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By Y. Karmok. University of Rhode Island.

Frozen section analysis is important for the and nutritional status with jejunal pouch after total gastrec- intraoperative confirmation of negative margins generic top avana 80mg fast delivery. Roux-en-Y esophagojejunostomy past two decades generic top avana 80 mg without prescription, the standard operation performed for gas- with a J-pouch is easy to construct and functions well purchase 80 mg top avana. Cancers of the cardia or fundus a minimum of 15 lymph nodes must be removed and assessed are treated with total gastrectomy or proximal subtotal gas- pathologically purchase top avana 80 mg fast delivery. While it is generally acknowledged in this trectomy with high ligation of the left gastric artery and situation that the more lymph nodes removed the better, the removal of the gastrosplenic ligament and lesser omentum role of extended lymph node dissection for gastric cancer together with the crural lymphatic tissue. Despite increasing interest in more extensive sur- pyloric and infrapyloric, right and left crural), while a D2 gical procedures for the treatment of gastric adenocarci- dissection removes level N1 and N2 nodes (nodes along the noma, none has definitively improved the cure rate left gastric, common hepatic, celiac, and splenic arteries). Splenectomy and distal pancreatectomy are not routinely 28 Concepts in Surgery of the Stomach and Duodenum 275 performed as part of D2 gastrectomy, as this extensive bariatric surgery center for evaluation. Surgical weight loss surgery has been shown to increase perioperative morbidity options include laparoscopic adjustable gastric band, sleeve without improving the cure rate. The operative trials comparing extended lymphadenectomy to D1 lymph- mortality risk varies inversely with the expected weight loss adenectomy in gastric cancer have failed to show a survival and directly with the extent of comorbidities and patient size. Duodenal switch has a mortality risk of 1–2 % advantage of D2 over D1, except in patients T3 or T4 tumors and an expected durable weight loss of 40–50 %. Preoperative, intraoperative, and postoperative care by a Laparoscopy multidisciplinary experienced bariatric team optimizes out- comes and maximizes patient safety. The answer to this postoperative death, now a relatively rare event following question depends somewhat on the surgeon’s attitude toward bariatric surgery. Preoperative cardiac assessment should be traindicated if liver or peritoneal disease is extensive. Intraoperative testing of gastric anastomo- Laparoscopy helps avoid a major unnecessary operation in sis or staple lines is routine. Finally, it is clear that in experi- Each bariatric operation has a specific set of possible long- enced hands, laparoscopic radical gastrectomy for gastric term complications, nutritional and otherwise. Lap-band slippage can be a surgical emergency since gastric necrosis may ensue, but band erosion into the stomach typi- Operation for Morbid Obesity cally is handled with elective band removal and drainage. Duodenal switch and biliopancreatic ered for bariatric surgery and referral to a multidisciplinary diversion are not commonly performed bariatric procedures. For interstitial cells of Cajal, and though they may occur any- safe application, it is important to adhere to certain principles. There are three histologic sub- dividing stomach or duodenum if the staples are too types: spindle cell (70 %), epithelioid (20 %), and mixed big, excessive staple-line bleeding can occur or rarely (10 %). If the staples are too small, they will not go patients with completely resected nonmetastatic disease, full thickness through both walls and the staples will prognosis is related to (inter alia) tumor size and mitotic not form correctly. It is probably better to use a staple size that kinase blocker imatinib (Gleevec). There may be a role for preoperative imatinib for pany’s stapler for 10 years cannot assume that she knows very large tumors that appear marginally resectable on exactly how to use the other company’s similar stapler. Patients who experience disease familiar with the new instrument before using it in the progression or intolerable side effects on imatinib are operating room. This is why when stapling across an existing antrum and pylorus, resulting in gastric stasis. When feasible, staple lines in the stomach and duodenum mosis and Roux duodenojejunostomy. Instillation 28 Concepts in Surgery of the Stomach and Duodenum 277 of methylene blue and intraoperative endoscopy are other Pancreatitis useful methods to confirm staple-line integrity. Staple-line bleeding into the lumen can be problematic Pancreatitis following gastroduodenal operation is generally and rarely can be life threatening. Either of the papillae can be injured during aggres- rhage and bleeders controlled. More com- gastrojejunostomy, intraoperative endoscopy should monly, the more proximal minor papilla is occluded or be performed if excessive staple-line hemorrhage is transected. The problems are interrelated in that infection predisposes to the other two complications, and all Postoperative Complications three share risk factors. Wound infection is related to intra- operative