- Email: [email protected]
Gastrointestinal Surgery: Pathophysiology and Management
GASTROENTEROLOGY 2004;127:355–357
PRINT AND MEDIA REVIEWS Ian S. Grimm, M.D. Print and Media Review Editor Division of Gastroenterology and Hepatology University of North Carolina at Chapel Hill Chapel Hill, North Carolina
Targets of Treatment in Chronic Inflammatory Bowel Diseases. Edited by H. Herfarth, B. G. Feagan, U. R. Fo¨lsch, J. Scho¨lmerich, M. H. Vatn, and M. Zeitz. 272 pp. $165.00. Dordrecht, The Netherlands: Kluwer Academic Publishers, 2003. ISBN 0792387848. Web address for ordering: www. wkap.nl One might ask whether the gastroenterology community needs another book discussing the pathogenesis and therapy of Crohn’s disease and ulcerative colitis. However, Targets of Treatment in Chronic Inflammatory Bowel Diseases is not a comprehensive inflammatory bowel disease (IBD) text and was not intended to be such. Its scope is much more limited than many of the standard IBD texts, and the editors do not claim that this book should replace such texts in the libraries of gastroenterologists, surgeons, and scientists. In this book, the editors have put together a summary of the proceedings of an IBD symposium held in Freiberg, Germany in October 2002. That symposium was intended to discuss and explore potential new targets for the treatment of inflammatory bowel disease. The book’s intended audience includes both clinicians and basic scientists. The book begins with an interesting historical perspective provided by David Sachar. His paper, published in 1980 on the etiological theories of IBD, is reproduced with a preface in which he attempts to place the prevailing theories from the 1960s and 1970s into a present-day context. The subsequent chapters dealing with targets for new drug development, innate immunity, and mucosal defense and the role of the enteric flora in IBD pathogenesis are very good summaries of the current state of knowledge and provide a reasonable list of references that could serve as a starting point for scientists interested in the field. These chapters are then followed by several unique chapters that discuss the relative merits and drawbacks of various model systems used for the investigation of the immunopathogenesis of IBD and the potential usefulness of new therapies. These include animal models, cell culture systems, and models that assess the integrity of the mucosal barrier. Taken together, these chapters provide a good primer for the clinician wishing to become familiar with experimental model systems, but they may not be sufficiently detailed for scientists working in the field. In addition, the discussion of cell culture systems is mainly limited to the work being done in one laboratory with human intestinal epithelial cells and human macrophages. A broader perspective with the inclusion of T-cell experiments would have been appropriate. Although the main emphasis was the exploration of potential new therapeutic targets–right from the basic science of
IBD to the clinical application of basic science breakthroughs– there are several chapters that do not fit within the stated objectives. In particular, the chapters on functional genomics of wound repair, management of intestinal strictures, IBDassociated arthropathies, and the role of MRI for assessing inflammatory activity seemed out of place. Several chapters were also devoted to a discussion of symptom or outcomespecific management of IBD– diarrhea, abdominal pain, quality of life, and avoidance of drug side effects. In most cases, these chapters ended up being more of a discussion of the pathogenesis of these symptoms rather than the role of antiinflammatory or immunomodulator therapy in causing symptomatic improvement and the mechanism whereby such improvement occurs. Useful, however, was the presentation of a case for the symptomatic treatment of diarrhea using nonspecific antidiarrheals. Given the significant psychosocial impact of IBD, a discussion of antidepressant or anxiolytic therapy and the use of alternative non-pharmacologic forms of psychosocial support would have been appropriate in the chapters on quality of life, quality of care, and neuroendocrine-immune interactions. Overall, this book has many well-written, concise, and worthwhile chapters but as a whole it suffers from some degree of inconsistency in style and editing. The use of Tables and Figures often does not add to the text discussion. Despite the reservations outlined above, this book does have some chapters that are worth reading for both the basic scientist and the clinician. However, as a total package it falls short of its goal and would not necessarily be a “must-have” addition to the libraries of most individuals working in the field. Bottom Line: Misses the mark.
