member. As a re- 0105. (301) 592-8573. <www.nhlhi.nih.gov/>. sult, more caregivers than ever are turning to outside re- OTHER sources to help with the care of a family member. Aetna InteliHealth Inc. Lung Cancer. [cited May 17, 2003]. <www.intelihealth.com.>. Demographics American Cancer Society (ACS). Cancer Reference Informa- tion [cited May 17, 2003]. <www3.cancer.org/cancer In 2030, it is anticipated that people aged 65 and info>. over will comprise 20% of the population. The United States Census Bureau is projecting that the population Michael Zuck, Ph.D. aged 65 and over will be 39.7 million in 2010, 53.7 mil- Crystal H. Kaczkowski, M.Sc. lion in 2020, and 70.3 million in 2030. As of 2003, at least 6.4 million people aged 65 and over require LTC; one in two people over the age of 85 require this kind of care now, and at least half of the population who are over Local anesthetic see Anesthesia, local the age of 85 will need help with ADLs. 906 GALE ENCYCLOPEDIA OF SURGERY

Although the elderly rely on LTC most frequently, quality of life for their caregiver. By having LTC at younger persons who have chronic illnesses, severe dis- home, spouses and other family members are able to abilities, or have experienced a serious injury may also continue working or run errands while their loved one is benefit from having LTC insurance. being care for. People of all ages usually prefer to receive LTC in Long-term care insurance Advantages to purchasing LTC insurance their own homes, or in homelike assisted-living facilities. More than three-quarters of older Americans in need of The financial risks of illness and injury are rarely LTC live in their communities. Most receive no paid ser- considered when one is healthy and able, but that is also vices. The majority of LTC is provided by unpaid, infor- when the greatest choice of products with the best flexi- mal caregivers, such as family members and friends. bility in cost is available for those considering LTC in- surance. Having a LTC insurance policy enables access to quality care and choice of care provider when the need Government assistance is greatest. Purchasing a policy when a person does not Long-term care options can be uncoordinated and need it gives them the opportunity to investigate the expensive for individuals, their families, and public pro- company’s financial stability (whether it is solid and how grams. According to AARP (formerly known as Ameri- it is rated), operating performance, insurance industry can Association of Retired Persons) millions of Ameri- rating, and its claims ratio. Rates should be guaranteed cans have no access to LTC services. They are caught in renewable, and coverage shouldn’t be canceled because the trap of having too much money to qualify for govern- of age or a change in a person’s health nor should premi- ment assistance, but not enough money to afford the ums be increased on a class-wide basis. types of services they need. There are several government organizations that can Recent changes in the United States federal tax law be of assistance in the purchase, evaluation, and monitor- allow for a portion of a long-term insurance premium to ing of LTC insurance. One is the state health insurance as- be tax-deductible. The amount of the deduction increases sistance program—SHIP—that can review the policy be- with the insured person’s age. fore the actual purchase. Another excellent organization is the Health Insurance Association of America (HIAA), Medicare may cover a month or two of home health which protects consumers from the financial risks of in- care after a stay in the hospital, but benefits are then usu- jury and illness by providing affordable and flexible ser- ally capped. This government program, administered by vices that represent a choice. In the United States, HIAA the Social Security Administration, is well known for focuses on managed care, and, specifically, advocates on providing financial assistance to seniors 65 years of age issues such as disability income and LTC insurance. and older and to the disabled—for medical and hospital expenses—but it does not cover LTC expenses. Medicare The mission of the Health Insurance Association of Supplement Insurance does not cover LTC either. America is to preserve financial security, freedom of choice, and dignity in LTC insurance. Because of its The federal/state Medicaid program is available, but mission, HIAA seeks to: the criteria to qualify for assistance is strict. Those who meet the guidelines for Medicaid must demonstrate fi- • Provide access to quality care and let a person choose nancial need to receive assistance; most individuals must where care is obtained. deplete most or all of their savings and assets before be- • Eliminate out-of-pocket costs and avoid reliance on coming eligible for any benefits. Still, in 2003, approxi- government programs for the poor. mately two-thirds of nursing home residents were depen- • Ensure quality of life for a patient’s caregivers. dent on Medicaid to finance at least some of their care. For the majority of residents, LTC insurance is cost-pro- hibitive. To make matters worse, preexisting conditions Description often prevent them from obtaining coverage for which Advantages they might qualify. Having a LTC insurance policy cuts out-of-pocket Personal policies costs and keeps the patient from having to rely on gov- ernment assistance programs. Studies from the United Long-term care insurance policies are often com- States Department of Health and Human Services esti- plex. People who purchase them may not read the fine mate that people with LTC insurance save between print and are later forced to cancel their policies because $60,000 and $75,000 in nursing home costs, more than they do not fit their needs. Increasing rates factored into $100,000 for assisted living, and actually ensure a higher some long-term policies, known as climbing premiums, GALE ENCYCLOPEDIA OF SURGERY 907

Long-term care insurance • Will the policy meet my needs? ered. Some LTC policies are pure indemnity programs, which pay the insured a daily benefit contracted for by QUESTIONS the insured. The pure indemnity program pays the full TO ASK BEFORE PURCHASING LTC INSURANCE daily benefit regardless of the amount of care that the in- sured receives each day. Other LTC policies pay for covered losses, or the cost of care actually received each day, up to the selected • Is the policy affordable? • What restrictions or exemptions exist? pool-of-money contract. • Under what conditions, if any, can this plan be can- daily benefit level. This type of policy is referred to as a Insurance for LTC is available either as part of a celed? group or as individual coverage, although most policies • Are there any laws to protect me from insurance are currently purchased by individuals. Most policies companies or LTC facilities that provide substan- cover skilled, custodial, and intermediate LTC services. dard conditions and/or services? A purchaser would be wise to consider a contract that covers all of these levels. Benefits under a LTC contract are triggered in a tax- qualified policy when an insured person becomes unable may also become prohibitively expensive. However, to perform a number of activities associated with normal long-term care insurance can benefit consumers, provid- daily living or develops a cognitive impairment that re- ed that such items as affordability, coverage gaps, and quires supervision. Non–tax-qualified policies usually timing of purchase are carefully considered. offer more liberal eligibility criteria. This includes long- It is advisable to check the financial stability and the term benefits required due to medical necessity. claims ratio of an insurance company. Long-term insur- ance is a serious financial investment and should be con- Risks sidered a part of estate planning. A qualified, indepen- dent professional should be consulted to review the poli- Long-term care insurance policies can be expensive cy before purchase. The state health insurance assistance and may be restrictive in what they provide. Before pur- program (SHIP) is also available to answer questions. chasing the policy, persons should be certain that the cost is within their means and that the plan will meet The type of care that an individual seeks or requires their anticipated needs. Some policies allow policy hold- is an important consideration before purchasing a policy. ers to use survivor death benefits for health care needs. It Currently, there is no universal standard for defining is advisable for several different policies to be compared long-term care facilities. A placement that is covered in detail. Policies that seem too inexpensive when com- under one company’s policy may not be covered by an- pared against the competition should be carefully evalu- other. Physicians can also play a part in denial of a place- ated. There may be hidden clauses in the contracts that ment by stating that the facility of choice is either not ad- limit coverage. equate or too advanced for an individual’s needs. When to purchase a policy is another important con- Organizations that can help consumers sideration. Individuals with a preexisting diagnosis for a debilitating condition or illness may not be eligible for The Health Insurance Association of America coverage. This clause is common in most insurance poli- (HIAA) protects consumers from the financial risks of ill- cies of any type. However, purchasing a policy too far in ness and injury by providing flexible and affordable prod- advance of an anticipated need can work against a buyer. ucts and services that embody freedom of choice, and ad- The health care industry is currently in a state of flux, vocates on a number of issues—including LTC insurance. and technological advances are rapid. The benefits pro- The United States Department of Health and Human vided in a policy that is purchased at one point in time Services oversees the Administration on Aging’s Om- may not match the care available in the distant future, budsmen Program. Established in 1972 by the Older giving the company reason to deny benefits. Americans Act, the Program operates throughout the Generally, LTC insurance operates as an indemnity country on behalf of aging residents. Its purpose is to in- program for potential nursing home and home health vestigate over 260,000 complaints annually regarding care costs. Additionally, many policies provide coverage various topics, including selection and payment of LTC for adult daycare, for care delivered in an assisted living insurance policies. The ombudsmen advocate for resi- facility, and for hospice care. Rarely are all costs cov- dents of nursing homes, LTC homes, assisted living fa- 908 GALE ENCYCLOPEDIA OF SURGERY

cilities, and similar adult care facilities, they have made dramatic differences in the lives of LTC residents. On KEY TERMS behalf of individuals and groups of residents, they pro- vide information to residents and their families about the Chronic illness—A condition that lasts a year or LTC system and work to improve local, state and nation- longer, limits activity, and may require ongoing Long-term care insurance al level programs. Ombudsmen also provide an ongoing care. presence in LTC facilities, monitoring care and condi- Estate planning—Preparation of a plan of admin- tions and providing a voice for those who are unable to istration and disposition of one’s property before speak for themselves. or after death, including will, trusts, gifts, and power of attorney. Alternatives Indemnity—Protection, as by insurance, against The only alternative to LTC insurance for individu- damage or loss. als is to pay for all expenses themselves when the need Long-term care (LTC)—The type of care one may for LTC arises. need if one can no longer perform activities of See also Private insurance plans. daily living (ADLs) alone, such as eating, bathing or getting dressed. It also includes the kind of care Resources one would need with a severe cognitive impair- ment, such as Alzheimer’s disease. Care can be re- BOOKS ceived in a variety of settings, including the home, Abromovitz, L. Long-Term Care Insurance Made Simple. Los Angeles, CA: Health Information Press, 1999. assisted living facilities, adult day care centers, or Lipson, B. J. K. Lasser’s Choosing the Right Long-Term Care hospice facilities. Insurance. New York, Wiley, 2002. Medicaid—Public assistance funded through the McCall, N. Who Will Pay for Long-Term Care: Insights from state to individuals unable to pay for health care. the Partnership Programs. Chicago, IL: Health Adminis- Medicaid can be accessed only when all prior as- tration Press, 2001. sets and funds are depleted. Stevens, W. S. Health Insurance: Current Issues and Back- ground. Hauppauge, NY: Nova Science Publishers, 2003. Medicare—A government program, administered by the Social Security Administration, which pro- PERIODICALS vides financial assistance to individuals over the Cohen, M. A. “Private Long-term Care Insurance: A Look age of 65 for hospital and medical expenses. Ahead.” Journal of Aging and Health 15, no. 1 (2003): Medicare does not cover long-term care expenses. 74–98. Cubanski J., and J. Kline. “Medicaid: Focusing on State Innova- Skilled nursing facility (SNF)—A facility equipped tion.” Commonwealth Fund Issue Brief 617 (2003): 1–8. to handle individuals with 24-hour nursing needs, Luecke R. W., and D. T. Blair. “Designing Long-term Disabili- postoperative recuperation, or complex medical ty Plans: Tax Efficiency vs. Maximizing Wage Replace- care demands, as well as chronically-ill individu- ment.” Benefits Quarterly 19, no. 1 (2003): 51–60. als who can no longer live independently. These Polivka, L., et al. “The Nursing Home Problem in Florida.” facilities must be licensed by the state in which Gerontologist 43, no. 2 (2003): 7–18. they operate to meet standards of safety, staffing, Schwartz, M. “Dentistry for the Long-term Care Patient.” Den- and care procedures. tistry Today 22, no. 1 (2003): 52–57. ORGANIZATIONS AARP. 601 E. Street NW, Washington, DC 20049. (800) 424- 3410. <http://www.aarp.org>. United States Department of Health and Human Services, 200 American College of Healthcare Executives. One North Independence Avenue, SW, Washington, DC 20201. (877) Franklin, Suite 1700, Chicago, IL 60606-4425. (312) 424- 696-6775. <http://www.hhs.gov>. 2800. <http://www.ache.org>. American Medical Association. 515 N. State Street, Chicago, OTHER IL 60610. (312) 464-5000. <http://www.ama-assn.org>. American Health Care Association, National Center for Assist- Health Insurance Association of America. 1201 F Street, NW, ed Living. Cited May 6, 2003. <http://www.longtermcare Suite 500, Washington, DC 20004-1204. (202) 824-1600. living.com>. <http://www.hiaa.org>. The Federal Long Term Care Insurance Program. July 1, 2003 U.S. Administration on Aging (AOA), United States Depart- (cited July 7, 2003). <http://www.ltcfeds.com>. ment of Health and Human Services. 330 Independence Avenue, SW, Washington, DC 20201. (202) 619-0724. The National Council on the Aging. Cited July 7, 2003. <http:// <http://www.aoa.gov>. www.unitedseniorshealth.org>. GALE ENCYCLOPEDIA OF SURGERY 909

Lumpectomy “Planning for Long-Term Care.” Booklet. United Seniors WHERE IS IT PERFORMED? Health Council, Washington, DC. New York: McGraw- WHO PERFORMS Hill, 2002. THE PROCEDURE AND Teachers Insurance Annuity Association of America (TIAA- CREF). (Cited May 6, 2003.) <http://www.tiaa-cref. org/ltc>. Lumpectomy is usually performed by a general surgeon or surgical oncologist. Radiation thera- L. Fleming Fallon, Jr., MD, DrPH py is administered by a radiation oncologist, Randi B. Jenkins, BA and chemotherapy by a medical oncologist. The procedure is frequently done in a hospital setting (especially if lymph nodes are to be re- Lower GI exam see Barium enema moved at the same time), but specialized out- patient facilities are sometimes preferred. LTC insurance see Long-term care insurance Lumbar laminectomy see Laminectomy course of radiation therapy after surgery is part of the Lumbar puncture see Cerebrospinal fluid treatment. Chemotherapy or hormone treatment may (CSF) analysis also be prescribed. In some instances, women with later stage breast cancer may be able to have lumpectomies. Chemother- apy may be administered before surgery to decrease tumor size and the chance of metastasis in selected cases. Lumpectomy Definition Contraindications to lumpectomy Lumpectomy is a type of surgery for breast cancer. There are a number of factors that may prevent or It is considered “breast-conserving” surgery because prohibit a breast cancer patient from having a lumpecto- only the malignant tumor and a surrounding margin of my. The tumor itself may be too large or located in an normal breast tissue are removed. Lymph nodes in the area where it would be difficult to remove with good armpit (axilla) may also be removed. This procedure is cosmetic results. Sometimes several areas of cancer are also called lymph node dissection. found in one breast, so the tumor cannot be removed as a single lump. A cancer that has already attached itself to nearby structures, such as the skin or the chest wall, Purpose needs more extensive surgery. Lumpectomy is a surgical treatment for newly diag- Certain medical or physical circumstances may nosed breast cancer. It is estimated that at least 50% of also eliminate lumpectomy as a treatment option. women with breast cancer are good candidates for this Sometimes lumpectomy may be attempted, but the sur- procedure. The location, size, and type of tumor are of geon is unable to remove the tumor with a sufficient primary importance when considering breast cancer amount of surrounding normal tissue. This may be surgery options. The size of the breast is another factor termed “persistently positive margins,” or “lack of clear the surgeon considers when recommending surgery. The margins.” Lumpectomy is suitable for women who have patient’s psychological outlook, as well as her lifestyle had previous lumpectomies and have a recurrence of and preferences, should also be taken into account when breast cancer. treatment decisions are being made. Because of the need for radiation therapy after The extent and severity of a cancer is evaluated, or lumpectomy, this surgery may be medically unaccept- “staged,” according to a fairly complex system. Staging able. A breast cancer discovered during pregnancy is considers the size of the tumor and whether the cancer not amenable to lumpectomy because radiation therapy has spread (metastasized) to adjacent tissues, such as the is part of the treatment. Radiation therapy cannot be chest wall, the lymph nodes, and/or to distant parts of the administered to pregnant women because it may injure body. Women with early stage breast cancers are usually the fetus. If, however, delivery would be completed better candidates for lumpectomy. In most cases, a prior to the need for radiation, pregnant women may 910 GALE ENCYCLOPEDIA OF SURGERY

