Psammoma Bodies

Round collection of calcium.
- thought to arise from infarction and calcification of intralymphatic tumor thrombi

Commonly seen with:
- papillary thyroid cancer
- papillary RCC
- serous papillary ovarian adenoca
- endometrial adenoca
- meningioma
- mesothelioma
- prolactinoma
- endosalpingiosis

Papillary thyroid cancer

Lymph node metastases are most common.
Distant metastatic spread is rare. Lun and bone are two most common sites

- Ground glass nuclei, cellular grooving and psammoma bodies are diagnostic features of papillary thyroid cancer and if seen can be used to confirm diagnosis.

- 30-50% of papillary thyroid cancers are multicentric with a simultaneous cancer in the contralateral lobe.

- this is the reason for endorsement of a total thyroidectomy in cases where the lesion is a papillary thyroid cancer.

- while distant mets to bone and lung are the most common sites for papillary cancer metastases, distant mets are rare.  Whereas lymph node mets are quite common with this type of thyroid cancer

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Pediatric thyroid malignancy

Relativrly uncommon malignancy.
- occurs predominantly in children >10
- males and females affected equally

Pathology:
- 70% are papillary or mixed-papillary-follicular carcinomas
- 18% are follicular
- 4-10% medullary
- 2-5% anaplastic
- hurthle and lymphoma are exceedingly rare in peds

Work-up:
- laryngoscopy to evaluate chords
- thyroid function, anti-thyroid antibody
- ultrasound
- technetium scan; in kids. Warm or. Cold nodules should both be treated as cold nodules, malignancy occurs in 14-40% of solid thyroid nodules in kids not just predominantly in cold nodules
- tissue diangosis: fna and if inconclusive then lobeactomy may be required

Prognosis:
- children with well differentiated thyroid cancer have a better prognosis than adults despite presentation with more advanced disease and high incidence of regional and distant metastases at time of presentation

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Supralevator anorectal abscess

Relatively rare 2.5% of anorectal abscessess.
- perianal and buttock pain are the most common presenting complaints.
- most with this rare type of abscess have underlying pelvic inflammatory process, prior recent abdominal surgery or crohn's disease.
- can also occur in continuity with cepahalad extension of transsphincteric fistula/abscess

Treatment:
- cause determines therapy.
- transrectal or transvaginal drainage for abscess caused by pelvic sepsis
- if extension if transsphincteric abscess then manage primary trans sphincteric process

Key is to know the patients history.
- crohns or recent abdominal surgery.
- then go to or. Look for crypt abscess
- if absent the internal drainage following a seeker needle with a
Foley/malecot/t-tube in place for 24-48 hrs
- if crypt abscess found the. Drain exteriorly through a large skim incision to adequately drain the supralevator abscess component

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Anorectal abscess

Drainage is key.
- there is no role for primary antibiotic therapy.
- Some controversy over culturing abscess fluid. Drainage usually sufficient so C&S is redundant. Some Evidence to suggest that presence of gut flora in culture helps to predict who gets persistent fistula.

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Fistula rate after anorectal abscess

If internal opening recognized in OR at time of anorectal I&D procedure it is reasonable to perform synchronous fistulotomy if low-lying fistula.
- however, usually very difficult to identify the internal opening site.

Anorectal Abscess

Hemorrhoids

Ensure you have the right diagnosis.
- cancer
- prolapse
- disordered defecation
- fissure. Hemorrhoidectomy in a fissure patient will result in excessive pain, poor healing. Consider doing lateral sphinceterotomy at the same time.

Treatment options:
- patients with bleeding disorders consider an operative approach to hemorrhoid management
- use of banding in these patients can result in bleeding when the hemorrhoid sloughs off in 5-10 days.

Suture material
- catgut us often used as a suture material because it is absorbed quickly
- potential for infection when long absorbing suture is used.