contamination, which is more significant in the set- Pulmonary Problems ting of acid suppression, gastric cancer, and obstruction. Appropriate use of prophylactic antibiotics and good surgical Atelectasis is probably the most common complication technique are important preventative measures. Adequate analgesia, incentive spi- disease, abdominal distension, obesity, infection, malnutri- rometry, and early ambulation help minimize this prob- tion, and steroid therapy have all been shown to increase the lem. Pulmonary embolism is unusual with current prophylactic practices but should be considered Early Gastric Stasis in any postoperative patient with acute shortness of breath, chest pain, or unexplained fever and tachycardia. Occasionally in the hospitalized patient who is recovering from gastric surgery, the nasogastric tube “cannot be removed” because of persistent nausea and vomiting. Alternative methods of gastric intubation and alimentation Following a gastric or duodenal operation, any suture line are preferable to a major reoperation during the first 6 weeks may leak and create a potentially fatal situation. These prob- postoperatively when the inflammatory response in the sur- lems manifest by the fifth or sixth postoperative day and are gical field may be intense. Reoperation during this early associated with increasing abdominal pain, fever, distension, postoperative period is often difficult, hazardous, and usually and leukocytosis. In patients and drainage of the peritoneal cavity, decompression of the with a small gastric remnant where a Stamm gastrostomy leaking segment (e. If the initial Witzel technique), and another (distal) tube may be placed operation was laparoscopic, sometimes an adequate reopera- antegrade as a Witzel feeding jejunostomy. Reoperation should thus usually be delayed for patients with postvagotomy diarrhea respond to cholestyr- 3–6 months after the first operation unless a high-grade or amine, and in others codeine or loperamide is useful. Following ablation or resection of the pylorus, most patients have bile in the stomach on endoscopic examination along with some degree of gross or microscopic gastric inflamma- Dumping Syndrome tion (Malagelada et al. Attributing post- operative symptoms to bile reflux is therefore problematic, Clinically significant dumping occurs in 5–10 % of patients as most asymptomatic patients also have bile reflux. It is usually epigastric pain, and quantitative evidence of excess entero- due to ablation of the pylorus, but decreased gastric compli- gastric reflux. Curiously, symptoms often develop months or ance with accelerated emptying of liquids (e. Medical therapy for early dumping syndrome consists of Remedial operation eliminates the bile from the vomitus dietary management and if necessary somatostatin analog and may improve the epigastric pain, but it is quite unusual to (octreotide). Bile reflux gastritis after distal It is the rare patient with dumping symptoms who requires gastric resection may be treated by Roux-en-Y gastrojejunos- an operation. To eliminate bile reflux, the Roux results of remedial operation for dumping are variable and limb or Henley loop should be at least 45 cm long, and a unpredictable. A variety of surgical approaches have been Braun enteroenterostomy should be placed a similar distance described, none of which works consistently well. Excessively long jejunal limbs may be include simple takedown of the gastrojejunostomy if the associated with obstruction or malabsorption. Whether Roux-en-Y proximal a previous operation, the Roux or Braun operations may be duodenojejunostomy (i. The benefits of decreased acid secretion would benefit the rare patient with disabling dumping fol- following total gastric vagotomy may be outweighed by lowing pyloroplasty is unclear. The Roux operation may be associ- Diarrhea ated with an increased risk of emptying problems compared to the other two options, but controlled data are lacking. Truncal vagotomy is associated with clinically significant Primary bile reflux gastritis (i. It occurs soon after operation is rare and may be treated with duodenal switch operation, and is usually not associated with other symptoms, a fact that essentially an end-to-end Roux-en-Y to the proximal duo- helps distinguish it from dumping (see above). The Achilles’ heel of this operation is, not surpris- may be a daily occurrence or it may be more sporadic and ingly, marginal ulceration. Possible mechanisms include intestinal dys- with proximal gastric vagotomy and/or chronic acid motility and accelerated transit, bile acid malabsorption, suppressive medication. Gastric stasis following operation on the stomach may be due to gastric motor dysfunction or mechanical obstruction (Speicher et al. The gas- Metabolic Problems tric motility abnormality may have been preexistent and unrecognized by the operating surgeon. Weight loss is common in patients who have be secondary to deliberate or unintentional vagotomy or undergone vagotomy or gastric resection (or both) (Harju 1990). An obstruction The degree of weight loss tends to parallel the magnitude of the may be mechanical (e. It may be insignificant in the large person or devastat- ulcer, efferent limb kink from adhesions or constricting ing in the asthenic female patient.

