Immediately prior to completion of the infrahepatic vena caval anastomosis buy discount aggrenox caps 200 mg line, the liver is purged with chilled or room temperature albumin and/or crystalloid solution via the allograft portal vein to remove the preservative solution purchase online aggrenox caps, which may contain high + concentrations of potassium (~145 mEq/L K ) proven 200 mg aggrenox caps. In addition, flushing the liver also removes a significant amount of the air that gets introduced during the procurement and preparation of the allograft for transplantation. Finally, the portal vein reconstruction is completed with an end-to-end anastomosis. At this point, the clamps are removed, ending the anhepatic phase of the operation. Venous bypass is not necessary when the piggyback technique of liver transplantation is utilized because the diseased liver is separated from the vena cava (systemic venous return remains unimpaired), and vascular control is obtained by placing a clamp across the confluence of the hepatic veins as they join the vena cava (Fig. The first anastomosis is between the suprahepatic vena cava of the liver allograft and the cuff created from the hepatic veins. The infrahepatic vena cava of the liver allograft is ligated, and the portal vein reconstruction is then completed. Note that the recipient’s vena cava is left intact and systemic venous return is unimpaired. The postrevascularization stage of the transplant begins with the removal of the vascular clamps. Despite flushing the liver to remove the high K -containing organ preservation solution, hyperkalemia may be troublesome following liver reperfusion, particularly with livers that sustained significant injury during preservation and reperfusion. In addition, massive air embolism is an immediate concern following revascularization, as it may quickly lead to cardiac arrest. Pulmonary hypertension and right heart failure must be treated aggressively with inotropic agents; otherwise, the liver is subjected to high outflow resistance resulting in congestion and worsening of the allograft preservation injury. The cause of this phenomenon is not well understood; fortunately, it is seen in very few patients. Another reperfusion phenomenon is that of systemic hypotension secondary to peripheral vasodilation. This may be due to the release of systemic inflammatory mediators, which include kinins, cytokines, and free radicals from the liver allograft. Reperfusion of the liver also can have dramatic effects on coagulation, such as fibrinolysis resulting in severe hemorrhage or hypercoagulation that can result in venous thrombosis and massive pulmonary embolism with cardiovascular collapse. Immediately prior to revascularization, the patient is usually given methylprednisolone (250–1000 mg) as part of the immunosuppressive regimen, as well as an adjunct to counteract the systemic effects of ischemia-reperfusion injury of the liver. At this point, all of the vascular anastomoses, the peritoneum, and the liver (especially the cut surface in segmental or reduced-size grafts) are inspected for surgical bleeding. The hepatic artery reconstruction is performed after stabilization of the patient following revascularization of the liver. This is especially critical in pediatric transplant recipients, where the hepatic artery diameter ranges from 1–3 mm. The last part of the procedure involves hemostasis, removal of the gallbladder, and reconstruction of the bile duct (Fig. There are two basic methods for the bile duct reconstruction: an end-to-end anastomosis, with or without a T tube (in patients with normal common bile ducts), or a choledochojejunostomy to a Roux-en-Y limb of jejunum (Fig. In cadaveric or live-donor segmental transplantation, the technique for the recipient’s hepatectomy and the implantation of the allograft is not different from that of full-size liver transplantation; however, the technique of piggyback liver transplantation must be used with live donors because the allograft segment does not include the vena cava. The anesthesiologist must be alert during the reperfusion of a segmental graft because significant bleeding may ensue from the raw surface of the liver. The hepatic artery and portal vein are extended with donor iliac artery and vein, respectively. The cut surface of the liver can bleed excessively if the central venous pressure is too high. These patients are extremely complex to manage because of the hemodynamic instability, massive blood loss, coagulopathy, and metabolic problems. It is convenient to divide the operation into three stages: preanhepatic, anhepatic and neohepatic (discussed later). Adachi T: Anesthetic principles in living-donor liver transplantation at Kyoto University Hospital: experiences of 760 cases. Grande L, Rimola A, Cugat E, et al: Effect of venovenous bypass on perioperative renal function in liver transplantation: results