Alfred H. Stammers, MSA, CCP, PBMT

• Director of Perfusion Services
• Division of Cardiothoracic Surgery
• Geisinger Health Systems
• Danville, Pennsylvania

It is important to note that for all of these studies blood pressure chart runners cheap 50mg tenormin with visa, if the bowel lumen is not completely distended heart attack las vegas 100 mg tenormin amex, the flattened loops could be mistaken for abscesses heart attack billy buy tenormin 50mg on-line, masses blood pressure chart pediatric order genuine tenormin online, strictures arteria gastroepiploica tenormin 50mg fast delivery, or thickened segments of bowel blood pressure chart related to age purchase genuine tenormin line. This allows for better evaluation of the wall of the small bowel, leading to higher accuracy in detection of inflammation associated with Crohn disease. This is an important consideration for patients who will have multiple imaging studies over their lifetime due to the chronic, recurrent nature of Crohn disease. Refinements in imaging modalities in the future will hopefully provide better ways for the clinician to determine the degree of active inflammation versus chronic scar in patients with Crohn disease. As many as 50% of patients have active disease on biopsy despite lacking reported symptoms. The active phase of the disease is identified when inflammatory changes are present in the tissue. Active lesions begin as small, flat, soft aphthous ulcers with a pale, white center and surrounding erythema. These lesions deepen into transmural inflammatory lesions, leading to abscesses and fistulae. When the tissue heals and scars, strictures can form obstructive lesions at the site of previous inflammation. It is important to note that these lesions can coalescence into a continuous pattern similar to that seen with ulcerative colitis. In addition to the cobblestone appearance, other classic descriptions of intestinal lesions include bowel wall and mesenteric thickening, in some patients resulting in narrowing of the lumen. In addition, mesenteric thickening from fat thickening and enlarged lymph nodes are also common features of Crohn disease. The remission phase occurs after the inflammatory phase and is identified by healing and fibrosis of the previously inflamed tissue. The most common site of Crohn disease is the ileocecal area, with the majority of patients (80%) having some small bowel involvement. Approximately one-third of patients have disease confined to the small intestine, and 20% have disease confined to the colon. Patients are diagnosed with Crohn disease due to the presence of active symptoms; therefore the clinician must first treat the active disease in an attempt to achieve remission and then focus on finding a treatment that will maintain remission over the long term. Both of these scales can be simplified to identify four grades of disease: asymptomatic remission, mild to moderate Crohn disease, moderate to severe Crohn disease, and severe-fulminant disease (Table 75. Asymptomatic patients who require continued use of steroids are referred to as "steroid-dependent" and are not considered to be in remission. There are two distinct treatment strategies in treating patients with mild to moderate Crohn disease: the step-up approach and top-down approach. The step-up approach starts with the least potent therapies and moves on to more potent therapies if they are ineffective. The less potent therapies generally have fewer side effects; therefore this was traditionally how this disease was treated. Many patients now receive biologic and immunomodulator therapies before they are given glucocorticoids in an effort to avoid glucocorticoid dependence. Although steroids appear to be effective in the short term, some patients become intolerant to steroids due to serious side effects and others might see little or no improvement in their symptoms after multiple treatments (steroidresistant patients). Still other patients might become dependent on steroids, exhibiting disease flares when tapering off the drug. Due to its extensive first-pass liver metabolism, budesonide has less systemic steroidal effects compared with the standard oral corticosteroid, prednisone. However, this medication is effective only in up to 70% of patients and has been found to be less effective in patients with left-sided colonic disease. Although oral 5-aminosalicylates, including mesalamine and sulfasalazine, have historically been used to induce remission in patients with Crohn disease, studies evaluating their efficacy have produced mixed results. Experts agree that these medications are not very effective in maintaining remission, and there is disagreement on whether they are useful in inducing remission with active disease. Metronidazole and ciprofloxacin are the two most commonly used antibiotics currently. A trial comparing metronidazole to placebo found that it is superior in inducing remission77; however, its efficacy and safety compared with other agents has not been as positive. The use of these agents in patients with mild symptoms is recommended by some experts only as a second line therapy if there is concern for an undetected pathogen, bacterial overgrowth, or unsuspected microperforation that is contributing to active symptoms. Patients who fail to improve with the aforementioned treatments are categorized as having refractory Crohn disease and require more aggressive therapy with immunomodulators or biologic agents. In addition, patients who present with severe Crohn disease might warrant treatment with these more aggressive medical treatments early on in the disease course (top-down approach). Patients presenting with severe symptoms should first be hospitalized and provided intravenous glucocorticoids in addition to bowel rest, parenteral nutrition, and hydration. Immunomodulators used in Crohn disease include azathioprine, 6-mercaptopurine, and methotrexate. They are precursors to purine antimetabolites, which block proliferation of mitotically active lymphocytes. Multiple studies have proven the efficacy of these medications; however, their effect is reported to take 3 to 6 months. Side effects of both of these medications include bone marrow suppression, increased risk of infection, allergic reactions, and pancreatitis. It has been shown to be effective in inducing remission in Crohn disease compared with placebo and is used in patients who have resistance or intolerance to treatment with steroids and other immunomodulators. Side effects of methotrexate include liver toxicity and nausea; it is also a teratogen. The main biologic agents used in the treatment of Crohn disease in the United States include infliximab, adalimumab, and certolizumab pegol. Other biologic agents that are being developed and increasingly used in the treatment of Crohn disease include natalizumab, ustekinumab, and vedolizumab. Natalizumab is a humanized monoclonal antibody directed against 4 integrin; however, its side effect profile currently limits its use. This can be achieved with a variety of medications; however, it is important to consider the possible side effects of each of the medications from long-term use. Daily azathioprine and 6-mercaptopurine have proven efficacy in maintaining remission after medical induction compared with placebo. There are mixed results on the rates of relapse after withdrawal of these medications from no relapses over a 5-year period to a 2- to 3-fold increased relapse risk compared with continued therapy. This medication is given on a weekly basis, and patients should be assessed for risk of liver disease and desire to become pregnant prior to initiation of long-term therapy. Infusion centers should be equipped to deal with these potentially life threatening side effects. In addition, patients have been reported to develop resistance to