I. Rhobar. Northwestern College, Iowa.

Theophylline cheap duricef 250mg overnight delivery, a xanthine derivative safe 250mg duricef, may be added to the regimen if beta-2 agonists and anticholinergics are not effective in managing the symptoms of chronic obstructive lung disease buy generic duricef 500 mg online. Theophylline levels increase with fluoroquinolones purchase 500 mg duricef with visa, clarithromycin, H2-blockers (cimetidine, ranitidine), certain beta blockers and calcium channel blockers. Theophylline levels decrease (due to increased clearance) with rifampin, phenytoin, phenobarbital, and smoking. Home oxygen therapy is given to patients with hypoxemia (Pao <55 mm Hg or2 saturation <88%), and the goal is to try to keep the O saturation >90% as much2 as possible, especially at night when patients generally desaturate. A special2 category is the patient who desaturates with exercise; in that case, intermittent oxygen will be beneficial. Other precipitating causes that should be sought out are bacterial infections, heart failure, myocardial ischemia, pulmonary embolism, lung cancer, esophageal reflux disease, and medications (e. Initial Management Measure O2 saturation via pulse oximetry (on the spot) to determine oxygen saturation. It may also show evidence of pulmonary edema, indicating possible heart failure as the cause of the exacerbation. In the acute setting, check levels in patients on chronic treatment with theophylline. Drugs like erythromycin, cimetidine, and ciprofloxacin may decrease theophylline clearance and cause theophylline toxicity. Any significant changes of hypercapnia or hypoxemia from baseline should prompt consideration for admission to the hospital. Also, patients on home O2 who have exacerbation, and those with severe symptoms, should be hospitalized. Consider intubation and mechanical ventilation in patients with decreased levels of consciousness, cyanosis, or hemodynamic instability and in those with persistent hypoxemia despite adequate oxygen supplementation. Specific Therapy Oxygen supplementation should be titrated to ~90% saturation on the pulse oximeter. Corticosteroids may be given intravenously or orally because the efficacy is similar in both modes of administration. The equivalent of 60 mg prednisone appears to be the sufficient starting dose and is usually continued for 2 weeks. Patients with productive, purulent cough benefit the most because they are more likely to have an underlying bacterial infection. Antibiotics commonly used are second-generation macrolides (clarithromycin, azithromycin), extended-spectrum fluoroquinolones (levofloxacin, moxifloxacin), cephalosporins (second- and third-generation), and amoxicillin clavulanate. However, if the patient is using theophylline on a chronic basis (in outpatient setting), it should be continued during the exacerbation because abrupt discontinuation may worsen symptoms. Always avoid opiates and sedatives because they may suppress the respiratory system. Counseling the patient on smoking cessation in the hospital setting is the single most important intervention. Treatment of this patient in the acute exacerbation would be systemic steroids, antibiotics, and bronchodilators, with O as needed. She gives you a history of recurrent pneumonias, some of which have kept her in the hospital for weeks, and of chronic productive cough that occurs every day. Bronchiectasis is the permanent dilation of small- and medium-sized bronchi which results from destruction of bronchial elastic and muscular elements. Bronchiectasis can occur secondary to repeated pneumonic processes such as tuberculosis, fungal infections, lung abscess, and pneumonia (focal bronchiectasis) or when the defense mechanisms of the lung are compromised as in cystic fibrosis and immotile cilia syndrome (diffuse bronchiectasis). About 50% of patients with primary ciliary dyskinesia will have situs inversus and sinusitis (Kartagener syndrome). Bronchiectasis should be suspected in any patient with chronic cough, hemoptysis, foul-smelling sputum production, and recurrent pulmonary infections, sinusitis, and immune deficiencies. Patients will have persistent cough with purulent copious sputum