By M. Orknarok. Pikeville College.
However almost all the patients who present with intraperitoneal haemorrhage as a consequence of rupture of hepatic adenoma were taking oral contraceptives order levitra plus 400 mg fast delivery impotence kegel exercises. The explanation may be that the patients who stop using oral contraceptives and become pregnant are at considerable risk for tumour rupture and haemorrhage buy 400 mg levitra plus erectile dysfunction over 65. If the lesion has not ruptured operation can be avoided buy levitra plus us erectile dysfunction jacksonville doctor, since there is no evidence that this lesion becomes malignant. Mesenchymal hamartomas are rare but they grow to an extremely large size in infants. Carcinoids are also rare in liverand are usually associated with carcinoid syndromes. Biliary cystadenomas are also rare and may cause pain and extrahepatic biliary obstruction. Whereas it is quite common in Africa — particularly in Nigeria and Mozambique and China. However the predisposing factors are — (i) hepatitis B; (ii) alcoholic cirrhosis (post necrotic cirrhosis) is the type most commonly preceding hepatocellular carcinoma; cirrhosis is present in 60% of cases. On the other hand hepatoma occurs 5% of cirrhotic patients; (iii) haemochromatosis; (iv) parasitic infestation with the liver fluke Clonorchis sinensis (more commonly seen in China and Japan) (this has also been considered a factor in the development of cholangiocarcinoma); (v) low protein intake; (vi) alpha-antitrypsin deficiency; (vii) blood group B. The risk of hepatocellular carcinoma with oral contraceptive is not clear, though a number of such tumours have been reported to have started within benign adenomas in oral contraceptives users. Alphatoxins, products of the fungus Aspergillus flavus, which is found in wheat, soyabins, corn, oats are the principal diets of the Africans and Asian communities with high incidence of hepatocellular carcinoma. Occasionally due to rupture ofthe tumour or necrotic erosion of a blood vessel sudden pain may be complained of. Hepatomegaly or enlargement of the liver is the only diagnostic criteria clinically. The most common presenting symptom is abdominal lump, next is pain and next is weight loss. A high alkaline phosphatase level in absence of bone disease and obstructive jaundice is considered presumptive evidence of hepatocellular carcinoma. This protein is normally present in foetus and disappers within a few weeks after birth. Straight X-ray will show an enlarged liver, elevated right cupola of the diaphragm and occasional calcification of the tumour. Ultrasonography is a non-invasive and inexpensive method to visualise a suspected mass in the liver. Radionuclide scans (liver scans) are extremely helpful, but have more false positive results. Lesions less than 2 or 3 cm in diameter are often not detected by ultrasonography or liver scan. Selective hepatic arteriography has been utilised to demonstrate the tumour characterised by pooling and increased vascularity- It ihelpful in identifying the number and locations of multiple lesions. Splenoportography may demonstrate invasion of the portal vein and intrahepatic spread of tumour. But the lesion must be solitary or localised, must not involve lymph nodes, blood vessels or bile and should not have distant metastasis to qualify for excision. According to the position of the lesion segmental resection or lobar resection may be performed. Extensive radiation causes damage to the liver and even produces suppurative cholangitis. Carcinoma arising from the small ducts or ductules are included in this category, though carcinoma may occur in major hepatic ducts outside the liver substance. Extahepatic cholangiocarcinoma may arise anywhere in the hepatic ducts or common bile ducts. Vague abdominal pain, fever, pruritus and jaundice are the usual symptoms Folciform Lig. Only Middle Hepatic Vein when there is extrahepatic cholangiocarcinoma, gallbladder may be palpable. Iridium seeds may be implanted through a biliary Exlended For mo I drainage tube but its effectivity is still questioned and Lefl Lefl Left Lateral how far can it improve the survival rate is not yet determined. In poor risk patients with unresectable tumour, percutaneous biliary drainage is the only available palliative treatment. Intestinal anastomosis with intrahepatic duct such as Longmire procedure may be tried if possible in unresected cholangiocarcinoma. These are (i) Hepatoblastoma — an epithelial malignant tumour occurring primarily in children (60% of cases occur below 2 years of age). Other carcinomas are (ii) Cystadenocarcinoma and (iii) Squamous cell carcinoma, (iv) Carcinoid and (v) Fig. Liver is the second organ only to the lymph nodes as the most frequent site