infliximab infusions. Medical therapies that are not recommended for maintenance therapy include steroids and 5-aminosalicylates. Due to their long-term side effect profile, steroids are not recommended in maintaining remission of Crohn disease. Budesonide has been found to prolong the time to relapse; however, studies have shown that it is not effective for long-term maintenance beyond 6 months. When determining the right maintenance therapy for a given patient, the clinician must consider efficacy, adverse effects, and cost. The biologic agents are generally much more expensive than immunomodulator therapies; however, all of these therapies have toxicities. The goal of nutritional interventions in Crohn disease includes maximizing nutritional status, maintaining adequate intake, and avoiding foods that seem to contribute to flares of symptoms. The first step to determining the nutritional health of the patient is to perform a nutritional assessment. This assessment should include a focused history, physical exam, and measurement of dietary intake, energy expenditure, body composition, and serum studies. Malnutrition Malnutrition is common in patients with Crohn disease and can be related to reduced nutritional intake due to anorexia, abdominal pain and bowel obstructions, malabsorption, drug effects, and increased metabolic requirements including vitamin B 12 (cobalamin), calcium, fat-soluble vitamins, folate, iron, selenium, and zinc. In addition, patients with extensive terminal ileal disease or resection could suffer from fat malabsorption. Consequences of malnutrition in these patients are growth failure and pubertal delay in children, bone loss, delayed healing of fistulas and wounds, and increased susceptibility to infection. Nutrition supplementation with protein, calories, and micronutrients can be provided to patients through oral, enteral, or parenteral routes. In general, the most optimal way to provide nutrients to patients is by oral route, then enteral feeding, and finally parenteral routes due to complications associated with placement of feeding tubes and intravenous access. However, if patients are unable to tolerate oral feedings, nutrition should be provided by the available route. Total parenteral nutrition is expensive and has the greatest risk for complications; therefore its use should be limited to patients with bowel obstruction or high-output fistulas, with the goal of using it for limited time periods. Exceptions to this are patients with short-gut syndrome, who cannot achieve the caloric intake needed to support themselves by oral and enteral methods alone. Some studies have shown that preoperative parenteral nutrition can correct nutritional deficiencies and improve surgical outcomes; the utility of total parenteral nutrition in the preoperative setting is limited. Nutrition as Primary Therapy Many patients with Crohn disease can identify types of food that seem to precipitate flares of their disease. As such, many clinicians propose that patients undergo an elimination diet to identify other potential at risk foods that can be avoided long term. There is currently no convincing evidence that high-fiber diets, probiotics, omega-3 polyunsaturated fatty acids, glutamine supplementation, or antioxidants affect the disease course of patients with Crohn disease. As stated earlier, the majority of patients with Crohn disease have small bowel involvement; therefore surgeons caring for patients with Crohn disease should understand the indications for surgical intervention in small bowel Crohn disease and the techniques currently used to ensure that patients receive appropriate care (Box 75. The presence of adhesions, malnutrition, and medical therapy with immunosuppressive agents are factors that can impact surgical decision making, but most important is the understanding that Crohn disease is a chronic condition with high recurrence rates after surgery. The majority of patients with Crohn disease will need input from a surgeon who understands the nature of their disease. A cohort study of patients with Crohn disease found that 57% of patients require at least one surgical resection. Interestingly, a more historical cohort study found that 78% of patients required surgery by 20 years after symptom onset. The purpose of all operations is to treat the complications that cannot be treated by less invasive means (medical or endoscopic therapy). All operations should be performed with the goal of conserving as much small intestinal length as possible due to the potential for recurrence and need for reoperation. The number, length, and location of strictures should inform surgical decision making when considering stricturoplasty versus resection. All patients with high-grade small bowel obstruction should undergo decompression and resuscitation prior to surgical intervention. Contained perforations resulting in abscess formation are usually best addressed initially using interventional radiology drainage and systemic antibiotics, but subsequent surgical intervention is often required. Rates of medical therapy failure may be decreasing with the development of more effective biologic agents. Preoperative Preparation Thorough preoperative preparation is imperative to ensure the best outcome for patients presenting for surgical intervention in Crohn disease. Each patient should undergo a history and physical exam to assess for comorbid medical conditions. Appropriate ancillary testing should be performed prior to nonurgent surgical interventions to ensure appropriate risk stratification. Oral and enteral supplementation are the preferred routes to optimize nutrition prior to surgery; however, total parenteral nutrition can be helpful in severely malnourished patients. Patients who smoke should be counseled about smoking cessation to reduce their cardiovascular risk, as well as decrease their risk for disease recurrence after the operation. However, regardless of the preoperative testing results, the surgeon should examine the entire small intestine at the time of operation to ensure that no skip lesions are left untreated. In addition, it is useful to directly measure the amount of remaining small bowel in each patient since this may be important to future surgical decision making. It is important to note that all patients undergoing surgical interventions should be provided with adequate resuscitation, antibiotics (for treatment or prophylaxis), and thromboembolic prophylaxis. The impact of preoperative immunosuppressive drugs on surgical outcomes is controversial. Most of these medications can be safely discontinued prior to surgery without any side effects with the exception of corticosteroids. Patients on long-term corticosteroid therapy should be given preoperative stress-dose steroid coverage and should have their steroids gradually tapered postoperatively. For elective or less urgent operations, patients should meet with an enterostomal therapist to have stoma site markings placed and receive education on stoma care. Inappropriate stoma placement can make postoperative management difficult and in some cases increase the likelihood of leakage of bowel contents onto the peristomal skin and/or into the surgical wound. Surgical techniques for relieving these obstructive lesions are broadly classified as those involving bowel resection and those not involving resection. The fear of iatrogenic short bowel syndrome has led surgeons to develop techniques to spare the bowel in this clinical setting. This mindfulness for retaining bowel length has led to excellent outcomes, with only 5% of patients being left with less than 180 cm of residual intestine and only 1. In addition, the risk of disease recurrence appears to be unchanged in this technique compared with resection, which was a previous concern of many clinicians.

