By V. Faesul. Ohio University.

If only the 25-mm sizer can be inserted buy 50 mg avana otc, there result in one or more longitudinal tears of the mucosa and is danger of postoperative stenosis when this size staple car- submucosa 200 mg avana mastercard. Although this type of stenosis frequently the safest way to achieve lumen of adequate size for anasto- responds well to postoperative dilatation buy generic avana 200mg online, we prefer to utilize mosis purchase 200 mg avana mastercard. Use a 16-F Foley catheter with a 5-cc balloon attached the alternative technique described above (Figs. Withdraw the inflated balloon slowly Use a purse-string suture to tighten the esophagus around the after each inflation. After inserting a 28- or 31-mm sizer, always be inserted with ease (use the largest size that can be place one or two purse-string sutures of 0 or 2-0 Prolene, inserted easily). Place four long Allis clamps or guy sutures making certain to include the mucosa and the muscularis in equidistant around the circumference of the esophagus to each bite. We generally prefer to use the posterior wall if the anastomosis is high in the chest, as it allows an easy anterior hemifundoplication. Make a 3-cm linear incision somewhere in the antrum of the gastric pouch utilizing electrocautery. Through this open- ing in the anterior wall of the gastric pouch, insert the car- tridge of a circular stapling device after having removed the anvil. Then choose a point 5–6 cm from the proximal cut end of the gastric pouch and use the spike of the stapler to puncture it. Advance the shaft as far as it will go and then insert a small purse-string suture of 2-0 Prolene around the shaft. Alternatively, place the purse-string suture first; then make a stab wound in the middle of it (Fig. When this has been accomplished, tie the purse-string suture around the instrument’s shaft, fixing the esophagus in position (Fig. Be certain that the purse-string Now rotate the wing nut the appropriate number of turns suture fits snugly around the shaft and that it does not catch in a counterclockwise direction, gently disengage the anvil on grooves in the shaft. After this has been accomplished, from the newly created anastomosis, and remove the entire fire the stapling device. Carefully inspect the newly 15 Esophagogastrectomy: Left Thoracoabdominal Approach 157 necrosis. These authors found that there was a reduc- tion in the leak rate from their gastrotomy closures if they oversewed the gastrotomy staple line with a continuous non- inverting layer of 3-0 Mersilene. We have used a 4-0 poly- propylene running, inverting seromuscular suture to cover the staple line and have seen leaks only. Stabilizing the Gastric Pouch To prevent any gravity-induced tension on the anastomosis, the apex of the gastric pouch should be sutured to the medi- astinal pleura or the prevertebral fascia with 2-0 or 3-0 non- absorbable sutures. The gastric pouch should then be fixed to the enlarged diaphragmatic hiatus with interrupted 2-0 or 3-0 nonabsorbable sutures, which attach the gastric wall to the margins of the hiatus (Fig. These sutures should be 2 cm apart and should not penetrate the gastric mucosa lest they induce a gastropleural fistula. Consider performing a jejunostomy for immediate postoperative enteral alimentation. Confirm this by In either case, take fairly large (1 cm) bites, as dehiscence of inserting the index finger through the previously made gas- this suture line can have serious consequences, such as her- trotomy incision and pass the finger into the esophagus, con- niation of small intestine into the chest. Now apply Allis plete this closure until the costal margin has been clamps to the gastrotomy incision on the anterior wall of the approximated to avoid tearing the diaphragm. Apply a linear stapling device for thick tissue Excise approximately 1 cm of cartilage from the costal (4. Close the inci- remove the stapler, and lightly electrocoagulate bleeding sion in the costal margin with one or two sutures of mono- vessels. Carefully inspect the staple line to be sure all of the filament stainless steel wire (Fig. Bring a 30-F sutures of a nonabsorbable nature, although this step may not chest tube through the ninth intercostal space in the anterior be essential if 4. If it does not sit comfortably, would for a pyloroplasty because it increases tension on the suture it to the parietal pleura posterior to the aorta using fine suture line. Inflate the lung to eliminate any atelec- Muehrcke and Donnelly reported four leaks from stapled tatic patches. If a significant number of air leaks from the gastrotomies in 195 patients undergoing esophageal resec- lung are noted, pass a second chest catheter anterior to the tion using circular stapling instruments. Tie the pericostal sutures tion for failure of the stapled gastrotomy closure to heal and the final diaphragm sutures and close the muscles in two properly is the use of a 3. Stapling technic for esophagogastrostomy after esophago- diaphragm is continuous with the endoabdominal fascia, and gastric resection. Use Esophagogastrectomy for carcinoma of the esophagus and cardia: a comparison of findings and results after standard resection in three staples or a subcuticular suture to close the skin (Fig. Recurrence after neoadjuvant chemoradiation and surgery for esophageal cancer: does the pattern of recurrence differ for patients with complete response and those with See Chap. Chassin† Indications Undetected pneumothorax Ischemia or trauma to tip of gastric tube in the neck inducing Carcinoma of the esophagus necrosis and sepsis Barrett’s esophagus with severe dysplasia Anastomotic leak Esophageal stricture Inadvertent laceration of right gastroepiploic artery Achalasia Perforation Operative Strategy Preoperative Preparation Although a large portion of this operation is accomplished by blunt dissection, there are five areas where dissection See Chap. A small linear laceration of the Prepare a single-lumen endotracheal tube, not cut short. However, if a patch of the membranous trachea is avulsed while dissecting an esophageal cancer that has invaded the trachea, adequate repair may be impossible. In the Pitfalls and Danger Points absence of a malignancy in the area of the trachea, dissec- tion of the esophagus away from the trachea should not be Excessive bleeding difficult if carried out in a gentle manner. While dissecting the omen- Injury to spleen tum away from the gastroepiploic artery, continually keep Hypotension during mediastinal dissection due to compres- in mind that this vessel constitutes the major blood supply sion of the heart to the tip of the gastric tube to be constructed. In many