By M. Kapotth. Indiana University - Purdue University, Fort Wayne.

The advantages of this method are that the cutting of stricture is done under direct vision minimising the chance of false passage formation and the stricture is cut in one position without causing generalised trauma to it order 75 mcg thyroxine amex. The procedure can be repeated if necessary after 3 months when urethroscopy should be performed to know the condition of the stricture order thyroxine 125 mcg mastercard. If there is a short stricture in the bulbous urethra generic 75mcg thyroxine visa, it may be excised and end-to-end anastomosis is performed. Long strictures particularly in the anterior urethra are best treated by splitting the urethra and suturing the edges of the open urethra to the adjacent skin. A perineal skin flap may be constructed (technique devised by Blandy) or a scrotal tunnel is taken up to be sutured to open edges of the urethral defect (Turner-Warwick technique). Tubed scrotal flap pull-through urethroplasty devised by Mr Innes Williams has also been satisfactory as reported by a few centres. The end of the scrotal flap is fastened to a catheter, which is pulled up in the Badenoch-fashion into the bladder. After 3 weeks the catheter is withdrawn and the scrotal tube is found to have healed. There are various other methods of urethroplasty which are described in the various text books of Urosurgery, but beyond the scope of this book. A few congenital anomalies, though rare, sometimes seen in surgical practise and are mentioned below :— Congenital urethral stricture. The effects of such urethral stricture are mainly obstruction to the flow of urine and back pressure from obstruction leading to hypertrophy of detrusor muscle, ureterovesical reflux, hydronephrosis and hydroureter. Urethrogram may be necessary to delineate the site, degree and length of the stricture. Cystoscopic examination should be performed but the passage of the instrument may be arrested by the stricture. Urethral dilatations with sounds or filiform bougies with followers are main treatment. Such strictures do respond well to dilatation, but if fails internal urethrotomy or surgical repair of the stricture (urethroplasty) is performed. The peculiarity of these valves is that these allow the catheter to be passed easily, but obstruct the outflow of urine. Three types of clinical presentations are seen — (a) when the valves are incomplete, the patient may reach adolescence or adult life without symptoms, but hypertrophy of the detrusor muscle, vesical diverticula, dilatation of the prostatic urethra and hypertrophy of the trigonal muscles are often noticed, (b) Patients with moderate obstruction and abnormal urograms usually present earlier and (c) severe obstruction with uraemia. The most reliable method to confirm the diagnosis is voiding cystourethrography, that means radiographs are taken during the act of micturition after the bladder has been fdled with contrast medium. Cysto-urethroscopy fails to identify the valves as the irrigating fluid flows into the bladder with fully opening of the valves. After treatment, the hypertrophy of the trigone muscles and detrusor muscles subside. Sometimes removal of the valves may not be sufficient as hydroureter has become atonic and the condition does not resolve. In these cases loop cutaneous ureterostomies may have to be performed to preserve renal function. Proper antibiotics should always be given for a long course as infection is difficult to control in these cases. The valves are destroyed by transurethral route by fulguration through panendoscopy or by fragmentation by the passage of sounds. Diagnosis can be made by cystoscopy through which hypertrophied interureteric ridge can be seen. When the aetiology is congenital muscular hypertrophy, patients are usually young children. Dysuria is the main symptom with ultimate development of hydroureter and hydronephrosis. When the condition presents after the age of 50 years, it is difficult to differentiate from benign enlargement of the prostate from symptoms point of view. That straining helps to increase the flow of urine and that there is no prostatic enlargement are the findings in favour of this condition. The condition may recur in a few cases due to inadequate division of the fibres at the bladder neck. The apex between two limbs of the Y is brought down to the end of the vertical limb of the Y to make the incision a V-shaped one. Such calculus may be formed behind a urethral stricture or in an urethral diverticulum. Calculus may secondarily come to the urethra from above and become arrested in the prostatic (rarest), bulbous or in penile part of the urethra. Such migratory calculi are usually seen in children due to the comparatively large neck of the bladder which allows these calculi to pass through. The varieties of neoplasms which can be seen in the urethra are—polyp, papilloma, angioma and carcinoma Polyp. Occasionally multiple papillomas of the posterior urethra have been detected which are usually associated with papilloma of the bladder. Treatment of all benign neoplasms is diathermy coagulation through a urethroscope. When carcinoma is situated in the posterior urethra, more extensive operation in the form of radical prostatectomy should be considered. This thickened epithelium continues to proliferate displacing the mesonephros in a dorsilateral direction and forming a projection into the coelomic cavity, which is termed the genital ridge. The proliferating epithelium on the surface sends a number of cellular cords inwards which are known as testis cords. At the 7th week a mesenchyme cuts off the testis cords from the surface and forms the tunica albuginea. At this stage one can differentiate between testis (where tunica albuginea is prominently present) and ovary (where tunica albuginea is absent). The testis cords encroach on the medulla where they unite with the network derived from the mesenchyme and become rete testis. The premordial germ cells are incorporated in the cords (testis cords), which later become enlarged and canalised to form the seminiferous tubules.