Infection
- can manifest as pain greater than anticipated, urinary retention and fever.
- manage patient by taking to or, remove elastic band and start on IV abx

Reference:
ACS surgery

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Autonomously functioning "hot" thyroid nodules

- rate of carcinoma in an autonomously functioning thyroid nodule: 0.7%
(Mizukami et al, Am J Clin Path 1994)

Thyroid MCQ

 1)    to prove a thyroid cyst is benign:

a)     CT neck

b)    cytology and FNA

c)     US

d)    thyroid scan

2)    the best treatment for a women with a thyroid nodule which is hot on thyroid scanning and decreased TSH and increased free T4 is:

a)     radioactive iodine

b)    thyroid suppression

c)     operation

d)    FNAB to R/O malignancy

e)     Observation

3)    thyroid nodule 4cms in size:

a)     observe

b)    suppress

c)     resect

4)    what is the best initial investigation for a solid mass in the thyroid:

a)     US

b)    Thryroid function test

c)     FNA

d)    Scan

e)     serial physical exam

5)    10 yo seen by school nurse, found 3cm mass non-tender inferior aspect of the thyroid:

a)     observe and reasses in 6 months

b)    thryroid suppression

c)     radioactive iodine

d)    operate

e)     wait until puberty

6)    with regards to thyroid ca:

a)     lymphatic spread

b)    hematogenous spread

c)     may be multinodular and encapsulated

d)    mets may look normal

Complications of Thyroxine

What are the complications of Thyroxime?

Hyperthyroidism:

Surgical Management of Hyperthyroid:
- Grave's disease
- Toxic nodular goitre (single or multiple)
- Amiodarone-induced thyrotoxicosis

Preop preparation of patients required to normalize T3/T4 using thioamides.  In the past super-saturated potassium iodide or Lugol's solution used to resture thyroid function and decrease thyroid vascularity but does so only temporarily.

Medical management:
- Thioamides (propylthiouracil, methimazole): decrease thyroid hormone synthesis, takes several weeks to take effect.  Effective in 90% of patients, but relapses occur in ~80% of pts.  Complications: Agranulocytosis rare (0.5%)
- Radioactive iodine 131-I, highly effective in Grave's disease (90%), pt becomes hypothyroid.  Can worsen thyrotoxicosis
- 131-I contraindicated during pregnancy or in lactating mothers

Pemberton's Sign:
- facial plethora, inspiratory stridor, venous congestion when arms raised above head
- sign of jugular venous compression (thoracic outlet obstruction can be from large goiter)

Hyperthyroidism Questions:

1)    indications for surgery in hyperthyroidism, all except:

a)     childhood

b)    pregnancy

c)    reoperation for hyperthyroidism

d)    toxic adenoma

e)     toxic multinodular goiter

2)    a 30yo nurse presents with a 3 week history of malaise and weakness. Her thyroid gland is diffusely enlarged and tender. Her ESR is slightly elevated, and her T4 is twice normal. What should be done:

a)     total thyroidectomy

b)    radioactive iodine ablation

c)    treatment with NSAIDS and rest

d)    treatment with propanolol and PTU

e)     FNA

3)    a 35yo male has an asymmetrically enlarged thyroid gland. The ESR is 60. T4 is 180 and iodine uptake is 4%. He most likely has:

a)     Graves

b)    Ridel’s struma

c)     Haschimotos disease

d)   subacute thyroiditis

e)     toxic multinodular goitre

4)    Hashimoto’s thyroididtis may be associated with:

a)     follicular thryroid ca

b)    papillary thyroid ca

c)    lymphoma

d)    leukemia

e)     Hurtle cell tumors

5)    which of the following statements regarding Hashimoto’s thyroiditis is not true:

a)     it is the commonest type of thyroiditis

b)    there is a familial predisposition

c)     the gland is infiltrated with giant cells

d)    it occurs mostly in the middle age females

e)     antithyroid Ab may be present

Recurrent Laryngeal nerve anatomy

RLN arises from the vagus nerve
- passes beneath vessel derived from the primitive 4th aortic arch
- on the right it recurs around the subclavian artery
- on the left it recurs around the aortic arch
- 1% of patients have a retroesophageal right subclavian artery and the laryngeal nerve arises directly from vagus to the larynx

