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V. Dimitar. Saint Thomas University.

It should document that the case was discussed ing care or if the patient wishes to switch to another health- with the patient and that the procedure was explained to care provider order ranitidine 300mg amex. Such note will provide the necessary the patient along with its risks and benefits buy ranitidine 300mg otc. It will further documents for billing and auditing purposes and for risk confirm that an informed consent was obtained and who management cheap 300 mg ranitidine otc. Suppose you were to read the opera- tive note and should include several components order ranitidine online now. Would components include the time-out, anesthesia type, monitor- it provide sufficient level of detail that you could easily visu- ing lines, Foley catheters, position, prepping and draping, alize what was done and why? The details of the procedure performed will include information in the management of these patients (DeOrio the anatomic location, specimen resected, viability of rem- 2002). Having templates for dictations or to describe the nants, configuration of anastomoses, staples or hand sewn, operative notes allows the surgeon to use a systematic any testing of anastomosis, placement of drains and tubes, approach to the dictation that will not allow for missing any and finally the closure technique. How to prepare an appropriate In summary the operative note is a solid reflection of the operative note was rarely taught or instructed to the budding care provided. It is the responsibility of the surgeon to ensure surgical residents starting their surgical training. Such need that the essential elements of a surgical procedure are was identified and addressed by a book entitled Operative promptly documented in an accessible operative note. Dictations in General and Vascular Surgery, coedited by Carol Scott-Conner and Jamal J Hoballah (2011), which has served as a companion to Chassin’s textbook. This has been References a very useful educational resource to the surgical residents in training as a quick guide prior to performing a surgical pro- DeOrio J. The quality of the operative report for women American Board of Surgery examination. New York: Springer Science + tate the ability of the surgeon to maintain soft copies of all his/ Business Communication; 2011. Gouge Advances in diagnostic studies, perioperative management, Important concepts are resection with adequate margins and the techniques of esophageal surgery have greatly of normal esophagus and stomach, resection of the fibroareo- reduced mortality, morbidity, and length of hospital stay. The the long-term results of treatment for esophageal malig- stomach must be well mobilized with preserved vascularity nancy. Long-term survival following resection of a carci- and esophagogastric continuity restored with an end-to-side noma of the esophagus is usually limited to those patients or side-to-side anastomosis. The gastroepiploic arcade must without regional spread whose tumors are confined to the be carefully preserved and the esophageal hiatus widened to wall of the esophagus. Successful esophageal surgery still prevent a tourniquet effect with obstruction to venous out- requires knowledge of the anatomy and physiology of the flow. Properly performed, esophagogastrectomy is a safe esophagus and attention to the details of the operative operation with good symptomatic and nutritional results. If a tumor extends into the stomach, a significant distance either along the lesser curvature or into the fundus, a signifi- cant proximal gastrectomy is necessary for adequate tumor Carcinoma of the Cardia Region margin. If resection of more than 50 % of the stomach is required for tumor margins or if the anastomosis is less than Resection of lesions of the distal esophagus and gastric car- 10 cm from the pylorus, a total gastrectomy with Roux-en-Y dia with esophagogastric anastomosis is no longer an opera- esophagojejunostomy gives a much more satisfactory result. Resection with an overall rus leave too small a gastric remnant to construct a satisfac- mortality of 2 % should be routine, and anastomotic leakage tory end-to-side anastomosis. Operation without an intensive have a higher leak rate and severe problems with uncon- care unit stay, with early ambulation, return to oral intake trolled bile reflux esophagitis. Continuing epidural analgesia with esophagectomy is an option for lesions in the distal 10 cm of patient control after surgery has been an important advance. The use of minimally invasive approaches Although return of normal appetite and meal volume is utilizing laparoscopy and thoracoscopy have largely sup- slow, most patients have no dietary restrictions after the planted the left thoracoabdominal approach with the patient early narrowing of the anastomosis due to edema has in the lateral position for tumors whose proximal extent on resolved. A com- bined minimally invasive operation is rapidly becoming the approach of choice. Gouge lateral position for bulky tumors of the distal esophagus and in the neck is minimally (if any) longer than for an for salvage surgery when neoadjuvant therapy has failed to anastomosis at the apex of the thorax. The direct visualization of both chest been toward anastomosis in the neck, with experience an and abdomen is a great advantage for this palliative surgery, intrathoracic anastomosis is no more difficult in minimally and anastomosis in the chest is easily accomplished. As the incidence of anastomotic failure of intrathoracic anas- tomoses has been reduced to an uncommon event, the previ- Carcinoma of the Middle ous arguments about safety have lost their force. As