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Placement of a T-tube that is placed across the defect arteria lusoria buy hytrin 5 mg on line, with a long limb led out through the Roux loop and through the abdominal wall, should be considered in these cases. Second, the jejunal serosa is used to cover the defect, secured in place with fine, interrupted absorbable sutures to the bile duct wall without attempting direct approaches to the ragged edge of the damaged duct. Finally, the T-tube provides biliary decompression across the jejunum so that when it is removed, any leaking bile drains into the bowel lumen rather than the abdominal cavity. This method may be particularly useful to an inexperienced surgeon in a difficult situation. Biliary injuries not appreciated intraoperatively may appear in the first few days after operation. In the setting of an external biliary fistula, the essential consideration in management is to avoid early reoperation. It is wiser to take full stock of the situation, to carry out appropriate investigations as described earlier, and to keep the patient well nourished and free of infection. This is particularly true of bile leakage from the cystic duct or a subvesical duct of Luschka (type A) or from a noncircumferential laceration (type D). More severe lacerations or complete transections of the common duct or an aberrant right sectoral hepatic duct with ongoing bile leakage require careful consideration. Because the biliary tree is decompressed, the proximal ducts are small in caliber. Adequate repair requires exposing healthy bile duct mucosa within a sufficiently dilated proximal duct to allow precise anastomosis. In the setting of a decompressed biliary tree and significant inflammation, this exposure can be quite B. Biliary Stricture and Fistula Chapter 42 Biliary fistulae and strictures 705 demanding or even impossible. If fluid losses from the biliary fistula remain high over a prolonged period, a useful but rarely used technique is creation of a temporary internal fistulojejunostomy, with definitive repair deferred for a later date (Smith et al, 1982). Alternatively, placement of an endoscopic or percutaneous stent across the defect may reduce output from the fistula, hasten closure, and make operative management easier. Long-term results of such interventions have shown excellent results, and often, greater than 90% of patients with peripheral leaks or strictures can be treated endoscopically, although this therapy can be associated with complications, including cholangitis, hepatic abscess, and stent occlusion and migration (Lalezari et al, 2013; Weber A. Some authors advocate early endoscopic sphincterotomy to decrease the relative resistance of transpapillary bile drainage to promote closure (Abdel et al, 1996; Fujii et al, 1998; Inui et al, 1998; Liguory et al, 1991). Although these approaches are occasionally useful, no evidence is available to show that they provide a significant advantage. Drainage of the bile collection and control of ongoing bile leak is the primary objective and often requires percutaneous abscess drains in combination with percutaneous biliary catheters. Definitive repair is seldom possible initially, with the bile ducts collapsed, deeply bile stained, and friable; repair is best delayed until the biliary leak has been controlled completely and the patient has been fully resuscitated.
Sica G hypertension genetic 1 mg hytrin purchase with amex, et al: Neuroendocrine carcinomas of the gallbladder: a clinicopathologic analysis of 23 cases, Mod Pathol 23(1):168A, 2010. Vance C, et al: Non-neoplastic polyps of the gallbladder: incidence, histologic types, and clinicopathologic associations in an analysis of 162 cases, Mod Pathol [Abstract] 24(1):375A, 2011. Linehan Painless jaundice is frequently caused by obstruction of the extrahepatic bile duct by malignant neoplasms, but benign tumors and pseudotumors of the biliary tract, although relatively rare, should be included in the differential diagnosis. Benign biliary tumors have frequently been the subject of case reports, usually combined with a review of the literature.
Tian Y heart attack young 5 mg hytrin with visa, et al: Management of type I choledochal cyst in adult: totally laparoscopic resection and Roux-en-Y hepaticoenterostomy, J Gastrointest Surg 14:1381e1388, 2010.
Reliability is the degree to which an instrument is free from random error and includes both reproducibility and internal consistency blood pressure yoga poses hytrin 5 mg free shipping. Validity is the degree to which an instrument measures what it is suppose to measure and consists of content, criteria,and construct validity. Responsiveness is the ability of an instrument to detect and measure changes during time and treatments. Responsiveness is dependent on the number of items in a questionnaire as well as the number of potential responses. From a practical standpoint, the number of items and associated responses must be optimized to ensure sufficient responsiveness without creating overly cumbersome questionnaires in which respondents experience "question fatigue," leading to increased rates of nonresponse and missing data. A fourth parameter, "sensibility," is also essential and refers to the need for strategic balance between practicality and the basic necessity of instruments to be reliable, valid, and sensitive (Feinstein, 1987). In addition to choosing a reliable, valid, sensitive, and practical instrument, a thorough understanding of how a given disease progresses and the expected effects of intervention is requisite (Avery & Blazeby 2006). In turn, each domain contains a number of items (questions or statements) for which respondents must provide an answer, either categorically. Each item is individually scored, and scores from all items in a given domain are summed to give each domain a specific score (Fraser, 1993). The generic nature of these measures allows comparison across disease states and treatment types. Chapter 28 Quality of life and hepatobiliary tumors 481 diseases and/or treatments. However, these preference-based methods are essential and often used in the setting of health economics and policy. At present, the cost of health care is exorbitant, and while we forge ahead toward more and more precision/designer medicine, this will only increase, and cost-utility assessment of intervention will be essential. These types of instruments focus more on expected changes specifically related to cancer and its treatment. It refers to the use of a core cancer questionnaire in conjunction with validated modules for specific disease sites. The comprehensive nature of these tools provides increased sensitivity; however, practicality, in terms of time and resources required to complete, may be prohibitive in some settings. Based on this, attempts to develop brief scales that adequately correlate with the more extensive evaluations have been attempted. Low level refers to de facto questionnaires developed for a single study, midlevel to questionnaires not developed or validated in study group of interest (psychological assessment, depression scales, etc.
