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Sometimes the patient may complain of a chronic sensa­ tion of a foreign body lodged in the throat buy levitra extra dosage 40 mg otc erectile dysfunction treatment herbal. This seems to be due to reflux into the upper oesophagus causing irritation and spasm of cricopharyngeal sphincter safe levitra extra dosage 60mg erectile dysfunction cleveland clinic. This is due to muscle spasm and motor disorder due to irritation of the oesophageal mucosa. Direct injury to the oesophageal mucosa may cause oedema, inflammation, spasm, fibrosis and even stricture in advanced cases. It must be remembered that an ulcer developing in oesophagus containing gastric epithelium i. Whether this is the cause or effect of reflux oesophagitis is still a controversy. One must remember respiratory symptoms may be mere association with this disease rather than being definitely caused by reflux oesophagitis. The whole of the oesophagus and stomach are to be examined first to exclude any disorder in the upper oesophagus or any abnormalities of the stomach including delayed gastric emptying. It must be remembered that the radiologists must see spontaneous free gastro-oesophageal reflux during the course of barium swallow examination. Unfortunately only half of the patients who ultimately are proved to have this disorder reveals reflux during barium swallow examination. Oesophagitis is graded from 0 to 4 according to the severity of changes observed through oesophagoscope. Presence of columnar epithelium more than 3 cm above the gastro-oesophageal junction suggests the diagnosis of Barrett’s oesophagus. This is due to metaplasia and is known to be precursor of adeno­ carcinoma of the distal oesophagus. It re­ quires skill to introduce rigid oesophagoscope and is not unsafe in the hands of experts, though there is significant risk of perfo­ ration. This instrument is probably better for examination of the lower pharynx and the cricopharyngeal area, as the view with flexible endoscope is rather poor in this area. Dilatation of oe­ sophageal stricture was undertaken with this rigid instrument and the classic Chevalier Jackson Bougie for many years, but now with flexible oesophagoscope the dilators passed over guidewires are much safer. First of all it does not require any general anaesthesia and can be performed as an out-patient method. The quality of magni­ fied image is far superior and the instrument is quite safe to pass through the oesophagus. It provides detailed images of the layers of the oesophageal wall and also gives Fig 43. Taking biopsies is quite easy with this instrument and it oesophagus due to oesophagitis following gastro-oesophageal reflux. Medical treatment includes : (i) The patients are instructed to sleep with the head end of the bed elevated on 6 inches blocks. This has been a major advance in the treatment of this condition and oesophagitis heals in majority of cases. Some suspicion has been raised whether it increases incidence of adenocarcinoma of the lower oesophagus and cardia due to long use of these drugs. The drugs which should be avoided in this condition are : Muscle relaxants, Anticholinergic drugs and Tranquillizers. When indications for surgical treatment are clear, the operation performed^s an anti-reflux operation. This operation is aimed at restoration of the intra-abdomi­ nal segment of oesophagus and mainte­ nance of the distal oesophagus as a tube like structure. A thorough exploration is done to exclude presence of gallbladder disease, peptic ulcer, pancreatic pathology and diverticular disease. The oesophageal hiatus is now explored and the size of the hernia, if at all present, is assessed. The triangular ligament of the left lobe of the liver is divided and it is retracted to the right. Traction on the stomach is made to reduce the hernia and to facilitate division of phreno-oesophageal ligaments which constitute the sac of the hernia. If only too much adhesion of the oesophagus is antici­ pated, a thoracic approach is worthwhile. If there is a good gap in the oe­ sophageal hiatus, this should be repaired anterior or posteriorly with non-absorbable material. Now the fundus of the stomach is exposed and upper short gastric vessels are divided. The fundus of the stomach is brought posteriorly around the oesophagus and sutured. Sutures are placed through the anterior fun­ dus, the wall of the oesophagus and the fundus brought posteriorly and sutured. It must be remembered that the fundus should be anchored to the intra-abdominal oesophagus securely, lest it should slip down on to the body of the stomach and cause obstruction to the stomach. This technique involves full 360° plica­ tion of