Local complications of pancreatitis include pancreatic pseudocysts and pancreatic necrosis. Pancreatic pseudocysts are localized fluid collections that develop 4 weeks after pancreatitis. They are typically treated with endoscopic or surgical drainage if symptomatic. Necrosis involves tissue death and requires drainage and possibly necrosectomy. Complications are managed based on their type, location, and severity with options including endoscopic, percutaneous, or surgical interventions. