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Both obstruction and pancre- the portal vein to the superior mesenteric vein is possible atitis produce thickening of the pancreatic duct and the pan- when the segment to be resected is short generic 2 mg ginette-35 visa women's health clinic quesnel. Ligating the portal vein is often fatal unless the supe- walled duct to the jejunum produces a high failure rate safe ginette-35 2 mg women's health bendigo. If the patient Avoiding Postoperative Hemorrhage has a soft pancreas and a pancreatic duct that is not markedly enlarged ginette-35 2mg discount womens health subscription, do not try to construct a duct-to-mucosa anastomo- Postoperative hemorrhage is a preventable and potentially sis. It stems from one of four major causes: (1) of the jejunum for a depth of at least 2 cm with two layers of gastric stress ulcers or gastritis, (2) marginal ulcer, (3) diges- sutures, as described later in the chapter. When the remain- tion of the retroperitoneal blood vessels by combined leakage ing pancreas is thickened with ﬁbrosis and the duct has been of both bile and pancreatic juice, or (4) inadequate ligature of markedly enlarged by the chronic obstruction, careful con- the innumerable blood vessels divided during surgery. Rossi common hepatic artery arose from the superior mesenteric and Braasch insert a small catheter into the pancreatic duct in and passed through the head of the pancreas on its way to the most patients and then lead the catheter through a puncture liver; in this case pancreaticoduodenectomy necessitates wound in the wall of the jejunum and out through the abdom- dividing and ligating this vessel. The adequacy of the col- inal wall to drain the pancreatic secretions away from the lateral circulation determines the effect on hepatic perfusion healing anastomosis into a drainage bag. Proper anatomic dissection of the superior mesenteric If leakage of pancreatic juice occurs, it is important to vessels away from the superior uncinate process with alert have adequate drains in the area of the anastomosis. Leakage palpation of the posterior pancreas allows the surgeon to of pure pancreatic juice that has not been activated does not identify this anomaly if it is not demonstrated on preopera- damage the surrounding tissues, and the pancreatocutaneous tive studies. On the other hand, if leakage from the pancreaticoje- junostomy is accompanied by simultaneous seepage of bile Documentation Basics into the same region, the pancreatic enzymes become acti- vated and begin to digest the surrounding retroperitoneal tis- • Findings sues, leading to sepsis and bleeding—complications that • Pylorus sparing or not? Consequently, make every attempt to divert the ﬂow of bile from the area of the pancreaticojejunostomy, Operative Technique allowing an adequate length of jejunum to separate these anastomoses. This may help prevent the bile from reﬂuxing Standard pancreaticoduodenectomy up into the pancreatojejunal anastomosis. Incision Treating a Pancreatic Fistula by Removing the Pancreatic Stump Make a midline incision from the xiphoid to a point 10 cm below the umbilicus. In stocky patients with a broad subcos- When a patient suffers a pancreatocutaneous ﬁstula that tal arch, a bilateral subcostal incision is an excellent leaks clear pancreatic juice, only expectant therapy is neces- alternative. If the clear, watery secretion turns green after a few days, indicating bile admixture, the situation is much more Evaluation of Pathology: Conﬁrmation serious. A major leak of bile and pancreatic juice is associ- of Malignancy ated with a high mortality rate. Under certain hemostats to expose the anterior surface of the pancreatic conditions converting the Whipple operation to a total pan- head (Fig. If a stony-hard area of tumor is visible on createctomy constitutes a lifesaving operation. Trede and the anterior or posterior surface of the pancreas, shave the sur- Schwall reported success with this reoperation. Use a 10 ml syringe contain- Avoiding Trauma to an Anomalous Hepatic ing 4–5 ml of air. Aspirate and then expel the sample on a Artery Arising from the Superior Mesenteric sterile slide, spray the slide promptly with a ﬁxation solution, Artery and submit the slide for immediate cytologic study. About 18–20 % of individuals have an anomaly in which the If the results are not conﬁrmatory for cancer, perform a common hepatic artery or right hepatic artery arises from the biopsy by passing a cutting biopsy needle through both walls superior mesenteric artery, generally running posterior to the of the duodenum on its way to the pancreas. In 1 % of the cases in the anatomic study, the sion and scrape the region of the suspected malignancy. Divide the lateral duodenal ligament to the point where the superior mesenteric vein crosses the Fig. Avoid excessive upward traction on the duodenum and pancreas, as it may tear the superior mesenteric vein. Choledochoscopy is an excellent means for obtaining a If the head of the pancreas is replaced by a relatively biopsy of common duct tumors. If a tumor is palpable in the bulky tumor, it may be difﬁcult to expose the superior mes- region of the ampulla, make a longitudinal or oblique duode- enteric vein. In such cases, after dividing the omentum to notomy incision over the mass and excise a sample under expose the anterior surface of the pancreas, identify the mid- direct vision. Discard all instru- dle colic vein and trace it to its junction with the superior ments that have come into contact with the tumor during the mesenteric vein (Fig.
