The stitches are then tightened seriatim to draw the seromuscular layers in contact order cardizem 120mg with amex. Now join together the stomach and the duodenum using a continuous all-coats suture purchase cardizem 120mg with amex. This all-coats suture is continued to unite the anterior walls of the two viscera cardizem 120mg on line. The anastomosis is completed by using the seromuscular stitch for the anterior walls of the two viscera cheap cardizem 180 mg with mastercard. If it is suspected that the ulcer can be of malignant variety, a portion of the pancreas should be excised along with the stomach wall around the ulcer leaving the base in situ. Two hourly suction and intravenous infusion are continued as discussed under gastrojejunostomy operation. Dietary regime is more or less like postoperative care of gastrojejunostomy operation. Patients are instructed to take small and frequent meals due to the greatly reduced size of the stomach. Complications peculiar to gastric operations can be conveniently divided into two groups — (a) Early, i. If at all this complication takes place, continuous gastric lavage with I ml 1 : 1000 solution of adrenalin usually stops the bleeding. If still the haemorrhage persists the abdomen is reopened, the suture is reinforced with through-and-through catgut. In these occasions, the stomach should be opened and actual bleeding points are under-run. It results in peritoneal soilage with gastroduodenal contents and is associated with peritonitis, ileus, sepsis with a moderately high (10 to 15%) mortality rate. As soon as this condition is suspected, a drain is immediately inserted upto the gastroduodenal anastomosis alongwith nasogastric aspiration and intravenous fluid administration. This is generally treated conservatively by nasogastric suction and intravenous therapy to correct the electrolyte balance. Potassium deficiency is more or less always associated with this condition and potassium supplementation is of utmost importance, (b) Retrograde jejuno-gastric intussus ception, in which efferent loop of jejunum enters stomach through gastrojejunostomy stoma, may occur as early as 3rd day or may delay upto 3rd week. If these fail, operation has to be performed and the jejunum is slowly dragged down to reduce the intussusception. Later on the afferent and efferent loops are sutured seromuscularly to prevent recurrence, (c) Technical error during operation may cause stomal obstruction e. This causes obstruction of the outflow from the stomach, (d) Stomal obstruction may be caused by oedematous and hypertrophied mucosa of the antrum following Billroth I operation. In this case the hypertrophied mucosa has to be excised, (e) Apparent stomal obstruction may be due to lack of muscle tone of the stomach without any organic lesion in the stoma. So in case of a stomal obstruction if no cause can be found out by barium meal X-ray, one must perform endoscopy to see if the stoma is widely patent or not. It is a serious complication, but fortunately enough this is very rare and mostly due to surgeon’s fault. But the present theory is that this ‘give way’ is due to avascular necrosis from over-distension of the afferent loop of the jejunum. Sudden intense thoraco-abdominal pain in the first postoperative week should be thought in the line of duodenal blow out rather than basal pneumonia with pleurisy. Jejunostomy may be performed and the duodenal discharge is pushed through the jejunostomy tube to maintain proper electrolyte balance. If the afferent loop is kinked at the anastomosing site, the contents of this loop (pancreatic juice and biliary secretion) will not get access and will ultimately blow out the duodenal stump, (ii) A drain should be put down to the duodenal stump if such complication is anticipated, (iii) The stump should be closed very meticulously through normal duodenal wall and not through ischaemic duodenal wall caused by the use of crushing clamp, (iv) The surgeon must be careful not to close the stump through an inflamed duodenal wall or through an active duodenal ulcer. It is also referred to as “Dumping syndrome” because it has been supposed to result from rapid emptying of the stomach and consequent distension of the jejunum. Post-prandial discomfort, giddiness and sweating are common phenomena in early days after gastrectomy and are expected to disappear with the passage of time. Majority find them nuisance during first 6 months and may disappear within one year, that is why this group is included in the early complications. These syndromes can be better described under three heads — early