By F. Gelford. Lee University.

The sutures are now held tight so that the pelvic colon is pushed down till its posterior edge comes in contact with the rectum generic 100 mcg thyroxine with amex. The anterior layer is also sutured using interrupted all-coat vertical mattress stitches buy thyroxine 125 mcg with visa. The lower cut end of the rectum is tied with a purse string suture as tightly as possible around the shaft of the instrument above the cartridge purchase thyroxine with a mastercard. The pelvic colon is now manipulated over the top of the anvil and is also tied with a purse string suture as tightly as possible. Care must be taken to see that no other structure is being caught between the anvil and the cartridge even the appendices epiploicae. It must be remembered that the stapler removes an extra 8 mm of rectum and this must be kept in mind while estimating the distal clearance below the tumour. If there is break in the circumference it should be repaired with interrupted sutures. A drain is inserted through a stab wound at the left iliac fossa into the presacral space down the lateral side of the peritoneum. To prevent spillage of cancer cells into the remnant of the rectum and anal canal, one can wash this part with 1 : 500 perchloride of mercury. The operative technique is almost the same as the standard procedure, which is performed through the abdomen using various ports according to the choice of the surgeon. After anterior resection, the anastomosis is a rather difficult task and mostly performed intraperitoneally using a modified circular stapling gun. Nowadays reports are coming up where laparoscopic anastomosis are being performed below the peritoneal reflection. The problem of efficacy of this procedure remains as there is risk of implanting of cancer cells. If the lesion is within 8 cm of the anus an additional 500 rads may be given through the perineal route. Intracavitary radiotherapy may be administered directly through a sigmoidoscope like device. Electrocoagulation and intracavitary irradiations may be considered as curative therapy for early and well differentiated cancers. A variety of drugs has been tried both as an adjuvant therapy and for the treatment of disseminated disease. Such adjuvant therapy should prevent formation of metastasis following operative manipulation of the tumour. Initial results are encouraging to reduce the incidence of metastasis subsequently and to prolong survival. The 3 drug regimen (5-Fu + levamisole + leucovorin) is more toxic with no superior effect on survival. Various monoclonal antibodies to carcinoembryonic antigen have been used to destroy the cancerous cells. These antibodies are also conjugated to cancericidal agents to have the same effect. But these antibodies are not sufficiently specific and they also damage normal tissues. Immune therapies with agents such as interferon-aIpha-2a, monoclonal antibody 17-1A and autologus tumour vaccines can further improve survival. Pelvic evisceration (Brunschwig’s operation)—the patient is in lithotomy-Trendelenburg position. All the pelvic viscera together with internal iliac and obturator group of lymph nodes are removed. In these centres resectability rate is as high as 95% and operative mortality is less than 5%. One point should arouse interest that with the more frequent use of sphincter- saving resection compared with abdominoperineal excision, survival has not been affected. In such cases, the emergency treatment requires formation of a stoma either to decompress the colon prior to definite surgery or as part of Hartmann’s operation. In these cases, the patient requires a second operation to restore interstinal continuity. The patients can then undergo elective surgery when fully resuscitated and prepared. It usually remains in the submucous coat and the mucous mem­ brane over it remains intact. Though carcinoid tumour here is less common than in small intestine and appendix, yet one should always keep in mind this tumour when an abnor­ mal tumour in rectum is come across. Incidence of malignancy is about 10% and it is more than appendicular carcinoid tumour but much less than carcinoid tumour of small intestine. This abnormality can be broadly classified into the low anomaly and high anomaly depending on whether the termination of the bowel is below or above the pelvic floor respectively. A thin track runs forward under cover of that skin so that the anal opening is somewhere in front at the perineal raphe. The treatment is to open the track with scissors upto the normal position of the anus followed by regular dilatation of the anus. In this case the anal canal is nonnally developed but a thick skin covers the normal anal opening. Treatment is mobilisation of the rectum, an opening is made through the pelvic floor and end-to-end anastomo­ sis is performed with the anal canal. The rectum ends above the pelvic floor and is usually connected with the bladder or with the posterior fornix of the vagina through fistulous communication. In this condition the hind gut, urinary bladder and genital tract all open into a common wide cavity. On examination in high anomalies there is no proper anal canal in anorectal agenesis. Particularly in the female there may not be any intestinal obstruction as meconium is passing through the vagina. On careful examination one can find out the variety of anomaly which is present in this particular case. With a metal button or a coin strapped at the site of the anus or a metal bougie inserted into the blind anal canal the infant is held upside down. By that time gas will reach the end of the rectum and one can see the distance between the end of the gas shadow and the metal indicator. The only fallacy is that a plug of meconium in the rectum may show an increased gap between these two. It must be remembered that one has to wait till the rectal gas appears and sometimes it takes about a day or more for rectal gas to appear. If the intestinal obstruction is the main feature a preliminary transverse colostomy may be performed. Otherwise treatment of such anomaly can be done in the one stage as the infant can tolerate operation quite well. A passage is made exactly in the midline between the two halves of the pelvic foor.