A. HILLARY STEINHART, M.D., MS.c. Division of Gastroenterology University of Toronto Mount Sinai Hospital University Health Network Toronto, Canada Gastrointestinal Surgery: Pathophysiology and Management. By Haile T. Debas. 391 pp. $119.00. New York, New York: Springer-Verlag, 2003. ISBN 0-387-00721-0. Web address for ordering: www.springeronline.com In his long career, Haile T. Debas has shared and imparted his wisdom and skill to numerous students, residents, surgeons and patients; and his new textbook Gastrointestinal Surgery: Pathophysiology and Management is the latest vehicle to pass his considerable knowledge to his surgical readership. The stated
356
PRINT AND MEDIA REVIEWS
goal of this work was to provide an understanding of the pathophysiology and treatment process of gastrointestinal disease to a target audience comprised of students and residents. He appears to have exceeded his goal. Dr. Debas has organized this text anatomically, with chapters dedicated to each part of the gastrointestinal tract. Each begins with a brief and informative discussion of relevant normal anatomy. Various disease states and their respective treatments are then discussed, with well-drawn diagrams, radiographic films, and tables that are strategically placed to parallel the flow of information. The tables outline the text, which itself somewhat paraphrases what one might find in a more dense surgical manuscript, minus much of the superfluous minutia. A demonstration of his method can be found in the chapter about the appendix. The chapter begins with a brief description of the relevant anatomy of the appendix and its surrounding structures, mentioning the variant anatomy and adding a good illustration as well. The following section is focused on two items of pathophysiology involving the appendix. The first is appendicitis, and the other is carcinoid tumor of the appendix. The “Clinical Management” section comprises the crux of the chapter, broadly covering the presentations of not only classic appendicitis, but also of those patients with variant anatomy such as retrocecal and pelvic positioning and appendicitis during pregnancy. “Investigation” labels a segment within the discussion of management that explores the diagnostic evidence that may yield the decision to operate. While the expected laboratory tests, radiological studies, and even laparoscopy are mentioned, Dr. Debas emphasizes physical diagnosis as the standard by which the decision should be made. After discussing the differential diagnosis, the surgical approach to the management of appendicitis is addressed. A wonderful diagram demonstrating port placement for laparoscopic removal is positioned adjacent to another diagram showing the potential incisions through which an open approach could be made. The open procedure is described, and mention of the stump inversion is complemented with drawings from the Sabiston atlas. Two common complications of appendicitis are then discussed: perforation and appendiceal abscess. The histories of presentation of both parallel the discussion of diagnosis and treatment. Personal preference is even mentioned in the discussion of how one should approach the rare occurrence of a perforation right at the cecum where the cecal edges may become so inflamed and indurated that the perforation cannot be closed primarily. Two alternatives are mentioned: either placement of a cecostomy tube and drainage of the right lower quadrant, or a limited right hemicolectomy; and Dr. Debas states that he prefers the latter. There are two chapters that deserve special mention. The first is entirely dedicated to the surgical management of obesity, and the second describes diseases and management of the abdominal wall, peritoneum, and retroperitoneum. In an age that bears witness to the most explosive rise of obesity in recorded history, it seems only appropriate that the surgical management of the second-most deadly disease in America be
GASTROENTEROLOGY Vol. 127, No. 1
addressed. The inclusion of this topic in such a prominent way may represent the beginning of obesity as a separately recognized disease state in surgical textbooks. Also, the incorporation of the retroperitoneum in a text about gastrointestinal surgery is a welcomed departure from the norm. The major premise of this work is that the hoofbeats the readers hear are more likely to be those of horses, while still making mention of the zebras. Although broad strokes are taken in the discussion of general gastrointestinal physiology, great detail is used with topics that are common. Not only are other comparable books filled with facts that require rote memorization, but they also lack uniformity of style because multiple authors write them. With his latest contribution to surgical education, Dr. Debas reveals his uniquely individual approach to gastrointestinal pathology and its treatment. The general ergonomics of the book are appealing as well, with print that is easy to read, and information that flows extraordinarily well. Bottom Line: An important supplement to the reference armamentarium of a student, resident or surgeon of any experience level.
