Dorsal

Figure 1-11 Wall structure at the esophagogastric junction. The tunica muscularls Is composed of both a longitudinal and a circular layer, (a muscularls mucosae, b lamina propria, c epithelium, G1 esophage il glands, G2 gastric glands, Ly lymph vessels, N1 myenteric plexus, N2 submucous nerve plexus.) Figure 1-13 Structures at the pharyngoesophageal junction viewed from a posterior aspect. These are shown (A) in a human dried-fiber specimen (by Liebermann-Meffert), (B) in a schematic drawing of...

Ues

Hypertensive UES Hypotensive UES Premature closure Delayed relaxation Incomplete relaxation UES upper esophageal sphincter. Muscular Causes of Oropharyngeal Dysphagia Muscular diseases tend to interfere predominantly with the effectiveness of pharyngeal muscular contraction. In patients with poliomyelitis or dermatomyositis, dysphagia is the predominant symptom, and weakness of pharyngomuscular contraction secondary to inflammation of the striated muscle is the cause. Myotonic dystrophy and...

Victor F Trastek

In 1906, Tileston reported on peptic ulcerations arising in the lower esophagus lined by columnar epithelium. In 1950, Barrett ( Fig. 15-1 ), at the Brompton Hospital in London, described a condition characterized by a columnar epithelium-lined tube extending below the squamocolumnar junction in patients with hiatal hernia and reflux. Barrett postulated initially that this tube was an attenuated segment of stomach drawn into the chest by a shortened esophagus. Subsequently, Allison and...

Anatomy

The pancreas ( Fig. 1-1 ) is a soft, yellow, glandular organ approximately 20 cm in length that weighs about 95 g and lies posterior to the stomach at the level of the second lumbar vertebra. The organ is covered by peritoneum anteriorly, where it forms the floor of the lesser sac, and it is partially fixed to the retroperitoneum posteriorly. The retroperitoneal nature of the pancreas and its central position in the middle of the major abdominal blood vessels create some complicated anatomic...

Types Of Dilators

Esophageal dilators can be divided into two basic groups the push dilators ( Fig. 8-1 ) and the balloon dilators ( Fig. 8-2 ). The push dilators can be further subdivided into those that require guidewire passage and those that do not. Balloon dilators can be further classified as those requiring fluoroscopic placement and those that can be passed through the endoscope. Other types of dilators that have been advocated but are rarely used include tapered-tip endoscopes, mechanical dilators with...

Incidence And Importance Of The Hiatal Hernia Problem

Although its exact prevalence in the normal population remains unknown, it is certain that hiatal hernia is the most common abnormality, reported on barium studies of the upper gastrointestinal tract. Women are more likely to be afflicted than men, the highest incidence occurring in the fifth and sixth decades of life. Skinner estimates that routine gastrointestinal series show hiatal hernia in 10 of the population, with 5 of this group having pathologic reflux. If these figures are correct,...

Omental space

Figure 1-3 Blood supply of the stomach, duodenum, spleen, and pancreas. The stomach Is shown reflected upward, and the pancreatic duct Is exposed. Figure 1-3 Blood supply of the stomach, duodenum, spleen, and pancreas. The stomach Is shown reflected upward, and the pancreatic duct Is exposed. Figure 1-5 Surface of gastric mucosa of a man (drawing based on binocular microscope view). The cut surfaces are slightly diagrammatic. At the left, the normal distribution of the gastric glands to the...

V372

Figure 25-20 Multiple sites of infiltrating, extensively ulcerating, and malignant lymphoma in the jejunum. (From Teplick, J.G., and Haskin, M.E. Surgical Radiology. Philadelphia, W.B. Saunders, 1981, with permission.) Figure 25-21 A, Computed tomogram in a patient with lymphoma of the small bowel presenting with intussusception. B, Computed tomogram in a patient with small bowel lymphoma. Note extensive thickening of the bowel with extension into the small bowel mesentery. Figure 25-21 A,...

Peter M Sagar John H Pemberton

The optimal surgical procedure for most patients with chronic ulcerative colitis (CUC) is ileal pouch-anal anastomosis (IPAA). I ' Patients with CUC need no longer live with the fear that their ultimate surgical fate is a permanent ileostomy with its attendant psychological, social, physical, and sexual problems. Indeed, IPAA confers a good quality of life. The principal aim of this chapter is to review the technical details of IPAA, the available choices of ileal pouch and ileoanal...

Slims Spiral Myotomy

Eraklis, A.J., Rossello, P.J., and Ballintine, T.V.N. Circular esophagomyotomy of the upper pouch in primary repair of long segment esophageal atresia. J. Pediatr. Surg., 11 709, 1976. 86. Kontor, E.J. Esophageal atresia with wide gap Primary anastomosis following Livaditis procedure. J. Pediatr. Surg., 11 583, 1976. 87. Slim, M.S. Circular myotomy of the esophagus Clinical application in esophageal atresia. Ann. Thorac. Surg., 23 62, 1977. 88. Vizas, D., Ein, S.H., and Simpson, J.S. The...

Iv37

Colonic transit, attributable to the obstruction of luminal contents by retained stool, colonic motor dysfunction unrelated to obstructed defecation, rectocolonic inhibition, or decreased colonic motor response to a meal. The latter is reversible after biofeedback therapy.1 Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome) In acute megacolon (Ogilvie's syndrome), colonic dilatation is attributed to a sympathetically mediated reflex response to a number of serious medical or surgical...

General Aspects And Technical Matters

From 70 to 90 of patients with Crohn's disease will, at some time, undergo an operation. By far the leading indication for operation is the failure of medical management. The most common complications leading to surgery are intestinal obstruction, which is rarely complete but is high grade spontaneous perforation with peritonitis fistula formation or abscess and gastrointestinal bleeding.1 ' Obstruction with nausea and vomiting is usually managed by inserting a nasogastric tube and intravenous...

