Because there is no hemodynamic abnormality epitol 100 mg, the heart is normal in size cheap 100mg epitol visa, and there is no rib notching cheap epitol 100mg with amex. A convex bulge (arrows) on the left side of the superior mediastinum represents dilatation of the aortic end of the ductus (“ductus bump”). Because of the left-to-right ventricular shunt, the pulmonary vasculature is engorged. Infantile type of Small (or normal) aorta; pulmonary venous Narrowing of a long segment of aorta proximal to coarctation of aorta congestion; cardiomegaly (biventricular but the ductus arteriosus. Mitral stenosis Small aorta; enlarged left atrium and increased Decreased left ventricular output causes dimini- pulmonary venous congestion; eventual shed aortic blood flow. Decreased cardiac output Small aorta; various patterns of heart size; Gross cardiomegaly in endocardial fibroelastosis usually pulmonary venous congestion, pleural and the cardiomyopathies. Normal-sized or small effusion, and prominence of the superior vena heart with characteristic calcification in chronic cava. Endocardial cushion defect Nonspecific globular enlargement of the heart Atrial and ventricular septal defects cause shunting with increased pulmonary vascularity. Hypoplastic left heart Small aorta; globular cardiomegaly with severe Underdevelopment of the left side of the heart is syndrome pulmonary venous congestion. Underdevelopment and stenosis of the supravalvu- stenosis lar portion of the aorta. Transposition of great Narrowing of the vascular pedicle on frontal Caused by superimposition of the abnormally vessels projection. Widening of the vascular pedicle on lateral projection (due to the anterior position of the aorta with reference to the pulmonary artery). Small aortic arch with pedicle resulting from superimposition of the abnormally moderate enlargement of the left ventricle. Frequently associated with con- genital heart disease (tetralogy of Fallot, truncus and pseudotruncus, tricuspid atresia, and trans- position). Aberrant left subclavian Characteristic oblique posterior indentation on Left subclavian artery arises as the most distal artery the barium-filled esophagus. Left subclavian artery is atretic at its base (totally artery isolated from the aorta) and receives its blood supply from the left pulmonary artery or via the ipsilateral vertebral artery (congenital subclavian steal syndrome). Right aortic arch with left Prominent indentation on the posterior wall of Transverse portion of the aorta must cross the descending aorta the barium-filled esophagus. Reverse S-shaped indentation on limbs of the aorta completely encircle the trachea the barium-filled esophagus. Aberrant right subclavian Posterior esophageal indentation on lateral Arises as the last major vessel of the aortic arch artery views. Lateral esophagram demonstrates the characteristic indentation of the anterior wall of the esophagus. Note the posterior impression and anterior displacement of the trachea (arrows) caused by the aberrant artery. Tetralogy of Fallot Decreased pulmonary vascularity; flat or con- Right aortic arch in approximately 25% of cases. Persistent truncus Increased pulmonary vascularity; concave Right aortic arch in approximately 25% of cases. Tricuspid atresia Decreased pulmonary vascularity; striking en- Right aortic arch in approximately 5% of cases. An largement of the right atrium if small atrial obligatory right-to-left shunt at the atrial level shunt; large left ventricle; small right ventricle. Transposition of great Increased pulmonary vascularity; generally Right aortic arch in approximately 5% of cases. Two patients with the characteristic concave appearance of the pulmonary outflow tract (arrowheads, arrow) associated with a right aortic arch. Congestive heart failure Cardiomegaly with evidence of pulmonary Failure of the left side of the heart leads to increased venous congestion. Initially normal heart size, then right rial disease (thromboembolism, arteritis, primary ventricular enlargement, and eventually disten- pulmonary hypertension); chronic heart disease tion of the superior vena cava. Plain chest radiograph in a normal young woman demonstrates prominence of the pulmonary artery (arrow) that simulates the poststenotic dilatation associated with pulmonary valvular stenosis. The lateral displacement of the cardiac apex and filling of the retrosternal air space indicate right ventricular enlargement. The right and left pulmonary artery branches are huge, but the peripheral pulmonary vasculature is relatively sparse. Long-standing pulmonary hypertension has produced degenerative intimal changes in the pulmonary arteries, which have become densely calcified. Pulmonary thromboembolic Enlargement of the main pulmonary