UNIT 4.1/4.1G

SURGICAL IMMUNOLOGY AND ORGAN TRANSPLANTATION

 

PART  A:  SURGICAL IMMUNOLOGY

 

 

UNIT OBJECTIVES:

 

Demonstrate an understanding of general immunological principles and their application to surgical practice.

 

Demonstrate an understanding of the principles of care for patients with abnormal immune function who are undergoing general surgery procedures.

 

Demonstrate an understanding of the emerging field of molecular biology and the novel immune therapies having potential application to clinical surgery.

 

 


COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

 

Section One:  General Immunologic Principles

1.   Describe the basic concepts of the human immune system, including:

      a.   Cells involved in host defense

      b.   Central roles of lymphocytes and macrophages

      c.   Their derivation from pluripotent stem cells

2.   Summarize the major activities of the macrophage, its products of secretion, and its role as the antigen-presenting cell (APC).

3.   Describe the ontogeny, function, and role in cellular immunity and graft rejection of the T-lymphocyte; demonstrate understanding of the T-cell receptor and its interaction with the human leukocyte antigen (HLA) complex.

4.   Summarize the events in T-cell activation, including the roles of CD4+ and CD8+ cells and the release of involved interleukins.

5.   Explain the development, differentiation, and function of B-lymphocytes in the formation of antibodies; outline and describe the functional anatomy of an immunoglobulin molecule.

 

 

 

6.      Describe the immune functions of the spleen, liver, thymus, and bone marrow; summarize the impact of their manipulation on the immune system.

7.      Describe immunological changes which occur in the elderly patient compared to a younger patient.

 

Section Two:  Defenses against Infection

1.   Describe the resident flora, mechanical barriers, local hormones, and chemicals of the epithelium in the following tracts involved in the body's defenses against infection:

      a.   Gastrointestinal

      b.   Respiratory

      c.   Genitourinary

2.   Describe the body's response to infection when:

      a.   There has been no prior antigenic contact

      b.   There has been prior contact

            (1)  Passive and active immunization

            (2)  T-cell memory activation

3.   Explain the therapeutic and prophylactic roles of intravenous immunoglobulin and viral vaccines.

4.   Distinguish between several known congenital and acquired immunodeficiency states, including sepsis and severe burns.

5.   Describe tests of cellular immune integrity, including skin and laboratory tests of lymphocyte function.

 

Section Three:  Clinical Immunology

1.   Describe the mechanism of action and potential side effects of current immunosuppressive agents; state the rationale for their use and timing in transplantation and in other medical applications:

      a.   Prednisone

      b.   Cyclosporine

      c.   Azathioprine

      d.   Tacrolimus (FK5O6)

e.      Mycophenolatemofetil (RS6144)

f.       Monoclonal antibody ( Moab ) use for induction

2.   Differentiate between agents used to treat acute transplant rejection:

      a.   Steroids

      b.   Radiation therapy

      c.   Poly- and mono- clonal antibodies

3.   Summarize the role and preparation of monoclonal antibodies in the treatment of neoplastic lesions.  Describe their application to clinical pathology and diagnostic and therapeutic oncology. Describe side effects and their treatment.

4.   Explain the preparation, quality control, and application of polyclonal antibodies. Describe side effects and their treatment.

5.   Outline an approach to the management of infection in immunocompromised patients resulting from:

      a.   Iatrogenic immunosuppression secondary to drugs

      b.   Natural immune deficiency states

      c.   Impaired immunity secondary to cancer

6.   Formulate a plan for management of immunosuppression in patients with severe surgical morbidity or complications.

 

 

Section Four:  Trends in Immunology and Molecular Biology

1.   Recognize new and investigational immunosuppressive drugs used for nontransplant medical conditions.

2.   Summarize the current rationale and clinical status of novel oncologic treatments using biologic modifiers and immunomodulation; analyze their potential limitations and side effects.

3.   Explain the manipulation of gene transplantation and   describe several clinical applications currently being investigated.

4.   Discuss the growing importance of molecular biology and the basic techniques of recombinant DNA technology to investigate problems in immunology, oncology, and pathology.

5.   Explain the significance of transgenic animals, their creation, and potential application to experimental and clinical transplantation.

 

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

 

1.   Participate in the perioperative management of immunosuppressive agents in chronically-medicated patients undergoing general surgery.

2.   Plan and perform elective surgery in immunosuppressed patients with attention to minimizing infectious risks; perform emergent surgical intervention (treatment of perforated viscous) in similar high-risk patients.

