Info

Figure 11-48 A, The mucosal suture is continued along the length of the anterior aspect of the anastomosis. B, An anterior layer of interrupted silk sutures completes the anastomosis. (A from Soybel, D.I., and Zinner, M.J. Stomach and duodenum Operative procedures. In Zinner, M.J., Schwartz, S.I., and Ellis, H. eds. Maingot's Abdominal Operations. Stamford, CT, Appleton & Lange, 1997, p. 1112. B from Mulholland M. W. Atlas of gastric surgery. In Bell, R.H., Jr., Rikkers, L.F., and...

Iis8

H. pylori is a spiral-shaped, flagellated, microaerophlllc, motile gram-negative rod. It is believed that more than 50 of the world's population is Infecied with H. pylori. Most infected persons are asymptomatic, although almost all infected individuals demonstrate some degree of antral gastritis on pathology.1 1 In the United States, the prevalence of H. pylori Infecilon is about 30 , which represents a 50 decline from 1970. It is more common among elderly persons and among Hispanics or...

Tumor Relapse

The rate of recurrence of colorectal cancer is reported to be 25 to 50 . The incidence of relapse depends in part on the length and intensity of follow-up and on whether early, first site of relapse, late, or all sites of relapse are reported. Of these, the most important is the first site of relapse because curative attempts would be favorably influenced by efforts directed at early relapse. First sites of relapse most often develop in the liver, locoregional sites, or lungs ( Fig. 21-1 )....

Ii578

With cessation of hemorrhage and in the absence of other injuries, the patient can be discharged from the hospital after 1 week of complete bed rest. Ambulation must be reinstituted gradually to avoid the orthostatic hypotension that may result from resumption of upright posture after a prolonged period of bed rest. At this point, the child and family are instructed to pursue a lifestyle that minimizes the risk of recurrent injury. The period of this restriction varies from several weeks to 6...

Locoregional Recurrence

Single-site locoregional recurrences account for 5 to 19 of colon cancer and 7 to 33 of rectal cancer relapses. Of these, between 7 and 20 are resectable with a curative intent.1 ' 1 ' 1 ' As discussed later, local recurrences are more likely to follow resections of rectal cancers compared with those of the colon. This section therefore focuses on locally recurrent rectal cancer, because most of the strategies for diagnosis and therapy can be similarly applied to locally recurrent colon...

V74

Chaphery, A.D., Gupta, R.L., and Currie, R.D. Carcinoma of the head of the pancreas with aortoduodenal fistula. Am. J. Surg., 111 580, 1966. 16. Chiari, H. Uber fremdkorperverletzung des oesophagus mit aorten perforation. Berl. Klin. Wochenschr., 51 7, 1914. 17. Clagett, G.P., Bowers, B.L., Lopez-Viego, M.A., et al. Creation of a neo-aortoiliac system from lower extremity deep and superficial veins. Ann. Surg., 218 239, 1993. 18. Cordell, A.R., Wright, R.H., and Johnston, F.R....

I287

Peracchia, A., Bonavina, L., Narne, S., et al. Minimally invasive surgery for Zenker diverticulum. Arch. Surg., 133 695, 1998. 63. Richter, J. E., and Castell, D. O. Diffuse esophageal spasm A reappraisal. Ann. Intern. Med., 100 242, 1984. 64. Richter, J. E., Dalton, C. B., Bradley, L. A., and Castell, B. O. Oral nifedipine in the treatment of noncardiac chest pain in patients with the nutcracker esophagus. Gastroenterology, 93 21, 1987. 65. Robertson, C. S., Fellows, I. W., Mayberry, J....

Iii396

Simplified esophageal transection for bleeding varices. BMJ, 1 1388, 1978. 162. Vankemmel, M. Deconnexion oesophago-portala par ligature, resection segmentaire et anastomose de l'oesophage abdominal a l'appareil PKS 25 ch z le cirrhotique. Acta Chir. Belg., 74 123, 1975. 163. Vankemmel, M. Resection anastomose de l'oesophage suscardinal pour rupture de varices oesophagiennes. Nouv. Presse Med., 5 1123, 1976. 164. Wexler, M.J. Treatment of bleeding esophageal varices by...