artery Caused by pulmonary hypertension or distention disease segment. This sign is prima- (see Fig C 10-4) rily of value when serial radiographs demonstrate progressive enlargement. Mitral stenosis or Enlargement of the left atrium and right Obstruction of flow from the left atrium to the left insufficiency ventricle; normal-sized left ventricle and small ventricle during diastole results in increased aortic arch; pulmonary vascular congestion. The increased pressure is transmitted to the pulmonary veins and eventually to the pulmonary arteries and the right side of the heart. Usually caused by rheumatic valvular lesion; also by congenital mitral stenosis and the parachute deformity (all chordae tendineae originating from a single papillary muscle). There is a similar mechanism in the hypo- plastic left heart syndrome and a large left atrial myxoma. The pulmonary trunk is very large and overshadows the normal-sized aorta, which seems small by comparison. The pulmonary artery branches in the hilum and in the periphery of the lung are enlarged, and the pulmonary vascular volume is increased. Scimitar sign (crescent-shaped anomalous venous channel) on the right if associated with hypoplasia of the right lung. Increased pressure on the right side of the heart due to pulmonary stenosis causes the interatrial shunt to be right to left (patient is cyanotic). Tricuspid atresia without Marked cardiomegaly and increased pulmonary May be associated with transposition of the great pulmonary stenosis vascularity. Total anomalous pulmonary Increased pulmonary vascularity and enlarged All pulmonary veins connect to the right atrium venous return main pulmonary artery segment; various directly or to the systemic veins or their tributaries. Marked poststenotic dilatation (arrow) of the pulmonary artery with decrease in overall pulmonary vascularity. Plain chest radiograph in a patient with Ebstein’s anomaly shows widening of the right side of the superior portion of the mediastinum (arrows), reflecting marked dilatation of the superior vena cava. There is enlarge- ment of the right atrium, causing upward and outward bulging of the right border of the heart (squared appearance).
The stitches are then tightened seriatim to draw the seromuscular layers in contact trusted 100 mg epitol. Now join together the stomach and the duodenum using a continuous all-coats suture epitol 100mg cheap. This all-coats suture is continued to unite the anterior walls of the two viscera generic 100 mg epitol with mastercard. The anastomosis is completed by using the seromuscular stitch for the anterior walls of the two viscera. If it is suspected that the ulcer can be of malignant variety, a portion of the pancreas should be excised along with the stomach wall around the ulcer leaving the base in situ. Two hourly suction and intravenous infusion are continued as discussed under gastrojejunostomy operation. Dietary regime is more or less like postoperative care of gastrojejunostomy operation. Patients are instructed to take small and frequent meals due to the greatly reduced size of the stomach. Complications peculiar to gastric operations can be conveniently divided into two groups — (a) Early, i. If at all this complication takes place, continuous gastric lavage with I ml 1 : 1000 solution of adrenalin usually stops the bleeding. If still the haemorrhage persists the abdomen is reopened, the suture is reinforced with through-and-through catgut. In these occasions, the stomach should be opened and actual bleeding points are under-run. It results in peritoneal soilage with gastroduodenal contents and is associated with peritonitis, ileus, sepsis with a moderately high (10 to 15%) mortality rate. As soon as this condition is suspected, a drain is immediately inserted upto the gastroduodenal anastomosis alongwith nasogastric aspiration and intravenous fluid administration. This is generally treated conservatively by nasogastric suction and intravenous therapy to correct the electrolyte balance. Potassium deficiency is more or less always associated with this condition and potassium supplementation is of utmost importance, (b) Retrograde jejuno-gastric intussus ception, in which efferent loop of jejunum enters stomach through gastrojejunostomy stoma, may occur as early as 3rd day or may delay upto 3rd week. If these fail, operation has to be performed and the jejunum is slowly dragged down to reduce the intussusception. Later on the afferent and efferent loops are sutured seromuscularly to prevent recurrence, (c) Technical error during operation may cause stomal obstruction e. This causes obstruction of the outflow from the stomach, (d) Stomal obstruction may be caused by oedematous and hypertrophied mucosa of the antrum following Billroth