already mentioned, the use of agus is subtotal resection following full mobilization of the the combined or semi-mechanical anastomosis in the neck stomach. The anastomosis should be con- for the back of the anastomosis and sutures for the front, cer- structed with an end-to-side or side-to-side technique at the vical leaks are more likely to remain localized or drain ante- apex of the right chest or in the neck. If it does not drain exteriorly, a cervical leak can track at the apex of the chest usually provides at least as much caudad and cause thoracic mediastinitis. The success often caused strictures that require dilation and can be diffi- rate of cervical anastomoses has been improved by the cult to manage with circular anastomoses, but the problem development of the semi-mechanical technique of anasto- seems less common with the combined technique. The same considerations of anastomosis has improved neither local recurrence nor long- blood supply and lack of tension apply. The tumor must be staged as completely as possible with radiation and chemotherapy and then reevaluated for prior to operation to ensure resectability because the surgeon surgical treatment after completing the course of neoadjuvant cannot assess local fixation until after completion of the therapy. For patients with significant invasion beyond the abdominal mobilization if the thoracic phase is done second. Doing the thoracic mobilization first has the advan- for palliation or even with curative intent after such tage of evaluating the local condition early in the operation, treatment. It is doubtful that thoracotomy so the substantial increase in operating time is heroic measures can prove more beneficial than a palliative not an issue. Distant approach only for mid-esophageal lesions that are clearly metastases are not a contraindication to palliative resection confined to the wall of the esophagus to avoid injury to major of a locally resectable tumor, but they do preclude cure at the vessels and the trachea. The patient’s condition and the gus is not as feasible in the mid- and upper esophagus as it is potential benefit must be carefully weighed when deciding in the lower third and cardia because of the adjacent respira- whether to resect for palliation. For such a patient, the mosis when the location of the tumor permits rather than ability to swallow can significantly enhance the quality of using a cervical anastomosis on principle in open surgery. A palliative resection can be accomplished during a The amount of esophagus resected with an anastomosis short hospitalization in appropriately selected patients. Restoration of continuity to the esophagus or pharynx tion of obstruction caused by an unresectable carcinoma, the is straightforward and requires only a single anastomosis. The tial antireflux “fundoplication” by wrapping or “ink welling” development of new techniques including endoscopic treat- the anastomosis help decrease the amount of reflux, all ment with dilators, lasers, and stents provides a much more patients with an esophagogastrostomy have abnormal gas- acceptable means of palliation. Significantly symptomatic reflux, how- ever, is seen primarily with low anastomoses and rarely with higher anastomoses. Deprived of vagal innervation, the Carcinoma of the Esophagus: Transhiatal stomach is only a passive conduit, but its function is usually or Transthoracic Approach satisfactory. High anastomoses (in the neck or apex of the pleural space) help minimize the amount of reflux. I believe Each approach to resection of esophageal cancers has had this improvement is on a purely mechanical basis. Each also has advantages and disadvan- plete vagotomy that occurs as part of an esophageal resection tages, and no series has demonstrated a clear superiority of makes acid secretion minimal. Although the left-sided approach I favor long, thin gastric tube helps minimize pooling in the intra- for certain distal lesions has been widely accepted, some thoracic stomach and facilitates emptying, thereby decreas- have reported excessive mortality and leak rates. When the stomach is available, not had this experience, and others have also noted exceed- we have used it preferentially and reserved intestinal interpo- ingly low mortality and complication rates. With a large expe- The use of the jejunum or colon to replace a resected seg- rience, Orringer and John (2008) results with transhiatal ment of esophagus preserves a functioning stomach intact. The minimally invasive and minimally Although less used today than previously, colon or jejunal invasive-assisted approaches are rapidly gaining adherents interposition is an essential technique if the stomach is dis- after the pioneering work by many surgeons around the eased or was previously resected. Most of the benign stric- world who championed the approach and demonstrated its tures formerly treated by short-segment colon interposition equivalency and perhaps superiority. The colon is easily interest in the use of robotic-assisted surgery, but it has yet to mobilized and can be supported on one of several major vas- prove itself. The transverse and Each operative approach requires knowledge of the anat- descending colon based on the ascending branches of the left omy, appropriate staging and preparation of the patient, a colic artery in isoperistaltic position is the appropriate size well-orchestrated team approach in the operating room and and length for substernal or intrathoracic interposition. The afterward with meticulous and delicate surgical technique, arterial supply of that segment is reliable and the venous careful anesthetic technique and monitoring, and devoted pedicle short and less prone to kinking or twisting.