Advancing the Colon Segment to the Neck Be certain to enlarge the diaphragmatic hiatus (see Fig buy top avana from india. The most direct route to the neck follows the course of the original esopha- geal bed in the posterior mediastinum buy cheap top avana 80 mg on line. Place several studies between the proximal end of the colon transplant and the distal end of the esophagus; then draw the colon up into the neck by withdrawing the esophagus into the neck purchase top avana 80mg online. This brings the colon into the posterior mediastinum behind the arch of the aorta and into the neck posterior to the trachea purchase 80mg top avana free shipping. If there is no constriction in the chest along this route, the ster- num and clavicle at the root of the neck are also not likely to Fig. Before closing the anterior portion of the of adjacent sternal manubrium to be certain there is no anastomosis, ask the anesthesiologist to pass a nasogastric obstruction at that point. Obtain a sterile plastic Retrosternal Passage of Colon Transplant sheath such as a laser drape and suture the end of this plastic When the posterior mediastinum is not a suitable pathway cylinder to the termination of the rubber catheter. Insert the for the colon or if the esophagus has not been removed, make proximal end of the colon into this plastic sheath and suture a retrosternal tunnel to pass the colon up to the neck. By withdrawing the cath- left lobe of the liver is large or if it appears to be exerting eter through the thoracic cavity into the neck, the colon with pressure on the posterior aspect of the colon transplant, liber- its delicate blood supply can be delivered into the neck with- ate the left lobe by dividing the triangular ligament. If the xiphoid process curves posteri- nal cavity lies in a straight line and there is no surplus of orly and impinges on the colon, resect the xiphoid. Leaving redundant colon in the thorax Enter the plane just posterior to the periosteum of the ster- may produce a functional obstruction to the passage of food. Start the dissection with Metzenbaum scissors; then Then suture the colon to the muscle of the diaphragmatic insert one or two fingers of the right hand. Finally, pass the hiatus with interrupted sutures of atraumatic 4-0 Tevdek at entire hand just deep to the sternum up to the suprasternal intervals of about 2 cm around half the circumference of the notch. This helps maintain a direct passageway from the segment so the mesentery enters from the patient’s left side. Be sure not to pass the needle deep Resect the medial 3–4 cm of clavicle using a Gigli saw. Then to the submucosa of the colon, as colonic leaks have been rongeur away about 2 cm of adjacent sternal manubrium to reported to result from this error. Pass Dissecting the Cervical Esophagus a long sponge holder into the retrosternal tunnel from the Change the position of the patient’s left hand, which is sus- neck down into the abdomen and suture the proximal end of pended from the ether screen. Turn the head pass the colon into the substernal tunnel while simultane- slightly to the right and make an incision along the anterior ously drawing the sutures in a cephalad direction. Be vicular head if it is performed on the side opposite the domi- careful not to damage the left or the right recurrent laryngeal nant hand. After dissecting the esophagus free down into the the colon segment is good, perform the esophagocolonic superior mediastinum, extract the thoracic esophagus by anastomosis as above. Cyanosis indicates venous obstruction, which anastomosis and leave them in place 7–10 days. Close the thoracoabdominal inci- transplant to a point about 6–7 cm above the cut end of the sion as illustrated in Figs. Colon Interposition, Short Segment Esophagocolonic Anastomosis Perform an end-to-side esophagocolonic anastomosis at a In rare cases of benign peptic stricture of the lower esopha- point about 4 cm below the proximal end of the colon using gus, it is impossible to dilate the stricture, even in the operat- a technique similar to that described in Figs. If the exploration appears satisfactory, close the opening in the colon about 1 cm away from the circular stapled anastomosis using a 55-/3. Jejunum Interposition Incision and Mobilization Although Polk advocated mobilizing the esophagogastric junction through an upper midline abdominal incision, we prefer the left sixth-interspace thoracoabdominal incision with a vertical