of a randomized controlled trial. Consequently, the waiting time to receive an organ has increased significantly, and ~15% of patients will die while waiting. The success of living- donor renal transplantation, coupled with the experience in adult-to-pediatric living-donor liver transplantation, as well as advances in surgical and postsurgical care of patients undergoing major liver resections, has lead to the implementation of adult-to-adult living-donor liver transplantation. Potential living liver donors undergo extensive medical and psychosocial evaluation to ensure psychological as well as physical fitness to undergo a major surgical procedure that provides no medical benefits to the donor. Donors must have full blood typing to ensure compatibility with the recipient and then fill out an extensive medical questionnaire, followed by a complete physical exam and screening lab tests. After the potential donor is medically and psychosocially cleared, they undergo a detailed magnetic resonance imaging study of the liver to assess liver segment size, anastomosis, and possible anatomical contraindications. The donor and recipient operations are usually conducted simultaneously to minimize the ischemic injury to the donor liver segment. The donor operation, however, is initiated first, with the recipient operation commencing only after the donor liver has been directly examined and no unforeseen anatomic barriers to donation are found. The living donor operation is similar to a right or left hepatic lobectomy undertaken for hepatic disease, although there are some differences that can have a significant impact on anesthetic management. The donor may elect to have an epidural catheter for postop analgesia, and this usually is placed before surgery. Living donor liver resection has been successfully performed laparoscopically; however, due to limited experience and utilization of this technique, it will not be detailed here. A vertical midline incision is made from the xiphoid to just above the umbilicus and extended transversely to the right anterior axillary line. Following exploration of the abdomen, intraoperative ultrasound may be performed to map the hepatic venous anatomy so the plane of resection can be delineated. In addition, an intraoperative cholangiogram is performed via the cystic duct (a cholecystectomy is performed in either right or left hepatic lobectomy) or the common bile duct, to define the biliary anatomy. After this is performed, the corresponding portal vein and hepatic artery are isolated. Unlike in a hepatic lobectomy for tumor, the venous and arterial inflow to the liver segment is not ligated; thus, the transaction of the liver parenchyma may result in significant hemorrhage. The respective lobe of the liver is mobilized from its attachments, and the liver is dissected from the retrohepatic vena cava, with ligation of the short-hepatic veins. Next, the hepatic vein is isolated, and the liver parenchyma is then divided, which can be a slow and tedious process. Following division of the hepatic parenchyma, the liver segment is ready to be removed.
On occasion discount 25/200mg aggrenox caps fast delivery, physiological dis- Place it on a glass slide and examine under a micro- charge can lead to slight vulvar irritation and mild scope for the presence of eggs purchase generic aggrenox caps. The vaginal pH is less able to see the worms by shining a fashlight on the than 4 generic 200 mg aggrenox caps with visa. It tal wart has been identifed, when there has been sexual is often found after intercourse with a new partner or in contact, or when the Pap test indicates dysplasia. Fifty percent of women application of 5% acetic acid (vinegar) to the cervix, are asymptomatic; infection is associated with in- labia, or perianal area causes the lesion to turn white creased preterm labor in pregnant women and patients (acetowhite). Saturate a gauze pad with vinegar and undergoing vaginal surgical procedures (increased place on the lesion for 5 to 10 minutes. Microscopic evaluation is patients with vaginal discharge will have bacterial vaginosis, required to identify clue cells (bacterial vaginosis), yeast 25% will have candidiasis, and 10% will have trichomonia- forms (vaginal candidiasis), or trichomonads (vaginal tricho- sis. Foreign Body The presenting symptom in foreign body retention is a Candida Vulvovaginitis very malodorous, whitish discharge. In children, the for- Ninety percent of women with candida vulvovaginitis eign body is as variable as those objects found in the ears present with vulvar pruritus. The discharge is often thick, not have the coordination to insert anything into their va- white, and “curdy;” the labia are erythematous and gina, so suspect child abuse in such cases and inspect for edematous. Gonorrhea and chlamydia coexist in up to 60% of transmitted via sexual contact but can also be spread