3.   Optimize patients' immune state secondary to systemic compromise following major surgery, burns, trauma, and malnutrition.

4.   Recognize and treat wound infections and other complex disorders in chronically immunosuppressed patients undergoing elective and emergent surgery.

5.   Monitor drug levels and side effects in immunosuppressants.

6.   Participate in the care of patients receiving immunostimulatory medications (e.g., IV immunoglobulin [IVIG], granulocyte stimulating factor).

 


7.   Describe differences in survival rate which occur in elderly patients compared to younger patients.  Consider the following factors:

a.      Differences in work-ups that occur in elderly patients.

b.      Complications in elderly versus younger patients

 

 

 

 

 

 


 

 

 

 

 

PART B:  ORGAN TRANSPLANTATION

 

UNIT OBJECTIVES:

 

Demonstrate an understanding of the history of clinical transplantation and interpret the guidelines for preparing patients for organ transplantation.

 

Demonstrate a working understanding of the fundamental immunologic principles governing organ transplantation and immunosuppression.

 

Demonstrate understanding of the potential metabolic, physiologic, and malignant side effects of immunosuppressants.


 

 


COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

 

Section One:  Background/Preparation

1.   Demonstrate a working knowledge of the history and evolution of clinical transplantation, including:

      a.   Early vascular surgery

      b.   Concept of tolerance

      c.   First successful organ transplants

      d.   Introduction of immunosuppressive agents

2.   Describe the anatomic and biologic terms associated with organ transplantation, donor and recipient relationships, and grafting between species.

3.   Explain the human leukocyte antigen (HLA) complex, including its genetic location and composition, pattern of inheritance, and the difference between Class I and II antigens of the major histocompatability complex (MHC).  Consider these aspects:

      a.   Serological determination HLA

      b.   Molecular methods of HLA

      c.   Crossmatching

4.   Discuss the role of tissue typing in the identification and preparation of patients for organ transplantation to include:

      a.   Natural, pre-formed antibodies

      b.   Acquired antibodies

      c.   The role of panel reactive antibody (PRA)(sensitization)

      d.   The effect of tissue typing compatibility on graft survival

5.   Discuss advanced age as a positive consideration in solid organ transplantation by considering the importance of:

a.      Physiologic status vs. absolute age in years

b.      Rates of organ rejection and its severity among the elderly

c.      Elderly compliance with medical regimens

d.      Extended life expectancy

6.   Compare the 5-year survival for patients aged 60 and older receiving a renal transplant with those undergoing dialysis.

7.   Define the criteria for organ and tissue donation; apply these criteria to critically ill patients.

8.   Explain the clinical definition of brain death, including a discussion of the available laboratory and radiologic studies to support the clinical criteria.

9.   Analyze and formulate a plan for management of the organ donor.

10. Outline the development of organ preserving solutions and techniques, and  describe the currently practiced methods for handling and storing vascularized organs.

 

Section Two:  Clinical Transplantation

1.   Discuss the current method for the allocation of organs for transplantation, including consideration of the need, availability, and philosophical biases surrounding organ donation. (Be prepared to utilize the algorithm for assigning organs based on the results of HLA typing, PRA, blood type, age, and time-waiting.)

2.   Explain the united organ sharing (UNOS) method for assigning organs to potential recipients. Discuss how local procurement agencies function to optimize the donor organ pool and facilitate coordination of organ harvesting and their subsequent distribution.

3.   Analyze and outline the indications for kidney, pancreas, heart, and lung transplant; relate the relative frequency of these operations as well as rates of patient and graft survival.

4.   Specify the various drug schemes for induction, maintenance, and rejection therapy, including new "rescue" therapies.

5.   Describe the mechanism of action, dosing schedule, and side effects of the following immunosuppressive drugs:

      a.   Azathioprine

      b.   Prednisone

      c.   Anti-lymphocyte globulin     

      d.   Cyclosporine

      e.   Anti-T3 monoclonal antibody

f.    Tacrolimus (FK506)

g.      Anti IL-2R Moab

h.      Mycophenolate mofetil

      i.    Rapamycin

6.   Analyze the short- and long- term risks of chronic immunosuppression:

      a.   Opportunistic infections        d.   Lymphoproliferative disease

      b.   Cardiovascular problems      e.   Rejection

      c.   Autoimmune diseases

7.   Evaluate the diagnostic maneuvers to detect hyperacute, acute, and chronic organ rejection.

 

 

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

 

1.   Evaluate potential candidates for living-related and cadaveric vascularized organ transplantation, including:

      a.   Clinical suitability

      b.   Strength of social support

      c.   Expected graft and patient survival

2.   Participate in the pre- and post- operative surgical management of patients after vascularized organ transplant.

3.   Assist/perform kidney, pancreas, and heart transplantation.

4.   Participate in the perioperative management of immunosuppressive drug therapy, including monitoring drug levels and treating potential toxicities.