production, wheezes, or crackles. There is a significant history of recurrent pneumonias that commonly involve gram-negative bacteria, especially Pseudomonas species. In advanced cases chest x-ray may show 1- to 2-cm cysts and crowding of the bronchi (tram-tracking). Bronchodilators, chest physical therapy, and postural drainage are used to control and improve drainage of bronchial secretions. Give an antibiotic such as trimethoprim sulfamethoxazole, amoxicillin, or amoxicillin/clavulanic acid when sputum production increases or there are mild symptoms. Consider surgical therapy for patients with localized bronchiectasis who have adequate pulmonary function or in massive hemoptysis. All patients with bronchiectasis require yearly vaccination for influenza and vaccination for pneumococcal infection with a single booster at 5 years. Going back to our earlier patient, you would treat with antipseudomonal antibiotics (ciprofloxacin, ceftazidime). The worst prognosis is with idiopathic pulmonary fibrosis and usual interstitial pneumonitis. The interstitium of the lung (supporting structure) is the area in and around the small blood vessels and alveoli where the exchange of oxygen and carbon dioxide takes place. Inflammation and scarring of the interstitium (and eventually extension into the alveoli) will disrupt normal gas exchange. Examination shows the typical coarse crackles, evidence of pulmonary hypertension (increased pulmonic sound, right heart failure), and clubbing (not always). Chest x-ray is consistent with reticular or reticulonodular pattern (“ground-glass” appearance). Causes include: Idiopathic pulmonary fibrosis Sarcoidosis Pneumoconiosis and occupational lung disease Connective tissue or autoimmune disease–related pulmonary fibrosis Hypersensitivity pneumonitis Eosinophilic granuloma (a. He informs you that over the past week he cannot walk across the room without getting “short of breath. The physical exam is significant for a respiratory rate of 24/min, jugular venous distention ~8 cm, coarse crackles on auscultation, clubbing, and trace pedal edema on both legs. It characteristically involves only the lung and has no extrapulmonary manifestations except clubbing. Bronchoalveolar lavage will show nonspecific findings, specifically increased macrophages. Non-pharmacologic treatment for eligible patients includes lung transplantation (shown to reduce the risk of death by 75% as compared with those who remain on the waiting list). She has no other complaints except joint swelling and pain that occurred 3 days ago. Sarcoidosis is a systemic disease of unknown cause, characterized histologically by the presence of nonspecific noncaseating granulomas in the lung and other organs. Sarcoidosis can involve almost any organ system, but pulmonary involvement is most common. Dermatologic manifestations occur in 25% of patients with sarcoidosis; they include lupus pernio, erythema nodosum, non-scarring alopecia, and papules. Commonly, sarcoidosis is discovered in a completely asymptomatic patient, usually in the form of hilar adenopathy on chest x-ray. There are 2 distinct sarcoid syndromes with acute presentation: Löfgren syndrome includes erythema nodosum, arthritis, and hilar adenopathy. Heerfordt-Waldenstrom syndrome describes fever, parotid enlargement, uveitis, and facial palsy. Lung involvement in sarcoidosis occurs in 90% of patients at some time in their course. Interstitial lung disease with or without hilar adenopathy can also be a presentation of sarcoidosis. The definitive diagnosis of sarcoidosis rests on biopsy of suspected tissues, which show noncaseating granulomas. Eighty percent of patients with lung involvement from sarcoidosis remain stable, or the sarcoidosis spontaneously resolves. Twenty percent of patients develop progressive disease with evidence of end-organ compromise. Generally in the setting of organ impairment, a trial of steroids may be used, giving a high dose for 2 months followed by tapering the dose over 3 months. Usually, pneumoconiosis appears 20–30 years after constant exposure to offending agents (metal mining of gold, silver, lead, copper), but it can develop in <10 years when dust exposure is extremely high.