The standard approach to reconstructing an accessory right hepatic artery is to either attach the aberrant right vessel to the splenic or gastroduodenal artery off the celiac trunk or to put the aortic sides of the celiac and superior mesenteric artery stumps together to create a single inflow through the more distal superior mesenteric artery trunk arteria genus media order tenormin 50mg with amex. Because the superior mesenteric artery trunk is also used during pancreas transplantation pulse blood pressure monitor buy tenormin 100mg with amex, the finding of an aberrant right hepatic vessel during organ recovery may have implications for whether the pancreas can be successfully transplanted arrhythmia hyperkalemia discount tenormin 100 mg mastercard. Recovery teams and transplant teams should work jointly during the donor surgery to resolve these issues heart attack signs tenormin 100mg otc, but priority and final approval is typically given to the liver procurement blood pressure log printable buy tenormin 100 mg line. Once considered a major technical advance in liver transplantation blood pressure chart for infants generic tenormin 100 mg online, some transplant programs routinely use venovenous bypass, whereas in others it is virtually never used. Bypass may be required to minimize edematous enlargement of the intestines, thereby facilitating implantation of large allografts. In addition, the presence of excessive portal hypertensive bleeding may be managed by temporary portal decompression through bypass. Bypass cannulas may be placed using a cutdown technique or percutaneous techniques. In the former, the cannulation sites are usually saphenous vein and axillary veins, whereas the latter use the femoral and jugular or cephalic veins. Portal vein inflow is easily added to the inflow circuit using an additional cannula in the portal vein. A heat exchanger is often safely added to the circuit to reduce ambient heat loss in the extracorporeal tubing and to warm patients with obligatory heat loss during the procedure. Cold ischemic time is considered the time from cessation of endogenous organ perfusion in the donor (which typically occurs at the time of aortic cross-clamp) to the time that the donor organ is removed from cold storage for implantation in the recipient. The maximal allowable cold ischemic time for any given liver varies with the quality of the graft. In general, low-risk organs can tolerate cold ischemic times of up to 12 hours, whereas higher-risk organs should be implanted within 8 hours or less. Warm ischemic time is considered the time from which the organ is removed from cold storage until the time the organ is reperfused in the recipient. Vascular reattachment of the donor organ follows a logical sequence with emphasis on both quality and speed. The decision to use venovenous bypass should be made prior to dividing the portal vein during the total hepatectomy. The third step is an end-to-end anastomosis between donor and recipient portal veins. This is also performed with a running suture with care taken to avoid excessive redundancy that could predispose to kinking and thrombosis. A growth factor roughly half the circumference of the portal vein is usually included in the anastomosis to allow maximal dilation and to prevent a purse-string compromise of the vessel caliber. The organ is typically reperfused with portal flow after completion of the portal vein anastomosis, followed by immediate arterial reconstruction and subsequent arterial reperfusion. However, if the hepatic arterial anastomosis can be completed quickly, some prefer to proceed to this anastomosis before portal reperfusion, which allows the graft to have complete simultaneous portal and arterial reperfusion. The arterial anastomosis can be performed in a number of different ways but should always adhere to vascular surgery principles of maximizing vessel caliber, minimizing intimal injury, and avoiding vessel kinking. A common approach that can be performed quickly is to create a running end-to-end anastomosis between the celiac trunk of the donor organ and a branch patch of the common hepatic artery at the gastroduodenal artery takeoff of the recipient. This degree of bleeding is rarely amenable to surgical control and is best handled with packing. In rare cases, this degree of bleeding and liver injury may require urgent retransplantation. The donor gallbladder is removed and the donor and recipient bile ducts are trimmed to appropriate lengths and to the point of demonstrating healthy bleeding from periductal vessels. Most often, an end-to-end anastomosis between donor and recipient ducts is fashioned with interrupted absorbable suture. In the past, T-tubes were used commonly but were associated with a number of biliary complications. In the circumstance of an unhealthy or unusable recipient duct, Roux-en-Y hepaticojejunostomy reconstruction is performed. Most acute and chronic thrombi can be removed with eversion atherectomy with restoration of portal venous inflow. If the lumen is obliterated or the occlusion extends substantially into the superior mesenteric vein, this technique may not be sufficient, and consideration should be given to use of an interposition venous graft. Iliac veins from the deceased donor should always be obtained at the time of organ procurement for just this purpose. The inability to identify a vessel with adequate portal flow to reperfuse the allograft is a rare but potentially catastrophic occurrence. Although this technique may allow the patient to survive surgery, they are left with persistent portal hypertension as well as vena caval obstruction and its sequelae. If the inflow at this level is inadequate, then it may be necessary to create alternative hepatic arterial inflow. Donor iliac artery can be used to fashion a conduit from other sources, most commonly the infrarenal aorta. Other options include taking a graft off the recipient splenic artery or the supraceliac aorta. Supraceliac aortic cross-clamp carries some risk of paralysis and should be employed with caution. Sudden exposure of the heart to cold, hyperkalemic fluid and the milieu of cytokines released from the transplanted organ are the likely causes. An ominous sign is that of an escalating pulmonary artery pressure associated with a falling systolic blood pressure. This scenario is more common in recipients with preexisting pulmonary hypertension, diastolic dysfunction, or any other condition leading to fixed cardiac output or limited cardiac reserve. Although the best measure is to prevent severe reperfusion syndrome, it may be unavoidable in certain circumstances, especially when combining marginal organs with sick recipients. Remarkably, intraoperative cardiac arrest due to reperfusion syndrome can be survived if the patient has sufficient reserve and the graft failure is not profound. The vascular anastomoses are inspected individually, along with the retroperitoneal area along the diaphragmatic attachments and the bare area. A dramatic improvement can be effected with release of the celiac axis from this ligament at its origin off the aorta. Graft Function and Primary Nonfunction the assessment of graft function relies on clinical signs, laboratory analysis, and a certain amount of intuition. In the ideal scenario, the graft shows a healthy perfusion pattern and starts producing bile within 30 minutes of reperfusion. Over the next 12 to 24 hours, acidosis should resolve, and