V420

Occurs, the enteric portion of the duct is the usual portion that persists and forms a Meckel's diverticulum. Rarely, the entire omphalomesenteric duct remains patent and forms an external fistula. The diagnosis should be suggested by the appearance of fecal material at the umbilicus after the postnatal slough of the umbilical cord. Trauma Traumatic injury to the small intestine that results in fistula formation usually occurs from an internal source, such as a swallowed fish bone, toothpick,...

I299

Holinger, P.H., and Johnston, F-C. Endoscopic surgery of Zenker's diverticula Experience with the Dohlman technique. Ann. Otol. Rhinol. Laryngol., 70 1117, 1961. 47. Huang, B., Payne, W.S., and Cameron, A.J. Surgical management for recurrent pharyngoesophageal (Zenker's) diverticulum. Ann. Thorac. Surg., 37 189, 1984. 48. Huang, B., Unni, K.K., and Payne, W.S. Long-term survival following diverticulectomy for cancer in pharyngoesophageal (Zenker's) diverticulum. Ann. Thorac. Surg., 38 207,...

Info

Posterior abdominal wall, femoral or inguinal region Medial to anterosuperior iliac spine Posterior abdominal wall posterior to inguinal ligament Medial to anterosuperior iliac spine anterior abdomen Hyperextension or external rotation of hip increases pain. Limitation of internal rotation extension of hip increases pain. Minimal hip extension increases pain. Loss of cremasteric reflex ejaculatory dysfunction Quadriceps muscle weakness and atrophy loss of patellar reflex *From Sampath, P., Yeo,...

Evaluation And Management Of Splenic Injury

After these priorities have been ensured, attention is turned to a determination of the presence or absence of intra-abdominal hemorrhage. At this point, the evaluation and management of splenic injury in the child may differ from those in the adult and may rely heavily on a non-invasive approach to evaluate the child and a non-operative mode of treatment. Crucial to the safe management of the child with the injured spleen is an appreciation of when non-invasive evaluation techniques and a...

V100 For Rectum

Stoppa, R.E., and Warlaumont, C.R. Repair of recurrent groin hernias by giant prosthesis and midline preperitoneal approach (G.P.M.P.A.). In Madden, J. (ed.) Abdominal Wall Hernia Atlas of Anatomy and Repair. Philadelphia, W.B. Saunders, 1989, p. 242. 59. Sun, C.N., White, H.J., Wagh, P.V., and Read, R.C. Alteration of collagen fibrils in the direct inguinal herniation in men. Presented at the Eighth International Congress on Electron Microscopy, Canberra, ii 482, 1974. 60. United States...

Cecum

The cecum is the commencement of the large intestine and is the portion located below a transverse line passing just above the ileocecal valve. The ileum, the vermiform appendix, and the ascending colon are all continuous with the cecum. Its average axial diameter is approximately 6 cm, with a breadth of about 7.5 cm. It is related posteriorly to the iliacus and psoas major muscles and to the lateral cutaneous nerve of the thigh, which lies on the iliacus. Anteriorly, the cecum is in contact...

Incisions For Exposing The Gallbladder And Biliary Ducts

Satisfactory exposure is of paramount importance in operating on the gallbladder and extrahepatic bile ducts, irrespective of the object of the operation. Although adequate exposure is necessary for all fields of operation, it is especially important in this case because of the depth at which the structures lie, the unusual importance of their surroundings, and the difficulties that may be encountered. The commonly used incisions for exposing the biliary tract are the right oblique subcostal...

Iv270

Figure 20-4 Mucosectomy of the rectal stump. Figure 20-4 Mucosectomy of the rectal stump. Figure 20-5 Preparation of the colonic reservoir for hand-sewn coloanal anastomosis. Figure 20-5 Preparation of the colonic reservoir for hand-sewn coloanal anastomosis. Figure 20-7 The apex of the pouch is drawn through the anus. Figure 20-7 The apex of the pouch is drawn through the anus. Figure 20-8 Hand-sewn coloanal anastomosis. Figure 20-8 Hand-sewn coloanal anastomosis. The apex of the colonic pouch...

Fa f7A

Figure 13-14 Construction of a 360-degree fundoplication after the Collis procedure. Main illustration, Elongated narrow gastric fundus remaining after the Collis procedure. The posterior crural sutures have been placed but not tied. A, The sixth left interspace incision used for the operation. B and C, Wrapping the gastric fundus behind the gastroplasty tube and adjacent upper stomach. (From Orringer, M.B., and Sloan, H. Combined Collis-Nissen reconstruction of the esophagogastric junction....

Christopher J Sonnenday Md

Senior Resident, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland Pseudocysts and Other Complications of Pancreatitis DAVID I. SOYBEL M.D. Associate Professor of Surgery, Harvard Medical School, Boston Staff Surgeon, West Roxbury Veterans Administration Medical Center, Anatomy and Embryology ofthe Small Intestine Division of the Biological Sciences, and Vice President for Medical Affairs, Division of the Biological Sciences, Adenocarcinoma ofthe Colon...

I540

Disorders of the pharyngoesophageal junction. In Motor Disorders of the Esophagus. Baltimore, Williams & Wilkins, 1976, p. 184. 83. Henderson, R.D., and Maryatt, G. Cricopharyngeal myotomy as a method of treating cricopharyngeal dysphagia secondary to gastroesophageal reflux. J. Thorac. Cardiovasc. Surg., 74 721, 1977. 84. Henderson, R.E. The Esophagus Reflux and Primary Motor Disorders. Baltimore, Williams & Wilkins, 1980, p. 223. 85. Herrera, J.L. Case report...

Pancreatic Pseudocysts

A pancreatic pseudocyst is a localized collection of pancreatic secretions, surrounded by a wall of fibrous or granulation tissue, which arises as a result of acute or chronic pancreatitis, pancreatic trauma, or obstruction of the pancreatic duct by a neoplasm ( Fig. 4-1 and Fig. 4-2 ). Pseudocysts account for about 75 of cystic lesions of the pancreas. They are distinguished from other peripancreatic fluid collections (cystic neoplasms, congenital, parasitic, and extrapancreatic cysts) by...