Jff

Figure 3-12 A pancreatic rest, heterotopic pancreas, noted in the stomach. It is a submucosal lesion with a characteristic central umbilication. Figure 3-13 Erosive gastritis secondary to salicylates. Figure 3-13 Erosive gastritis secondary to salicylates. Figure 3-14 A large, deep gastric ulcer with nodular edges. Extensive biopsy samples must be taken to exclude malignancy. If the ulcer is benign, it must be followed with repeated biopsies to complete healing. Figure 3-15 A leiomyoma of the...

Iv473

Chordoma Occipital Bone

Figure 36-2 Gross pathologic specimen of tailgut cyst revealing multicystic, multilocular appearance. Figure 36-7 Large presacral desmoid. Figure 36-4 Distribution of chordomas, showing predilection for sacrococcygeal and spheno-occipital sites. (From Dahlin, D.C. Bone Tumors General Aspects and Data on 6,221 Cases, 3rd ed. 1978. Springfield, IL, Charles C Thomas, 1978.) Figure 36-7 Large presacral desmoid. Figure 36-8 Appearance of presacral desmoid after preoperative radiation therapy. Figure...

Causes Of Biliary Obstruction And Cholangitis

The causes of acute cholangitis have changed in recent years. Stone disease is less often a cause, whereas strictures, either benign or malignant, have become more common causes. Indeed, one's experience is skewed by the practice environment. Reports in the literature are increasingly from tertiary hospitals treating patients with more complex malignant obstructions as opposed to stone disease. Pitt's group 1 ' treated more patients with cholangitis resulting from malignant strictures (57 of 96...

Cooper MJ Mackie CR Dhorajiwala J et al Hemorrhage from ileal varices after total proctocolectomy Am J Surg 141178 1981

Hosking, S.W., Smart, H.L., Johnson, A.G., and Triger, D.R. Anorectal varices, haemorrhoids, and portal hypertension. Lancet, 1 349, 1989. 22. Wilson, S.E., Stone, R.T., Christie, J.P., et al. Massive lower gastrointestinal bleeding from intestinal varices. Arch. Surg., 114 1158, 1979. 23. Pascal, J.P., Cales, P., and Desmorat, H. Natural history of esophageal varices. In Bosch, J., Rodes, J. (eds.) Recent Advances in the Pathophysiology and Therapy of Portal Hypertenison. Rome, Ares Serono...

Management Of Perforations And Fistulas

Acute intraoperative gastric or duodenal perforations should be repaired during the course of the operation. This simple principle presupposes both that the perforation is recognized and that its repair is possible. In particular, laparoscopic surgical procedures may produce perforations that are not recognized at that time. An adequate laparoscopic repair of gastric or duodenal lacerations may be quite difficult to perform laparoscopically. Conversion to laparotomy in these circumstances to...

Evaluation

The causes of fecal incontinence are divided into factors that alter anorectal anatomy (trauma, surgery), overwhelm physiologic control mechanisms (diarrhea, secretory tumors, fecal impaction), or interfere with neurologic function (diabetes, spinal cord injury, pudendal nerve injury). In many cases, a combination of factors leads to incontinence ( Table 31-1 ). For example, incontinence associated with rectal prolapse is due to excessive physical stretching of both the anal sphincter and...

History

Of duodenal ulcers in men and women has equalized. Duodenal ulcer patients as a group are younger than gastric ulcer patients. 1 2 2 58 Despite the improvement in the treatment of duodenal ulcer, it remains an enormous health problem. Approximately 25 million Americans will have an ulcer in their lifetime.1 ' 1 ' Each year, 500,000 to 850,000 new cases of ulcer disease develop, and approximately 1 million ulcer-related hospitalizations occur.1 ' At any given time, approximately 2 of the U.S....