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The heart is in fact is confined in a rigid inelastic case preventing it from its proper functioning purchase 200 mcg thyroxine with mastercard. The pathological effect of this condition is that it prevents ventricles from proper filling in diastole 125mcg thyroxine visa. There is corresponding increase in right atrial pressure and right ventricular diastolic pressure buy genuine thyroxine. This venous hypertension may produce peripheral oedema, hepatic enlargement and ascites. Gradually the patient complains of oedematous swelling of the feet and abdominal enlargement due to ascites. On examination, peripheral oedema, enlargement of liver and ascites should be detected. The pulse pressure is normally decreased and a paradoxic pulse is found in a small percentage of cases. The patient is prepared with diuretics and aspirations of pleural or ascitic fluid. The constricting pericardium should be removed from the entire heart, although removal of pericardium from the ventricles may relieve the diseased condition. It is always the technique to free the left ventricle first to prevent pulmonary congestion. It is sometimes difficult to remove the adherent pericardium from the diaphragmatic part of the ventricle. Removal of pericardium from the atria and vena cava is physiologically less important, though it should be done. The risk of operation varies with the age of the patient and the severity of the case. Pericardiotomy or pericardial biopsy may be required for establishing the cause of pericardial disease. Post pericardiotomy syndrome is sometimes come across in 10 to 40% of cases by the appearance of fever, pericarditis and pleuritis. It begins at the lower border of the pharynx which is situated opposite 6th cervical vertebra or at the lower border of the cricoid cartilage. It descends through superior and posterior mediastinum and ends at the cardiac orifice of the stomach at level of the 11th thoracic vertebra. It descends vertically almost through midline but presents two slight curves to the left. At the commencement it is placed in the midline, as it descends downwards it slightly inclines to the left upto the root of the neck. It again moves towards the midline as it descends downwards and reaches the midline at the 5th thoracic vertebra. It follows the midline course till the 7th thoracic vertebra when again it gradually shifts to the left till it passes through the oesophageal orifice of the diaphragm at the level of the 10th thoracic vertebra. The oesophagus also presents anteroposterior curvatures following the curvature of the cervical and thoracic portions of the vertebral column. During its course it is constricted at 4 places — (i) at its commencement, 6 inches from the incisor teeth, which is the narrowest point in the gastointestinal tract measuring 14 mm in diameter, (ii) where it is crossed by the aortic arch, 9 inches from the incisor teeth; (iii) where it is crossed by the left main bronchus, 11 inches from the incisors and (iv) where it crosses the diaphragm (the diameter is about 16 to 18 mm), about 16 inches from the incisors. The uppermost constriction is the most vulnerable part and a common site of perforation during oesophagoscopy. The cervical part is about 5 to 6 cm in length and ends at the lower border of the 1st thoracic vertebra, where it is continuous with the thoracic part. The cervical part of the oesophagus is in close relation with the trachea and the recurrent laryngeal nerve on each side anteriorly; the vertebral column, prevertebral muscles and the prevertebral layer of the deep cervical fascia posteriorly; the common carotid artery and the posterior part of the lobe of the thyroid gland on each side. The thoracic part of the oesophagus is at first situated in the superior mediastinum between the trachea and the vertebral column. Then it passes behind and to the right of the aortic arch and descends into the posterior mediastinum along the right side of the descending thoracic aorta. After the 7th thoracic vertebra it inclines to the left and crosses in front of the aorta to enter the orifice in the diaphragm meant for it at the level of the 10th thoracic vertebra to commence the abdominal part. It is in relation, anteriorly (from above downwards) with the trachea, right pulmonary artery, the left main bronchus and the pericardium. Posteriorly it is in relation with vertebral column, the longus colli muscles, the right posterior intercostal arteries, the thoracic duct, the azygos veins, terminal parts of the hemiazygos and accessory hemiazygos veins and in the lower part the thoracic aorta. On the left side the aortic arch, the left subclavian artery, the thoracic duct and the left pleura and the left recurrent laryngeal nerve runs upwards in the groove between it and the trachea to come in relation with the oesophagus in the superior mediastinum; whereas in the posterior mediastinum the oesophagus is in relation with descending thoracic aort i and the left pleura. On the right side the oesophagus is related to the right pleura and the azygos vein while it arches forwards to join