Technique

ERUS equipment is readily available at most institutions managing a significant volume of anorectal conditions. The technique for ERUS has been well described in the literature. We use a model 3535 Bruel and Kjaer (B & K, Denmark) scanner with a rigid 1850 rotating endosonic probe ( Fig. 25-1 ). Transducers of 7.0 and 10.0 MHz are used and provide a focal length of 2 to 5 and 1 to 4 cm, respectively, and a 90-degree scanning plane is rotated at four to six cycles per second to provide a...

[131

Modifications to the original device included the addition of a fourth port Figure 26-1 A, The triple-lumen, double-balloon Sengstaken-Blakemore tube for tamponade of bleeding esophageal varices. This tube has no port for esophageal aspiration. B, The Linton-Nachlas tube, which has only a gastric balloon but ports for both gastric and esophageal aspiration. Figure 26-2 Esophageal transection using the end-to-end anastomosis stapler. The periesophageal veins are ligated and divided. The...

Parasites

Parasitic infection should always be included in the differential diagnosis of patients with perianal pruritus. Pinworms (Enterobius vermicularis) are the most common cause of perianal itching in children. The diagnosis can be made by microscopically evaluating perianal skin samples collected on cellulose tape. It is imperative that other family members be evaluated so they can be treated and recontamination does not occur. The symptoms usually occur in the evening, when these 6-mm-long...

Embryology

The colon develops from the primitive midgut, which opens ventrally into the yolk sac. Starting at the fifth gestational week, the midgut rapidly grows and reorganizes to delineate the permanent gastrointestinal tract structures, including the colon. This progression is traditionally divided into three separate stages ( Fig. 2-1 ). In the first stage, the elongated midgut loop enters the extraembryonic celom into the umbilical cord, a process referred to as physiologic umbilical herniation. The...

Anatomic Considerations

As previously stated, proctalgia fugax, levator spasm, and pelvic pain can involve overlapping presentations. Pain syndromes may involve any or all of the structures of the pelvis. Disorders of the following organs or organ systems can lead to the complaint of pelvic pain. A complete assessment should exclude each of these as potential causes. An integrated approach may be required and may necessitate orthopedic, neurosurgery, gynecology, and urology consultation. Primary and secondary diseases...

Iv43

Most patients undergo anorectal examination in the prone jackknife or left lateral decubitus position ( Fig. 4-1 ). The former position provides the examiner with the greatest comfort, whereas the latter is easiest for the patient. The prone jackknife position requires a special examination table that can be flexed to 90 degrees and tilted head-down. The patient kneels on a shallow ledge that is height adjusted to allow comfortable hip flexion and lowers his or her clothing and undergarments...

[19 [27

In addition, the patient's medications should be carefully reviewed to ensure proper dosing adjustments for hepatic metabolism and should be reviewed for any sedative effect. Most patients respond to lactulose therapy.1 ' 1 ' Rarely, a trial of metronidazole or perhaps neomycin can be used in patients refractory to or intolerant of lactulose. Should acute exacerbations of encephalopathy occur, a thorough search for new medications, metabolic (electrolyte disturbance) derangements,...

Iii331

Using fresh frozen plasma and vitamin K. As stated earlier, administration of histamine H2 antagonists or proton-pump inhibitors or alkalinization of the stomach (if one can be certain this will be meticulously attended to) is carried out for at least the first 3 days postoperatively or until the patient is eating. Early return to oral nutrition is encouraged. If oral nutrition is delayed and a transnasal intragastric (in an alert patient able to protect the airway from aspiration) or...

R81 [281 [291 [301

Characteristic of leiomyoma have been well described.1 ' 1 ' 1 ' 1 ' Contrast esophagogram demonstrates a segmental lesion that focally impinges on the column of swallowed contrast medium ( Fig. 23-2 ). The crescent-shaped mass generally shows half the mass to be in the esophageal wall and the rest extending into the lumen. The Junction of the mass and the esophageal wall demonstrates sharp margins (approaching 90 degrees). There is little obstruction to the flow of the contrast medium. The...

[26

Increasing evidence suggests that pancreatic ductal adenocarcinoma has identifiable precursor lesions. In pancreata resected for pancreatic cancer, the epithelial Figure 5-1 A moderately differentiated ductal adenocarcinoma, which contains infiltrative glands of varous shapes and sizes surrounded by dense fibrous tissue. The duct forming cells are markedly atypical. (Original magnification, xlOO from W entz, R.E., andHruban, R.H. Pathology of cancer of the pancreas. Surg. Oncol. Clin. North...

Iv422

Relevant tests include anal manometry, pudendal nerve latency testing, endoanal ultrasound, and defecography or peritoneography. Anal manometry determines anal canal pressure to provide an assessment of internal and external anal sphincter function. The entire length of the anal canal is evaluated, using either a station or continuous pull-through technique, and any one of a number of available catheters (e.g., water perfused, microballoon, and solid state). Despite the lack of methodologic...

Decide on Timing of Reoperation

If at all possible, 3 or preferably even 6 months should be allowed before reoperative pelvic surgery is attempted. This is to reduce the difficulty and potential complications attributable to adhesions. Should early reoperative pelvic surgery be required, there is a window of about 7 to 10 days before the adhesions reach their worst when re-exploration may perhaps be undertaken safely. After this, there is a significant risk of iatrogenic injury, and alternative approaches such as percutaneous...

I22

T., and Nyhus, L. M. Lower esophageal sphincter competence Anatomic-physiologic correlation. In DeMeester, T. R., and Skinner, D. B. (eds.) Esophageal Disorders Pathophysiology and Therapy. New York, Raven Press, 1985. 55. Savary, M., and Miller, G. The Esophagus Handbook and Atlas of Endoscopy. Switzerland, Gassmann, 1978. 56. Shapiro, A. L., and Robillard, G. L. The esophageal arteries Their configurational anatomy and variations in relation to surgery. Ann....