The patient may fear cancer and the discharge itself causes annoyance and social embarrassment purchase 150mg ranitidine with amex. In the history the patient should be questioned whether the discharge is unilateral or bilateral buy ranitidine toronto, whether it is associated with a lump or not buy ranitidine line, or whether the discharge is blood stained or not order generic ranitidine. On inspection, one may detect the duct or ducts from where the discharge is coming out. Excessive crusting may occasionally be seen on the nipple which is nothing but dried product of secretion. On palpation, the whole breast is examined with particular attention towards the subareolar region. On mammography the most important feature to be noticed is the intraductal microcalcification of carcinoma in situ. In neonates a milky nipple discharge may occur transiently due to transplacental passage of luteal hormones from the mother’s circulation. It may be seen at menarche and menopause and even may occur years after cessation of breast feeding. In these physiological circum­ stances simple reassurance is all that is required. Hyperprolactinaemia due to a prolactin-secreting tumour or from a secondary source of bronchogenic carcinoma may cause galactorrhoea. Fibrocystic disease or cystic mastopathy typically produces multiple-duct discharge and is another commonly associated disease. It must be remembered that multiple papillomas particularly occurring in the periphery of the breast involving more than one duct carry an increased risk of malignant change. These peripheral lesions are more likely to cause a breast mass than nipple discharge. After thorough investigations if no cause can be found out simple reassurance is enough for serous or watery or non­ blood-stained discharges. If the discharge is blood-stained, it should be assumed that the cause is there, but not detected. Though the ductal system of the breast is continuously secreting fluid under normal circumstances, yet it is uncommon for women to notice any discharge through the nipple. Only in extremely rare cases due to excessive physiological activity nipple discharge may be noticed in the second phase of menstrual cycle. Lactation may continue for months or years after suckling if the patient continues to express milk because she thinks this should be done. Drugs including the contraceptive pills may occasionally lead to slight discharge of milk perhaps through pituitary prolactin mechanism. Milk discharge may be seen in case of milk fistula following chronic subareolar mastitis. Serous discharge may be seen in cases of fibroadenosis and mammary duct ectasia, though greenish-black discharge is more common in fibroadenosis and thick creamy discharge is more often seen in mammary duct ectasia. Duct papilloma and non-infiltrating duct carcinoma may produce serous discharge in the intervals of bloody discharge. Non-infiltrating or infiltrating type of duct carcinoma may cause blood stained discharge which are more commonly seen after the age of 50 years. Similar coloured fluid can also be obtained from cyst aspiration in similar cases. Serous, brownish or even greenish discharge may also be found in mammary duct ectasia. But if the discharge continues and is proving intolerable, microdochectomy should be performed. When the duct cannot be located, cone excision of the major ducts (Hadfield’s operation) should be performed. Galactorrhoea if caused by mechanical stimulation and ingestion of the drugs, these should be stopped. In other cases prolactin level should be detected and if the level is normal, simple reassurance should be given. If it is due to prolactin-secreting tumour or from bronchogenic carcinoma these should be treated. So it is the treatment of choice in case of young women with single duct discharge. A stiff nylon suture or a fine probe is inserted into the duct from which the discharge is coming out and is fixed to the skin of the nipple with fine silk stitches. With a pair of fine-pointed scissors a triangular area is cut 1 mm away from the point of entry of the stiff nylon. With fine-pointed scissors the breast tissue alongwith the duct is dissected off to reach the depth. The specimen of duct alongwith the triangular skin is removed intact including the stiff nylon. With blunt dissection a plane of cleavage is dissected circumferentially around the terminal lactiferous ducts. Once the ducts are dissected out they are divided close to the nipple and are removed with a conical wedge of tissue with long axis of 2 to 4 cm and with the base of 1 to 2 cm of the subareolar tissue. Any opened ducts are closed by ligature and the cavity in the breast substance is obliterated with deep sutures. The wound is closed with 3/0 