midline abdominal component. This is because the jejunal interposition operation is performed pri- marily in patients who have had multiple failed previous operations for reflux esophagitis. The Collis-Nissen gastro- plasty combined with dilatation of the esophageal stricture suffices in most patients. This leaves a few of the most advanced cases that require a colon (short segment) or jeju- num interposition. The combined thoracoabdominal incision provides superb exposure and makes this operation as safe as possible. It should be emphasized that creating a jejunal segment is much more difficult than the short-segment colon interposi- tion. When performing the thoracoabdominal incision, incise the diaphragm with electrocautery in a circumferential fash- ion, as depicted in Fig. Dissect the left lobe of the liver carefully away from the anterior wall of the stomach; in doing so, approach the dis- section from the lesser curvature aspect of the stomach. At the same time, incise the gastrohepatic omentum by proceed- ing up toward the hiatus. It may also be difficult pulmonary ligament, resect the diseased esophagus down to to free the upper stomach from its posterior attachments to the esophagogastric junction and replace the missing esoph- the pancreas. Careful dissection with good exposure from agus with a short isoperistaltic segment of colon to extend the thoracoabdominal incision should make it possible to from the divided esophagus to a point about one-third the preserve the spleen from irreparable injury. Freeing the esophagus in the middle colic artery, and only the distal portion of the the upper abdomen may be expedited by first dissecting the transverse colon and the splenic flexure need be employed. The esoph- Resection of Diseased Esophagus agocolonic anastomosis may be sutured in an end-to-end After the esophagus has been freed from its fibrotic attachments fashion, an end-to-side fashion, or even by a stapling tech- in the mediastinum and upper stomach, select a point near the nique. The latter involves inserting a proper circular stapling esophagogastric junction for resection. If the upper stomach cartridge (generally 28 or 25 mm) into the open proximal has been perforated during this dissection and the perforation end of the colonic segment. If the upper stom- between the end of the esophagus and the side of the colon ach is not excessively thickened, apply a 55- or 90-mm linear by the usual circular stapling technique. Transect the gaging the instrument, explore the anastomosis visually and esophagogastric junction just above the stapling device. A technique similar to that described in Deliver the transected esophagus into the chest and select the Figs. If the point of division of the esophagus is not higher than the Pass the nasogastric tube through this anastomosis down to the inferior pulmonary vein, jejunal interposition is a good method lower end of the jejunal graft. If the esophagus must be transected stapled esophagojejunostomy by the technique described in at a higher level, use a short segment of colon for the interposi- Fig s. The mal margin of the stomach in an area of stomach that is rela- graft of jejunum may be lengthened safely if its circulation can tively free of fibrosis and that permits the vascular pedicle to be boosted by creating microvascular anastomoses from a tho- be free of tension. This may be done by the same suture tech- racic artery and vein to the upper end of the graft. The appearance of the vidualize the dissection according to the conditions completed anastomosis is shown in Fig. First, try to stretch the proximal jejunum in a cephalad direction to determine where the greatest mobility Jejunojejunostomy is located. Be certain to leave intact at least the first major Reestablish the continuity of the jejunum by creating a func- jejunal artery to the proximal jejunum. The average length of tional end-to-end anastomosis using the stapling technique the jejunal segment to be transplanted varies between 12 and described in Figs. Be certain preserve a vascular pedicle containing two arcade vessels not to compress the vascular pedicle. When dividing an arcade vessel, be sure to place the point of transection sufficiently proximal to Gastrostomy; Pyloromyotomy a bifurcation so the continuity of the “marginal” artery and Although the nasogastric tube has been passed through the vein is not interrupted. Divide and temporarily close the jeju- jejunal