of metastatic carcinomas. Metastasis in the liver reaches by four routes :— (i) Portal vein, (ii) lymphatic spread, (iii) hepatic artery and (iv) direct infiltration. When the metastasis in the liver is solitary, it may not preclude radical resection of the primary tumour followed by resection of that part of the liver containing the solitary metastasis. Increased urinary excretion of 5-hydroxyindole acetic acid is diagnostic of such secondary metastasis. Metastasis in the liver is often quite late and may take place even years after removal of the primary growth. Resection of the segment of the liver containing metastasis has given the patients a resonable long survival without recurrence. Even when one lobe has been involved by metastasis, lobectomy may be performed if the primary tumour has been treated properly, there is no other secondaries in the body and when the patient’s condition will approve. Mitomycin C is another chemotherapeutic agent which has also been used with some success in liver metastases following colorectal carcinomas. Recently a percutaneous refillable pump is implanted in the subcutaneous tissue and attached to the catheter surgically positioned in the hepatic artery. Chemotherapy combined with hepatic irradiation has provided palliation to a certain extent. In established cases of portal hypertension, direct portal pressure measurement may be elevated to 15 mm Hg or even more. Portal hypertension is due to obstruction somewhere in the portal vein or its tributaries (pre-hepatic), in the portal venules and sinusoides in the liver (hepatic) or in the hepatic veins draining into the inferior vena cava (post-hepatic). Bacteria may be transmitted through a patent umbilical vein, there maybe history of neonatal omphalitis. Nutritional cirrhosis is the most common cause and in the Western World it is frequently associated with chronic alcoholism. Postnecrotic cirrhosis represents progression of viral hepatitis or toxic hepatic injury. Wilson’s disease (hepatolenticular degeneration) is characterised by alteration of hepatic function and structure and mental deterioration.
It is of no use to apply stitches to the urethra purchase levitra plus us erectile dysfunction treatment pune, since these will not hold and the friable tissues will give way cheap 400mg levitra plus with amex erectile dysfunction treatment in qatar. An indwelling catheter is pushed through the urethra into the bladder and this acts as a splint for healing of the urethra 400mg levitra plus amex erectile dysfunction injections side effects. Only occasionally surgical reconstruction may be required when the stricture has significantly reduced the urinary flow. It is said that about lOto 15%of cases of fractured pelvis sustain either rupture of membranous urethra or extraperitoneal rupture of bladder or both. When pelvic fractures occur from blunt trauma, the membranous urethra is sheared from the apex of the prostate at the prostatomembranous junction. Most common causes of pelvic fracture are road traffic accident, severe crush injuries and falls from buildings. Note that the prostate is displaced upwards immediately indicate not to pass a and posteriorly with rupture of puboprostatic ligaments. Rectal examination may reveal a large pelvic haematoma with the prostate dis placed superiorly, so that it may not be palpable, or if palpable with the tip of the finger. It must be remembered that the prostate cannot float or be displaced superiorly if the puboprostatic ligaments remain intact. Partial disruption of membranous urethra is not accompanied by prostatic displacement. Suprapubic bladder drain and retropubic drplete rupture and diagnosis between this ain are seen. A vertical incision is made just above the symphysis pubis to expose the extra-peritoneal tissues in which bladder urine will be seen. If the bladder is empty, the injury is vesical and if it contains some urine, a ruptured urethra is the probable diagnosis. In the latter case, it is rather impossible to repair by suture and the surgeon should be content with splinting the ruptured urethra with a self-retaining catheter. The bladder is opened and a bougie is passed in retrograde manner along the urethra to the site of the rupture. A second bougie is passed through the external meatus and the two bougies are made to contact each other. The first bougie is now slowly withdrawn, which is followed by the second bougie, till the second bougie enters the bladder. A rubber tube is now fitted over the tip of this 2nd bougie and is secured by a ligature. Therefore, the tip of a Foley catheter is attached to the rubber tube, which has come out through the external meatus This is known as Rail-road’ technique The rubber tube is now withdrawn from the bladder to draw the