2. URGICAL Springer New York Berlin Heidelberg Hong Kong London Milan Paris Tokyo
3. An Algorithmic Approach NCOLOGY T h e o d o r e J . S a c l a r i d e s , m . d . K e i t h W. M i l l i k a n , m . d . C o n s ta n t i n e V. G o d e l l a s , m . d . Department of General Surgery Rush Medical College Chicago, IL Editors 1 3
4. T H E O D O R E J . S A C L A R I D E S , M . D . Professor of Surgery, Rush Medical College Head, Section of Colon and Rectal Surgery Department of General Surgery Rush-Presbyterian-St. Lukes Medical Center Chicago, IL 60612, USA K E I T H W. M I L L I K A N , M . D . Associate Professor of Surgery, Rush Medical College Director of Undergraduate Surgical Education Director, Nutrition Consultation Service Department of General Surgery Rush-Presbyterian-St. Lukes Medical Center Chicago, IL 60612, USA C O N S T A N T I N E V. G O D E L L A S , M . D . Assistant Professor of Surgery, Rush Medical College Academic Program Coordinator Department of General Surgery Rush-Presbyterian-St. Lukes Medical Center Chicago, IL 60612, USA L I B R A R Y O F C O N G R E S S C A T A L O G I N G - I N - P U B L I C A T I O N D A T A Surgical oncology: an algorithmic approach / editors, Theodore J. Saclarides, Keith W. Millikan, Constantine V. Godellas. p. ; cm. Includes bibliographical references and index. ISBN 0-387-95201-2 (h/c : alk. paper) 1. CancerSurgery. 2. Oncology. 3. Algorithms. I. Saclarides, Theodore J., 1956 II. Millikan, Keith W. III. Godellas, Constantine V. [DNLM: 1. Neoplasmssurgery. 2. Surgical Procedures, Operativemethods. QZ 268 S961105 2001] RD651 .S8833 2001 616.994059dc21 2001032003 ISBN 0-387-95201-2 Printed on acid-free paper. 2003 S P R I N G E R - V E R L A G N E W Y O R K , I N C . All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identied as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Text design by Steven Pisano. Printed in the United States of America. 9 8 7 6 5 4 3 2 1 SPIN 10860606 www.springer-ny.com Springer-Verlag New York Berlin Heidelberg A member of BertelsmannSpringer Science+Business Media GmbH
5. My deepest gratitude to Frs. John Athas, George Scoulas (eternal be their memory) and Angelo Artemas for their inspiration and healing. Th e o d o r e J . S ac l a r i d e s I dedicate this work to my grandfather, Aunt Marge and Aunt Mary, who all suffered from lung cancer and, lastly, to Delores Deselich, who spent the majority of her shortened life nursing the sick, many of whom had the diseases described in the following pages. K e i t h W. M i l l i k a n In memory of my mother, Elaine, who was valiant in her ght against cancer, but ultimately lost the battle. Also, for all the patients I have and will care for who ght the same battle, fortunately with better results. I would also like to acknowledge my father, Dr. William Godellas, who practiced Internal Medicine for 40 years and taught me how to be a caring physician. And nally, to my wife, Erin, who completes me. C o n s t a n t i n e V. G o d e l l a s
6. oreword I t was not too many years ago that a hospitals daily surgical schedule included a number of exploratory operations. It was the era when the multipotential general surgeon was the star of the surgical amphitheater. While the need to make an incision to take a look inside the body might be compelling enough based on the presenting signs and symptoms, and often was lifesaving, beyond that what was found could be a total surprise, a thrilling adventure or a misguided exercise. Thats why the general surgeon needed prolonged operating room exposure as an observer and then as an assis- tant, to gain the experience, condence, and indeed the courage, to handle cases that today are com- monly done by residents. It was in just such a restricted, yet beckoning, climate that general surgery functioned until the great burst of progress that was triggered and fueled by the Second World War and its aftermath. The next several decades ushered in the establishment and maturation of the surgical specialties. Inexorably from this fertile foundation the surgical subspecialties blossomed. It is now clear that surgery is in the midst of a multifaceted evolution, whose speed and breadth are truly impressive. While it also is true that some areas of surgery are not narrowly compartmentalized, so much new information of all sortstechnical and scienticis being made available and is pertinent to good care, that to collect, analyze, and