The indications for biopsy continue to evolve arrhythmia natural cures hytrin 5 mg order otc, and although percutaneous biopsy of a given mass is possible, biopsy is not always indicated. As with any invasive procedure, percutaneous biopsy has associated risks that should be weighed before the procedure. Needle biopsy is warranted when the result of the biopsy will influence patient management. These indications include establishing a diagnosis before surgery or in patients who are not surgical candidates, evaluation of organ dysfunction, and obtaining material for receptor or gene mutation evaluation. While we enter the era of personalized medicine, this last indication is becoming increasingly important (see Chapter 9). Several methods are available to obtain tissue, including biopsy by percutaneous needle or by endoluminal and transvenous techniques. Needles ranging in size from 25 to 14 gauge are typically used, and outside the central nervous system, a biopsy can be obtained from almost any abnormality that can be imaged. Most needles contain an inner stylet, which is removed when the needle is appropriately positioned immediately before obtaining the specimen; the stylet prevents the needle from coring interposed structures and accumulating nontarget material before optimal placement.
This may be advantageous in children blood pressure medication klonopin discount hytrin 1 mg on line, as an intact biliary sphincter will presumably decrease the risk of recurrent choledocholithiasis. Furthermore, because there is no cutting involved with sphincteroplasty, there is a lower risk of procedurerelated bleeding. Thus use of this tech nique may be preferred to sphincterotomy in patients who are at increased risk of bleeding, such as those on antiplatelet or anticoagulation therapy that cannot be held for the procedure. Primary biliary sphincteroplasty can also be helpful in facilitating biliary cannulation in patients with surgically altered anatomy in whom standard sphincterotomy cannot be performed safely or is technically difficult. The main drawback of performing sphincteroplasty alone is its association with a higher risk of pancreatitis and lower rates of stone clearance compared with sphincterotomy (Baron & Harewood, 2004; DiSario et al, 2004). Furthermore, balloon sphinctero plasty following sphincterotomy has been shown to be safe, with comparable complication rates compared with sphincterotomy alone (Maydeo & Bhandari, 2007; Weinberg et al, 2006). Transpancreatic Precut Sphincterotomy (Goff Technique) Transpancreatic precut (transeptal) sphincterotomy for biliary access was first described by Goff et al (1995). In this technique, following selective cannulation of the pancreatic duct, precut sphincterotomy is performed by cutting the septum between the pancreatic and bile duct with the standard sphincterotome directed cephalad toward the bile duct. Additional advanced tech niques for biliary access, including those in patients with surgi cally altered anatomy, will be covered later in this chapter. Choledocholithiasis is concomitantly present in up to 20% of patients with cholelithiasis at the time of cholecystectomy (Menezes et al, 2000). The basic technique of sphincterotomy has not changed significantly since its initial description. The standard sphincterotome, the Erlangen "pulltype" model, consists of a catheter containing an electrosurgical cutting wire exposed 20 to 25 mm near the tip of the sphincterotome. Once deep biliary can nulation has been achieved, the sphincterotome is retracted slowly, until one fourth to one half of the wire length is exposed outside the papilla. The sphincterotome is slightly bowed so that the cutting wire is in contact with the roof of the papilla. A, Cholangiogram showing diffusely dilated biliary system with stone in the commonbileduct(arrow). The extraction balloon is inflated (to the diameter of the bile duct) above the stone and pulled back gently to the level of the papilla. In the setting of multiple stones, it is important to remove the stones individually starting with the most distal one, to avoid stone impaction. Similarly, there are also a variety of wire baskets in different sizes and configurations. The stone is entrapped between the wires when the basket is closed, and subsequent removal is achieved by traction removal of the basket in the axis of the bile duct. Conversely, the extraction balloon may be more suitable for the removal of small stones/fragments that are difficult to entrap between the wires or when opening of the basket is constrained by duct caliber. Lithotripsy Standard stone extraction techniques may fail when a stone is large, impacted, proximal to a stricture, or when stones are multiple.