EDWARD N. RAMPERSAUD, M.D. THEODORE N. PAPPAS, M.D. Department of Surgery Duke University Durham, North Carolina Surgical Pathology of the GI Tract, Liver, Biliary Tract, and Pancreas. By Robert D. Odze, John R. Goldblum, and James M. Crawford. 1067 pp. $249.00. Philadelphia, Pennsylvania: Saunders, 2004. ISBN 0-7216-9318-0. Web address for ordering: www.us.elsevierhealth.com A major goal of the authors was to create “the first complete and comprehensive textbook in gastrointestinal (GI), liver, biliary tract, and pancreatic pathology.” Textbook chapters were written by the 3 editors and 56 additional contributors. All authors enjoy well-deserved reputations as experts in the pathology of the organs covered in the text. The above goal has been accomplished without a doubt. The text is divided into three parts. Part I, the GI tract, is by far the largest, taking up about 55% of the book. However, 4 of 24 chapters in this section are more general in their scope: infectious diseases, immunodeficiency disorders, systemic illness, and neuromuscular disorders. Part II, gallbladder, extrahepatic biliary tree and pancreas, is the smallest section, representing about 17% of the text. Part III covers the liver in the remaining 28% of the text. Pathologic entities have been generally divided into inflammatory and neoplastic processes. An innovative and extremely effective approach has been to cover polypoid lesions of the esophagus, stomach, small bowel, and large bowel in 4 separate chapters. A submitted clinical diagnosis of “polyp” is quite frequently encountered in pathologic practice, and I expect
PRINT AND MEDIA REVIEWS Ian S. Grimm, M.D. Print and Media Review Editor Division of Gastroenterology and Hepatology University of North Carolina at Chapel Hill Chapel Hill, North Carolina
Targets of Treatment in Chronic Inflammatory Bowel Diseases. Edited by H. Herfarth, B. G. Feagan, U. R. Fo¨lsch, J. Scho¨lmerich, M. H. Vatn, and M. Zeitz. 272 pp. $165.00. Dordrecht, The Netherlands: Kluwer Academic Publishers, 2003. ISBN 0792387848. Web address for ordering: www. wkap.nl One might ask whether the gastroenterology community needs another book discussing the pathogenesis and therapy of Crohn’s disease and ulcerative colitis. However, Targets of Treatment in Chronic Inflammatory Bowel Diseases is not a comprehensive inflammatory bowel disease (IBD) text and was not intended to be such. Its scope is much more limited than many of the standard IBD texts, and the editors do not claim that this book should replace such texts in the libraries of gastroenterologists, surgeons, and scientists. In this book, the editors have put together a summary of the proceedings of an IBD symposium held in Freiberg, Germany in October 2002. That symposium was intended to discuss and explore potential new targets for the treatment of inflammatory bowel disease. The book’s intended audience includes both clinicians and basic scientists. The book begins with an interesting historical perspective provided by David Sachar. His paper, published in 1980 on the etiological theories of IBD, is reproduced with a preface in which he attempts to place the prevailing theories from the 1960s and 1970s into a present-day context. The subsequent chapters dealing with targets for new drug development, innate immunity, and mucosal defense and the role of the enteric flora in IBD pathogenesis are very good summaries of the current state of knowledge and provide a reasonable list of references that could serve as a starting point for scientists interested in the field. These chapters are then followed by several unique chapters that discuss the relative merits and drawbacks of various model systems used for the investigation of the immunopathogenesis of IBD and the potential usefulness of new therapies. These include animal models, cell culture systems, and models that assess the integrity of the mucosal barrier. Taken together, these chapters provide a good primer for the clinician wishing to become familiar with experimental model systems, but they may not be sufficiently detailed for scientists working in the field. In addition, the discussion of cell culture systems is mainly limited to the work being done in one laboratory with human intestinal epithelial cells and human macrophages. A broader perspective with the inclusion of T-cell experiments would have been appropriate. Although the main emphasis was the exploration of potential new therapeutic targets–right from the basic science of
IBD to the clinical application of basic science breakthroughs– there are several chapters that do not fit within the stated objectives. In particular, the chapters on functional genomics of wound repair, management of intestinal strictures, IBDassociated arthropathies, and the role of MRI for assessing inflammatory activity seemed out of place. Several chapters were also devoted to a discussion of symptom or outcomespecific management of IBD– diarrhea, abdominal pain, quality of life, and avoidance of drug side effects. In most cases, these chapters ended up being more of a discussion of the pathogenesis of these symptoms rather than the role of antiinflammatory or immunomodulator therapy in causing symptomatic improvement and the mechanism whereby such improvement occurs. Useful, however, was the presentation of a case for the symptomatic treatment of diarrhea using nonspecific antidiarrheals. Given the significant psychosocial impact of IBD, a discussion of antidepressant or anxiolytic therapy and the use of alternative non-pharmacologic forms of psychosocial support would have been appropriate in the chapters on quality of life, quality of care, and neuroendocrine-immune interactions. Overall, this book has many well-written, concise, and worthwhile chapters but as a whole it suffers from some degree of inconsistency in style and editing. The use of Tables and Figures often does not add to the text discussion. Despite the reservations outlined above, this book does have some chapters that are worth reading for both the basic scientist and the clinician. However, as a total package it falls short of its goal and would not necessarily be a “must-have” addition to the libraries of most individuals working in the field. Bottom Line: Misses the mark.