subcuticular dexon suture with a small vaccuum drain. Nipple inversion means congenital failure of eversion of nipple during development. Nipple retraction means a secondary process in which the nipple is retracted, which was normal before. This does not always interfere with the breast feeding, as the infant creates a ‘teat’ from the surrounding breast tissue. With this condition there is a chance of higher incidence of duct ectasia and periductal mastitis. The only surgical way of everting the nipple is to divide all the underlying ducts. Furthermore even after such cosmetic surgery the nipples often take flattened appearance rather than being protuberant. In the early stage it is possible to do digital eversion, though at later stage it becomes more and more difficult. Other features of duct ectasia such as nipple discharge and periareolar abscess may be present. In case of carcinoma associated with nipple retraction, the case should be treated according to the type of breast carcinoma. To prevent cracked nipple the areola and the nipple should be washed, dried and lubricated with lanolin during last 2 months of pregnancy and during lactation. If such precautionary measure has not been taken and the nipple is cracked during lactation, no breast feeding should be allowed through the involved nipple and breast pump should be used to empty the breast. The cracked nipple is treated with antibiotic ointment and feeding is only resumed when the condition is cured. It usually occurs either from the syphilitic buccal ulcer in the mouth of the partner or from a syphilitic baby. But in case of the latter, the wet nurse is usually involved and not the mother, as the mother is immune to reinfection from her own child. It is almost an acceptable fact that there is some relationship between excess oestrogen level and fibroadenoma. The gross appearance is characteristic with smooth boundaries and the cut surface is glistening white. Blacks have greater propensity than whites to develop fibroadenomas and at a younger age. This lesion invariably has a relationship to oestrogen sensitivity and it occurs predominantly in the 2nd and 3rd decades of life. Other variants of fibroadenoma are characterised by increased cellularity of the stroma and/or epithelium. These typically occur in adolescence and bear resemblance to benign phyllodes (leaf-like) tumours.

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Occasionally the infection may go up to abscess formation and discharge of pus may occur through the scrotal skin safe 300mg ranitidine. It must be remembered that acute epididymo-orchitis often follows prostatectomy and urethral instrumentation cheap ranitidine online master card. It is particularly common when there is an indwelling catheter with associated infection of the prostate 300mg ranitidine overnight delivery. In case of indwelling catheter order generic ranitidine, closed drainage often reduce the incidence of epididymo- orchitis alongwith early use of antibiotics. In early stage swollen and tender epididymis can be separated from the testis, but later on both testis and epididymis become one mass with great tenderness. Two conditions should be kept in mind when one comes across a case of acute epididymo-orchitis. Firstly it may develop from mumps in about 18% of males suffering from mumps when the partial swelling of parotids is getting reduced. The main problem in this condition is that it may cause testicular atrophy, which if occurs on both sides may even lead to infertility. It must be remembered that epididymitis may even occur in mumps in absence of parotitis particularly in infanis. Another condition — acute tuberculous epididymitis may occur in rare cases when it does not respond to antibiotics and the vas becomes thickened. Finally epididymo-orchitis may be involved by infections with other enteroviruses, brucellosis and lymphogranuloma venereum. Culture for urinary infection, scan and ultrasound of the scrotum may help in the diagnosis. A previous history of prostatectomy and long term urethral catheterisation give hint to the diagnosis. Doxycycline 100 mg daily is particularly effective in young individuals with Chlamydial infection. If any organism can be isolated from urine, it should be cultured and tested for sensitivity to chose the right antibiotic. Otherwise broad spectrum antibiotics with ampicillin, tetracycline or aminoglycocides may be tried. Only if abscess has been formed, surgical intervention is required in the form of drainage. Vasectomy may be considered if acute epididymis is of retrograde type following prostatectomy or prolonged use of intraurethral catheter. Gradually the whole epididymis is involved but the testis remains almost unaffected. Gradually