Foley catheter into the bladder. The bulb of the catheter is now inflated and a length of a silk is tied to the eye of the catheter in order to facilitate subsequent changing of this Foley catheter. A Malecot catheter is now pushed through the cystostomy wound and this cystostomy is closed around the catheter. The silk, which is fixed to the tip of the Foley catheter, is brought outside the abdomen and wound round a gauze piece, which is strapped to the anterior abdominal wall. The Foley catheter is used for traction for a fortnight and the catheter should be changed biweekly with the help of the silk strand. After the Foley’s catheter has been removed, the silk thread is used for the passage ofbougies to dilate the urethra. When a normal bougie can be passed through the urethra, the suprapubic drainage is closed intermittently to see that the patient is micturating properly. Stricture is usually very short and direct vision urethrotomy with an optical urethrotome which is passed endoscopically. A transpubic approach has been advocated by a few surgeons which allows a satisfactory end-to-end anastomosis to be performed. The incidence may be reduced to 10% by suprapubic drainage with delayed urethral reconstruction. If impotence is still present 2 years after reconstruction, implantation of penile prosthesis should be considered. The spread of the extravasated urine depends on the part of the urethra through which urine has come out. The urine first collects in the superficial perineal pouch, which is bounded below by the fascia of Colles and above by the inferior fascia of the urogenital diaphragm. The space is closed posteriorly by the fusion of the two fasciae and laterally by their attachment to the ischio-pubic rami. In front, this space is open and urine passes through this open space into the scrotum, penis and the anterior abdominal wall, deep to the fascia of Scarpa. The extravasated urine cannot spread downwards into the thigh due to the attachment of the fascia of Scarpa to the fascia lata of the thigh. When a case presents with extravasation of urine, it is already a late case and direct end-to-end suturing of the urethra is almost impossible as the sutures will cut through the oedematous inflamed tissues of the urethra. That is why suprapubic cystostomy is performed with the patient in the lithotomy position, a metal bougie is passed through the bladder and through the internal urethral meatus to the perineum and another metal bougie is passed from the external urinary meatusto the perineum. By rail-road’ method a sialastic tube with multiple holes (or Foley’s catheter of average size) is introduced into the urinary bladder The bladder is closed around a malecot catheter. The perineal wound is dressed daily with a weak Eusol solution The catheter is removed after 10 to 14 days. A voiding study (urethrography) is performed after 2 to 3 weeks through the suprapubic catheter. Removal of suprapubic cystostomy catheter may be done if no extravasation is documented. If the puboprostatic ligaments are torn, prostate together with the neck of the bladder is displaced upwards and posteriorly causing wide separation between the severed ends of the urethra. The extravasated urine collects in the cave of Retzius and ascends in the extraperitoneal space behind the fascia transversalis. Such deep extravasation may also occur in case of extraperitoneal rupture of bladder. In this condition urine extravasates in the layers of the pelvic fascia and in the retroperitoneal tissue. Rest of the treatment is according to rupture of posterior urethra or extraperitoneal rupture of the bladder. This scab usually closes the meatus and the child micturates by bursting this scab. So micturition is often accompanied with pain and a few drops of blood may be passed. When the scab is thus shade off, raw ulcer becomes visible, which is again covered by a new scab and this process continues. In late untreated cases cicatricial contracture of the meatus may result to cause a pin-hole meatus (acquired). The glans and external urethral meatus are washed with a solution of boric acid, which is prepared by boiling boric acid crystals in water. When cicatricial contracture has already developed, medicinal treatment does not help and operative meatotomy remains the only answer.