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With replacement of iron order 500 mg duricef with mastercard, a brisk increase in reticulocytes will be seen 2 weeks into treatment order 250mg duricef. Parenteral iron is used in patients with malabsorption buy 500 mg duricef visa, kidney disease generic duricef 500 mg with amex, or an intolerance to oral therapy. Blood transfusion is the most effective way to deliver iron but is reserved for those with severe symptoms. Anemia can accompany virtually any chronic inflammatory, infectious, or neoplastic condition. Hepcidin, a regulator of iron metabolism, plays an important role in anemia of chronic disease. This typically leads to anemia caused by an inadequate amount of serum iron being available for developing red cells. Hepcidin inhibits iron transport by binding to the iron export channel ferroportin located on the surface of gut enterocytes and the plasma membrane of macrophages. By inhibiting ferroportin, it prevents iron from being exported and the iron is sequestered in the cells. It also prevents enterocytes from allowing iron into the hepatic portal system, thereby reducing dietary iron absorption. In genetic diseases where hepcidin level is abnormally low, iron overload may occur (hemochromatosis) due to unwarranted ferroportin facilitated iron influx. Iron supplementation and erythropoietin will not help, except in renal disease and anemia caused by chemotherapy or radiation therapy. The hereditary form is due to a defect in aminolevulinic acid synthase or an abnormality in vitamin B6 metabolism. Sideroblastic anemia may progress to acute myelogenous leukemia in a small percentage of patients. There is no specific finding that will be sufficiently suggestive of sideroblastic anemia to allow a diagnosis without significant lab evaluation. Sideroblastic anemia is the only microcytic anemia in which serum iron is elevated. Basophilic Stippling, a Feature of Lead Poisoning and Other Diseases Copyright 2007 Gold Standard Multimedia Inc. Alpha thalassemia is more common in Asian populations, while beta thalassemia is more common in Mediterranean populations. Patients become severely symptomatic starting age 6 months, when the body would normally switch from fetal hemoglobin to adult hemoglobin. They are severely symptomatic with growth failure, hepatosplenomegaly, jaundice, and bony deformities secondary to extramedullary hematopoiesis. Clues to the diagnosis of thalassemia trait is a mild anemia with a profound microcytosis. Beta thalassemia major has the severe symptoms, large spleen, and bone abnormalities described. Both forms of thalassemia are diagnosed by having a microcytic anemia with normal iron studies. In beta thalassemia, there is an increased level of hemoglobin F and hemoglobin A. Thalassemia traits of both the alpha and beta types do not require specific treatment. The chronic transfusions lead to iron overload, which requires treatment with deferasirox. Splenectomy eliminates a major area of hemolysis and therefore helps reduce transfusion requirements. Iron Indices in Microcytic Anemia Syndromes Clinical Recall Which of the following laboratory investigations has the highest specificity and sensitivity in the diagnosis of iron deficiency anemia? The most common cause is pernicious anemia, a disorder causing decreased intrinsic factor production due to autoimmune destruction of parietal cells. Various forms of malabsorption such as sprue, regional enteritis, and blind loop syndrome can block absorption of vitamin B12. As such, you cannot specifically determine that a patient has B12 deficiency only from the symptoms of anemia. Patients may have peripheral neuropathy, position sense abnormality, vibratory, psychiatric, autonomic, motor, cranial nerve, bowel, bladder, and sexual dysfunction. You may have either the hematologic or neurologic deficits individually or combined. Although macrocytosis can occur with hemolysis, liver disease, and myelodysplasia, these give round macrocytes. The hematologic pattern of vitamin B12 deficiency is indistinguishable from folate deficiency. Antibodies to intrinsic factor and parietal cells confirm the etiology as pernicious anemia. The Schilling test is rarely used to determine the etiology of vitamin B12 deficiency. It is not necessary if the patient has a low B12 level combined with the presence of antibodies to intrinsic factor. An elevated methylmalonic acid level occurs with B12 deficiency and is useful if the B12 level is equivocal. Options available for treating clinical vitamin B12 deficiency include oral (daily) and parenteral (monthly intramuscular or subcutaneous) preparations. Parenteral route is recommended for patients with neurologic manifestations of B12 deficiency. Response of vitamin B12 deficiency anemia to treatment is usually rapid, with reticulocytosis occurring within 2–5 days and hematocrit normalizing within weeks. Treatment with cobalamin effectively halts progression of the deficiency process but might not fully reverse more advanced neurologic effects. Patients who have vitamin B12 deficiency with associated megaloblastic anemia might experience severe hypokalemia and fluid overload