stomach around the oesophagus and causes a higher intraluminal pressure in the abdominal oesophagus which is the sole objective of anti-reflux operation and in this respect this operation seems to be the most effective of all anti-reflux procedures. The only complication is that it may be a too tight repair and thus causes oesophageal obstruction. Postoperative barium swallow examination should be done to exclude such complication. The oesophagus is mobilised above upto the aortic arch to allow a sufficient long intra­ abdominal oesophagus. The fundus of the stomach is fixed firmly around 2/3rds of the circumference of the oesophagus along its lower 3 to 5 cm. Post-operative barium swallow should demonstrate a 4 cm segment of intra-abdominal oesophagus. As it is not a total fundoplication recurrence rate is more in long-term follow up. The oesophagus is mobilised extensively through the hiatus, but the phreno-oe- sophageal membranes are kept intact. The opening of the hiatus is narrowed by inserting sutures anterior to the oesopha­ gus, so that only one finger can Fig. Now the stomach is wrapped around the entrance of the oesopha­ gus into stomach by placing sutures on both anterior and posterior aspects of the gastro-oesophageal junction. These sutures are also passed through the median arcuate ligament for posterior gastropexy. Manometric pressure readings before, during and after this procedure indicate a rise in sphincter pressure to a level of 40 to 50 mmHg. The lower oesophagus and the car­ dia are separated from the diaphragmatic hiatus.

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Many experienced laparoscopic surgeons use an angled Begin with the operating table at a comfortable height for laparoscope (usually a 30° scope) as their standard scope buy levitra extra dosage with american express erectile dysfunction just before penetration. Place the patient in Become accustomed to an angled laparoscope by using it for 10–15° Trendelenburg position buy levitra extra dosage line impotence reasons. Estimate the distance laparoscopic cholecystectomy and note how it facilitates between the abdominal wall and the abdominal aorta by pal- visualization of both sides of critical structures. Make a 1-cm incision at the chosen entry site and deepen the incision to expose the anterior rectus fascia. This Choice of Initial Puncture Site is most easily done by spreading with a hemostat. The inci- sion must be large enough to accept the 10-/11-mm trocar if When planning trocar sites, particularly the initial puncture a 10-mm laparoscope is being used. It is better to err on the site, examine the abdomen for masses and scars from previ- side of slightly larger, as a small incision causes the trocar ous surgery and plan the location of the probable operative sheath to catch at the skin level. If the subcutaneous fat is thick and it is difficult to visualize the fascia, apply a Kocher clamp to the underside of the umbilicus and pull up. The umbilicus is adherent to the fascia, and this traction pulls the fascia into view. New York: Springer-Verlag, distance between the abdominal wall and the great vessels. Begin at low flow or regulate the inflow to a rate dle has been inserted into the abdominal wall, place one drop of 1 L/min. The initial reading in the gauge measuring intra- of saline in the hub of the needle. Aim the needle roughly in abdominal pressure should be 5–10 mmHg if the needle is in the direction of the sacral promontory. After 3–4 L of gas has been through the abdominal wall, one should feel a pop as it injected into the peritoneal cavity, percuss the four quadrants passes through the fascia and another when it penetrates the of the abdomen to confirm that the gas is being evenly dis- peritoneum (Fig. Increase hub should be drawn into the peritoneal cavity owing to the the flow rate until the intra-abdominal pressure has reached negative pressure that exists in the peritoneal cavity with 15 mmHg. At this stage, remove the Veress needle and insert traction upward on the abdominal wall. Direct ing another drop of saline in the hub of the needle and then this device in the direction of the sacral promontory and elevating the abdominal wall to create more negative pres- exert gradual pressure with no sudden motions until it has sure. If the drop of fluid is not drawn into the peritoneal cav- penetrated the abdominal cavity. If this move is tion device to the cannula and continue insufflation to main- unsuccessful, withdraw the needle and reinsert it. This initial cannula needle appears to be in the proper position, perform a confir- should have a diameter of 10–11 mm for the standard 10-mm matory test by attaching a syringe containing 10 ml