Iv464

During the perioperative period, maintenance immunosuppression should be continued. If the patient does not have a functioning GI tract, intravenous preparations may be administered, but the transplant pharmacist should be consulted to determine equivalent dosing based on bioavailability. Daily monitoring of serum trough levels of agents such as cyclosporine or tacrolimus is necessary to prevent inadequate immunosuppression or drug toxicity. Cancer Immunosuppression Malignancy may cause or be a...

David L Smith Anthony A Meyer

The spleen is an extremely vascular, distensible lymphatic organ specialized to filter blood, but with multiple other functions, including erythrocyte maintenance, immunologic response, and hematologic reservoir. It represents approximately 1 of total body weight, but it receives approximately 5 to 10 of the cardiac output at rest. The functions of the spleen and its response to disease and injury provide the spectrum of problems with this organ that are encountered by the surgeon. Surgeons...

[74[28

With the continued improvement in graft survival and patient outcome, liver transplantation for cirrhotic liver disease has become well accepted. This has changed the management of patients with liver disease who are potential candidates for liver transplantation. Previous abdominal surgery, especially in the portal triad, increases the technical difficulty during removal of the patient's liver. The decision to undertake portal shunting or surgical procedures of the biliary tract therefore...

[25

Transplantation immunosuppression is directed at the cellular immune response and results in a significant impairment in the host's ability to fight bacterial and viral infections. From 50 to 75 of transplant recipients have one or more episodes of bacterial infection, and 30 to 60 have one or more serious viral infections after transplantation.1 ' Most common infectious complications, such as bronchitis after lung transplantation and urinary tract infection after renal transplantation, can be...

Patricia L Roberts

Rectovaginal fistulas are relatively uncommon and account for approximately 5 of all anorectal fistulas. They may cause significant complications and social embarrassment. The operative approach to such fistulas depends on a variety of factors, including the size, location, condition of the surrounding tissues, and association with concomitant disease, such as inflammatory bowel disease. ETIOLOGY The most common cause of a rectovaginal fistula is obstetric trauma. A prolonged second stage of...

Claude Deschamps Peter C Pairolero Victor F Trastek

PHARYNGOESOPHAGEAL (ZENKER'S) DIVERTICULUM Nature and Pathophysiology Pharyngoesophageal diverticulum was first described in 1769 by Ludlow of Bristol, England, who noted a preternatural bag formed in the pharynx of a patient with symptoms who was followed through death and autopsy. By 1878, Zenker had collected 27 additional autopsy cases and had added seven new cases. His precise and perceptive clinicopathologic correlations have stood the test of time and account for his name becoming...

Iii484

Figure 32-1 Anatomy of the inferior surface of the liver. Figure 32-1 Anatomy of the inferior surface of the liver. Figure 32-2 Anterior view of segmental anatomy. HV hepatic vein, IVC inferior vena cava, PV portal vein. Figure 32-3 This 25-year-old patient was involved in a T-bone motor vehicle accident (major crushing injury). He had extensive transverse lacerations across both lobes of the liver. The patient was managed nonoperatively. Figure 32-3 This 25-year-old patient was involved in a...

I541

Monilial esophagitis An increasingly frequent cause of esophageal stenosis Ann. Thorac. Surg., 26 364, 1978. 139. Orringer, M.B. Extended cervical esophagomyotomy for cricopharyngeal dysfunction. J. Thorac. Cardiovasc. Surg., 80 669, 1980. 140. Orringer, M.B., and Stirling, M.C. Cervical esophagogastric anastomosis for benign disease-functional results. J. Thorac. Cardiovasc. Surg., 96 887, 1988. 141. Pang, J., Vicary, F.R., and Beck, E.R. Coexisting...

Iv444

Mavrantonis, C., and Wexner, S.D. Anorectal manometry Practical pointers towards consistent results. Tech. Coloproctol. (in press). 63. Le Blanc, I., Michot, F., Duparc, F., et al. Anorectal manometry and ileo-anal anastomosis Pre- and postoperative manometric comparison. Ann. Chir., 48 183, 1994. 64. Mahieu, P., Pringot, J., and Bodart, P. Defecography I. Description of a new procedure and results in normal patients. Gastrointest. Radiol., 5 247, 1984. 65. Kuijpers, H.C., and Strijk, S.P....

[63

A standard amino acid solution is the first approach, with monitoring of plasma amino acid patterns for the prevalent hepatic encephalopathy pattern of decreased branched-chain amino acids and increased aromatic amino acids.1 ' If, because of encephalopathy, the patient is incapable of achieving the metabolic requirement of 1.1 g amino acids kg using a standard parenteral nutrition mixture, a branched-chain-enriched, aromatic-deficient amino acid-deficient mixture (of which...

Ii577

The decision to intervene operatively is not based solely on the CT appearance or grade of the splenic injury. However, CT appears to enable the clinician to define a population of injured patients who may be more likely to require more aggressive treatment. The presence of acute extravasation, also referred to as vascular blush, seems to identify a subgroup of patients who may need more invasive management in the event that their condition does not stabilize ( Fig. 39-1 ). This management may...

[1

The retrorectal space is actually a potential space, identical to the presacral plane. The posterior wall of the rectum or, more accurately, the mesorectum, forms the anterior boundary of the space, and the anterior aspect of the sacrum forms the posterior border. Superiorly, the space extends to the peritoneal reflection and inferiorly to the rectosacral fascia.1 ' Below this is the U-shaped supralevator space. The lateral boundaries are demarcated by the lateral ligaments, the ureters, and...

Ii87

TABLE 7-2 -- Non-Neoplastic Lesions of the Stomach Fundic gland polyps and polyposis Peutz-Jeghers polyps and polyposis Juvenile polyps Heterotopias Pancreatic heterotopia Gastric gland heterotopia Hypertrophic rugal lesions Giant rugal hypertrophy (Menetrier's disease) Fundic gland hyperplasia (Zollinger-Ellison syndrome) Gastritis cystica polyposa (stromal polypoid hypertrophic gastritis) Cronkhite-Canada polyposis Inflammatory fibroid polyp Endocrine cell hyperplasia and micronest Benign...