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Most commonly involved are the vertebrae thyroxine 25 mcg fast delivery, ribs buy thyroxine 125 mcg low cost, pelvic bones order thyroxine 200 mcg online, and bones of the thigh and upper arm. A bone marrow biopsy with >10% plasma cells confirms a diagnosis of multiple myeloma. Bence-Jones protein is often not detected by a standard protein test on a urinalysis, which mainly is meant to detect albumin. A specific test for Bence- Jones protein involving acidification of the urine is required. Increased gamma globulin levels will increase the total protein and decrease the albumin level. Younger patients (age <70) should be treated with autologous bone marrow transplantation in an attempt to cure the disease. Patients who are candidates for transplants should receive thalidomide (or lenalidomide) and dexamethasone. Patients who are not candidates for transplants should receive melphalan, prednisone, and thalidomide. Hypercalcemia is treated initially with hydration and loop diuretics and then with bisphosphonates such as pamidronate. Bortezomib is a proteasome inhibitor useful for relapsed myeloma or in combination with the other medications. The overproduction of a particular immunoglobulin by plasma cells without the systemic manifestations of myeloma such as bone lesions, renal failure, anemia, and hypercalcemia. It is characterized by the presence of Reed-Sternberg cells on histology which spreads in an orderly, centripetal fashion to contiguous areas of lymph nodes. Although there is a clear increase in Hodgkin disease among relatives of those with the disease, there are no clear environmental or infectious etiologies for the disorder. Enlarged, painless, rubbery, nonerythematous, nontender lymph nodes are the hallmark of the disease. Patients may also develop what are labeled “B” symptoms, which are drenching night sweats, 10% weight loss, and fevers. Cervical, supraclavicular, and axillary lymphadenopathy are the most common initial signs of disease. An excisional lymph node biopsy is the essential first step in determining the diagnosis. After the initial diagnosis is determined by the biopsy, the most important step is to determine the extent of disease because the stage will determine the nature of the therapy, i. A bone marrow biopsy is used to definitively determine if the disease is truly localized. Lymphocyte-predominant has the best prognosis, and lymphocyte-depleted has the worst prognosis. The neoplastic transformation of both the B and T cell lineages of lymphatic cells. The main point of knowing this is that they are both high-grade lymphomas with an aggressive progression of disease. Enlarged, painless, rubbery, nonerythematous, nontender lymph nodes are the hallmark of the disease. Patients may also develop what are labeled “B” symptoms, which are drenching night sweats, 10% weight loss, and fevers. After this, the most important step is to determine the stage of the disease to determine therapy. Uric acid excretion can result in the precipitation of uric acid in the renal tubules; it can also induce renal vasoconstriction, reduced renal blood flow, and inflammation, resulting in acute kidney injury. Hyperphosphatemia with calcium phosphate deposition in the renal tubules can also cause acute kidney injury. Clinical Recall A 25-year-old man comes to the clinic complaining of enlarged, rubbery, non-erythematous, painless, non-tender cervical lymphadenopathy. The idiopathic production of an antibody to the platelet, leading to removal of platelets from the peripheral circulation by phagocytosis by macrophages. The platelets are bound by the macrophage and brought to the spleen, leading to low platelet counts. The bone marrow should be filled with megakaryocytes indicating that there is a problem with platelet destruction and not platelet production. The bone marrow will also exclude other causes of thrombocytopenia such as primary or metastatic cancer, infiltration by infections such as tuberculosis or fungi, or decreased production problems such as drug, radiation, or chemotherapy effect on the bone marrow. The peripheral smear and creatinine should be normal, excluding other platelet destruction problems such as hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, and disseminated intravascular coagulation. In those who recur after splenectomy, we use thrombopoietin