5.   Participate in the evaluation of patients suspected of organ rejection to include:

      a.   Laboratory and radiologic testing

      b.   Administration of immunosuppressive (IS) agents

      c.   Following patients for potential acute and chronic side effects

6.   Participate in the preparation and handling of multiple organ harvest in the brain dead patient.

7.      Define suitability characteristics of organs for transplantation.

8.      Formulate a response to these ethical questions:

a.      Should an individual with renal disease, who is 70-75 years old, have access to the scarce resource of cadaver kidneys?

b.      Should the surgeon reasonably consider renal transplantation in older recipients when the nephrologist contends that dialysis is the preferred method of treatment?

9.   Manage postoperative surgical complications, including wound infection, anastomotic stenoses and leaks, and lymphocele formation.

 

 

The Surgical Immunology and Organ Transplantation unit was revised by Carl E. Haisch, MD from the Curriculum, third edition.

 

 

SELECTED BIBLIOGRAPHY:

 

 

Albrechtsen D, Leivestad T, Sodal G, et al. Kidney transplantation in patients older than 70 years of age. Transplant Proc 1995;27:986-988.

 

Bromberg JS, Punch JD, Merion RM, et al. Transplantation and immunology.  In: Greenfield LJ, Mulholland M, Oldham KT, Zelenock GB, Lillemoe KD (eds), Surgery: Scientific Principles and Practice (2nd ed). Philadelphia : Lippincott-Raven, 1997;527-632.

 

Cecka JM, Terasaka PI. Optimal use of older donor kidneys: older recipients. Transplant Proc 1995;27:801-802.

 

Diethelm AG, Deierhoi MH, Barber WH, et al. Organ transplantation in clinical surgery. In: Davis JH, Sheldon GF (eds), Clinical Surgery (2nd ed). St. Louis :  Mosby/Multimedia, 1995:880-914.

 

Faubert PF, Porush JG. Renal Disease in the Elderly (2nd ed). New York : Marcel Dekkar, Inc., 1998;1-488.

 

Flye MW. Atlas of Organ Transplantation. Philadelphia : WB Saunders Co., 1994.

 

Ghobrial RM, Kahan BD. Physiologic basis of transplantation.  In: Miller TA (ed), Modern Surgical Care: Physiologic Foundations and Clinical Applications (2nd ed).  St. Louis : Quality Medical Publishing, Inc., 1998;110-148.

 

Greenfield LJ, Mulholland M, Oldham KT, Zelenock GB, Lillemoe KD (eds). Transplantation and immunology. Surgery: Scientific Principles and Practice (3rd  ed). Philadelphia : Lippincott-Raven, 2001:518-632

 

Haisch CE, Verbanac KM. Immunity and the immunocompromised patient.  In: Miller TA (ed), Modern Surgical Care: Physiologic Foundations and Clinical Applications (2nd ed).  St. Louis : Quality Medical Publishing, Inc., 1998;83-109.

 

Janeway CA , Travers P, Walport M, Shlomchik M (eds). Immunobiology. New York : Garland Publishing, 2001.

 

Kahan BD, Ponticelli C. Principles and Practice of Renal Transplantation. Malden , MA : Blackwell Science, 2000.

 

Morris PJ. Kidney Transplantation: Principles and Practice (5th ed). Philadelphia : WB Saunders Co., 2001.

 

Norman DJ, Turka LA. Primer on Transplantation. Mt. Laurel , NJ : American Society of Transplantation, 2001.

 

Richie RE, Pierson RN, III, Fox M, et al. Solid organ transplantation. In:  Adkins RB, Jr., Scott HW, Jr. (eds), Surgical Care for the Elderly (2nd ed). Philadelphia : Lippincott-Raven Publishers, 1998;477-490.

 

Rohrer RJ. Basic immunology for surgeons.  In: O’Leary JP (ed), The Physiologic Basis of Surgery (2nd ed). Baltimore : Williams and Wilkins, 1996;141-152.