A. HILLARY STEINHART, M.D., MS.c. Division of Gastroenterology University of Toronto Mount Sinai Hospital University Health Network Toronto, Canada Gastrointestinal Surgery: Pathophysiology and Management. By Haile T. Debas. 391 pp. $119.00. New York, New York: Springer-Verlag, 2003. ISBN 0-387-00721-0. Web address for ordering: www.springeronline.com In his long career, Haile T. Debas has shared and imparted his wisdom and skill to numerous students, residents, surgeons and patients; and his new textbook Gastrointestinal Surgery: Pathophysiology and Management is the latest vehicle to pass his considerable knowledge to his surgical readership. The stated
356
PRINT AND MEDIA REVIEWS
goal of this work was to provide an understanding of the pathophysiology and treatment process of gastrointestinal disease to a target audience comprised of students and residents. He appears to have exceeded his goal. Dr. Debas has organized this text anatomically, with chapters dedicated to each part of the gastrointestinal tract. Each begins with a brief and informative discussion of relevant normal anatomy. Various disease states and their respective treatments are then discussed, with well-drawn diagrams, radiographic films, and tables that are strategically placed to parallel the flow of information. The tables outline the text, which itself somewhat paraphrases what one might find in a more dense surgical manuscript, minus much of the superfluous minutia. A demonstration of his method can be found in the chapter about the appendix. The chapter begins with a brief description of the relevant anatomy of the appendix and its surrounding structures, mentioning the variant anatomy and adding a good illustration as well. The following section is focused on two items of pathophysiology involving the appendix. The first is appendicitis, and the other is carcinoid tumor of the appendix. The “Clinical Management” section comprises the crux of the chapter, broadly covering the presentations of not only classic appendicitis, but also of those patients with variant anatomy such as retrocecal and pelvic positioning and appendicitis during pregnancy. “Investigation” labels a segment within the discussion of management that explores the diagnostic evidence that may yield the decision to operate. While the expected laboratory tests, radiological studies, and even laparoscopy are mentioned, Dr. Debas emphasizes physical diagnosis as the standard by which the decision should be made. After discussing the differential diagnosis, the surgical approach to the management of appendicitis is addressed. A wonderful diagram demonstrating port placement for laparoscopic removal is positioned adjacent to another diagram showing the potential incisions through which an open approach could be made. The open procedure is described, and mention of the stump inversion is complemented with drawings from the Sabiston atlas. Two common complications of appendicitis are then discussed: perforation and appendiceal abscess. The histories of presentation of both parallel the discussion of diagnosis and treatment. Personal preference is even mentioned in the discussion of how one should approach the rare occurrence of a perforation right at the cecum where the cecal edges may become so inflamed and indurated that the perforation cannot be closed primarily. Two alternatives are mentioned: either placement of a cecostomy tube and drainage of the right lower quadrant, or a limited right hemicolectomy; and Dr. Debas states that he prefers the latter. There are two chapters that deserve special mention. The first is entirely dedicated to the surgical management of obesity, and the second describes diseases and management of the abdominal wall, peritoneum, and retroperitoneum. In an age that bears witness to the most explosive rise of obesity in recorded history, it seems only appropriate that the surgical management of the second-most deadly disease in America be
GASTROENTEROLOGY Vol. 127, No. 1
addressed. The inclusion of this topic in such a prominent way may represent the beginning of obesity as a separately recognized disease state in surgical textbooks. Also, the incorporation of the retroperitoneum in a text about gastrointestinal surgery is a welcomed departure from the norm. The major premise of this work is that the hoofbeats the readers hear are more likely to be those of horses, while still making mention of the zebras. Although broad strokes are taken in the discussion of general gastrointestinal physiology, great detail is used with topics that are common. Not only are other comparable books filled with facts that require rote memorization, but they also lack uniformity of style because multiple authors write them. With his latest contribution to surgical education, Dr. Debas reveals his uniquely individual approach to gastrointestinal pathology and its treatment. The general ergonomics of the book are appealing as well, with print that is easy to read, and information that flows extraordinarily well. Bottom Line: An important supplement to the reference armamentarium of a student, resident or surgeon of any experience level.
EDWARD N. RAMPERSAUD, M.D. THEODORE N. PAPPAS, M.D. Department of Surgery Duke University Durham, North Carolina Surgical Pathology of the GI Tract, Liver, Biliary Tract, and Pancreas. By Robert D. Odze, John R. Goldblum, and James M. Crawford. 1067 pp. $249.00. Philadelphia, Pennsylvania: Saunders, 2004. ISBN 0-7216-9318-0. Web address for ordering: www.us.elsevierhealth.com A major goal of the authors was to create “the first complete and comprehensive textbook in gastrointestinal (GI), liver, biliary tract, and pancreatic pathology.” Textbook chapters were written by the 3 editors and 56 additional contributors. All authors enjoy well-deserved reputations as experts in the pathology of the organs covered in the text. The above goal has been accomplished without a doubt. The text is divided into three parts. Part I, the GI tract, is by far the largest, taking up about 55% of the book. However, 4 of 24 chapters in this section are more general in their scope: infectious diseases, immunodeficiency disorders, systemic illness, and neuromuscular disorders. Part II, gallbladder, extrahepatic biliary tree and pancreas, is the smallest section, representing about 17% of the text. Part III covers the liver in the remaining 28% of the text. Pathologic entities have been generally divided into inflammatory and neoplastic processes. An innovative and extremely effective approach has been to cover polypoid lesions of the esophagus, stomach, small bowel, and large bowel in 4 separate chapters. A submitted clinical diagnosis of “polyp” is quite frequently encountered in pathologic practice, and I expect