Lumpectomy Lumpectomy Skin flap Pectoralis major muscle Lump Incision Mammary glands A. B. Scar tissue C. During a lumpectomy, a small incision is made around the area of the lump (A).The skin is pulled back, and the tumor re- moved (B).The incision is closed (C). (Illustration by GGS Inc.) undergo lumpectomy. A woman who has already had surgery so that radiation will not be required. The com- therapeutic radiation to the chest area for other reasons mitment of time, usually five days a week for six cannot undergo additional exposure for breast cancer weeks, may not be acceptable for others. This may be therapy. due to financial, personal, or job-related constraints. Fi- nally, in geographically isolated areas, a course of radi- The need for radiation therapy may also be a barri- ation therapy may require lengthy travel and perhaps er due to nonmedical concerns. Some women simply unacceptable amounts of time away from family and fear this type of treatment and choose more extensive other responsibilities. GALE ENCYCLOPEDIA OF SURGERY 911

If axillary lymph nodes were not removed before, a Lumpectomy TO ASK THE DOCTOR second incision is made in the armpit. The fat pad that QUESTIONS contains lymph nodes is removed from this area and is also sent to the pathologist for analysis. This portion of the procedure is called an axillary lymph node dissec- • Why is a lumpectomy recommended? tion; it is critical for determining the stage of the cancer. • What method of anesthesia/pain relief will be Typically, 10 to 15 nodes are removed, but the number used? may vary. Surgical drains may be left in place in either • Will radiation or chemotherapy be adminis- location to prevent fluid accumulation. The surgery may tered? last from one to three hours. • Will a lymph node dissection be performed? • Am I a candidate for sentinel node biopsy? Diagnosis/Preparation Routine preoperative preparations, such as having nothing to eat or drink the night before surgery, are typi- Demographics cally ordered for a lumpectomy. Information about ex- pected outcomes and potential complications is also part The American Cancer Society estimated that in of preparation for lumpectomy, as it is for any surgical 2003, 211,300 new cases of breast cancer would be diag- procedure. It is especially important that women know nosed in the United States and 39,800 women would die about sensations they might experience after the opera- as a result of the disease. Approximately one in eight tion, so the they are not misinterpreted as signs of further women will develop breast cancer at some point in her cancer or poor healing. life. The risk of developing breast cancer increases with age: women aged 30 to 40 have a one in 252 chance of If the tumor is not able to be felt (not palpable), a developing breast cancer; women aged 40 to 50 have a pre-operative localization procedure is needed. A fine one in 68 chance; women aged 50 to 60 have a one in 35 wire, or other device, is placed at the tumor site, using x chance; and women aged 60 to 70 have a one in 27 ray or ultrasound for guidance. This is usually done in chance—and these statistics do not even account for ge- the radiology department of a hospital. The woman is netic and environmental factors. most often sitting up and awake, although some sedation may be administered. In the 1990s, the incidence of breast cancer was higher among white women (113.1 cases per 100,000 women) than African-American women (100.3 per Aftercare 100,000). The death rate associated with breast cancer, The patient may stay in the hospital one or two days, however, was higher among African American women or return home the same day. This generally depends on (29.6 per 100,000) than white women (22.2 per the extent of the surgery, the medical condition of the pa- 100,000). Rates were lower among Hispanic women tient, and physician and patient preferences. A woman (14.2 per 100,000), American Indian women (12.0), and usually goes home with a small bandage. The inner part Asian women (11.2 per 100,000). of the surgical site usually has dissolvable stitches. The skin may be sutured or stitched; or the skin edges may be held together with steristrips, which are special thin, Description clear pieces of tape. Any amount of tissue, from 1–50% of the breast, After a lumpectomy, patients are usually cautioned may be removed and called a lumpectomy. Breast con- against lifting anything which weighs over five pounds servation surgery is a frequently used synonym for for several days. Other activities may be restricted (espe- lumpectomy. Partial mastectomy, quadrantectomy,seg- cially if the axillary lymph nodes were removed) accord- mental excision, wide excision, and tylectomy are other, ing to individual needs. Pain is often enough to limit in- less commonly used names for this procedure. appropriate motion. Women are often instructed to wear a well-fitting support bra both day and night for approxi- The surgery is usually done while the patient is mately one week after surgery. under general anesthetic. Local anesthetic with addi- tional sedation may be used for some patients. The Pain is usually well controlled with prescribed med- tumor and surrounding margin of tissue is removed and ication. If it is not, the patient should contact the sur- sent to a pathologist for examination. The surgical site is geon, as severe pain may be a sign of a complication, then closed. which needs medical attention. A return visit to the sur- 912 GALE ENCYCLOPEDIA OF SURGERY

geon is normally scheduled approximately ten days to two weeks after the operation. KEY TERMS Radiation therapy is usually started as soon as possi- Lumpectomy ble after lumpectomy. Other additional treatments, such as Axillary lymph node—Lymph nodes under the arm. chemotherapy or hormone therapy, may also be prescribed. Lymph node—A small mass of tissue in the form The timing of these is specific to each individual patient. of a knot or protuberance. They are the primary source of lymph fluid, which serves in the body’s Risks defense by removing toxic fluids and bacteria. Quadrantectomy—Removal of a quadrant, or The risks are similar to those associated with any surgical procedure. Risks include bleeding, infection, about a quarter of the breast. breast asymmetry, anesthesia reaction, or unexpected scarring. A lumpectomy may also cause loss of sensation in the breast. The size and shape of the breast will be af- lumpectomy too risky. Others may feel uncomfortable fected by the operation. Fluid can accumulate in the area with a breast that has had a cancer, and would experience where tissue was removed, requiring drainage. more peace of mind with the entire breast removed. If lymph node dissection is performed, there are A new technique that may eliminate the need for re- several potential complications. A woman may experi- moving many axillary lymph nodes is being tested. Sen- ence decreased feeling in the back of her armpit. She tinel lymph node mapping and biopsy is based on the may also experience other sensations, including idea that the condition of the first lymph node in the net- numbness, tingling, or increased skin sensitivity. An work, which drains the affected area, can predict whether inflammation of the arm vein, called phlebitis, can the cancer may have spread to the rest of the nodes. It is occur. There may be injury to the nerves controlling thought that if this first, or sentinel, node is cancer-free, arm motion. then there is no need to look further. Many patients with There is a risk of developing lymphedema (swelling of early-stage breast cancers may be spared the risks and the arm) after axillary lymph node dissection. This swelling complications of axillary lymph node dissection as the can range from mild to very severe. It can be treated with use of this approach continues to increase. elastic bandages and specialized physical therapy, but it is a chronic condition, requiring continuing care. Lymphedema Resources can arise at any time, even years after surgery. BOOKS Normal results Love, Susan M., with Karen Lindsey. Dr. Susan Love’s Breast Book, 3rd ed. Cambridge: Perseus Publishing, 2000. When lumpectomy is performed, it is anticipated Robinson, Rebecca Y. and Jeanne A. Petrek. A Step-by-Step that it will be the definitive surgical treatment for breast Guide to Dealing With Your Breast Cancer. New York: cancer. Other forms of therapy, especially radiation, are Carol Publishing Group, 1999. often prescribed as part of the total treatment plan. The PERIODICALS expected outcome is no recurrence of the breast cancer. Apantaku, Leila. “Breast-Conserving Surgery for Breast Can- cer.” American Family Physician 66, no. 12 (December Morbidity and mortality rates 15, 2002): 2271–8. Approximately 2–10% of patients develop lym- Dershaw, D. David. “Breast imaging and the conservative treat- phedema after axillary lymph node dissection. Five per- ment of breast cancer.” Radiologic Clinics of North Amer- cent of women are unhappy with the cosmetic effects of ica 40, no. 3 (May 2002): 501–16. the surgery. The rate of cancer recurrence after five years ORGANIZATION is about 5–10%, and 10–15% after 10 years. American Cancer Society. 1599 Clifton Rd. NE, Atlanta, GA 30329-4251. (800) 227-2345. <http://www.cancer.org>. Alternatives National Cancer Institute (NCI) <http://cancertrials. nci.nih.gov/types/breast/treatment/sentnode>. A procedure in which the entire affected breast is re- National Lymphedema Network. 2211 Post St., Suite 404, San moved, called a mastectomy, has been shown to be equal- Francisco, CA 94115-3427. (800) 541-3259 or (415) 921- ly effective in treating breast cancer as lumpectomy, in 1306. <http://www.wenet.net/~lymphnet>. terms of rates of recurrence and survival. Some women may choose to have a mastectomy because they strongly Ellen S. Weber, MSN fear a recurrence of breast cancer, and may consider a Stephanie Dionne Sherk GALE ENCYCLOPEDIA OF SURGERY 913

Lung biopsy Definition close to the chest wall, a needle biopsy can be done. If Lung biopsy both methods fail to diagnose the problem, an open lung biopsy may be performed. When there is a question about whether the lung cancer or suspicious mass has Lung biopsy is a procedure for obtaining a small spread to the lymph nodes in the mediastinum, a medi- sample of lung tissue for examination. The tissue is usu- astinoscopy is performed. ally examined under a microscope, and may be sent to a BRONCHOSCOPIC BIOPSY. During the bronchoscopy, microbiological laboratory for culture. Microscopic ex- a thin, lighted tube (bronchoscope) is passed from the amination is performed by a pathologist. nose or mouth, down the windpipe (trachea) to the air pas- sages (bronchi) leading to the lungs. Through the bron- Purpose choscope, the physician views the airways, and is able to A lung biopsy is usually performed to determine the clear mucus from blocked airways, and collect cells or tis- cause of abnormalities, such as nodules that appear on sue samples for laboratory analysis. chest x rays. It can confirm a diagnosis of cancer, espe- NEEDLE BIOPSY. The patient is mildly sedated, but cially if malignant cells are detected in the patient’s spu- awake during the needle biopsy procedure. He or she sits tum or bronchial washing. In addition to evaluating lung in a chair with arms folded in front on a table. An x ray tumors and their associated symptoms, lung biopsies technician uses a computerized axial tomography (CAT) may be used to diagnose lung infections, especially tu- scanner or a fluoroscope to identify the precise location berculosis and Pneumocystis pneumonia, drug reactions, of the suspicious areas. Markers are placed on the overly- and chronic diseases of the lungs such as sarcoidosis and ing skin to identify the biopsy site. The skin is thoroughly pulmonary fibrosis. cleansed with an antiseptic solution, and a local anesthet- A lung biopsy can be used for treatment as well as ic is injected to numb the area. The patient will feel a diagnosis. Bronchoscopy, a type of lung biopsy per- brief stinging sensation when the anesthetic is injected. formed with a long, flexible slender instrument called a The physician makes a small incision, about half an bronchoscope, can be used to clear a patient’s air pas- inch (1.25 cm) in length. The patient is asked to take a sages of secretions and to remove airway blockages. deep breath and hold it while the physician inserts the biopsy needle through the incision into the lung tissue to Demographics be biopsied. The patient may feel pressure, and a brief sharp pain when the needle touches the lung tissue. Most According to the American Cancer Society, approxi- patients do not experience severe pain. The patient should mately 77% of all cancers are diagnosed in people ages refrain from coughing during the procedure. The needle is 55 and older. Lung cancer is the leading cause of cancer withdrawn when enough tissue has been obtained. Pres- deaths in the United States. Each year, about 170,000 sure is applied at the biopsy site and a sterile bandage is Americans are diagnosed with lung cancer. It is much placed over the incision. A chest x ray is performed im- more prevalent among African Americans than the gen- mediately after the procedure to check for potential com- eral population. Nine out of 10 cases of lung cancer are plications. The entire procedure takes 30 to 60 minutes. caused by smoking cigarettes, pipes, or cigars. OPEN BIOPSY. Open biopsies are performed in a hos- Description pital operating room under general anesthesia. Once the anesthesia has taken effect, the surgeon makes an incision Overview over the lung area, a procedure called a thoracotomy. The right and left lungs are separated by the medi- Some lung tissue is removed and the incision is closed astinum, which contains the heart, trachea, lymph nodes, with sutures. Chest tubes are placed with one end inside and esophagus. Lung biopsies sometimes involve medi- the lung and the other end protruding through the closed astinoscopy. incision. Chest tubes are used to drain fluid and blood, and re-expand the lungs. They are usually removed the day Types of lung biopsies after the procedure. The entire procedure normally takes about an hour. A chest x ray is performed immediately Lung biopsies are performed using a variety of tech- after the procedure to check for potential complications. niques, depending on where the abnormal tissue is locat- ed in the lung, the health and age of the patient, and the VIDEO-ASSISTED THORACOSCOPIC SURGERY. A presence of lung disease. A bronchoscopy is ordered if a minimally invasive technique, video-assisted thoraco- lesion identified on the x ray seems to be located on the scopic surgery (VATS) can be used to biopsy lung and wall (periphery) of the chest. If the suspicious area lies mediastinal lesions. VATS may be performed on selected 914 GALE ENCYCLOPEDIA OF SURGERY

patients in place of open lung biopsy. While the patient is under general anesthetia, the surgeon makes several WHO PERFORMS small incisions in the his or her chest wall. A thorascope, THE PROCEDURE AND Lung biopsy a thin, hollow, lighted tube with a tiny video camera WHERE IS IT PERFORMED? mounted on it, is inserted through one of the small inci- sions. The other incisions allow the surgeon to insert Fiberoptic bronchoscopy is performed by pul- special instruments to retrieve tissue for biopsy. monologists, physician specialists in pul- MEDIASTINOSCOPY. This procedure is performed monary medicine. CAT guided needle biopsy is under general anesthesia. A 2–3 in (5–8 cm) incision is done by interventional radiologists, physician made at the base of the neck. A thin, hollow, lighted specialists in radiological procedures. Thoracic tube, called a mediastinoscope, is inserted through the surgeons perform open biopsies and VATS. Spe- incision into the space between the right and the left cially trained nurses, x ray, and laboratory tech- lungs. The surgeon removes any lymph nodes or tissues nicians assist during the procedures and pro- that look abnormal. The mediastinoscope is then re- vide pre- and postoperative education and sup- moved, and the incision is sutured and bandaged. A me- portive care. diastinoscopy takes about an hour. The procedures are performed in an oper- ating or procedure room in a hospital. Diagnosis/Preparation Diagnosis purpose is to deliver the general anesthetic. The chest Before scheduling a lung biopsy, the physician per- area is cleansed with an antiseptic solution. In the medi- forms a careful evaluation of the patient’s medical history astinoscopy procedure, the neck is also cleansed to pre- and symptoms, and performs a physical examination. pare for the incision. Chest x rays and sputum cytology (examination of cells obtained from a deep-cough mucus sample) are other diag- Smoking cessation nostic tests that may be performed. An electrocardiogram Patients who will undergo surgical diagnostic and (EKG) and laboratory tests may be performed before the treatment procedures should be encouraged to stop procedure to check for blood clotting problems, anemia, smoking and stop using tobacco products. The patient and blood type, should a transfusion become necessary. needs to make the commitment to be a nonsmoker after the procedure. Patients able to stop smoking several Preparation weeks before surgical procedures have fewer postopera- During a preoperative appointment, usually sched- tive complications. Smoking cessation programs are uled within one to two weeks before the procedure, the available in many communities. The patient should ask a patient receives information about what to expect during health care provider for more information if he or she the procedure and the recovery period. During this ap- needs help with smoking cessation. pointment or just before the procedure, the patient usual- ly meets with the physician (or physicians) performing Informed consent the procedure (the pulmonologist, interventional radiolo- Informed consent is an educational process be- gist, or thoracic surgeon). tween health care providers and patients. Before any pro- A chest x ray or CAT scan of the chest is used to cedure is performed, the patient is asked to sign a con- identify the area to be biopsied. sent form. Prior to signing the form, the patient should understand the nature and purpose of the diagnostic pro- About an hour before the biopsy procedure, the pa- cedure or treatment, its risks and benefits, and alterna- tient receives a sedative. Medication may also be given tives, including the option of not proceeding with the test to dry up airway secretions. General anesthesia is not or treatment. During the discussions, the health care used for this procedure. providers are available to answer the patient’s questions For at least 12 hours before the open biopsy, VATS, about the consent form or procedure. or mediastinoscopy procedures, the patient should not eat or drink anything. Prior to these procedures, an intra- Aftercare venous line is placed in a vein in the patient’s arm to de- Needle biopsy liver medications or fluids as necessary. A hollow tube, called an endotracheal tube, is passed through the pa- Following a needle biopsy, the patient is allowed to tient’s mouth into the airway leading to the lungs. Its rest comfortably. He or she may be required to lie flat for GALE ENCYCLOPEDIA OF SURGERY 915