dumping, late dumping and bilious vomiting. This consists of abdominal colic, nausea, vomiting, fainting, diarrhoea, epigastric discomfort, sweating, pallor and palpitation. This is due to sudden entry of hyperosmolar foods into the jejunum causing splanchnic hypovolaemia (fall in the blood volume). There is often pronounced fall in serum potassium associated with T and S-T segments alterations. The other theories postulated as cause of this syndrome are — (a) that there is some disorder of carbohydrate metabolism and following ingestion of carbohydrate diet there is initial transient hyperglycaemia. This causes suppression of absorption of glucose which is retained in the intestine, causes hyperosmolarity and leads to fluid shift from the blood to the lumen of the intestine leading to fall of blood volume and increased intestinal activity, (b) Many physicians find a correlation of the severity of dumping syndrome with symptoms of emotional instability. This is due to the fact that while almost all post-gastrectomy patients will have minor dumping symptoms, why is it that only 5% of patients have symptoms severe enough to bring them back to the surgeons. If still the symptoms persist for 8 months and are becoming more troublesome, operation is justified. A small segment of reversed jejunum (approximately 10 cm) may be placed between stomach and duodenum to impede gastric emptying (Henley loop). After initial rise of blood sugar, there is rapid fall of the blood sugar to about 50 mg/100 ml or so. This was considered to be due to mechanical obstruction from kinking of the afferent jejunal loop. The afferent jejunal loop is divided 2-3 cm from the point where it joins the stomach. The attached end is closed by invagination and the free end is anastomosed to the jejunum in an end-to-side fashion well below the gastrectomy stoma. When bilious vomiting occurs after Billroth I operation, a portion of jejunum is interposed between the duodenum and the stomach to prevent biliary regurgitation into the stomach remnant. As soon as this has been suspected, the abdomen is reopened, the hemia is reduced and if the hemia has become gangrenous, that portion of the bowel should be resected. It goes without saying that incidence of recurrent ulcer can be very much reduced by proper case selection and selection of the ideal operation which will be suited for the particular patient. The acid status of the individual should be brought down by selecting proper operation. Some surgeons are in the opinion that application of occlusion clamps predispose to ulcer formation and better be avoided. That is why the incidence of recurrent ulcer has gone down recently to less than 2%. One word of caution should be remembered by the students and young doctors that while performing partial gastrectomy the level of the excision of the stomach should not be as low as to leave a part of antrum, which will increase the incidence of recurrent ulcer to 40% or should not be as high as to produce nutritional deficiencies later on. The symptoms generally appear 2 years after operation and consist of persistent pain ‘burning’ in type, which becomes worse within half an hour of taking food.
When phimosis is associated with considerable inflammation of the prepuce generic 120mg cardizem free shipping, a dorsal slit of the prepuce is performed cheap cardizem 180mg mastercard, which is followed by circumcision at a later date when infection has subsided cardizem 60 mg free shipping. First of all sub-prepucial adhesions are severed by blunt dissection with a probe buy cardizem 180 mg. Two pairs of artery forceps are applied to the prepuce and a dorsal slit is made with scissors upto 1 cm of the corona. Then the prepuce with the mucous membrane layer is divided parallel to the corona glandis 1 cm distal to it till the frenum is reached. Here artery forceps is applied to secure the artery of the frenum and then division of the foreskin is completed. All the bleeding vessels are ligatured with particular care to secure the artery of the frenum. Now the skin of the prepuce is sutured to the mucous membrane with fine interrupted catgut sutures. This constricting band of phimotic prepuce behind the corona glandis causes obstruction to the venous outflow, which leads to oedema and congestion of the glans. It is an emergency condition and patients present with severe pain and swelling of the glans penis. It is uncommon for the urethra to be compressed, so that micturition is normally not affected. The swelling is gradually reduced due to absorption of the oedema fluid and after 15 minutes