graft into the stomach to maintain the position of the num proximally and distally with a linear cutting stapler, graft, there is a risk that the nasogastric tube may be inadver- preserving a segment measuring 15–20 cm for interposition. For this reason, perform a Stamm gastros- avascular portion just to the left of the middle colic vessels. Be absolutely certain the inci- pyloroplasty during this type of operation because it is sion in the mesentery does not constrict the veins of the vas- assumed that the vagus nerves have been interrupted during cular pedicle. Pass the course of dissecting a heavily scarred esophagus out of the proximal portion of the jejunal segment through the hia- the mediastinum. Closure Esophagojejunostomy Repair the diaphragm and close the thoracoabdominal Establish an end-to-side esophagojejunal anastomosis on the incision as illustrated in Figs. No distal to the staple line on the proximal closed end of the abdominal drains are utilized. Jejunal interposition for reflux esophagitis and esopha- managing-your-practice/coding-billing-insurance/cpt. Colon interposition of esophageal replacement: current indications and long-term func- benign esophageal disease.

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It is It is crucial that the proper operation be chosen and that the also sometimes used in young male patients to avoid the procedure is tailored to the patient (see Further Reading) discount top avana master card. Accurately assess and document the degree of preoperative In women purchase generic top avana line, the perineal approach may be combined with continence by: repair of any cystocele or other perineal problem top avana 80mg generic. Finally 80 mg top avana, abdominal and perineal procedures com- • Colon transit times if severe constipation is present. The Thiersch operation is indicated in extremely poor-risk Bowel preparation as for resection. Other perineal operations, including the Delorme procedure, are excellent alternatives in poor-risk Pitfalls and Danger Points patients and have largely supplanted this legacy procedure Perineal Proctosigmoidectomy When surgery is performed for recurrent prolapse (e. Chassin Operative Strategy Perineal Proctosigmoidectomy The procedure is most easily performed with the patient in the prone jackknife position. Injecting the rectal wall with lidocaine solution containing epinephrine will help minimize bleeding and display the correct dissection plane. Begin with a full-thickness incision in the posterior rectal wall above the dentate line. Place four full-thickness sutures alone the rectal cuff to keep the layers aligned and facilitate later anastomosis. Secure the mesentery as the bowel is delivered; ensure safety by hug- ging the rectal wall. Commonly, the peritoneal reflection is first encountered anteriorly as a hernia sac. If levatorplasty is desired, perform this before anastomo- sis by approximating the levators either anterior or posterior Fig. Take care not to tighten the levator sling too much, as most of these patients are prone to constipation. If only a short prolapse is encountered, a partial thickness oozing and help develop the plane. Note that dissection will (mucosal) resection with plication is an excellent alternative begin with a full-thickness incision through the rectal wall (see Delorme procedure in references at the end). Thiersch Operation (Surgical Legacy Begin with a full-thickness incision 1–2 cm above the Procedure) dentate line (Fig. Place a total of four full-thickness sutures of 2-0 Monocryl equally distributed around the cuff Lomas and Cooperman (1972) recommended that the anal of anorectum, leaving the needles on. These provide traction canal be encircled by a four-ply layer of polypropylene and exposure. Labow and asso- Finally, these four-quadrant sutures will be the first sutures ciates (1972) used a Dacron-impregnated Silastic sheet placed to approximate the rectosigmoid to the rectal cuff. Small bleeders can be secured with electrocautery band be adjusted to fit snugly around a Hegar dilator, we (Fig. Simply retract the prolapsed segment anteriorly or posteriorly and place one or two interrupted 2-0 silk sutures to approximate the Operative Technique levator muscles. Check that the plication has not compro- mised the lumen too much; the desired result produces some Perineal Proctosigmoidectomy snugness but is not tight. Resect the redundant segment using the four-quadrant Place