References Vju
1. Bradley EL. A clinically based classification system for acute pancreatitis. Arch Surg 1993 128 586-590. 2. Elechi EN, Calender CO, Leffal LD, et al. The treatment of pancreatic pseudocysts by external drainage. Surg Gynecol Obstet 1979 148 707-710. 3. Siegelman SS, Copeland BE, Saba GP, et al. CT of fluid collections associated with pancreatitis. Am J Radiol 1980 134 1121-1132. 4. Pitchhumoni CS, Agarwal N. Pancreatic pseudocysts. When and how should drainage be performed Gastroenterol...
Alternative Procedures Yqn
Endovascular stent grafts are an alternative to the conventional open surgical repair of abdominal aortic aneurysms in carefully selected patients. Improvements in technology have increased the ability to perform these procedures. With current technology, 50 of patients with AAA are candidates for an endovascular repair rather than conventional surgery. These compact systems are comprised of prosthetic grafts coupled to stents that are deployed via a transfemoral approach. The reported...
Types Of Cholecystectomy
Cholecystectomy consists of two basic steps-dissection of the gallbladder from the liver and identification and division of the cystic duct and artery Fig. 1C . The procedure may be performed either by an open or laparoscopic technique. In the open procedure, the abdomen is entered through a right subcostal incision and the gallbladder is dissected from the liver bed from top down, that is from fundus to the neck. As the cystic duct and cystic artery are reached, they are both ligated and...
Humana Press
2003 Humana Press Inc. 999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher. Cover Illustration From Figs. 1 and 2 in Chapter 1, Esophagectomy and Reconstruction by Michael Kent, Jeffrey Port, and Nasser Altorki Fig. 3 in Chapter 11,...
Percutaneous Endoscopic Gastrostomy Peg
A gastrostomy is a fistulous communication between the stomach and the abdominal surface. It is generally indicated in patients who require supplemental nutrition for more From Clinical Gastroenterology An Internist's Illustrated Guide to Gastrointestinal Surgery Edited by George Y. Wu, Khalid Aziz, and Giles F. Whalen Humana Press Inc., Totowa, NJ Impaired swallowing mechanism Facial trauma Neoplasms of the oral cavity or esophagus Inadequate caloric intake Gastric decompression Gastric...
Cryoablation and Radiofrequency Ablation
There are several other nonresectional techniques for obliterating tumors in the hepatic parenchyma. These modern ablative procedures include cryoablation and radiofrequency ablation RFA . In both cases, a major operation is typically required, although both may be employed laparscopically and even percutaneously in select circumstances. In both cases, a probe is placed into the tumor, typically under ultrasound guidance. For RFA, microwave energy is passed down the probe into the tumor cooking...
Alternative Procedures Tvw
Ultrasound and CT-guided drainage of pseudocysts provide alternatives to surgical drainage of pseudocysts. Internal drainage with endoscopy has been developed recently see Chapter 21 . Pseudocysts can be drained through the stomach, duodenum, or pancreatic duct. Recent reports have encouraging results 35-38 . However, these are fairly recent developments, and studies are needed to compare endoscopic treatment with surgical drainage. At this time, endoscopic and radiologic the inability to...
endoscopic sclerotherapy est Indications and Technique
Endoscopic sclerotherapy is being performed on an emergent basis to stop acute bleeding, and selectively to prevent rebleeding after control of initial episode is achieved. The goal of sclerotherapy is initial thrombosis and further obliteration of varices by injection of sclerosing agent. EST is performed with a short 25-gage needle that is directed into the veins intravariceal injection or into the esophageal wall next to the variceal vein paravariceal injection . Both techniques are...
Indications Col
Small bowel resections are most commonly performed for benign disease. The most common of these are intestinal ischemia and Crohn's disease. Intestinal ischemia may be a local phenomenon involving vascular compromise of a solitary loop of small intes- From Clinical Gastroenterology An Internist's Illustrated Guide to Gastrointestinal Surgery Edited by George Y. Wu, Khalid Aziz, and Giles F. Whalen Humana Press Inc., Totowa, NJ tine. Examples of this situation include strangulation of an...
Postvagotomy Diarrhea Syndrome
Vagal innervation is an important factor in the control of pancreaticobiliary secretion and intestinal absorption. Truncal vagotomy may result in excessive small bowel secretions or bile acids with resulting diarrhea. Diarrhea occurs in up to 25 of patients following a complete truncal vagotomy with gastric drainage or resection 17 . Less than 2 of patients have incapacitating symptoms. The syndrome is characterized by frequent watery stools, usually unrelated to meals, and occurring at night....