Operative Management

The cornerstone of treatment for either primary or secondary AEF is aggressive surgical evaluation and early operation. Diagnosis and preparation for surgery must proceed simultaneously. Survival is inversely related to the interval between onset of bleeding and operative intervention. Appropriate monitoring and transfusion lines should be inserted and broad-spectrum antibiotics initiated preoperatively. Antibiotics should cover any organisms recovered from preoperative blood cultures, draining...

Approach From The Groin

Hippocrates (500 B.C.), the father of medicine, did not mention hernia in his writings. Nevertheless, the condition, then a subject for ribald humor, is portrayed in Greek, Phoenician, and Roman statuary. An Egyptian papyrus (Ebers, 1550 B.C.) describes bandaging (a truss). Unlike in the Indian civilization of the time, the abdominal cavity was not opened for strangulation the Romans instead tried cathartics, enemas, and hot poultices. The encyclopedist Celsus ( Fig. 9-1 ), a Greek immigrant to...

[25

Medical therapy for anal stenosis combines bulking of the stool with dilation in the office or at home using the finger or calibrated rubber dilators and topical anesthetics. Dilatation is an ideal treatment for patients with Crohn's disease or high-risk patients with otherwise weakened external sphincters.1 ' The combination of repeated dilation and steroid suppositories may prevent early recurrence of the stenosis, but no well-controlled trials have been reported. Anal stenosis in elderly...

[24

Inhibition of pancreatic enzyme activation provides a solid theoretic basis for the treatment of AP. Protease inhibitors such as aprotinin, gabexate, camostate, and fresh frozen plasma have all been studied. In clinical trials, most evidence suggests that these treatments are not beneficial in AP. However, gabexate does not appear to reduce the incidence of ERCP- and ES-induced AP. In summary, the use of specific measures to inhibit pancreatic enzyme activation has been partly efficacious in...

Charles J Yeomd

The Johns Hopkins University School of Medicine, Pseudocysts and Other Complications of Pancreatitis Pancreatic and Periampullary Carcinoma (Nonendocrine) Operative Management of Strictures and Benign Obstructive Disorders of the Bile Duct Duodenal Ulcer Assistant Professor of Surgery, Mayo Medical School, Rochester Consultant, Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota Laparoscopic Colorectal Surgery Neoplasms of the Anus Retrorectal Tumors

Cirrhosis In Liver Disease

The liver has immense reserve and regenerative powers. It is estimated that at least 75 of normal hepatic function must be absent for any changes in standard hepatic function tests to occur. Thus, taking an accurate history is important. Careful attention should be given to factors such as alcohol ingestion, state of nutrition, previous history of hepatitis, jaundice, or anorexia, and protean manifestations such fatigue and loss of stamina. A carefully directed physical examination includes a...

Acute Appendicitis

Acute appendicitis is one of the most common causes of an abdominal emergency and accounts for approximately 1 of all surgical operations.1 Although rare in infants, appendicitis becomes increasingly common throughout childhood and reaches its maximal incidence between the ages of 10 and 30 years. After 30 years of age, the incidence declines, but appendicitis can occur in individuals of any age. Among teenagers and young adults, the male female ratio is about 3 2. After age 25 years, the ratio...

Mucus And Bicarbonate

Mucus and bicarbonate combine to neutralize gastric acid at the gastric mucosal surface. Both are secreted by the surface mucous cells and by mucous neck cells located in the acid-secreting portion of the stomach and the antrum. The mucus is a viscoelastic gel that contains approximately 85 water and 15 glycoproteins and provides a mechanical barrier to injury by contributing to the unstirred layer of water found at the luminal surface of the gastric mucosa. It provides some impediment to ion...

E

Figure 8 8 Sectional view of sliding inguinal hernia involving the ascending colon, cecum, and terminal ileum. (From Watson, L. F. Hernia, 3rd ed. St. Louis, C. V. Mosby, 1948, with permission.) Figure 8 8 Sectional view of sliding inguinal hernia involving the ascending colon, cecum, and terminal ileum. (From Watson, L. F. Hernia, 3rd ed. St. Louis, C. V. Mosby, 1948, with permission.) Figure 8-10 Inguinal hernioplasty in women. A, The opened sac, separated from the round ligament of the...

Luca Stocchi Denis C N K Nyam John H Pemberton

Renewed interest in the aggressive management of adenocarcinoma of the rectum with precise anatomic dissection has sparked renewed interest in the anatomy and physiology of the anorectum. There is little doubt that an anatomic rectal dissection is the key factor that minimizes the chance of local recurrence. It is quite necessary, at this juncture, to consider again the rectum, its anatomy, and its relations within the pelvis. Moreover, a better understanding of the complex mechanisms that...

Info

Viability of the jejunum and resulting in a clear demarcation of the affected intestinal segment at the time of laparotomy. A minority of emboli (15 ) occlude the SMA at its origin, with ischemic regions extending proximally to the ligament of Treitz. Smaller emboli may occlude distal arterioles, resulting in a patchy bowel appearance with segmental ischemia. In up to 20 of patients suffering viability of the jejunum and resulting in a clear demarcation of the affected intestinal segment at the...

Posterior

Figure 19-24 Standard thoracotomy incision (rib resection technique). Incision of the periosteum and parietal pleura. The fingers of the surgeon's left hand are inserted to hold the lung away from the points of the scissors. (From Sweet, R.H. Thoracic Surgery, 2nd ed. Philadelphia, W.B. Saunders, 1954, with permission.) Figure 19-25 Standard thoracotomy incision (rib resection technique). Method of enlarging the incision posteriorly by cutting adjacent ribs. (From Sweet, R.H. Thoracic Surgery,...

V292

In Oldham, K.T., Colombani, P.M., and Foglia, R.P. (eds.) Surgery of Infants and Children Scientific Principles and Practice. Philadelphia, Lippincott-Raven, 1997, pp. 1241-1248. 25. Doolin, J., Ormsbee, H.S., and Hill, J.L. Motility abnormality in intestinal atresia. J. Pediatr. Surg., 22320, 1987. 26. Edwards, P.A.W. Is mucus a selective barrier to macromolecules Br. Med. Bull., 34(1) 55-56, 1978. 27. Eklof, O.A., Johanson, L., and Lohr, G. Childhood...