I operation. In this case the hypertrophied mucosa has to be excised, (e) Apparent stomal obstruction may be due to lack of muscle tone of the stomach without any organic lesion in the stoma. So in case of a stomal obstruction if no cause can be found out by barium meal X-ray, one must perform endoscopy to see if the stoma is widely patent or not. It is a serious complication, but fortunately enough this is very rare and mostly due to surgeon’s fault. But the present theory is that this ‘give way’ is due to avascular necrosis from over-distension of the afferent loop of the jejunum. Sudden intense thoraco-abdominal pain in the first postoperative week should be thought in the line of duodenal blow out rather than basal pneumonia with pleurisy. Jejunostomy may be performed and the duodenal discharge is pushed through the jejunostomy tube to maintain proper electrolyte balance. If the afferent loop is kinked at the anastomosing site, the contents of this loop (pancreatic juice and biliary secretion) will not get access and will ultimately blow out the duodenal stump, (ii) A drain should be put down to the duodenal stump if such complication is anticipated, (iii) The stump should be closed very meticulously through normal duodenal wall and not through ischaemic duodenal wall caused by the use of crushing clamp, (iv) The surgeon must be careful not to close the stump through an inflamed duodenal wall or through an active duodenal ulcer. It is also referred to as “Dumping syndrome” because it has been supposed to result from rapid emptying of the stomach and consequent distension of the jejunum. Post-prandial discomfort, giddiness and sweating are common phenomena in early days after gastrectomy and are expected to disappear with the passage of time. Majority find them nuisance during first 6 months and may disappear within one year, that is why this group is included in the early complications. These syndromes can be better described under three heads — early dumping, late dumping and bilious vomiting. This consists of abdominal colic, nausea, vomiting, fainting, diarrhoea, epigastric discomfort, sweating, pallor and palpitation. This is due to sudden entry of hyperosmolar foods into the jejunum causing splanchnic hypovolaemia (fall in the blood volume). There is often pronounced fall in serum potassium associated with T and S-T segments alterations. The other theories postulated as cause of this syndrome are — (a) that there is some disorder of carbohydrate metabolism and following ingestion of carbohydrate diet there is initial transient hyperglycaemia. This causes suppression of absorption of glucose which is retained in the intestine, causes hyperosmolarity and leads to fluid shift from the blood to the lumen of the intestine leading to fall of blood volume and increased intestinal activity, (b) Many physicians find a correlation of the severity of dumping syndrome with symptoms of emotional instability. This is due to the fact that while almost all post-gastrectomy patients will have minor dumping symptoms, why is it that only 5% of patients have symptoms severe enough to bring them back to the surgeons. If still the symptoms persist for 8 months and are becoming more troublesome, operation is justified. A small segment of reversed jejunum (approximately 10 cm) may be placed between stomach and duodenum to impede gastric emptying (Henley loop). After initial rise of blood sugar, there is rapid fall of the blood sugar to about 50 mg/100 ml or so. This was considered to be due to mechanical obstruction from kinking of the afferent jejunal loop. The afferent jejunal loop is divided 2-3 cm from the point where it joins the stomach. The attached end is closed by invagination and the free end is anastomosed to the jejunum in an end-to-side fashion well below the gastrectomy stoma. When bilious vomiting occurs after Billroth I operation, a portion of jejunum is interposed between the duodenum and the stomach to prevent biliary regurgitation into the stomach remnant. As soon as this has been suspected, the abdomen is reopened, the hemia is reduced and if the hemia has become gangrenous, that portion of the bowel should be resected. It goes without saying that incidence of recurrent ulcer can be very much reduced by proper case selection and selection of the ideal operation which will be suited for the particular patient. The acid status of the individual should be brought down by selecting proper operation. Some surgeons are in the opinion that application of occlusion clamps predispose to ulcer formation and better be avoided. That is why the incidence of recurrent ulcer has gone down recently to less than 2%.