Iv24

Figure 2-12 The spleen is related to the left kidney, adrenal gland, and tail of the pancreas. (From Fozard JBJ, Pemberton JH Applied surgical anatomy intra-abdominal contents. In Fielding, L.P., and Goldberg, S.M. eds. Rob and Smith's Operative Surgery of the Colon, Rectum, and Anus, ed. 5. Chapman & Hall, 1994.) Figure 2-13 Sigmoid colon, its mesentery and arterial supply, and the intersigmoid recess. The sigmoid colon and mesocolon are raised forward and upward to show the vertical and...

Abdominoperineal Resection For Adenocarcinoma Of The Rectum

Abdominoperineal resection is thought of by most surgeons as the operation performed when there simply is no sphincter-preserving option available due to distal location of the primary tumor. Evidence suggests that in most instances, APR is the appropriate operation for distal rectal cancer and is not just an amputation of the rectum as a last resort. During the 1990s, sufficient evidence accrued to suggest that low rectal cancer (0 to 5 cm from the anal verge) represents a biologically more...

Fascial Plates Of Liver Hilus

Safe hepatic resection depends on a clear understanding of the hepatic anatomy. Although hepatic regenerative capacity and metabolic reserve permit many types of resections, resection based on preservation of residual anatomic integrity best reduces the operative risk and optimizes function. Couinaud's1 ' description of hepatic anatomy highlights the anatomic features of the liver relevant to resection and in adults provides anatomic terminology that is clinically useful. The hilar plate is the...

[66

The syndrome of hepatic encephalopathy includes subclinical latent encephalopathy,1 a prodrome of decreased attention span and poor judgment, which progresses to decreased cooperativeness and responsiveness, lethargy, or excitement, and finally stupor and coma. These patients are difficult to manage clinically. They accumulate secretions, cannot protect their airway, cannot cooperate in respiratory and other care, and have an increased tendency to pneumonitis. A lengthy discussion of hepatic...

[19

Cinedefecography can demonstrate dysfunction of pelvic floor musculature, although EMG is more sensitive for the diagnosis of paradoxical puborectalis contraction.1 Cinedefecography can also show rectocele, increased perineal descent, and early rectovaginal intussusception. Because these radiologic findings can be detected in patients who are completely asymptomatic, some authors have questioned the clinical significance of these findings as far as providing clues for therapeutic intervention....

V64

Ruptured atherosclerotic aneurysm of the superior mesenteric artery with celiac axis occlusion. Ann. Surg. 174 207, 1971. 106. Wagner, D.S., Shaprt, W.V., and Cook, A.J. Celiac artery aneurysm diagnosed by dynamic computed tomography. Contemp. Surg., 24 23, 1984. 107. Wallace, S., Medellin, H., and Nelson, R.S. Angiographic changes due to needle biopsy of the liver. Radiology 105 13, 1972. 108. Werner, K., Tarasoutchi, F., Lunardi, W., et al. Mycotic aneurysm...

[34[24 [34 [69 [70 [71[65

O' In addition, intestinal infarction tends to involve shorter segments of bowel than mesenteric arterial occlusion. Since 1989, several series have reported a mortality ranging from 13 to 38 .1 1 1 1 1 Mortality appears to be higher among patients with secondary MVT.1 example, 11 (69 ) of 16 patients with MVT were managed without laparotomy, and the overall mortality rate was only 12 . In addition, intestinal infarction tends to involve shorter segments of bowel than mesenteric arterial...

Diagnostic Studies

Algorithms for the initial management of patients with lower gastrointestinal hemorrhage vary based on the degree of hemorrhage, the presence of ongoing bleeding, and foremost the hemodynamic status of the patient. In hemodynamically stable patients, the blood loss is less than 20 of blood volume, and brisk hemorrhage has usually stopped. Patients who are hemodynamically stable but continue to pass melena or hematochezia should first undergo emergency colonoscopy. In patients with hemorrhage...

Modified from Yeo CJ and Sarr MG Cystic and pseudocystic diseases of the pancreas Curr Probl Surg 31165 1994 with

Figure 4-3 A computed tomography scan of a patient with an acute fluid collection 10 days after an episode of acute alcoholic pancreatitis. The collection is located anterior to the spleen and appears to have a thin wall. The acute fluid collection was not causing symptoms and gradually resolved with observation. Mucinous cystic Variable Usually positive Usually high High variable neoplasm CEA CA-125 carcinoembryonic antigen cancer antigen 125. * Modified from Lewandrowski, K.B., Southern,...

[23[21

Reported a total recurrence rate of 7 , with 16 of patients counted as treatment failures secondary to the eventual need for drainage by other techniques. Although most of the studies included in this review consisted of small, selected groups of patients, a large retrospective review from a single center compared patients managed percutaneously, operatively, and expectantly. This review found that only 42 of patients who underwent percutaneous drainage did not require other intervention,...

[57[31

Decreased peripheral resistance that is pathognomonic for this condition. If progressive, these cardiovascular changes result ultimately in high-output congestive failure, as well as diversion of blood away from the kidney, which results in the type II hepatorenal syndrome. The therapy for this condition is extraordinarily difficult and, in the absence of improvement in hepatic function, these patients almost always die with and as a result of high-output congestive failure. Digitalis is of...

[31

Arterioles divide to become capillaries. Exchange of fluid, electrolytes, nutrients, and oxygen occurs across the thin-walled capillaries, which are termed exchange vessels and constitute a nutrient bed. The amount of exchange depends mainly on the surface area of perfused capillaries, because only a small portion of the total number of capillaries are perfused at any one time.1 ' A precapillary sphincter at the junction of arteriole and capillary governs entry of blood into individual...