early in treatment due to increased erythropoiesis, cellular uptake of potassium, and increased blood volume. Once treated for a vitamin B12 deficiency due to pernicious anemia or other irreversible problems with absorption, patients need to continue some form of cobalamin therapy lifelong. Folic acid replacement can correct the hematologic abnormalities of B12 deficiency, but not the neurologic abnormalities. Occasionally, increased requirements from pregnancy, skin loss in diseases like eczema, or increased loss from dialysis and certain anticonvulsants such as phenytoin may occur. Consumption of high amounts of alcohol may have a direct effect on the folate absorption, due to inhibition of the enzyme intestinal conjugase. Folate is presented in foods as polyglutamate, which is then converted into monoglutamates by intestinal conjugase. The hematologic presentation of folic acid deficiency is identical to B12 deficiency. The destruction may be inside the blood vessels (intravascular) or outside (extravascular), which generally means inside the spleen. Hemolytic anemia may be chronic (sickle cell disease, paroxysmal nocturnal hemoglobinuria, and hereditary spherocytosis) or acute (drug-induced hemolysis, autoimmune hemolysis, or glucose 6-phosphate dehydrogenase deficiency). The usual symptoms of anemia are present based on the severity of the disease, not necessarily the etiology. The major difference between hemolytic anemia and the micro- and macrocytic anemias is that hemolysis is more often the etiology when the onset is sudden. Fever, chills, chest pain, tachycardia, and backache may occur if the intravascular hemolysis is particularly rapid. The peripheral smear may aid in the specific diagnosis, and the haptoglobin may be low with intravascular hemolysis. Hemoglobin may be present in the urine when intravascular hemolysis is sudden and severe because free hemoglobin spills into the urine. There should not be bilirubin in the urine because indirect bilirubin is bound to albumin and should not filter through the glomerulus. Hemosiderin may be present in the urine if the hemolysis is severe and lasts for several days. Hydration is, in general, useful to help prevent toxicity to the kidney tubule from the free hemoglobin. Patients with chronic hemolytic anemia need to be maintained on chronic folic acid therapy, as there is an increase in cell turnover.

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A multicenter randomized controlled trial evaluating the effect of small stitches on the incidence of incisional hernia in mid- line incisions cheap 500 mg duricef overnight delivery. Effect of stitch length on wound complications after closure of midline incisions: a randomized con- trolled trial buy duricef 250 mg line. Current practice of abdominal wall closure in elective surgery – is there any consensus? This maneuver is also useful when incising adventitia of the auxiliary vein during a Of all the skills involved in the craft of surgery buy 500 mg duricef visa, perhaps the mastectomy buy 250 mg duricef. To do this, the closed Metzenbaum scissors are single most important is the discovery, delineation, and sepa- inserted between the adventitia and the vein itself, they are then ration of anatomic planes. When this is skillfully accom- withdrawn, the blades are opened, and one blade is inserted plished, there is scant blood loss and tissue trauma is minimal. Finally, the jaws of the scissors are The delicacy and speed with which dissection is accom- closed, and the tissue is divided. This maneuver is repeated plished can mark the difference between the master surgeon until the entire adventitia anterior to the vein has been divided. The particular anatomic planes (often bloodless In many situations, a closed blunt-tipped right-angle embryologic fusion planes) that are used are described for Mixter clamp may be used the same way as Metzenbaum each operation in the remainder of the book. Identification and skeletonization of the inferior mesenteric Of all the instruments available to expedite the discovery artery or the cystic artery and delineation of the circular mus- and delineation of tissue planes, none is better than the sur- cle of the esophagus during cardiomyotomy are some uses to geon’s left index finger. When the scalpel is held at a 45° angle and behind the gastrophrenic ligament during a gastric fun- to the direction of the incision (Fig. Dissection of all these structures by other tech- advanced pathologic changes involving dense scar tissue, such niques not only is more time consuming, it is frequently as may exist when elevating the posterior wall of the duode- more traumatic and produces more blood loss. This maneuver until the natural plane of cleavage between the duodenum and produces gentle traction on the tissue to be incised. A folded 10×10 cm gauze square grasped in a sponge holder has occasional application for sweeping perirenal fat Selection of Needle from the posterior aspect of the peritoneum during lumbar sympathectomy. It is useful also for separating the posterior The needle selected for any use should have the least possi- wall of the stomach from peripancreatic filmy peritoneal