Trauma to thoracic duct, chylothorax areas this vessel is covered by omental fat so its exact Traction injury or laceration of the recurrent laryngeal nerve location is not obvious to the naked eye. Consequently, Bowel herniation through a too large diaphragmatic hiatus when dividing the omentum, leave a few centimeters of omentum attached to the artery, as inadvertent division of this vessel makes the stomach useless as an esophageal substitute. Be aware that the gastroepiploic artery does Department of Surgery , not continue to the tip of the gastric tube. Chassin sary trauma to this area can threaten this precarious anas- Abdomen tomosis. Consequently, be aware throughout the operation that this tissue must be protected from rough handling. Make a midline incision from the xyphoid to a point a few Even inserting a suture between the gastric tip and the centimeters distal to the umbilicus, and enter the abdomi- prevertebral fascia in the neck has been reported to have nal cavity. Check the stomach carefully to ascertain that it caused focal necrosis of the stomach and a gastric fistula is indeed suitable for the development of a gastric tube that with vertebral osteomyelitis. Liberate the left lobe of the liver by incising the place the suture too deeply, and do not tie a tight knot. Aside from hoarseness, dam- sions that involve the capsule of the spleen, so the short gas- age to the left recurrent laryngeal nerve during the cervi- tric and left gastroepiploic vessels are easily identified. Insert cal dissection can also result in swallowing difficulty and the Weinberg blade of the Thompson retractor underneath the aspiration. Use the assistant’s index finger rather than a sternum and retract the liver in a cephalad direction, exposing rigid instrument to retract the trachea and the thyroid the esophageal hiatus. Encircle the esophagus results in massive hemorrhage that in most cases requires with the index finger and then with a 2 cm wide Penrose drain. Apply caudad traction operative staging and careful dissection at the point where to the esophagus via the Penrose drain and free up the lower the azygos vein crosses the esophagus. If the tumor can be reached by digital palpation, ascertain that it is not fixed to the aorta or vertebral column. If it is fixed, transhiatal esophagectomy Documentation Basics without thoracotomy is contraindicated. If not, expose the gastric cardia and then carefully divide and ligate each of the Coding for esophageal procedures is complex. In clamps leaving 3–5 cm of omentum attached to the right gas- general, it is important to document: troepiploic arcade to avoid injury to the gastroepiploic artery. Elevate the greater curvature of the stomach in a cephalad direction and identify the origin of the left gastric artery. Cover the abdominal incision with sterile and insert bilateral intravenous catheters and one intra- towels and start the neck operation. If a central venous pressure or a Swan- Cervical Dissection Ganz catheter is to be used, insert it into the right internal jugular vein, as the left side of the neck is preserved for the Expose and mobilize the cervical esophagus as described in esophagogastric anastomosis. Encircle the esophagus with a Penrose drain and gist use a standard endotracheal tube of standard length that apply cephalad traction.

It must be remembered that any tumour lying immediately deep to the nipple will be fixed to the nipple be it benign or malignant as the main mammary ducts may have travelled through the growth and so the nipple becomes fixed cheap avana 50mg free shipping. A fibroadenoma is not fixed to the breast tissue and can be easily moved within the breast substance best buy for avana. A carcinoma on the other hand is fixed to the breast substance and cannot be moved within it order avana 200mg with mastercard. Fixity to the underlying fascia and muscles (pectoralis major and serratus anterior) proven avana 100mg. The lump is moved in the direction of the fibres of pectoralis major first and then at right angles to them as far as possible. Feel the anterior fold of the axilla to verify that the muscle has been made taut (Figs. Any restriction in mobility indicates fixity to the pectoral fascia and pectoralis major. There will be total restriction of mobility along the line of the muscle fibres if it is fixed to it but slight movement along the right angle of the fibres may be possible. A swelling occupying the outer and lower quadrant of the breast will lie on serratus anterior, to which it may be fixed. This is ascertained by asking the patient to push against a wall with the outstretched hand of the affected side while the mobility of the swelling is tested. The underlying lump is moved and see if this movement causes or increases nipple retraction. When the discharge is visible, try to decide its nature — whether blood, serum, pus or milk. The source of such discharge must be found out by gently pressing on each segment of the breast and areola. On the finding of this examination the staging of the breast cancer can be judged as also the prognosis. If this cannot be properly achieved this examination can be done in lying down position. The thumb of the same hand is used to push the pectoralis major backwards from the front (See Fig. The group is felt with the palm directed laterally against the upper end of the humerus (Fig. Now the nodes are palpated lying on this surface with the palm of the examining hand looking backwards (Fig. Lymphatic drainage from the subareolar plexus of Sappey and outer quadrant of the breast takes place first to the pectoral (P), then central (C) and lastly to the apical (A) group of axillary lymph nodes. The upper quadrant of the breast drains partly to the delto-pectoral node but mainly to the apical group. From the inner quadrant the lymph spread occurs to the internal mammary group (In. From the lower and inner parts of the breast the lymph vessels form a plexus over the rectus sheath and pierce the costal margin to communicate with the subperitoneal lymph plexus. From this place, cancer cells may drop by gravity into the pelvis (Transcoelomic implantation) and may cause metastases in the ovary (Krukenberg’s tumour). It may be noted that the liver may be involved in two ways — subperitoneal plexus and by blood spread. Blood spread — occurs in addition to the liver, to the bones, especially to the sternum, ribs, spine and upper ends of the humerus and femur. The other hand of the clinician is now placed on the opposite shoulder to steady the patient. Palpation is carried out by sliding the fingers against the chest wall when the lymph nodes can be felt to slip out from the fingers (Fig. If the