[58 [59 [60

About 90 of pancreatic cancers contain mutations in the k-ras proto-oncogene. k-ras mutations have been detected from duodenal juice, pancreatic juice, stool and fine-needle aspirates of patients with proven pancreatic adenocarcinoma. Although this test is not commercially available, the use of such molecular genetic markers in the early diagnosis of pancreatic cancer may be crucial for earlier Diagnostic imaging modalities for patients with suspected periampullary neoplasms include...

Parts Of A Hernia

Vestige Medicine For Hernia

A hernia consists of a sac (from the Latin saccus, bag), the sac contents, and the ring or edges of a defect. The ring is more important than the protrusion because on examination it is frequently the only physical sign. The sac is generally composed of peritoneum covered by vestiges of the layers of the abdominal wall it has penetrated. ETIOLOGY Hernias may be congenital, acquired, or a combination thereof. There may be a family history. Acquired hernias reflect wear and tear from aging,...

Ii131

And reconstruction via gastroduodenoscopy, sutured technique ( Fig. 11-51 Fig. 11-52 Fig. 11-53 (Figure Not Available) Fig. 11-54 (Figure Not Available) Fig. 11-55 ) and stapled technique ( Fig. 11-56 and Fig. 11-57 ). Total Gastrectomy The steps involved in total gastrectomy include the following sequence division of short and left gastric vessels ( Fig. 11-58 Fig. 11-59 Fig. 11-60 ), pursestring suture and division of esophagus ( Fig. 11-61 ), creation of Roux-en-Y limb (Fig. 11-62 (Figure...

Michael W De Boisblanc Donald D Trunkey

Early decision making Influences survivability after major hepatobiliary trauma. Severe hepatic hemorrhage remains a significant cause of possibly preventable mortality. Morbidity after hepatobiliary trauma Is significant and predictable by the severity of Injury. Management methods have evolved since 1950, and therapy continues to be Improved on currently. Hepatic parenchymal Injuries, vascular Injuries, and biliary Injuries present specific management problems and often occur concomitantly....

Frederic E Eckhauser George Sarosi

Variceal bleeding is the most catastrophic complication of portal hypertension associated with cirrhotic and noncirrhotic forms of liver disease. Almost 40 of patients with cirrhosis die within 6 weeks after the index hemorrhage, usually of progressive liver failure. If a patient survives the initial period, the risk of late current rebleeding approximates that of unselected patients with cirrhosis who enter the risk pool for the first time. However, during the initial high-risk period, the...

Achalasia

Achalasia of the esophagus is a degenerative neural disorder characterized by loss of ganglion cells within the myenteric plexus and reduction of nerve fibers in the esophageal wall. Recent histochemical studies have demonstrated a decrease in both vasoactive intestinal polypeptide and nitrous oxide, which are known mediators of smooth muscle relaxation in many gastrointestinal sphincters in patients with achalasia Paradoxical esophageal contraction to known inhibitory peptides such as...

Calvin B Ernst

Discussion of anatomy of the blood supply to the gastrointestinal tract must be qualified with knowledge that the incidence of normal anatomic variation is great and that the number of possible combinations of variations from normal is even greater. This chapter describes and illustrates the usual anatomy of visceral vessels and their more common variations as well as the chief communicating pathways between major visceral circuits that supply the gastrointestinal tract. The focus is on the...

Thomas R Eubanks Carlos A Pellegrini

Laparoscopy has dramatically changed the operative approach to the distal esophagus. A once difficult exposure has been improved with the use of videoendoscopy to view the esophageal hiatus and gastroesophageal (GE) junction. In addition to better exposure, the minimally invasive approach has made elective operations more palatable to patients and referring physicians. This change is based on the shorter hospital stay, smaller incisions, and decreased postoperative pain. Gastroesophageal reflux...

7 Sub100pm

Figure 3-6 High-amplitude propagated contractions Induced by neostigmine. Figure 3-6 High-amplitude propagated contractions Induced by neostigmine. Figure 3-7 Colonic motor response to a 1000-Kcal meal showing increased phasic pressure activity recorded by manometric sensors and reduction in barostat balloon volume maintained at constant pressure, indicating increased tone. Figure 3-8 Schematic of events that precede defecation. Figure 3-8 Schematic of events that precede defecation. Figure 3-9...

V217

Between artery and vein enabling efficient secretion and absorption of water, electrolytes, and nutrients. In addition, a central lymphatic vessel called a lacteal facilitates transport of fats and immunologic substances. The muscularis mucosae consists of a thin layer of smooth muscle cells between the mucosa and the submucosa. INTESTINAL EPITHELIUM AND ITS FUNCTIONS General Considerations Intestinal epithelial cells form a layer that separates the internal milieu from an external environment...

Modified From Netter

Figure 1-2 Celiac axis variations. 1, Celiac axis 2, left gastric artery 3, common hepatic artery 4, splenic artery 5, superior mesenteric artery. (From Ruzicka, F. F., and Rossi, P. Normal celiac and hepatic arteriogram. N.Y. State J. Med., 23 3032, 1968, with permission.) Figure 1-3 Variations in liver blood supply. l, Celiac axis 2, left gastric artery 3, common hepatic artery 4, splenic artery 5, superior mesenteric artery 6, right hepatic artery 7, left hepatic artery 8, gastroduodenal...

Hernia Of The Linea Alba

Hernia in the linea alba above the umbilicus is called an epigastric hernia hernia in the linea alba below the umbilicus is termed hypogastric hernia. Epigastric hernia is far more common. One per cent of all hernias are reported to be epigastric, whereas hypogastric hernias are rare. This difference probably is a result of the linea alba being much broader above the umbilicus than below it. Epigastric hernias occur five times more commonly in men than in women and are usually seen in patients...

Open Operative Technique

The principles of successful surgery for reflux disease are entirely predicated on the creation of a valvular mechanism that will control the reflux of gastric acid into the lower esophagus. There should be a requisite emphasis on the correction of associated hiatal hernias because maintenance of the esophogagastric junction below the diaphragm greatly enhances the physiologic effects on the lower esophageal sphincter mechanisms. The transabdominal operation is best performed through an upper...