 

Schaubel D, Desmeules M, Mao Y, et al. Survival experience among elderly end-stage renal disease patients—a controlled comparison of transplantation and dialysis. Transplantation 1995;60:1389-1394.

 

Vivas CA, Hickey DP, Jordan ML, et al. Renal transplantation in patients 65 years old or older. J Urol 1992;147:990-993.

 

Web reference

http://www.unos.org


 

UNIT 4.2/4.2G

SURGICAL ONCOLOGY

 

UNIT OBJECTIVES:

 

Demonstrate understanding of the biology, pathology, diagnosis, treatment, and prognosis of neoplastic diseases.

 

Demonstrate proficiency in diagnosis, preparation, operative treatment, and total management of the cancer patient,

including long-term follow-up care.

 

                  Understand surgical options of curative and palliative care for cancer patients.

                 

                  Understand the network of community resources and their functions, available to patients at end of life.

 

 

 

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Junior Level:

 

1.   Discuss frequency/death rates of the top five benign and malignant neoplasms in men, women, and children in the United States .

2.   Describe trends of increasing, decreasing, and high incidence for certain solid neoplasms.

3.      Explain the implications of the heterogeneous cellular makeup of most solid neoplasms with reference to clinical behavior and response to adjuvant treatment.

4.      Discuss the mechanisms of cellular apoptosis and the potential feasibility for therapeutic applications.

5.   Identify genetic factors associated with neoplastic disease in regard to known proto-oncogenes.

6.   Define current theories of carcinogenesis.

7.   Summarize the tenets of tumor biology, including the biochemical events of invasion and metastasis; describe the natural history of these lesions.

 

 

 

 

 

 

8.   Identify and differentiate between the diagnostic features of benign versus malignant neoplasms (gross and microscopic).

9.   Predict patterns of presentation of malignant neoplasms.

10. Describe the characteristics of the various staging systems and explain their use in evaluating malignant neoplasms.

11. Outline the appropriate usage of tumor markers, tumor excretory metabolites, and diagnostic cytologic techniques.

12. Describe the principles of surgical technique for operative procedures designed for cure of malignant diseases and their application to endoscopic operative techniques.

13. Summarize the nutritional requirements for cancer patients, and describe how they differ from those recommended for a healthy patient.

14. Describe indications for curative versus palliative treatment, and formulate therapeutic plans for each approach.

15. Outline the status of the current predominant investigative work in cancer immunotherapy.

16. Explain the rationale for the use of heat shock proteins in conjunction with immunology.

17. Summarize current techniques of genetic screening for cancer.

18. Describe the biologic rationale, mechanisms, and current status of gene therapy for malignancy.

19. Describe the enzymatic determinants of prognosis for epithelial derived cancers and their biologic sources.

20. Discuss the economic and psychosocial issues associated with malignant disease, and analyze how they affect the management of patients with cancer, including:

      a.   Ethics of cancer management

      b.   Rehabilitation

      c.   Home care resources

      d.   Patient support groups

      e.   Family support groups

      f.    Enterostomal therapy

      g.   Cost containment

      h.   Pre-admission procedures and authorization

      i.    Conservation of in-patient resources

      j.    Special problems of the elderly

      k.   Tumor registry data

21. Identify available social service and community agency resources to address the issues listed in #20 above.

 

Senior Level:

 

1.   Apply clinical screening for common malignancies. Recognize typical presentations and clinical manifestations for different types of neoplasms.

2.   Describe the stimuli for and the biologic events in angiogenesis and the potential therapeutic implications thereof.

3.   Discuss the known facts relative to tumor suppressive genes and the implications of mutations.

4.   Stage specific neoplasms both clinically and pathologically, including the tumor, nodes, and metastasis system (TNM).

5.   Relate tumor staging to prognosis.

6.   Describe differences in presentation, treatment, and outcomes for malignancy in older patients.

7.   Compare each applicable treatment modality to the prognosis for tumors within the scope of general surgery.

8.   Apply post-treatment screening/surveillance for common malignancies.

9.   Discuss the known facts relative to tumor recurrence after local resection of a primary lesion of the breast and colon with regard to survival.

10. Identify margins of resection and how this relates to local recurrence.

11. Describe the indications for and actions of pharmacologic support in the postoperative state.

12. Describe the indications and means for implementing nutritional support in the pre- and post- operative cancer patient.

13. Explain the fundamental principles of radiation oncology and detail its application as a primary therapy for the treatment of selected benign and malignant lesions.