hemodynamics, mental status, and urine output should improve. When a transplanted organ shows signs of dysfunction in the first several hours or days after transplant, several factors must be considered. Although most grafts do show at least partial function, the signs and symptoms of a truly nonfunctional graft are easy to recognize. These grafts appear hyperemic, "blebbed," and firm, and may fracture with manipulation. Recipient acidosis, persistent vasodilation, renal failure, coagulopathy, and even cerebral edema may occur. In extreme circumstances, if no suitable replacement organ is available and a patient is unstable, removal of the nonfunctional graft and creation of a temporary portacaval shunt may allow the patient to stabilize. This anhepatic state represents a true emergency, and survival without a new liver is typically less than 48 hours. Other manipulations, such as plasmapheresis or utilization of experimental artificial hepatic support devices have been attempted with varying degrees of success. Some of these grafts may recover, provided other major complications such as infection do not destabilize the patient. In other cases, graft dysfunction leads to a cascade of events leading to multiorgan dysfunction syndrome and a "failure to thrive," which may ultimately lead to sepsis and death. It is up to the transplant team to weigh the risks of watchful waiting versus that of retransplantation. Although early retransplantation can be technically straightforward, it is not to be taken lightly as it removes another donor organ from the pool and subjects the recipient to a renewed period of intense immunosuppression. Definitive diagnosis is often obtained by surgical exploration, angiography, or cross-sectional imaging. Strictures at this level can often be managed with endoscopic or percutaneous interventional radiology techniques, but occasionally surgical revision with hepaticojejunostomy is required. Intrahepatic strictures and those that are remote from the anastomosis generally reflect a more diffusely diseased biliary tree. Many grafts with intrahepatic strictures can be temporized with aggressive and repeated percutaneous or endoscopic interventions, but some will require repeat transplantation because of recurrent cholangitis or secondary biliary cirrhosis. If the bile leak is of a large volume or is associated with peritonitis, surgical repair should be attempted promptly. A skilled endoscopist or radiologist can often manage smaller volume leaks by stenting the anastomosis and decompressing the biliary tree. The augmented immunosuppression used to treat rejection is thought to play a role in viral replication and the more aggressive return of viral hepatitis. Chronic rejection is a poorly understood entity often referred to as "vanishing bile duct syndrome. There is no effective therapy and some of these patients may ultimately require retransplantation. Not surprisingly, the use of medications designed to disrupt immune competence puts individuals at increased risk for infection. The nature of that risk depends on a number of parameters including the interval since transplantation, the intensity of immunosuppression, preexisting exposures to certain infectious agents, the age of the recipient, and the nature and extent of other comorbid conditions (Table 127. As with other surgical procedures, the risk for bacterial infections is greatest in the first few weeks after transplant. Because of their impaired cell-mediated immunity, transplant patients remain at higher than normal risk for viral and fungal infections for life. Prophylactic antibiotics are given after transplant, although the exact agent and duration varies among programs. This agent was once a common cause of morbidity and death of liver transplant but is now seen with an incidence of less than 5%. Although the exact mechanisms are still incompletely understood, immunosuppression clearly increases the risk of some types of malignancy. Treatment options include simply increasing the maintenance immunosuppression in mild cases, and initiating a steroid pulse in cases that are more severe. Although the incidence of other primary neoplasms, such as those of the breast and colon, are not increased in solid organ recipients, they tend to demonstrate a more aggressive behavior in the transplant patient when they do occur. All transplant patients should undergo vigilant screening for breast, prostate, colorectal, gynecologic, and skin cancer. Cardiovascular Side Effects Cardiovascular disease has become one of the leading causes of long-term morbidity in liver transplant survivors. Only after the shortage of organs reached a critical threshold was consideration given to performing such a procedure, which poses substantial perioperative and perhaps long-term risks to the healthy donor. Many ethical issues continue to be raised including the age, relationship to recipient, and the social circumstances of potential donors. First, transplantation can be timed to intervene before a recipient becomes severely decompensated, thereby minimizing the risks of certain complications, avoiding repeated hospitalizations, and even minimizing costs. Second, the quality of the allograft should be optimal with minimal cold ischemia and without the physiologic insults often suffered by deceased donors. On the other hand, the relatively smaller volume and the increased technical anastomotic challenges presented by partial grafts create a new set of potential recipient problems. Add to that the most paramount concern of donor health, and the advantages of living versus deceased donors become less distinct. The most compelling objection focuses on the morbidity and mortality risk associated with live liver donation. In a survey of 71 transplant programs that performed 11,553 donor hepatectomies, Cheah et al. A description of the living donor partial hepatectomy and the living donor transplant procedure is beyond the scope of this chapter. There are ongoing efforts to increase the deceased donor organ pool by several other distinct pathways. The first approach is to increase the number of potential donors by improving intensive care unit and resuscitation protocols for patients with lethal brain injury, so that organ quality is maintained until organ recovery can be coordinated. The second approach is to decrease the number of donors that are lost because of lack of family consent by using a variety of public educational and public health measures. The third approach is to increase the utilization of organs that are not ideal and that might otherwise not be recovered. These marginal, or "extended criteria" donors, include older or less hemodynamically stable donors, non-heartbeating donors, or those with comorbid conditions such as severe hepatic steatosis. Use of these organs, however, may carry an increased risk of graft loss and death. Although recovery is possible, outcomes are unpredictable and survival without retransplantation may be uncertain. Sepsis and multiorgan failure can follow, and retransplantation must often be performed within a narrow window of time. At this juncture, only a handful of higher-volume programs exist, yet recent donor deaths have been reported in the media. The role for this procedure in the armamentarium for liver transplant surgeons is still in evolution. Split Grafts the increasing shortage of deceased donor organs has led to a number of methods to expand the donor organ pool.