Top

Figure 24-14 A and B, Retention sutures of No. 28 stainless steel are placed to include all layers of the abdominal wall except the skin and subcutaneous tissue. Sutures are kept taut while the peritoneum and posterior sheath are closed. C, The sutures are then tied to be snug but not so tight as to cause tissue edema and vascular impairment. (From Cooper, P. ed. The Craft of Surgery, 2nd ed. Boston, Little, Brown, 1971, p. 1283, with permission.) Figure 24-15 Stay suture, including rectus...

Frederic E Eckhauser James A Knol George A Sarosi

Esophageal varices are thin-walled submucosal veins that develop most commonly in the lower esophagus and gastric cardia in response to elevated pressure in the portal circulation. Acute bleeding is the only clinical manifestation of esophageal varices and can be torrential. Management of variceal hemorrhage requires a thorough knowledge of the various treatment options, astute clinical judgment, and timely interventions. Our understanding of the pathophysiology, diagnosis, and management of...

Vascular Ectasias

Vascular ectasias of the colon are by far the most common vascular lesions found in the colon and are probably the most frequent cause of recurrent lower intestinal bleeding after 60 years of age. They are distinct pathologic and clinical entities, and in our concept of their pathogenesis, they arise from age-related degeneration of previously normal colonic blood vessels. Vascular ectasias almost always occur in the cecum or the proximal ascending colon, are usually multiple, are less than 5...

I163

Figure 7-13 A, An esophageal leiomyoma. A barium esophagram shows an extraluminal mass (arrows), with no mucosal involvement. B, The extraluminal mass at esophagoscopy. C, On esophageal ultrasound, a hypoechoic tumor (T) can be seen arising from the fourth ultrasound layer (arrows). This intramural mass is confined to this layer with no invasion of adjacent layers. Figure 7-15 Foregut cyst. A, There is no extrinsic esophageal compression at esophagoscopy. B, On esophageal ultrasound, the cyst...

Contaminated Wounds

Contamination in surgical wounds causes a significant increase in both morbidity and mortality rates. Hospitalization periods are prolonged. In one study, major complications developed in 10.5 of patients with contaminated wounds, whereas individuals with clean wounds had a complication rate of 1 to 2 . Identification of the obviously contaminated wound is not a problem. An incision where surfaces are in contact with pus or an infective fluid during an operative procedure is considered highly...

W Robert Rout

Good exposure is essential for operations on the stomach and duodenum. An upper midline incision from the xiphoid to the umbilicus offers a highly satisfactory and versatile approach for the common operations on the stomach and duodenum. It can be easily extended into an abdominothoracic incision when desired for total gastrectomy or operations on the cardiac end of the stomach. This is accomplished by extending the incision laterally to the left at the upper end of the vertical incision ( Fig....

Endoscopic Anatomy Of The Esophagus

The length of the esophagus Is related directly to the height of the Individual and averages 25 cm In the adult. The cricopharyngeus lies 15 to 18 cm from the Incisors, whereas the lower esophageal sphincter Is found about 40 cm from the Incisors. The Internal diameter of the esophagus Is 1.5 to 2.5 cm and Is maximal In the distal portion. Compression of the lumen on the left lateral portion by the aortic arch Is found approximately 25 cm from the incisors, and compression from the left main...

Iv326

Figure 23-23 The various parts of the appliance that are in contact with the skin may be the source of skin excoriation. Figure 23-24 Closure of loop ileostomy by resection. A, A stapled anastomosis may be constructed by passing a linear staple cutter down the two adjacent loops of bowel through an enterotomy in each of the ileal segments. B, The damaged segment and the two enterotomies are resected by a second firing of the stapler at right angles to the long axis of the bowel as shown the...

T23 A

Figure 22-10 Schematic representation of the functional anatomy of the liver. Three main hepatic veins divide the liver into four sectors, each of them receiving a portal pedicle hepatic veins and portal pedicles are intertwined as the fingers of the two hands. (From Bismuth, H. Surgical anatomy and anatomical surgery of the liver. World J. Surg., 6 3, 1982, with permission.) Figure 22-11 The functional division of the liver and the segments according to Couinaud's nomenclature (see text)....

Iv63

Figure 6-1 A, Barium enema of ileocolic intussusception demonstrating an invaginating mass into the right colon with the coiled-spring appearance of proximal small bowel obstruction. B, Computed tomography scan showing ileocolic intussusception, with the typical bull's eye appearance of bowel within bowel in the right abdomen. Figure 6-3 A, Barium enema of sigmoid volvulus demonstrating the classic bird's beak at the point of the twist. B, Barium enema of cecal volvulus, with the bird's beak in...

Natural History Of Dilated Strictures

Although stricture dilatation is widely used to treat all forms of benign esophageal strictures, the information on rate of stricture recurrence and long-term effectiveness of bougienage is limited. Patterson looked at 154 patients for time to redilatation and the percentage requiring redilatation. Only 98 patients achieved initial dilatation to 40 French or greater and were followed for up to 48 months. Life-table analysis showed that the highest risk for redilatation was in the first year,...

Ts W

Figure 2-2 The autoregulatory escape phenomenon accounts for maintenance of intestinal blood flow at nearly normal levels despite continuous sympathetic stimulation. (From Sernka, T., and Jacobson, E. Gastrointestinal Physiology The Essentials, 1979, by Williams I_ Wilkins, Baltimore.) Figure 2-3 Schematic diagram of the mucosal countercurrent exchange mechanism. Arterial and venous channels are adjacent in the villus shaft. Because of a diffusion gradient, some oxygen passes directly into the...

Iii237

Ruptured Viscus

The patient under general anesthesia, it is highly desirable to have the patient's cooperation. Only mild sedation is required under such circumstances. Other contraindications are perforated viscus and a newly created esophageal, gastric, or duodenal anastomosis. Relative contraindications include active acute pancreatitis, cholangitis, pancreatic pseudocyst, and allergy to iodinated contrast. ERCP can be performed usually without exacerbation of acute pancreatitis if care is taken to avoid...

