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By O. Sven. Gettysburg College.

The patients who will benefit the most from hepatic teria of arterial enhancement and venous washout (Fig purchase doxycycline with paypal. In general buy online doxycycline, transplantation is preferred for patients When a patient presents with resectable liver metastases cheap generic doxycycline canada, a with multifocal disease or underlying cirrhosis buy doxycycline 200mg without a prescription. Resection is limited course of neoadjuvant chemotherapy prior to surgery preferred in patients with a single-lesion and well-preserved may be considered. First, liver function, since it avoids the morbidity of transplanta- it allows a period of time for the tumor to declare its biology; tion and the need for lifelong immunosuppression (Bruix if the lesion continues to grow on treatment, or other lesions and Sherman 2010 ). Ablative procedures can also be used as an alternative fluid boluses or those needing repeated blood transfusions to or to supplement resection. If recurrences develop, repeat interventions can be perihepatic packing (Pachter and Feliciano 1996). If hemorrhage continues after packing, the Hepatic Trauma Pringle maneuver can be applied by placement of an atrau- matic vascular clamp across the porta hepatis. This provides The liver is the largest intra-abdominal organ and the most the surgeon the ability to visualize and repair the site of frequently injured by trauma. Liver resection is only indicated in patients with shat- very resilient, and as a result most hepatic trauma can be tered or devascularized hepatic lobes. Minor bile leaks after nonoperative quently fatal even with prompt exploration since the mobili- management are not unusual, but these can be effectively zation of the liver required to access this portion of the cava managed by percutaneous drainage as described above. The classic example of this The choice of an anatomic resection versus a non-anatomic situation is the tachycardic patient with blunt abdominal (or wedge) resection depends on both the tumor type and the 698 U. Through this mechanism, preserve liver parenchyma when feasible – particularly in thrombocytopenia serves as a surrogate marker for hepatic patients with borderline liver function. The presence of esophageal varices is an alternate suggest that for primary liver cancer, an anatomic resection marker of portal hypertension resulting from the same patho- of the functional liver unit provides improved survival physiologic process. This concept does appear not hold for More sophisticated methods of quantifying the function metastatic colorectal lesions which arrived by hematogenous of the future liver remnant have been investigated, but none dissemination and are not based within a functional hepatic have proven consistently useful or superior. Certain In determining resectability, strict rules as to the number and patients with borderline liver function can be optimized by location of hepatic lesions have not proven to be useful in portal vein embolization to induce hypertrophy of the future guiding decision making. Mortality following liver resection should be rare, with rates In general, the determination of whether a liver lesion is of 1–3 % at high-volume centers (Torzilli et al. The resectable can be guided by ascertaining “inflow, outflow, major intraoperative risk of hepatectomy is that of massive and parenchyma. Intimate knowledge of the intrahepatic vascula- tomy were to be performed, the surgeon should consider ture – specifically the hepatic veins – is necessary to plan whether there will remain blood inflow to the remnant liver, lines of transection and to prevent inadvertent injury. Control venous outflow from the remnant, and sufficient hepatic of hepatic inflow by clamping the hepatoduodenal ligament, parenchyma to support liver function. Inflow may be the known as the Pringle maneuver, is useful to limit bleeding concern when, for example, a cholangiocarcinoma encases during transection. The Pringle maneuver can be applied the bifurcation of the hepatic artery or portal vein. While this may at first seem counterintuitive, maintenance of In a noncirrhotic patient with normal liver function, low intravascular volume leads to lower blood loss during approximately 80 % of the liver can be resected without con- hepatic transection (Wang et al. A hepatic trisegmentectomy for multi- that although the surgeon can control hepatic inflow using focal colorectal liver metastases is an example of this type of the Pringle maneuver, back bleeding of the inferior vena massive resection of parenchyma that can be performed with cava through the hepatic venous branches still occurs. However, bleeding is exacerbated when aggressive infusion of intrave- this amount of tissue loss would not be tolerated in a cir- nous fluids leads to a full vena cava. Maintenance of low rhotic patient where even a limited wedge resection can lead intravascular volume requires good communication between to fatal postoperative liver failure. Turcotte-Pugh score is a useful starting point, since liver There are several acceptable techniques for performing resection is uniformly fatal in Child C cirrhotics, and only transection