reduction may be performed with ease. Multiple punctures may be made in the oedematous prepuce in the idea to drain the fluid out, so that reduction may be performed. This lesion is a fleeting, painless, genital papule or ulcer which is often unnoticed by the patient and is reported in only /iof the cases. This is soon followed by (about 2 weeks later) progressive swelling and enlargement of the inguinal lymph nodes. As the inflammatory process extends into the perinodal tissues, the nodes become matted together. In the male the adenopathy is almost invariably localised to the inguinal region and is usually bilateral. However in the female, the adenopathy may or may not affect the inguinal nodes depending on the location of the primary lesion. If the vagina or the posterior fomix is the site of primary lesion, the pelvis and perirectal nodes are involved which may cause vaginal or rectal stricture. In later stage, in a small percentage of cases there is lymphatic obstruction leading to oedema and elephantiasis of the external genitalia In the female vaginal stricture or rectal stricture is not uncommon. The suppurative exudate from bubo of a known case is diluted and heat-treated to make the antigen for the skin test. When this antigen is injected into the skin of the suspected patient, redness and induration after 48 hours of injection indicates positive test. Indirect immuno-fluorescence test for specific antibodies to lymphogranuloma venereum antigens if present is almost diagnostic. Oxytetracycline 500 mg 4 times daily or erythromycin in the same dose or sulphonamide 1 g 4 times a day for 14 days is curative. The fluctuant bubos should not be incised, as this will invariably lead to sinus formation. This causative agent is seen within the phagocytic mononuclear cells as encapsulated gram-negative cocco-bacilli or rod like forms, referred to as Donovan bodies. This condition should not be confused with lymphogranuloma inguinale which is of viral aetiology, whereas this condition is a bacterial disease. This condition is uncommon and is occasionally seen in Europe and in the United States. It is included in the group of venereal diseases, though the evidence that the disease is spread by sexual contact is somewhat equivocal. The original papule enlarges, ulcerates and becomes a chronic spreading lesion having a necrotic centre and raised inflammatory border. Characteristically this border is rounded and red due to accumulation of granulation tissue. This is due to excessive fibrosis which may cause large and irregular scars resembling keloid. Extensive inflammatory scarring may cause lymphatic obstruction and elephantiasis of the external genitalia resembling that described in lym phogranuloma inguinale. The ulcerated area rarely bleeds if touched due to presence of immense granulation tissue, but it is painless. Drainage occurs along the lymphatics to the regional lymph nodes and leads to suppurative necrosis and fluctuant enlargement resembling bubos. Streptomycin in the dose of 4 g in divided doses for 5 days or Cotrimoxazole (not ordinary sulphonamide) 2 tablets twice daily for 10 days is also effective to cure this disease. Examination reveals an indurated mass felt on the dorsal surface of one corpus cavemosum. Some cases show spontaneous disappearance of the indurated plaque in over 5 years. Injection of hydrocortisone into the indurated plaque may be tried with some success. In the penis these lesions are mostly seen near the coronal sulcus and inner surface of the prepuce. These are usually sessile or pedunculated, red papillary excrescences that vary from minute lesions of 1 to several millimetres in diameter upto large Raspberry-like masses several centimetres in diameter. Clear vacuolisation ofthe prickle cells may appear and is said to be the characteristic of these lesions. Normal orderly maturation of the epithelial cells is preserved but may be slightly modified by increased mitotic activity in the basal layers. The basement membrane is usually intact and there is no evidence of invasion of underlying stroma. Trichloroacetic acid is more satisfactory for hard warts and for intrameatal warts. Patients should not be allowed to use the chemical themselves lest severe bum should result. Particularly in case of parianal warts surgery should be advised under general anaesthesia. The whole lesion is excised after infiltration to the subcutaneous tissue with diluted adrenalin solution. This lesion displays somewhat greater cellular pleomorphism but it usually does not present atypia and anaplasia, which are typical of carcinoma. Only in extremely rare cases one may find malignant melanoma, haemangiosarcoma or fibrosarcoma. This is an accepted fact and it is for this reason that carcinoma of the penis is virtually unknown among Jews (in whom ritual circumcision is performed very early) and it is extremely rare among muslims (in whom circumcision is performed between 4 and 10 years). Obviously carcinoma is more common in men who have not been circumcised in early infancy.
The flap is raised which includes the parotid duct for a distance into the cheek till the calculus is reached buy cardizem 180 mg without a prescription. The calculus is removed buy discount cardizem 60 mg on line, the duct is reinserted and intraoral incision around the parotid papilla is sutured purchase cardizem 180mg mastercard. In case of calculi in the intraglandular portion of the duct buy cardizem 180 mg mastercard, these are approached from outside through preauricular incision as made for parotidectomy. The duct is identified at the anterior border of the gland and traced forwards and backwards till the calculus is discovered. The calculus is extracted and the duct is kept open or sutured with fine suture material. This ulceration may subsequently heal by stenosis causing obstruction to the flow of saliva. Ulceration of the parotid duct opening or papilla may follow irritation from a sharp tooth or bite of the cheek. In case of stenosis resulting from fibrosis of the ulcer, treatment is papillotomy with suture of the duct lining with the oral mucus membrane. A few swellings may appear anywhere in the midline which are swellings of the skin and superficial fascia (sebaceous cyst, lipoma, fibroma, neurofibroma etc. In addition to the above list the following lesions can occur anywhere in the neck. Chronic swellings may be further subdivided into (a) cystic swellings, (b) solid swellings and (c) pulsatile swellings. The various pathological swellings are now described in detail in the following section. These arches, in lower vertebrates, provide for water-breathing animals an efficient respiratory apparatus which are called ‘gills ’. The branchial clefts in these animals breakdown and a series of gill slits develop which communicate between the exterior and the inside of the pharynx. Periodically the oxygen-bearing water is taken into the pharynx through the mouth and expelled through the gill slits. In its passage it bathes into the endodermal surfaces of the branchial arches filled with capillaries. In human beings at first the arches form rounded ridge-like projections in the overlying ectoderm and corresponding projections in the entodermal floor of the pharynx. These ridges are separated from one another by a series of furrows, where the surface ectoderm and the pharyngeal entoderm come into direct contact with each other. The ectodermal furrows are termed the branchial clefts and the entodermal furrows the pharyngeal pouches. At this stage the pharynx possesses a wide roof and a wide floor which meet on each side and there is no true lateral wall. So each arch consists of an ectodermal covering, a mesenchymal core and an entodermal covering. The mesenchymal core gives rise to skeletal element, striated muscles, vessels and nerves. The innervation of the muscle masses once established will persist, no matter how far the muscle may migrate from the site of its development. The intermediate portion disappears but its sheath persists as (iii) anterior ligament of the malleus and (iv) sphenomandibular ligament. The part extending from-the mental foramen to the symphysis menti is by cartilaginous ossification and the rest is membraneous bone. Muscular elements develop into (i) tensor tympani, (ii) tensor veli palatini and muscles of mastication which include (iii) the masseter, (iv) temporalis muscle, (v) medial and lateral pterygoids, (vi) mylohyoid and (vii) anterior belly of the digastric. According to some the maxillary artery may be the remnant of the first aortic arch. Thereafter it forms as it passes ventrally (ii) styloid process, (iii) stylohyoid ligament, (iv) the lesser cornu and (v) the upper part of the body of the hyoid bone. The ventral portion chondrifies and persists as the (i) greater comu of the hyoid bone and (ii) lower part of whole of the body of the hyoid. The external carotid artery appears as a sprout from the middle of the third arch and grows headwards. The ventral portion of the arch upto the sprout forms the common carotid artery and the dorsal portion from the sprout forms the internal carotid artery. The dorsal part disappears on the right side, while it