the superior vena cava. The abdominal part of the oesophagus is in direct relation with the oesophageal groove on the posterior surface on the left lobe of the liver. This part of the oesophagus is directly related to the left crus of the diaphragm and the left inferior phrenic artery posteriorly. The left vagus nerve lies on the anterior wall of the oesophagus while the right vagus nerve lies on the posterior wall of the oesophagus. The diaphragmatic oesophageal hiatus is elliptical in shape and is formed by the splitting of the medial fibres of the right crus. It transmits the oesophagus, the vagus nerve and the oesophageal branches of the left gastric artery. The fascia on the undersurface of the diaphragm is continuous with the transversalis fascia and is particularly rich in elastic fibres in this area. This fascia extends upwards through the oesophageal hiatus in a conical fashion to be attached to the wall of the oesophagus slightly above this hiatus. Some of its elastic fibres penetrate through the muscle coat of the oesophagus and reach the submucosa. This ligament permits some mobility during the movements of swallowing and respiration, but at the same timelimits upwards displacement of the oesophagus. It should better be called phreno-oesophageal membrane as it does not contain the strong fibrous bands to be qualified for the term ‘ligament’. The precise location of the junction of the oesophagus and stomach is controversial. These are—(i) where the oesophageal squamous epithelium turns into gastric columnar epithelium. But unfortunately the distal part of the oesophagus often contains columnar epithelium, (ii) It is the junction where the tubular oesophagus joins the gastric pouch. Of course endoscopically the gastro-oesophageal junction is identified by the presence of columnar red epithelium. The longitudinal muscles from a complete investment for nearly whole of oesophagus except the posterior portion of the upper most 3 or 4 cm, before which the longitudinal muscles diverge away from the median plane forming two longitudinal muscular fasciculi which incline upwards and forwards to the front of the tube and pass deep to the inferior constrictor muscle to be attached to the upper part of the ridge on the posterior surface of the lamina of the cricoid cartilage. Circular muscle fibres are continuous superiorly with the inferior constrictormuscle posteriorly and with the two longitudinal fasciculi anteriorly.

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In advanced cases chest x-ray may show 1- to 2-cm cysts and crowding of the bronchi (tram-tracking) order generic thyroxine line. Bronchodilators 25 mcg thyroxine for sale, chest physical therapy buy generic thyroxine 100 mcg online, 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. History is of primary importance in assessing possible occupational lung diseases. Alveolar macrophages engulf offending agents, causing inflammation and fibrosis of the lung parenchyma in pneumoconiosis. Signs and symptoms include dyspnea, shortness of breath, cough, sputum production, cor pulmonale, and clubbing. Asbestosis Asbestosis is an occupational lung disease caused by prolonged inhalation of asbestos dust. Asbestos fiber exposure may be seen in mining, milling, foundry work, shipyards, or the application of asbestos products to pipes, brake linings, insulation, and boilers. Signs and symptoms include exertional dyspnea and reduced exercise tolerance, cough and wheezing (especially among smokers), chest wall pain, and ultimately respiratory failure. On chest x-ray, diffuse or local pleural thickening, pleural plaques, and calcifications at the level of the diaphragm are seen. Pleural effusions are commonly seen, and the interstitial lung process associated with asbestosis usually involves the lower lung fields. The most common cancer associated with asbestosis is bronchogenic carcinoma (adenocarcinoma or squamous cell carcinoma). Pleural or peritoneal mesotheliomas are also associated with asbestos exposure but are not as common as bronchogenic cancer. For diagnosis, a lung biopsy is usually needed; the classic barbell-shaped asbestos fiber is found. Patients with asbestos exposure should strongly be advised to stop smoking since their risk of lung cancer is 75 times higher than that of the normal population. Silicosis Silicosis is an occupational lung disease caused by inhalation of silica dust. It is seen in individuals who work in mining, quarrying, tunneling, glass and pottery making, and sandblasting. Silicosis causes similar symptoms to asbestosis (or any other pneumoconiosis) except the acute form of silicosis, which is caused by massive exposure that causes lung failure in months. Silica causes inflammatory reactions with pathologic lesions being the hyaline nodule. In silicosis there are nodules (1–10 mm) seen throughout the lungs that are most prominent in the upper lobes. In progressive massive fibrosis, densities are 10 mm or more and coalesce in large masses. Patients clinically present as they would with any other occupational lung disease.

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