Association with the inferior thyroid artery is variable.  Most course anterior to all branches, some course between branches and a few course totally behind branches of the inferior thyroid artery.
- text advocates encircling inferior thyroid artery as it arises from carotid and lifting it up to try and help identify the RLN.

Most consistent location of RLN is its insertion between the thyroid and cricoid cartilage.  Even in cases of recurrent laryngeal nerves it inserts in this location.  Its location relative to the cornu of the thyroid cartilage is quite consistent.
- This is where DCW looks for RLN initially.

External branch of the superior laryngeal nerve runs along the cricothyroid membrane and care should be taken to avoid damaging the SLN.

Silver and Rubin Atlas of Head and Neck Surgery: pg 284

Oral exam: Colon cancer

46 yo patient presents to you with a biopsy proven adenocarcinoma in the cecum and a 1.5 cm villous polyp 8cm from the anal verge.

What is your workup and management?

Moore Retreat: Pelvic Fracture

Drive 1st pack deep into the pelvis
- hematoma opens the space up for you
- If laparotomy needed then try to keep fascial defect above the perperitoneal incision

Pelvic Fixator:
- C-clamp used as a pelvic fixator
- can be maneuvered for OR/CT

PPP should be a joint decision with orthopod

Angio:
- if ongoing bleeding pt may still need angio
- angio still needed in 10-12% of patients

Average dates to:
- pack removal: 3d
- ventilator days: 14d
- ICU LOS: 18d

mortality in refractory shock patients:
40-50% mortality without PPP
20-25% mortality with PPP

Moore Retreat: Colon and Rectum

To Divert or Not?
- 2-3% leak rate with primary repair
- although low leak rate consider whether patient "can take a joke?"

Rectum:
- Pendulum has swung from primarily diverting to observational management more popular now
- A situation where observation might be dangerous is with a massive open pelvic # where diversion can prevent pelvic sepsis/osteomyelitis

Diversion:
- EEM uses loop ileostomy as his primary diversion technique (without on-table lavage)
- sigmoid end colostomy might be done if there is destructive injury to sigmoid where simpler just to take out sigmoid as colostomy
- don't just do a small local exicision: especially in watershed areas
- need to resect from one named vessel to the next! (ie; R hemi/L hemi)tra

Moore Retreat: Liver

Severe injuries:
- Grade 3 central, Grade IV and Grade V
- treat all as severe liver injuries
- Biliary stent can be used to manage a bilious fistula injury
- Tolerate permissive hypotension and decreased pRBC transfusion if suspect a liver injury

- increased blood pressure can aggravate liver bleeding

- CT very helpful in mapping hepatic injury

Perform pringle early!

- pack and don't keep looking at the liver

- Packing can be used to control even retrohepatic injuries

- EEM also uses veno-veno bypass with a femoral/SMV line feeding into a subclavian line

Moore Retreat: Spleen

Immunizations:
Boosters given;
- Pneumococcus @ 5yrs
- no boosters given for HIB or meningococcus
- Influenza vaccine given qYr
- EEM ideally gives vaccinations 2-3 weeks post-op; if the patient is unreliable then he will give @ time of discharge
- grade 4-5 and transfused 1-2U pRBC, will give immunizations

Prophylactic Antibiotics:
- Amoxicillin or Erythromycin prophylaxis given from 3-5 yo
- @ UAH pediatricians suggest until age of 7 yo

Unlike liver; 
- spleen can bleed in a delayed fashion, even 7-10d out from injury
- Even grade 1-2 injuries can bleed significantly

Conservative Treatment:
Grade 1-3:
- AAT, DAT - let the responsible adult manage and D/C when they see fit.
- D/C pack qD when pt feels fit
Grade 4-5:
- U/S follow-up as outpatient - no need  for inpatient CT.