Embryology

The liver, extrahepatic bile ducts, gallbladder, and ventral portion of the pancreas originate from the hepatic diverticulum during early embryonic development.1 1 1 The hepatic diverticulum becomes evident in the human embryo during the fourth week of intrauterine life. This diverticulum arises as an outpouching from the ventral surface of the primitive foregut.1 Soon after its appearance, the hepatic diverticulum migrates superiorly into the ventral mesogastrium as a solid cord of endodermal...

Rectus Muscle

Figure 16-4 A, Original method for the staged primary repair of a large omphalocele with intact sac. 1, The patient preoperatively. 2, An incision is made around the omphalocele, leaving the sac intact. The incision is extended superiorly and inferiorly to expose the entire length of the rectus muscles. 3, Separate sheets of knitted PTFE mesh are sutured along the medial edge of the rectus muscles. 4, The omphalocele mass is compressed gently into the abdomen as the sheets of PTFE are...

Yaron Sternbach Bruce A Perler

Acute mesenteric ischemia (AMI) may be defined as an abrupt reduction in blood flow to the intestinal circulation of sufficient magnitude to compromise the metabolic requirements and potentially threaten the viability of the affected organs. It is a disease that has been recognized with increasing frequency since the original description of a successful superior mesenteric artery (SMA) thromboembolectomy nearly 50 years ago. Chronic occlusive disease of the mesenteric circulation is not...

Tumor Characteristics

Because of the nature of the tumor, preoperative localization of gastrinoma may prove difficult or, in some cases, unreliable. The tumor may be single or multiple and can range in size for less than 1 cm to more than 3 cm. When associated with MEN-1, studies suggest that gastrinomas are usually multiple and commonly found within the duodenum and pancreas.1 ' Although it has been suggested that the tumors found in patients with MEN-1 may have a lower potential for metastases, they appear to...

V207

Intestinal Atresia With Figure

Figure 17-1 View of the mesenteries and attachments of the small intestine. The small intestines have been removed, as has the sigmoid colon. (From Clemente, C.D. Anatomy A Regional Atlas of the Human Body. Philadelphia, Lea & Febiger, 1975, plate 305, with permission.) Figure 17-1 View of the mesenteries and attachments of the small intestine. The small intestines have been removed, as has the sigmoid colon. (From Clemente, C.D. Anatomy A Regional Atlas of the Human Body. Philadelphia, Lea...

I387

Figure 24-1 To perform a counterincision, the scapula is retracted off the chest wall and a higher interspace selected. A seventh and fourth interspace approach is illustrated. (From the Society of Thoracic Surgeons. Ann. Thorac. Surg., 46 250, 1988, with permission.) Figure 24-1 To perform a counterincision, the scapula is retracted off the chest wall and a higher interspace selected. A seventh and fourth interspace approach is illustrated. (From the Society of Thoracic Surgeons. Ann. Thorac....

S

Figure 11-4 The obturator artery and a frequent variation In Its origin. Figure 11-5 Femoral hernia of 3 years' duration in a 30-year-old man. A, The hernia remains reduced with the patient in the standing position. B, Note that the right femoral hernia appears after a strain or cough. (From Watson, L.F. Hernia, 3rd ed. St. Louis, C. V. Mosby, 1948, with permission.) Figure 11-5 Femoral hernia of 3 years' duration in a 30-year-old man. A, The hernia remains reduced with the patient in the...

Esophageal Perforation Home Remedy

Esophageal Tear Drawing Images

Figure 27-7 Inadvertently swallowed brldgework. Attempted endoscopic removal resulted in extensive esophageal laceration and perforation, which was shown by the presence of mediastinal air. At exploratory thoracotomy, repair of the esophagus was not possible, and an esophagectomy with cervical esophagogastric anastomosis was carried out. Figure 27-8 Delayed recognition of cervical esophageal perforation after attempted endotracheal intubation. The large abscess in the upper left thorax required...

Sandra L Wong Susan Galandiuk

Pneumatosis cystoides intestinalis (PCI), pneumatosis cystoides coli, peritoneal pneumatosis, pneumatosis cystoides intestinorum, abdominal gas cysts, cystic lymphopneumatosis, and intestina gas cysts are all terms used to describe the uncommon occurrence of multiple, gas-filled cysts of the gastrointestinal tract that are subserosal, submucosal, or both. PCI was first described by du Vernoi in 1730 based on findings during a cadaver dissection. The term was coined by Mayer in 1835, and the...

I245

Reconstruction with stomach. In Skinner, D.B., and Belsey, R.H. Management of Esophageal Disease. Philadelphia, W.B. Saunders, 1988, p. 228. 115. Skinner, D.B., and Belsey, R.H. Surgical management of esophageal reflux and hiatus hernia. J. Thorac. Cardiovasc. Surg., 55 33, 1967. 116. Skinner, D.B., and Belsey, R.H. Surgical management of esophageal reflux and hiatus hernia and long term results with 1,030 patients. J. Thorac. Cardiovasc. Surg., 55 33, 1967....

Scott A Engum Jay L Grosfeld

Malformations of the anorectum are relatively common congenital anomalies. The cause of anorectal malformation is unknown. The vast majority of experience in the management of these problems has been obtained at specialized children's hospitals that deal with disorders of the newborn. The reported incidence of anorectal anomalies ranges from 1 3500 to 1 5000 live births. Some families have a genetic predisposition, with anorectal malformations noted in succeeding generations. Malformations...

Annular Pancreas

An annular pancreas is a rare malformation in which a band of pancreatic tissue surrounds the descending portion of the duodenum with smooth continuation to the head of the pancreas. The pancreatic tissue of the annulus is histologically normal and contains both acini and islets. Theories have been developed to explain the process of formation of the annular pancreas. The most widely accepted theory is that of fixation of the tip of the ventral pancreatic primordium to the duodenal wall before...