The surgeon should make sure that these sacs are sturdy enough to prevent rupture and large enough to envelop the entire spleen blood pressure chart too low cheap tenormin 100mg with amex. Some surgeons prefer leaving the superior-most portion of the phrenosplenic ligament intact prehypertension at 20 tenormin 50 mg overnight delivery. This method leaves the spleen tethered to the diaphragm hypertension remedies order cheap tenormin on-line, and can facilitate its placement into the endoscopic bag blood pressure healthy vs unhealthy buy tenormin with visa. Opening the bag widely and having a handle can greatly facilitate placement of the spleen into the retrieval sac blood pressure normal unit 50mg tenormin with amex. Some surgeons have used sterilized medium or large heart attack the alias radio remix demi lovato heart attack remixes 20 cheap 50mg tenormin mastercard, heavy-duty plastic freezer bags as an acceptable alternative. Morcellation or piecemeal extraction of the spleen is then undertaken, unless the spleen must be removed intact for pathologic purpose. When the lateral approach is used, extraction of the specimen bag is often through one of the lateral left subcostal ports. Typically, the surgeon morcellates the spleen within the bag, allowing extraction of fragments through the small port incision. Caution is needed to avoid crashing the bag, as peritoneal spillage can lead to splenosis (disseminated splenic implantation), a particularly troubling problem after splenectomy for hematologic disorders. After the spleen has been successfully extracted, the operative field is carefully inspected for hemostasis, previously undetected accessory spleens, or other unexpected damages. No surgical drains are needed, reflecting the established experience from open surgery. Once the operative team is satisfied with inspection of the operative field, all ports are removed under direct visualization. The skin edges are closed with subcuticular closure, and Steri-Strips or tissue sealant is placed, followed by simple dressings. Larger vessels are often challenging for standard endoclip control, even with larger metallic endoclips. Energy devices such as the Harmonic Scalpel (Ethicon, Cincinnati, Ohio) and LigaSure (Valleyabs, Boulder, Colorado) have evolved; both can be used to divide and seal vessels up to 7 mm in diameter. The 10-mm LigaSure has a lower risk of adjacent tissue damage, but it is cumbersome to use for a splenic hilar dissection. The 5-mm diameter LigaSure is easier to use but results in higher risks of adjacent tissue damage because of its smaller surface area to absorb the impedance of the device. The 5-mm diameter Harmonic scalpel has a gentle curve to facilitate dissection but it should be used with caution to avoid contact with adjacent tissues, and to ensure that the device is completely across target vessels to seal them. Both Harmonic scalpel and LigaSure technologies are safe, effective, and have shortened operative times. Minimally Invasive Surgery Approaches to Massive Spleens Hand-Assisted Laparoscopic Splenectomy. Options for hand port placement include the midline just above the umbilicus, the lower midline, or the left lower quadrant using a muscle-splitting incision. The most common location for the hand port is in the midline, between the xiphoid and the umbilicus. Of note, the incidence of portal venous thrombosis was also similar in both groups. The evolution to flexible and/or curved instruments and adoption of crossing instrument techniques is helping to address these challenges. Outcomes at 18-month follow-up were good and no hernia at the port site was reported. Blood loss and morbidity were similar in the three groups, as were the clinical outcomes in terms of complications, reoperation, and duration of hospital stay. Robotic surgery restores a three-dimensional view, allows greater degrees of freedom, and improves surgical precision. Limitations are the absence of haptic feedback, the costs, and the unproven benefit for some procedures where laparoscopy is still the gold standard. The robotic approach has been reported by few authors and it has been proposed as a valuable option for complex situations, such as partial splenectomy for patients with splenomegaly. Mean postoperative stay was 1 day longer, and costs were almost one-third higher in the robotic group. This analysis failed to show any relevant benefit with robot-assisted splenectomy. Transvaginal extraction of a laparoscopically dissected spleen was described in the early 1990s but has not been widely adopted. Orogastric tubes and urinary catheters are removed immediately after the operation. Information on the Internet for asplenic patients is a resource they are likely to access, and although many websites have incomplete information, almost all discuss the long-term risk of serious infection and need for vaccination. The actual effectiveness of antibiotics is unknown and there is no agreement on how long they should be taken or which subgroups to treat. In adults, guidelines recommend prophylaxis with 250 to 500 mg per day of amoxicillin or 500 mg per day of phenoxymethylpenicillin. Recognition that splenic vascular anatomy is variable and complex, and that the spleen is a fragile solid organ with a delicate capsule underscore preemptive efforts to avoid bleeding. Instruments should be introduced to the operative field under direct visualization, avoiding inadvertent injury to the splenic parenchyma. Dissection should be methodical-identifying, isolating, and controlling vessels sequentially. Improper Harmonic scalpel application can result in hemorrhage from a partially sectioned vessel. Blind linear stapler application can result in damage to the tail of the pancreas. Hemorrhage can occur from partial division of a major splenic vessel after release of the stapler. Early complications include bleeding, pneumonia, left pleural effusions, atelectasis and, rarely, injury to other organs (colon, small bowel, stomach, liver, and pancreas). Conversion rate to open splenectomy was 6%, complications were reported in 17% of patients, and perioperative death was 0. Spleen longitudinal size and surgical conversion were independent predictors of postoperative complications. When present, symptoms are vague and include fatigue, nausea, vomiting, and nonspecific abdominal pain. Risk factors include splenomegaly and hereditary hemolytic anemias, whereas risk may be lower in autoimmune thrombocytopenia and trauma. Treatment of splenic/ portal vein thrombosis with heparin and warfarin leads to complete or partial resolution of thrombosis in 80% of cases and persistent occlusion, portal hypertension, or cavernoma in 20% of patients. Well-designed prospective studies on prophylaxis of visceral venous thrombosis following splenectomy are lacking. Minimally invasive vascular interventional techniques for the spleen were rapidly popularized in the 1970s and 1980s and play an increasing role in algorithms of contemporary surgical practice, particularly with the shift toward preservation of functioning splenic tissue through nonoperative management. This section reviews techniques and