of saline laparoscope. If turbid fluid is Open Technique with Hasson Cannula aspirated, suspect that the needle has entered bowel. If blood returns, remove the needle and promptly insert a Hasson can- The Hasson cannula is designed to be inserted under direct nula as described below and insert the laparoscope to inspect vision through a minilaparotomy incision. Make a scalpel incision through telescope is inserted and the operation can begin. Insert the index Occasionally, there is difficulty or uncertainty about finger and carefully explore the undersurface of the fascia for inserting the initial trocar cannula into the abdomen. Open the peritoneum under direct vision cases, do not hesitate to abandon the blind steps of inserting with a scalpel. The commonest error is to make the incision the Veress needle or the trocar cannula and to switch to an too small. The peritoneal incision should comfortably admit open “minilaparotomy” for insertion of a Hasson cannula. After visual and finger exploration ascertains that the abdominal cavity has been Management of Hypotension entered, insert the Hasson cannula under direct vision During Laparoscopy (Fig. This cannula has an adjustable olive-shaped obtu- rator that partially enters the small incision. These sutures are used to instruments into the trocars and release the pneumoperito- anchor the cannula and at the end of the procedure to close neum while seeking the cause of the problem. The increased intra- cannula, which firmly anchors the olive obturator in the inci- abdominal pressure is not always tolerated, especially in sion and prevents loss of pneumoperitoneum. Scott-Conner frequent use of reverse Trendelenburg position and rela- tive hypovolemia due to bowel preparation or overnight fasting prior to surgery. Often the procedure can resume if additional volume is infused and the insufflator is set at a lower pressure. Some patients do not tolerate pneumo- peritoneum, and the procedure must then be converted to an open laparotomy. Subcutaneous emphysema may be the result of an excessively high intra-abdominal pressure. After checking all of these possibilities, the anesthesiologist can generally maintain the patient with hyperventila- tion. This should be suspected if unex- 1999, with permission) pected hypotension occurs during the operation. It is par- ticularly apt to occur during laparoscopic surgery in the vicinity of the esophageal hiatus. This is the only way to become proficient A quick survey of the abdomen with the laparoscope is with the maneuvers needed for laparoscopic suturing and indicated. If the laparoscopic search is not ade- secondary operating ports should intersect at the operative quate, do not hesitate to make an emergency midline lapa- field at an angle of 60–90°. If you are uncertain, try out a rotomy incision, leaving all of the instruments and trocars contemplated trocar site by passing a long spinal needle in place. Explore the retroperitoneal area for damage to through the insufflated abdominal wall into the field under the great vessels, including the aorta, vena cava, and iliac direct vision and observe the position and angle at which it vessels. Trocar diagrams given in textbooks, Secondary Trocar Placement including this one, are just guidelines as each case is slightly different. If you are having difficulty, consider whether Place secondary trocars in accordance with the triangle rule: inserting another trocar for additional retraction or to substi- Think of the laparoscope (the surgeon’s eyes) as being at the tute for an ill-placed port might help. It is generally neces- apex of an inverted isosceles triangle with the primary and sary to leave the original trocar in place to avoid loss of the secondary operating ports as the left and right hands, as pneumoperitoneum. For that reason inspect the abdomen with the laparo- Ergonomic Considerations scope and, if necessary, insert one of the ports that will be used for retraction before placing the operating ports. For Once the ports have been placed, adjust the operating table example, when setting up ports for a laparoscopic cholecys- and dim the overhead lights. Then allows the hands to be held at approximately elbow height grasp the fundus of the gallbladder and try lifting it to get a with instruments in the trocars. Because laparoscopic 9 Mechanical Basics of Laparoscopic Surgery 65 instruments are longer than conventional instruments, it is laparoscopic appendectomy. Adjust the position of should have basic laparoscopic suturing and knot-tying the operating table to allow gravity to displace viscera skills. Practice suturing in a box trainer until you are (reverse Trendelenburg for upper abdominal surgery, facile.