14. Summarize the indications and appropriate modalities for adjuvant therapy within the scope of general surgery, including chemotherapy, radiation therapy, immunotherapy, and gene therapy.

15. Describe radioimmunoguided surgery (RIGS) and its clinical applications.

16. Explain the rationale and methodology employed in lymphatic mapping and sentinel node biopsies along with the expected level of positive findings.

17. Understand the surgical options for venous access and oncologic care, and their risks/complications.

18. Describe the criteria and necessary procedures for intraoperative monitoring of cardiovascular and pulmonary functions of the cancer patient.

19. Analyze and explain an holistic approach to the treatment of patients with cancer.

20. Analyze the medical preparation of patients for cancer surgery to include the correction of metabolic and nutritional deficits.

21. Indicate the potential alterations in pulmonary function in the elderly patient which may affect preoperative preparation and postoperative management.

22. Identify the indications of anticipated need in elderly patients for:

a.      Postoperative urinary tract decompression

b.      Nutritional support

c.      Thromboembolism prophylaxis

23. Define and apply the criteria for palliative versus curative treatment plans.

24. Analyze and explain the rationale for combined adjuvant modalities in the prevention and treatment of cancer recurrence.

25. Apply proper clinical and demographic data to the tumor registry.

26. Outline the indications for and initiate requests for appropriate consultation.

27. Demonstrate a working knowledge of prior research milestones, current research efforts, and cancer research methodology.

 

 

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Junior Level:

 

1.   Perform a complete history and physical examination on patients with cancer.

2.   Formulate an appropriate differential cancer diagnosis, and record an independent, written diagnosis for each cancer patient assigned.

3.   Excise benign lesions of skin, dermal appendages, and breast. Demonstrate proper wound care and follow-up management.

4.   Excise skin cancers, demonstrating proper wound margins and appropriate wound closure and follow-up management.

5.   Close wounds following major resections.

6.   Manage colostomies and ileostomies.

7.   Design an appropriate nutritional support program for a cancer patient both pre- and post- operatively.

8.   First assist on colostomies, ileostomies, and wedge resections of lung and liver.

9.   Perform lymph node biopsies, breast biopsies, and procedures of similar magnitude.

10. Cut en bloc gross surgical specimens.

11. Interpret frozen section slides with supervision.

12. Perform nutritional assessments and plan nutritional support programs.

13. Perform feeding gastrostomies and tube jejunostomies.

14. Record clinical and pathological correlations by presenting the clinical picture and operative findings on each assigned cancer patient.

15. Perform all varieties of endoscopy (upper and lower gastrointestinal) and bronchoscopy.

 

Senior Level:

 

1.   Demonstrate the capability for independent function in all aspects of cancer patient management, including palliative care planning.

2.   Prepare and defend the preoperative assessment plan for the elderly patient in preparation for:

a.      Gastric resection

b.      Colon resection

c.      Pancreatic resection (Whipple Procedure)

      d.   Mastectomy

3.   Stage specific neoplasms clinically and pathologically using the TNM system.

4.   Prepare patients medically for cancer surgery, including correction of nutritional and metabolic deficits.

5.   Specify and prepare management plans for nutritional support in the elderly patient.  Indicate differences to be expected in requirements compared to patients less than 50 years of age.

6.   Assess the need and institute appropriate monitoring both pre- and post- operatively.

7.   Use appropriate support from pharmacologic agents.

8.   Prepare an operative plan for treatment of malignant disease.

9.   Perform colostomies, colostomy closures, and bowel anastomoses of all types.

10. Demonstrate proficiency in the use and interpretation of operative and endoscopic ultrasonography.

11. Demonstrate proficiency in fine-needle and core biopsies of the breast.

12. Demonstrate proficiency in endoscopic ultrasonography for detection of hepatic metastases and depth of invasion of colorectal lesions.

13. Demonstrate proficiency in gamma probe-directed or dye-directed sentinel lymph node biopsy for breast cancer and melanoma.

14. Assume responsibility for managing the psychosocial aspects of neoplastic disease.

15. Perform, with appropriate supervision, major resections in neck, chest, abdomen, breast, and extremity, including complex operative procedures (e.g., Whipple procedures, construction of ileal loop bladder, major neck dissections, segmental and lobar hepatic resections).

16. Utilize appropriate social agencies and support groups in cancer patient management.

17. Assume teaching responsibilities for junior residents as assigned.

18. Use laser therapy, photodynamic therapy, and cryotherapy when indicated, observing proper precautions.

19. Participate in a multidisciplinary tumor board.

 

The Surgical Oncology unit was revised by Rosa E. Cuenca, MD, from the Curriculum, third edition, by Douglas M. Evans, MD.