patients. Women with chronic infections will have amount of vaginal discharge and bleeding after inter- copious amounts of discharge and little or no infam- course. When there is an acute than 25 years, sexually active with three or more part- infection, they will report vulvar itching, swelling, ners, and not using barrier methods of contraception. If the woman has douched transmission has not been reported; therefore, suspect within the past 24 hours, the sensitivity of tests will child abuse in children with chlamydia infection. However, the patient may have purulent In atrophic vaginitis, there is a dry (shiny), pale, thin discharge that originates from the endocervical co- vaginal wall caused by an insuffcient amount of lumnar and transitional cells. During menopause, the vaginal ence infammation of Skene glands, Bartholin glands, mucosa and vulva, which lack glycogen, become frag- or the urethra, which causes pain and dysuria. A fnding of may experience burning, dryness, irritation, or dyspa- gonorrhea in children is considered specifc evidence reunia. In the child, the most common offending of vaginal discharge and bleeding after intercourse. Adult Infection begins intravaginally in most cases and then vulvovaginitis involves any harsh or caustic substance spreads upward, causing salpingitis. Patients may have a of vaginal lubricant, douche, spermicide, or condom purulent discharge that originates from the endocervi- will cause the infammation and edema. With gonorrhea, douches stronger than 1 to 2 tablespoons per quart patients often experience infammation of Skene Chapter 37 • Vaginal Discharge and Itching 443 Itching and Lesions glands, Bartholin glands, or the urethra, which causes pain and dysuria. As The chancre of primary syphilis is an ulcerative lesion with peritonitis, patients may also have guarding and that most often develops at the site of initial inocula- rebound tenderness. Genital Warts Genital warts (condylomata acuminata) are caused by the human papillomavirus and may be precursors to genital cancers. The patient usu- ally notices a bump in the genital region accompanied by itching and leukorrhea. Referral to a dermatologist or gynecologist is indicated for treatment of warts of the urethra or anus. Herpetic outbreaks can involve the cervix, vagina, vulva, anus, or extra- genital organs, like the pharynx. If the mother has an active primary herpes simplex virus infection at the time of birth, the infant has a 50% risk of becoming infected. Clinical signs of the infant’s infection become appar- ent in the frst week of life and pose the possibility of death. Molluscum Contagiosum Molluscum are small (2 to 5 mm in diameter), umbili- cated, fesh-tone papules (Figure 37-5). Quan M: Vaginitis: Diagnosis and management, Postgrad Med Gradison M: Pelvic infammatory disease, Am Fam Physician 122:117, 2010. For vision to oc- Distinguish between loss of vision and loss of visual cur, light is transmitted through the eye to photore- acuity. Vision loss is the absence of vision, completely ceptors in the retina that collect light and send neural or partially, in one or both eyes. Vision loss occurs with any interruption in this visual pathway, such as opacifcation of the cornea, lens, or Ability to Focus vitreous body (see Chapter 30, Figure 30-1 for the Patients who are without sight have no ocular align- anatomical structures of the eye). Vision loss also ment and commonly manifest a gross searching and occurs when light energy cannot be converted into wandering nystagmus. Nystagmus in the frst year of neural impulses, such as in glaucoma, retinal detach- life suggests bilateral vision loss until proved other- ment, ischemic optic nerve atrophy, and pituitary wise. However, knowledge of the present, and by 2 months of age fxation will be well causes of vision loss can provide important clues to developed. Total Absence of Vision Disease that affects the optic nerve or retina, such as Onset retinal detachment, leads to total loss of vision. Sudden loss of vision suggests a vascular etiology, spe- Blindness is a complete lack of form and visual light cifcally occlusion of the central retinal artery until proven perception. In occlusion of the central retinal artery, the 446 Chapter 38 • Vision Loss 447 patient notes that vision is lost suddenly, and light cannot dark are distinguished. Loss of vision in one eye in- ated with macular degeneration, retinal detachment, dia- dicates that the problem is anterior to the chiasm; hemi- betic retinopathy, and anterior ischemic optic neuropathy. Occlusion of the central retinal ar- Children tery is an emergency and requires immediate treatment. In children, acute optic neuritis rarely occurs as an isolated condition and is usually a manifestation of a Pain neurological or systemic disease such as meningitis, viral Sudden loss of vision with eye pain and photophobia infection, or demyelinizing