Alternative Procedures 1
Colonic resections have been performed laparoscopically since the early 1990s. The technical limitations of the procedure have largely been overcome. The procedure is performed with four or five trocars placed through the abdominal wall. Some resections can be preformed completely laparoscopically. Others can be performed hand-assisted. Fig. 7. Schematic diagram of anatomy after a sigmoid colectomy. The left or descending colon is then anastomosed to the rectum. Fig. 7. Schematic diagram of...
Portacaval Shunt PCS
Fig. 4. Small-diameter portacaval shunt. Fig. 4. Small-diameter portacaval shunt. The overall postoperative morbidity averages about 30 . Complications include perioperative bleeding requiring multiple transfusions, postoperative ascites including chylous ascites , pancreatitis from operative trauma to the gland, sepsis, and portal vein thrombosis. Specific complications from portasystemic shunting include postoperative hepatic encephalopathy, deterioration of liver function, and recurrent...
Gallbladder And Biliary Imaging
Ultrasound and cholescintigraphy are the preferred imaging methods for the routine evaluation and diagnosis of gallbladder pathology and each offers unique advantages and limitations. Ultrasound is used most frequently for several reasons. First, the typical right upper quadrant ultrasound exam can be performed quickly and takes about 15 min for the experienced technician to complete. Second, other abdominal organs such as the liver, pancreas, kidneys, and spleen can be visualized and other...
Operative Technique
The abdominal aorta may be approached by either a transperitoneal using either a midline or transverse abdominal incision or a retroperitoneal flank approach. The traditional, and most common, technique is via a midline, transperitoneal approach. Although there are some data to suggest a decreased incidence of postoperative pulmonary complications and ileus with the retroperitoneal approach, the final decision is ultimately based on the patient's anatomy, body habitus, and on the individual...
complications 1
The ease of insertion and effectiveness in relieving dysphagia has made placement of SEMS the current therapy of choice for palliation of unresectable esophageal carcinoma. On one hand, immediate palliation is achieved in 70-80 of patients. On the other hand, the incidence of postinsertion complications, such as stent migration, hemorrhage, and fistulization is high, with a reported incidence of 20-40 . Patients with prior radiation or chemotherapy seem prone to more frequent and serious...
References Tqi
1. LeVeen HH. The LeVeen shunt. Ann Rev Med 1985 36 453-469. 2. Moskovitz M. The peritonvenous shunt expectations and reality. Am J Gastroenterol 1990 85 917-929. 3. Wong F, Blendis L. Peritoneovenous shunting in cirrhosis its role in the management of refractory ascites in the 90s. Am J Gastroenterol 1995 90 2087-2089. 4. Yu AS, Hu KQ. 2001 Management of ascites. Clin Liver Dis 2001 5 541-568. 5. Fulenwider JT, Galambos JD, Smith RB, et al. LeVeen vs Denver peritoneovenous shunts for...
Small Stomach Syndrome
This syndrome is a result of loss of reservoir function when 80 or more of the stomach is removed. It differs from gastric stasis syndrome in that gastric emptying is normal. Symptoms include early satiety, epigastric pain after eating, and vomiting. Some patients develop severe weight loss, malnutrition, and anemia secondary to folate, vitamin B12 or iron deficiency. Dietary treatment is often successful and consists of increasing the frequency and decreasing the size of the meals, adding...
Introduction Puc
Enteral alimentation is the primary and preferred route for nutritional support. Enteral nutrition maintains intestinal integrity, reduces bacterial translocation, and maintains normal gut flora while preserving the enteral immune system. Furthermore, it has been shown to significantly reduce morbidity and mortality in high-risk surgical patients, and it is more convenient, cost effective, and fraught with fewer complications. Parenteral nutrition should be recommended for patients where...
Abdominal wall
Fig. 4. Schematic diagram of a loop colostomy. Fig. 6. Anatomy after sigmoid colectomy. The descending colon is then anastomosed to the rectum. Fig. 6. Anatomy after sigmoid colectomy. The descending colon is then anastomosed to the rectum. wall Fig. 4 . The anterior surface of the loop is opened allowing egress of stool. With either type of colostomy, an appliance is placed over the ostomy for collection of stool. As with colectomy with primary anastomosis, colectomy with colostomy may be...