V30

Although there has clearly been some Improvement In outcome among patients who present with AMI In contemporary practice, this remains a particularly lethal condition. Although the Incidence of NOMI may be declining as a result of refinements In Intensive care management of critically 111 patients In recent years, In view of the aging of our population, one may anticipate stability or even an Increase In the prevalence of mesenteric arterial occlusive disease in the future, and MVT remains an...

I300

The present status of one-stage pharyngoesophageal diverticulectomy. Surg. Clin. North Am., 53 953, 1973. 106. Wheeler, W.I. Pharyngocele and dilatation of pharynx, with existing diverticulum at lower portion of pharynx lying posterior to the oesophagus, cured by pharyngotomy, being the first case of the kind recorded. J. Med. Sci. (3rd series, Dublin), 82 349, 1886. 107. White, I.L. Endoscopic treatment of hypopharyngeal diverticula. Cal. Med., 109 374, 1968....

Iv420

Minor surgical conditions of the anus and perineum (in pediatrics). Med. J. Aust., 1 224, 1958. 28. Stuart, M. Proctitis cystica profunda Incidence, etiology, and treatment. Dis. Colon Rectum, 27 153, 1984. 29. Theuerkauf, F.J., Beahrs, O.H., and Hill, J.R. Rectal prolapse, causation and surgical treatment. Ann. Surg., 171 819, 1970. 30. Uhlig, B.E., and Sullivan, E.S. The modified Delorme operation Its place in surgical treatment of massive rectal prolapse. Dis. Colon...

Ii542

Figure 35-2 Locations of accessory spleens. A, Splenic hilus. B, Along splenic vessels tail of pancreas. C, Splenocolic ligament. D, Greater omentum perirenal regions. E, Small-intestinal mesentery. F, Presacral region. G, Uterine adnexal region. H, Peritesticular region. (From Schwartz, S. I., Adams, J. T., and Bauman, A. W. Splenectomy for hematologic disorders. Curr. Probl. Surg., 8 4, 1971, with permission. Copyright 1971 by Year Book Medical Publishers, Inc., Chicago.) Figure 35-3 A,...

Raymond C Read

A femoral hernia is a protrusion of an abdominal or pelvic viscus through the femoral ring into or through the femoral canal. Femoral hernias usually have an associated sac but may consist of extraperitoneal fat only. A sliding femoral hernia is uncommon but may occur. When a viscus is involved in a sliding hernia, it is the bladder more often than intestine. A Richter type of hernia occurs more frequently in the femoral region than in any other area and is frequently strangulated when at this...

[232 [378

With regard to the crucial survival parameter, no study has demonstrated any significant difference in either crude or actuarial survival between selective and total shunts. In one patient group, however, the DSRS may confer a survival advantage over the total shunts, and that is among patients who do not have alcoholism.1 1 At 10 years in the Emory trial, the crude survival rate among patients without alcoholism was 29 for those who had a nonselective shunt and 63 for those who had a selective...

[406 [407 [408[407

Devascularization without transection has also been advocated. Lemos-Torres and Degni described an extensive devascularization procedure that includes extramural division of all vascular connections to the lower esophagus and proximal half of the stomach, ligation of all retroperitoneal veins at the esophageal hiatus, splenectomy, and transgastic varix ligation. This devascularization included ligature of the left gastric artery and coronary vein. In addition, in selected patients, these...

Iv39

34. von der Ohe, M.R., Camilleri, M., and Kvols, L.K. A 5-HT3 antagonist corrects the postprandial colonic hypertonic response in carcinoid diarrhea. Gastroenterology, 106 1184, 1994. 35. Dapoigny, M., Cowles, V.E., Zhu, Y.R., et al. Vagal influence on colonic motor activity in conscious nonhuman primates. Am. J. Physiol., 262 G231, 1992. 36. Steadman, C.J., Phillips, S.F., Camilleri, M., et al. Control of muscle tone in the human colon. Gut, 33 541, 1992. 37. Coulie, B., Tack, J., Gevers, A.,...

Iv183

Signs and symptoms remain stable, it is appropriate to perform a CT scan. The risk of appendicitis during pregnancy is the same as it is in nonpregnant women of the same age the incidence is 1 in 2,000 pregnancies. Appendicitis occurs more frequently during the first two trimesters, and during this time period the symptoms of appendicitis are similar to those seen in nonpregnant women.1 Surgery should be performed during pregnancy when appendicitis is suspected, just as it would be in a...

Wb Saunders Company

A Harcourt Health Sciences Company The Curtis Center Independence Square West Philadelphia, Pennsylvania 19106 Library of Congress Cataloging-in-Publication Data Shackelford's surgery of the alimentary tract edited by George D. Zuidema, Charles J. Yeo. 5th ed. p. cm. Rev. ed. of Shackelford's surgery of the alimentary tract edited by George D. Zuidema. 4th ed. c1996. Includes bibliographical references and indexes. ISBN 0-7216-8203-0 (5 vol. set) 1. Alimentary canal Surgery. I. Zuidema, George...

General Aspects Of Operation

Operations on the small intestine can be performed with the patient supine and the table level. A midline incision, when possible, allows for easy access to the abdominal contents and can be extended superiorly and inferiorly as needed. When necessary, small intestinal procedures can be performed through alternate incisions, such as resection of a Meckel's diverticulum through an appendectomy incision. A thorough exploration should be undertaken upon entering the abdomen. The liver, pancreas,...

Fundamentals Of Ultrasonography

Sound waves are produced by the vibration of a source within a medium. The vibration produces cyclic compression and rarefaction (expansion) of the molecules in the medium, thus transmitting the sound wave through the medium. The number of cycles (compression and rarefaction) of a sound wave occurring in 1 second is the frequency and is measured in hertz (Hz). The frequency of sound waves audible to the human ear is between 20 and 20,000 Hz. Sound waves with frequencies higher than these...