Indications For Esophagoscopy

Diagnostic esophagoscopy is performed to make a thorough visual examination of the entire esophagus and relevant portions of the stomach and duodenum, to discover all significant abnormalities, and to take samples of lesions for biopsy when appropriate. It is generally indicated when the endoscopic findings influence patient management or when an empiric trial of therapy for an esophageal disease is unsuccessful Esophagoscopy should be performed when upper abdominal discomfort is associated...

Technical Points

At the time of endoscopy, a biopsy should be performed to rule out malignancy. The site should be marked with India ink. If the site is not tattooed, intraoperative colonoscopy is often necessary, because the site of the polyp may not be apparent from the serosal aspect of the bowel. This in turn has the disadvantage of distending the colon, which compromises exposure. Patients with familial adenomatous polyposis present with multiple (> 100) tubular adenomas of the colon, which in turn poses...

I178

G., Soriano, A., Ferguson, M. K., et al. Surgical treatment of achalasia Results with esophagomyotomy and Belsey repair. Ann. Thorac. Surg., 45 489, 1988. 70. Mandelstam, P., Block, C., Newell, L., and Dillon, M. The role of bougienage in the management of achalasia the need for reappraisal. Gastrointest. Endosc., 28 169, 1982. 71. Marks, R. D., and Richter, J. E. Peptic strictures of the esophagus. Am. J. Gastroenterol., 88 1160, 1993. 72. Marks, R., Richter, J. C., Koehler, R.,...

Definition And Etiology

Portal hypertension is defined as PVP that exceeds the normal value of 3 to 6 mmHg. It is not the elevated portal pressure itself, but rather the complications of this pathophysiologic state hemorrhage from gastroesophageal varices, portal hypertensive gastropathy, ascites, spontaneous bacterial peritonitis (SBP), encephalopathy, and hypersplenism that demand treatment. Of these potential complications, bleeding from ruptured gastroesophageal varices is directly responsible for the largest...

Hiram C Polk Jr Mark A Wilson

The discovery of the existence and pathophysiology of gastroesophageal reflux disease (GERD) proceeded in a sequential and orderly manner. Unfortunately, as a result of Allison's widely read and appreciated article, excessive emphasis was placed on the existence of a hiatal hernia, and insufficient emphasis was placed on the true underlying process of abnormal acid reflux. Not surprisingly, a large number of patients, often without significant acid reflux or esophagitis, underwent either...

G

Ligature Hernial Clamp Calf

Figure 15-2 A, If one tries to reduce an incarcerated hernia by pushing up the contents from the scrotum, the hernia balloons over the internal or external ring and prohibits reduction. B, By applying slow, steady pressure with one hand at the level of the ring, the hernial contents can be funneled into an intra-abdominal position. Figure 15-3 Management of sliding hernias in infants. A, Male infant with an inguinal hernia on the left side. B, Opened indirect inguinal hernial sac shows the...

Omphalocele And Gastroschisis

An omphalocele is a developmental defect of closure of the umbilical stalk characterized by protrusion of viscera, often including the liver, from a smaller than usual abdominal cavity into the stalk the viscera are covered by a translucent bilaminar omphalocele sac consisting of fused amnion and peritoneum. The sac is avascular except for the umbilical vessels. This thin sac may tear prenatally or during delivery rupture is more likely in giant omphaloceles (greater than 10 cm in diameter)....

Johnston TD and Katz SM Special considerations in the transplant patient requiring other surgery Surg Clin North Am

Burack, J.H., Mandel, M.S., and Bizer, L.S. Emergency abdominal operations in the patient with acquired immunodeficiency syndrome. Arch. Surg., 124 285, 1989. 27. Harris, H.W., and Schecter, W.P. Surgical risk assessment and management in patients with HIV disease. Gastroenterol. Clin. North Am., 26 377, 1997. 28. Dunn, D.L. Problems related to immunosuppression Infection and malignancy occurring after solid organ transplantation. Crit. Care Clin., 6 955, 199G. 29. Alexander, P., Schuman,...

Vagal Function

The vagus nerve is the longest of the cranial nerves, and it has an extended distribution with branches to the cervical, thoracic, and abdominal regions. It has fibers that are somatic and visceral afferent fibers that innervate the mucosa of the stomach and play a major role in the cephalic phase of gastric acid secretion by releasing Figure 10-1 Anatomy of the vagus nerve on the lower esophagus and stomach. (From Lawrence, P.F. Essentials of General Surgery. Philadelphia, Lippincott,...

Eczema

Atopic eczema is a chronic, relapsing pruritic dermatitis that usually occurs in adults and is localized to the flexural surfaces of the face, neck, cubital or popliteal fossa, and hands. The dermatitis usually occurs in patients with a personal or family history of atopy or hay fever asthma urticaria lesions may present as papular, scaly, or chronic lichenified plaques. The cause is unknown but is believed to be IgE mediated. fill Some researchers support food allergies and proteinaceous...

Ii297

Ends can be cut or can be left long and held for traction until the next suture has been placed. When the cut edges of the linea alba can be approximated only with tension, one can close with interrupted far-near sutures. These penetrate the rectus sheath about 3 cm lateral to the cut edge, pass beneath it through the anterior fibers of the rectus muscle to cross the wound and emerge through the anterior rectus sheath 0.5 cm from its cut edge on the other side, cross over the wound to penetrate...

[14

The Y-V advancement flap is based on a slightly different principle.1 ' The vertical limb of the Yis inscribed on the anal canal at the level of the stenosis, and the V of the Y Figure 39-1 V-Y advancement flap. A, Lateral inverted V inscribed over ectropion or mucosal defect. B, Flap mobilized to preserve vasculature after stenosis is divided or ectropion is excised. C, Flap sutured in place with Y closure. (From Fleshman, J. W. Fissure-in-ano and anal stenosis. In Beck, D.E., and Wexner, S.D....

Iii304

The normal metabolic pathway for red cell-derived bilirubin (70 of total) is shown. uBILIRUBIN is unconjugated (water-insoluble) bilirubin that is reversibly carried by albumin. Ligandin is thought to mediate intracellular transport of bilirubin. cBILIRUBIN is conjugated (water-soluble) bilirubin. Urobilinogen is increased in the urine in liver disease. TABLE 23-1 -- Causes of Elevated Total Bilirubin Crigler-Najjar syndrome (types 1 and 2) Hematoma resorption...