With a Harrington retractor elevating the uterus generic levitra plus 400mg line impotence uk, position of the respective ureter and hypogastric nerve to be use scalpel dissection to initiate the plane of dissection certain they lie away from the point of division buy levitra plus with a mastercard erectile dysfunction medication muse. Then divide separating the peritoneum and fascia of Denonvilliers from the fascia of Waldeyer buy genuine levitra plus on-line erectile dysfunction pumps cost, which extends from the coccyx to the the posterior lip of the cervix until the proximal vagina posterior rectal wall (Fig. Some surgeons routinely perform bilat- Now direct attention to the anterior dissection. Use a eral salpingo-oophorectomy in women who have rectal and Lloyd-Davies bladder retractor to pull the bladder (in women, sigmoid cancer because the ovaries are sometimes a site of the uterus) in an anterior and caudal direction. Whether this step is of value has not been neum of the rectovesical pouch has not already been incised, ascertained. Generally this is not performed in the absence of perform this maneuver now, thereby connecting the incisions visible metastasis to the ovaries. Apply one or more long hemostats or forceps to the posterior lip of the incised Pelvic Hemostasis peritoneum of the rectovesical pouch. Although hemo- scissors dissection to separate the rectum from the seminal static clips may control clearly identified vessels along 53 Low Anterior Resection for Rectal Cancer 511 Fig. Here the vessels consist of thin-walled a ball-tipped electrode is safer than one with a blade or veins, which are easily torn by metallic clips at the time pointed tip. Almost point that can be held in a forceps, electrocautery may also invariably, presacral bleeding results from a tear in one or be hazardous, as the coagulating tip may act as a scalpel and more of the veins that drain into a sacral foramen. If the area of bleeding is only 1–2 cm in diameter, removing the gauze pack may be attempted at a later stage in the operation, leaving a small Selection of Anastomotic Technique patch of hemostatic agent. Unless this maneuver produces complete hemostasis, replace the gauze pack in the presacral Use the side-to-end suture technique for a low colorectal space and leave it there for 24–48 h. See also the discussion under section “Operative Mobilization of Proximal Colon strategy”, above. If the previously selected point on the descending colon does Side-to-End Low Sutured Colorectal Anastomosis not easily reach down into the pelvis, mobilize the remainder (Baker) of the descending colon by incising ﬁrst the peritoneum in Turn to the previously cleared area on the descending colon the paracolic gutter and then the “renocolic” ligament. Place an Allen clamp 1 cm distal to the stapler be obtained by dividing the transverse branch of the left colic to occlude the specimen side. Completely clear the fat and mesentery stapling device using a scalpel, and lightly cauterize the from a 1 cm width of serosa at the point selected for dividing everted mucosa (Fig. After the Allen clamp is removed, apply a sterile rubber glove over the ligated end, and tie the glove in place with another umbilical tape ligature (Fig. Preparation of Rectal Stump Alternatively, divide the colon with a linear cutting stapler. Retain this segment of colon containing the specimen tempo- When the rectum is divided at a low level, the mesorectum is rarily to provide traction on the rectal stump. Place a scratch mark along the antimesen- and seek the plane between the muscularis of the rectum and teric border of the descending colon beginning at a point the surrounding blood vessels. This plane can sometimes be 1 cm proximal to the stapled end and continuing cephalad for palpated with the ﬁnger; and at other times a large blunt- a distance equal to the diameter of the rectal stump. In most patients this Now insert a lateral guy suture into the left lateral margin of vascular layer can be divided by electrocoagulation after the rectal stump and the proximal colon, and hold this suture in passing a right-angle clamp between the vasculature and the a hemostat. Approximate the posterior visible all around the lower rectum at the site selected for the muscular layer with interrupted 4-0 silk Cushing sutures, taking anastomosis. Finochietto angled needle holder (see Glossary) when sewing deep in the pelvis; this facilitates smooth insertion of the curved needle. Insert these sutures 6–7 mm behind the anticipated lines Irrigation of Rectal Stump of transection of the colon and rectum. Tie none of If there is any question as to the adequacy of the bowel prep- these sutures until all have been placed. When the anastomosis aration, insert a Foley catheter with a 5 ml bag into the rec- is at a very low level, it is convenient to keep the proximal tum. Attach the catheter to plastic tubing to permit the colonic segment well above the promontory of the sacrum until intermittent inﬂow and drainage of 500 ml of sterile water. Be This not only removes retained fecal matter but lyses any sure these stitches catch the longitudinal muscle of the rectum. After the irrigation is completed and the If only the mucosa is used