Techniques Of Endoscopic Sclerotherapy

The flexible fiberoptic endoscope has largely replaced the rigid endoscope in the management of esophageal variceal hemorrhage. Both instruments have unique advantages and disadvantages. The advantages of the rigid endoscope are a slotted distal end to allow prolapse of the varix into the lumen of the esophagoscope for ease of injection. After injection of sclerosant, the scope can be rotated to tamponade the injected varix and facilitate hemostasis. The rigid esophagoscope has a larger...

Iii553

Patients with the more severe manifestations of this disease may develop one or more cytopenias, particularly thrombocytopenia. Usually, these cytopenias are manageable by effective treatment of the underlying disease. In a few patients, the cytopenia is severe and is refractory to nonoperative measures. Splenectomy brings about a prompt cytologic improvement in approximately two thirds of patients, but late relapse is more common than in patients with ITP or AIHA. The more severe the lupus,...

Ii212

Cells produce biologically active peptides and amines by intracellular decarboxylation these are referred to as amine precursor uptake and decarboxylation cells, the so-called APUD cells. Because they are morphologically similar to other APUD cells of neuroendocrine origin, they are presumed to migrate from the neural crest to the fetal stomach and may stimulate differentiation of the fetal stomach. These cells produce intracellular signaling molecules that regulate the complex events involving...

[97

Small amounts of necrosis (< 100 g), d bridement and lavage for more extensive necrosis, and d bridement with open packing and scheduled reoperation for patients with the most extensive necrosis.1 Correction of Associated Biliary Tract Disease Gallstone pancreatitis is a clear indication for a definitive biliary tract procedure intended to reduce the risk of recurrent attacks of pancreatitis. In the past, definitive biliary tract surgery (open cholecystectomy plus cholangiography with or...

[96 [220[212

Years from the time of resection is 80 to 90 .1 1 More than half of patients who experience weight loss preoperatively regain the lost weight within 1 year following operation. Although less than 50 of patients are able to work at the time of diagnosis owing to poor performance status, more than 80 of survivors do sufficiently well to work between 2 and 5 years postoperatively. 1 Resection, whether palliative or potentially curative, also lessens the likelihood of chronic tumor pain, bleeding,...

[8

Certain relatively straightforward guidelines pertain to the issue of whether to take a sample for biopsy. Cystic lesions usually do not require a biopsy because the results will not alter the management. Although some authors recommend a biopsy of all solid lesions,1 the most common solid tumor, chordoma, usually has a very characteristic appearance on plain films of the sacrum and CT scans and does not, in our practice, require a biopsy unless the diagnosis is uncertain. Violation of the...

[6

And in more than two thirds of these patients, the lesion is malignant. Bone destruction may also be seen with benign tumors such as giant cell tumors, neurilemoma, aneurysmal bone cysts, and osteochondroma.1 A scimitar sign on sacral views is classic for anterior sacral meningocele, a diagnosis that should be confirmed with myelography. Imaging with CT or MRI has become the preferred approach in establishing a diagnosis in these lesions. These techniques distinguish among cystic, solid, and...

[58

Histamine produces mesenteric vasodilation when it is administered intravenously or intra-arterially. Histamine causes contraction of nonvascular intestinal smooth muscle, an effect that may limit the increase in intestinal blood flow produced by vasodilation.1 ' Serotonin (5-hydroxytryptamine) occurs in large quantities in the bowel, and a physiologic role for this substance in the mesenteric circulation has been 5 proposed. Vascular responses to exogenous serotonin occur only at high...

[53

In transplant recipients, carcinomas of the skin and lips are the most common and are 38 of all malignancies in the Cincinnati Transplant Tumor Registry.1 ' Compared with the frequencies of these cancers in the general population, the incidence was increased four- to sevenfold in low sun exposure areas and more than 20-fold in high sun exposure areas. The lesions were more likely to be multiple in location and aggressive these were mostly squamous cell carcinomas. In the general population,...