I4s

The use of the long-acting somatostatin analog octreotide in decreasing pancreatic and enterocutaneous fistulous output has been popularized during the 1990s. Its inhibitory effect on gastric, biliary, and pancreatic secretions is generally observed in clinical use. With typical subcutaneous dosages of 100 pg every 8 hours, fistulous output is reduced by 40 to 60 after the first day. Side effects are usually not severe and include hyperglycemia, decreased bowel motility, and elevated...

Ii64

Operative therapy of perforated duodenal ulcers can be divided into simple closure versus definitive treatment groups. In the past, simple closure of perforated duodenal ulcers, which consists of closing and buttressing the ulcer perforation with a pedicle of omentum (omental flap), was the standard form of treatment, but later it was reserved for the most seriously ill patients ( Fig. 5-3 ). Simple closure is appropriate for patients with major underlying medical illnesses, patients with...

Operative Technique

The patient is placed supine with the legs abducted. After pneumoperitoneum is established, trocar positions are plotted on the abdominal wall ( Fig. 16-1 ). A 10-mm port is placed through the left rectus muscle, 15 cm below the xiphoid process, for an angled operative laparoscope. Another 10-mm port is placed 11 cm down the left costal margin for the surgeon's right hand. A 5-mm trocar is inserted 20 cm along the left costal margin for retraction by the first assistant. A 5-mm port is then...

Diagnosis

The history and physical findings associated with the diagnosis of portal hypertension are those produced either by its causes or by its complications. In fact, the evaluation of portal hypertension is usually prompted by the development of variceal hemorrhage or ascites. Cirrhosis is the most common cause of portal hypertension in the United States, and although the diagnosis of chronic liver disease is beyond the scope of this chapter, a thorough inquiry should be made to determine alcohol...

Way L and Sleisenger M Cholelithiasis Chronic and acute cholecystitis In Sleisenger M and Fordtran J eds

Moreau, J.A., Zinsmeister, A.R., Melton, L.J., et al. Gallstone pancreatitis and the effect of cholecystectomy A population-based cohort study. Mayo Clin. Proc., 63 466, 1988. 14. Acosta, J.M., Pellegrini, C.A., and Skinner, D.B. Etiology and pathogenesis of acute biliary pancreatitis. Surgery, < 9 118, 1980. 15. Kelly, T.R. Gallstone pancreatitis Pathophysiology. Surgery, < 0 488, 1976. 16. Lee, S.P., Nichols, J.F., and Park, H.Z. Biliary sludge as a cause of acute pancreatitis. N....

Charles J Yeo Keith D Lillemoe Steven A Ahrendt Henry A Pitt

Strictures and other benign obstructive disorders of the bile ducts represent a heterogeneous group of conditions, largely with similar clinical manifestations, which often require challenging surgical approaches. The many causes of benign obstruction of the bile ducts are listed in Table 18-1 . Although numerous technologic developments have improved diagnosis and management, bile duct strictures remain a significant clinical problem. If these strictures or benign obstructive disorders are...

Tf

Figure 24-27 The anatomy of the anorectum might explain radial variations In resting pressure. The puborectalis muscle swings around behind the anal canal at Its most proximal limit posterior resting pressures are thus higher than anterior resting pressures. In the distal anal canal, radial pressures are lowest posteriorly and highest anteriorly. Figure 24-28 The angulation between the rectum and anal canal. This angle Is formed by the anteriorly directed pull of the puborectalis muscle and Is...

Karen M Horton Bronwyn Jones Elliot K Fishman

Endoscopic studies are often considered the diagnostic modality of choice for the evaluation of esophageal pathology. However, radiologic studies continue to play a vital role in the diagnosis of many benign and malignant diseases of the esophagus. Although upper endoscopy can be used to evaluate the esophageal lumen and mucosa, it cannot be used to detect extrinsic disease and provides limited functional information. Contrast esophagography allows real-time visualization of esophageal...

I289

The advanced diverticulum may come to lie in the same vertical axis as the pharynx, permitting selective filling of the sac, which may compress and angulate the adjacent esophagus anteriorly. These anatomic changes obstruct swallowing. Moreover, because the mouth of the diverticulum is above the cricopharyngeus, spontaneous emptying of the diverticulum is unimpeded and often associated with laryngotracheal aspiration as well as regurgitation into the mouth. Several investigators have commented...

Iii248

Before the widespread use of laparoscopic cholecystectomy, major bile duct injuries were relatively infrequent, occurring in approximately 2 of every 1,000 open cholecystectomies. It appears that the rate of bile duct injury has at least doubled since the introduction of laparoscopic cholecystectomy. It is likely that the exact incidence of bile duct injury is unknown, because many wide 5 t cases go unreported in the literature. However, a wide range in the...

Iii530

Figure 34-8 Pediatric living donor hepatic transplantation. Donor segments II and III usually provide sufficient liver for an adult-to-child transplantation. The adult donor liver is excised just to the left of the falciform ligament and with minimal hilar dissection (upperleft). The donor left hepatic vein is clamped and divided at the junction with the vena cava (upperright). Sometimes, vascular extensions are anastomosed to the donor graft hepatic artery and portal vein (lower left)....

Treatment

Pilling Esophagoscope

Two critical questions must be answered about every newly diagnosed esophageal stricture (1) Is the stricture benign or malignant, and (2) if benign, can it be dilated The relative technologic explosion in the variety of available flexible fiberoptic esophagogastroscopes and instrumentation possible through them has resulted in this instrument becoming the most common means of assessing the esophageal lumen and stenoses visually. Rigid esophagoscopy still has its place in the esophageal...