ble thickness commensurate with adequate strength to attachments. Tapered-point needles are used to insert mit anatomic precision, small veins may be torn during this sutures into soft tissue such as the fascia, fat, or gastrointes- type of gross dissection; therefore, the sponge’s applicability tinal viscera. Use of a too The surgeon who wants to perform accurate dissections is delicate needle risks bending or breaking the needle. More greatly aided by a talent for quickly recognizing tissues and often such damage is due to failure to follow the curve of the structures as they are revealed by the scalpel or scissors. An intimate knowledge of Size of Bite anatomy is required for the surgeon to know exactly where each structure will appear even before it has been revealed The width of the tissue enclosed in the typical seromuscular by dissection. Hypertrophied gastric wall requires a larger bite than the normally thin Sewing Technique colon. Thus, the size of the bite must be matched to the purpose of the Smooth rotatory wrist action and the surgeon’s awareness of suture, the size of the suture, and the amount of force the what it feels like when a needle penetrates the submucosa of suture line must withstand. Nylon sutures also exhibit excessive slip- seromuscular layer with interrupted Lembert sutures is 5 mm. When nylon sutures in the skin have been tied with the same as those specified for interrupted stitches. The same ill test the degree of inversion that is required to allow the sec- effects occur when intestinal sutures are made too tight, but ond layer to be inserted without tension. Catching Both Walls of Intestine with One Pass Size of Suture Material of the Needle Holder As there must never be any tension on an anastomosis in the Most surgeons who insert seromuscular sutures to approxi- gastrointestinal tract, it is not necessary to use suture mate- mate two segments of intestine were taught to insert the rial heavier than 4-0 or 3-0. Failure to heal often is due to a Lembert suture through the intestine on one side of the anas- stitch tearing through the tissue; it is almost never due to a tomosis. This layer provides immediate, pass a needle of proper length through one side of the intes- accurate approximation of the mucosa and, in some instances, tine and then, without removing the needle holder, pass the hemostasis. The danger associated with this shortcut is that one sile strength, such as with the Smead-Jones closure of the may traumatize the entrance wound made on the side of the abdominal wall, heavier suture material is indicated. Obviously, the size of the suture mate- problem can occur as the surgeon moves the needle and the rial must be proportional to the strength of the tissues into intestinal wall in a lateral direction to bring it closer to which it is inserted and to the strain it must sustain. Instead, the surgeon gently picks up the opposing interrupted seromuscular sutures to avoid the possibility that the purse-string effect of the continuous stitch would narrow the lumen. A continuous suture is permissible in the mucosal layer if it is inserted with care to avoid narrowing. If the knot on a suture approximating the seromuscular coats of two segments of intestine is tied so tightly it causes isch- emic necrosis, an anastomotic leak may follow. This is espe- cially likely if the stitch has been placed erroneously through the entire wall of the bowel into the lumen. Because consid- erable edema follows construction of an anastomosis, knots should be tied with tension sufficient only to provide apposi- tion of the two seromuscular coats. Caution must be exer- cised when tying suture material such as silk or Prolene, Fig. Then, with a purely rotatory motion of the wrist, the surgeon allows the needle to penetrate the sec- Fig. If the surgeon is conscious of the need to avoid trauma and uses a rotatory maneuver, there are situa- should be tied with excessive tension if cross-hatching is to tions in which this technique is acceptable and efficient. With practice the sur- Simple Everting Skin Stitch geon may insert it rapidly and obtain a good cosmetic result Eversion of the edges is desired when closing the skin. Because it is absorbable, there are no sutures to Consequently, the wrist should be pronated and the needle remove postoperatively. If preferred, continuous 3-0 nylon may inserted so the deeper portion of the bite is slightly wider be used, with lead shot or an external knot fixing the stitch at its than the superficial portion (Fig. Vertical Mattress (Stewart) Stitch With the classic Stewart method of skin suturing, eversion is Skin Staples guaranteed by the nature of the vertical mattress stitch Skin staples can be applied with force just sufficient to achieve (Figs. Neither of these two types of skin suture approximation without producing cross-hatching of the skin. Depending on the thickness of the skin and the underlying structures, staples may be placed 5–10 mm apart (Fig. When working with a less-skilled assistant, it is preferable for the surgeon to align the edges and allow the assistant to place the staples. Simple Interrupted Fascial Stitch The McBurney and other special