[47i

Controlled by conservative measures, an unrecognized perforation in this area can also have fatal consequences. The site of perforation is the cervical esophagus in 40 of patients, the midesophagus in 25 , and the distal esophagus in 35 .1 Females appear to be more likely to have cervical perforations, whereas male patients more commonly develop perforations in the thoracic esophagus. Rigid esophagoscopes account for relatively more perforations than do flexible scopes (80 of the total in one...

[46[47

And intervention may prevent recurrent pancreatitis.1 However, ERCP has no role in the standard diagnostic evaluation of most patients with AP.1 The therapeutic use of ERCP and ES in the setting of gallstone pancreatitis is discussed later in this chapter. TABLE 2-6 -- Balthazar-Ranson Grading System B. Focal or diffuse enlargement of the pancreas C. Pancreatic glandular abnormalities associated with mild peripancreatic inflammatory changes (stranding) D. Fluid collection in a single location,...

[23[50

12 cases in which the occlusion was associated with arteriosclerosis, there was a story of chronic recurrent abdominal pain preceding the fatal attack by weeks, months or years.1 ' The term intestinal angina was coined by Mikkelsen in 1957 he recognized the proximal nature of the occlusive process within the visceral arteries and was the first to suggest surgical correction of the problem.1 ' A year later, Shaw and . Retrograde aortomesenteric bypass was introduced in the early 1960s, followed...

[23[24

In two patients so treated showed good quality defecation with good tolerance volumes, compliance, and anal manometry.1 ' Soave's procedure has also been used as a sphincter-preserving solution for radiation-induced rectal pathology. Faucheron et al.1 ' performed this operation on 30 patients and noted complications of postoperative hemorrhage, small bowel obstruction, pelvic or perianal sepsis, and anastomotic strictures. Of 23 evaluable patients, continence was described as normal in 19. The...

[19 [61 [62[63

It is postulated that single vacuoles become separated and remain within the esophageal wall and develop into duplications or cysts.1 1 1 Another theory has been advocated by Hutchison and Thomson.1 Because the endodermal tube, which is destined to form the gut, is a part of the yolk sac or archenteron, they propose that all developmental gastrointestinal cysts should be labeled as archenteric cysts. According to their theory, at an early stage in development, a...

[15 [44

Whether patients with cirrhosis have specific deficiencies in the ability to resist infection that are not caused by either alcohol ingestion or chronic malnutrition is not clear. Suffice it that, as with any patient with malnutrition, there are certain deficiencies in host resistance against infection. 1 1 In addition, other deficiencies appear to be related more to chronic alcohol ingestion and decreased hepatic protein synthesis. Again, these are probably relatively nonspecific and can be...

[13 [14 [15

Attractive as a possible means to avoid surgery, they are unlikely to stop bleeding with a single session. Radiation-induced hemorrhagic cystitis has been treated with intravesical instillation of formalin solutions, and the success that was noted stimulated interest in the use of this form of treatment for hemorrhagic proctitis. Bladder complications occurred more frequently when concentrations of 10 formalin were used fewer problems were noted when the concentration was reduced to 4 ....

V325

Figure 23-1 Small bowel obstruction arrow denotes upright film. Dilated loops of small bowel and air-fluid levels. Figure 23-2 Small bowel obstruction supine film. Dilated loops of small bowel with edematous wall. Figure 23-2 Small bowel obstruction supine film. Dilated loops of small bowel with edematous wall. Figure 23-3 Normal bowel patterns. Gas in the small bowel can usually be identified because small bowel mucosa has very fine lines that cross all the way across the lumen. Colonic air...

V307

Colon Crypt Apoptose

Figure 22-8 Photomicrograph of intestinal rejection in a transplanted intestinal graft. Apoptosis is a prominent feature. A single crypt is seen in the center with multiple apoptotic cells. Figure 22-8 Photomicrograph of intestinal rejection in a transplanted intestinal graft. Apoptosis is a prominent feature. A single crypt is seen in the center with multiple apoptotic cells. Figure 22-9 Surgical management of the short bowel syndrome. (From Thompson, J.S., et al. Surgical approach to the...