provides updates on clinical applications of image-guided splenic interventions, which include splenic trauma, splenic artery pseudoaneurysm, hypersplenism, drainage of splenic collections, and splenic biopsy, with focus on the complementary role of image-guided interventions for the spleen as adjuncts to minimally invasive surgery-particularly in the management of splenic trauma and giant spleens. Catheter-directed therapies provide an adjunct to surgery achieving therapeutic goals while preserving adequate functioning splenic tissue for host immunity. In some cases, image-guided splenic intervention, such as splenic embolization, can obviate the need for surgery and support the nonoperative trauma management. Anatomic variations of the splenic artery are uncommon but include a separate origin from the aorta. One should note that the pancreas also receives a blood supply from the pancreaticoduodenal and transverse pancreatic arcades, and the spleen has a rich vascular network from the short gastric and gastroepiploic arteries. Normal anteroposterior celiac arteriogram demonstrating splenic artery (long black arrow), dorsal pancreatic artery (long white arrow), pancreatica magna (short white arrow), splenic artery hilar branches (white arrowheads), hepatic artery (short black arrowhead), and gastroduodenal artery (arrowhead). Normal anteroposterior celiac arteriogram demonstrates the splenic artery (long arrow) and parenchymal phase enhancement of the spleen (short arrow). Technique Most splenic interventions can be performed with conscious sedation, though pediatric patients may require general anesthesia. An initial aortogram is performed with a 5-French (5-Fr) flush catheter through a 5-Fr sheath in the femoral artery. This assesses globally for sites of bleeding and depicts the normal and variant anatomy for selective angiography. The celiac axis and splenic artery are selected using a combination of 5-Fr Simmons 1 or Cobra glide catheter and a 0. With proximal placement of the catheter, a selective splenic angiogram is performed with arterial, parenchymal, and portal venous phase timing of the contrast bolus. Smaller, more distal hilar and branch vessels may be selected with the 5-Fr catheter combined with a 3-Fr microcatheter over a 0. Smaller, more distal arteries and parenchyma may be temporarily embolized with gelatin sponge pledgets or slurry or autologous blood clot. The embolic agents may be soaked in antibiotic to decrease the risk of abscess formation. The splenic artery may be permanently embolized with metallic coils from the second-order branches into the main splenic artery. Coils are deployed distal to the dorsal pancreatic and pancreatica magna arteries in an effort to avoid splenic infarction by preserving collateral supply to functioning splenic pulp. Depending on the indication, a combination approach of coil and embolic agents may be employed. One must remain cognizant that proximally placed coils may limit future interventions if required. Three-dimensional volume-rendered anteroposterior projection multidetector-row computed tomography of the splenic artery (arrowheads). Three-dimensional fluoroscopic digital subtraction angiography that offers infinite planes and projections for interpretation and can unravel complex anatomy. The algorithm for managing the patient with splenic injury is an evolving practice and, in the past decades, the treatment of patients with blunt splenic injury has shifted from operative to nonoperative management. Outcomes are predominantly based on large-volume studies from level 1 trauma centers in the United States, but emerging data suggest good outcomes even from smaller centers. Management today largely depends on local expertise and organization of the trauma team, which evaluates each case on its individual merits. A retrospective study over 7 years at a level 1 trauma center reviewed 499 patients who suffered blunt splenic trauma; the authors found that 407 (81. One group reported 46 patients with splenic trauma of whom 17 were treated surgically, 15 conservatively, and 14 with splenic artery embolization. Splenic angiography findings include abrupt termination of vessels, vasospasm, pseudoaneurysm, and arteriovenous fistula formation. Intrasplenic vessels may be displaced and the extrasplenic artery may be "accordioned" from the hematoma. The parenchymal phase may demonstrate contrast extravasation, avascular segments, abnormal accumulation of contrast within the pulp, and loss of the smooth splenic contour. In the setting of large subcapsular hematoma, the spleen will be displaced anteromedially and the left kidney may be displaced inferiorly. Bleeding may initially be treated with a temporary distal particulate agent but the definitive therapy is permanent coil embolization of the splenic artery. If there are only two to three identifiable bleeding sites, they may be selectively coiled distally. However, if there are multiple sites, a more proximal embolization will be required. Absence of extravasation at angiography is a reliable sign of successful therapy,106 and such patients will not likely need later laparotomy. Patients failing nonoperative management (3% to 17%) and requiring splenectomy are decreasing. The presence of an arteriovenous fistula may predict operative failure, but this will depend on how aggressively the fistula is treated. Bacterial peritonitis, septicemia, splenic abscesses, and rupture are other possible complications. Postembolization infarction rates are quoted to be up to 20% but depend on the site of injury and the extent of embolization required. Studies evaluating adult trauma patients sustaining blunt splenic injury managed by angioembolization were systematically evaluated for grade of splenic injury, indication, site (proximal vs. Fifteen of 147 studies were included, all retrospective, for a cohort of 479 embolized patients. Rebleeding was the most common reason for failure but did not differ between distal and proximal angioembolization techniques. Minor complications occurred more often after distal than proximal embolization, and this is explained by a higher rate of segmental infarctions after distal embolization. Although the precise etiology of splenic artery aneurysm remains unknown, it has been associated with systemic hypertension, portal hypertension, cirrhosis, liver transplantation, and pregnancy. Splenic aneurysms are typically saccular and situated in the distal third of the splenic artery. In addition, up to 60% of those who bleed will be unstable and the mortality rate of bleeding is quoted as high as 15%. For broad-necked, saccular, or fusiform aneurysms, coils are deployed, from a distal to proximal direction, within the splenic artery. Percutaneous injection of thrombin has also been reported, but it is an uncommon approach. The success rate was 100% in both the transcatheter embolization and open surgical repair groups, with shorter length of stay (8 vs. Surgical ligation and percutaneous embolization have been reported to be equally effective. In addition, percutaneous placement of an occlusion device has been reported as yet another emerging alternative.