of the liver parenchyma, based on surgeon pref- the most limited resections are tolerated in select Child B erence. However, the Child A designation is a large umbrella sected vessels should be ligated with gentle figure-of-eight term and contains too wide of a group of patients to be suf- sutures. Generalized oozing from the cut surface of the liver ficiently sensitive to guide resection (Poon and Fan 2005 ). In these patients, certain laboratory values can be used as Argon beam cautery and thrombin-soaked foam sponges can surrogate markers of the presence of cirrhosis and can help be useful adjuncts, but cannot be relied upon to remedy sur- guide decision making. Significant hepatic fibrosis Use of Drains leads to portal hypertension; the back pressure into the The use of drains following liver resection is at the discretion splanchnic circulation leads to splenomegaly, which in turn of the operating surgeon. Percutaneous cholecystostomy in patients with acute cholecystitis: experience of (Gurusamy et al. Mechanisms of controlled release of ascitic fluid and prevents the weeping of major biliary injury during laparoscopic cholecystectomy. Trends in survival of patients with hepatocellular carcinoma between 1977 and 1996 in the United States. Postoperative Management Prognostic factors for the development of gangrenous cholecystitis. Clinical score The major complication of hepatectomy in the postoperative for predicting recurrence after hepatic resection for metastatic period is liver failure. All patients will demonstrate a transa- colorectal cancer: analysis of 1001 consecutive cases. Trends in the leading causes of death in parameters, and the presence of new ascites. Management of acute cholecystitis in the laparoscopic era; results ally resolve with supportive care. Gastrointest Endosc Overburdening the remnant liver with high volumes is Clin N Am. Therefore, especially in of lamivudine on outcome after liver resection for hepatocellular cirrhotics, many hepatic surgeons allow relatively low urine carcinoma in patients with active replication of hepatitis B virus. A comparative study of antiviral therapy after resection of hepatocellular carcinoma in jaundice, coagulopathy, and encephalopathy. Follow-up after combined surgical and radiologic within the first week after resection, as evidenced by the wel- management. Common duct diameter as an independent predictor of choledocholithiasis: is it useful? Preoperative portal vein embolization for major liver resection: a 2008;34(3):306–12. Assessment of hepatic reserve for indication Surgery of the liver, biliary tract and pancreas. Torzilli G, Makuuchi M, Inoue K, Takayama T, Sakamoto Y, Sugawara Y, 2004;240:698–708. No-mortality liver resection for hepatocellular carci- Sakamoto Y, Makuuchi M, Takayama T, Minagawa M, Kita Y. Chassin† Indications Operative Strategy Symptomatic cholelithiasis, when laparoscopic cholecystec- Anomalies of the Extrahepatic Bile Ducts tomy is not feasible Acute cholecystitis, both calculous and acalculous Anomalies, major and minor, of the extrahepatic bile ducts Chronic acalculous cholecystosis and cholesterosis, when are quite common. A surgeon who is not aware of the varia- accompanied by symptoms of gallbladder colic tional anatomy of these ducts is much more prone to injure Carcinoma of gallbladder them during biliary surgery. The most common anomaly is a Trauma right segmental hepatic duct that drains the dorsal caudal Incidental removal during laparotomy for another indication, segment of the right lobe. This segmental duct may drain either for technical reasons or gallstones into the right hepatic duct, the common hepatic duct Failed laparoscopic cholecystectomy (“conversion”) (Fig. Division of this segmental duct may result in a postoperative bile fistula that drains as much Preoperative Preparation as 500 ml of bile per day. Ligation, rather than preservation, is the appropriate management if a small segmental duct is Diagnostic confirmation of gallbladder disease injured. Pitfalls and Danger Points Another extremely important anomaly of which the sur- geon should be aware is the apparent entrance of the right Injury to bile ducts main hepatic duct into the cystic duct. In this case, dividing and ligating the cys- Injury to duodenum or colon tic duct at its apparent point of origin early in the operation results in occluding the right hepatic duct. If the technique described in the next section is carefully followed, this acci- dent can be avoided. The surgeon who makes this mistake must also divide the common hepatic duct before the gallbladder is freed from all its attachments. This leaves a 2- to 4-cm segment of common and hepatic duct attached to the specimen (Fig. Because this is the most common cause of serious duct injury, we never permit the cystic duct to be clamped or divided until the entire gallbladder has been dissected free down to its junction with the cystic duct. When the back wall of the gallbladder is being dissected away from the liver, it is important carefully to dis- sect out each structure that may enter the gallbladder from the liver. Generally, there are only a few minor blood vessels that may be divided by sharp dissection and then occluded by electrocoagulation.