Procedure Qea
The patient undergoes preoperative bowel preparation as aforementioned. The procedure is performed as a two-team operation, with the patient positioned in lithotomy position. As described for LAR, the abdominal operator makes a lower midline incision. Exploration is carried out to ensure both resectability and the absence of metastatic disease, and then mobilization to the level of the pelvic floor is carried out exactly as described for LAR. The rectum is, however, not divided with a stapler...
postgastrectomy syndromes
The most important common postgastrectomy syndromes are dumping, alkaline reflux gastritis, and gastric stasis. Less common postgastrectomy syndromes include small stomach syndrome, postvagotomy diarrhea, afferent loop syndrome, efferent loop syndrome, and recurrent ulcer. Most patients also develop iron deficiency anemia likely caused by exclusion of the duodenum from the enteral stream. The duodenum is the primary site of iron absorption. Poor mixing of the bile and food can result in...
Current Role Of Surgical Shunts
The management of a complex disease such as portal hypertension requires a multidisciplinary effort, and each specialist has a defined role and contribution gastroenterologist overall management of the liver disease, medical management of variceal hemorrhage, sclerotherapy or variceal banding , vascular transplant surgeon surgical shunting, liver transplantation , and interventional radiologist TIPS . The treatment of each patient should be selected based on the severity of the underlying liver...
Complications Lcp
Endoscopic sclerotherapy using cyanoacrylate glue, a tissue adhesive, was reported to be a safe procedure, but not free from serious complications. A main concern with the use of cyanoacrylate is the risk of embolization. Reports of cerebral stroke 15 , pulmonary embolism 16 , portal vein embolism, and splenic infarction 17 raised questions about the safety of this procedure. Additional complications in the form of visceral fistulas were also reported 18 . Though embolic complications are rare...
Efferent Loop Syndrome
The efferent loop syndrome is a purely mechanical problem characterized by gastric outlet obstruction at or near the gastrojejunostomy. The etiology may be kinking or adhesions of the efferent limb, or internal herniation behind the gastroenterostomy. Symptoms include diffuse abdominal pain, nausea, and bilious vomiting. The syndrome may occur months to years after the operation. The diagnosis may be confirmed by contrast studies, which demonstrates obstruction of the efferent limb. Surgical...
introduction Ugr
Distal gastrectomy has been a standard part of the abdominal surgeon's armamentarium since 1881 when Billroth performed the first distal gastrectomy for malignancy. The primary indications for distal gastrectomy in the past have been peptic ulcer disease and gastric tumors. Establishing the continuity of the gastrointestinal tract following distal gastrectomy has a rich and fascinating history. No other reconstruction of the gastrointestinal tract has produced such a variety of approaches 1 ....
Complications and Management Vug
The rate of complications following LAR has been reported as high as 41 5 . Most of these are common to most major abdominal procedures and would include atelectasis, urinary tract infection, wound infection, and deep venous thrombosis. Significant complications specific to LAR include anastomotic leakage, anastomotic stricture, and imperfections of continence or bowel habit. Leakage from the anastomosis after LAR Fig. 1. Use of a circular stapler to create an anastomosis. A Resection of bowel...
Description Of Small Bowel Resection
Thanks to the profuse collaterals within the mesenteric arterial arcades, surgeons may resect segments of small bowel anywhere along its length with little concern of compromising the blood supply. This is in contrast to colon resection, where the blood supply must be carefully considered. The resection margins are selected and the small bowel is divided proximally and distally with a linear stapler. The mesentery is divided between hemostats and the contents of each hemostat are ligated with...
Operations For Hernia Repair
The repair of all hernias, regardless of their location or the technique used, requires first the reduction of the herniated tissue second, the closure or reduction of the peritoneal sack that contained the herniated tissue and finally, restoration of the anatomy of the abdominal wall to prevent a future hernia. Difficulties in this operation arise from the complexity of the anatomy especially in the groin , individual variations there of and alterations in the regional anatomy caused by the...
Complications And Their Management
Morbidity and mortality can result from endovascular grafting as they can from open repair. It is fairly well established that in high-risk patients, endovascular grafting holds a safety advantage over open repair, but it has been much harder to establish an advantage in low-risk patients. Open conversion refers to the abandonment of the endovascular approach in favor of a conventional open procedure. On intent to treat basis, this currently occurs acutely in 1-5 of cases. However, rates of...
complications and management
Anastomotic leaks are unusual after Billroth II. If they occur, it is usually owing to an inadequate gastric blood supply and requires revision by further distal gastrectomy and another Billroth II or Roux-en-Y reconstruction. Recurrent ulcers are common and can lead to stomal stenosis. Dilatation or revision will then be necessary. Billroth II also has a greater incidence of dumping and alkaline reflux gastritis than Billroth I and these complications are discussed later. The most feared...
billroth i reconstruction
The Billroth I reconstruction is a gastroduodenostomy following distal gastrectomy Fig. 2 . This procedure involves Kocherization after Theodor Kocher , which releases the duodenum laterally from the peritoneal reflection so as to reduce tension on the anastomosis. The distal stomach is transected proximally, usually by a stapling device. The duodenum is transected just distal to the pylorus, and the two ends are anastomosed, either by handsewn technique or using a mechanical stapling device....