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Discontinuation of imatinib in patients with advanced gastrointestinal stromal tumours after 3 years of treatment: an open-label multicentre randomised phase 3 trial arrhythmia cardiac buy tenormin cheap online. Clinical efficacy of second-generation tyrosine kinase inhibitors in imatinib-resistant 4 blood pressure medication used in pregnancy cheap 100 mg tenormin visa. Underreporting of gastrointestinal stromal tumors: is the true incidence being captured Validation of the Joensuu risk criteria for primary resectable gastrointestinal stromal tumour- the impact of tumour rupture on patient outcomes arteria maxilar purchase tenormin 100mg fast delivery. Development and validation of a prognostic nomogram for recurrence-free survival after complete surgical resection of localised primary gastrointestinal stromal tumour: a retrospective analysis pulse pressure variation ppt purchase tenormin us. Microscopically positive margins for primary gastrointestinal stromal tumors: analysis of risk factors and tumor recurrence blood pressure 152 over 90 order tenormin 100mg with visa. Surgical management and clinical outcome of gastrointestinal stromal tumor of the colon and rectum heart attack ft thea austin eye of the tiger cheap tenormin online. Comparison of the post-operative outcomes and survival of laparoscopic versus open resections for gastric gastrointestinal stromal tumors: a multi-center prospective cohort study. What are the current outcomes of advanced gastrointestinal stromal tumors: who are the long-term survivors treated initially with imatinib Furthermore, upon laparotomy, the bowel lesion had to be shown to be dominant, and only involvement of lymph nodes in the immediate vicinity of the primary lesion was acceptable. Patients were excluded from analysis when distant abdominal lymph nodes, spleen, or liver were involved. Histologically, tumors consist of diffuse sheets of large, blastic lymphoid cells, 2 to 4 times larger than normal lymphocytes, often infiltrating and destroying the gastric glandular architecture. Lymphoid follicles develop in the presence of chronic inflammation and gastritis associated with H. In general, a specialist in hematology or medical oncology is the "quarterback" of the multidisciplinary team managing these patients. This strategy of nonsurgical management has been established in two randomized controlled trials evaluating the role of surgery in the management of early Lugano system (Table 82. Perhaps the worst outcome in patients undergoing primary resection is the occasional patient who incurs serious postoperative complications such as intraabdominal abscess, enterocutaneous fistula, prolonged sepsis, and inanition, which greatly delay or impair the delivery of adequate chemoimmunotherapy. If a lymphoma is confirmed, the surgeon must make a decision about whether to proceed with the planned resection. In general, if a safe, low-risk resection will remove all grossly involved bowel, this would be the preferred course; however, if the surgical procedure is nonemergent and resection would be complex, high-risk, multivisceral, and/or include major vascular resection, it should be avoided and the procedure terminated after adequate tissue for diagnostic studies is obtained. The radiology diagnosis was angiosarcoma, but this proved to be a diffuse large B-cell lymphoma. Routine surgical pathology including evaluation of frozen section and fixed hematoxylin and eosin sections which, combined with clinical correlation (site of presentation, age, predisposing factors), provide a tentative diagnosis. These tests establish the cell lineage and monoclonality of the abnormal cell population and confirm or modify the initial pathologic diagnosis. When a surgeon resects tissue in a known or suspected case of lymphoma, communication with the pathologist on duty is important to make sure that adequate tissue is obtained and handled properly to allow the full range of diagnostic testing. For example, flow cytometry requires fresh tissue, so if a diagnosis of lymphoma is suspected clinically and/or on a frozen section of surgical biopsy but is not definitively established, fresh, nonfixed tissue should be set aside in appropriate tissue media and kept until the initial histopathology determines whether flow cytometry is needed. Especially when the surgical procedure is being performed solely for the purpose of obtaining tissue for diagnostic purposes, it is best to confirm with the pathologist that adequate tissue of good diagnostic quality has been obtained before concluding the surgical procedure. These recommendations do not apply to patients who are very elderly (>80 years old), frail, or with poor left ventricular function. In fact, the explosion of new agents has opened up a daunting number of possibilities for future research,49 which will take some time to come into focus. Although a comprehensive discussion is beyond the scope of this chapter, the following will provide a current overview for the reader, who is also referred to a number of current reviews on these topics. Cyclophosphamide and fludarabine are also administered as conditioning chemotherapy. Despite this, nine patients remained in ongoing remission at last follow-up, with the longest remission at 23 months from therapy. The conditioning regimen varied depending on the histologic subtype and past treatment history. Management of primary gastrointestinal non-Hodgkin lymphomas: a population-based survival analysis. Enteropathy-type T-cell lymphoma: clinical features and treatment of 31 patients in a single institution. Survival in refractory celiac disease and enteropathy-associated T-cell lymphoma: retrospective evaluation of single-centre experience. Enteropathy-associated T-cell lymphoma: clinical and histological findings from the international peripheral T-cell lymphoma project. Targeting B cell receptor signaling with ibrutinib in diffuse large B cell lymphoma. Idelalisib, a selective inhibitor of phosphatidylinositol 3-kinase-delta, as therapy for previously treated indolent non-Hodgkin lymphoma. Primary gastrointestinal lymphoma: spectrum of imaging findings with pathologic correlation. A revised European-American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group. Primary gastrointestinal lymphoma in Japan: a clinicopathologic analysis of 455 patients with special reference to its time trends. Lymphoma/leukemia molecular profiling project: the use of molecular profiling to predict survival after chemotherapy for diffuse large-B-cell lymphoma. Bcl-6 protein expression, and not the germinal centre immunophenotype, predicts favourable prognosis in a series of primary nodal diffuse large B-cell lymphomas: a single centre experience. Survival prediction of diffuse large-B-cell lymphoma based on both clinical and gene expression information. Chromosomal translocation t(11;18)(q21;q21) in gastrointestinal mucosa associated lymphoid tissue lymphoma. Report on a workshop convened to discuss the pathologic and staging classification of gastrointestinal tract lymphoma. The role of surgery in primary gastric lymphoma: results of a controlled clinical trial. Survival of patients with marginal zone lymphoma: analysis of the survival, epidemiology, and end-results database. Congenital lesions, such as rotational anomalies, duodenal or jejunoileal atresia, meconium ileus, omphalomesenteric remnants, and duplication cysts, are more likely to present in infancy, if not