Pelvic ultrasound will be helpful in diagnosing endometriosis order epitol 100mg without a prescription, ectopic pregnancy cheap epitol 100mg with mastercard, and pelvic appendicitis generic 100mg epitol overnight delivery. The presence of a periorbital or facial rash should suggest contact dermatitis, angioneurotic edema, trichinosis, and herpes zoster. The presence of generalized edema suggests myxedema, cirrhosis, acute and chronic glomerulonephritis, congestive heart failure, and other disorders. The presence of fever suggests acute sinusitis, cavernous sinus thrombosis, orbital cellulitis, meningitis, and neurosyphilis. If there is fever, a nose and throat culture and blood culture should be done and antibiotics begun without delay. Trichinosis can be diagnosed by the skin test, serologic studies, or a muscle biopsy. In infants with pyloric obstruction, the vomiting is projectile, and the severe dehydration that follows, along with the right upper quadrant mass (a hypertrophied pylorus), helps to make the diagnosis. In adults with pyloric obstruction, the enlarged stomach with peristaltic waves going downward from left to right and a succussion splash are useful diagnostic signs. A flat plate of the abdomen (demonstrating the dilated stomach) and significant electrolyte alteration of metabolic alkalosis and potassium depletion will help confirm the diagnosis, but an exploratory laparotomy will remove all doubts. The peristalsis is transverse in small intestinal obstruction and vertical in large intestinal obstruction. Quinine, cocaine, atropine, and Apresoline are just a few of the drugs that may cause photophobia. Almost any condition of the eye may cause photophobia, including conjunctivitis, blepharitis, keratitis, iritis, corneal ulcers, and retinitis. Without fever or with only a low-grade fever, the presence of nuchal rigidity should suggest subarachnoid hemorrhage. If there is fever without nuchal rigidity, the workup can proceed as outlined on page 198. The fistula results from ruptured diverticulitis, ruptured appendix, or a neoplasm that forms a pelvic abscess that gradually eats its way into the bladder. Looking through her chart, you find laboratory results that show an increase in hemoglobin and hematocrit. Following the algorithm, you check for clinical signs of dehydration, and there are none. Her oxygen saturation is 96%, so pulmonary fibrosis or emphysema is an unlikely cause. You suspect polycythemia vera, but note that she is obese and has purple abdominal striae. If the plasma volume is decreased, think of dehydration, diuretic use, or other factors. Decreased oxygen saturation would suggest emphysema, pulmonary fibrosis, or cardiovascular disorder. An increase in the blood erythropoietin would suggest an erythropoietin-secreting tumor such as renal carcinoma or pheochromocytoma. A normal or decreased erythropoietin would point to polycythemia vera, heavy cigarette smoking, or methemoglobinemia. A hematology consult would be wise before undertaking any of the more expensive studies. The presence of these symptoms would suggest diabetes mellitus and hyperthyroidism. The presence of massive polyuria suggests diabetes insipidus or psychogenic polydipsia. The presence of mild polyuria should suggest chronic renal failure, renal tubular acidosis, hyperparathyroidism, and febrile illnesses. Also, a 24-hour urine collection for calcium may be done to help diagnose this condition. Microscopic examination of the urinary sediment will help diagnose renal disease, as will renal biopsies. The Hickey–Hare test and monitoring intake and output before and after vasopressin (Pitressin) will be useful in differentiating pituitary diabetes insipidus from nephrogenic diabetes insipidus. An endocrinologist should be consulted before ordering these expensive diagnostic tests. The presence of these symptoms would suggest diabetes mellitus or hyperthyroidism. This symptom would indicate that the patient has an insulinoma, Cushing’s disease, or idiopathic obesity. These symptoms would signal that the polyphagia is related to bulimia, hysteria, or other psychic disorder. If an insulinoma is suspected, plasma insulin or C-peptide levels may be done, or the patient may be hospitalized for a 72-hour fast with frequent blood sugar determinations. If hyperthyroidism, diabetes mellitus, insulinoma, and intestinal disorders have been ruled out, a referral to a psychiatrist would be indicated. Massive polyuria is usually because of pituitary or nephrogenic diabetes insipidus and psychogenic polydipsia. The presence of polyphagia and polydipsia suggests the possibility of diabetes mellitus and hyperthyroidism. The presence of a mild polyuria suggests chronic nephritis, renal tubular acidosis, hyperparathyroidism, Fanconi’s syndrome, and mild diabetes mellitus. The presence of glycosuria suggests