Despite these enhancements to diagnostic accuracy blood pressure 60 over 40 hytrin 5 mg buy low cost, false-positive cytologic evaluations leading to unnecessary operations may still occur, especially in cases of autoimmune pancreatitis (Learn et al, 2011). Endoscopic Ultrasound Fine Needle Aspiration of Pancreatic Cystic Lesions Cystic lesions of the pancreas remain a diagnostic and therapeutic challenge (see Chapter 60). The differential diagnosis includes retention/simple cysts, pseudocysts, cystic neoplasms, and cystic degeneration of solid masses (Table 16. Retention cysts are generally small, thin-walled, and unilocular; they carry no malignant potential and can be left untreated. Regarding cystic neoplasms, it is important to distinguish mucinous and papillary tumors from serous lesions (see Chapter 60). Serous tumors have no malignant potential and do not require resection unless symptoms occur or they encroach on vascular structures. Papillary lesions and solid pseudopapillary tumors, carry the risk of malignant transformation and should be referred for resection. Cyst fluid can be analyzed for tumor markers, amylase, and molecular markers, and it provides material for cytopathologic assessment. Cyst fluid tends to be paucicellular; thus the sensitivity and negative predictive value of cytology is low (Centeno et al, 1997; Sedlack et al, 2002). The presence of thick, viscous fluid and a positive mucin stain is suggestive of a mucinous lesion. Nonetheless, a reliable and sufficiently sensitive biomarker for malignancy is still lacking. Major extraluminal hemorrhage is a rare complication and occurs at a rate of less than 1% (Affi et al, 2001). The same can be said for determining vascular invasion and resectability of large pancreatic tumors (>3 cm). Preoperative Reassessment after Neoadjuvant Chemoradiotherapy Studies on the treatment of pancreatic cancer have recently focused on neoadjuvant treatment with chemotherapy and radiation therapy, followed by attempted radical resection (see Chapter 68). These results suggest that inflammatory changes in the tumor bed, pancreas, and lymph nodes alter the anatomy and blur the distinction between normal tissue planes and between tumor and normal tissue. Two recent meta-analyses demonstrated improved sustained pain relief in 72% to 80% of patients at a follow-up range of 1 to 6 months (Kaufman et al, 2010; Puli et al, 2009). Diagnostic specimens can be obtained by rubbing a cytology brush against the stricture, but the sensitivity is low, with a yield of only 40% to 50% (Ponchon et al, 1995; Victor et al, 2012; Wakatsuki et al, 2005). Hypoechoic infiltration invading through the biliary wall layers or an adjacent pancreatic mass can also be seen. Chapter 16 Endoscopic ultrasound of the biliary tract and pancreas 283 with inoperable pancreatic cancer (Wyse et al, 2011).
Rocko, 60 years: The most common reason for major bile duct injury is failure to identify the anatomy of the triangle of Calot (Strasberg et al, 1995). Technical Factors General Cholecystectomy is performed so commonly that it is easy to adopt a casual attitude toward the procedure; this is unwise, however, because some of these cases can be quite challenging.
Snorre, 57 years: Preoperative portal vein embolization can be considered in certain patients in whom the anticipated residual liver is questionable. Pancreatic endocrine neoplasm appearing as a hypervascularmassinthehead(arrows)inthepancreaticparenchymal (latearterial)phase.
Yasmin, 55 years: The opening of the duct of Wirsung usually is identified as a small orifice from which clear, colorless pancreatic juice flows. Careful attention should be made to observe for any aberrant portosystemic venous collateralization, either in the liver bed, porta hepatis, or even in the abdominal wall.
Sanford, 25 years: Treece G, et al: 3D ultrasound measurement of large organ volume, Med Image Anal 5(1):4154, 2001. The risk of subsequent biliary malignancy in patients undergoing cyst excision for congenital choledochal cysts has been reported as 0.
Knut, 26 years: Kennedy A, et al: Radioembolization for the treatment of liver tumors: general principles, Am J Clin Oncol 35:9199, 2012. Olsen D: Bile duct injuries during laparoscopic cholecystectomy, Surg Endosc 11:133138, 1997.
Kurt, 62 years: As with hepatolithiasis, an increased incidence of cholangiocarcinoma resulting from clonorchiasis has been noted (Hou, 1956; Ohta et al, 1984) (see Chapters 50 and 51). Amebic abscesses caused by Entamoeba histolytica and fungal abscesses each account for about 10% of liver abscesses (see Chapter 73).
Ali, 63 years: Mas A, et al: Comparison of rifaximin and lactitol in the treatment of acute hepatic encephalopathy: results of a randomized, doubleblind, double-dummy, controlled clinical trial, J Hepatol 38(1):5158, 2003. Cystic dilation of the bile ducts may occur (Zen et al, 2006) and some cases exhibit mucin hypersecretion (Katabi et al, 2012; Shibahara et al, 2004).
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