prenatally. Although 90% of cases manifest during the first year of life (with 50% to 75% presenting within the first month of life),1 patients may present with midgut volvulus and/or obstruction at any age, making an understanding of the embryology, diagnosis, and treatment of malrotation essential for all abdominal surgeons. At week 10, the midgut returns to the abdomen, rotating another 180 degrees counterclockwise. The right and left colons are anchored to the posterior abdominal wall by mesenteric attachments. In addition, Ladd bands extending from the right paracolic region to the malpositioned cecum may obstruct the duodenum. Congenital diaphragmatic hernias and abdominal wall defects (omphaloceles and gastroschisis) interfere with or abrogate normal rotation before the 10th week of gestation; as such, infants with these conditions are malrotated by definition. Forty to 60% of neonatal bilious emesis is attributable to surgical bowel obstructions, of which malrotation is the most common cause. However, it should be noted that volvulized patients may never develop abdominal distention because the point of obstruction may be as proximal as the ligament of Treitz. Malrotation without volvulus may manifest as chronic abdominal pain and/or failure to thrive. It may also be completely asymptomatic and found incidentally during work-up for an unrelated condition. Early diagnosis of malrotation with volvulus is paramount to prevent potentially life-threatening bowel ischemia. Children with suspected midgut volvulus who show signs of bowel ischemia should undergo emergent surgical exploration without radiologic evaluation. There are no plain film findings that are pathognomonic for malrotation with volvulus; x-rays may demonstrate a gasless abdomen, a high-grade bowel obstruction, or an essentially normal bowel gas pattern. However, caution is warranted because false-positive rates of up to 21% are reported with ultrasonographic diagnoses. Acquired pediatric small intestinal diseases include necrotizing enterocolitis and intussusception. This anomaly is the most frequent type of malrotation, and the risk for midgut volvulus is ever present. This abnormality may be manifested clinically as duodenal obstruction secondary to abnormal mesenteric (Ladd) bands from the colon across the anterior duodenum. This abnormality may be manifested clinically as obstruction of the transverse colon. Contrast enema is rarely used in the work-up for malrotation because the presence of a normally located cecum in the right lower quadrant does not exclude duodenojejunal malrotation and infants often have mobile cecum that may result in false-positive results. If ischemic bowel is encountered, its viability should be assessed after a period of observation. Small areas of frankly necrotic bowel should be resected with or without primary anastomosis. Bowel with marginal viability should be left and allowed to declare itself; a second-look procedure should be performed 24 to 36 hours later. If an operation is electively pursued, it may be approached laparoscopically; the steps of the operation are the same. Long-term complications include adhesive small bowel obstruction (10%), recurrent volvulus, and, if significant bowel loss has been sustained, short gut syndrome. It arises from a recanalization error; the gut tube fails to obliterate its lumen in the sixth week of gestation. Eighty-five percent of duodenal atresias are located at the junction of the first and second portions of the duodenum. Commonly, the distal common bile duct traverses the medial septum, to which the ampulla is proximal. Type I duodenal atresias may be incompletely obstructing and therefore remain undetected until solid foods are introduced. In 1936 William Ladd described the surgical procedure for correction of malrotation and midgut volvulus that continues to be used currently. Coils of intestine or ascending colon are wrapped around the root of an incompletely anchored mesentery. The descending duodenum is dilated because of extrinsic pressure from Ladd bands or peritoneal folds that cross it. The small intestines lie on the right side of the abdomen, and the cecum and ascending colon are in the midline or left side of the abdomen. A nasogastric tube has been passed into the jejunum to exclude intrinsic obstruction. Alternatively, duodenojejunostomy or gastrojejunostomy may be performed, although the latter carries the risks of marginal ulceration and blind loop syndrome. A work-up should be undertaken to look for associated anomalies: 28% have Down syndrome, 23% annular pancreas, 23% congenital heart disease, and 20% malrotation. Thin webs may be excised through a longitudinal duodenotomy that is started near the point of obstruction, carried proximally over the web, and later closed transversely. The postnatal presentation is usually that of an infant who develops bilious emesis and progressive abdominal distention. The frequency of the emesis and the degree of distention vary in relation to the location of the atresia; infants with proximal atresias will vomit frequently and display minimal distention, whereas those with distal atresias will exhibit more distention but lateronset emesis. Ten percent of patients present with meconium peritonitis from in utero bowel perforation. Contrast studies are generally not required to make the diagnosis of jejunoileal atresia, but a contrast enema may be helpful, particularly for differentiating it from colonic atresia or meconium ileus. Similarly, in colonic atresia, contrast will stop progressing; it will not fill the cecum or ileocecal valve. In meconium ileus, microcolon may also be seen, but pellets of inspissated meconium will be encountered, outlined by contrast. Preoperative management includes fluid and electrolyte resuscitation, gastric decompression, and antibiotic administration. Operative interventions for jejunoileal atresias should be directed at restoring bowel continuity while preserving functional intestinal length; resection and primary anastomosis should be performed in most cases. Saline should be injected in the distal segment to evaluate for additional distal atresias. Often the proximal atretic segment will be quite dilated and atonic; it should be resected if there is adequate length of the remaining bowel. In infants who have an isolated atresia and a short segment of dilated proximal intestine, an end-to-end or oblique end-to-back anastomosis may be performed. If there is a long segment of dilated proximal intestine, an antimesenteric tapering enteroplasty may be performed to preserve bowel length and improve peristalsis in the proximal segment. Mortality is dependent on the length of the remaining small bowel; in those with 40 cm or more, survival reaches 95%, whereas in those with 14 to 40 cm, survival decreases to 50%. Gastric or pancreatic mucosa is found in approximately 25% and may cause ulceration, bleeding, and/or perforation. They more frequently communicate with the lumen of the normal intestine and have a significant incidence of ectopic gastric mucosa. Technetium 99m sodium pertechnetate scans may demonstrate duplication cysts containing ectopic gastric mucosa. The presence of a shared common wall and blood supply usually necessitates segmental bowel resection encompassing both the duplication cyst and the adjacent bowel; to minimize bowel loss, resection should be reserved for cystic and short (<20 cm) tubular duplications.

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