Procedure 1
Elective colon surgery requires bowel preparation. The goal of bowel preparation is to diminish the bacterial load logarithmically. The mechanical portion of the prep is accomplished by oral laxatives, which have replaced old-fashioned enema preps. The oral prep may be performed with a high volume solution of polyethylene glycol plus electrolytes, with Fleets phospho-soda solution, or with magnesium citrate. Additional antimicrobial preparation is achieved via the oral intake of poorly absorbed...
Complications Eml
The most feared complication of VBG is dehiscence of the staple line. The risk of breakdown is about 20 per patient per year. In the event of breakdown of the staple line, the stomach may return to its original size resulting in no further weight loss. Another common complication of the VBG is narrowing of the pouch outlet, which occurs in approx 3 of patients. Patients present with nausea, vomiting, and dysphagia. Initially, treatment consists of conservative measures such as instructing the...
Abdominal
Fig. 6. An endoscopically placed G-J tube. For patients in whom feeding infusions directly into the stomach are contraindicated, e.g., gastroesophageal reflux, a J-tube can be placed through a gastrostomy tube to permit infusion directly into the duodenum jejunum. Fig. 7. An externally anchored surgically placed J-tube. Fig. 7. An externally anchored surgically placed J-tube. Fig. 8. A Roux-en-Y jejunostomy with a low-profile port. Fig. 8. A Roux-en-Y jejunostomy with a low-profile port....
Biliaryenteric Anastomosis
When the bile duct is obstructed, it may be surgically bypassed. When resected, it must be surgically reconstructed. In both cases, the small intestine is anastomosed to the biliary tree. The only variation is which piece of small intestine is used for the anastomosis and how it is brought up to the biliary tree. The names of these procedures are based on these variations and the level of the anastomosis on the biliary tree. For example, a side-to-side choledochoduodenostomy refers to an...
Advanced Techniques
TIPS have been successfully created through occluded hepatic veins, thrombosed portal veins, and tumor-occluded portal veins. Techniques for accessing difficult portal anatomy have included shunt into left, middle, or caudate portal veins, portal access via transhepatic or transsplenic punctures, minilaparotomy allowing portal access via jejunal veins, and portal access through enlarged umbilical veins 9 . Techniques to avoid difficult hepatic venous anatomy include use of the left and middle...
Surgery For Rectal Prolapse
Rectal prolapse is an uncommon condition defined as complete protrusion of the entire thickness of the rectal wall through the anus. It is seen far more commonly in women than in men and generally after the age of 40 15 . Pathologic defects noted are a diastasis of the levator ani muscles, an abnormally deep cul de sac, an elongated sigmoid colon, and loss of the rectal fixation to the sacrum. Prolapse can secondarily result in incontinence caused by a patulous anus. Numerous procedures have...
Technique Lzg
The following is a basic step-by step description of the procedure. All moves are made with fluoroscopic guidance. The reader may find the illustrations helpful in visualizing the below Fig. 1 shows the relevant anatomy 6,7 . 1. The right internal jugular vein is accessed percutaneously, and a large-bore vascular sheath is advanced through the right atrium into the upper inferior vena cava IVC . 2. The right hepatic vein is accessed with a steerable angiographic catheter, and a hepatic venogram...
Esophagojejunostomy
Fig. 2. Common reconstruction technique with a Roux-en-Y limb. After total gastrectomy jejunal pouch is constructed and connected to esophagus. Fig. 2. Common reconstruction technique with a Roux-en-Y limb. After total gastrectomy jejunal pouch is constructed and connected to esophagus. The more common major perioperative complications seen after total gastrectomy are pneumonia and leakage of the anastomosis. Anastomotic leakage is seen more frequently following an esophageal anastomosis than...
Open Technique
1. Stamm gastrostomy 5 . The Stamm gastrostomy is considered the standard today. The procedure may be performed under general or local anesthesia as part of a major abdominal procedure or for feeding access alone. The aim of the procedure is to create a serosa-lined fistula between the stomach and the anterior abdominal wall Fig. 4 . Fig. 3. A low-profile PEG port. For patients who are mobile, a low-profile PEG port eliminates the need for a permanently protruding feeding tube. A resealable cap...