diabetes mellitus, hyperthyroidism, and Fanconi’s syndrome. If renal disease is suspected, the urinary sediment should be examined microscopically and renal biopsy may be necessary. An endocrinologist and nephrologist should be consulted before undertaking expensive diagnostic tests. A soft popliteal swelling may be an abscess, varicose vein, Baker’s cyst, popliteal aneurysm, or swollen bursa. A firm popliteal swelling may be an osteosarcoma, periostitis, giant cell tumor, exostoses, lymphadenitis, lipoma, or fibroma. Masses that are connected to the bone are more likely exostoses, osteosarcomas, periostitis, or giant cell tumors. However, it is more cost-effective to seek an orthopedic consultation before ordering these tests or undertaking aspiration of the swelling. Children may take birth control pills early in life, and young boys may want to take anabolic steroids to increase their muscular mass. These findings would suggest a brain tumor, and a pinealoma is one that should be excluded. The presence of an adnexal mass would suggest a granulosa cell tumor or arrhenoblastoma. The presence of an adrenal mass would suggest adrenocortical hyperplasia or tumor.
Patients require at least 14 days to become fully immu- Splenic preservation is feasible in select patients with nized against encapsulated organisms (Streptococcus pneu- benign tumors order 100 mg epitol overnight delivery, small neuroendocrine tumors buy epitol 100 mg mastercard, or cystic neo- moniae cheap epitol 100 mg with visa, Haemophilus inﬂuenza type B, and Neisseria plasms without proximity or invasion of the spleen paren- chyma. Recent reports indicate that splenic preservation with division of the splenic artery and vein is safe in select patients. Also, if bleeding were Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Dr. Port placement will be variable depending on should also have an open tray of instruments available for the patient’s body habitus. Once a camera is placed in the supraumbilical location, a secondary port is placed to allow General Considerations for exposure of the undersurface of the liver and palpation of any suspicious lesions. Variant anatomy may present a challenge when divid- are carefully evaluated, and any suspicious lesions are biop- ing the splenic artery where inadvertent division may occur sied and sent for frozen section analysis. Replaced of M1 disease in a patient with pancreatic adenocarcinoma, left gastric vessels may also appear in the operative ﬁeld. Patient positioning and port placement options are shown After thoroughly exploring the abdomen, expose the in Fig. The importance of the hepatic artery is to have a very clear idea of its location to avoid inadvertent transection during stapling of the splenic artery. This can be done bluntly with ﬁngers if using a hand port or laparo- scopically with a laparoscopic Kitner or other blunt instru- ment. The splenic artery typically runs superior to the pancreas and is tortuous in nature. It can be stapled at any point during the operation and will slow bleeding from the spleen if the spleen is injured during Fig. Once the splenic artery is divided, the spleen will shrink to facilitate extrac- tion. Depending on the thickness of the pancreatic paren- chyma, the splenic vein and parenchyma may be divided together using a 2. Otherwise the splenic vein is freed from the posterior border of the pancreas and stapled separately. The order for division of the parenchyma, splenic artery, and vein is not ﬁxed and can be performed to optimize safety (Fig. Avoiding Damage to Blood Vessels Once the decision has been made to proceed with distal pan- createctomy and splenectomy, locate the splenic artery a few Fig. There are many devices available for tissue tran- volume of blood loss if the splenic capsule is ruptured during section, and this is left to the discretion of the surgeon. The short gastrics are then the pancreas arises when a malignancy in the body obscures divided (if splenic preservation is not planned) up to the gas- the junction between the splenic and portal veins or the tric fundus. If elevation of the tail the pancreas, the transverse mesocolon is lowered away and body of the pancreas together with the tumor should from its retroperitoneal attachments to the pancreas result in a tear at the junction of the splenic and portal veins (Fig. If the pancreas is of average thickness, the portal and superior mesenteric veins exposed after the simply apply a 3. Once the pancreas is divided, the specimen may be clamps may be applied and the laceration repaired. This removed in a medial to lateral fashion with removal of the complication can generally be avoided by careful inspection spleen being the last step in the operation (Fig. The of the