the patient in the prone jackknife position, with the sutures to secure the proximal bowel and avoid retraction buttocks distracted by tape. Inject mosis by placing sutures between the four-quadrant sutures this region with dilute epinephrine solution to minimize (Fig. Cut the strip so it is elastic along its longitudinal axis and roll it into a cylinder 1. This operation may be done with the patient in the prone jackknife or the lithotomy position, under general or regional anesthesia. Make a 2 cm radial incision at 10 o’clock starting at the lateral bor- der of the anal sphincter muscle and continue laterally. Insert a large curved Kelly hemostat or a large right-angle clamp into the incision at 4 o’clock and gently pass the instrument around the external sphincter muscles so it emerges from the incision at 10 o’clock. Then pass the hemostat through the 10 o’clock incision around the other half of the circumference of the anal canal until it emerges from the 4 o’clock incision. Insert the end of the mesh into the jaws of the hemostat and draw the hemostat back along this path (Fig. At this time the entire anal canal has been encircled by the band of mesh, and both ends protrude through the posterior inci- sion. During this manipulation be careful not to penetrate the vagina or the anterior rectal wall. Also, do not permit the mesh to become twisted during its passage around the anal canal. Ask the assistant to increase the tension gradually by over- lapping the two ends of mesh. When the band feels snug several additional 2-0 Prolene interrupted sutures or a row of around the index finger, ask the assistant to insert a 2-0 55 mm linear staples to approximate the two ends of the Prolene suture to maintain this tension. Insert cling the external sphincter muscles at the midpoint of the 74 Perineal Operations for Rectal Prolapse 681 Initiate sitz baths after each bowel movement and two additional times daily for the first 10 days. Complications Altemeier Procedure Anastomotic leaks are relatively common after the Altemeier procedure but rarely require intervention. First, open the incision to obtain adequate drainage and treat the patient with antibi- otics. Some patients experience perineal pain following surgery, but it usually diminishes in time. If removal can be postponed for 4–6 months, there may be enough residual perirectal fibrosis to prevent recurrence of the prolapse. Recurrence and quality of life following perineal proctectomy for rectal prolapse. Close the deep perirectal fat with interrupted to suspend, to fix, to encircle, to plicate or to resect? Results of Delorme’s procedure for with interrupted or continuous subcuticular sutures of the rectal prolapse. Delorme’s procedure for complete rectal prolapse in severely debili- Prescribe perioperative antibiotics. Treatment any additional cathartic that may be necessary to prevent of rectal prolapse in the elderly by perineal rectosigmoidectomy. On the other hand, the fibrous tissue lining the pilonidal cyst contracts fairly rapidly, producing approxi- Recurrent symptoms of pain, swelling, and purulent drainage mation of the marsupialized edges of skin over a period of only several weeks. Conservative skin excision is fol- Pitfalls and Danger Points lowed by more rapid healing. Of course, all granulation tis- sue and hair must be curetted away from the fibrous lining of Unnecessarily radical excision the pilonidal cyst. Operative Strategy Excision with Primary Suture Acute Pilonidal Abscess Allow several months to pass after an episode of acute infec- tion to minimize the bacterial content of the pilonidal com- If an adequate incision can be made and all of the granulation plex. Successful accomplishment of primary healing requires tissue and hair are removed from the cavity, a cure is that the pilonidal cyst be encompassed by excision of a narrow accomplished in a number of patients with acute abscesses strip of skin that includes the sinus pits and a patch of subcu- by simple incision, drainage, and curettage. If this can be achieved without entering the cyst, closing the relatively shal- low, narrow wound is not difficult. Hemostasis must be perfect to ensure complete excision of the cyst and any sinus tracts without During marsupialization a narrow elliptical incision is used unnecessary contamination of the wound. If this is accomplished, one can coccygeal ligaments to ensure successful elimination of the approximate the lateral