If the service of experienced radiotherapist is available ginette-35 2 mg with mastercard pregnancy lower back pain, this treatment may be tried first order online ginette-35 women's health center university of maryland. There is proliferation and heaping up of the cornified epithelium with the formation of milk-white patches generic 2mg ginette-35 with visa breast cancer 5k columbia sc. This condition may occur anywhere in the mouth, but most commonly seen on the tongue. Leukoplakia are now more often involving the lips and occasionally the cheek, gum and palate. Leukoplakia may be seen in other places such as the larynx, glans penis, vulva and the perianal region. Here we shall discuss the leukoplakia on the tongue or chronic superficial glossitis. The surface may become fissured and cracked due to contraction of the underlying scarred tissue caused by chronic inflammation. Macroscopically, the affected area of the tongue shows milk-white patches with cracks and fissures. In course of time atrophy tends to succeed hypertrophy, the thickened papillae disappear and the white membrane is worn off. Microscopically, the epidermis is greatly thickened and shows excessive comification. The prickle cell layer hypertrophies and swollen cells with nuclei reach the surface (parakeratosis). The underlying tissue is infiltrated with chronic inflammatory cells of the small round type to be replaced later by fibrous tissue. The practical importance of leukoplakia is the danger of its developing into carcinoma. Desquamation also appears simulta neously which leaves areas of smooth red and shiny tongue. Appearance of ‘warty excrescences’ or small lump should arouse suspicion and these portions should be excised and examined histologically. It does improve the condition initially, but it increases the chance of malignancy. Moreover, to add more problem such malignant lesions become resistant to further radiotherapy. Aphthous (dyspeptic) ulcer — is a small painful ulcer seen on the tip, undersurface and sides of the tongue in its anterior part. The ulcer is small, superficial with white floor, yellowish border and surrounded by a hyperaemic zone. Dental ulcer — is caused by mechanical irritation either by a jagged tooth or denture. These ulcers occur at the periphery or on the undersurface of the tongue at the sides. It often presents a slough at its base and surrounded by a zone of erythema and induration. The syphilitic conditions which are more often seen in the tongue are the gumma and chronic superficial glossitis. Such ulcers are shallow, often multiple and greyish yellow with slightly red undermining margin. It is usually seen at the upper part of frenum linguae and in the undersurface of the tip. It is usually single, but may be multiple if superimposed on chronic superficial glossitis. These are discrete, hard and mobile in the early stage but become fixed to the underlying structures in late stages. Gradually vesicles appear which later on burst to form multiple superficial ulcers which are extremely painful. In this case the aetiology is mainly smoking and hence this ulcer is called ‘smoker’s ulcer’. These are — (i) Papilloma; (ii) Haemangioma; (iii) Lipoma; (iv) Lymphangioma; (v) Neurofibroma; (Vi) Lingual thyroid; (vii) Salivary gland tumour; (viii) Osteoma. Sometimes a hard swelling may be seen in the posterior third of the tongue just beneath the foramen caecum.