for anastomosis, failure is likely. Start a continuous locked suture at the midpoint, and continue it to the right lateral margin. The second suture of the same mate- rial should progress from the midpoint toward the left lateral margin of the suture line (Fig. Divide the anterior wall of the rectum below the large right-angle clamp and remove the specimen. Request an immediate frozen section histologic examination of the dis- tal margin of the specimen to rule out the presence of cancer. If tumor cells are found at the margin, resection of additional rectum is indicated. Now approximate the anterior mucosal layer by a contin- uous suture of the Connell or Cushing type (Fig. Accomplish this by grasping the needle, which has com- pleted the posterior mucosal layer and is now in the lumen at the right margin of the anastomosis, and passing it from inside out through the rectum. The suture line should prog- ress from the right lateral margin toward the midpoint of the anterior layer. When this has been reached, grasp the second needle, located at the left lateral margin of the posterior mucosal layer. Use this needle to complete the anterior mucosal layer from the left lateral margin to the midpoint Fig. Close the anterior muscular layer with interrupted 4-0 atraumatic silk Lembert or Cushing sutures (Figs. Insert this row of sutures about 6 mm away from the mucosal suture line to accomplish a certain amount of invag- ination of the rectum into the colon. Because the dimension of the side-to-end lumen is large, narrowing does not result. After the anastomosis is completed, carefully inspect the posterior suture line for possible defects, which if present can be corrected by additional sutures. At this point cut the sutures and thoroughly irrigate the pelvis with a dilute solution of antibiotics. This omission has brought no noticeable ill effect, probably because the defect Fig. If there is, additional proximal colon Incise the previous scratch mark in the proximal colonic must be liberated. There must be sufﬁcient slack that the segment with a scalpel and Metzenbaum scissors (Fig. If exposure is difﬁcult, it is sometimes helpful to maintain Alternative to Colorectal Side-to-End gentle traction on the tails of the Cushing sutures to improve Anastomosis exposure while suturing the mucosa. Then cut the tails of the When the surgeon does not ﬁnd it practicable to leave the Cushing sutures successively as the mucosal sutures are specimen attached to the rectal stump for purposes of traction inserted.
It is interesting to note that lung carcinomas develop twice as frequently in the upper lobes as in the lower lobes levitra plus 400mg low price erectile dysfunction prescription medications. This neoplasm may be present for several years before symptoms occur and when symptoms occur it has Fig cheapest levitra plus erectile dysfunction virgin. This carci noma is usually seen in smokers and is almost unknown among non-smokers buy 400 mg levitra plus mastercard impotence over 70. Majority of squamous cell carcinomas occur in the main bronchi and so are centrally located. It usually arises after preliminary squamous metaplasia has replaced the normal respiratory pseudos Fig. When occurs in main bronchi, this neoplasm often becomes bulky and central necrosis with cavitation is not uncommon. This tumour is known for its slow growth, though it involves quickly the hilar lymph nodes, paratracheal and subcarinal group of lymph nodes. Growth is more rapid than squamous cell variety and it early metastasises by the vascular route to the liver, brain, bone and adrenals. It sometimes undergoes symmetrical expansion in the lung periphery so as to be called a ‘cannon ball’ tumour. In majority of cases it is central in location due to its origin in a proximal bronchus. It not only spreads early to the hilar and mediastinal groups of lymph nodes, this tumour aggressively invades surrounding structures and is also disseminated by early vascular invasion. The large cell and the small cell varieties are usually peripherally located and lymphatic spread is not seen in these cases. The most characteristic feature of the lesion is its favourable prognosis in comparison to other types of primary carcinomas. The tumour spreads considerably through the submucosa of the bronchial wall for a distance of variable length. In a few cases the lymphatic spread occurs upwards to involve paratracheal group of lymph nodes (by the side of the trachea), (iii) From the paratracheal group, the supraclavicular nodes (including the scalene nodes) may be involved. Left supraclavicular group (Virchow’s nodes) is often involved earlier by retrograde permeation. Direct spread may occur within the lung through the peribronchial and perivascular lymphatics. The