incisions may be closed by simple interrupted fascial sutures. These sutures are placed so they include 8–10 mm of tissue with each bite, as shown in Fig. Except for use in the McBurney and Pfannenstiel incisions, this abdominal wall closure should be considered obsolete. It is, in essence, a buried “retention” Lembert Stitch suture, as it encompasses all layers of the abdominal wall, Perhaps the most widely used technique for approximating except the skin, in its large loop. The large loop is followed by the seromuscular layer of a bowel or gastric anastomosis is a small loop, which catches only 4–5 mm of linea alba on each the Lembert stitch (Fig. The purpose of this small loop is to orient the abdominal 5 mm of tissue, including a bite of submucosa, and emerges wall in perfect apposition. Under proper Hemostatic Figure-of-Eight Stitch circumstances, it may be applied in a continuous fashion. The classic hemostatic figure-of-eight stitch is used for occlusion of a bleeding vessel that has retracted into the mus- Cushing Stitch cle or similar tissue. The Cushing stitch is similar to the Lembert stitch, except it is inserted parallel to and 2–4 mm from the cut edge of the Single-Layer Bowel Anastomosis bowel. It should catch about 5 mm of the bowel, including the Bowel anastomoses employing one layer of sutures have submucosa. An effective method for accomplishing approximation for anastomoses in poorly accessible loca- inversion and approximation simultaneously is the use of the tions, such as the low colorectal anastomosis. When used as a catches the seromuscular and submucosal layers and a small continuous stitch (Fig. When properly applied, it produces slight tive to the Connell stitch for inverting the anterior mucosal inversion of the mucosal layer and approximation. The main difference between the necessary to pass this stitch deeper than the submucosal layer. Connell stitch (see below) and a continuous Cushing suture is If it is passed into the lumen before emerging from the that the former penetrates the lumen of the bowel, whereas mucosal layer, it is identical with that described by Gambee, the latter passes only to the depth of the submucosal layer. Cushing stitch the danger that when tied with excessive 4 Dissecting and Suturing 33 a b Fig. The suture is placed loosely to avoid purse- stringing the anastomosis and hence is inadequate to produce hemostasis for small arterial bleeders. As the bowel is tension, it causes strangulation of a larger bite of tissue than inverted, intraluminal bleeding does not remain visible to the does the Lembert suture.

It must be remembered that in 5 to 10% of cases carcinoma may be associated with this condition duricef 500mg low cost. This is mainly due to the result of mucosal irritation and subsequent metaplasia induced by the retention oesophagitis discount duricef 250mg free shipping. It must be noted that oesophageal carcinoma in this condition tends to arise in the middle-third of the organ buy discount duricef 500mg on-line. As the disease progresses the oesophagus becomes dilated and the lower most portion of the oesophagus ends like a ‘bird-beak’ tapering purchase 500mg duricef with amex. It will reveal that the pressure in the body of the oesophagus is higher than normal and may be equal to the atmospheric pressure. Being a thoracic organ its pressure should be much below the atmospheric pressure. This manometric study will also reveal that there is no typical co-ordinated peristaltic wave of the oesophagus in response to swallowing, instead feeble and repetitive contractions may occur throughout the oesophagus. The pecu­ liarity one may notice that the upper oesophageal sphincter relaxes normally in the majority of cases, but the lower oesophageal sphincter fails to relax after swallowing. This produces marked elevation of the intra-oesoph- ageal pressure and frequency of simultaneous oesophageal contractions corresponding with complaints of chest pain. In the former condition the lower oesophagus will look whit­ at the oesophago-gastric junction. So for symptomatic relief there are three devices which have been put forward by their proponents as the treatment of choice. Sublingual nifedipine may be used for transient relief of symp­ toms, but hence no place in definitive treatment. Its effect is also not permanent and the injection may be repeated after a few months. Previously such dilatation was also tried by Hurst-Maloney bougies in the range of 50 to 54 French type. Nowadays plastic balloons with precisely controlled external diameter are being used. Balloons of 30-40 mm in diameter are being used and are inserted over a guide wire. The most probable complication of this technique is oesophageal perforation, which is less than 0. The risk is more with bigger balloons, but these may be used by progressive dilatation over a period of weeks. But he performed the operation transabdominally and oesophagotomy was performed both on the anterior and posterior walls of the gastro-oesophageal junction. But the modern oesophagomyotomy is a modification of Heller’s operation in which thoracic approach is preferred and the myotomy is performed only on the anterior wall of the