lymph nodes are very much enlarged they may push themselves through the clavipectoral fascia to be felt through the pectoralis major just below the clavicle. To examine this group the clinician stands behind the patient and dips the fingers down behind the middle of the clavicle. Passive elevation of the shoulders would relax the muscles and fasciae of the neck to facilitate palpation. One must always flex the neck of the patient slightly for better palpation of this group of lymph nodes. While palpating the lymph nodes careful assessment must be made as to their number, size, consistency, mobility etc. Lungs and bones particularly the ribs, spine, sternum, pelvis, upper ends of femur and humerus should also be examined as they may be involved by metastasis. Patients having stilboestrol as treatment of prostatic cancer may persent with this condition. The testis should be examined for anorchism, cryptorchism, teratoma or chorionepithelioma. Certain drugs like digitalis, spironolactone, isoniazide may initiate enlargement of breast. Of course, certain amount of breast enlargement in male is noticed during puberty, which is considered normal. But if the aspirated fluid is blood-stained, if the mass does not completely disappear on aspiration and if the cyst recurs rapidly after two aspirations, excision biopsy should be called for. Though negative results is of little importance, yet the positive result means excision of the lump or even mastectomy. There has been many technical improvements and modifications of equipment design in Fig. This is not a different process but rather a different method of recording X-ray images. Xeroradiography utilizes an aluminium plate thinly coated on one surface with vitreous selenium. The charged xeroradiographic plate is placed beneath the breast and a conventional exposure is made. The positive charges on the selenium are discharged in proportion to the varying intensities of the X-rays reaching the plate, modified by the tissues traversed. A finely divided negatively charged blue powder or toner is sprayed on the surface of the plate and is attracted to the latent image of positive charges. This produces a blue image of the breast which is transferred to a special plastic-coated paper and permanently fused by heat. Malignant lesions reveal themselves as localized fine or punctate calcification and small areas of increased stromal density and architectural distortion (See Fig. Benign tumours like fibroadenoma present as denser calcification with smooth outline (Fig. Accuracy is significantly lower in younger patients whose dense glandular breasts can obscure even clinically obvious masses. Intraductal tumour (duct papilloma is demonstrated by smooth filling defect; whereas duct carcinoma is demonstrated by irregular filling defect) can be detected by this technique. This shows malignant lesions as areas of increased heat production and increase in vascularity. But thermography has proved to be somewhat disappointing in the diagnosis of carcinoma of breast. At present 50 to 75 per cent of cancers are recorded as not being detected by thermographic scan. But when used in conjunction with physical examination and mammography, thermography can be expected to increase the number of cancers detected by 3 to 5 per cent. At present, ultrasonic ^hb^H examination of the breast is useful only in differentiation of solid from cystic swellings greater than 2. Fluid-filled lesions lack an internal echo pattern, whereas solid lesions are filled with internal echoes. If the solid lesions are homogeneous, the echo pattern is evenly distributed throughout the mass. Breast ultrasonograms are of limited usefulness in the detection and diagnosis of breast cancer.

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Generally antibiotics are continued for 7–10 days after A long midline incision provides the best exposure to all abdominal surgery for perforation or dead bowel order 50mg avana amex. Carefully separate fibrinous adhe- Consider using prophylactic antifungal therapy when a sions between loops of bowel purchase avana in india. Copious irrigation with warm Preoperative Imaging saline generic 100 mg avana fast delivery, removal of fibrin purchase 100 mg avana with amex, and packing the abdomen in quad- rants will allow identification of the source. If a discrete, contained abscess is found, allow inspection of the back of the stomach). Fill the abdo- consider parental antibiotics and percutaneous drainage men with warm saline and have the anesthesiologist inject air rather than surgery. Intraoperative Considerations Similarly carefully mobilize the sigmoid colon and look for a tiny diverticular perforation. When nothing is found, close the Supporting the Patient/Continuous abdomen and continue antibiotics while awaiting results of Resuscitation cultures. Some surgeons will place closed suction drains near the most likely source, for example, near the sigmoid colon if Continue goal-directed resuscitation in the operating room. Hypothermia during abdominal surgery has been associated with an increase in surgical wound infections. In animals, it has been shown to cause intraoperative and postoperative Surgical Technique: Does the Surgeon vasoconstriction with a resulting decrease in subcutaneous Make a Difference? Decreased oxygen tension, in turn, results in decreased microbial defense and impaired immune Studies have shown that when infection rates of individual function. Thus, attention has been directed to the effect of surgeons are followed and the surgeons are provided with perioperative normothermia versus hypothermia and the feedback regarding these data, their postoperative infection incidence of surgical wound infection. Unfortunately, most such studies concern a prospective double-blind randomized study in humans clean elective surgery where the anticipated wound infection undergoing elective colorectal surgery and showed that rate is extremely low. Sharp dissection, gentle tissue of the contaminated segment of the operation, change gown, manipulation, and adequate hemostasis have often been cited gloves, and instruments prior to abdominal wall closure. Although there are historical data that attempt to compare resistance of surgical wounds to infection based on the use of Wound Irrigation a steel knife versus electrocautery, few data support one technique or the other. Some attention has been also given to Adequate intraoperative irrigation of the wound minimizes proper suture usage. The guiding message in this regard the bacterial inoculum and has been shown to decrease post- should be to limit suture use to a necessary minimum, avoid- operative infection. It has long been