persists on the left side as ductus arteriosus communicating with the arch of the aorta. Ductus arteriosus after birth becomcs obliterated and forms ligamentum arteriosum. The second arch gradually overlaps over the third and fourth arches at the end of the fifth week. The ridge produced by this arch grows downwards and meets caudally a smaller bridge termed the epipericardial ridge just above the pericardium. A small depression is formed which lies superficial to the third and fourth arches and deep to the second arch. So in fact, third and fourth arches do not take part in forming the ectodermal covering of the neck. From the ridge formed by the second branchial arch develops the stemomastoid and the trapezius muscles. If the sec ond arch fails to fuse with the 5th arch or epiper icardial ridge, a fistula develops and it connects the precervical sinus. If it arises from the internal branchial furrow the epithelium may be columnar and ciliated. The striking feature of this cyst is that its wall contains large amount of lymphoid tissue. The contents are viscid, mucoid, cheesy material and cholesterol crystals in large numbers. If infected the swelling may be painful and it becomes difficult to differentiate from acute lymphadenitis, chronic lymphadenitis or tuberculous lymphadenitis and cold abscess. The stemomastoid muscle develops from the migrated myotome in the ridge of the second branchial arch which covers the pre- cervical sinus. The branchial cyst develops from the precervical sinus, so it will always be deep to the stemomastoid muscle. The overlying skin looks normal, though if infected, may be red and angry looking. Fluctuation test will be positive, but is difficult to elicit when the cyst is small and the stemomastoid muscle is thick. Some amount of the content may be aspirated before dissection so that the wall of the cyst may be grasped with suitable forceps without injuring it. Sometimes it extends between the origins of the internal and external carotid arteries upto the pharyngeal wall. Hypoglossal and glossopharyngeal nerves lie deep to the cyst and they should be protected. It is usually situated in the upper or middle thirds of the neck and often continues to discharge. Congenital branchial fistula is often a branchial sinus without any communication inside.
Alpha cells are the source of glucagon order cardizem 180 mg without a prescription, beta cells are the source of insulin and delta cells produce somatostatin and gastrin quality 180mg cardizem. These exert a number of gastrointestinal effects causing diarrhoea generic cardizem 60mg overnight delivery, hypermotility and hypochlorhydria buy 60mg cardizem visa. Glucagon stimulates hyperglycaemia by promoting breakdown of liver glycogen with consequent release of glucose into the circulation. This glucagon also inhibits exocrine secretion ofthe pancreas and for this it is often used in acute pancreatitis. It also inhibits gastric acid secretion, inhibits gastric and intestinal motility, stimulates the flow of bile and stimulates intestinal secretion. Release of insulin from the beta cells is controlled by alterations in the concentration of blood sugar. An increase in the concentration of sugar will cause an increase in circulating insulin. This action is presumably the result of the effect of vagal stimulation on acid secretion and in turn stimulation ofsecretin release by acid in the duodenum. Various hormones which increase the blood sugar, such as growth hormone, glucocorticoids, thyroid hormone and epinephrine may secondarily increase the secretion of insulin. The transfer of sugars into muscle cells, fibroblasts and adipose tissue requires insulin. In the absence of glucose fat is utilised with the resultant ketosis and acidosis. Aminoacids may be oxidised to provide energy and may cause a negative nitrogen balance when glucose is not being used properly. Partial duodenal obstruction with indentation of the right lateral wall can be seen on barium meal X-ray in majority of cases. But in majority of cases it is technically difficult to perform Partial resection of the annular portion of the gland is frequently followed by pancreatic fistula. This is most commonly found in the submucosa of the stomach, duodenum, small intestine or Meckel’s diverticulum. This is also detected in the wall of the gallbladder, in the hilum of the spleen or within the liver. Ectopic pancreas in the wall of the intestine may be the starting point of intussusception. This causes obstruction of the pancreatic ducts and retention of pancreatic secretions. The other abnormality is that