diseases. It may also be as- indicates pathology of the cornea, iris, and ciliary sociated with lead poisoning and long-term use of certain body. Sudden loss of vision with a red painful eye may drugs, most notably chloramphenicol or vincristine. Infammation, demyelinization, or degeneration of the Flash of Light With Loss of Vision optic nerve causes pain on movement of the eye and is Patients who have retinal detachment describe a fash thought to be the result of general infammation of of light shortly before loss of vision. Examples of visual feld defects along the optic nerve, optic chiasm, optic tracts, and optic radiations in the cortex. They may also experience momen- Minutes make a difference with chemical trauma to tary total or partial loss of vision in the affected eye. Wash the eye with copious amounts of water or normal saline solution Transient Loss of Vision immediately for an alkaline burn. Some patients with migraine headaches experience a scotoma, or an area of impaired vision within the visual Is the vision loss because of a chronic problem?
The epiglottis and vocal cords open up and the air is then expelled out of 240 Forensic Pathology the lungs cheap aggrenox caps express, under pressure purchase aggrenox caps on line amex, usually carrying with it any foreign material present in the bronchi and trachea generic 25/200mg aggrenox caps otc. Occasionally, choking deaths occur when an individual falls into ﬁnely ground material, such as cornmeal or sawdust. There is involuntary inhala- tion and the airway is completely occluded by this material. The ﬁnding of small amounts of food material in the airway at autopsy does not indicate that the individual choked to death. Approximately 20–25% of all individuals aspirate food agonally, independent of the cause of death. Death caused by massive aspiration of food is rarely seen in a medical examiner’s ofﬁce. It is most common in comatose patients who have impaired functioning of the central nervous system. The diagnosis of choking death is made at autopsy when the airway is found occluded. If the individual had an occluded airway and the object or food was removed during resuscitation, the only way to make the diagnosis would be by history. There are no speciﬁc autopsy ﬁndings indicative of choking except for occlusion of the airway. Some medical personnel will ascribe a death to choking even though the airway was never completely occluded. If laryngospasm did occur, one would expect relaxation of the larynx as the victim became agonal. Others hypothesize that a fatal “vagal reaction” or “reﬂex cardiac death,” mediated through the parasympathetic nervous system, occurred through hypersensitivity of the larynx to aspirated food. Mechanical Asphyxia In mechanical asphyxia, pressure on the outside of the body prevents respi- ration. Traumatic asphyxia (a term often used interchangeably with mechan- ical asphyxia) 2. Riot-crush or “human pile” deaths Traumatic Asphyxia Traumatic asphyxia occurs when a heavy weight presses down on an individ- ual’s chest or upper abdomen, making respiration impossible. One common form of Asphyxia 241 traumatic asphyxia is individuals under a car, repairing it, when the jack slips and the vehicle falls on top of them (Figure 8. At autopsy, there is con- gestion of the head, neck, and upper trunk with numerous petechiae in these areas, the sclerae, the conjunctivae and the periorbital skin. Internally, there is often no evidence of trauma in spite of the heavy weight on the chest. Individuals who survive an episode of traumatic asphyxia usually make an uneventful recovery, though occasion- ally there is some permanent visual impairment due to retinal hemorrhage. One individual who survived described a severe crushing pain and suffusion of his face followed by immediate unconsciousness. Thus, in one instance, an individual was knocked to the ground and a refrigerator and stereo were piled on top of him. An occasionally encountered form of accidental traumatic asphyxia involves individuals buried in cave-ins with their heads above the ground. The most unusual case of traumatic asphyxia seen by the authors was that of a 5-month-old infant killed by a python. The snake wrapped itself around the baby, tightening its coils whenever the child exhaled. At autopsy, the only marks on the child were teeth marks on the face where the snake had tried to swallow the child whole (his head was too big for the snake’s mouth) (Figure 8. Positional asphyxia Positional asphyxia is virtually always an accident and is associated with alcohol or drug intoxication. In this entity, individuals become trapped in restricted spaces, where, because of the position of their bodies, they cannot move out of that area or position. This results in restriction of their ability to breathe, followed by death (Figure 8. Positional asphyxia might occur if individuals fall down a well