V304

The primary goal of surgical therapy for the short bowel syndrome is to increase intestinal absorptive capacity. This can be achieved by either improving absorption by existing intestine or by increasing the area of absorption ( Table 22-5 ). Recruiting additional intestine into continuity, relieving obstruction, or slowing intestinal transit will often improve absorption. The intestinal lengthening procedure is feasible in selected patients. The most significant increase in length, however, is...

V

Figure 26-13 Technique of primary repair of esophageal perforation (continuation of Fig. 26-12). Traction sutures placed through the inflamed pouting mucosal edge of the tear elevate the submucosa so that an Endo-GIA cartridge can be applied and fixed (A and inset). The staple suture-line is covered by approximating the adjacent muscle over it from a running absorbable suture (B). (From Whyte, R.I., lannettoni, M. D., and Orringer, M.B. Intrathoracic esophageal perforation The merit of primary...

Surface Anatomy

The surface projection of the cecum ( Fig. 1-2 ) is bounded by the right lateral plane, the transtubercular plane, and the inguinal ligament. From here, the ascending colon moves up to the right of the lateral plane until a point midway between the subcostal and transpyloric planes at the hepatic flexure. Here, the ascending colon meets the transverse colon, which drops to the umbilicus before passing upward and to the left to a point (splenic flexure) above and lateral to where the left...

Stk11

AD autosomal dominant, AR autosomal recessive, FAMMM familial atypical multiple-mole melanoma syndrome, HNPCC hereditary nonpolyposis colorectal cancer. 'From Hruban, R.H., Peterson, G.M., Ha, P.K., et al. Genetics of pancreatic cancer From genes to families. Surg. Oncol. Clin. North Am., 7 1, 1998, with permission. 'From Hruban, R.H., Peterson, G.M., Ha, P.K., et al. Genetics of pancreatic cancer From genes to families. Surg. Oncol. Clin. North Am., 7 1, 1998, with permission. pancreatic...

Steven A Ahrendt Md

Assistant Professor of Surgery, University of Rochester School of Medicine Attending Surgeon, University of Rochester Hospitals, Rochester, New York Operative Management ofStrictures and Benign Obstructive Disorders of the Bile Duct R. PETER ALTMAN M.D. Professor of Surgery and Pediatrics, College of Physicians and Surgeons, Columbia University Attending Surgeon and Surgeon-in-Chief, Children's Hospital of New York, New York Presbyterian Hospital New York, New York Neonatal Biliary Artresia,...

Rare Anal Neoplasms

This is an extremely rare lesion of the perianal skin. Commonly, patients complain of pruritus, occassionally with bleeding, lump, soiling, or change in bowel habit. Examination usually reveals an erythematous, scaling, rash-like lesion with well-demarcated edges. Patients are elderly (mean age, 60s), with equal gender distribution. Paget cells are the characteristic finding. These epithelial cells are large and rounded, with abundant pale cytoplasm and a large peripheral nucleus. The cells may...

Pathogenesis

Aortoenteric fistulas have been reported to involve all segments of the gastrointestinal tract from the esophagus to the colon, although the most common site (more than 80 of cases) is the distal duodenum. The close proximity of the infrarenal aorta to the overlying, relatively fixed third portion of the duodenum accounts for the high incidence of AEF in this location. Primary fistulas most commonly result from direct erosion of an aneurysm into adjacent bowel. With aneurysm expansion, adherent...

Kenric M Murayama Thomas A Miller

Although discussions of gastric ulcer are frequently lumped together with those of duodenal ulcer under the broad heading of acid-peptic disease, a number of features distinguish these two entities, justifying separate consideration. Although it is true that both types of ulcer require a luminal acid milieu to develop, the overnight acid output in the typical patient with a gastric ulcer is usually in the range of 1.2 mEq hr, whereas in the average patient with a duodenal ulcer outputs...