Lung biopsy TO ASK THE DOCTOR The patient receives oxygen via a face mask or nasal can- nula. If no complications develop, the patient is taken to a QUESTIONS hospital room. Temperature, blood oxygen level, pulse, blood pressure, and respiration are monitored. Chest • Why is this procedure being performed? tubes remain in place after surgery to prevent the lungs from collapsing, and to remove blood and fluids. The • Are there any alternative options to having tubes are usually removed the day after the procedure. this procedure? • What type of lung biopsy procedure is The patient may experience some grogginess for a recommended? few hours after the procedure. He or she may have a sore throat from the endotracheal tube. The patient may also • Is minimally invasive surgery an option? have some pain or discomfort at the incision site, which • Will the patient be awake during the proce- can be relieved by pain medication. It is common for pa- dure? tients to require some pain medication for up to two • Who will be performing the procedure? How weeks following the procedure. many years of experience does this physician After receiving instructions about resuming normal have? How many other lung biopsies has the activities and caring for the incision, the patient usually physician performed? goes home the day after surgery. The patient should not • Can medications be taken the day of the pro- drive while taking narcotic pain medication. cedure? Patients may experience fatigue and muscle aches • Can the patient have food or drink before the for a day or two because of the general anesthesia. The procedure? If not, how long before the proce- patient can gradually increase activities, as tolerated. dure should these activities be stopped? Walking is recommended. Sutures are usually removed • How long is the hospitalization? after one to two weeks. • After discharge, how long will it take to re- The physician should be notified immediately if the cover from the procedure? patient experiences extreme pain, light-headedness, or dif- • How is pain or discomfort relieved after the ficulty breathing after the procedure. Sputum may be procedure? slightly bloody for a day or two after the procedure. Heavy or persistent bleeding requires evaluation by the physician. • What types of symptoms should be reported to the physician? • When can normal activities be resumed? Risks • When cam driving be resumed? Lung biopsies should not be performed on patients • When can the patient return to work? who have a bleeding disorder or abnormal blood clotting because of low platelet counts, or prolonged prothrombin • When will the results of the procedure be time (PT) or partial thromboplastin time (PTT). Platelets given to the patient? are small blood cells that play a role in the blood clotting • How often are follow-up physician visits process. PT and PTT measure how well blood is clotting. needed after the procedure? If clotting times are prolonged, it may be unsafe to per- form a biopsy because of the risk of bleeding. If the platelet count is lower than 50,000/cubic mm, the patient two hours following the procedure to prevent the risk of may be given a platelet transfusion as a temporary relief bleeding. The nurse checks the patient’s status at two- measure, and a biopsy can then be performed. hour intervals. If there are no complications after four In addition, lung biopsies should not be performed if hours, the patient can go home once he or she has re- other tests indicate the patient has enlarged alveoli asso- ceived instructions about resuming normal activities. ciated with emphysema, pulmonary hypertension, or en- The patient should rest at home for a day or two before largement of the right ventricle of the heart (cor pul- returning to regular activities, and should avoid strenu- monale). ous activities for one week after the biopsy. The normal risks of any surgical procedure include bleeding, infection, or pneumonia. The risk of these Open biopsy, VATS, or mediastinoscopy complications is higher in patients undergoing open After an open biopsy, VATS, or mediastinoscopy, the biopsy procedures, as is the risk of pneumothorax (lung patient is taken to the recovery room for observation. collapse). In rare cases, the lung collapses because of air 916 GALE ENCYCLOPEDIA OF SURGERY

KEY TERMS Lung biopsy Bronchoscopy—A medical test that enables the Mediastinum—The area between the lungs, physician to see the breathing passages and the bounded by the spine, breastbone, and diaphragm. lungs through a hollow, lighted tube. Pleural cavity—The space between the lungs and Chest x ray—Brief exposure of the chest to radia- the chest wall. tion to produce an image of the chest and its inter- Pneumothorax—A condition in which air or gas nal structures. enters the pleura (area around the lungs) and caus- Endotracheal tube—A hollow tube that is inserted es a collapse of the lung. into the windpipe to administer anesthesia. Pulmonary nodule—A lesion surrounded by nor- Lung nodule—See pulmonary nodule. mal lung tissue. Nodules may be caused by bacte- Lymph nodes—Small, bean-shaped structures that ria, fungi, or a tumor (benign or cancerous). serve as filters, scattered along the lymphatic ves- Sputum—A mucus-rich secretion that is coughed sels. Lymph nodes trap bacteria or cancer cells that up from the passageways (bronchial tubes) and the are traveling through the lymphatic system. lungs. Malignant—Cancerous. Sputum cytology—A lab test in which a micro- Mediastinoscopy—A procedure that allows the scope is used to check for cancer cells in the spu- physician to see the organs in the mediastinal tum. space using a thin, lighted, hollow tube (a medi- Thoracentesis—Removal of fluid from the pleural astinoscope). cavity. that leaks in through the hole made by the biopsy needle. breathing problems before the biopsy, breathing may be A chest x ray is done immediately after the biopsy to de- further impaired following the operation. Patients with tect the development of this potential complication. If a normal lung function prior to the biopsy have a very pneumothorax occurs, a chest tube is inserted into the small risk of respiratory problems resulting from or fol- pleural cavity to re-expand the lung. Signs of pneumoth- lowing the procedure. orax include shortness of breath, rapid heart rate, or blueness of the skin (a late sign). If the patient has any of Mediastinoscopy these symptoms after being discharged from the hospital, Complications due to mediastinoscopy are rare. Pos- it is important to call the health care provider or emer- sible complications include pneumothorax or bleeding gency services immediately. caused by damage to the blood vessels near the heart. Mediastinitis, infection of the mediastinum, may devel- Bronchoscopic biopsy op. Injury to the esophagus or larynx may occur. If the Bronchoscopy is generally safe, and complications nerves leading to the larynx are injured, the patient may are rare. If they do occur, complications may include be left with a permanently hoarse voice. All of these spasms of the bronchial tubes that can impair breathing, complications are rare. irregular heart rhythms, or infections such as pneumonia. Normal results Needle biopsy Normal results indicate no evidence of infection in Needle biopsy is associated with fewer risks than the lungs, no detection of lumps or nodules, and cells open biopsy because it does not involve general anesthe- that are free from cancerous abnormalities. sia. Some hemoptysis (coughing up blood) occurs in 5% of needle biopsies. Prolonged bleeding or infection may Abnormal results of needle biopsy, VATS, and open also occur, although these are very rare complications. biopsy may be associated with diseases other than can- cer. Nodules in the lungs may be due to active infections such as tuberculosis, or may be scars from a previous in- Open biopsy fection. In 33% of biopsies using a mediastinoscope, the Possible complications of an open biopsy include biopsied lymph nodes prove to be cancerous. Abnormal infection or pneumothorax. If the patient has very severe results should always be considered in the context of the GALE ENCYCLOPEDIA OF SURGERY 917

Lung transplantation patient’s medical history, physical examination, and Lung Line National Jewish Medical and Research Center. 14090 Jackson Street, Denver, CO 80206. (800) 222- other tests such as sputum examination, and chest x rays 5864. E-mail: [email protected]. <http://www.national before a final diagnosis is made. jewish.org>. National Cancer Institute (National Institutes of Health). 9000 Morbidity and mortality rates Rockville Pike, Bethesda, MD 20892. (800) 422-6237. <http://www.nci.nih.gov>. The risk of death from needle biopsy is rare. The risk of death from open biopsy is one in 3,000 cases. In medi- P.O. Box 30105, Bethesda, MD 20824-0105. (301) 251- astinoscopy, death occurs in fewer than one in 3,000 cases. National Heart, Lung and Blood Institute. Information Center. 2222. <http://www.nhlbi.nih.gov>. Alternatives OTHER Dailylung.com <http://www.dailylung.com>. The type of alternative diagnostic procedures avail- Chest Medicine On-Line <http://www.priory.com/chest.htm>. able depend upon each patient’s diagnosis. National Lung Health Education Program. <http://www. nlhep.com>. Some people may be eligible to participate in clinical Pulmonarypaper.org P.O. Box 877, Ormond Beach, FL 32175. trials, research programs conducted with patients to eval- (800) 950- 3698. <http://www.pulmonarypaper.org>. uate a new medical treatment, drug, or device. The pur- Pulmonary Forum <http://www.pulmonarychannel.com>. pose of clinical trials is to find new and improved meth- ods of treating different diseases and special conditions. Barbara Wexler For more information on current clinical trials, visit the Angela M. Costello National Institutes of Health’s ClinicalTrials.gov at <http://www.clinicaltrials.gov> or call (888) FIND-NLM [(888) 346-3656] or (301) 594- 5983. Lung surgery see Lobectomy, pulmonary The National Cancer Institute (NCI) has conducted a clinical trial to evaluate a technology—low-dose heli- cal computed tomography—for its effectiveness in screening for lung cancer. One study concluded that this test is more sensitive in detecting specific conditions re- Lung transplantation lated to lung cancer than other screening tests. Definition Resources Lung transplantation involves removal of one or BOOKS both diseased lungs from a patient and the replacement “Bronchoscopy.” In The Merck Manual of Diagnosis and Ther- of the lungs with healthy organs from a donor. Lung apy, Seventeenth Edition. Edited by Beers, M.D., Mark H., and Robert Berkow, M.D. Whitehouse Station, NJ: transplantation may refer to single, double, or even Merck & Co., Inc., 1999. heart-lung transplantation. Groenwald, S.L. et al. Cancer Nursing Principles and Practice. Fifth Edition. Sudbury, MA: Jones and Bartlett Publishers, Purpose 2000. The purpose of lung transplantation is to replace a ORGANIZATIONS lung that no longer functions with a healthy lung. To per- American Association for Respiratory Care (AARC). 11030 form a lung transplantation, there should be potential for Ables Lane, Dallas, TX 75229. E-mail: [email protected]. rehabilitated breathing function. Other medical treat- <http://www.aarc.org>. ments should be attempted before transplantion is consid- American Cancer Society. 1599 Clifton Road, N.E., Atlanta, ered. Many candidates for this procedure have end-stage GA 30329. (800) 227-2345 or (404) 320-3333. <http:// fibrotic lung disease, are dependent on oxygen therapy, www.cancer.org>. American College of Chest Physicians. 3300 Dundee Road, and are likely to die of their disease in 12 to 18 months. Northbrook, IL 60062-2348. (847) 498-1400. <http:// www.chestnet.org>. Demographics American Lung Association and American Thoracic Society. 1740 Broadway, New York, NY 10019-4374. (800) 586- In order to qualify for lung transplantation, a patient 4872 or (212) 315-8700. <http://www.lungusa.org> and must suffer from severe lung disease such as: <http://www.thoracic.org>. • emphysema Cancer Research Institute. 681 Fifth Avenue, New York, NY 10022. (800) 992-2623. <http://www.cancerresearch.org>. • cystic fibrosis 918 GALE ENCYCLOPEDIA OF SURGERY

Lung transplantation Heart Left atrium Pulmonary artery Lung transplantation Superior pulmonary vein Pulmonary veins Lung A. B. Lung Bronchus Pulmonary artery Donor lung C. D. Donor lung Pulmonary veins E. During a lung transplant, the chest is opened to reveal the heart, lungs, and major blood vessels (A). Inferior and superior pulmonary veins and pulmonary artery are separated, and lung is removed (B).The bronchus of the donor lung is connected to the patient’s existing bronchus (C).The pulmonary artery is attached (D), and the pulmonary vein and other blood vessels are also connected (E). (Illustration by GGS Inc.) • pulmonary fibrosis age, have a life expectancy without transplantation of • pulmonary hypertension two years or less, progressive deterioration, and emo- tional stability in order to be considered for lung trans- • bronchiectasis plantation. Young patients with end-stage silicosis may • sarcoidosis be candidates for lung or heart-lung transplantation. Pa- • silicosis tients with stage III or stage IV sarcoidosis with cor pul- Patients with emphysema or chronic obstructive pul- monale (right-sided heart failure) should be considered monary disease (COPD) should be under 60 years of as early as possible for lung transplantation. GALE ENCYCLOPEDIA OF SURGERY 919

Lung transplantation Lung transplantations are performed in a special- lected for lung transplant. This includes patients who are acutely ill and unstable; have uncontrolled or untreatable WHO PERFORMS pulmonary infection; significant dysfunction of other or- THE PROCEDURE AND gans, particularly the liver, kidney, or central nervous sys- WHERE IS IT PERFORMED? tem; and those with significant coronary disease or left ventricular dysfunction. Patients who actively smoke cig- ized organ transplantation hospital. Every trans- selected. There are a variety of protocols that are used to plant hospital in the United States is a member of determine if a patient will be placed on a transplant recip- the United Network for Organ Sharing (UNOS) arettes or are dependent on drugs or alcohol may not be and must meet specific requirements. ient list, and criteria may vary depending on location. Lung transplantations involve specialized The following diagnostic tests are usually per- transplant teams usually consisting of an anes- formed to evaluate a patient for lung transplantation: thesiologist, an infectious disease specialist, a • Arterial blood gases (ABG) test, which measures the thoracic surgeon, an ear, nose, and throat (ENT) amount of oxygen that the blood is able to carry to specialist, a cardiologist, and a transplant dieti- body tissues. cian who all perform with a high level of coor- dination. • Pulmonary function tests (PFTs), which measure lung volume and the rate of air flow through the lungs; the results measure the progress of the lung disease. • Radiographic studies (x rays). The most common is the Description chest x ray (CXR), which takes an internal picture of Once a patient has been selected as a possible organ the chest including the lungs, ribs, heart, and the con- recipient, the process of waiting for a donor organ match tours of the major vessels of the chest. begins. The donor organ must meet specific requirements • Computerized tomography (CT) scan. A chest CT scan for tissue match in order to reduce the chance of organ re- is taken of horizontal slices of the chest to provide de- jection. It is estimated that it takes an average of one to tailed images of the structure of the chest. two years to receive a suitable donor lung, and the wait is made less predictable by the necessity for tissue match. • Ventilation perfusion scan (lung scan, V/Q scan) is a Patients on a recipient list must be available and ready to test that compares right and left lung function. come to the hospital immediately when a donor match is • Electrocardiogram (EKG) is performed by placing found, since the life of the lungs outside the body is brief. electrodes on the chest and one electrode on each of the four limbs. A recording of the electrical activity of the Single lung transplantation is performed via a stan- heart is obtained to provide information about the rate dard thoracotomy (incision in the chest wall) with the pa- and rhythm of the heartbeat, and to assess any damage. tient under general anesthesia. Cardiopulmonary bypass (diversion of blood flow from the heart) is not always nec- • Echocardiogram (ECHO) is an ultrasound of the heart, essary for a single lung transplant. If bypass is necessary, performed to evaluate the impact of lung disease on the it involves re-routing of the blood through tubes to a heart- heart. It examines the chambers, valves, aorta, and the lung bypass machine. Double lung transplantation in- wall motion of the heart. ECHO also provides informa- volves implanting the lungs as two separate lungs, and tion concerning the blood pressure in the pulmonary ar- cardiopulmonary bypass is usually required. The patient’s teries. This information is required to plan the trans- lung or lungs are removed and the donor lungs are stitched plantation surgery. into place. Drainage tubes are inserted into the chest area • Blood tests. Blood samples are required for both rou- to help drain fluid, blood, and air out of the chest. tine and specialized testing. Heart-lung transplants always require the use of car- In addition to tests and criteria for selection as a diopulmonary bypass. An incision is made through the mid- candidate for transplantation, patients are prepared by dle of the sternum. The heart, lung, and supporting struc- discussing at length the procedure, risks, and expected tures are transplanted into the recipient at the same time. prognosis with the doctor. Patients should continue to follow all therapies and medications for treatment of the underlying disease, unless otherwise instructed by their Diagnosis/Preparation physician. Since lung transplantation takes place under Patients who have diseases or conditions that may general anesthesia, patients are advised not to take food make them more susceptible to organ rejection are not se- or drink from midnight before the surgery. 920 GALE ENCYCLOPEDIA OF SURGERY