customary to pour sev- ing undue tissue tension and strangulation. Localizing Contamination Frequent irrigation with 200 ml of saline followed by aspira- tion is a rational approach to washing out bacteria spilled Adequate exposure with proper retraction is essential for con- into the field. Take care not to let the irrigation fluid spill over ducting appropriate exploration of the contaminated field. Experimental models have shown Many surgeons drape off (isolate) the surgical incision by that the most important factor that determines wound infec- applying wet towels or gauze to the subcutaneous tissue, which tion during contaminated surgery is the number of bacteria minimizes contact with gross contamination but does not pre- present at the wound margins at the end of the operation. Use of a wound protector drape, effect of operative field irrigation on the incidence of deep such as the Alexis O Wound Protector/Retractor (Applied wound/abscess formation is less clear. Irrigants have contained and then opened and spread out to cover the subcutaneous fat such antibiotics as a cephalosporin, an aminoglycoside, neo- and musculoaponeurotic layers of the abdominal wall (Fig. It is a well-accepted practice to leave the skin and subcutaneous tissue open after such operations to allow drainage. The main goal of such management is to prevent potentially devastat- ing complications, such as fasciitis. Delayed primary closure, within 4–6 postoperative days, results in fewer wound infections than primary closure after contaminated operations. Many surgeons believe that attempted delayed primary closure is a reasonable “compro- mise” between healing by secondary intention and primary Fig. When successful, delayed primary closure avoids large wounds that require labor-intensive, potentially expen- bacterial inoculum, wound irrigation rinses the operative sive care. Wound Dressings Other Considerations Wound dressings are a means to protect the wound and a mechanism for absorbing wound drainage. Wounds that are Drains are used when a localized collection of pus (a well- to heal by secondary intention or delayed primary closure formed abscess) is found or when there is concern over con- require a wound dressing. These dressings must be changed at within a short period of time, consider damage control lapa- least twice a day. Limit the initial operation to control of is removed from the wound without soaking the gauze prior contamination and reserve any gastrointestinal reconstruc- to removal. On occasion, contaminated and attention in the United States, with most of the available lit- infected abdominal operations require marsupialization, erature arising from European study groups. In these cases dressing of local antibiotic therapy has the advantage of providing changes using sterile technique and optimal exposure must high concentrations of antibiotic to a well-defined area. They can also take the other hand, once the wound is closed, it is not simple to place, with care, in the intensive care setting. Local antibiotic therapy has been supplied in the form of Acknowledgment This chapter was contributed by Claudia L. Antibiotic-containing collagen sponges appear to be most practical, as the collagen dissolves and does not require Further Reading removal. The sponges are usually in the form of sheets and therefore can be used to cover large areas more accurately Ambrosetti P, Gervaz P, Fossung-Wiblishauser A. Local antibiotic therapy has been utilized for tis in 2011: many questions, few answers. Risk factors for severe sepsis in secondary dures, and cardiovascular and vascular surgery. Surviving Sepsis Campaign: international guide- lines for management of severe sepsis and septic shock: 2008. Re-operation for complicated secondary Wound Closure peritonitis – how to identify patients at risk for persistent sepsis. Thus, rate in abdominal surgery patients after introduction of fluconazole healing by secondary intention has been the tradition when prophylaxis. Relaparotomy in peritonitis: prognosis and treat- surgery: a randomized clinical trial. Direct peritoneal resuscitation accelerates primary age control laparotomy in pancreatic surgery. Scott-Conner Damage control laparotomy is performed under dire situa- of blood and blood products (including activation of a mas- tions, when a patient requires surgery but is too unstable to sive transfusion protocol). It was initially developed, Prep and drape the entire abdomen, chest, neck, and and is still most commonly used, in the trauma situation. Prep wide, flank to flank, to allow for stomas and There are two major advantages: First, operative time is min- drains. Make a long laparotomy incision from xiphoid to imized by concentrating on control of injuries rather than pubis. Anticipate additional blood loss when the abdomen is definitive repair and, second, postoperative problems with entered and any venous tamponade is relieved. Eviscerate abdominal compartment syndrome are avoided by leaving the bowel to gain better exposure to all quadrants. Resuscitation continues after surgery and evacuate the abdomen of blood and clots and pack it in definitive repair can then be undertaken after the physiologic quadrants. Identify and control bleeding sites by packing solid organ It is also applicable to other emergency situations, most injuries, repairing major vessels and ligating small ones. In this situation, Control contamination from hollow viscus injuries with a planned second-look operation provides the best opportu- clamps, staples, or suture. Massive intra-abdominal bleeding in blunt trauma com- The technique may be lifesaving but is associated with monly comes from spleen or liver, less commonly from kid- significant morbidity. Delayed abdominal closure is associ- ney injuries, pelvic fractures, vascular injuries, mesenteric ated with an increased risk of enterocutaneous fistula forma- tears, or other sources. Ventral hernia formation is common, and most patients management in the damage control situation are discussed in will require a subsequent operation for repair of their the sections that follow. Decision to Perform Damage Control Damage Control in Trauma The decision to perform damage control rather than to pur- Always follow the basic principles of trauma surgery. These sue definitive repair of all injuries depends upon physiologic include warming the operating room, intravenous fluids, and stability of patient, other injuries, and the nature of damage ventilator circuit, having at least two large bore intravenous found on laparotomy. Physiologic criteria include acidosis, catheters in place and adequate (but not excessive) resuscita- hypothermia, and coagulopathy.