Iv413

Peritoneum covering the anterior rectal wall, loss of posterior fixation of the rectum to the sacral curve, and lengthening and downward displacement of the sigmoid and rectum ( Fig. 30-4 ). Other changes, possibly resulting from the descent of a full-thickness rectal prolapse, include diastasis of the levator ani and an incompetent anal sphincter mechanism. That intussusception was the mechanism for development of rectal procidentia can be attributed to Devadhar. Figure 30-4 A, Normal...

Iii87

Palliative therapy for pancreatic cancer. Surg. Oncol. Clin. North Am., 7 199, 1998. 77. Potts, J.R., Broughan, T.A., Hermann, R.E. Palliative operations for pancreatic carcinoma. Am. J. Surg., 159 72, 1990. 78. Watanapa, P., and Williamson, R.C.N. Surgical palliation for pancreatic cancer. Developments during the past two decades. Br. J. Surg., 79 8, 1992. 79. Singh, S.M., Longmire, W.P., Reber, H.A. Surgical palliation for pancreatic cancer. Surg. Clin. North Am., 69 599,...

Iii438

HCC derives almost all its blood supply from the hepatic artery, occlusion of feeding arterial vessels renders the tumor ischemic. Unlike embolization with metal coils, embolization with gelatin particles results in temporary blockage of circulation, because the particles are absorbed over 48 to 72 hours. This allows for repeated treatments with TAE, which may be necessary because of regrowth of tumors or the appearance of new tumor nodules. Often, a chemotherapeutic agent, either alone or...

Iii120

Exposure of the gland and an evaluation of the pancreatic parenchyma. An evaluation of the pancreas first requires complete exposure of the gland. Entry into the lesser sac through the gastrocolic ligament allows visualization and palpation of the ventral surface of the body of the gland. Mobilization of the second portion of the duodenum (Kocher's maneuver) permits palpation of the head of the gland and uncinate process as well as visualization of the dorsal surface of these portions of the...

Ii329

Edlich, R.F., Rogers, W., Kasper, G., et al. Studies in the management of the contaminated wound. I Optimal time for closure of contaminated open wound. II Comparison of resistance to infection of open and closed wounds during healing. Am. J. Surg., 117 323, 1969. 4. Krizek, T.J., and Robson, M.C. Evolution of quantitative bacteriology in wound management. Am. J. Surg., 130 579, 1975. 5. Lineaweaver, W., Howard, R., Soucy, D., et al. Topical antimicrobial toxicity. Arch. Surg., 120 267, 1985....

Ibs

Pelvic floor dysfunction + Slow-transit TABLE 3-3 -- Diagnostic Tests for Obstructed Defecation (During Simulated Defecation) Anorectal Manometry Anal Sphincter Electromyography Failure of anal canal pressure electromyographic activity to decline Inability to expel rectal balloon within established norms for weight to facilitate expulsion Increase in rectoanal angle by < 15 degrees Perineal descent by < 1 or > 4 cm motor response to eating, or both.1 Patients with colonic inertia...

I39

Pathology of the Esophagus. New York, Springer, 1984. 7. Forssner, H. Die angeborene Darm- und Oesophagusatresie. Arb. Anat. Inst. Wiesbaden, 34 1, 1907. 8. Gaudecker, B. von Lymphatische Organe. In Hinrichsen, K. V. (ed.) Human Embryologie. Lehrbuch und Atlas der vorgeburtlichen Entwicklung des Menschen. Berlin, Springer, 1990, p. 340. 9. Gray, S. W., and Skandalakis, J. E. Embryology for Surgeons. The Embryological Basis for the Treatment of Congenital Defects....

I386

Divided, leaving the right gastric and right gastroepiploic arteries to supply the entire transpositioned stomach. Division of these arteries is possible because of the presence of extensive intrinsic collaterals within the gastric wall. A second reason for the reliability of the stomach in replacement of the esophagus is its size and contour, which, after total division of the greater and lesser omenta and lateral peritoneal liberation of the duodenal sweep (Kocher's maneuver), permit...