oesophagus. Preoperatively washing of the dilated oesophagus should be performed for the last 24 hours and the patient should be on liquid diet. A longi­ tudinal incision is made on the anterior wall of the oesophagus 7 to 10 cm in length through all the muscle layers of the distal oesophagus. The incision must reach well above the constricted portion of the oesophagus proximally and must reach the stomach within 1 cm distally. Damage to the vagus nerve and the supporting structures around the hiatus is avoided. So majority of surgeons believe that this should be the treatment of choice in achalasia of the oesophagus. But others are in the opinion that as non-operative treatment like hydrostatic dilatation can cure 65% of patients, it is worthwhile trying first and opera­ tion should be reserved for those who have failed to show good result by hydrostatic dilatation. If the incision on the stomach becomes more than 1 cm, a prophylactic antireflux operation should be performed. The usual practice is to perform a partial rather than total fundoplication in this situation. So a few surgeons are in the opinion that it is better to perform an anti­ reflux procedure alongwith Heller’s operation. But it must be remembered that anti-reflux operations may also fail in a few cases, so it is not justified to do anti-reflux procedure as a routine. Majority of cases of failure of Heller’s operation is due to persistent obstruction of the distal oesophagus or persistent achalasia. A history of irritable bowel syndrome, spastic colon, py- lorospasm or other gastrointestinal conditions e. It may radiate through to the back, to the shoulders and to the arms resembling angina pectoris. Dysphagia is not that significant as pain and the clinician must give the patient a lead to find out this symptom. Regurgitation is quite rare, but some clever patients may give a history of regurgitation of intra-oesophageal saliva at the time of oesophageal colic. Primary peristaltic wave may be recognised in the upper half of the oesophagus, but in the lower half it is usually replaced by multiphasic, repititive and high- amplitude contractions. The lower limit of the longitudinal incision is same as that of achalasia, but the upper limit should be extended as high as the aortic arch or above. Oesophagomyotomy has benefited only 75% to 80% of patients in most of the series and it is less effective than for achalasia. If hiatus hernia is associated with this condition it should be treated by an anti-reflux operation. Dysphagia due to slow emptying of the oesophagus and severe heart burn due to gastro-oesophageal reflux are common complaints of this condition. Gastro-oesophageal reflux will lead to reflex oesophagitis and even stricture formation in the distal oesophagus. Diagnosis is mainly performed by contrast radiography, oesophageal manometry, acid-reflux test and oesophagoscopy. Treatment is mainly aimed at relieving the patient from gatro-oesophageal reflux problems. Death usually comes from cardiac, renal and pulmonary involvement and only half of the patients survive more than 5 years. In case of stricture formation2 Collis gastroplasty alongwith Nissen fundoplication should be performed. Oesophageal diverticulum can be further classified into (1) Pulsion diverticulum, in which the diverticulum arises due to elevated intraluminal pressure which forces the mucosa and the submucosa to herniate through the oesophageal musculature. Whereas pharyngo-oesophageal and epiphrenic diverticula are Pulsion diverticula and are ‘false’, the parabronchial diverticulum is a ‘true’ diverticulum and of traction variety. It must be remembered that all the three varieties of oesophageal diverticula are acquired. It is hardly seen before 30 years of age and usually occurs after 50 years of age. Premature contraction of the cricopharyngeus muscle during swallowing seems to be the cause of this condition. This increases the intraluminal pressure and the mucous membrane of the pharyngo-oesophageal junction alongwith submucous coat finds its way posteriorly between the cricopharyngeus muscle inferiorly and the oblique fibres of the thyropharyngeus muscle superiorly. The muscular gap on the posterior aspect of the pharyngo-oesophageal junction through which this diverticulum comes out is called Killian’s triangle. Gradually the diverticulum develops and insinuates itself in the prevertebral space between the oesophagus and the cervical vertebrae. As the ingested material fills in the diverticulum it develops caudally and may even reach the superior mediastinum. For more detail description of aetiology, clinical features and treatment see page 630. While the last one appears late when the diverticulum is quite large, the other two appear quite early, particularly the cervical dysphagia which seems to be the first symptom of this condition. Weight loss is a noticeable feature and may confuse this condition with malignancy. Regurgitation is particularly prominent during sleep and this may wake the patient up during sleep. Due to regurgitation recurrent episodes of airway contamination and aspiration pneumonitis may result.

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