I492

Finley, R.J., Pearson, F.G., Weisel, R.D., et al. The management of nonmalignant intrathoracic esophageal perforations. Ann. Thorac. Surg., 30 515, 1980. 29. Foley, M.J., Ghahremani, G.G., and Rogers, L.F. Reappraisal of contrast media used to detect upper gastrointestinal perforations Comparison of ionic water-soluble media with barium sulfate. Radiology, 144 231, 1982. 30. Gayett, B., and Ancona, E. Esophageal perforations High risk group patients and treatment. A GEEMO questionnaire. In...

V33

Figure 4-1 Anteroposterior (A) and lateral (B) aortograms of patient with chronic mesenteric ischemia and typical proximal visceral artery atherosclerosis. Stenoses at the origins of the celiac and superior mesenteric arteries are best demonstrated on lateral views. These occlusive lesions are missed on anteroposterior views, which often show reasonable filling of celiac and superior mesenteric artery branches. TABLE 4-1 -- Results of Current Studies of Chronic Mesenteric Ischemia TABLE 4-1 --...

Iv450

Figure 33-1b C, The flap Is raised, and dissection Is performed laterally to permit a tension-free closure. D, The Internal sphincter muscle Is plicated over the area of the fistula. E, Excess flap, Including the site of the Internal opening of the fistula, Is trimmed. F, The flap Is secured with absorbable sutures. (Reprintedby permission of Lahey Clinic, Burlington, MA.) TABLE 33-3 -- Results of Sphincteroplasty for Rectovaginal Fistula TABLE 33-3 -- Results of Sphincteroplasty for...

Iv448

The presence of methylene blue on the tampon confirms the fistula is present and open. Another method is to examine the patient in the lithotomy position. Water is placed in the vagina, and air is insufflated into the rectum with a sigmoidoscope. The presence of air bubbles in the vagina indicates a fistula. It is essential to assess the anatomy and function of the sphincter muscles, especially in patients who have a rectovaginal fistula resulting from obstetric injury. In one study...

Indications

Liver transplantation is appropriate for most causes of end-stage, life-threatening, or severely debilitating liver disease.1 ' 1 ' 1 ' Guidelines for initiating an evaluation of patients with hepatic cirrhosis are provided in Table 34-1 . General indications and specific diseases for which liver transplantation is common are listed in Table 34-2 and Table 34-3 . The most common indications in adults are hepatitis C cirrhosis and alcoholic cirrhosis. In children, the most frequent indication by...

Jeffrey L Cohen John P Welch

Diverticular disease refers to a spectrum of clinical scenarios that can vary from an asymptomatic state to life-threatening peritonitis. This chapter gives a clinical overview of the pathophysiology, diagnosis, and clinical management of a wide variety of complications of the disorder. PATHOPHYSIOLOGY AND EPIDEMIOLOGY Colonic diverticulosis refers to the presence of 0.5- to 1- cm saccular outpouchings termed diverticular ' Anatomically, diverticula are situated between the single mesenteric...

[48 [49 [50

Abdominal pain, and diarrhea in a neutropenic patient. Other symptoms include nausea, vomiting, hematochezia, and abdominal distention. Symptoms generally occur approximately 7 to 9 days after the onset of neutropenia. A rapid course suggests a more virulent form of the disease.1 1 1 The differential diagnosis includes other causes of acute abdominal pain, such as appendicitis, diverticulitis, ischemic colitis, pseudomembranous colitis, and chemotherapy-induced gastroenteritis.

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Figure 8-2 Lone Star retractor facilitates transanal mucosal resection. Figure 8-5 In a healthy pouch, the ileal pressure waves remain well below resting anal pressure (A), whereas in patients with fecal seepage, the pressure waves may reach (B) or even regularly exceed (C) the resting tone of the anal sphincter. TABLE 8-2 -- Complications After Restorative Proctocolectomy TABLE 8-2 -- Complications After Restorative Proctocolectomy

Jeffrey L Barnett Frederic E Eckhauser

Since the first report of endoscopic retrograde cholangiopancreatography (ERCP) in 1968 by McCune and associates,1 endoscopic methods have become one of the standard modalities for diagnosis and treatment for pancreatobiliary diseases. Various disorders that traditionally had been treated by surgery, including biliary ductal stones and parasites, benign and malignant biliary strictures, acute cholangitis, gallstone pancreatitis, and pancreatic ductal strictures, have been successfully treated...

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However, the path of a missile cannot be determined from the external location of wounds or from the location of the projectile on radiographs. Hemodynamically stable patients with anterior abdominal stab wounds and no significant abdominal tenderness do not all require celiotomy. In such patients, celiotomy is indicated with positive findings on diagnostic peritoneal lavage or changes in physical findings during a period of careful observation. Similarly, stab wounds to the back and...

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Thomas, B.L., Krummel, T.M., Parker, G.A., et al. Use of intraoperative ultrasound during hepatic resection in pediatric patients. J. Pediatr. Surg., 24 690, 1989. 95. Ong, G.B., and Lee, N.W. Hepatic resection. Br. J. Surg., 62 421, 1975. 96. McEntee, G.P., and Nagorney, D.M. Use of vascular staplers in major hepatic resections. Br. J. Surg., 78 40, 1991. 97. Voyles, C.R., and Vogel, S.B. Hepatic resection using stapling devices to control the hepatic veins. Am. J. Surg., 158 459, 1989....

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Ouwendijk, R.J., Koster, J.C., Wilson, J.H., et al. Budd-Chiari syndrome in a young patient with anticardiolipin antibodies Need for prolonged anticoagulant therapy. Gut 35 1004, 1994. 5. Bourliere, M., Le Treut, Y.P., and Arnoux, D. Acute Budd-Chiari syndrome with hepatic failure and obstruction of the inferior vena cava as presenting manifestations of hereditary protein C deficiency. Gut, 31 949, 1990. 6. Bayraktar, Y., Bakanci, F., Kansu, E., et al. Budd-Chiari syndrome Analysis of 30 cases....