and are wedged between the walls. Every time they exhale, they slip farther and farther down the well, preventing inhalation. Riot-crush Riot-crush, as the name implies, occurs in riots, when the chest is compressed by stampeding people piling on top of each other. Traumatic Asphyxia Combined with Smothering Traumatic asphyxia combined with smothering is a combination of both these entities. An accidental form is overlay, where an infant is placed in bed for the night with either an adult or a larger child. During the night, the other individual rolled onto the infant, killing it by a combination of 242 Forensic Pathology A B Figure 8. Puncture marks on face have a semicircular conﬁguration and are caused by the needle-like teeth of the python. Other deaths in this category are individuals buried in cave-ins, grain, or sand, etc. Rarely, a few ﬁne petechiae of the facial skin, but not of the sclerae or conjunctivae, will be found. Burking is a combination of suffocation and traumatic asphyxia devel- oped (or at least perfected) by the “resurrectionists” Burke and Hare in the early 19th century. Victims, usually intoxicated, were brought to the ground, whereupon Burke knelt or sat on their chests, expelling the air and interfering with inspiratory efforts. He then put one hand over the victim’s nose and mouth and used the other hand to press the lower jaw towards the upper. Suffocating Gases Deaths from suffocating gases are caused, not by the toxic nature of the gases, but rather by displacement of oxygen from the atmosphere. Carbon dioxide and methane are the two most commonly encountered suffocating gases. Methane is the principal constituent (94–96%) of natural gas that is used for cooking. It is odorless; the smell we detect from natural gas is an added ingredient to make leaks detectable. Reduction of atmospheric oxygen to less than 25% of normal (5–6% by volume of oxygen) by displacement of oxygen by inert gases, such as carbon dioxide and methane, produces uncon- sciousness in seconds and death in a matter of minutes. Determination of the cause of death in such cases is by knowledge of the circumstances sur- rounding the death. Toxicological analysis of the blood is of no help in the case of carbon dioxide, because it Asphyxia 245 is a normal constituent of blood. Since the gas is not toxic, however, all that its identiﬁcation would indicate is that the individual was exposed to an atmosphere containing methane, not that death was due to it. Strangulation Strangulation is a form of asphyxia characterized by closure of the blood vessels and air passages of the neck as a result of external pressure on the neck. Manual strangulation Virtually all hangings are suicide and all ligature and manual strangula- tions homicide.
The bowel is cleaned of adherent skin buy aggrenox caps from india, and the previously opened antimesenteric border of the bowel is simply closed with sutures 25/200mg aggrenox caps with amex. Alternatively buy generic aggrenox caps 200mg line, the previously exteriorized portion of bowel is resected, and the two ends are anastomosed with sutures or staples. On rare occasions, it is necessary to extend the incision transversely through the abdominal wall to safely perform an anastomosis. Loop ileostomies are most commonly performed for patients who have had surgery for rectal cancer and who have a low colorectal anastomosis. A loop ileostomy is also created as part of a restorative proctocolectomy with an ileal J pouch anal anastomosis. They may have only recently been weaned off chronic glucocorticoid therapy and may require stress dose steroids as part of the procedure. Closure of end stoma: Closure of an end stoma usually requires a midline abdominal incision. The most common indication for closure of an end colostomy is restoration of intestinal continuity after emergent surgery for perforated diverticulitis or an obstructing rectal cancer. The severity and indication for the original procedure can have a significant impact on the difficulty of the colostomy takedown. Not infrequently, this procedure begins with cystoscopy and placement of bilateral ureteral stents by a urologist given the risk of ureteral injury in reoperative pelvic surgery. It may be necessary to mobilize the proximal bowel to provide a tension-free anastomosis. Paracolostomy hernia repair: The abdomen may be entered via a midline or a peristomal incision. The stoma is then moved to an alternate site, and the defect in the abdominal wall is closed. Alternatively, the stoma may be left in its original site and the fascia closed around the bowel that then may be reinforced with biologic or prosthetic mesh. When performed laparoscopically, transfascial sutures and tackers are used to hold the mesh in place. The majority of colorectal procedures are performed laparoscopically, with a relatively small incision for the hand-port. The postoperative