Morbidity and mortality rates QUESTIONS TO ASK THE DOCTOR According to the Scientific Registry of Transplant Recipients (SRTR), a total of 1,076 lung transplants and 31 heart-lungs transplants were performed in the United Lung transplantation • Are there organizations who can help me af- States in 2002. Of these transplants, 1,041 lungs were ob- ford the cost of transplantation? tained from deceased donors and 35 from living donors. • How does the lung matching process work? The survival rate at one year after transplant was 77% for • How do I get on the lung waiting list? lung transplants and 64% for heart-lung transplants. • How will they find the right donor for me? See also Heart transplantation; Thoracotomy. • How many lung transplantations do you per- form each year? Resources • What happens during transplantation? BOOKS Couture, K. A. The Lung Transplantation Handbook: A Guide For Patients, 2nd edition. Victoria, BC: Trafford, 2001. Hertz, M. I., R. M. Bolman, and J. M. Dunitz. Manual of Lung Aftercare Transplant Medical Care. Minneapolis, MN: Fairview Press, 2001. Transplantation requires a long hospital stay, and re- Maurer, Janet R., Ronald F. Grossman, and Noel Zamel. “Lung covery can last up to six months. Careful monitoring will Transplantation.” In Textbook of Respiratory Medicine, take place in a recovery room immediately following 2nd edition, edited by John F. Murray and Jay A. Nadel. the surgery and in the patient’s hospital room. Patients Philadelphia: W. B. Saunders Co., 1994. must take immunosuppressive, or anti-rejection, drugs to Schum, J. M. Taking Flight: Inspirational Stories in Lung reduce the risk of rejection of the transplanted organ. Transplanation. Victoria, BC: Trafford, 2002. The body considers the new organ an invader and will PERIODICALS fight its presence. The anti-rejection drugs lower the Algar, F. J., et al. “Lung Transplantation in Patients under Me- body’s immune function in order to improve acceptance chanical Ventilation.” Transplantation Proceedings, 35 of the new organs. This also makes the patient more sus- (March 2003): 737–738. ceptible to infection. Burns, K. E., B. A. Johnson, and A. T. Iacono. “Diagnostic Properties of Transbronchial Biopsy in Lung Transplant Frequent check-ups, including x ray and blood tests, Recipients Who Require Mechanical Ventilation.” Journal will be necessary following surgery, probably for a peri- of Heart and Lung Transplantation, 22 (March 2003): od of several years. 267–275. Chan, K. M., and S. A. Allen. “Infectious Pulmonary Compli- Risks cations in Lung Transplant Recipients.” Seminars in Res- piratory Infections, 17 (December 2002): 291–302. Lung transplantation is a complicated and risky Helmi, M., R. B. Love, D. Welter, R. D. Cornwell, and K. C. procedure, partly because of the organs and systems in- Meyer. “ Aspergillus Infection in Lung Transplant Recipi- volved, and also because of the risk of rejection by the ents with Cystic Fibrosis: Risk Factors and Outcomes recipient’s body. Acute rejection most often occurs Comparison to Other Types of Transplant Recipients.” within the first four months following surgery, but may Chest, 123 (March 2003): 800–808. Kyle, U. G., L. Nicod, J. A. Romand, D. O. Slosman, A. occur years later. Infection is a substantial risk for organ Spiliopoulos, and C. Pichard. “Four-year Follow-up of recipients. An early complication of the surgery can be Body Composition in Lung Transplant Patients.” Trans- poor healing of the bronchial and tracheal openings cre- plantation, 75 (March 2003): 821–828. ated during the surgery. A late complication and risk is Van Der Woude, B. T., et al. “Peripheral Muscle Force and Ex- chronic rejection. This can result in inflammation of the ercise Capacity in Lung Transplant Candidates.” Interna- bronchial tubes or in late infection from the prolonged tional Journal of Rehabilitation Research, 25 (December use of immunosuppressive drugs to fight rejection. 2002): 351–355. ORGANIZATIONS Normal results American Society of Transplantation (AST). 17000 Commerce Parkway, Suite C, Mount Laurel, NJ 08054. (856) 439- Demonstration of normal results for lung transplan- 9986. <http://www.a-s-t.org>. tation patients include adequate lung function and im- Children’s Organ Transplant Association, Inc. 2501 COTA proved quality of life, as well as lack of infection and Drive, Bloomington, IN 47403. (800) 366-2682. <http:// rejection. www.cota.org>. GALE ENCYCLOPEDIA OF SURGERY 921

Lymphadenectomy Anesthesia—The loss of feeling or sensation in- foreign material; immunosuppressive drugs reduce KEY TERMS the immune system’s ability to reject a transplanted duced by use of drugs called anesthetics. Bronchi—Any of the larger air passages of the lungs. Pulmonary—Refers to the respiratory system, or Bronchiectasis—Persistent and progressive dilation organ. of bronchi or bronchioles as a consequence of in- breathing function and system. flammatory disease such as lung infections, ob- Pulmonary fibrosis—Chronic inflammation and structions, tumors, or congenital abnormality. progressive formation of fibrous tissue in the pul- Bronchioles—The tiny branches of air tubes within monary alveolar walls, with steadily progressive the lungs that are the continuation of bronchi and shortness of breath, resulting in death from lack of connect to the lung air sacs (alveoli). oxygen or heart failure. Cor pulmonale—Enlargement of the right ventricle Pulmonary hypertension—Abnormally high blood of the heart caused by pulmonary hypertension pressure within the pulmonary artery. that may result from emphysema or bronchiectasis; eventually, the condition leads to congestive heart Rejection—Occurs when the body tries to attack a failure. transplanted organ because it reacts to the organ or tissue as a foreign object and produces antibodies Cystic fibrosis—A generalized disorder of infants, children, and young adults characterized by wide- to destroy it. Anti-rejection (immunosuppressive) spread dysfunction of the exocrine glands, and drugs help prevent rejection. chronic pulmonary disease due to excess mucus Sarcoidosis—A chronic disease with unknown production in the respiratory tract. cause that involves formation of nodules in bones, Emphysema—A pathological accumulation of air skin, lymph nodes, and lungs. in tissues or organs, especially in the lungs. Silicosis—A progressive disease that results in im- Immunosuppressive—Relating to the weakening pairment of lung function and is caused by inhala- or reducing of the immune system’s responses to tion of dust containing silica. The National Heart, Lung, and Blood Institute (NHLBI). P.O. Box 30105, Bethesda, MD 20824-0105. (301) 592-8573. Lymphadenectomy <http://www.nhlbi.nih.gov/index.htm>. Second Wind Lung Transplant Association, Inc. 9030 West Definition Lakeview Court, Crystal River, FL 34428. (888) 222- Lymphadenectomy, also called lymph node dissec- 2690. <http://www.arthouse.com/secondwind>. tion, is a surgical procedure in which lymph glands are OTHER removed from the body and examined for the presence “Lung Transplantation.” The Brigham Women’s Hospital. of cancerous cells. A limited or modified lymphadenec- <http://www.cheshire-med.com/programs/pulrehab/trans tomy removes only some of the lymph nodes in the area plant.html>. around a tumor; a total or radical lymphadenectomy re- “Lung Transplantation.” Medline Plus. <http://www.nlm.nih. moves all of the lymph nodes in the area. gov/medlineplus/lungtransplantation.html>. Teresa Norris, RN Purpose Monique Laberge, PhD The lymphatic system is responsible for returning excess fluid from body tissues to the circulatory system and for defending against foreign or harmful agents such Luque rod see Spinal instrumentation as bacteria, viruses, or cancerous cells. The major com- Lymph node biopsy see Sentinel lymph ponents of the lymphatic system are lymph capillaries, node biopsy lymph vessels, and lymph nodes. Lymph is a clear fluid found in tissues that originates from the circulatory sys- Lymph node removal see tem. Lymph capillaries are tiny vessels that carry excess Lymphadenectomy lymph to larger lymph vessels; these in turn empty to the 922 GALE ENCYCLOPEDIA OF SURGERY

circulatory system. Lymph nodes are small, oval- or bean-shaped masses found throughout the lymphatic WHO PERFORMS system that act as filters against foreign materials. They THE PROCEDURE AND tend to group in clusters in such areas as the neck (cervi- WHERE IS IT PERFORMED? Lymphadenectomy cal lymph nodes), under the arm (axillary lymph nodes), the pelvis (iliac lymph nodes), and the groin (inguinal Lymphadenectomy is usually performed in a lymph nodes). hospital operating room by a surgical oncolo- The lymphatic system plays an important role in the gist, a medical doctor who specializes in the spread of cancerous cells throughout the body. Cancer surgical diagnosis and treatment of cancers. cells can break away from their primary site of growth and travel through the bloodstream or lymphatic system to other sites in body. They may then begin growing at scope is a thin, lighted tube that is inserted into the ab- these distant sites or in the lymph nodes themselves; this dominal cavity through a small incision. Images taken by process is called metastasis. Removal of the lymph the laparoscope may be seen on a video monitor con- nodes, then, is a way that doctors can determine if a can- nected to the scope. Certain lymph nodes, such as the cer has begun to metastasize. Lymphadenectomy may pelvic and aortic lymph nodes, may be removed using also be pursued as a cancer treatment to help prevent fur- this technology. ther spread of abnormal cells. Demographics Diagnosis/Preparation Lymph nodes may become swollen or enlarged as The American Cancer Society estimates that ap- result of invasion by cancer cells. Swollen lymph nodes proximately 1 million cases of cancer are diagnosed each may be palpated (felt) during a physical exam. Before year. Seventy-seven percent of cancers are diagnosed in lymph nodes are removed, a small amount of tissue is men and women over the age of 55, although cancer may usually removed. A biopsy will be performed on it to affect individuals of any age. Men are more often affect- check for the presence of abnormal cells. ed than women; during his lifetime, one in two men will be diagnosed with cancer, compared to one in three The patient will be asked to stop taking aspirin or women. Cancer affects people of all races and ethnic aspirin-containing drugs for a period of time prior to backgrounds, although cancer type does vary somewhat surgery, as these can interfere with the blood’s ability to depending upon these factors. clot. Such drugs may include prescription blood thinners (for example, Coumadin—generically known as war- Description farin and heparin). However, patients should discuss their medications with regard to their upcoming surgery Although the specific surgical procedure may differ with their doctors, and not make any adjustments or pre- according to which lymph nodes are to be removed, scription changes on their own. No food or drink after some steps are common among all lymphadenectomies. midnight the night before surgery will be allowed. General anesthesia is usually administered for the dura- tion of surgery; this ensures that the patient remain un- conscious and relaxed, and awaken with no memory of Aftercare the procedure. Directly following surgery, the patient will be taken First, an incision is made into the skin and through to the recovery room for constant monitoring and to re- the subcutaneous layers in the area where the lymph cover from the effects of anesthesia. The patient may nodes are to be removed. The lymph nodes are identified then be transferred to a regular room. If axillary nodes and isolated. They are then carefully taken out from sur- have been removed, the patient’s arm will be elevated to rounding tissues (that is, muscles, blood vessels, and help prevent postsurgical swelling. Likewise, the legs nerves). In the case of axillary node dissection, the pad will be elevated if an inguinal lymphadenectomy had of fat under the skin of the armpit is removed; generally, been performed. A drain placed during surgery to re- about 10 to 20 lymph nodes are embedded in the fat and move excess fluids from the surgical site will remain separately removed. The incision is sutured (stitched) until the amount of fluid collected in the drain decreases closed with a drain left in place to remove excess fluid significantly. The patient will generally remain in the from the surgical site. hospital for one day. Alternatively, laparoscopy may be used as a less in- Specific steps should be taken to minimize the risk vasive method of removing lymph nodes. The laparo- of developing lymphedema, a condition in which excess GALE ENCYCLOPEDIA OF SURGERY 923

Lymphadenectomy • Why is lymphadenectomy recommended? may be labeled node-negative (no presence of cancer cells) or node-positive (presence of cancer cells). These QUESTIONS TO ASK THE DOCTOR findings are the basis for deciding the next step in cancer treatment, if one is indicated. • How many lymph nodes will be removed? The rate of complications following lymphadenecto- • How long will the procedure take? Morbidity and mortality rates my depends on the specific lymph nodes being removed. • When will I find out the results? For example, following axillary lymphadenectomy, there • Am I a candidate for sentinel node biopsy? is a 10% chance of chronic lymphedema and 20% • What will happen if the results are positive chance of abnormal skin sensations. The overall rate of for cancer? complications following inguinal lymphadenectomy is approximately 15%, and 5–7% following pelvic lym- phadenectomy. fluid is not properly drained from body tissues, resulting Alternatives in swelling. This swelling can sometimes become severe enough to interfere with daily activity. Common sites A technique designed to spare the unnecessary re- where lymphedema can develop are the arm or leg. Prior moval of normal lymph nodes is called sentinel node to being discharged, the patient will receive the follow- biopsy. When lymph fluid moves out of a region, the sen- ing instructions for care of areas of the body that may be tinel lymph node is the first node it reaches. The theory affected by lymph node removal: behind sentinel lymph node biopsy is that if cancer is not present in the sentinel node, it is unlikely to have spread to • All cuts to the area should be properly cleaned, treated other nearby nodes. This procedure may allow individuals with an antibiotic ointment, and covered with a bandage. with early stage cancers to avoid the complications associ- • Heavy lifting should be avoided; bags should be carried ated with partial or radical removal of lymph nodes if on the unaffected arm. there is little or no chance that cancer has spread to them. • Tight jewelry and clothing with tight elastic bands Resources should be avoided. BOOKS • Injections, blood draws, and blood pressure measure- St. Louis, James D. and Richard L. McCann. “Lymphatic Sys- ments should be done on the unaffected arm. tem” (Chapter 65). In Sabiston Textbook of Surgery. • Sunblock should be worn on the affected area to mini- Philadelphia: W. B. Saunders Company, 2001. mize the risk of sunburn. PERIODICALS • Steps should be taken to avoid cuts to the skin. For ex- Beneditti-Panici, Pierluigi, et al. “Pelvic and Aortic Lym- ample, an electric razor should be used to shave the af- phadenectomy.” Surgical Clinics of North America 81, no. fected area; protective gloves should be worn when 4 (August 1, 2001): 841-58. working with abrasive items. Colberg, John W. “Inguinal Lymph Node Dissection for Penile Carcinoma: Modified Verses Radical Lymphadenectomy.” Infections in Urology 13, no. 5 (2000): 115-20. Risks Gervasoni, James E., et al. “Biological and Clinical Signifi- cance of Lymphadenectomy.” Surgical Clinics of North Some of the risks associated with lymphadenectomy America 80, no. 6 (December 1, 2000): 1631-73. include excessive bleeding, infection, pain, excessive ORGANIZATIONS swelling, vein inflammation (phlebitis), and damage to American Cancer Society. 1599 Clifton Rd. NE, Atlanta, GA nerves during surgery. Nerve damage may be temporary 30329-4251. (800) 227-2345. <http://www.cancer.org>. or permanent and may result in weakness, numbness, tin- Society of Surgical Oncology. 85 W. Algonquin Rd., Suite 550, gling, and/or drooping. Lymphedema is also a risk when- Arlington Heights, IL 60005. (847) 427-1400. <http:// ever lymph nodes have been removed; it may occur imme- www.surgonc.org>. diately following surgery or from months to years later. OTHER “All About Cancer: Detailed Guide.” American Cancer Society. Normal results 2003 [cited April 9, 2003]. <http://www.cancer.org/ docroot/CRI/CRI_2_3.asp>. After removed lymph nodes have been examined microscopically for the presence of cancerous cells, they Stephanie Dionne Sherk 924 GALE ENCYCLOPEDIA OF SURGERY