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Increased pressure in the dental canal compresses the inferior dental nerve and this will cause numbness of the chin in the distribution of mental nerve buy doxycycline 100 mg lowest price. Gradually the swelling points externally or internally and if the swelling bursts buy doxycycline 200mg free shipping, a sinus is formed externally or internally purchase 200 mg doxycycline free shipping. The most important finding is formation of a cavity due to osteolytic lesion with surrounding sclerosis (almost like Brodie’s abscess) with or without sequestrum formation cheap doxycycline 200 mg free shipping. Sequestrum formation is not so common as in long bones, as these bones are membranous bones. A suitable incision is made at the dependent part of the affected area of the mandible. This organism often lives as a harmless parasite in tonsillar crypts and dental cavities of an otherwise normal mouth (normal commensals of the mouth). If the organism invades tissue, it causes a subacute pyogenic inflammation with considerable induration and sinus formation. These constitute the well known ‘ sulphur granules’ or less known ‘Fish-roebodies’. If one of these granules is crushed under a cover glass and examined unstained, two elements can be distinguished — branching mycelial filaments and club forms. The filaments constitute the greater part of the body, whereas the clubs are pear-shaped bodies which form fringes round the periphery of the colony. These clubs probably represent means of defence against the protective forces of the tissues and are produced as deposition of lipid material derived from the host tissues. The characteristic radial arrangement is responsible for the familial term ‘ray-fungus’. More peripherally there is cellular infiltrate which consists of mononuclear histiocytes, lymphocytes and occasional giant-cells. Dense scar gradually replaces all other elements and imparts characteristic woody, indurated nature of the lesion. It must be remembered that mycelium may not be found in sections of the tissue and should not be accepted as the only point of diagnostic value. Myecelium is more often seen in soft areas and in pus rather than in a piece of hard tissue. Facio-cervical is the commonest with about 60% occurrence, followed by ileo-caecal 25%. Chronicity, dense induration and sinuses surrounded by bluish skin are the most characteristic features of cervico-facial actinomycosis. When the lesion is old and discharging for sometime, it may not be possible to demonstrate sulphur granules. In such cases it is best to allow a considerable amount of secretion to collect before examining it. The dose is gradually reduced to 4 mega units daily and this is continued for even 3 months. Role of surgery is restricted to chronic and resistant cases which are not responding to antibiotics properly. Roller gauze soaked in tincture iodine (2%) should be loosely packed after opening the abscess cavity. A few drops of Detol may be instilled in a glass of warm water and rinsing the mouth with such water is quite effective in controlling the stomatitis. In the beginning on the inside of the mouth one can see small vesicles with hyperaemic base. Otherwise maintenance of oral hygiene is the most important step in the treatment. Mouth should be kept clean and it should be rinsed thrice with diluted Detol-water or Listerin-water solution. These spots are small red patches which appear on the buccal mucosa and the tongue. These turn white as white exudate composed of desquamated epithelial cells are entangled in the mycelium. Nystatin is the specific antibiotic against this fungus and this should be used immediately. Both these organisms may be found in normal mouths, but are particularly found in large numbers in association with this disease. Whether these are the cause of this disease or secondary invaders is yet to be answered. Small ulcers can be seen on the gum which are covered with yellowish slough or membrane. When the fauces are involved the condition must be differentiated from diphtheria and secondary syphilis. Vitamin supplemen­ tation particularly vitamin B complex, vitamin C and oral iron preparation are important. It used to be associated with measles, malnutrition and serious diseases such as the blood dyscrasias (particularly leukaemia). Nowadays, if this disease is at all seen, it is often a complication of leukaemia. The area of necrosis spreads steadily and large areas of lips, cheeks and jaws may be destroyed. The general treatment of the disease which remains in the background should be treated simultaneously. Healing takes place with gross scarring which may prevent proper movement of the jaw. Similarly thinning of the oral mucosa makes the mouth more susceptible to trauma, hot drinks and spices. Features of stomatitis due to this disease are loosening of the teeth and bleeding gums. This syndrome is the combination of smooth