margin of the pilonidal cyst wall to pilonidal disease. In essence, the surgeon is simply excising a the subcuticular layer of the skin with interrupted sutures. At chronic granulomas surrounded by a fibrous capsule and cov- the conclusion of the procedure, no subcutaneous fat is ered by a strip of skin containing the pits that constituted the visible in the wound. Healing of exposed subcutaneous fat original portal of entry of infection and hair into the abscess. Documentation Basics Coding for anorectal procedures is complex, and the com- plexity is multiplied when flap closure is elected. In general, it is important to document: • Findings • Primary closure or marsupialization? Operative Technique Although it is possible to excise the midline sinus pits and to evacuate the pus and hair through this incision under local anesthesia, often the abscess points in an area away from the Fig. Consequently, in most cases simply evac- uate the pus during the initial drainage procedure, and postpone subcuticular level of the skin to the lateral margin of the a definitive operation until the infection has subsided.

These can be divided into two main groups — local complications and systemic or remote complications purchase top avana 80 mg mastercard. Necrotising inflammation of the smooth muscle of the bowel due to deep ulcers and at times damage to the myenteric plexus seems to be the main cause purchase top avana on line amex. Other factors which may play role in this condition are hypocalcaemia discount 80 mg top avana amex, hypoproteinaemia cheap top avana online american express, anticholinergic drugs etc. Diagnosis should be immediately suspected in any patient with acute colitis in whom number of stools suddenly decreases with bloody rectal discharge and the patient is obviously very toxic and febrile with progressive abdominal distension and absent bowel sound. Plain abdominal X-ray will show marked gaseous distension particularly of the transverse colon. Carcinomatous growths following ulcerative colitis are usually multiple, flat and infiltrating with poorly differentiated mucus-secreting types. These cancers may develop anywhere in the colon and does not show predilection towards rectum as the original disease shows. No specific symptom of cancer has been detected, yet excessive diarrhoea with abdominal pain, rectal bleeding and weight loss are suggestive. The only preventive measure which can be adopted is to advise total colectomy with ileostomy for any patient who is suffering from active total colitis for more than 10 years. This disease produces complications in certain specific organs such as (a) eyes — conjunctivitis, iritis, choroiditis, even ulcerative panophthalmitis, (b) Joints — arthralgias (swelling, pain, redness with migratory involvement) mainly affecting lower limb joints, ankylosing spondylitis, sacroilitis. The components of therapy are (i) antidiarrhoeal, (ii) antibiotics, (iii) corticosteroid, (iv) diet, (v) vitamin, (vi) minerals and (vii) general support. Most frequently lomotil (diphenoxylate hydrochloride with atropine) or codeine is used. This may inhibit mucosal prostaglandin synthesis to produce such a good response in this disease. If there is no significant improvement in 7 to 10 days, surgery should be seriously considered. Maintenance steroid therapy is with oral prednisolone starting at 60 mg daily in dividing doses and taperring as rapidly as possible to 15 mg or less. Retention enemas with water soluble corticosteroids are often beneficial in patients with disease limited to rectum and sigmoid colon. The main function of these agents is to maintain remission rather than treating an acute attack. A balanced milk-free diet should be given and too hot or too cold food should be rejected. In nutshell medical management for mild and moderate attack should be as follows : Prednisolone 5 mg four times a day, sulphasalazine 0. If sudden relapse breaks out during this therapy medical management for severe attack should be adopted. Hydrocortisone sodium succinate 100 mg in approximately 120 ml saline administered by rectal drip twice a day. Parenteral feeding by aminosol with fructose or ethanol or some equivalent preparation and parentrovite are prescribed. Patient is discharged with the treatment of prednisolone 5 mg 4 times a day, sulphasalazine 0. Immunosuppressive drug like azathioprine should do good in this disease as it has got some autoimmune background. After