pain after laparoscopic cases can be treated with iv opioids in majority of patients. For open procedures, thoracic epidural is associated with improved postoperative pain control, earlier return of bowel function, early intake of food, and out-of-bed mobilization. Intraoperative use of low concentration bupivacaine or ropivacaine blunts the surgical stress and reduces the intraoperative opioid requirements. Carli F, Mayo N, Klubien K, et al: Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Carli F, Trudel J, Belliveau P: The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomized trial. Nelson R, Edwards S, Tse B: Prophylactic nasogastric decompression after abdominal surgery. It must be distinguished from rectal mucosal prolapse, caused by elongation of the mucosal attachments to the underlying sphincter muscle, and internal intussusception, where the upper rectum folds into the lower rectum, but does not descend through the sphincter mechanism. Rectal mucosal prolapse is treated as part of the spectrum of hemorrhoidal disease, and mild-to-moderate intussusception does not benefit from surgery. The surgical approaches to procidentia are determined by patient age, concurrent medical disease, sphincter function, and prior operative history, including previous abdominal surgery and prior attempts at surgical repair. Surgical treatment of procidentia may be undertaken through an abdominal or a perineal approach. Abdominal repair of rectal prolapse can be performed in either an open or laparoscopic fashion. The abdominal approaches have a lower recurrence rate and because they do not diminish the capacity of the rectal reservoir and are generally preferable for maintaining fecal continence. Rectopexy is an abdominal approach in which the rectum is mobilized in the posterior plane from the sacral promontory to the levator muscles. The rectum is then pulled cephalad and sutured to the presacral fascia with multiple nonabsorbable sutures, or tacked to the presacral fascia using surgical tacks. Mesh may or may not be used to fix the rectum to the sacrum depending on the operative preference of the surgeon. They believe that removal of the redundant sigmoid further diminishes the chance of late recurrence and may alleviate constipation. A number of approaches have been described, the most popular being the Ripstein procedure. As in rectopexy, the rectum is mobilized along the presacral plane down to the level of the levators. A band of Marlex mesh is sewn to the presacral fascia at the sacral promontory, upward traction is placed on the rectum, and the mesh is sutured to the rectum. Transabdominal repair of rectal prolapse is the favored approach for younger patients with rectal prolapse or older paints with few medical comorbidities due to the significantly lower rate of recurrence of the prolapse. Not uncommonly, however, patients with rectal prolapse are significantly advanced in age or have significant medical comorbidities. The prolapsed rectum is withdrawn through the anal canal to its full extent, and a circumferential incision is made in the outer tube of the prolapsed bowel just proximal to the dentate line. Redundant bowel is mobilized from the distal end, up to the point that no additional bowel can be delivered into the operative field. The redundant bowel is transected, and a primary anastomosis is fashioned between the cut ends of the inner and outer bowel. Prior to anastomosis, the levator muscles are often approximated in the midline in an effort to aid continence. When the volume of prolapsed tissue is small or a previous abdominal approach makes blood supply to the rectum questionable, the Delorme procedure often is performed. During this procedure, the mucosa is stripped off the prolapsed rectum, and the prolapsed rectal muscle is foreshortened by plication until it resides above the sphincters. Perineal repair of rectal prolapse is most commonly done under a general anesthetic as the patient is typically positioned prone, the procedure can take 60–90 min; and in the case of a perineal rectosigmoidectomy, the peritoneal cavity is entered. However, in very high risk patients for whom intubation or general anesthesia is a concern, the procedure can be done under an epidural, or local with sedation. Lesions such as carcinoid tumor, endometrioma, and solitary rectal ulcer also may be locally excised. Transanal excision of benign lesions may be performed in the submucosal plane, whereas suspected malignancies are excised by removing the entire thickness of the rectal wall. Transanal excision usually is performed in the prone jackknife position, although the lithotomy position may be used when the lesion is located on the posterior rectal wall. On occasion, lesions may be prolapsed all the way through the anus and excised outside the body. Generally, the dissection starts at the distal end of the lesion and proceeds proximally.