M Magnetic resonance angiography see early in their development. Often, physicians prescribe Magnetic resonance imaging an MRI scan to more fully investigate earlier findings from other imaging techniques. • Scope. All body parts can be imaged using MRI. More- over, MRI scans are not adversely affected by bone, gas, or body waste, which can hinder other imaging Magnetic resonance imaging techniques. (The scans can, however, be degraded by motion such as breathing, heartbeat, and normal bowel Definition activity.) A close series of two-dimensional images can provide a three-dimensional view of a targeted area. Magnetic resonance imaging (MRI) is a unique and Unlike other techniques, MRI can provide images in versatile medical imaging diagnostic tool. Using MRI, multiple planes. physicians obtain highly refined images of the body’s in- terior. Strong magnetic fields and pulses of radio waves • Safety. MRI does not depend on potentially harmful ion- manipulate the body’s natural magnetic, producing im- izing radiation, as do standard x rays and CT scans. ages not possible with other diagnostic imaging meth- There are no known risks specific to the procedure, other ods. MRI is particularly useful for imaging the brain and than for people who have metal objects in their bodies. spine, as well as the soft tissues of joints and the interior Physicians sometimes choose other imaging tech- structure of bones. The entire body can be imaged using niques, such as ultrasound scanning, because the MRI MRI, and the technology poses few known health risks. process is complex, time-consuming, and costly. The process requires large, expensive, and complicated Purpose equipment; a highly trained operator; and a physician specializing in radiology. Generally, MRI is prescribed MRI was developed in the 1980s. The latest addi- only when serious symptoms or negative results from tions to MRI technology are magnetic resonance angiog- other tests indicate a need. In many cases, an alternative raphy (MRA) and magnetic resonance spectroscopy imaging procedure is more appropriate for the type of di- (MRS). MRA studies blood flow, while MRS identifies agnosis needed. However, some diseases such as multi- the chemical composition of diseased tissue and pro- ple sclerosis are best imaged by MRI. duces color images of brain function. The many advan- tages of MRI include: Physicians may prescribe an MRI scan of different areas of the body. • Detail. MRI creates precise images of the body based on the varying proportions of magnetically polarizable • Brain and head. MRI technology was developed be- elements in different tissues. Very minor fluctuations in cause of the need for brain imaging. It is one of the few chemical composition can be determined. MRI images imaging tools that can see through bone (the skull) and have greater subject contrast than those produced with deliver high quality pictures of the brain’s delicate soft standard x rays, computed tomography (CT), or ultra- tissue structures. MRI may be needed for patients with sound, all of which depend on the differing physical symptoms of a brain tumor, stroke, or infection (such as properties of tissues. This contrast sensitivity lets MRI meningitis). MRI also may be needed when cognitive or distinguish fine variations in tissues deep within the psychological symptoms suggest brain disease (such as body. It is particularly useful for spotting and distin- Alzheimer’s or Huntington’s diseases, or multiple scle- guishing diseased tissues (tumors and other lesions) rosis), or when developmental retardation suggests a GALE ENCYCLOPEDIA OF SURGERY 925

Magnetic resonance imaging • Skeleton. The properties of MRI that allow it to see though the skull also allow it to view the interior of bones. It can be used to detect bone cancer, inspect the marrow for leukemia and other diseases, assess bone loss (osteoporosis), and examine complex fractures. • The rest of the body. While CT and ultrasound satisfy most chest, abdominal, and general body imaging needs, MRI may be required to provide more detailed images in certain circumstances, or when repeated scanning is necessary. MRI is also used in cases when the progress of therapy, such as liver cancer treatment, needs to be monitored, and the effect of repeated x ray exposure is a concern. Description Magnetic resonance imaging MRI produces a map of hydrogen atoms distributed in the body. Hydrogen is the simplest element known, the most abundant in biological tissue, and one that can be magnetically polarized. It will align itself within a strong magnetic field, like the needle of a compass. The earth’s magnetic field is not strong enough to polarize a person’s hydrogen atoms, but the superconducting mag- net of an MRI machine can do this. The strength of the earth’s magnetic field is approximately 1 gauss. Typical field strength of an MRI unit, with a superconducting magnet, is 1,500 gauss, expressed as 1.5 kilogauss or 1.5 Tesla units. This comprises the “magnetic” part of MRI. There are also low field units with 0.5 Tesla strength, A patient receiving a magnetic resonance imaging (MRI) scan. A technologist monitors the equipment in an adjacent often with open MRI units. control room. (Will & Deni McIntyre/Photo Researchers, Inc. Once a patient’s hydrogen atoms have been aligned in Reproduced by permission.) the magnet, pulses of very specific radio wave frequencies jolt them out of alignment. The hydrogen atoms alternate- birth defect. MRI can also provide pictures of the sinus- ly absorb and emit radio wave energy, vibrating back and es and other areas of the head beneath the face. forth between their resting (polarized) state and their agi- tated (radio pulse) state. This comprises the “resonance” • Spine. Spinal problems can cause neck or back pain, or part of MRI. The patient does not detect this process. numbness or weakness in the arm or leg. MRI is partic- ularly useful for identifying and evaluating degenerated The MRI equipment detects the duration, strength, or herniated intervertebral discs. It can also be used to and source location of the signals emitted by the atoms determine the condition of nerve tissue within the as they relax. This data is translated into an image on a spinal cord. television monitor. The amount of hydrogen in diseased tissue differs from the amount in healthy tissue of the • Joints. MRI scanning is often used to diagnose and as- same type, making MRI particularly effective at identify- sess joint problems. MRI can provide clear images of ing tumors and other lesions. In some cases, chemical the bone, cartilage, ligaments, and tendons that com- agents such as gadolinium can be injected to improve the prise a joint. MRI can be used to diagnose joint damage contrast between healthy and diseased tissue. due to sports, advancing age, or arthritis. It can also be used to diagnose shoulder problems, such as a torn ro- A single MRI exposure produces a two-dimensional tator cuff. MRI can detect the presence of an otherwise image of a slice through the entire target area. A series of hidden tumor or infection in a joint, and can be used to these image slices closely spaced (usually less than half diagnose the nature of developmental joint abnormali- an inch [1.25 cm]) provides a virtual three-dimensional ties in children. view of the area. 926 GALE ENCYCLOPEDIA OF SURGERY

Magnetic resonance spectroscopy Depending on the area to be imaged, the radio-wave transmitters are positioned in different locations. Magnetic resonance spectroscopy (MRS) is differ- ent from MRI because MRS uses a continuous band of • For the head and neck, a helmet-like hat is worn. radio wave frequencies to excite hydrogen atoms in a va- • For the spine, chest, and abdomen, the patient lies riety of chemical compounds other than water. These down on transmitters known as coils. Magnetic resonance imaging compounds absorb and emit radio energy at characteris- tic frequencies, or spectra, that can be used to identify • For the knee, shoulder, or other joint, the transmitters them. Generally, a color image is created by assigning a are applied directly to the joint. hue to each distinctive spectral emission. This comprises Additional probes will monitor such vital signs as the “spectroscopy” part of MRS. MRS is still experimen- pulse and respiration. tal, and is available in only a few research centers. The process is very noisy and confining. The patient Physicians mainly use MRS to study the brain and hears a thumping sound for the duration of the proce- disorders such as epilepsy, Alzheimer’s disease, brain tu- dure. To increase comfort, music supplied via earphones mors, and the effects of drugs on brain growth and me- is often provided. Some patients become anxious, or tabolism. The technique is also useful in evaluating they may panic because they are inside a small, enclosed metabolic disorders of the muscles and nervous system. tube. This is why vital signs are monitored, and the pa- tient and medical team communicate with each other. If Magnetic resonance angiography a patient has claustrophobia, the physician may prescribe an anti-anxiety drug prior to the procedure. If the chest Magnetic resonance angiography (MRA) is a vari- or abdomen is to be imaged, the patient is asked to hold ation on standard MRI. MRA, like other types of an- his or her breath for each exposure. Other instructions giography, looks specifically at blood flow within the may be given as needed. vascular system, without the injection of contrast agents (dye) or radioactive tracers. Standard MRI can- In many cases, the entire examination will be per- not detect blood flow, but MRA uses specific radio formed by an MRI operator who is not a physician. pulse sequences to capture usable signals. The tech- However, the supervising radiologist should be available nique is generally used in combination with MRI to ob- to consult as necessary during the exam, and will view tain images that show both the structure of blood ves- and interpret the results at a later time. sels and flow within the brain and head in cases of stroke, suspected blood clot, or aneurysm. In general, Open MRI units MRA is performed without contrast when examining Many adult patients and, especially children, be- the brain. Intravenous contrast is usually administered come extremely claustrophobic when placed inside the when other blood vessels, such as those in the neck, confines of a full strength (1.5 Tesla) superconducting chest, or abdomen are studied. magnet. This problem is often severe enough to prevent them from having an MRI scan. In an alternative design, Procedure the magnet is comprised of two opposed halves with a Regardless of the type of MRI planned, or area of large space in between. These units are known as open the body targeted, the procedure involved is basically the MRI machines. The advantage is that they can be used same, and occurs in a special MRI suite. The patient lies for patients who are claustrophobic. The disadvantage is back on a narrow table and is made as comfortable as that the field strength of the magnets is lower (usually possible. Transmitters are positioned on the body and the 0.2–0.5 Tesla) than with standard full-strength machines. cushioned table that the patient is lying on moves into a Lower strength magnetic fields require more time for long tube that houses the magnet. The tube is the length image acquisition, increasing the risk of image problems of an average adult lying down, and the tube is narrow because patients may have difficulty remaining still for and open at both ends. Once the area to be examined has longer periods of time. been properly positioned, a radio pulse is applied. Then a two-dimensional image corresponding to one slice Preparation through the area is made. The table then moves a fraction of an inch and the next image is made, and so on. Each In some cases (such as for MRI brain scanning or image exposure takes several seconds, and the entire MRA), a chemical designed to increase image contrast exam lasts 30–90 minutes. During this time, the patient may be given by the radiologist immediately before the is not allowed to move. Movement during the scan re- exam. If a patient suffers from anxiety or claustrophobia, sults in an unclear image. drugs may be given to help the patient relax. GALE ENCYCLOPEDIA OF SURGERY 927

The patient must remove all metal objects (i.e., Magnetic resonance imaging watches, jewelry, eyeglasses, hair clips). Any magnetized Angiography—Any of the different methods for in- KEY TERMS objects, such as credit and bank machine cards or audio tapes, should be kept far away from the MRI equipment vestigating the condition of blood vessels, usually because they can be erased. The patient cannnot bring a via a combination of radiological imaging and in- wallet or keys into the MRI machine. He or she may be jections of chemical tracing and contrast agents. asked to wear clothing without metal snaps, buckles, or zippers, unless a medical gown is provided. The patient Gadolinium—A very rare metallic element useful may also be asked to remove any hair spray, hair gel, or for its sensitivity to electromagnetic resonance, cosmetics that could interfere with the scan. among other things. Traces of it can be injected into the body to enhance MRI images. Side effects Hydrogen—The simplest, most common element known in the universe. It is composed of a single The potential side effects of magnetic and electric electron (negatively charged particle) circling a nu- fields on human health remain a source of debate. In par- cleus consisting of a single proton (positively ticular, the possible effects on an unborn baby are not charged particle). It is the nuclear proton of hydro- well known. Any woman who is, or may be, pregnant gen that makes MRI possible by reacting resonant- should carefully discuss this issue with her physician and ly to radio waves while aligned in a magnetic field. radiologist before undergoing a scan. Ionizing radiation—Electromagnetic radiation that Chemical agents may be injected to improve the can damage living tissue by disrupting and de- image or allow for the imaging of blood or other fluid flow stroying individual cells. All types of nuclear during MRA. In rare cases, patients may be allergic to or decay radiation (including x rays) are potentially intolerant of these agents, and should not receive them. If ionizing. Radio waves do not damage organic tis- chemical agents are to be used, patients should discuss any sues through which they pass. concerns they have with their physician and radiologist. Magnetic field—The three-dimensional area sur- As in other medical imaging techniques, obesity rounding a magnet, in which its force is active. greatly interferes with the quality of MRI. During MRI, the patient’s body is permeated by the force field of a superconducting magnet. Aftercare Radio waves—Electromagnetic energy of the fre- quency range corresponding to that used in radio No aftercare is necessary, unless the patient received communications, usually 10,000 cycles per sec- medication or had a reaction to a contrast agent. Normal- ond to 300 billion cycles per second. Radio waves ly, patients can return to their daily activities immediate- are the same as visible light, x rays, and all other ly. If the exam reveals a serious condition that requires types of electromagnetic radiation, but are of a more testing or treatment, appropriate information and higher frequency. counseling will be needed. Precautions Generally, a joint replacement or other orthopedic MRI scanning should not be used when there is the hardware is not a problem if another part of the body is potential for an interaction between the strong MRI mag- being scanned. netic field and metal objects that might be imbedded in a patient’s body. The force of magnetic attraction on cer- • Injury. Patients must tell their physicians if they have tain types of metal objects (including surgical steel and bullet fragments or other metal pieces in their body clips used to pinch off blood vessels) could move them from old wounds. The suspected presence of metal, within the body and cause serious injury. The movement whether from an old or recent wound, should be con- would occur when the patient is placed into and out of firmed before scanning. the magnetic field. Metal may be imbedded in a person’s • Occupational. People with significant work exposure to body for several reasons: metal particles (working with a metal grinder, for ex- • Medical. People with implanted cardiac pacemakers, ample) should discuss this with their physician and ra- metal aneurysm clips, or who have had broken bones diologist. The patient may need prescan testing—usual- repaired with metal pins, screws, rods, or plates must ly a single, standard x ray of the eyes to see if any inform their radiologist prior to having an MRI scan. metal is present. 928 GALE ENCYCLOPEDIA OF SURGERY

Normal results Mammography A normal MRI, MRA, or MRS result is one that shows that the patient’s physical condition falls within Definition Mammography the normal range for the target area scanned. Mammography is the study of the breast using x Generally, MRI is prescribed only when serious rays. The actual test is called a mammogram. It is an x symptoms or negative results from other tests indicate a ray of the breast which shows the fatty, fibrous, and need. There often exists strong evidence of a condition glandular tissues. There are two types of mammograms. that the scan is designed to detect and assess. Thus, the A screening mammogram is ordered for women who results will often be abnormal, confirming the earlier di- have no problems with their breasts. It consists of two x agnosis. At that point, further testing and appropriate ray views of each breast: a craniocaudal (from above) medical treatment are needed. For example, if the MRI and a mediolateral oblique (from the sides). A diagnostic indicates the presence of a brain tumor, an MRS may be mammogram is for evaluation of abnormalities in either prescribed to determine the type of tumor so that aggres- men or women. Additional x rays from other angles, or sive treatment can begin immediately without the need special coned views of certain areas, are taken. for a surgical biopsy. Resources Purpose BOOKS The purpose of screening mammography is breast Haaga, John R., et al., eds. Computed Tomography and Mag- cancer detection. A screening test, by definition, is used netic Resonance Imaging of the Whole Body. St. Louis, for patients without any signs or symptoms, in order to MO: Mosby, 1994. detect disease as early as possible. Many studies have Hornak, Ph.D., P. Joseph. The Basics of MRI. <http//www.cis. shown that having regular mammograms increases a rit.edu/htbooks/mri/>. woman’s chances of finding breast cancer in an early Zaret, Barry L., et al., eds. The Patient’s Guide to Medical stage, when it is more likely to be curable. It has been es- Tests. Boston: Houghton Mifflin Company, 1997. timated that a mammogram may find a cancer as much PERIODICALS as two or three years before it can be felt. The American Jung, H. “Discrimination of Metastatic from Acute Osteoporot- Cancer Society (ACS) guidelines recommend an annual ic Compression Spinal Fractures with MR Imaging.” Ra- screening mammogram for every woman of average risk diographics 179 (January/February 2003). beginning at age 40. Radiologists look specifically for Kevles, Bettyann “Body Imaging.” Newsweek Extra Millenni- the presence of microcalcifications and other abnormali- um Issue (Winter 97/98): 74–6. ties that can be associated with malignancy. New digital ORGANIZATIONS mammography and computer-aided reporting can auto- American College of Radiology. 1891 Preston White Dr., Re- matically enhance and magnify the mammograms for ston, VA 22091. (703) 648-8900. <http://www.acr.org. >. easier finding of these tiny calcifications. American Society of Radiologic Technologists. 15000 Central Ave. SE, Albuquerque, NM 87123-3917. (505) 298-4500. The highest risk factor for developing cancer is age. <http://www.asrt.org>. Some women are at an increased risk for developing Center for Devices and Radiological Health. United States breast cancer, such as those with a positive family histo- Food and Drug Administration. 1901 Chapman Ave., ry of the disease. Beginning screening mammography at Rockville, MD 20857. (301) 443-4109. <http://www.fda. a younger age may be recommended for these women. gov/cdrh>. Diagnostic mammography is used to evaluate an exist- OTHER ing problem, such as a lump, discharge from the nipple, or Smith, Steve. “Brief Introduction to FMRI.” FMRIB. 1998. unusual tenderness in one area. It is also done to evaluate <http://www.fmrib.ox.ac.uk/fmri_intro/>. further abnormalities that have been seen on screening Stephen John Hage, AAAS, RT-R, FAHRA mammograms. The radiologist normally views the films Lee A. Shratter, M.D. immediately and may ask for additional views such as a magnification view of one specific area. Additional studies such as an ultrasound of the breast may be performed as Magnetic resonance spectroscopy see well to determine if the lesion is cystic or solid. Breast-spe- Magnetic resonance imaging cific positron emission tomography (PET) scans as well as an MRI (magnetic resonance imaging) may be ordered Mallet toe surgery see Hammer, claw, and to further evaluate a tumor, but mammography is still the mallet toe surgery first choice in detecting small tumors on a screening basis. GALE ENCYCLOPEDIA OF SURGERY 929