agents romiplostim or eltrombopag. An increased predisposition to platelet-type bleeding from decreased amounts of von Willebrand factor. An autosomal dominant disorder resulting in a decreased amount of von Willebrand factor. This is different from platelets aggregating with each other, which is mediated by fibrinogen. This is mucosal and skin bleeding such as epistaxis, petechiae, bruising, and menstrual abnormalities. The ristocetin platelet aggregation test, which examines the ability of platelets to bind to an artificial endothelial surface (ristocetin), is abnormal. Both hemophilia A and B are X-linked recessive disorders resulting in disease in males. Females do not express the disease because they would have to be homozygous, which is a condition resulting in intrauterine death of the fetus. Mild deficiencies (25% or greater activity) result in either the absence of symptoms or with symptoms only during surgical procedures or with trauma. Factor-type bleeding is generally deeper than that produced with platelet disorders. The mixing study will only tell you that a deficiency is present; it will not tell you which specific factor is deficient. Vitamin K deficiency can be produced by dietary deficiency, malabsorption, and the use of antibiotics that kill the bacteria in the colon that produce vitamin K. The antibiotics most commonly associated are broad- spectrum drugs such as fluoroquinolones, cephalosporins, and other penicillin derivatives.

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Close the gastrotomy with a running Have 30 cc of air injected into the balloon port of the Baker 3 buy thyroxine 25 mcg without prescription. Once the gastric pouch is created generic 125mcg thyroxine fast delivery, use an anvil grasper to Identify the Roux limb and take care to insure there is no hold the anvil and remove the spike with a locking grasper purchase 50mcg thyroxine free shipping. Divide the mesentery of the jejunum with the har- 2 cm away from the stapled edge with the harmonic scalpel. Reinforce the anterior staple line into the Roux limb via the enterotomy and bring the spike with 2-0 silk sutures (Fig. Note the spike toward the gastric pouch and connect it with the that for clarity this is shown antecolic, but is normally con- anvil (Fig. Place a bowel clamp across the distal 41 Laparoscopic Roux-en-Y Gastric Bypass 379 a liquid diet and must be tolerating this diet before discharge (usually by postoperative day 3). Complications Early Anastomotic and Staple Line Leaks Related to tension and/or hematomas of the staple lines that lead to tissue disruption. As described earlier, additional sutures to relieve tension on the superior border of the gas- trojejunostomy and the distal corner of the stapled jejunoje- junostomy are recommended routinely. Additional maneuvers such as adequate division of the Roux limb mes- entery and the division of the greater omentum are some- times necessary. Fevers and abdom- Roux limb, fill the upper abdomen with saline, and perform an inal pain are often absent in these patients. Large anasto- intraoperative fiberoptic gastroscopy to evaluate for air leak and motic leaks tend to cause hemodynamic instability, and intraluminal bleeding. Drain the irrigation fluid and remove the reoperation may be necessary without radiologic confirma- bowel clamp. Often closure of a leak at the gastrojejunostomy with an Close the fascial defect of the left most lateral port using a omental patch is preferred than attempted suture ligation. The addition of wide drainage of the area is usually adequate Place a 10 French Jackson-Pratt drain via left subcostal port and to control the local inflammation. Position the drain anterior systemic inflammatory response syndrome may occur, and to the gastrojejunostomy, remove the liver retractor under direct adequate surgical intensive care management is paramount vision, and deflate the pneumoperitoneum. High risk patients may require continuation of erative nausea and vomiting and treated as needed. Persistent bleeding will require either endoscopic or operatively; severe nausea may limit oral intake and require surgical intervention. Initial treatment is correction of remnant) may be present despite the absence of clinical inciting factors and administration of proton pump inhibi- obstipation and food intolerance. Ulcers may require surgery for uncontrolled