the meconium becomes abnormally viscid and it causes obstruction of the intestine more frequently at the distal ileum. Viscid mucus into the bronchioles causes bronchiolar obstruction predisposes to respiratory infection. Sweat glands produce sweat containing four times more sodium chloride than normal. Patients complain of dyspnoea with inspiratory indrawing of the lower chest and suprasternal notch. Due to fibrocystic disease of the pancreas patients present with steatorrhoea and the stools are pale in colour, greasy and with bad odour. Excessive loss of salts through sweat is a problem for maintenance of the electrolyte balance ofthe patient. Normal content of sodium is 70 mEq/litre, chloride is 60 mEq/litre and potassium 20 mEq/litre. In case of streatorrhoea fat intake should be drastically reduced and extraprotein should be given. Enteric coated capsules of pancreatin (5 to lOg) are given before meals to supplement deficiency of pancreatic enzymes in the duodenum 200 units of vitamin D and 10,000 units of Vitamin A are given daily. Acute pancreatitis — a single episode of pancreatitis in a previously normal gland. Acute relapsing pancreatitis— recurrent attacks of acute pancreatitis with normalcy in the intervals between attacks and without permanent functional damage of the pancreas. Chronic pancreatitis — irreversible destruction of pancreatic function with constant pain. The mechanism by which gallstones result pancreatitis is not very clearly known, (a) For quite a long time common channel theory ’ has given much importance in which bile reflux into the pancreatic duct as the two ducts join together to form the common channel before they open into the duodenum. Active perfusion of normal bile into pancreatic duct at normal pressure does not cause pancreatitis. Moreover pressure in the pancreatic duct system is consistently higher than that in the bile duct system and that is why one cannot expect that bile will perfuse the pancreatic ducts, (b) Transient obstruction of the pancreatic duct by gallstones can result in pancreatitis. Transampullary migration of biliary calculi appears to be well established as an important cause of acute and acute relapsing pancreatitis. Several studies have indicated that choledocholithiasis can lead to the development of acute pancreatitis even in the absence of a common biliary-pancreatic channel. Presumably the presence of an ampullary stone or oedema at the papilla can obstruct pancreatic duct outflow and thus results increase in pressure within the pancreatic duct system. This seems to be the most reasonable explanation of how alcohol causes acute pancreatitis. Closed-loop duodenal obstruction with biliary exclusion is followed by fulminating type of acute pancreatitis. Obstructed duodenum may elaborate factors that may provoke pancreatic inflammation 4. The second variety of hyperlipidaemia which causes pancreatitis is often diagnosed as idiopathic variety. In this case neutral fats are usually increased immediately before the onset of abdominal symptoms and return to normal when attack is over. Dietary-induced hypertriglyceridaemia may cause attacks of acute pancreatitis in alcoholic patients. It seems that conversion of triglycerides to toxic free acids within the pancreatic parenchyma by pancreatic lipase may be the cause of pancreatitis in hyperlipidaemia. Fat emboli may cause obstruction of the pancreatic duct and may cause pancreatitis. Precipitation of calcium phosphate in the pancreatic duct will lead to obstruction alongwith increased pancreatic secretion to cause pancreatitis. Parathyroid function should always be investigated in any patient with pancreatitis of obscure cause. Sometimes in older patients who have widespread vascular obstruction from atherosclerosis and patients who have undergone cardiopulmonary bypass are sometimes seen with severe haemorrhagic pancreatitis. After common bile duct exploration, specially if a long-armed T-tube has been placed through the sphincter of Oddi pancreatitis may follow. Even after exploration of the common bile duct while passing dilator through the sphincter of Oddi one may injure the papilla causing oedematous swelling and even pancreatic duct injury, which will all cause pancreatitis. During gastrectomy when the region of the head of the pancreas is being dissected injuiy will cause pancreatitis. After splenectomy pancreatitis may result following operative injury to the tail of the pancreas. It must be remembered that mortality rate of postoperative pancreatitis is quite high reaching about 50%.
By U. Jack. Texas Lutheran University.