Mammography technologist to record any lumps, nipple discharge, breast pain or other concerns of the patient. All visible scars, tattoos and nipple alterations must be carefully noted as well. Clothing from the waist up is removed, along with necklaces and dangling earrings. A hospital gown or similar covering is put on. A small self-adhesive metal marker may be placed on each nipple by the x ray tech- nologist. This allows the nipple to be viewed as a refer- ence point on the film for concise tumor location and easier centering for additional views. Patients are positioned for mammograms differently, depending on the type of mammogram being performed: • Craniocaudal position (CC): The woman stands or sits facing the mammogram machine. One breast is ex- posed and raised to a level position while the height of the cassette holder is adjusted to the same level. The breast is placed mid-film with the nipple in profile and the head turned away from the side being x rayed. The shoulder is relaxed and pulled slightly backward while the breast is pulled as far forward as possible. The tech- nologist holds the breast in place and slowly lowers the compression with a foot pedal. The breast is com- pressed between the film holder and a rectangle of plastic (called a paddle). The breast is compressed until the skin is taut and the breast tissue firm when touched on the lateral side. The exposure is taken immediately and the compression released. Good compression can Description be uncomfortable, but it is very necessary. Compres- sion reduces the thickness of the breast, creates a uni- A mammogram may be offered in a variety of set- form density and separates overlying tissues. This al- tings. Hospitals, outpatient clinics, physician’s offices, or lows for a detailed image with a lower exposure time other facilities may have mammography equipment. In and decreased radiation dose to the patient. The same the United States only places certified by the Food and view is repeated on the opposite breast. Drug Administration (FDA) are legally permitted to per- form, interpret, or develop mammograms. Mammograms • Mediolateral oblique position (MLO): The woman is are taken with dedicated machines using high frequency positioned with her side towards the mammography generators, low kvp, molybdenum targets and special- unit. The film holder is angled parallel to the pectoral ized x ray beam filtration. Sensitive high contrast film muscle, anywhere from 30 to 60 degrees depending on and screen combinations along with prolonged develop- the size and height of the patient. The taller and thin- ing enable the visualization of minute breast detail. ner the patient the higher the angle. The height of the machine is level with the axilla (armpit). The arm is In addition to the usual paperwork, a woman will be placed at the top of the cassette holder with a corner asked to fill out a questionnaire asking for information touching the armpit. The breast is lifted forward and on her current medical history. Beyond her personal and upward and compression is applied until the breast is family history of cancer, details about menstruation, pre- held firmly in place by the paddle. The nipple should vious breast surgeries, child bearing, birth control, and be in profile and the opposite breast held away if nec- hormone replacement therapy are recorded. Information essary by the patient. This procedure is repeated for about breast self-examination (BSE) and other breast the other breast. A total of four x rays, two of each health issues are usually available at no charge. breast, are taken for a screening mammogram. Addi- At some centers, a technologist may perform a tional x rays, using special paddles, different breast physical examination of the breasts before the mammo- positions, or other techniques may be taken for a diag- gram. Whether or not this is done, it is essential for the nostic mammogram. 930 GALE ENCYCLOPEDIA OF SURGERY

The mammogram may be seen and interpreted by a be learned before a technologist can x ray a patient with radiologist right away, or it may not be reviewed until breast implants. later. If there is any questionable area or abnormality, Some breast cancers do not show up on mammo- Mammography extra x rays may be recommended. These may be taken grams, or “hide” in dense breast tissue. A normal (or during the same appointment. More commonly, especial- negative) study is not a guarantee that a woman is can- ly for screening mammograms, the woman is called back cer-free. The false-negative rate is estimated to be on another day for these additional films. 15–20%, higher in younger women and women with A screening mammogram usually takes approxi- dense breasts. mately 15 to 30 minutes. A woman having a diagnostic False positive readings are also possible. Breast mammogram can expect to spend up to an hour for the biopsies may be recommended on the basis of a mam- procedure. mogram, and find no cancer. It is estimated that 75–80% The cost of mammography varies widely. Many mam- of all breast biopsies resulted in benign (no cancer pre- mography facilities accept “self referral.” This means sent) findings. This is considered an acceptable rate, be- women can schedule themselves without a physician’s re- cause recommending fewer biopsies would result in too ferral. However, some insurance policies do require a doc- many missed cancers. tor’s prescription to ensure payment. Medicare will pay for annual screening mammograms for all women over age 39. Normal results Preparation A mammography report describes details about the x ray appearance of the breasts. It also rates the mammo- The compression or squeezing of the breast neces- gram according to standardized categories, as part of the sary for a mammogram is a concern of many women. Breast Imaging Reporting and Data System (BIRADS) Mammograms should be scheduled when a woman’s created by the American College of Radiology (ACR). A breasts are least likely to be tender. One to two weeks normal mammogram may be rated as BIRADS 1 or neg- after the first day of the menstrual period is usually best, ative, which means no abnormalities were seen. A nor- as the breasts may be tender during a menstrual period. mal mammogram may also be rated as BIRADS 2 or be- Some women with sensitive breasts also find that stop- nign findings. This means there are one or more abnor- ping or decreasing caffeine intake from coffee, tea, colas, malities but they are clearly benign (not cancerous), or and chocolate for a week or two before the examination variations of normal. Some kinds of calcifications, en- decreases any discomfort. Women receiving hormone larged lymph nodes or obvious cysts might generate a therapy may also have sensitive breasts. Over-the-counter BIRADS 2 rating. pain relievers are recommended an hour before the mam- mogram appointment when pain is a significant problem. Many mammograms are considered borderline or indeterminate in their findings. BIRADS 3 means either Women should not put deodorant, powder, or lotion additional images are needed, or an abnormality is seen on their upper body on the day the mammogram is per- and is probably (but not definitely) benign. A follow-up formed. Particles from these products can get on the mammogram within a short interval of six to 12 months breast or film holder and may show up as abnormalities is suggested. This helps to ensure that the abnormality is on the mammogram. Most facilities will have special not changing, or is “stable.” Only the affected side will wipes available for those patients who need to wash be- be x rayed at this time. Some women are uncomfortable fore the mammogram. or anxious about waiting, and may want to consult with their doctor about having a biopsy. BIRADS 4 means Aftercare suspicious for cancer. A biopsy is usually recommended in this case. BIRADS 5 means an abnormality is highly No special aftercare is required. suggestive of cancer. A biopsy or other appropriate ac- tion should be taken. Risks Screening mammograms are not usually recom- The risk of radiation exposure from a mammogram mended for women under age 40 who have no special is considered minimal and not significant. Experts are risk factors and a normal physical breast examination. A unanimous that any negligible risk is by far outweighed mammogram may be useful if a lump or other problem by the potential benefits of mammography. Patients who is discovered in a woman aged 30–40. Below age 30, have breast implants must be x rayed with caution and breasts tend to be “radiographically dense,” which means compression is minimally applied so that the sac is not the breasts contain a large amount of glandular tissue ruptured. Special techniques and positioning skills must which is difficult to image in fine detail. Mammograms GALE ENCYCLOPEDIA OF SURGERY 931

Managed care plans Breast biopsy—A procedure where suspicious tis- that integrate the financing and delivery of health care. Managed care plans KEY TERMS Definition sue is removed and examined by a pathologist for Managed care plans are health-care delivery systems cancer or other disease. The breast tissue may be obtained by open surgery, or through a needle. Craniocaudal—Head to tail, x ray beam directly Managed care organizations generally negotiate agree- ments with providers to offer packaged health care bene- overhead the part being examined. fits to covered individuals. Radiographically dense—An abundance of glan- dular tissue, that results in diminished anatomic Purpose detail on the mammogram. The purpose for managed care plans is to reduce the cost of health care services by stimulating competition and streamlining administration. for this age group are controversial. An ultrasound of the breasts is usually done instead. Description Patient education A majority of insured Americans belongs to a man- The mammography technologist must be empathetic aged care plan, a health care delivery system that applies to the patient’s modesty and anxiety. He or she must ex- corporate business practices to medical care in order to plain that compression is necessary to improve the quali- reduce costs and streamline care. The managed care era ty of the image but does not harm the breasts. Patients began in the late 1980s in response to skyrocketing may be very anxious when additional films are request- health care costs, which stemmed from a number of ed. Explaining that an extra view gives the radiologist sources. Under the fee-for-service, or indemnity, model more information will help to ease the patient’s tension. that preceded managed care, doctors and hospitals were One in eight women in North America will develop financially rewarded for using a multitude of expensive breast cancer. Educating the public on monthly breast tests and procedures to treat patients. Other contributors self-examinations and yearly mammograms will help in to the high cost of health care were the public health ad- achieving an early diagnosis and therefore a better cure. vances after World War II that lengthened the average lifespan of Americans. This put increased pressure on the Resources health care system. In response, providers have adopted state-of-the-art diagnostic and treatment technologies as PERIODICALS they have become available. Carmen, Ricard, R. T. R. Mammography: Techniques and Diffi- culties. O.T.R.Q., 1999. Managed care companies attempted to reduce costs Gagnon, Gilbert. Radioprotection in Mammography. O.T.R.Q., by negotiating lower fees with clinicians and hospitals in 1999. exchange for a steady flow of patients, developing stan- Ouimet, Guylaine, R. T. R. Mammography: Quality Control. dards of treatment for specific diseases, requiring clini- O.T.R.Q., 1999. cians to get plan approval before hospitalizing a patient ORGANIZATIONS (except in the case of an emergency), and encouraging American Cancer Society (ACS), 1599 Clifton Rd., Atlanta, clinicians to prescribe less expensive medicines. Many GA 30329. (800) ACS-2345. <http://www.cancer.org>. plans offer financial incentives to clinicians who mini- Federal Drug Administration (FDA), 5600 Fishers Ln., mize referrals and diagnostic tests, and some even apply Rockville, MD 20857. (800) 532-4440. <http://www. financial penalties, or disincentives, on those considered fda.gov>. to have ordered unnecessary care. The primary watchdog National Cancer Institute (NCI) and Cancer Information Ser- and accreditation agency for managed care organizations vice (CIS), Office of Cancer Communications, Bldg. 31, is the National Committee for Quality Assurance Room 10A16, Bethesda, MD 20892. (800) 4-CANCER (NCQA), a non-profit organization that also collects and (800) 422-6237. Fax: (800) 624-2511 or (301) 402-5874. disseminates health plan performance data. <[email protected]>. <http://cancernet.nci.nih. gov>. Three basic types of managed care plans exist: health maintenance organizations (HMOs), preferred Lorraine K. Ehresman provider organizations (PPOs), and point-of-service Lee A. Shratter, M.D. (POS) plans. 932 GALE ENCYCLOPEDIA OF SURGERY

• HMOs, in existence for more than 50 years, are the best principles such as cost cutting, mergers and acquisitions, known and oldest form of managed care. Participants in and layoffs. To thrive in such an environment, and to HMO plans must first see a primary care provider, who provide health care in accordance with professional val- may be a physician or an advanced practice registered ues, health care practitioners must educate themselves on Managed care plans nurse (APRN), in order to be referred to a specialist. the business of health care, including hospital operations Four types of HMOs exist: the Staff Model, Group and administrative decision making, in order to influence Model, Network Model, and the Independent Practice institutional and regional health-care policies. A sam- Association (IPA). The Staff Model hires clinicians to pling of the roles available for registered nurses in a work onsite. The Group Model contracts with group managed care environment include: practice physicians on an exclusive basis. The Network • Primary care provider. The individual responsible for Model resembles the group model except participating determining a plan of care, including referrals to spe- physicians can treat patients who are not plan members. cialists. The Independent Practice Association (IPA) contracts with physicians in private practice to see HMO patients • Case manager. The person who tracks patients through at a prepaid rate per visit as a part of their practice. the health care system to maintain continuity of care. • PPOs are more flexible than HMOs. Like HMOs, they • Triage nurse. In a managed care organization, these indi- negotiate with networks of physicians and hospitals to viduals help direct patients through the system by deter- get discounted rates for plan members. But, unlike mining the urgency and level of care necessary and ad- HMOs, PPOs allow plan members to seek care from vising incoming patients on self-care when appropriate. specialists without being referred by a primary care • Utilization/Resource reviewer. This individual helps practitioner. These plans use financial incentives to en- manage costs by assessing the appropriateness of spe- courage members to seek medical care from providers cialized treatments. inside the network. • POS plans are a blend of the other types of managed Normal results care plans. They encourage plan members to seek care from providers inside the network by charging low fees It is difficult to predict the effect of the managed for their services, but they add the option of choosing an care revolution on the health care profession. All health out-of-plan provider at any time and for any reason. POS care providers will benefit from building broad coali- plans carry a high premium, a high deductible, or a high- tions at the state and federal levels to publicize their er co-payment for choosing an out-of-plan provider. views on patient care issues. These coalitions will also be useful to monitor developing trends in the industry, Several managed care theories such as those stressing including the impact of proposed mergers and acquisi- continuity of care, prevention, and early intervention are ap- tions of health care institutions on the provision of care. plauded by health care practitioners and patients alike. But See also Finding a surgeon; Long-term insurance; managed care has come under fire by critics who feel pa- Medicare; Nursing homes. tient care may be compromised by managed care cost-cut- ting strategies such as early hospital discharge and use of fi- Resources nancial incentives to control referrals, which may make clinicians too cautious about sending patients to specialists. BOOKS In general, the rise of managed care has shifted decision- Bondeson, W. B., and J. W. Jones. Ethics of Managed Care: making power away from plan members, who are limited in Professional Integrity and Patient Rights. Amsterdam: their choices of providers, and away from clinicians, who Kluwer Academic Publishers, 2002. must concede to managed-care administrators regarding Kongstvedt, P. R. Essentials of Managed Health Care, 4th Edi- what is considered a medically necessary procedure. Many tion. Boston: Jones & Bartlett, 2003. people would like to see managed care restructured to rem- Kongstvedt, P. R., and W. Knight. Managed Care: What It Is and How It Works, 2nd edition. Boston: Jones & Bartlett, edy this inequitable distribution of power. Such actions 2002. would maximize consumer choice and allow health care Orin, Rhonda. Making Them Pay: How to Get the Most from practitioners the freedom to provide the best care possible. Health Insurance and Managed Care. New York: St. Mar- According to the American Medical Association, rejection tin’s Press, 2001. of care resulting from managed care stipulations should be subjected to an independent appeals process. PERIODICALS Kirkman-Liff, B. “Restoring Trust to Managed Care, Part 1: A The health-care industry today is dominated by cor- Focus on Patients.” American Journal of Managed Care 9, porate values of managed care and is subject to corporate no.2 (2003): 174–180. GALE ENCYCLOPEDIA OF SURGERY 933