These are less painful than lactation abscesses and usually restricted to a single obstructed duct system purchase avana line. If this abscess is allowed to burst spontaneously order avana american express, the lesion settles temporarily but recurrent abscesses usually develop order avana visa. This goes on till a chronic milk fistula develops at the edge of the areola which continues to discharge purchase avana with american express. The fistula may be excised to lay open the underlying tissue to be healed by granulation tissue. Only in very recurrent conditions with presence of periductal mastitis it is better to excise the breast tissue around the involved duct through a radial incision. The infection arises from the tissues deep to dotted area indicates deep surface of the the breast, (i) Infected haematoma, (ii) empyema, (iii) tuberculosis breast which can be readily exposed through this incision. The abscess is drained, a corrugated rubber sheet drainage is introduced and the wound is dressed properly. It must be remembered that the condition is much less painful than the pyogenic infection. The abscess is the cold abscess, so redness and oedema, calor and dolor are conspicuous by absence. The diagnosis is made by blood test, bacteriological examination of the discharge, chest X-ray, lymph node biopsy etc. Secondary stage of syphilis may be revealed in the form of mucous patches on the submammary fold. Usual chemotherapy is started and if the disease does not respond so effectively to this chemotherapy, local mastectomy is indicated. The cause is often not known and is a part of spontaneous thrombophlebitis anywhere in the body. Clinical feature is presence of painful red indurated subcutaneous thrombophlebitic cord. When the corresponding arm is raised there may be appearance of groove alongside the indurated vein. Some antibiotic treatment should be started and thrombophobe ointment may be applied. The condition usually subsides within a few months without recurrence or complication. This has resulted in many patients with benign breast disease receiving less attention from clinicians. Benign breast disease has also suffered from the major disadvantage of a hopelessly confusing terminology and inadequate classification. Breast lumps — — Cysts — galactocele — sclerosing adenosis — fat necrosis — cyclical nodularity — chronic abscess — lipoma. Disorders of the nipples and periareolar region — — nipple discharge and inversion — mammary fistula — duct ectasia/periductal mastitis — retraction — sepsis. A few non-breast disorders — (a) Musculoskeletal — (i) Tietz’s syndrome — pain at the costochondral junction. Despite complexity of classification, there are relatively few presenting symptoms of benign breast disease. Symptoms fall into 3 main groups — Breast pain, Lumps and Disorders of the nipples and periareolar region. The most common symptom is pain which accounts for 50% of cases, followed by lumps which accounts for 35% of cases. Clinician must be particular to exclude carcinoma while venturing to diagnose a condition as benign breast disease. One group of patients have symptoms which bear a definite relationship to the menstrual cycle — this is known as cyclical mastalgia. In the remainder there is no such correlation — this is known as non-cyclical mastalgia. Cyclical mastalgia has been described in the section of Aberrations of Normal Development and Involution. It is more chronic, unilateral and located in the medial quadrant of the breast and in the periareolar region. The pain is frequently described as burning or dragging rather than a ‘heavy feeling’. It must be remembered that in half of the cases such mastalgia arises not from the breast but from the surrounding musculoskeletal structures. The surgeon has two important tasks when confronted with a patient with such lumpy breast. Firstly, he has to decide whether the lump is truely an abnormality or whether it can be regarded as being within the spectrum of normality. The various conditions which are included in the classification of benign breast disease deserve separate management according to the individual case. About 2 or 3% of women refer to a clinic with cyclical mastalgia, the symptoms of which are more severe with distressing discomfort lasting a week or more. In the past all such patients were described as suffering from ‘fibrocystic disease’, although there is little histological evidence of either fibrosis or cyst formation. Other aetiological factors include excessive caffeine ingestion or inadequate essential fatty acid intake. There is a good evidence that essential fatty acid supplement can reduce the symptoms of cyclical mastalgia. Periductal mastitis leads to connective tissue hyperplasia of the periductal tissue and fibrous stroma. Early workers suggested that they might simply be distended ducts or they may result from cystic lobular involution. In the latter cases lobules develop microcysts which eventually coalesce to be larger cysts. This process is potentiated by obstruction of lobular outflow and replacement of surrounding stroma by fibrous tissue. More recent investigations have suggested that the aetiology of these cysts is more complex than previously believed. It seems that interstitial fluid passively diffuses through simple membrane to cause such cyst. This cyst tends to be single, non-recurrent and not associated with increased risk of cancer. The second type cyst is lined with apocrine epithelium characterised by large columnar cells resembling those found in apocrine sweat glands. It is suggested that apocrine epithelium actively secrete potassium into the cyst fluid. The cysts may become large when the solitary draining duct is blocked by kinking or hyperplasia. One cyst may be palpable whereas others in the surrounding breast tissue are not palpable. When one large cyst becomes tense and blue domed, the cyst is called ‘blue- domed cyst of Bloodgood’. The epithelial hyperplasia may be so extensive that it may result in papillomatous overgrowth within the ducts and cysts. This is easily distinguished from the hard, gritty and greyish lesion of carcinoma. A variant of this condition is known as sclerosing adenosis, where glandular proliferation (adenosis) is so distorted by proliferation of fibrous or myoepithelial cells as to lose the normal lobular arrangement. The clear difference is absence of mitosis in this condition, where the nuclei are regular and cystic spaces between cells can be found. One group of patients have symptoms which bear a definite relationship to the menstrual cycle — this is known as cyclical mastalgia. In the remainder there is no such correlation — this is known as non-cyclical mastalgia. Cyclical mastalgia is the common type of breast pain accounting for 40% of all cases referred to a breast clinic. In this condition discomfort lasts for a varying period of time prior to menstruation and this is usually seen in premenopausal women with median age of about 35 years. Episodes of discomfort may last for some months, there may be years of freedom of pain until symptoms begin again.