cold abscess develops in the epididymis and may burst in the posterior aspect of the scrotum to cause sinuses in the scrotum. Chest radiography and intravenous urogram may indicate tuberculosis of the lungs and renal tuberculosis respectively. It must be remembered that antitubercular drugs are less effective in genital tuberculosis. So if resolution does not occur after a full course of antitubercular chemotherapy, epididymectomy and even orchidectomy should be advised. Chronic non-tuberculous epididymitis does occur following failure to resolve the acute epididymo- orchitis. The diagnosis is difficult, but in this case the swelling is larger and smoother and the testis is also very much involved. It is always essential in this case to exclude urethral stricture causing reflux of urine along the vas deferens to involve the epididymis. If there is no resolution after 6 weeks one may consider epididymectomy or orchidectomy. Three varieties can be recognized — • Interstitial fibrosis causing painless destruction of the testis. The testis feels harder and heavy and becomes difficult to differentiate from tumour of the testis. Prehn’s sign is important in this respect — the scrotum is gently lifted up towards symphysis pubis. This will relieve pain in acute epididymo-orchitis and increase pain in torsion of testis. In both these conditions early exposure is required if any doubt exists about diagnosis. Secondary hydrocele — when hydrocele is secondary to a disease in the testis and/or in the epididymis. In this condition there is abnormal accumulation of serous fluid within the tunica vaginalis. The possible reasons are: (a) Defective absorption of hydrocele fluid by the tunica vaginalis — this is said to be the most common cause though the reason is still obscure. Damage to the endothelial wall by low grade infection is the most probable explanation. It contains water, inorganic salts, 6% of albumin and some fibrinogen and in old- standing cases variable amount of cholesterol and tyrosine crystals. Due to the presence of fibrinogen, the hydrocele fluid, when comes in contact with blood, clots firmly. Occasionally patient does not seek advise till the sac has attained enormous size. In case of secondary hydrocele when it is lax the testis may be palpable through the fluid. It is better to perform operation on both the sides even for unilateral cases, as there is predilection for hydrocele to develop on both sides one after the other. In this case incision is deepened till the tunica vaginalis of one side is approached. Now the other side is approached through the same incision and the incision is deepened till the tunica vaginalis of the other side is reached. For this purpose a transverse elliptical incision is made round the lower part of the scrotum. The skin and dartos muscle distal to the incision are removed and after the operation the proximal margin of the incision is closed by interrupted sutures. When the spermatic cord is reached the testis with the tunicavaginalis is pulled up through the inguinal incision. As soon as the tunica vaginalis is reached, the vaginal sac is separated from the rest of the scrotal wall by a finger. The sac is held in one hand and with another hand the tunica vaginalis is incised. The two margins of the incision are held with two pairs of artery forceps and held upwards. The incision is extended upwards and downwards to allow the testis to come out through this opening. The testis is brought out through the opening and the two margins of the tunica vaginalis are sutured behind the testis, so that the secreting surface of the tunica vaginalis will be lying outside. After dressing the wound, the patient should be instructed to wear suspensory bandage. The steps of operation upto opening of the tunica vaginalis are same as those ofthe previous operation. The tunica vaginalis is now sutured with 10 to 12 catgut or Dexon sutures from the outedge of the tunica to the reflection of the tunica from the testis and the epididymis. When these sutures are tied, the whole tunica is bunched at the edge of the testis. The whole of the sac of the tunica vaginalis is excised leaving a margin of Vz inch by the side of the testis and epididymis. Bleeding from the cut margin is always considerable and is controlled either by continuous mattress suture or with diathermy. This operation is particularly indicated in case of: (i) Haematocele; (ii) Infected sac. Subtotal excision is indicated in bigger hydroceles, where the incision is made in a circular fashion at the middle of the scrotum. The tunica vaginalis is now separated from the remaining scrotal wall and subtotal excision of the tunica vaginalis is made.

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