Angio:
- Does a contrast blush mandate angio?
- pts can have either an arterial or venous blush, location of blush matters too
- EEM uses this information to determine if pt to get angio; uses angio selectively
- Global embolization of splenic artery has a propensity to result in splenic abscess formation which can be much more challenging compared to a splenectomy would have been
- when patient hemocontracted what seems like a smaller subsegmental branch can in fact be a larger segmental branch and embolization can result in significant devascularization of spleen

Unstable Patient:
- open the lesser sac and clamp the hilum before mobilizing the spleen
- cut the ligaments 1-2 cm beyond the capsule of the spleen to prevent causing more bleeding by avulsing the capsule
- if you stay right on the the kidney when dividing the splenorenal ligament you avoid getting into the tail of the pancreas

Transfusion triggers to take out spleen:
- recurrent hypotension after 2U pRBC
- EEM aggressive in taking our spleen, risk of OPSS minimal in adult

OPSS:
- rare in adults,
- in children >2 yo rate is higher but salvage rate is 98%
- really of most concern in very young patients  < 2 yo

DVT Prophylaxis in pts with splenic injury:
- use of Thromboelastogram? Some pts resistant to LMWH and may need antiplatelet therapy (for upto 4 weeks)
- when deciding to anticoagulate in pt with splenic injury, consider that preventing a PE is probably much more important than preventing the spleen from coming out

Splenic Autotransplantation:
- In Denver they routinely autotransplant splenic fragments into an omental pouch
- there is retrospective data that demonstrates that autotransplanted pts have increased IgA, IgM and Tuftsin levels

Moore Retreat: Pancreas and duodenum injuries

Retroperitoneal air:
- represents a duodenal injury until proven otherwise
- repeat the CT with a po contrast agent

Examining the pancreas:
- Mobilize the duodenum and pancreas:
- Kocher, take down lig of Trietz
- open lesser sac
- incise the peritoneum above and below the pancreas
- you must get to the posterior surface of the pancereas
- classic missed injury is a posterior disruption of the pancreas where the anterior surface looks normal but if you slip your finger behind the pancreas is fractured where it lies over the spine.

Duodenal Injuries:
- EEM closes the duodenum with a 1 layer continuous suture
- duodenal injuries: most can close primarily unless the ampulla is involved
- if there is extensive blowout of the duodenum options include bringing up a R-en-Y limb and plugging it into the blowout
- ? duodenal diverticulization
- Wide drainage is an option with pyloric exclusion
- should not need to do a Whipple's for duodenal injuries

Pancreatic Injuries:
- Stents in neck of pancreatic duct; better than performing a 90% pancreatectomy with risk of leak
- if do distal pancreatectomy should be able to leave the spleen
- if need to can take splenic artery, just be sure you leave the short gastrics as you are opening the lesser sac
- can also perform intraoperative ERCP - even after having done Kocher - just clamp bowel @ LT and help guide scope down

Moore Retreat: CT imaging in Trauma

CT imaging of diaphragmatic injuries:

- Collar sign: narrow waist of herniated hollow organs as they herniate through diaphragmatic defect

- Disrupted diaphragm sign

- Dependent viscus sign: posterior wall of stomach lies in contact with posterior wall of the chest (which it normally doesn't)

Use of Triple contrast for colon injuries:

- with multidetector CT, may not need po/pr contrast to detect a colonic injury

- there are usually secondary signs such as a hematoma or air bubbles

- instilling rectal contrast has an inherent false negative rate as well

- pt may still need an exploration if suspicion high enough.