utilize it properly is a daunting challenge. As just one example, it is no longer adequate for a physician to be dened as an orthopedic surgeon. By choice, or because of need, there are those orthopedic surgeons who conne their work just to neoplasms or to trauma; acquired or congenital disorders; only the foot and ankle; the hand, knee, hip, or spine and other areas. Many of these are legitimate subspecializations simply because of the con- siderable variety of available therapies for each anatomic area and the nuances that determine which therapeutic choice is most appropriate. As well, there is the need to perform enough of each of the applicable operations so as to both acquire the clinical judgment and develop the technical skills to condently expect a high level of success. Multiply this by the robust growth of the other anatomic areas of surgical subspecialties and one can begin to understand the reasons why increasing numbers of surgeons have limited their repertoire of operations. At the same time, they improve their results and derive greater professional satisfaction. Added to the specialization and subspecialization of surgery are the other two arms of the thera- peutic trilogy, namely medicine and radiation therapy. Not surprisingly, they too have burgeoned to an extent unforeseen by most people who dispense health care. While all of the above developments have vastly expanded the choices of available treatments, they have also increased rather than lessened the challenges of deciding which therapy is most appropriate. Yet, in the nal reckoning, it is from such a cornucopia of variable relevant choices that the clinician must select the therapy that will most likely lead to the desired result.
7. I applaud the book Surgical Oncology: An Algorithmic Approach by Drs. Theodore Saclarides, Keith Millikan and Constantine Godellas, because these young, but experienced, surgeons have wisely chosen to address an important, yet incompletely fullled, need in the current cancer textbooksnamely, to recognize the presence of an oncologic problem; to logically and methodically explore and treat it; and in an algorithmic fashion coordinate the efforts of the different disciplines necessary for treating the cancer patient. I especially like the manner in which this book is arranged. The rst part of each chapter is pre- sented in a narrative exposition, offering the reader the choice of reading the material in a sweeping fashion or in a deliberate, studied way as the circumstances may require. The companion portion of each chapter is presented in the form of well-crafted algorithms that are logical and easy to follow. The concept of this book and the manner in which the contents are presented will make it an indispens- able favorite of many physicians. STEVEN G. ECONOMOU, m.d. Professor of Surgery and Chairman Emeritus Department of General Surgery Rush-Presbyterian-St. Lukes Medical Center
8. reface T he premise for this work is the realization that cancer cannot be adequately treated by a single specialty. The surgeon, medical oncologist, and radiation oncologist cannot and should not work or function in the secluded sphere of his/her own domain. Instead, successful management of the cancer patient must incorporate the best that each of these specialties has to offer. Added to the list of necessary healthcare professionals are genetic counselors, pain specialists, enterostomal therapists, and nutrition experts, just to name a few. Understanding the exact role of each of these entities can be a daunting challenge, thus the benet of our work which has attempted to display in an algorithmic fashion how the various treatment and support modalities can be employed. Treatment of the cancer patient must be individualized. One may incorrectly assume that an algo- rithmic approach advocates treatment of all patients with a particular cancer exactly the same or that a cookbook plan is being proposed. We rmly believe the contrary and comment throughout this work that controversy exists and that more that one approach may be taken depending on various institu- tional and geographic practices. Instead, our primary objective has been to display how many different specialties may interact and support one another with one goal in mindto improve treatment and outcome. We hope that this work will accomplish our goal and organize care of the cancer patient in an easy to follow way. THEODO RE J. SACLARI