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Haematuria may occur late in the course of disease if the bladder or urethra is invaded discount avana 200mg mastercard. Symptoms of renal insufficiency may be the first symptoms due to obstruction of the ureter by the primary tumour or compression of the ureters by masses of iliac lymph nodes secondarily involved buy 50 mg avana with mastercard. Similarly ureteral obstruction may cause hydronephrosis which will be revealed by bimanual palpation of the loin cheap avana generic. General examination should be performed carefully to exclude anaemia avana 100mg for sale, tenderness in the spine, enlarged lymph nodes in the abdomen or in the supraclavicular fossa. Rectal examination is by far the most important examination for the diagnosis of cancer prostate. Cancerous hard nodules, irregular induration, obliteration of the median sulcus, and non-mobility of the rectal mucosa over the enlarged prostate suggest carcinoma of the prostate. This gap is obliterated by invasion of the lateral pelvic wall is clear on both sides. This category includes those cases of the incidental finding of cancer in an operative or biopsy specimen. Smooth nodule may deform the contour but the lateral sulci and the seminal vesicles are not involved. T3 — the tumour has extended beyond the capsule with or without involvement of the lateral sulci and/or seminal vesicles. N4 — involvement of juxta-regional lymph nodes, which are common iliac or para-aortic nodes. This may be secondary to extensive marrow invasion or secondary to renal failure or due to haemorrhage or infection. The commonest primary malignant lesion which causes osseous metastasis is carcinoma of prostate. Sclerotic metastasis in the pelvic bones and lumbar vertebrae are quite common in this con­ dition. Osteolytic metastases may also be seen in cancer of the prostate and may coexist with sclerotic ones. Transrectal ultrasonography is now often used particularly in screening to detect early carcinoma of the prostate. This technique is considered to be the best method for staging of cancer prostate. But it must be confessed that its efficacy is less than mammography in detecting prostatic cancer. However advanced spread beyond the gland is often best identified on a Tl-weighted image, where tumour fat contrast is accentuated. Following injection of intravenous contrast medium prostatic tumours enhance and this may be valuable for defining both the intraprostatic extent of the tumour and spread beyond die gland. It also indicates the small extradural lesions, which may be treated before neurological damage has occurred. This is performed by injection of "Tc (techne­ tium) and the isotope is then monitored using a gamma camera. The isotopes will conglomerate in an area of increased blood flow producing ‘hot’ areas. Such hot areas may be found in os­ teomyelitis, healing fracture, arthropathies (particularly osteoar­ thritis) and Paget’s disease. As lymphangiography is associ­ ated with both false positive and false negatives, lymph node biopsy is more important for accurate staging. Various needles have been used and the accuracy has been claimed in the range of more than 80%. Such biopsy may be performed without general anaesthesia as an outpatient procedure. Besides positive proof of the diagnosis, biopsy also indicates the grade of malig­ nancy of the tumour With a very small nodule, such biopsy may be negative. In a few cases implantation of the tumour in the needle track have been recorded, but this is very much theoreti­Fig. Considering these facts, there may be a good place of pros­echopoor lesion (cancer) at the apex of the prostate tatic biopsy. Presently transrectal biopsy using an automated gun with appropriate antibiotic cover is used. When the cancer has extended outside the prostatic capsule and me­ tastases are present about 70% of patients have elevated lev­ els of this enzyme. This is considered to be pathognomonic of advanced disease whether or not metastasis is detected. The serum alkaline phosphatase is also elevated in patients with metastases in bone. It is therefore worth doing both acid and alkaline phosphatase estimation as part of the search for distant metastasis. It has been used as an index of bone destruction in metastatic cancer, but it needs a low gelatine diet for 24 hours before urine collection. In this figure scribed earlier in the section of‘benign enlargement of pros­one can see a tumour (t) replacing the left side of the gland. Relatively sudden attack of dysuria with very short history of other urinary troubles should give rise to suspicion of this diagnosis. If catheterisation becomes very difficult even after bouginage, transurethral resec­ tion should be performed to relieve the retention. As soon as the retention is relieved, by whatever method applied, stilboestrol should be started 5 mg daily. When the pathologist has found that the focus of carcinoma was entirely confined within the gland, the surgeon may be happy that he had re­ moved the tumour completely. It seems reasonable to conclude that no active treatment is indicated for well differentiated focal carcinoma detected in pro­ static specimens removed at operations. But follow- up should be continued till progression of the pro­ static cancer becomes evident. However the more diffuse or less differenti­ ated tumours may need immediate radiotherapy in a recommended dose of 5,000 rads over 4 weeks. There are various options to treat these cases — (i) radical prostatectomy or (ii) radical ra­ Fig. This is the group which do good with radical prostate­ ctomy particularly when the patient is below the age of 70 years, free from serious unrelated disease, no evidence of metastasis and prostatic induration does not exceed 1. Adjuvant radiotherapy offers nothing to the patient undergoing radical prostatectomy. Early androgen ablation seems to offer excel­ lent chances for 5-year progression-free survival to most men with stage T1-T2 prostate cancer. In this respect early hormonal therapy seerns to be even better than early androgen ablation. Recently iodine125 seeds have been implanted into the prostate gland alongwith lymph node dissection for staging. The capsule appears to provide an effective barrier against the spread of tumour and once this is breached, dissemination of the disease is likely to occur. So under these circumstances, local treatment to the prostate alone is unlikely to eradicate the disease. Various adjuvants have been used in an attempt to improve the result of radical prostatectomy in locally advanced disease. Infiltration of the prostatic bed with radio-active colloidal gold (l98Au) has been supplemented with radical prostatectomy. Direct retropubic implantation of the prostatic tumour with 125I seeds has been tried. This will provide low energy irradiation (half life 60 days), in the tune of no less than 8,000 rads in two months. External beam radiation therapy should ensure a more satisfactory dose distribution and the field can be extended to include para-aortic and pelvic lymph nodes. Extended surgical excision, in this patient, should be reserved for the rare cases, who have failed with hormonal and other methods of treatment and yet continue to exhibit local growths, which are incapacitating but without evidence of metastasis.