Mastoidectomy Health maintenance organization (HMO)—Verti- National Committee for Quality Assurance. [cited March 24, 2003] <http://www.ncqa.org>. KEY TERMS Pennsylvania Health Law Project. [cited March 24, 2003] <http://www.phlp.org/education/managedcareeast.html>. cally integrated health care provider employing many clinical professionals and usually owning or controlling a hospital. L. Fleming Fallon, Jr, MD, DrPH Preferred provider organization (PPO)—Roster of professionals who have been approved to provide Marshall-Marchetti-Krantz procedure see services to members of a particular managed care Retropubic suspension organization. Mastectomy see Lumpectomy; Modified radical mastectomy; Axillary dissection; Simple mastectomy; Quadrantectomy Kirkman-Liff, B. “Restoring Trust to Managed Care, Part 2: A Focus on Physicians.” American Journal of Managed Mastoid tympanoplasty see Mastoidectomy Care 9, no.3 (2003): 249–252. Rogoski, R. R. “Managed Care’s Challenges. Health Plans Use New IT to Meet the Burgeoning Challenges of Costs and Consumerism.” Health Management Technology 24, no.3 (2003): 20–25. Sparer, M. S. “Managed Long-term Care: Limits and Lessons.” Mastoidectomy Journal of Aging and Health 15, no.1 (2003): 269–291. Definition ORGANIZATIONS A mastoidectomy is a surgical procedure that re- Agency for Health Care Research and Quality. 2101 E. Jeffer- moves an infected portion of the mastoid bone when son St., Suite 501, Rockville, MD 20852. (301) 594-1364. medical treatment is not effective. American Association of Managed Care Nurses. P.O. Box 4975, Glen Allen, VA 23058-4975. (804) 747-9698. <http://www.aamcn.org/joinaamcn.htm>. Purpose American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106-1572. 800) 523-1546, A mastoidectomy is performed to remove infected x2600, or (215) 351-2600. <http://www.acponline.org>. mastoid air cells resulting from ear infections, such as mastoiditis or chronic otitis, or by inflammatory disease American College of Surgeons. 633 North St. Clair Street, of the middle ear (cholesteatoma). The mastoid air cells Chicago, IL 60611-32311. (312) 202-5000; Fax: (312) 202-5001. E-mail: <[email protected]>. <http://www. are open spaces containing air that are located through- facs.org>. out the mastoid bone, the prominent bone located behind American Hospital Association. One North Franklin, Chicago, the ear that projects from the temporal bone of the skull. IL 60606-3421. (312) 422-3000. <http://www.aha.org/ The air cells are connected to a cavity in the upper part index.asp>. of the bone, which is in turn connected to the middle ear. American Medical Association. 515 N. State Street, Chicago, Aggressive infections in the middle ear can thus some- IL 60610. (312) 464-5000. <http://www.ama-assn.org>. times spread through the mastoid bone. When antibi- American Nurses Association. 600 Maryland Avenue, SW, otics can’t clear this infection, it may be necessary to re- Suite 100 West, Washington, DC 20024. (800) 274-4262. move the infected area by surgery. The primary goal of <http://www.nursingworld.org>. the surgery is to completely remove infection so as to Center for Bioethics at the University of Pennsylvania. Suite produce an infection-free ear. Mastoidectomies are also 320, 3401 Market Street, Philadelphia, PA 19104-3308. performed sometimes to repair paralyzed facial nerves. (215) 898-7136. <http://bioethics.org>. National Committee for Quality Assurance. 2000 L St. NW, Washington, DC 20036. (202) 955-3500. <http://www. Demographics ncqa.org>. According to the American Society for Microbiolo- OTHER gy, middle ear infections increased in the United States American Academy of Pediatrics. [cited March 24, 2003]. from approximately three million cases in 1975 to over <http://www.aap.org/family/mancarbr.htm>. nine million in 1997. Middle ear infections are now the Centers for Medicare & Medicaid Services. [cited March 24, second leading cause of office visits to physicians, and 2003] <http://www.medicare.gov/choices/withdraws.asp>. this diagnosis accounts for over 40% of all outpatient an- 934 GALE ENCYCLOPEDIA OF SURGERY

tibiotic use. Ear infections are also very common in chil- dren between the ages of six months and two years. Most WHO PERFORMS children have at least one ear infection before their THE PROCEDURE AND Mastoidectomy eighth birthday. WHERE IS IT PERFORMED? An mastoidectomy is performed in a hospital Description by surgeons specialized in otolaryngology, the A mastoidectomy is performed with the patient fully branch of medicine concerned with the diag- asleep under general anesthesia. There are several differ- nosis and treatment of disorders and diseases of ent types of mastoidectomy procedures, depending on the ears, nose and throat. The procedure usual- the amount of infection present: ly takes between two and three hours. It is oc- casionally performed on an outpatient basis in • Simple (or closed) mastoidectomy. The operation is adults but usually involves hospitalization. performed through the ear or through a cut (incision) behind the ear. The surgeon opens the mastoid bone and removes the infected air cells. The eardrum is in- cised to drain the middle ear. Topical antibiotics are The patient should inform the physician if any of the then placed in the ear. following symptoms occur: • Radical mastoidectomy. The procedure removes the • bright red blood on the dressing most bone and is usually performed for extensive • stiff neck or disorientation (These may be signs of spread of a cholesteatoma. The eardrum and middle ear meningitis.) structures may be completely removed. Usually the stapes, the “stirrup” shaped bone, is spared if possible • facial paralysis, drooping mouth, or problems swallow- to help preserve some hearing. ing • Modified radical mastoidectomy. In this procedure, some middle ear bones are left in place and the Risks eardrum is rebuilt by tympanoplasty. Complications do not often occur, but they may in- After surgery, the wound is stitched up around a clude: drainage tube and a dressing is applied. • persistent ear discharge • infections, including meningitis or brain abscesses Diagnosis/Preparation • hearing loss The treating physician gives the patient a thorough • facial nerve injury (This is a rare complication.) ear, nose, and throat examination and uses detailed diag- nostic tests, including an audiogram and imaging studies • temporary dizziness of the mastoid bone using x rays or CT scans to evaluate • temporary loss of taste on the side of the tongue the patient for surgery. The patient is prepared for surgery by shaving the Normal results hair behind the ear on the mastoid bone. Mild soap and a The outcome of a mastoidectomy is a clean, healthy water solution are commonly used to cleanse the outer ear without infection. However, both a modified radical ear and surrounding skin. and a radical mastoidectomy usually result in less than normal hearing. After surgery, a hearing aid may be con- Aftercare sidered if the patient so chooses. The drainage tube inserted during surgery is typical- ly removed a day or two later. Morbidity and mortality rates Painkillers are usually needed for the first day or In the United States, death from intracranial compli- two after the operation. The patient should drink fluids cations of cholesteatoma is uncommon due to earlier freely. After the stitches are removed, the bulky mastoid recognition, timely surgical intervention, and supportive dressing can be replaced with a smaller dressing if the antibiotic therapy. Cholesteatoma remains a relatively ear is still draining. The patient is given antibiotics for common cause of permanent, moderate, and conductive several days. hearing loss. GALE ENCYCLOPEDIA OF SURGERY 935

Maze procedure for atrial fibrillation • What are the alternatives to mastoidectomy? Audiogram—A test of hearing at a range of sound KEY TERMS QUESTIONS TO ASK THE DOCTOR frequencies. Mastoid air cells—Numerous small intercommuni- • What are the risks associated with the surgery? cating cavities in the mastoid process of the tem- • How will the surgery affect hearing? poral bone that empty into the mastoid antrum. • What are the possible alternative treatments? Mastoid antrum—A cavity in the temporal bone • How long will it take to recover from the of the skull, communicating with the mastoid cells surgery? and with the middle ear. • How many mastoidectomies do you perform Mastoid bone—The prominent bone behind the ear each year? that projects from the temporal bone of the skull. Mastoiditis—An inflammation of the bone behind the ear (the mastoid bone) caused by an infection Alternatives spreading from the middle ear to the cavity in the mastoid bone. Alternatives to mastoidectomy include the use of medications and delaying surgery. However, these alter- Otitis—Inflammation of the ear, which may be marked by pain, fever, abnormalities of hearing, native methods carry their own risk of complications and hearing loss, tinnitus and vertigo. a varying degree of success. Thus, most physicians are of the opinion that patients for whom mastoidectomy is in- Tympanoplasty—Procedure to reconstruct the dicated should best undergo the operation, as it provides tympanic membrane (eardrum) and/or middle ear the patient with the best chance of successful treatment bone as the result of infection or trauma. and the lowest risk of complications. See also Tympanoplasty. Better Hearing Institute. 515 King Street, Suite 420, Alexan- Resources dria, VA 22314. (703) 684-3391. BOOKS OTHER Fisch, H. and J. May. Tympanoplasty, Mastoidectomy, and “Mastoidectomy series.” MedlinePlus. <www.nlm.nih.gov/ Stapes Surgery. New York: Thieme Medical Pub., 1994. medlineplus/ency/presentations/100032_1.htm>. PERIODICALS Cristobal, F., Gomez-Ullate, R., Cristobal, I., Arcocha, A., and Carol A. Turkington R. Arroyo. “Hearing results in the second stage of open Monique Laberge, Ph.D. mastoidectomy: A comparison of the different tech- niques.” Otolaryngology - Head and Neck Surgery 122 (May 2000): 350-351. Garap, J. P., and S. P. Dubey. “Canal-down mastoidectomy: ex- perience in 81 cases.” Otology & Neurotology 22 (July 2001): 451-456. Maze procedure for Jang, C. H. “Changes in external ear resonance after mas- toidectomy: open cavity mastoid versus obliterated mas- atrial fibrillation toid cavity.” Clinical Otolaryngology 27 (December Definition 2002): 509-511. Kronenberg, J., and L. Migirov. “The role of mastoidectomy in The Maze procedure, also known as the Cox-Maze cochlear implant surgery.” Acta Otolaryngologica 123 procedure, is a surgical treatment for chronic atrial fibril- (January 2003): 219-222. lation. The procedure restores the heart’s normal rhythm ORGANIZATIONS by surgically interrupting the conduction of abnormal American Academy of Otolaryngology-Head and Neck impulses. Surgery, Inc. One Prince St., Alexandria VA 22314-3357. (703) 836-4444. <http://www.entnet.org>. Purpose American Hearing Research Foundation. 55 E. Washington St., Suite 2022, Chicago, IL 60602. (312) 726-9670. <http:// When the heart beats too fast, blood no longer circu- www.american-hearing.org/>. lates effectively in the body. The Maze procedure is used 936 GALE ENCYCLOPEDIA OF SURGERY

to stop this abnormal beating so that the heart can begin its normal rhythm and pump more efficiently. The proce- WHO PERFORMS dure is also intended to control heart rate and prevent THE PROCEDURE AND blood clots and strokes. WHERE IS IT PERFORMED? Demographics Heart surgeons specially trained in the Maze procedure should perform this procedure. The The Maze procedure has been performed since 1987 Maze procedure for atrial fibrillation Maze procedure takes place in an operating and was developed by Dr. James L. Cox. The average room in a hospital. When evaluating where to age of patients undergoing this procedure is about 52. have the surgery performed, the patient should The Maze procedure is used to treat chronic or parox- find out how many Maze procedures have ysmal atrial fibrillation, a type of abnormal heart rhythm been performed at that facility, how many in which the upper chamber of the heart quivers instead of Maze procedures are performed per month, pumping in an organized way. In general, patients usually when the surgeons at that facility started per- have atrial fibrillation for about eight years before under- forming the procedure, and what the typical going the Maze procedure. The Maze procedure may be outcomes or results are for their patients. recommended for patients who need surgical treatment for coronary artery disease or valve disease. Therefore, the Maze procedure may be performed in combination with coronary artery bypass surgery (CABG), valve repair, use of a heart-lung bypass machine. This is also called valve replacement, or other cardiac surgery. beating heart surgery. The Maze procedure may be recommended for pa- The Maze surgery may be an option for some pa- tients whose atrial fibrillation has not been successfully tients. The minimally invasive technique enables the sur- treated with medications or other non-surgical interven- geon to work on the heart through small chest holes tional procedures. It may also be a treatment option for called ports and other small incisions. Advantages of patients who have a history of stroke or cardiac thrombus. minimally invasive surgery over the traditional method include smaller incisions, a shorter hospital stay, a short- Abnormal heart rhythms are slightly more common er recovery period, and lower costs. in men than in women, and the prevalence of abnormal heart rhythms, especially atrial fibrillation, increases During the procedure, precise incisions, also called with age. Atrial fibrillation is relatively uncommon in lesions, are made in the right and left atria to isolate and people under age 20. stop the unusual electrical impulses from forming. The in- cisions form a maze through which the impulses can trav- el in one direction from the top of the heart to the bottom. Description When the heart heals, scar tissue forms and the abnormal Elective Maze surgery is usually scheduled in ad- electrical impulses can no longer travel through the heart. vance. After arriving at the hospital, an intravenous (IV) These energy sources may be used during the proce- catheter will be placed in the arm to deliver medications dure: and fluids. General anesthesia is administered to put the patient to sleep. • Radiofrequency: A radiofrequency energy catheter is used to create the incisions or lesions in the heart. In most cases, a traditional incision is made down the • Microwave: A wand-like catheter is used to direct mi- center of the patient’s chest, cuts through the breastbone crowave energy to create the lesions in the heart. (sternum), and the rib cage is retracted open to expose the heart. The patient is connected to a heart-lung bypass ma- • Cryothermy (also called cryoablation): Very cold tem- chine, also called a cardiopulmonary bypass pump, which peratures are transmitted through a probe (cryoprobe) takes over for the heart and lungs during the surgery. The to create the lesions. heart-lung machine removes carbon dioxide from the When these energy sources are used, the procedure blood and replaces it with oxygen. A tube is inserted into is called surgical pulmonary vein isolation. the aorta to carry the oxygenated blood from the bypass machine to the aorta for circulation to the body. The Diagnosis/Preparation heart-lung machine allows the heart’s beating to be stopped so the surgeon can operate on a still heart. Diagnosis of abnormal heart rhythms Some patients may be candidates for off-pump A doctor may be able to detect an irregular heartbeat surgery, in which the surgery is performed without the during a physical exam by taking the patient’s pulse. In GALE ENCYCLOPEDIA OF SURGERY 937