tumor after elevating the tail of the pancreas and by spleen is freed from its retroperitoneal attachments as in a observing the area where the splenic vein joins the portal laparoscopic splenectomy (see Chap. If the tumor extends beyond this junction, it is probably The spleen remains attached to the greater curvature of inoperable. These maneuvers are typically performed once the stomach by means of the intact left gastroepiploic and the operation is converted to an open approach. If these structures were not completely divided at the time of mobilizing the stomach, the division can be completed at this point. Keep in mind if the goal is Identifying Splenic Artery splenic preservation, then these vessels should remain intact. For the hand-assisted approach, the specimen can be Palpate (hand port) or visualize (total laparoscopic) the enclosed in a specimen bag and removed through the hand splenic artery along the upper border of the neck of the pan- port incision. In a total laparoscopic approach, the supraum- creas at a point a few centimeters from its origin. If hepatic artery pulsation is normal, open the peritoneum overlying the splenic artery. Stump Closure For the total laparoscopic approach, be sure to have clear visualization of the artery before dividing it. Dividing the Splenic Vein and Pancreas and Removal of the Spleen Converting to an Open Approach Gently elevate the splenic vein by sweeping the areolar tissue away from this vessel until the junction between the splenic The ﬁrst and foremost indication for conversion is surgeon and portal vein is identiﬁed. If there is any concern for the safety of the may be stapled approximately 2 cm proximal to its junction patient or a lack of progression, then the operation should be 92 Laparoscopic Distal Pancreatectomy 847 a b Fig. Marking out the incision ahead of time will pro- closure (this is not supported currently by level I evidence). Postoperative Care References The decision to place a drain is left to the discretion of the surgeon. There is a lack of evidence to support routine drain Bassi C, Molinari E, Malleo G, et al. Early versus late drain removal after standard pancreatic resections: results of a prospective usage (Conlon et al. If a drain is left trial of the value of intraperitoneal drainage after pancreatic in place, it is recommended to place the drain to gravity to resection. Does prophylactic octreotide decrease the rates of pancreatic ﬁstula and other complications after If pancreatic ﬁstula develops, it generally resolves pancreaticoduodenectomy? If it does not resolve during that time, endoscopic stenting may facilitate Operations for Pancreatic Pseudocyst 9 3 Carol E. Differentiate chronic pseudocysts from acute collections of Cystogastrostomy or cystoduodenostomy is appropriate ﬂuid associated with acute pancreatitis (which generally only if the cyst is ﬁrmly attached to the wall of the stomach resolve without surgery) and from cystic neoplasms. If the cyst is not adherent, perform a Roux-en-Y cystojejunostomy because leakage from this Preoperative Preparation anastomosis is far less dangerous to the patient than is leak- age from the stomach or duodenum. The wall of the pseudocyst must be thick enough for a Rule out the presence of gallstones or bile duct obstruction safe anastomosis, particularly if a cystojejunostomy is per- by sonography, oral cholecystography, or endoscopic ret- formed. Aspirate the cyst before opening it Pitfalls and Danger Points to conﬁrm pancreatic juice without blood. Anastomotic leak Postoperative hemorrhage Mistaken diagnosis (cystadenocarcinoma) Pseudoaneurysm Overlooking an associated pseudoaneurysm Recurrence When arteriography has demonstrated a leaking pseudoan- eurysm of the splenic artery in a large pseudocyst, ask the angiographer to perform preoperative occlusion of the splenic artery. Carver control in the operating room, under emergency conditions, College of Medicine, University of Iowa, quite difﬁcult. Chassin Jaundiced Patient Although jaundice in the presence of a pseudocyst may well be the result of extrinsic pressure by the cyst against the dis- tal common bile duct, it is also important to rule out the pres- ence of calculi or periductal pancreatic ﬁbrosis as the cause of bile duct obstruction. If the jaundice is due to chronic ﬁbrosis in the head of the pancreas, endoscopic stenting or a bypass operation is required. It may be necessary to perform a side- to-side choledochojejunostomy to the defunctionalized limb of the Roux-en-Y distal to the cystojejunostomy. If the retrogastric mass is pulsatile, con- • Cystogastrostomy or cystoduodenostomy or sider seriously whether the mass represents an aortic aneu- cystojejunostomy?
S. Dargoth. University of Pennsylvania. 2019.