Indications and Contraindications Nqg
Total pancreatectomy may be indicated in cases where there is obvious tumor along the main pancreatic duct, and disease-free margins cannot be obtained. Rarely, a giant cystadenocarcinoma or sarcoma extends along the whole gland, and requires a complete resection. It may also be performed if the pancreatic remnant is friable, and will not hold sutures for a safe reconstruction. Total pancreatectomy may also be required for diffuse Fig. 3. Total pancreatectomy. A Mobilization of pancreas and...
gastric stasis syndrome
Gastric stasis also called gastric atony or gastroparesis results from two postgastrectomy derangements. Vagotomy decreases the frequency and amplitude of gastric contractions. Gastric resection disturbs the motility of the stomach, also impairing gastric emptying. These patients have postprandial epigastric pain, nausea, and vomiting of partially digested food eaten hours or even days before. They may be malnourished and Fig. 9. Gastric stasis after truncal vagotomy, partial gastrectomy and...
Alternative Procedure
As previously noted, the alternative procedure to TPC-IPAA for both ulcerative colitis and familial adenomatous polyposis is total proctocolectomy with permanent ileostomy. The major advantage of TPC-IPAA is its avoidance of the permanent ileostomy. The disadvantages are the need for a second-stage operation ileostomy closure and the higher complication rate. Fig. 2. Ileo J-pouch and anal anastomosis. A The rectum is divided and a reservoir pouch is then constructed from the distal 30 cm of...
Indications and Contraindications 1
Distal pancreatectomy is indicated for lesions at the body and tail of the pancreas. If the lesion is malignant, it must be ascertained whether or not the lesion is metastatic. In addition, a locally advanced lesion usually precludes a resection. This includes invasion into the duodenum, involvement of the celiac axis, common hepatic artery or portal vein. Adenocarcinoma of the pancreas occurs less frequently at the tail of the pancreas, however, most of the tumors are large and advanced at...
ENDOSCOPIC VARICEAL BAND LIGATION EVL Indications and Technique
Fig. 2. Esophageal variceal ligation. A Banding device including cylinder with rubber bands. B . Banding device is placed over the varix. C Suction is applied to aspirate varix into the cylinder. D Upon the release of the trip-wire, the rubber band strips off the cylinder and closes around the aspirated varix. E Ligated varix with endoscope removed. Fig. 2. Esophageal variceal ligation. A Banding device including cylinder with rubber bands. B . Banding device is placed over the varix. C Suction...
contraindications
A Roux-en-Y should not be done in the setting of delayed or marginal gastric emptying. The Roux will further delay gastric emptying and revisional surgery will be required 2 . If a Roux is indicated in the setting of poor gastric emptying, it should be accompanied with a near total gastrectomy. Fig. 6. Roux-en-Y gastrojejunostomy note truncal vagotomy and antrectomy . The Roux limb should be 40 cm in length. The afferent limb from the ligament of Treitz to the enteroenterostomy is 15-20 cm....
Transmural Or Transenteric Drainage
Transmural or transenteric endoscopic drainage procedures are performed through several endoscopic approaches through the stomach endoscopic cystogastrostomy or duodenum endoscopic cystoduodenostomy . Several prerequisites need to be fulfilled pursuant to endoscopic transmural drainage Table 1 . Ideally, the pseudocyst must be situated within the pancreatic head or body, and must be firmly adherent to the gastrointestinal tract to cause a visible impression on the gastric or duodenal wall at...
complications Wbj
The most important complication of the Billroth I procedure is anastomotic leakage. This creates intra-abdominal spillage with peritonitis, often results in enterocutoneous fistula, and has a high risk of mortality. Management can include percutaneous or open drainage, often requiring prolonged bowel rest and total parenteral therapy. Conversion to a Billroth II may be required. Intra-abdominal abscesses or wound infections occur after gastric surgery, especially in patients with gastric stasis...
Complications Of Biliaryenteric Anatomosis
The acute complications of these procedures are related to the magnitude of the upper-abdominal operation to accomplish them outlined in the section on liver resection as well as bile leaks. Bile leaks can occur not only from the anastomosis itself, but also from unappreciated ducts in the liver. This latter problem occurs almost exclusively in the setting of an acute repair of a bile duct injury when an injured segmental duct joins the injured bile duct at or below the bifurcation and is...
Complications Reo
Complications include urinary retention, urinary tract infection, bleeding, anal stenosis, incontinence, fecal impaction, infection, and fistula formation. Local infection and fistula formation are quite uncommon, easily recognized, and generally treated in the office with drainage or superficial fistulotomy. Urinary retention is generally secondary to both local pain and the amount of intravenous fluids received intraoperatively. Rates Fig. 7. Surgical hemorroidectomy. A Exposure of the...