Anatomy and Embryology

DOROTHEA LIEBERMANN-MEFFERT ANDR DURANCEAU HUBERT J. STEIN ANATOMY OF THE ESOPHAGUS MACROSCOPIC FEATURES Configuration The esophagus is the narrowest tube of the intestinal tract. It ends by widening into its most voluminous part, the stomach. At rest, the esophagus is collapsed it forms a soft muscular tube that is flat in its upper and middle parts, with a presenting diameter of 2.5 x 1.6 cm. The lower esophagus is rounded, and its diameter is 2.5 x 2.4 cm. Compression or constriction by...

V380

Figure 26-1 The external appearance of Crohn's disease at the terminal ileum and right colon. Gross features consistent with Crohn's disease can be seen in the terminal ileum (A), cecum opposite the ileocecal valve (B), and ascending colon (C). Extension of mesentery onto the serosal surface of the bowel is noted. (From Mottet, N.K. Histopathological Spectrum of Regional Enteritis and Ulcerative Colitis. Philadelphia, W.B. Saunders, 1971, with permission.) Figure 26-2 String sign in the...

Etiology

Postoperative leaks from gastric staple or suture lines after ulcer surgery have accounted for most perforations in the past. However, the decline in gastric resection for ulcer disease, with the broad application of new endoscopic and laparoscopic techniques for other diseases, accounts for many other newer causes of perforation. Endoscopy The capacity and compliance of the stomach make endoscopic examination routine, with a low incidence of injury. However, endoscopic polypectomy or attempts...

Years Postproceuure

Roslyn, J.J., Binns, G.S., Hughes, F.X.E., et al. Open cholecystectomy A contemporary analysis of 42,464 patients. Ann. Surg., 218 129, 1993. 2. Fletcher, D.R., Hobbs, M.S.T., Tan, P., et al. Complications of cholecystectomy Risks of the laparoscopic approach and protective effects of operative cholangiography A population-based study. Ann. Surg., 229 449, 1999. 3. Adamsen, S., Hansen, O.H., Funch-Jensen, P., et al. Bile duct injury during laparoscopic cholecystectomy A prospective nationwide...

Anatomic And Physiologic Considerations

Many of the complications of esophageal surgery are related directly to the unique features of esophageal anatomy and physiology. A thorough understanding and appreciation of these characteristics allows the informed esophageal surgeon to think and act defensively, thus averting complications before they occur. In performing esophagoscopy, for example, one must bear in mind the three naturally occurring sites of esophageal narrowing the upper esophageal introitus, or cricopharyngeal sphincter...

Ii85

Isenberg, J.I., McQuaid K., Laine, L., et al. Acid-peptic disorders. In Yamada, T., et al. (eds.) Textbook of Gastroenterology, 2nd ed. Philadelphia, J.B. Lippincott, 1995, p. 1347. 17. Isenberg, J.I., Peterson, W.L., Elashoff, J.D., et al. Healing of benign gastric ulcer with low-dose antacid or cimetidine A double-blind, randomized, placebo-controlled trial. N. Engl. J. Med., 308 13119, 1983. 18. Johnson, H.D. Gastric ulcer Classification, blood group characteristics, secretion patterns,...

Structural Adaptations Of Colo-rectum

TABLE 22-2 -- Intestinal Length and Nutritional Prognosis TABLE 22-2 -- Intestinal Length and Nutritional Prognosis 120-180 cm small intestine or 90-120 cm small intestine plus colon *Data from Carbonel, et al. > , Gouttebel, et al.L J , and Levy, et al.L > . From Thompson, J.S. Intestinal resection and the short bowel syndrome. In Quigley, E.M.M., and Sorrell, M.F. (eds.) Medical Management of the Gastrointestinal Surgery Patients. Baltimore, Williams & Wilkins, 1994, pp. S27-S52....

Nasogastric tube

Figure 5-5 The surgical approach to a bleeding posterior duodenal ulcer via pyloroplasty. Left, A longitudinal incision is made into the lumen across the pylorus, after the pylorus is tented up by stay sutures. Right, Transfixion of the posterior ulcer is shown, via the pyloroplasty incision. Because bleeding may be coming cephalad or caudad in the gastroduodenal artery, double ligation is recommended. (From Hardy, J.D. ed. Critical Surgical Illness, 1st ed., Philadelphia, W.B. Saunders, 1971.)...

Benign Tumors Of The Gallbladder

Benign tumors of the gallbladder are uncommon and consist of benign neoplasms (adenomas, leiomyomas, lipomas, granular cell tumors, hemangiomas) and hyperplastic or inflammatory pseudotumors (adenomatous hyperplasia, cholesterol polyps). They may present as polypoid lesions or as thickening of the gallbladder wall. Cholesterol Polyps Ultrasonography has led to the increased detection of polypoid lesions of the gallbladder. Most polyps are small projections from the gallbladder wall and...

Gastric Volvulus

Gastric torsion is a condition that complicates large hiatal hernias in which there is intrathoracic herniation of the stomach into the chest. Actual gastric volvulus is defined, in the strictest sense, as the occurrence of the actual complete obstruction of the gastric lumen from the torsion that accompanies such herniation. The number of reported cases in the literature before 1970 was 265, with the condition occurring fll primarily in elderly persons.1 In Figure 13-1 (Figure Not Available)...

Earle W Wilkins Jr Md

Clinical Professor of Surgery Emeritus, Harvard Medical School Senior Surgeon, Techniques of Esophageal Reconstruction Associate Professor of Surgery, University of Louisville Director, Price Institute of Surgical Research, University of Louisville, Louisville, Kentucky The Nissen Fundoplication Operative Technique and Clinical Experience BRUCE G. WOLFF M.D. Consultant in Colon and Rectal Surgery, Consultant in Colon and Rectal Surgery, Surgery for Distal Small Bowel, Colonic, and Anorectal...

Introduction To Radiotherapy

RT involves the use of ionizing radiation in the treatment of malignant disease. Conventional external-beam treatments are administered with high-energy photon beams, typically with energy of 1.25 megaelectron volts (MV) to 15 MV or higher. These energies significantly exceed those of x-rays used in diagnostic radiology. The high energy of therapeutic radiation beams enables the treatment to penetrate the body and to be used to treat deep tissues. Depending on the actual energy, only several...