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Toxic megacolon is a contraindication for barium enema because of the risk of perforation during air inflation buy levitra extra dosage impotence medication. Postcontrast images can be used to monitor the severity and the activity of the disease; the stronger the signal discount levitra extra dosage 60 mg visa erectile dysfunction medicine in pakistan, the higher the severity of the disease. Te synovial fuid analy- sis shows purulent content with neutrophils accumulation, but cultures are invariably negative. Humoral markers of infammatory diseases, including antinuclear antibodies and erythrocyte sedimentation rate, can be negative. Campa A, et al Management of a rare ulcerated erythema nodosum in a patient afected by crohn’s disease and tuberculosis. Prevalence of peripheral arthritis, sacroiliitis and ankylosing spondylitis in patients sufering from infam- matory bowel disease. Te “star-sign” in magnetic resonance enteroclysis: a characteristic fnding of internal fstulae in. Evaluation of criteria for the activity of Crohn’s 5 Enlarged mesenteric lymph nodes are commonly seen disease by power Doppler sonography. Current techniques in imaging of fstula in iting blood (hematemesis) and passing dark stool due to ano: three dimensional endoanal ultrasound and mag- blood digestion (melena). Active bleeding is detected by extrava- esophageal varices, Mallory–Weiss tear, and neoplasms. Indirect signs of bleeding include detection colitis, angiodysplasia, and neoplasms. Water can jet-like, linear, swirled, or pooled configuration dilute the extravasated contrast material, causing (. Radiologic features of vasculitis involving the by the presence of fuid seen around the porta hepatic gastrointestinal tract. It occurs in 10 % of cases and Pancreatitis is a disease characterized by infammation of the maintains a communication with the pancreatic duct. Pseudocyst can be mistaken with cystic pancreatic Both acute and chronic pancreatitis have diferent etiologies tumor. Cystic pancreatic tumors, in contrast to and radiological manifestations, which should be addressed pancreatic pseudocysts, have normal amylase level, separately. Fate of pancreatic pseudocyst will either (a) be resolved in 44 % Patients with acute pancreatitis typically present with abdom- spontaneously within 6 months or (b) develop a fbrous inal pain that can be epigastric or located in the right or less capsule afer 6 weeks and then needs drainage. Te pain is described (e) Pancreatic abscess: it is an infected necrotic tissue or as stabbing and commonly radiating to the back. Patients fuid collection that occurs usually afer 5 weeks with with acute pancreatitis are partially relieved from the pain by unhealed acute pancreatitis. It is a surgical emergence leaning forward, decreasing the retroperitoneal pressure on that occurs in 4 % of acute pancreatitis cases. Laboratory investigations (f) Pancreatic pseudoaneurysm: it is a condition that occurs typically show highly elevated serum and urinary amylase when an eroded blood vessel opens and bleeds into an and lipase levels. Te pseudocyst will collect blood T e most common causes of acute pancreatitis are gall- inside it forming what is called a pseudoaneurysm. Acute most common arteries involved are the pancreaticoduo- pancreatitis can be divided into two types according to sever- denal artery and the gastroduodenal arteries. Mild (g) Bowel ileus: it can be focal afecting regional small acute pancreatitis is characterized by reversible infammation bowel loops causing them to distend or difuse afecting and edema without pancreatic tissue necrosis. Radiological imaging has an important role in detecting Differential Diagnoses and Related Diseases and monitoring complications of acute pancreatitis which are: (a) Hemorrhagic pancreatitis: it is a serious surgical emer- A. Cholesterolosis (strawberry gallbladder): it is a rare gency of acute pancreatitis that occurs due to erosion of condition with unknown characterized by deposition of the pancreatic vessels by