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Doses greater than 50 Gy are associated with increased surgical mortality rates,1 1 and lower doses may be associated with increased local failure.1 Improved outcome is likely to depend on the development of better systemic therapy. ADJUVANT (POSTOPERATIVE) RADIOTHERAPY Postoperative Radiotherapy Limited Usefulness Postoperative RT has several potential benefits in comparison with preoperative RT. Because the treatment is administered after recovery from surgery, operative...

V301

In genes that encode transcription factors, not only those genes influencing cell proliferation TABLE 22-3 -- Factors Influencing Intestinal Adaptation From Thompson, J.S. Intestinal adaptation Nutritional and metabolic implications. In Latifi, R., and Dudrick, S.J. (eds.) Current Surgical Nutrition. Georgetown, TX, RG Landes, 1996, pp. 146-179. but also those augmenting nutrient trafficking as well as heat shock genes, which maintain normal cellular function. Many of these are novel genes, not...

[37

Most importantly, mucous glands are displaced deep within the submucosa and muscularis mucosae hence, the name colitis cystica profunda. Rutter and RiddelU ' believed that the displaced glands represented the healing phase of a rectal ulcer. These displaced mucinous glands associated with ulceration make it imperative to differentiate this lesion from well-differentiated mucinous adenocarcinoma lest an unwarrantably radical operation be performed. Cellular atypia, multilayering of the cystic...

Commentary

Laparoscopic hernia repair is a technique that continues to evolve and continues to be evaluated. Thus, the debate regarding laparoscopic hernia continues. Not yet fully adopted by general surgeons, it is practiced primarily by those who consider themselves laparoscopic surgeons. Mesh fixation is one area of controversy. The easiest approach is the multiple-fire disposable stapler, but this is costly. Spiral tacks are also available in disposable devices. The mesh can be sutured in place, but...

Epidemiology

Cancer of the esophagus represents 1.0 of all cancers diagnosed in the United States and accounts for 2.1 of all deaths due to cancer.1 An estimated 12,300 new esophageal cancers were diagnosed in 1998 and 11,900 deaths from esophageal cancer were predicted for the same year. Esophageal cancer accounts for 5.4 of all carcinomas of the digestive tract and causes 9.1 of all deaths due to these cancers. Cancer of the esophagus or cardia in the United States occurs in about 6 of 100,000 men and in...

[467

Salutory results were confirmed in another series of 23 cases with no operative mortality and 2 cases of recurrent bleeding. Makeshift shunts were, as anticipated, generally unsatisfactory. The experience with selective shunts is too small to evaluate. Splenectomy, varix ligation, and gastric transection were associated with almost universal failure. The results with the various resectional operations, given the desperate circumstance in which they were usually performed, seem to be acceptable....

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Rutgeerts, P., D'Haens, G., Targan, S., et al. Efficacy and safety of retreatment with anti-tumor necrosis factor antibody (infliximab) to maintain remission in Crohn's disease. Gastroenterology, 117 761, 1999. 82. Sachar, D.B. Maintenance therapy in ulcerative colitis and Crohn's disease. J. Clin. Gastroenterol., 20 117, 1995. 83. Sackett, D.L., and Whelan, G. Cancer risks in ulcerative colitis Scientific requirements for the study of prognosis. Gastroenterology, 78 1632, 1980. 84....

[263

Be wise to test clamp the renal vein before dividing it, and it is certainly prudent to have ascertained that right renal function is normal. The usual incision for renosplenic shunts has been transperitoneal. However, a retroperitoneal approach has been described, using a flank incision with resection of the eleventh rib.I ' This incision may be indicated in patients with multiple previous laparotomies or in those with massive ascites. The anterior surface of the left kidney is exposed,...

Historical Perspective

The practice of esophageal dilatation began 4 centuries ago with the use of wax dilators for food impaction in the esophagus. Fabricus ab Acquadendente (1537-1619) was the first physician to use a blunt implement to push a foreign object from the esophagus into the stomach.1 ' The original dilator bougie and the technique of bougienage received their names from the Algerian town of Bouginhay, which was the medieval capital of the wax candle trade. Although wax bougies required pressure...

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Research is being done to produce a combination of sclerosing materials to provide maximum therapeutic effect and minimal esophageal damage. Although endoscopic sclerotherapy has been practiced since 1939, few scientific studies have compared sclerosing agents. One retrospective report compared 1 STS with a combination of 1 STS, thrombin, and cefazolin and concluded that, when rebleeding rate, mortality, length of hospitalization, and transfusion requirements...

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MORTENSEN The colon extends from the end of the ileum to the peritoneal reflection at the junction of the sigmoid colon with the rectum and includes the ileocecal valve and appendix. It may be considered from its proximal end to be made up of cecum, which leads into the ascending, transverse, descending, and sigmoid colon. Together with the rectum and anus, they make up the large intestine ( Fig. 1-1 ), which differs considerably from the small intestine. The large...

[66 [67[68

Prenatal sonography has a positive predictive value of 56 in the detection of EA.1 1 The sonographic finding of an anechoic area observed in the middle of the fetal neck in association with polyhydramnios and a small stomach size may increase the accuracy of prenatal diagnosis of EA.1 Most infants with EA are symptomatic in the first few hours of life, with early clinical signs being excessive salivation as secretions pool in the posterior pharynx and regurgitation of the first feeding, often...

[4 [12 [54 [4 [12 [17 [2 [4 [53

Palliation with RT requires 4 to 6 weeks for effect, and higher doses of radiation (> 45 Gy) have been associated with better results.1 1 1 Recurrence of dysphagia owing to tumor regrowth or radiation fibrosis is reported in 30 to 50 of patients.1 1 1 Brachytherapy has been added to increase local control, but with apparent increases in esophagitis, ulceration, and late stricture formation.1 1 1 PRELIMINARY CONSIDERATIONS A moribund patient is not a candidate for laser treatment, PDT, or...

[12

Confirmed the observation that there was no increase in morbidity rate associated with primary anastomosis in a selected group of patients receiving less than 40 mg of prednisone day. I 1 However, high-dose steroids do appear to have significant adverse effects on bowel anastomoses. The authors' preferred technique is to reserve primary anastomosis for patients who have a technically uncomplicated operation and receive less than 40 mg of prednisone day. Diversion is performed in those with...