the abdomen has been opened, a full exploration is made with particular attention to the state of the liver and of the biliary tract, as gallstones are not uncommon. The colon is examined carefully with particular reference to any adhesion to any neighbouring structures which might have sealed-off perforation. If so, care must be taken to mobilise the colon lest spillage of faeces should contaminate the peritoneal cavity. The ureters are identified at the pelvic brim and a nylon tape is passed round each one, so that the subsequent dissection of the rectum can be carried out without risk of damaging them. The blood vessels to the ascending, transverse and descending colons are ligated with catgut and divided. The tissue, surrounding the rectum, is distended by injection of a solution of 1 : 200,000 noradrenalin in normal saline. The perineal surgeon, after a concentric dissection of anal sphincters, concentrates on dissecting anteriorly until the pouch of peritoneum in front of the rectum is opened. He follows the plane of cleavage just behind the rectum without entering the presacral space, where he can injure the autonomic nerves. He follows this plane of cleavage right upto the tip of the coccyx, where he meets the surgeon from the perineum. The proximal end is closed with a purse-string suture, the ends of which are held with a pair of artery forceps. The perineal skin is also sutured with nylon with a pelvic drain in the middle of the perineal wound. A disc of skin and subcutaneous tissue, 3 cm in diameter is cut from the anterior abdominal wall from the site previously marked. The ends of the purse-string suture of the ileum are used to pull the ileum out through this hole in the abdominal wall until it protrudes about 3 inches, thus ensuring that the finished ileostomy will be a spout of at least Vi inches in length. The ileum is anchored to the posterior rectal sheath by a number of interrupted sutures to prevent prolapse. At this stage of operation, a drain from the pelvic floor is brought out through a stab wound in the left iliac fossa. The ileum is turned inside out and the edge of the mucosa is anchored to the edge of the skin with interrupted catgut sutures. A suitable ileostomy appliance is immediately fixed and the operation is completed. As soon as ileostomy has started working, the patient can take ordinary light diet which can be increased gradually. Sometimes ileostomy alone may be performed in gravely ill patients, who are not suitable for total colectomy. Attempt should always be made not to do this operation as the diseased colon, which is often toxic and may easily perforate is left in the abdomen. Total colectomy is not a very difficult operation and if required an experienced surgeon should be called for to do this operation. Moreover, in subsequent stage when the patient has recovered to certain extent and a total colectomy is being planned, the surgeon may face adhesions due to previous ileostomy operation. Such bag is supported by a waist strap and also is adhered to the skin by special adhesive plaster. Care must be taken that the lower rim of the bag does not press on the lower margin of the ileostomy spout. During the first few postoperative days, liquid stool comes out and fluid and electrolyte balance should be well maintained. If soreness or excoriation of the skin occurs, a paste of aluminium 10 parts and zinc oxide 90 parts should be applied on the skin. A paste of Karaya gum may also be used as both protective and adhesive before applying the ileostomy bag. After a few weeks the stool gradually becomes thickened and semisolid, so ileostomy care becomes easier. Occasionally there may be bolus obstruction or stenosis of the stoma, which requires digital dilatation. This type of ileostomy requires no bag or appliance and can be emptied by the patient at a time he desires to do it. It is made in such a fashion that ileal content cannot escape through the ileostomy until the patient passes a catheter for emptying of the ileal pouch. A disposable appliance can be placed over the ileostomy so that the surrounding skin remains healthy. Modern appliances are also available to get a better stoma care with almost no skin problem. Complications of ileostomy are prolapse, retraction, stenosis, bleeding and paraileostomy hernia. Other possible alternative operation is subtotal colectomy with ileorectal anastomosis.

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