liver, brain, bones, adrenal glands and skin are mostly involved by blood-borne metastasis. In the bones, the ribs, the vertebrae, the pelvis and ends of the long bones are affected in that order of frequency. Primary lung carcinoma or bronchogenic carcinoma is seen predominantly in men of 45 to 65 years of age, with the pick incidence at 55 to 60 years. The disease has been discovered in patients younger than 40 years (incidence is less than 5%). Due importance should be given to the fact that lung cancer in younger individuals is often virulent and that the diagnosis is frequently delayed. Pancoast tumour deserves special mention as it produces all together different clinical feature. Most lesions that produce cough are located in major bronchi and produce irritation by neoplastic erosion of the mucosa. Sputum production usually accompanies cough and its character is dependant on the degree of infection accompanying the lesion. It must be noted that intermittent or chronic cough is quite common among long-term smokers. But certain change in the character of chronic cough should raise suspicion of this malignant lesion in cases of long term chain smokers. Gradually when the parietal pleura or chest wall is involved, a severe and constant pain is complained of locally or referred to other side due to referred pain. This may be due to bronchial obstruction, as wheezing is often a sign associated with this symptom. It may be due to direct tumour invasion or due to pressure of metastatic lymph nodes, (iii) Pressure on the oesophagus will cause dysphagia (present in 1 to 5% of cases), (iv) Pressure on the phrenic nerve or invasion into it may cause its paralysis which will lead to paralysis of the hemidiaphragm, evidenced by continuous elevated posi tion of the affected half of the diaphragm. Symptoms due to secondary deposits may also be seen — (i) Cervical lymph node metastasis occurs in 15 to 20% of cases and these nodes may be palpable. This lesion produces symmetrical proliferative subperiosteal osteitis with new bone formation which affects the distal segments of the shafts of the long bones. Chronic synovitis is also seen with joint pains which may divert the attention of the clinician to the diagnosis of rheumatoid arthritis. It is interesting to note that clubbing occurs more frequently in patients with squamous carcinomas and disappears rapidly following excision of the tumour. None of the patients with clubbing and hypertrophic pulmonary osteoarthropathy had oat cell carcinoma. These usually suggest that the tumour is probably unresectable or there is systemic metastases. Deliberate search should be made for systemic metastases by isotope scanning and computed tomography. The manifes tations are those of muscular origin consisting of polymyositis and those of neurologic origin with sensory and motor loss. This should arouse suspicion of bronchogenic carcinoma or carcinoma of lung when older male patients are involved. The tumour invades the superior mediastinum early and involves the brachial plexus and cervical sympathetic nerves and upper ribs to produce a collection of symptoms known as pancoast syndrome. It includes (a) Homer’s syndrome, (b) lower brachial plexus palsy, (c) erosion of upper two ribs on X-ray and (d) pain in the shoulder, arm and axilla, the inner aspect of the upper arm and the scapular region. If such tumour produces bronchial obstruction, only then a whezee may be heard in the involved area. There may be presence of pleural effusion secondary to the lung carcinoma which will give rise to dullness on percussion and diminished breath sounds on auscultation. En 8th cervical nerve larged cervical or axillary lymph nodes stellate ganglion may be palpable in the supraclavicular or dome of pleura axillary region respectively. Liver enlarge ment can be assessed clinically on careful oesophagus 1st thoracic nerve palpation. This figure shows out any metastasis to the hilar lymph nodes the structures which may be involved by the pancoast tumour to 0r to any distant sites, produce pancoast syndrome. This eosinophilia may be due to manifestation against tumour necrosis or a particular type of haemopoietic hormone may be produced by the tumour cells which stimulates bone marrows to produce more eosinophils. There may be isolated mass in the peripheral lung field either with a smooth border (known as ‘coin lesion’) or with irregular margin. Many of these may be without symptoms and are first noted on a routine chest film. Quite a few patients with lung cancer may not show any changes on the chest X-ray. These are (i) pleural effusion, (ii) osteolytic lesions in the ribs or vertebrae and (iii) evidence of paralysis of the phrenic nerve with an elevated non-mobile diaphragm on the affected side.