bleeding or bands that may cause bowel obstruction, two particular ana- perforation. Peterson’s defect describes the potential hernia behind Nutritional Deficiencies an antecolic Roux limb. The mesenteric defect of the jejuno- Nutritional deficiencies may result from both decreased oral jejunostomy can lead to herniation of the distal small bowel. Due to the bypass of the stomach and Both hernias may demonstrate swirling of the small bowel proximal small intestine, patients are prone to deficiencies in vascular mesenteries on computer tomography with intrave- B12, iron, folate, and calcium. Even with normal computer tomographic ments of these elements as well as multivitamins. Patients with studies, high index of suspicion and low threshold for diag- persistent emesis are at risk for thiamine deficiency. Abdominal pain in the postoperative gastric bypass patient Further Reading should be considered an internal hernia until proven otherwise. Surgery decreases long- Stricture term mortality, morbidity, and health care use in morbidly obese Strictures may develop at the gastrojejunostomy or jejunoje- patients. Outcomes after laparo- tion, whereas those at the jejunojejunostomy are more likely scopic Roux-en-Y gastric bypass for morbid obesity. Mulholland Multiple surgical diseases involve the small intestine or Small Bowel Resection with Anastomosis appendix and require knowledge relating to operations on the small bowel. This chapter introduces the concepts neces- Indications for small bowel resection and anastomosis sary to operate on the small bowel and appendix safely by include resection of tumor, injury secondary to blunt or pen- discussing the operations in the context of common patho- etrating trauma, mesenteric ischemia, inflammatory condi- logic entities. The blood supply derives from the supe- rior mesenteric artery, with collateral circulation of the prox- Small Bowel Tumors imal small bowel dependent upon the celiac artery and that of the distal small bowel dependent upon the inferior mesen- Small bowel tumors are rare. For convenience, the appendix is included in this nancies account for less than 3 % of all gastrointestinal section. They Procedures commonly performed on the small bowel are difficult to diagnose because symptoms are usually insid- include small bowel resection and anastomosis, enterolysis ious in onset and vague in presentation. They present insidi- for small bowel obstruction, stricturoplasty for treatment of ously with vague symptoms of abdominal pain, nausea, strictures secondary to inflammatory bowel disease, and weight loss, and anemia. The poor prognosis associated with malignant tumors of to the underlying cause, the extent of bowel involvement, and the small bowel is a result of the long delay between the the rapidity with which treatment is initiated. Treatment is is often appropriate, and the judicious use of revascularization resection with a fan of mesentery to include the draining by surgical or other means may be considered. Because it can be difficult to ascertain the extent of nonvi- able bowel, liberal use of second-look procedures is war- ranted. In that setting, it is common to perform resection but no reconstruction, simply returning the The incidence of gastrointestinal injury is over 80 % in the stapled ends of small bowel into the abdomen. Anastomosis setting of penetrating trauma, while injury to the small bowel or stoma formation is then performed at the second (or even is less frequent with blunt trauma and can be more difficult subsequent exploration) when the patient is more stable and to diagnose. It is important to have a high index of suspicion the extent of ischemic necrosis is completely demarcated and to carefully examine the entire length of small bowel (Kibbe and Hassoun 2011 ). The consequence of these injuries may range from clinically insignificant inju- Crohn’s Disease ries to devitalized small bowel with compromised blood sup- ply. A seat-belt sign (ecchymosis across the lower abdomen) About 60 % of patients with Crohn’s disease have involve- carries a 2. Patients may present ening, mesenteric hematoma, or extravasation of contrast with high-grade obstruction and sepsis, but operation is more (Fakhry et al. The Injuries range from simple perforation to mesenteric operative procedure of choice depends on whether the patient injury with areas of devitalized small bowel.