When the fluid is aspirated the cardiac orifice can only be located with difficulty due to its contracted condition generic 200mg avana otc. In case of benign stricture this investigation not only helps in the diagnosis but also can be used to dilate the stricture with an oesophageal bougie buy cheap avana line. In carcinoma of oesophagus it is not only diagnostic but also gives an indication about the histology of the cancer by taking biopsy specimen through oesophagoscopy discount avana amex. In reflux oesophagitis this investigation shows inflammation of the mucosa of the lower end of the oesophagus order avana line. In achalasia with a moderately dilated oesophagus if a lateral chest X- ray is taken a typical air-fluid level may be seen in the posterior mediastinum which along with the typical symptoms is diagnostic of achalasia. More or less all the conditions which may give rise to dysphagia will be diagnosed by this investigation. If a pharyngeal pouch is suspected a thin emulsion of barium should be used for barium swallow. This will show that the barium first feels the pharyngeal pouch, and then overflows from the top. In stricture the meal is first arrested in the dilated oesophagus immediately above the constriction and gradually trickles down through the stricture. The stenosed portion is usually smooth and does not produce any soft tissue shadow as may be obtained in carcinoma. In case of carcinoma the dilatation of the oesophagus above the tumour is less marked. In achalasia the radiographic appearance varies according to the extent of the disease. In early stage there is only mild dilatation of the oesophagus, whereas in late stage there is massive dilatation and tortuosity of the oesophagus. No benign oesophageal tumours produce characteristic features in barium swallow examination. In case of polyps there is also characteristic filling defect detected in this examination. In gastro-oesophageal reflux during the course of barium swallow examination reflux can be demonstrated. This study shows multiphasic, repeatitive and high-amplitude contractions that occur after swallowing in the smooth muscles of the oesophagus. In case of gastro-oesophageal reflux, pH recording in the oesophagus 5 cm above the distal oesophageal high-pressure zone shows decline in pH to less than 4, which is a clear evidence of gastro-oesophageal reflux. These investigations however may find out abnormal masses in the mediastinum and aortic aneurysm which may press on the oesophagus to cause dysphagia. The proximal oesophagus ends as a blind tube and the distal oesophagus is joined to the lower part of the trachea with a tracheo- oesophageal fistula. During foetal life this condition may be recognized by presence of hydramnios, but this may not be present. When the tip of this tube is radio-opaque, straight X-ray is situ can diagnose this condition. Straight X-ray also reveals intestinal gas which indicates communication of distal trachea with distal oesophagus. The greatest risk of this condition is that there is a great possibility of aspiration of gastric juice, which is highly injurious to the lungs. The patient is nearly always a middle-aged woman who presents with difficulty in swallowing. Dysphagia is due to spasm of the circular muscle fibres at the extreme upper portion of the oesophagus. It may be considered as a Pulsion diverticulum — herniation of the oesophageal mucosa and sub­ mucosa through the weakened area. Note the long age and more of the oesophagus above the smooth irregular narrowing with slight dilatation of frequently men narrowing of the lower end of the the oesophagus above the stricture. Sometimes the patients may wake up from sleep with a feeling of suffocation followed by a severe cough. When the pouch enlarges it tends to compress the oesophagus which leads to dysphagia. When the patient drinks the pouch can be seen to be enlarging with gurgling noise in the neck. X-ray with a very thin barium emulsion should be performed as thick mixture refuses to be washed out from the pouch following examination. Traction diverticula may be occasionally seen in the middle portion of the oesophagus near tracheal bifurcation. These result from pull of scar tissue from an adjacent inflammatory process, usually tuberculous lymph nodes. X-ray with barium meal will show a long tortuous stricture with some dilatation of the proximal oesophagus and without any shouldering at the proximal end of the stricture. Some sort of emotional stress and anxiety are often associated with along chest pain and dysphagia. There is also regurgitation of food, though many patients experience regurgitation of intraoesophageal saliva during oesophageal colic. Irritable bowel syndrome, pylorospasm, peptic ulcer disease, gallstone and pancreatitis may stimulate diffuse oesophageal spasm. Oesophageal manometry has been considered the ultimate test in the diagnosis of this condition. This is due to fibrous replacement of oesophageal smooth muscle and then the distal oesophagus loses its tone and normal response to swallowing and gastro-oesophageal reflux occurs. In distal 2/3rds or 3/4ths of the oesophagus normal peristalsis gives way to weak nonpropulsive contractions. At its most upper part at the pharyngo- oesophageal junction and is known as pharyngo- oesophageal diverticulum or pharyngeal pouch which has been discussed above. This occurs in association with tuberculosis or histoplasmosis of the subcarina and parabronchial lymph nodes to which this diverticulum becomes adherent. This condition rarely causes symptom and is discovered accidentally on barium oesophagogram. This is due to oesophageal motor dysfunction of the distal oesophagus leading to mechanical distal obstruction. There is virtually no the mucosa and submucosa of the oesophagus dilatation of the oesophagus above the growth. Many patients may remain constricted part is very much irregular — ‘rat-tail’ deformity of the lower end of the oesophagus. This condition is diagnosed by barium oesophagogram, though oesophageal manometry should be performed to identify the exact motor disturbance. It is generally located at the oesophagogastric junction and has squamous epithelium on one side, gastric mucosa on the other side and fibrous tissues in the centre. Due to sloughing of a portion of the growth dysphagia may be eased out temporarily. Regurgitated material is usually alkaline mixed with saliva and streaked with blood from malignant growth. Anorexia is another symptom but more often seen in growths at the lower end of the oesophagus. Exfoliative cytology from oesophageal lavage may clinch the diagnosis very early even when radiology has not been positive. In late stages pressure on recurrent laryngeal nerve may cause hoarseness of voice or erosion of bronchus may lead to broncho-oesophageal fistula. If symptoms occur these are usually fullness after meals, early satiety and post­ prandial vomiting. Gastro-oesophageal reflux, which is a very common occurrence in sliding or axial or type I hiatus hernia, does not take place in this condition. The filling defect is then it courses behind the oesophagus (or in rare instances usually more irregular than is shown in front of the oesophagus between the oesophagus and the in this case. It is only when reflux occurs with increased frequency and at times when the stomach is not distended that pathologic gastro-oesophageal reflux is considered. The symptoms of this reflux are heart-burn and regurgitation aggravated by postural change. These are associated with dysphagia, substernal chest pain, sensation of something sticking in the throat and bleeding. Reflux of gastric contents irritates the oesophagus causing secondary muscle spasm alongwith inflammation of the mucosa leading to fibrosis and stricture. Closed injuries are due to waves of shock or direct compression of a viscus against a bony prominence.