- ?if rectal bleed and penetrating stab or pelvic fracture just explore abdomen, rectal contrast perhaps useful if mechanism present but no clinical suspicion of injury and it may prevent an OR

Houndsfield Units:

- Fresh blood: 20-30 HFU (decreased intensity if old blood, or mixed with ascites, urine)

- Blood with IV contrast: 30-40 HFU

- Fat: <-10 HFU

- Water: 0-10 HFU

- Urine: 0-10 HFU

- Non-contrast (fatty) liver: 10-15 HFU

- Fatty liver contrast phase: 35-40 HFU

- Normal contrast phase liver: 70-80 HFU

- Bone: 400-500 HFU

- Metal: 1000 HFU

- Enhanced aorta: 190

- po contrast: 50-200 (depends on dilution)

Oral contrast can be negative or positive: use of a positive (ie; enhances) contrast agent prevents you from visualizing the bowel wall

- if you want to visualize the bowel wall then water contrast (negative) better

Radiation Exposure:

CT/Abdo/Pelvis:

- old scanners 10-15 mSi

- newer generation of scanners 3-4 mSi

10mSi of radiation carries a 1:2000 lifetime risk of cancer

- consider that everyone has a 1:5 lifetime of risk of caner without any exposure risk

- Therefore if CT is clinically indicated then theoretic risk of inducing cancer should not be a barrier

Moore Retreat: Role of ED Thoracotomy

Blunt Trauma:
- consider the institutional resources

When is ED Thoracotomy futile?
Blunt trauma:
- CPR > 5 min and no signs of life
- Asystole (without cardiac tamponade)

Penetrating trauma:
- CPR >15 min and no signs of life
- Asystole (without cardiac tramponade)

Once you've done it have an exit plan:
- what are your indications to stop your ED thoracotomy resuscitation?
- was a tamponade present?
- is the heart filling?
- don't let your ED physicians/anesthesiologists get to carried away with transfusion/epinepherine; SBP 90 is enough
- Base deficit >20 is a very, very strong predictor of mortality

Moore Retreat: Thoracic Great Vessels

Pearls:

- Consider forearm fasciotomies if upper arm ischemia (how?)

- know course of phrenic and vagus nerves as these come into play

Anterior lateral thoracotomy is the defacto incision for any thoracic vascular injury

- if you need access to the other side: Clamshell

- if you need access to proximal great vessels: T-up with a sternotomy +/- supraclavicular trap-door incision

Pneumonectomy in trauma patients is associated with a 95% mortality

- places significant right heart strain that unstable patient won't tolerate

Moore Retreat: Neck Injuries

Mandatory Zone 2 neck exploration:

- was the surgical dogma dating from Korean and Vietnam war

- This dogma is now changing with improvements in CT imaging and additional diagnostic testing to rule out injuries

- Mandatory exploration carries a 60% negative exploration rate

Selective Zone 2 neck exploration:

- now the approach in most centres

Zone 1 injuries:
- Use CT imaging to determine trajectory of injury
- trajectory helps you to guide further management

Quadroscopy not mandatory anymore
- With improvements in imaging, CT can guide further investigations if the tract is in proximity to other structures

Airway injuries
- Supraglottic injuries: ENT
- Below cricothyroid membrane: general surgery in Denver repairs primarily with 2-0 PDS interrupted sutures
- large injuries can be managed with a tracheostomy tube

Esophageal Injuries:
- rare
- Drain
- place a muscle interposition with SCM flap
- air in the mediastinum more commonly from a tracheal injury
- flexible esophagoscopy is first test: if you make a hole larger it need operative repair anyways
In OR: if unsure
- do an air leak test
- instill methylene blue or charcoal into esophagus and look for leak in neck or chest tube

Carotid Artery Injuries:
- Be wary of using shunts: any debris that flies past shunt can cause a devestating stroke
- Dr. Moore believes ALL carotid artery injuries should be repaired
- doesn't feel risk of hemorrhagic stroke is significant: short presentation times