I117

E., Sumner, H. W., et al. Cytomegalic inclusion disease diagnosed endoscopically. Dig. Dis. Sci., 26 133, 1981. 3. Altorki, N. K., Snady, H., and Skinner, D. B. Endosonography for cancer of the esophagus and cardia Is it worthwhile Dis. Esophagus, 5 198, 1996. 4. American Society for Gastrointestinal Endoscopy Appropriate use of gastrointestinal endoscopy. Manchester, MA, 1992, p. 5. 5. American Society for Gastrointestinal Endoscopy Antibiotic prophylaxis for...

Hey

Figure 23-3 Endoscopic appearance of a leiomyoma illustrating the segmental tumor bulge, intact overlying mucosa, and luminal narrowing without obstruction. Figure 23-3 Endoscopic appearance of a leiomyoma illustrating the segmental tumor bulge, intact overlying mucosa, and luminal narrowing without obstruction. Figure 23-5 The technique of enucleation is illustrated. A, The esophageal muscular fibers are split and the leiomyoma is bluntly extracted from the esophageal wall. B, Once removed,...

Alx

Abu-Elmagd, K., Reyes, J., Todo, S., et al. Clinical intestinal transplantation New perspectives and immunologic considerations. J. Am. Coll. Surg., 186(5) 512-527, 1998. 2. Aigrain, Y., Cornet, D., Cezard, S.P., and Boureau, M. Longitudinal division of the small intestine A surgical possibility for children with very short bowel syndrome. Z. Kindechir., 40 233, 1985. 3. Allard, J.P., and Jeejeebhoy, M.B. Nutritional support and therapy in the short bowel syndrome. Gastroenterol. Clin. North...

Howard S Kaufman Md

Associate Professor of Surgery, Gynecology, and Obstetrics, The Johns Hopkins University School of Medicine Active Staff, The Johns Hopkins Hospital, Baltimore, Maryland Neoplasms ofthe Small Intestine Crohn's Disease General Considerations, Presentation, Diagnosis, and Medical Management MICHAEL R.B. KEIGHLEY M.D., F.R.C.S. Barling Professor of Surgery, University Department of Surgery, University of Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom Ostomy Management

Exploration And Surgical Repair

In the operating room, the surgical field should include the entire chest, abdomen, and upper thighs to allow for thoracotomy, sternotomy, or saphenous vein harvesting if necessary. Placing the patient on vertically aligned rolls facilitates exposure of the chest to the posterior axillary line. Celiotomy is made through a long midline incision. If more exposure is needed, this incision can be modified in several ways. It can be extended diagonally across the upper rectus abdominus musculature...

Examination

Examination is primarily directed to the region of the body responsible for the presenting problem, but persons seen for the first time or in the remote past should undergo a more generalized physical examination. Along with a general survey and recording of vital signs, this procedure typically includes an examination of the eyes, mouth and pharynx, thorax and lungs, heart, peripheral vascular system, gross neurologic function, and mental status. Most patients examined for colorectal symptoms...

Edward E Cornwell

The small Intestine occupies a relatively large surface area within the peritoneal cavity and thus Is frequently Injured In patients with penetrating abdominal trauma. Because the small bowel Is relatively mobile, has a lower bacterial flora, and has fewer anaerobes than the colon, peritoneal contamination secondary to small bowel Injuries Is better tolerated than that associated with colon Injuries. The Penetrating Abdominal Trauma Index (PATI), which quantitates the severity of abdominal...

Diagnosis

Because of the high mortality rate associated with delayed diagnosis and treatment, any patient who presents with gastrointestinal bleeding and a history of an abdominal aortic aneurysm or prior aortic reconstruction must be considered to have an AEF until proven otherwise. Nonetheless, among patients with a history of aortic grafting and subsequent gastrointestinal bleeding, only 2 will prove to have an AEF. When hemorrhage is massive and exsanguinating, precise diagnosis is impossible, and...