the leaking pancreatic enzymes. Te disease can occur with may present with discoloration of the fanks (Grey or without the presence of gallbladder stones. Juxtapapillary duodenal diverticulum: it is defned as sonography should be performed to exclude duodenal diverticulum located at peripapillary location. Pancreatic pseudoaneurysm can be diagnosed by choledocholithiasis, common bile duct dilatation, and finding a mass with arterial flow within it (assessed pancreatitis. In cholesterolosis, highly echogenic foci are detected within the gallbladder wall with posterior echogenic shadow that forms a comet-like appearance (highly Signs on Plain Abdominal Radiograph specific) (. There are no reliable signs that can confirm or exclude acute pancreatitis in plain radiograph. However, one sign that can be highly suggestive of pancreatitis is the presence of significant gas within the duodenum due to adjacent inflammatory process ileus (sentinel loop sign). The typical sign of pancreatitis in ultrasound is thickening of the pancreas (head size > 4. Demonstration of fluid collection in the pancreatitis showing hypoechoic, edematous head of the peripancreatic region may be seen. Peripancreatic fluid: because the pancreas has no pancreatic cyst full of fluid-density material without capsule, the inflammatory fluid will roam free within air with variable wall thickness (. The cyst the abdomen and will collect mainly in the lesser sac material shows different attenuations according to and the flanks first since the pancreas is the presence of necrotic material or hemorrhage. The presence of free fluid cyst wall characteristically shows uniform within the lesser sac and the anterior pararenal space enhancement after contrast administration. There is diffuse pancreatic swelling with blurring of cystic neoplasms is evaluation of the lesion on serial its margin due to edema. Up to 60 % of pseudocysts will resolve pancreas with reduction of its density and without intervention; besides the amylase levels are peripancreatic fluid collection in the lesser sac are usually high in cases with pseudocysts. Renal halo sign: the kidney is separated from the fluid pseudocyst from pancreatic cystadenomas. Left-sided pleural effusion: it may arise due to left phrenic nerve irritation and can be seen in 30 % of cases in chest radiographs. If >90 % of the pancreatic width is necrotic, the gland is said to have undergone central cavitary necrosis. Therefore, any small contrast uptake and enhancement can be represented as a yellow hue/color over the plain images. A pancreatic pseudocyst contains serous fluid; therefore, no enhancement should be noticed. In contrast, cystadenomas are cancerous cysts, so iodinated contrast enhancement will be seen inside the cyst, differentiating the cystadenoma from pseudocyst. Pancreatic pseudoaneurysm is detected as a pancreatic pseudocyst with blood–fluid inside it. Juxtapapillary diverticulum is typically found within a air–fluid level, while the pseudocyst is a radius of 2–3 cm from papilla of Vater and is seen as a fluid-filled cavity without air. Focal pancreatitis is considered as carcinoma of the head Chronic pancreatitis is defned as prolonged infammation of the pancreas when it is seen. It is diagnosed as focal of the pancreas that is characterized by irreversible pancre- pancreatitis when the biopsy returns negative for tumor atic damage with fbrosis, calcifcation, and loss of exocrine cells and only infammatory cells are found. Te most common cause is be suspected when pancreatic calcifcations are found, alcoholism (70% of cases). Complications of chronic pan- which are not commonly seen in pancreatic tumors creatitis include pancreatic pseudocyst formation, diabetes (except in endocrinal pancreatic tumors). Patients with hereditary occurs posteriorly, the pancreatic fuid may track through the pancreatitis have high risk of developing pancreatic retroperitoneum via the aortic hiatus into the mediastinum carcinomas (50–60 times greater than normal and eventually into the pleural space, typically on the lef side.