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These slices should be done with the Bard-Parker knife or scalpel and not with the scissors as this may cause crushing of the nerve-ends order avana 100mg online. This is done by bringing the ulnar nerve in front of the medial epicondyle of the humerus or by bringing the radial nerve in front of the humerus avana 100mg. In this case unnecessary branches can be sacrificed and the important branches may be stripped and further mobilized generic avana 50 mg on line. Sometimes it may be necessary to separate the nerve fibres which form the branch from the main trunk cheap avana 50mg online. This will definitely mobilize the main trunk which was previously anchored by branches. This can be done by positioning the limb properly (as for example, flexion of the limb) to help their approximation. When the limb is more or less fully extended, the second operation is ventured and proper suturing of the nerve is peformed. This is occasionally carried out to repair the radial nerve when it is associated with ununited fracture of the humerus. In this case the result will not be good even if the two untrimmed ends are anchored or the limb is gradually extended. The donor nerve is generally an autogenous graft from the saphenous nerve of the thigh, sural nerve of the leg or the medial cutaneous nerve of the forearm. This type of nerve grafting does not help to restore the motor function but can restore sensory function to some extent. The epineurium of the graft is to be sutured with the epineurium of the host nerve. When the nerve is of bigger calibre, cable grafts may be-used, in which nerve of same diameter is sutured in the form of cable with the host nerve. Nerve grafting does not become successful if the intervening gap between the nerve ends becomes a mass of dense scar tissue. Microscopic surgery in nerve grafting is being popularised in States but its superiority is yet to be proved. Moreover formation of scar tissue following infection will also lessen the possibility of good nerve repair. This will definitely decrease the possibility of good result after nerve suturing. Irritant suture material will increase fibrosis and hence disturb good nerve regeneration. The limb should be immobilized in this position for at least a month, after that the limb is gradually straightened to bring to its normal position. An attempt at suturing of the partially divided nerve will simply initiate scar tissue formation and will deteriorate the function of the intact portion of the nerve. There is so much overlapping in the nervous system that even 4/5th division produces very little disability. Nerve suturing is only indicated when partial division has resulted in a siginificant deficit. Obviously full function cannot be expected, but again uncontrolled contractures may be found. When this nerve is injured there is partial (hyposmia) or total loss (anosmia) of smell of the corresponding side. When this nerve is injured, there may be partial or complete blindness of the affected eye. When this nerve is injured the main feature is dilated pupil on the affected side. With this there may be ptosis of the upper eye lid due to paralysis of levator palpebrae superioris. There may be proptosis or unusual protrusion of the eye ball due to paralysis of majority ocular muscles. Diplopia and external strabismus are due to unopposed action of the external rectus and superior oblique muscles of the eye ball which are not supplied by this nerve. There will also be loss of accommodation due to paralysis of the sphincter papillae and the ciliaris. This nerve supplies the superior oblique muscle of the eyeball and its damage will lead to diplopia and deficient movement of the eye to turn it downwards and laterally. It divides into 3 main branches — the ophthalmic, the maxillary and the mandibular. Pain is often precipitated by exposure to cold, eating, talking, touching certain parts of the face and even during walking. Various operative procedures have been suggested — (i) The trunks of the maxillary and mandibular nerves and the trigeminal ganglion itself is injected with alcohol with varying degrees of success. Endeavour is made to preserve the ophthalmic fibres which lie in the upper and medial part of the root. This is to avoid the complications of anaesthesia affecting the surface of the eye. Through the middle fossa the trigeminal ganglion is approached either extra- or intradurally. Through the posterior fossa the root of the 5th nerve is approached near the cerebello-pontine angle. This nerve supplies the lateral rectus muscle of the eye ball and this muscle becomes paralysed if this nerve is injured leading to internal strabismus. Damage of this nerve will cause complete to partial paralysis of the stemomastoid muscle and the trapezius muscle. When the nerve is involved in the upper part of the anterior triangle of the neck there may be paralysis of both stemomastoid and trapezius muscles. If the nerve is injured in the posterior triangle of the neck, which is more common, only the trapezius muscle will be affected. Trapezius paralysis also unables the patient to continue abduction of the arm after 90°. Strength of stemomastoid muscle can be tested by asking the patient to turn his face to the opposite side against resistance. It is only in case of this nerve that secondary suture may not be successful due to retraction of the cut ends. Though this, nerve supplies the Styloglossus, Hyoglossus, Geniohyoid and Genioglossus, yet its main supply is to the intrinsic muscles of the tongue. In this case, there will be anaesthesia of the whole upper limb except the upper part of the arm which is supplied by C3, 4 & 5 and by the intercostobrachial nerve. There will be also complete paralysis of the arm and scapular muscles, occasionally the long thoracic nerve supplying the serratus anterior or the nerve supplying the rhomboids may escape. It may affect new bom babies during difficult confinements or adult by a fall of weight on the shoulder. The muscles affected are biceps, brachialis, brachioradialis, supinator and deltoid. But if the 6th nerve is also affected, there will be an area of anaesthesia over the outerside of the arm and upper part of the outerside of the forearm. As the innervation of the hand is intact, functional improvement may be obtained conservatively by maintaining full range of passive movement of the limb to prevent contracture and the anaesthetic skin is protected to avoid pressure sores etc. Function of the limb can be best restored by arthrodesis of the shoulder and elbow joints. One may venture transplantation of muscles from the pectoral groups to the humerus. This type of lesion can occur when a falling person clutching at an object and hyper-abducting his arm or failing to obtain a foot-hold on a passing bus. The result is paralysis( of the intrinsic muscles of the hand (with claw-hand and features of combined median and ulnar nerves palsy) with anaesthesia of the inner one and half fingers. Very occasionally spasticity of the lower limb may be noticed associated with this condition, which is a result of damage to the pyramidal tract from haemorrhage following avulsion of the nerve roots. Recovery of function may occur when the lesion is due to stretching-(neurapraxia). But if the nerves have been ruptured, maldistribution of down-growing fibres will definitely lead to considerable reduction in functional efficiency.

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