Rohan Jeyarajah Robert V Rege

The term cholangitis refers to inflammation of the bile ducts within the liver, and the condition can be caused by many different factors including ischemia, infection, and chemicals.1 1 However, bacterial infection of the biliary tree complicating ductal obstruction is the most common cause of this entity. Histologic evaluation of the liver reveals an abundance of polymorphonuclear leukocytes that are mainly distributed in the portal triads and often spill out of the ducts. However, the mere...

Christophe Penna Rolland Parc

The goal of coloanal anastomosis is to preserve the anal sphincter and to restore bowel continuity after total removal of the rectum. This operation was originally described for rectal cancer, but it has since been widely used not only for malignant and benign tumors of the rectum but also for complex rectovaginal fistula, hemangioma, and radiation proctitis. Because tumor deposits or metastatic nodes can be found in the mesorectum for 2 to 5 cm (very rare) below the lower edge of the tumor,...

Aortoesophageal Fistula

Although the duodenum and small bowel remain the most common sites of AEF, communications between the esophagus and aorta have also been reported. Such fistulas are characterized by a different presentation, involve different management considerations, and are therefore worth individual mention. Both primary and secondary aortoesophageal fistulas have been described. A review of 79 primary aortoesophageal fistulas by Dossa and colleagues demonstrated that, although aortic pathology (63 ) is the...

Anne C Fischer Moritz M Ziegler

Developmental anomalies of the upper gastrointestinal (GI) tract present as common surgical problems in infants and children. A complete understanding of the developmental anatomy of the GI tract will assist in the evaluation and management of these anomalies. This chapter attempts to introduce an overview of the diagnosis and treatment of both congenital and acquired gastroduodenal anomalies in children. EMBRYOLOGIC DEVELOPMENT Briefly, the embryologic anatomic development establishes...

Acknowledgment

I would be remiss in not acknowledging the tremendous source of knowledge, inspiration, and direction that Drs. George D. Zuidema and John L. Cameron have provided to me during my career in surgery. Commencing as a medical student at Johns Hopkins (when Dr. Zuidema was the Chief of Surgery), carrying through to my years on the house staff at Johns Hopkins (under first Dr. Zuidema and then Dr. Cameron) and now as a faculty member (under Dr. Cameron), I have been privileged to work with these two...

Ba

Figure 25-17 Enter orrhaphy by the Czerny-Lembert interrupted suture. A, Interrupted Lembert suture through serous, muscular, and part of submucous coats applied from without. B, Interrupted Czerny suture through mucous and part of submucous coats applied from within. The latter is applied first. Figure 25-18 The Gould inverted mattress suture overlying the through-and-through marginal suture. Figure 25-18 The Gould inverted mattress suture overlying the through-and-through marginal suture....

Iv432

TABLE 32-1 -- Classification of Constipation Hirschsprung's disease Acquired Chagas' disease Mechanical Severe sigmoid diverticulitis Anal stenosis Inadequate fiber intake Irritable bowel syndrome Intussusception rectal prolapse Rectocele Sigmoidocele Descending perineum Paradoxical puborectalis contraction Perineal hernia Pharmacologic Analgesics Anesthetics Antidepressants Antiparkinsonian agents Antacids Metallic intoxication (arsenic, lead, phosphorus) Monoamine oxidase inhibitors...

I267

May provide information on which patients need immediate resection and which ones can be observed closely. Surveillance of patients who are found to have Barrett's disease needs to continue. Last, one must consider the opportunity to intervene with the Barrett's disease at an earlier point in time. Prophylactic antireflux procedure in those patients with known Barrett's disease would allow for elimination of both acid-and duodenal-content reflux. Coupling this with complete ablation of the...

Iii351

Chest are prepared and draped, in the event that a thoracic extension becomes necessary. Currently, a long incision 3 to 4 cm below the right costal margin is preferred, to avoid the thoracic complications associated with the older thoracoabdominal approach. The temptation to place the incision lower in patients with hepatomegaly should be avoided because exposure of the hepatoduodenal ligament will be compromised. The incision may be carried across the midline if desired. Once the incision is...

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,...

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

Benzos Rectal Form

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,...

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...

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...

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...

[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...