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Figure 21-5 A, Broad view of pelvic dissection. The iliac vessels are dissected from the level of the aortic bifurcation to at least the origin of the internal iliac branches. The ureters are located and followed from the pelvic brim to their insertion into the bladder. Once the vessels and ureters are located, it is safe to proceed with the posterior dissection, commencing at the sacral promontory. (Used with permission from Mayo Foundation.) B, Anterior approach (operative anatomy of pelvic...

Abc

Figure 30-8 Abdominal sigmoidectomy with rectal fixation. A, Prolapsed rectum demonstrating loss of sacralization and redundancy of sigmoid colon. B, Redundant sigmoid colon is resected. Rectum is sutured to presacral fascia. Figure 30-8 Abdominal sigmoidectomy with rectal fixation. A, Prolapsed rectum demonstrating loss of sacralization and redundancy of sigmoid colon. B, Redundant sigmoid colon is resected. Rectum is sutured to presacral fascia. Figure 30-9 Altemeier procedure. A, With the...

Methods Of Extracting Common Duct Stones

Because 90 to 95 of cholecystectomies are now being performed using the laparoscopic approach, laparoscopic extraction of common duct stones is becoming increasingly popular. Techniques are now described for either laparoscopic choledochotomy with stone extraction or transcystic common duct exploration. The results of laparoscopic common bile duct exploration are reviewed elsewhere and in 3 Chapter 14 . At the time of open cholecystectomy, common duct stones are generally removed through a...

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Figure 16-8 Time to recurrence, according to treatment. (From Gastrointestinal Tumor Study Group Prolongation of the disease-free interval in surgically treated rectal carcinoma. N. Engl. J. Med., 312 1470, 1985, by permission. Copyright 1985 Massachusetts Medical Society. All rights reserved.) Figure 16-9 Survival distribution according to treatment. (From Gastrointestinal Tumor Study Group Survival after postoperative combination treatment of rectal cancer. N. Engl. J. Med., 315 1294, 1985,...

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B., Reese, J., Shackford, S. R., and Osler, T. M. The use of venovenous bypass and total vascular isolation of the liver in the surgical management ofjuxtahepatic venous injuries in blunt hepatic trauma. J. Trauma, 43 530, 1997. 21. Kudsk, K. A., Sheldon, F. G., and Lim, R. C. Atrial caval shunting after trauma. J. Trauma, 22 81, 1982. 22. Fletcher, W. S. Nonpenetrating trauma to the gallbladder and extrahepatic bile ducts. Surg. Clin. North. Am., 52 111, 1972. 23. Howdieshell,...

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Gilliams, A., Curtis, S.C., Donald, J., et al. Technical considerations in 113 percutaneous cholecystolithotomies. Interv. Radiol., 183 163, 1992. 48. Giorgio, A., Tarantino, L., Marinello, N., et al. Pyogenic liver abscesses 13 years of experience in percutaneous needle aspiration with US guidance. Radiology, 195 122, 1995. 49. Goldberg, S.N., Gazelle, G.S., Solbiati, L., et al. Percutaneous radio-frequency liver tumor ablation. AJR Am. J. Roentgenol., 170 1023, 1998. 50. Goletti, O.,...

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O'Connell, P.R., Pemberton, J.H., Brown, M.L., and Kelly, K.A. Determinants of stool frequency after ileal pouch-anal anastomosis. Am. J. Surg., 153 157, 1987. 74. O'Connell, P.R., Pemberton, J.H., and Weiland, L.H. Does rectal mucosa regenerate after ileoanal anastomosis Dis. Colon Rectum, 30 1, 1987. 75. Oresland, T., Fasth, S., Nordgren, S., and Hulten, L. the clinical and functional outcome after restorative proctocolectomy A prospective study in 100 patients. Int. J. Colorectal Dis., 4...

The Donor Operation

Cadaveric multiorgan donors who died from irreversible brain injury are the usual source of donor livers.1 1 A single donor may contribute a heart, two lungs, liver, pancreas, two kidneys, and two corneas plus other tissues, thus helping nine or more individual patients. Our standard method incorporates dissection of the major abdominal vessels and hepatic trinity and placement of the aortic and inferior mesenteric vein cannulas for perfusion of the arterial and portal venous systems. The...

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For 3 to 4 weeks and follow-up tomographic evaluation. f f Splenectomy is the treatment of choice for most patients. However, this procedure may be difficult in patients with extensive parasplenic inflammation and adhesions. Preliminary ligation of the splenic vessels through an opening in the gastrosplenic ligament is desirable in this circumstance. After splenectomy, the left subphrenic space should be drained. If removal of the densely adherent spleen is judged to result in excessive...

[57

Incidence of anal dysplasia (15 ) in HIV-positive patients, and the rate of anal cancers may increase as lives are prolonged with highly active retroviral therapies.1 ' Prediction of the biology and planning for the treatment of tumors of the perianal region is dependent on precise localization of the tumor with respect to anal landmarks such as the dentate line, the anal verge, and the anal sphincters. These landmarks define two classes of perianal neoplasms tumors of the anal margin and...

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That can progress to pneumonia or acute respiratory failure. Spillage of gastric contents into the free peritoneal cavity through a full-thickness perforation can initiate an acute chemical peritonitis. The subsequent inflammatory process can lead to exudation of large quantities of fluid into the peritoneal cavity, resulting in an extracellular fluid loss similar to that observed in a 20 body surface burn. If diagnosis of a gastric perforation is delayed, bacterial peritonitis will ensue....

[18

Enteral nutrition is not always possible in surgical patients, and total parenteral nutrition may be the only route available. Total parenteral nutrition can improve outcome, but it may be associated with increased infectious non-catheter-related complications. In the Veterans Affairs Cooperative Study,1 ' severely malnourished patients had improved outcome with perioperative parenteral nutritional support. This study, however, also clearly demonstrated that, although moderately malnourished...