Maze procedure for atrial fibrillation • Am I a candidate for minimally invasive • shortness of breath QUESTIONS • chest discomfort TO ASK THE DOCTOR • fainting • dizziness or feeling light-headed surgery? • weakness, fatigue, or feeling tired • Am I a candidate for the “off-pump” surgery Not everyone with abnormal heart rhythms will ex- technique? perience symptoms, so the condition may be discovered • Who will be performing the surgery? How upon examination for another medical condition. many years of experience does this surgeon DIAGNOSTIC TESTS. Tests used to diagnose an ab- have? How many other Maze procedures has this surgeon performed? • blood tests • Can I take my medications the day of the surgery? normal heart rhythm or determine its cause include: • chest x rays • Can I or drink the day of the surgery? If not, • electrocardiogram how long before the surgery should I stop • ambulatory monitors such as the Holter monitor, loop eating and/or drinking? recorder, and trans-telephonic transmitter • How long will I have to stay in the hospital after the surgery? • stress test • After I go home from the hospital, how long • echocardiogram will it take me to recover from surgery? • cardiac catheterization • What should I do if I experience symptoms • electrophysiology study (EPS) similar to those I felt before surgery? • head-upright tilt table test • What types of symptoms should I report to my doctor? • nuclear medicine test such as a MUGA scan (multiple- • What types of medications will I have to take gated acquisition scanning) after surgery? Preparation • When will I be able I resume my normal ac- tivities, including work and driving? During a preoperative appointment, usually sched- • When will I find out if the surgery was suc- uled within one to two weeks before surgery, the patient cessful? will receive information about what to expect during the • What if the surgery was not successful? surgery and the recovery period. The patient will usually meet the cardiologist, anesthesiologist, nurse clinicians, • If I have had the surgery once, can I have it again to correct future blockages? and surgeon during this appointment or just before the procedure. • Will I have any pain or discomfort after the Medication to thin the blood (blood thinner or anti- surgery? If so, how can I relieve this pain or coagulant) is usually given for at least three weeks be- discomfort? fore the procedure. • Are there any medications, foods, or activi- ties I should avoid to prevent my symptoms If the patient develops a cold, fever, or sore throat from recurring? within a few days before the surgery, he or she should notify the surgeon’s office. • How often do I need to see my doctor for fol- low-up visits after the surgery? From midnight before the surgery, the patient should not eat or drink anything. The morning of the procedure, the patient should take all usual medications as prescribed, with a small sip addition, the diagnosis may be based upon the presence of water, unless other instructions have been given. Pa- of certain symptoms, including: tients who take diabetes medications or anticoagulants • palpitations (feeling of skipped heartbeats or fluttering should ask their doctor for specific instructions. in the chest) The patient is usually admitted to the hospital the • pounding in the chest same day the surgery is scheduled. The patient should 938 GALE ENCYCLOPEDIA OF SURGERY

bring a list of current medications, allergies, and appro- The average hospital stay after the Maze surgery is priate medical records upon admission to the hospital. five to seven days, depending on the patient’s rate of re- covery. The morning of surgery, the chest area is shaved and heart monitoring begins. The patient is given general Recovery at home anesthesia before the procedure, so he or she will be asleep during the procedure. MEDICATIONS. The doctor may prescribe anti-ar- rhythmic medications (such as beta-blockers, digitalis, or Maze procedure for atrial fibrillation The traditional Maze procedure takes about an hour calcium channel blockers) to prevent the abnormal heart to perform, while the surgical pulmonary vein isolation rhythm from returning. Some patients may need to take a procedure generally takes only a few minutes to per- diuretic for four to eight weeks after surgery to reduce form. However, the preparation and recovery time add a fluid retention that may occur after surgery. Potassium few hours to both procedures. The total time in the op- supplements may be prescribed along with the diuretic erating room for each of these procedures is about medications. Some patients may be prescribed anticoag- three to four hours. ulant medication such as warfarin and aspirin to reduce the risk of blood clots. The medications prescribed may be adjusted over time to determine the best dosage and Aftercare type of medication so the abnormal heart rhythm is ade- Recovery in the hospital quately controlled. The patient recovers in a surgical intensive care INCISION AND SKIN CARE. The incision should be unit for one to two days after the surgery. The patient kept clean and dry. When the skin is healed, the incision will be connected to chest and breathing tubes, a me- should be washed with soapy water. The scar should not chanical ventilator, a heart monitor, and other monitoring be bumped, scratched, or otherwise disturbed. Oint- equipment. A urinary catheter will be in place to drain ments, lotions, and dressings should not be applied to the urine. The breathing tube and ventilator are usually re- incision unless specific instructions have been given. moved about six hours after surgery, but the other tubes DISCOMFORT. While the incision scar heals, which usually remain in place as long as the patient is in the in- takes one to two months, it may be sore. Itching, tight- tensive care unit. ness, or numbness along the incision is common. Muscle Drugs are prescribed to control pain and to prevent or incision discomfort may occur in the chest during ac- unwanted blood clotting. Daily doses of aspirin are tivity. started within six to 24 hours after the procedure. LIFESTYLE CHANGES. The patient needs to make sev- eral lifestyle changes after surgery, including: The patient is closely monitored during the recovery period. Vital signs and other parameters such as heart • Quitting smoking. Smoking causes damage to blood sounds and oxygen and carbon dioxide levels in arterial vessels, increases the patient’s blood pressure and heart blood are checked frequently. The chest tube is checked rate, and decreases the amount of oxygen available in to ensure that it is draining properly. The patient may be the blood. fed intravenously for the first day or two. • Managing weight. Maintaining a healthy weight, by Chest physiotherapy is started after the ventilator watching portion sizes and exercising, is important. and breathing tube are removed. The therapy includes Being overweight increases the work of the heart. coughing, turning frequently, and taking deep breaths. • Participating in an exercise program. The cardiac reha- Sometimes oxygen is delivered via a mask to help loosen bilitation exercise program is usually tailored for the pa- and clear secretions from the lungs. Other exercises will tient, who will be supervised by fitness professionals. be encouraged to improve the patient’s circulation and prevent complications from prolonged bed rest. • Making dietary changes. Patients should eat a lot of fruits, vegetables, grains, and non-fat or low-fat dairy If there are no complications, the patient begins to products, and reduce fats to less than 30% of all calories. resume a normal routine around the second day. This in- • Taking medications as prescribed. Aspirin and other cludes eating regular food, sitting up, and walking heart medications may be prescribed, and the patient around a bit. Before being discharged from the hospital, may need to take these medications for life. the patient usually spends a few days under observation in a non-surgical unit. During this time, counseling is • Following up with health-care providers. An exercise usually provided on eating right and starting a light exer- test is often scheduled during one of the first follow-up cise program to keep the heart healthy. visits to determine how effective the surgery was and to GALE ENCYCLOPEDIA OF SURGERY 939

confirm that progressive exercise is safe. The patient Maze procedure for atrial fibrillation may experience any of the normal complications associ- U.S. surgeons reporting their data in the January 2000 needs to regularly see the physician for follow-up visits issue of Seminars in Thoracic and Cardiovascular Surgery, the overall success rate of the Maze procedure to monitor his or her recovery and control risk factors. is from 90–97%. Some hospitals report a 95–98% suc- cess rate in lone atrial fibrillation patients (those who do Risks not have any other underlying heart conditions) undergo- The Maze procedure is major surgery and patients ing the traditional Maze procedure. An 80–90% success rate has been reported for the surgical pulmonary vein ated with major surgery and anesthesia, such as the risk isolation procedure. of bleeding, pneumonia, or infection. The risk of stroke is 1%. One common complication that has occurred early Morbidity and mortality rates after surgery is fluid retention. However, diuretics are The overall operative mortality for patients undergo- now prescribed to reduce the risk of this complication. To date, minimal long-term adverse effects have been report- creases among patients over age 65. ed in patients undergoing the Maze procedure. ing the Maze procedure is 3%. The mortality rate in- Atrial fibrillation is not immediately life threaten- Normal results ing, but it can lead to other heart rhythm problems. Fol- low-up data from the Framingham Heart Study and the Full recovery from the Maze procedure takes six to Anti-arrhythmia Versus Implantable Defibrillators Trial eight weeks. Upon release from the hospital, the patient have shown that atrial fibrillation is a predictor of in- will feel weak because of the extended bed rest in the creased mortality. hospital. Within a few weeks, the patient should begin to feel stronger. According to a 2002 study published in the New England Journal of Medicine, controlling a patient’s Most patients are able to drive in about three to four heart rate is as important as controlling the patient’s weeks, after receiving approval from their physician. heart rhythm to prevent death and complications from Sexual activity can generally be resumed in three to four cardiovascular causes. The study also concluded that an- weeks, depending on the patient’s rate of recovery. ticoagulant therapy is important to reduce the risk of It takes about six to eight weeks for the sternum to stroke and is appropriate therapy in patients who have re- heal. During this time, the patient should not perform ac- curring, persistent atrial fibrillation even after they re- tivities that cause pressure or put weight on the breast- ceived treatment. bone or tension on the arms and chest. Pushing and pulling heavy objects (such as mowing the lawn) should Alternatives be avoided and lifting objects more than 20 lb (9 kg) is not permitted. The patient should not hold his or her Health care providers usually try to correct the heart arms above shoulder level for a long period of time. The rhythm with medication and recommend lifestyle patient should try not to stand in one place for longer changes and other interventional procedures such as car- than 15 minutes. Stair climbing is permitted unless other dioversion before recommending the Maze procedure. instructions have been given. Lifestyle changes often recommended to treat ab- Within four to six weeks, people with sedentary of- normal heart rhythms include: fice jobs can return to work; people with physical jobs • quitting smoking (such as construction work or jobs requiring heavy lift- • avoiding activities that prompt the symptoms of abnor- ing) must wait longer (up to 12 weeks). mal heart rhythms In about 30% of all patients, atrial fibrillation will • limiting alcohol intake recur temporarily right after surgery. This is common. Medications are usually prescribed to control atrial fib- • limiting or not using caffeine, which may produce rillation after surgery. About three months after the more symptoms in some people with abnormal heart surgery, medications are often reduced and then stopped. rhythms In about 7–10% of patients, a permanent pacemaker • avoiding medications containing stimulants such as is needed as a result of the procedure or sometimes due some cough and cold remedies to underlying sinus node dysfunction. If the Maze procedure is not successful in restoring About 90–95% of patients have a return of normal the normal heart rhythm, other treatments for abnormal heart rhythm within one year after the surgery. Among heart rhythms include: 940 GALE ENCYCLOPEDIA OF SURGERY

KEY TERMS Ablation—The removal or destruction of tissue. Electrophysiology study (EPS)—A test that evalu- Ablation therapy—A procedure used to treat ar- ates the electrical activity within the heart. rhythmias, especially atrial fibrillation. Head-upright tilt table test—A test used to deter- Ambulatory monitors—Small portable electrocar- mine the cause of fainting spells. Maze procedure for atrial fibrillation diograph machines that record the heart’s rhythm, Implantable cardioverter-defibrillator (ICD)—An and include the Holter monitor, loop recorder, and electronic device that is surgically placed to con- trans-telephonic transmitter. stantly monitor the patient’s heart rate and rhythm. Anti-arrhythmic—Medication used to treat abnor- If a very fast, abnormal heart rate is detected, the mal heart rhythms. device delivers electrical energy to the heart to re- Anticoagulant—A medication, also called a blood sume beating in a normal rhythm. thinner, that prevents blood from clotting. Nuclear imaging—Method of producing images by Atria—The right and left upper chambers of the detecting radiation from different parts of the body heart. after a radioactive tracer material is administered. Cardiac catheterization—An invasive procedure Pacemaker—A small electronic device implanted used to create x rays of the coronary arteries, heart under the skin that sends electrical impulses to the chambers and valves. heart to maintain a suitable heart rate and prevent Cardioversion—A procedure used to restore the slow heart rates. heart’s normal rhythm by applying a controlled electric shock to the exterior of the chest. Pulmonary vein isolation—A surgical procedure used to treat atrial fibrillation. Echocardiogram—An imaging procedure used to create a picture of the heart’s movement, valves Stress test—A test used to determine how the heart and chambers. responds to stress. Electrocardiogram (ECG, EKG)—A test that records Ventricles—The lower pumping chambers of the the electrical activity of the heart using small elec- heart; the heart has two ventricles: the right and trode patches attached to the skin on the chest. the left. • permanent pacemakers Wyse, D. G., et al. “Atrial Fibrillation: A Risk Factor for In- creased Mortality—An AVID Registry Analysis.” Journal • implantable cardioverter-defibrillator of Interventional Cardiac Electrophysiology, 5 (2001): 267–273. • ablation therapy ORGANIZATIONS Resources American College of Cardiology. Heart House. 9111 Old BOOKS Georgetown Rd., Bethesda, MD 20814-1699. (800) 253- 4636 ext. 694 or (301) 897-5400. <http://www.acc.org>. McGoon, Michael D., ed. and Bernard J. Gersh. Mayo Clinic Heart Book: The Ultimate Guide to Heart Health, Second American Heart Association. 7272 Greenville Ave., Dallas, TX Edition. New York: William Morrow and Co., Inc., 2000. 75231. (800) 242-8721 or (214) 373-6300. <http://www. Topol, Eric J. Cleveland Clinic Heart Book: The Definitive americanheart.org>. Guide for the Entire Family from the Nation’s Leading The Cleveland Clinic Heart Center, The Cleveland Clinic Heart Center. New York: Hyperion, 2000. Foundation. 9500 Euclid Avenue, F25, Cleveland, OH Trout, Darrell, and Ellen Welch. Surviving with Heart: Taking 44195. (800) 223-2273 ext. 46697 or (216) 444-6697. Charge of Your Heart Care. Golden, CO: Fulcrum Pub- <http://www.clevelandclinic.org/heartcenter>. lishing, 2002. National Heart, Lung and Blood Institute. National Institutes of PERIODICALS Health. Building 1. 1 Center Dr., Bethesda, MD 20892. E- mail: <[email protected].>. <http://www.nhlbi. Benjamin, E. J., P. A. Wolf, R. B. D’Agostino, H. Silbershatz, nih.gov>. W. B. Kannel, and D. Levy. “Impact of Atrial Fibrillation on the Risk of Death: The Framingham Heart Study.” Cir- Texas Heart Institute. Heart Information Service. P.O. Box 20345, culation, 98 (1998): 946–952. Houston, TX 77225-0345. <http://www.tmc.edu/thi>. GALE ENCYCLOPEDIA OF SURGERY 941

Some devices, along with the intra-aortic balloon Mechanical circulation support North American Society of Pacing and Electrophysiology. 6 pump (IABP), centrifugal pump, and extracorporeal Strathmore Rd., Natick, MA 01760-2499. (508) 647- 0100. <http://www.naspe.org>. membrane oxygenation (ECMO), are systems that are meant to sustain the patient until the heart recovers. If re- OTHER covery does not occur, or is not expected, then heart About Atrial Fibrillation. <http://www.aboutatrialfibrillation. transplantation becomes the next desired course of com>. treatment. In this case, intermediate- to long-term me- HeartCenterOnline. <http://www.heartcenteronline.com>. The Heart: An Online Exploration. The Franklin Institute Sci- chanical circulatory support devices are required. ence Museum. 222 North 20th Street, Philadelphia, PA, 19103. (215) 448-1200. <http://sln2.fi.edu/biosci/heart. html>. Heart Information Network. <http://www.heartinfo.org>. Short-, intermediate-, and long-term support requires Heart Surgeon.com. <http:www.heartsurgeon.com>. Description bedside monitoring of the equipment and patient through- out treatment. The specialized nature of the equipment Angela M. Costello and the intensive patient care require dedicated staff who are able to provide continuous bedside treatment. Mean corpuscular hemoglobin see Red In most instances, patients receive anticoagulants, blood cell indices drugs that prevent clots in the blood. Frequent laboratory testing determines the proper amount of medication re- Mean corpuscular volume see Red blood quired to prevent blood clots. To mimic the lining of cell indices blood vessels, some surfaces of the device attract the body’s cells, which stick to the device surface and elimi- nate the need for anticoagulation. Blood flow generated by these devices is able to sus- tain blood pressure and flow to the heart, kidneys, liver, Mechanical circulation and brain. Temporary assist devices sustain vital organ support tissues in situations where recovery of the heart function is anticipated. Long-term support devices sustain patients Definition until a donor heart is available for transplantation. Mechanical circulatory support is used to treat pa- tients with advanced heart failure. A mechanical pump is Short- to intermediate-term support devices surgically implanted to provide pulsatile or non-pulsatile ECMO circulatory support provides cardiopul- flow of blood to supplement or replace the blood flow monary bypass. Both cardiac and pulmonary (lung) generated by the native heart. Types of circulatory sup- function can be supplemented with this device. The com- port pumps include pneumatic and electromagnetic plexity of care and the need for highly trained staff with pumps. Rotary pumps are also available. specialized equipment limit the availability of ECMO to specialty care facilities. Surgical cannulation (placement Purpose of tubes) is required. Postoperative care in the critical care unit requires dedicated bedside staffing. Heart failure causes low cardiac output, which re- sults in inadequate blood pressure and reduced blood Blood flow to the lungs is reduced as blood is flow to the brain, kidneys, heart, and/or lungs. Pharma- drained from the venous circulation. Blood pumped by ceutical and surgical treatments (other than transplanta- the left ventricle is also reduced as blood is returned di- tion) are all typically exhausted before mechanical circu- rectly to the systemic circulation. The heart is allowed latory support is initiated. The extent of failure exhibited to rest, pumping less blood than needed to maintain by one or both ventricles of the heart determines if uni- pressure and flow to the vital organs. As cardiac func- ventricular or biventricular support is required. In either tion improves, flow from ECMO support is reduced, al- case, blood flow is supplemented or replaced by a me- lowing the heart to gradually resume normal function. chanical circulatory support device. The device works by The cannulae are surgically removed from the patient removing blood from the inlet of the ventricle(s) and once the heart can maintain adequate cardiac output. reinjecting it at the outlet of the ventricle(s) in order to Systemic anticoagulation is required throughout the increase blood pressure and blood flow to the brain, kid- length of support, and often leads to complications of neys, heart, and lungs. stroke and coagulapathies. Long-term use of ECMO is 942 GALE ENCYCLOPEDIA OF SURGERY