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In biliary colic the pain radiates from the right hypochondrium to inferior angle of the right scapula since the gallbladder is supplied by the 7th to 9th thoracic segments buy thyroxine 25 mcg lowest price. Of course pain is frequently referred to the right the same viscus also receives the parasympathetic shoulder and migrates along the right supply mostly from the vagus (the sole exception paracolic gutter towards the right iliac being the hindgut and the bladder which receive fossa cheap thyroxine 100 mcg on line. Ffein originating in the gallbladder may radiate to the back just below the the sacral sympathetic supply) buy thyroxine 25 mcg with mastercard. Splenic (S) pain is may occur in pleurisy, haemothorax or referred to the left shoulder (Kehr’s sign). It indicates Bilateral pain and tenderness over the hypogastrium (shown by criss-cross) obstruction to a hollow organ — either bowel characterize acute salpingitis. Colicky pain of acute intestinal obstruction may change into constant burning type which indicates strangulation. In acute appendicitis it may indicate perforation of an obstructive gangrenous appendix. In 2nd stage (stage of irritation) of peptic perforation, pain diminishes in intensity although the disease is continuing. This is due to the fact that the peritoneal exudate dilutes the irritant gastric content. In diaphragmatic pleurisy pain is aggravated during deep inspiration and coughing. In case of pain due to diaphragmatic irritation either due to inflammatory exudate or due to blood from injury to the liver or spleen deep inspiration will aggravate the pain. In case of cholecystitis fatty foods will aggravate the pain whereas fat-free diet will give some relief. In case of peptic ulcer alkalis will make the pain better whereas alcohol, spicy food or drugs like aspirin will aggravate the pain. In case of hiatus hernia and reflux oesophagitis, stooping will make the pain worse. In acute pancreatitis the pain is relieved to a certain extent by sitting up from the recumbent position. Application of local pressure relieves colicky pain (biliary ureteric or intestinal). In case of peptic ulcer perforation or general peritonitis the vomiting is quiet regurgitation of mouthfuls. In late cases of peritonitis the vomitus becomes dark brown, faeculent being mixed with altered blood. It may be once or twice during the first stage, it is more or less absent in the second stage and may reappear in the last stage with the characteristic vomitus of diffuse peritonitis. Both nausea and vomiting are the characteristic complaints in pre- or post-ileal appendicitis. In obstruction of the lower end of the ileum vomiting may not occur in the beginning but follows after a few hours; in large bowel obstruction vomiting is absent or is a late feature. Vomiting relieves pain in case of peptic ulcer but in colics it relieves pain temporarily so that it reappears immediately. A history of one motion in the beginning of intestinal obstruction is not unusual. In children features of intestinal obstruction accompanied by passage of mucus and blood per anum is suggestive of acute intussusception. Diarrhoea occurs in acute ulcerative colitis, regional ileitis and acute enteritis. In inflammatory conditions in the neighbourhood of the bladder and ureter, such as retrocaecal appendicitis, pelvic appendicitis and pelvic peritonitis, they may give rise to the same condition. Even retrocaecal appendicitis lying in very close proximity to the ureter, may lead to haematuria which may mislead the clinician. If a patient presents with symptoms very much similar to acute appendicitis in the middle of her menstrual period one should suspect ruptured follicular (lutein) cyst. An anxious look, bright eyes, pinched face and cold sweat on the surface are the features of this type of facies, which once seen will never be forgotten. The facies of dehydration is also typical and consists of sunken eyes, drawn cheeks and dry tongue. The peculiar lividity or blueness (cyanosis) of the face is a feature which is characteristic, though not often found, in acute haemorrhagic pancreatitis. In peritonitis the patient remains quiet because movements will only increase the pain. Only in the last stage of peritonitis and post-operative peritonitis the patient becomes highly excitable which is evidenced by throwing of bed clothes, tossing of the head, grumbling, ineffective movements of the hands and feet etc. Sometimes the patient who cannot locate the abdominal pain properly, probably the pulse plays an important role, so far as the diagnosis of acute appendicitis is concerned. In peptic perforation the pulse may become normal in the early stage but with the spread of peritonitis the pulse begins to quicken and becomes small in volume. In acute intestinal obstruction though the pulse remains normal in the beginning but with the advent of dehydration the volume and tension fall and its rate increases with no tendency to return to normal. If the temperature becomes high, the respiration rate will be proportionately increased. Referred pain in the abdomen is quite common in lobar pneumonia, basal pleurisy etc. This may be quite high in case of acute appendicitis particularly in children, in acute cholecystitis it is raised to a moderate degree, whereas in acute pancreatitis or in acute diverticulitis the temperature may not be raised that much. But it must be remembered that rise of temperature is never an early sign, it occurs late in the disease, e. Even in the early stage of appendicitis, it may be dry and thinly coated, as the patient might have vomited a good quantity. Jaundice is often noticed after biliary colic and occasionally in acute pancreatitis. The whole abdomen from the nipples above down to the saphenous openings (thus the inguinal and femoral rings are exposed) must be exposed.

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