tongue, desquamation of buccal and pharyngeal mucosa and subsequently dysphagia. Tertiary stage — gumma, chronic superficial glossitis and gummatous parenchymal infiltration. The ulcer ultimately heals and the lump also dissolves leaving only a fine superficial scar. These are linear ulcers which are covered with white boggy epithelium which makes them look like snail tracks. When the greyish white patch of dead epithelium separates the underlying mucosa bleeds. Gummata are also seen in the hard palate and nasal septum which may lead to perforation of the palate and nasal septum causing collapse of the bridge of the nose. Gummatous parenchymal infiltration usually involves the tongue and makes it stiff, big, thick and irregular. The inner surface of the lips and the whole of the inside of the mouth contain many small mucous secreting glands. If the overlying epithelium has been damaged by the teeth it will be white and scarred. The cyst is considered to be a mucous retention cyst arising from the glands of Blandin and Nuhn situated on the floor of the mouth. It is also considered by a few as dilatation of the duct of the sublingual salivary gland, but this theory is not entirely satisfactory. It is lined by columnar or cuboidal epithelium, which in turn is covered by delicate capsule of fibrous tissue. The cyst itself can be moved over the underlying structures, but such mobility is restricted due to lack of space around. Such prolongation comes down along the posterior border of the mylohyoid muscle and appears in the submandibular region. Deep or plunging ranula can be diagnosed by inspecting the submandibular region in all cases of ranula. If a swelling can be inspected in the submandibular region, bidigital palpation should be performed. One finger is placed inside the mouth on the ranula and the other finger is placed on the swelling in the submandibular region. If pressure on the first finger causes sense of fluctuation on the 2nd finger or vice versa, then it is a plunging ranula. That is why a small amount of the content is aspirated out and thus complete excision becomes easier as the tension within the cyst is decreased. The cut edge of the cyst wall is sutured with the cut edge of the mucous membrane.

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In pancreatic carcinoma the main pancreatic duct is narrowed and completely obstructed at the site of the tumour with dilatation of the distal part cheap 200 mg doxycycline otc. Cholangiography can suggest the site of tumour origin and is essential in planning successful resection discount doxycycline 100 mg on line. Even then as exploration is often justified in such cases intraoperative fine needle aspiration is preferred to percutaneous technique order generic doxycycline pills. Selective coeliac and mesenteric angiography generic doxycycline 100mg without prescription, combined with the evaluation of portal venous anatomy can be used for deliniation of major arterial and venous anatomy and for staging for resectability. Laparoscopy is now advocated as a means of improving staging and to detect unsuspected liver metastasis and peritoneal implants. Delay will cause further deterioration of hepatic function and will increase operative risk as the patient continues to lose weight. Adequate nutrition and correction of anaemia should be accomplished as early as possible. Preoperative evaluation of renal function is necessary, as postoperative renal failure is not uncommon in these cases. Preliminary transhepatic biliary drainage for 7 to 10 days may be of some value in deeply jaundiced patients. Clinically if there is no contraindication to surgery, one should explore the abdomen. This is mostly performed through right paramedian incision which starts at the right costal margin lateral to xiphoid process and extends downwards to a point to the right of the umbilicus. One can even use Vim-Silvermann needle to biopsy the tumour itself of the pancreas. Once the diagnosis is established the next step is to determine the feasibility of radical excision. When the distant lymph nodes are not involved, when the tumour is not fixed and when the liver is free from metastasis, one can go for radical surgery. Tumours less than 3 cm in diameter are usually resectable, whereas those greater than 5 cm are not resectable. Resectable tumours are most frequently situated near the ampulla, while the tumours in the body of the pancreas are mostly unresectable. So when resection is possible, the area resected is the head and neck of the pancreas together with the duodenum, which is known as pancreaticoduodenectomy or Whipple’s operation. An incision is made on the transverse mesocolon to free the hepatic flexure and right half of the transverse mesocolon as far as the middle colic vessels. This portion of the colon is now displaced below to expose the duodenum and anterior surface of the pancreas. The duodenum with the head of the pancreas is mobilised