 

SELECTED BIBLIOGRAPHY:

 

Ackerman RJ, Vogel RL, Johnson LA, et al. Morbidity, mortality, and functional outcome. J Fam Pract 1995;40:129-135.

 

Baile W, Lenzi R, Kudelka A, et al. Communicating bad news: outcome of a workshop for oncologists. J Cancer Educ 1997;12:166-173.

 

Balducci L (ed). Geriatric Oncology. Philadelphia: JB Lippincott, 1992;1-409.

 

Buckman R. What You Really Need to Know About Cancer—A Comprehensive Guide for Patients and Their Families. Baltimore: Johns Hopkins University Press, 1997.

 

Cameron JL (ed). Current Surgical Therapy (7h ed). St. Louis: Mosby, 2001.

 

Clement DG, Retchin SM, Brown RS, et al. Access and outcomes of elderly patients enrolled in managed care. JAMA 1994;271:1487-1492.

 

Eilber FC, Eilber FR. Soft tissue sarcoma. In: Cameron JL (ed). Current Surgical Therapy (7h ed). St. Louis: Mosby, 2001;1213-1217.

 

Girgis A, Sanson-Fisher W. Breaking bad news: consensus guidelines for medical practitioners. J Clin Oncol 1997;13:2449-2456.

 

Krag DN. Minimal access surgery for staging regional lymph nodes: the sentinel-node concept. Current Problems in Surgery 1998;35(11):953-1016.

 

Lange JR. Melanoma. In: Cameron JL (ed). Current Surgical Therapy (7th ed). St. Louis: Mosby, 2001;1208-1212.

 

McMasters KM, Wong SL, Edwards MJ, et al. Factors that predict the presence of sentinel lymph node metastasis in patients with melanoma. Surgery 2001;130:151-156.

 

Mulholland MW, Longo WE, Vernava AM, III. Neoplastic disorders of the gastrointestinal tract.  In: Miller TA (ed), Modern Surgical Care: Physiologic Foundations and Clinical Applications (2nd ed).  St. Louis: Quality Medical Publishing, Inc., 1998;668-687.

 

Niederhuber JE, Crooks D. Neoplastic disease: pathophysiology and rationale for treatment.  In: Miller TA (ed), Modern Surgical Care: Physiologic Foundations and Clinical Applications (2nd ed).  St. Louis: Quality Medical Publishing, Inc., 1998;220-249.

 

Nyhus LM, Baker RJ, Fischer JE (eds). Mastery of Surgery (3rd ed). Boston: Little, Brown and Co., 1997.

 

Obrand DI, Gordon PH. Results of local for rectal carcinoma. Can J Surg 1996;39:463-468.

 

Quirt CF, McKillop WJ, Ginsberg AD, et al. Do doctors know when their patients don’t? Survey of doctor/patient communication in lung cancer. Lung Cancer 1997;18:1-20.

 

Reinhold RB, Doherty FJ, Mele FM, et al. Selected technologies and general surgery.  In: O’Leary JP (ed), The Physiologic Basis of Surgery (2nd ed). Baltimore: Williams and Wilkins, 1996;618-644.

 

Roberts CS, Cox CE, Reintgen DS, et al. Influence of physician communication on newly diagnosed breast patients’ psychologic adjustment and decision-making. Cancer 1994;74:336-341.

 

Suzuki K, Dozois RR, Devine RM, et al. Curative reoperation for locally recurrent rectal carcinoma. Dis Colon Rectum 1996; 39:730-736.

 

 

 

 

 

 

 

 

 

 

 

 

 

Townsend CM, Jr., Beauchamp RD, Evers BM, Mattox KL (eds). Sabiston Textbook of Surgery (16th ed). Philadelphia: WB Saunders Company, 2001.

 

Velanovich V. Preoperative screening based on age, gender, and concomitant medical diseases. Surgery 1994;115:56-61.

 

Watters JM, Kirkpatrick SM, Hopbach D, et al. Aging exaggerates the blood glucose response to total parental nutrition. Can J Surg 1996;39:481-485.

 

Watters JM, Moulton SB, Clancy SM, et al. Aging exaggerates glucose intolerance following injury. Trauma 1994;37:786-791.

 

Web reference:

http://www.cancer.gov/cancer_information

http://www.cancer.org