Internal jugular veins:
- unilateral injury can be ligated

Vertebral artery injuries:
- Angio is primary treatment modality
- if vessel bleeds continuously in ER, can take to OR: make incision at base of neck, place balloon tamponade to get the patient to angio

Moore Retreat: Damage Control Laparotomy

Identify who needs a damage control lap:
- Temperature, acidosis, coagulopathy
- temperature should be largely controlled: bear huggers in ER, warm fluids; in Denver not an issue as pts rarely get to OR with temp<36.  With longer transports most of our pts hypothermic, pre-hospital bear huggers?
- Acidosis can be controlled with bicarb, Denver is quite liberally with use of bicarbonate during trauma resuscitation
- Most significant factor is coagulopathy
- Need for resuscitation should not be indication of damage control. Can resuscitate as well or better in OR vs. ICU

Newer evidence to demonstrate that ARDS is better with isofluorane vs. propofol sedation
- pt in OR on volatile anesthetics may in fact be safer than in ICU from respiratory standpoint

30 Minute Time out:
- pack site of bleeding for 30 mins
- close abdomen with towel clips and then go back and check for further bleeding
- warm patient, resuscitate
- when you go back look for arterial bleeding
- better than sending back to ICU with arterial bleeding

Temporary Abdominal Closures:
- all pts in Denver get abdominal compartment syndrome
- Vac closure is preferred method of closure
- They even apply this to select abdominal sepsis patients
- Relaparotomy in 12-24 hours: especially if shunts used or contamination
- patients very quickly go from being hypocoaguable to hypercoaguable

Abdominal Closure techniques:
- staged tension closure
1) Plastic drape
2) Nylon retention sutures
3) Repeat laparotomy every 48hours and place interrupted sutures each time gradually closing the abdomen
(AJS 2007)

Diuresis:
- Gives a 10mg Lasix trial
- if the patient responds and diureses he then starts a lasix gtt to aggressively diurese for closure
- if pt doesn't respond then he waits

Pearls:
- Chest can also be closed temporarily with plastic drapes

Moore Retreat: Zone I retroperitoneal injuries

Important aspects of managing retroperitoneal injuries:
1) identify if the injury is arterial or venous?
- arterial: hematoma extends into mesentery, pulsatile

ACCESS: 
Supraceliac aortic injury - becuase of dense neural plexus network at celiac plexus unable to really get much above renal arteries with a Mattox maneuver
- therefore a thoracotomy to get supradiaphragmatic control of aorta necessary

"Mattox" maneuver - start incision 1 cm lateral to the white line of toldt: keeps you from damaging ?retroperitoneal structures
- leave kidneys in place generally

Superior Mesenteric Vessel injuries: 
Fullen's zones: (1-4) - describes areas of injury to SMA
Zone 1: proximal to infero-pancreaticoduodenal branch
Zone 2: between IPD and middle colic branches
Zones 1-2 are proximal and sit behind the pancreas
- access in trauma situation can be gained by simply cutting pancreas with scissors
Zone 3: between middle and ileocolic branches
Zone 4: distal to ileocolic
Moore advocates repairing ALL SMA injuries with possible exception of most distal SMA where you just accept some dead SB and resect it.
- this is a long process and a temporary shunt can be used

Inferior Vena Cava:
- control: use sponge sticks proximally and distally, a vascular clamp is likely to lacerate the IVC even further
- a posterior IVC injury can be difficult to access, enlarging your anterior injury to gain access to the posterior wall is probably your easiest option.
- try to close transversely as a longitudinal repair is likely to cause hourglass deformity

Pearls: - if you can't find your injury after exploring the hematoma, perform an immediate CTA as the injury is probably temporarily sealed but if it lets loose in ICU it will be catastrophic

Vascular Trauma AHD

Supraceliac Control
- Insert NG to help locate esophagus
- use mets or scrape with fingers to break through fascia over aorta
- use fingers ot dissect down to spine
- if visceral/aortic penetrating injury, thoracic aorta control much better