medially by dividing the peritoneum on the lateral side of the duodenum (Kocher’s manoeuvre). It is made clear that superior mesenteric vessels and the portal vein are not involved in cancer. It is followed and the gastroduodenal artery is also identified, ligated and divided keeping safe the hepatic artery. The index finger of the left hand can then be passed behind the neck of the pancreas and in front of the portal vein so as to emerge below the body of the gland in front of the superior mesenteric vein. This is an excellent method of ascertaining that the portal and superior mesenteric vein are not adherent to the growth. The common bile duct is now doubly clamped, transected above the duodenum and the distal end is ligated with stout silk. The left gastric artery is isolated, ligated and divided between ligatures about an inch from the cardia. The left gastroepiploic vessels are similarly secured and divided close to the power pole of the spleen. Two occlusion clamps are placed on the body of the stomach at the junction of the upper and middle thirds. The distal end of the stomach is caught with a large Payr’s clamp which acts as a retractor. The pancreas is divided at the neck and haemorrhage is controlled with Babcock forceps. The duct of Wirsung is identified and dissected out before division and is allowed to project from the cut surface of the body of the pancreas. The distal raw surface of the pancreas is closed with a series of interrupted mattress sutures of silk leaving the duct of Wirsung projecting. The transverse colon is lifted up and the jejunum is divided between two clamps about 6 inches from the duodenojejunal flexure. The distal portion of the duodenum and short segment of the proximal jejunum are freed by blunt dissection and drawn out beneath the superior mesenteric vessels. Some surgeons prefer to excise the gallbladder and the cystic duct along with the common bile duct leaving only the common hepatic duct for anastomosis. Now the reconstruction is started with the distal limb of the jejunum bringing in front of the transverse colon and the transverse mesocolon towards the common bile duct or the common hepatic duct as the case may be. A small seromuscular incision is made on the antimesenteric surface of the bowel, which is sutured to the margins of the pancreas with interrupted silk sutures. The abdomen is closed in layers as usual but the areas of biliary and pancreatic anastomoses must be drained. The mortality of this operation in the experienced hand is approximately 5% in present days. A modification of the standard Whipple operation, the pylorus-preserving pancreaticoduodenectomy, is gaining popularity. This modification eliminates gastric resection and leaves a 2 cm cuff of duodenum for enteric reconstruction of duodenojejunostomy. At present the overall 5-year survival rate for all patients with resected periampullary carcinoma is approximately 15% to 25%. The most important determinant factor of survival is the site of origin of the tumour. Whereas cancers of the distal bile duct, ampulla and the duodenum are associated with high survival rates of 40% to 60% in 5-year, resectable carcinoma of the head of the pancreas is associated with a survival rate of only 5% to 20% in 5-years. It now appears that this is absolutely theoretical and no advantage can be gathered following total pancreatectomy in comparison to Whipple operation. On the contrary total pancreatectomy removes all exocrine and endocrine function of pancreas. But Fortner first showed that involvement of this vein adjacent to the uncinate process is not a contraindication. This operation should be accom­ panied with wider lymphatic clearance and this procedure is called regional pancreatectomy. The reason is that in over 80% of cases the disease has spread beyond surgical resec­ tion at the time of presentation. It has spread to the mesenteric and para-aortic lymph nodes, to the superior mesenteric vein and hepatic metastases. Moreover advanced age and limited cardiopulmonary reserve pro­ hibit resectional surgery. Palliative surgery is mainly aimed at to alleviate (i) tumour associated pain, (ii) biliary obstruction and (iii) rare duodenal obstruction. In case of intractable pain chemical splanchnicectomy using 50% alcohol should be performed. Dilated pancreatic duct may be anastomosed to the back of the stomach side-to-side, which is often advocated to relieve pain due to ductal obstruction. Choledochoduodenostomy is the most physi­ ological method, but cholecystojejunostomy is more often practised due to its simplicity. But the latter operation has fallen into disrepute due to the fact that the cystic duct through which drainage occurs is quite narrow. This process is particularly useful for the elderly with a limited life expectancy. Gastrojejunostomy is usually performed as palliative measure to alle­ viate duodenal obstruction.

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