Abdo Injury
- Zone 3 injury: explore only if intra-op explanding hematoma
- get another pair of expert hands,

Mesenteric hematoma (expanding)
- Explore take off of SMA
- Can get angio next day to look for bleeding branch and embolize (vs. exploring each branch of SMA)

Packing pelvis:
- open space of retzius and pack anteriorly

CArotid Injury:
- shunts while repairing carotid: in line shunts, baloon shunts
- Safetste ALWAYS to shunt
- if no stents available then use: IV tubing, with bevel but no point
- keep in place with umbo tape
- tie shunt in middle

Indications: to repair carotid
- <4hrs
- hemiplegic
- >4hrs intact function
- otherwisenecrotic when hook up will bleed

14jun10

-Most common mets to the adrenal gland.
-Benign adrenal lesions.

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ED Thoracotomy

Source: Cameron

Discussion revolves around definition of Presence of Vital Signs vs. Signs of Life.
- vital signs include blood pressure, palpable pulse and spontaneous respirations
- signs of life include electrical cardiac activity, respiratory effort, pupillary reactivity.

Indications for EDT
1) salvagable post injury cardiac arrest
2) hypotension from
- cardiac tamponade
- intrathoracic hemorrhage
- air embolism
- active intra-abdominal hemorrhage

Relative indications:
1) refractory moderate hypotension from the same reasons as 2) above.

Incision:
- start just lateral to the sternum just inferior to the nipple.
- curvilinear incision following inferior border of pec major
- continue all the way down to the lattisimus dorsi
- using mayo scissors cut intercostal muscles just above the rib

Things you can do after chest accessed
1) pericardiotomy
- open longitudinally, parallel to phrenic nerve
- extend up to root of aorta and down to the apex
2) Aortic cross-clamping
- divide pulmonary ligmament with straight scissors
- bluntly dissect away mediastinal pleura from aorta and esophagus
- dissect away esophagus and prevertebral fascia to the point where you can encircle the aorta.
- with aorta encircled with left hand apply a curves aortic clamp with the right hand.
- be judicious about aortic cross clamping. It increases cardiac work and will result in post-clamp shock when reperfusion occurs.
3) Open cardiac massage
- begin bimanual cardiac massage if arrest has occured
4) control non cardiac hemorrhage
- great vessel damage is almost impossible to repair in ED. Apply pressure and get to the OR
- pulmonary hemorrhage can be controlled with Duvall clamp or vascular clamp
- last resort is to clamp or occlude inflow at the hilum. Which will require division of the pulmonary ligament. Similar to aortic clamping will result in increase in cardiac afterload and may supress cardiac index.

Risks assoated with EDT.
- HIV. Trauma pt 4%. EDT pt 14%
- acutely injured pt. HIV 4% HepB 20% HepC 14%

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Soft Tissue Sarcomas

Diagnosis:
Tissue diagnosis is the key - need to differentiate from other disease processes
1) FNA is rarely diagnostic
2) Core needle biopsy is the primary modality:
- try to follow straight tract to lesion - remember you'll have to resect the biopsy tract
- prior imaging will help to guide route of biopsy, image guided biopsy may also be useful
3) if core biopsy is not diagnostic then open incisional biopsy may be necessary
- <5cm can consider exicisonal biopsy
- if >5cm do incisional biopsy reducing flaps and ensuring hemostasis

Pathology:
LN Mets are rare (2-3%): Some subtypes do have a higher association with LN mets (~20-30%) and you should resect LNs if positive, some even advocate doing SLNB in these cases:
- Synovial
- Epitheliod
- Clear Cell
- Rhabdomyosarcoma

Most common subtype in Children: Rhabdomyosarcoma
Most common subtype in Adults: Malignant Fibrous Histiocytoma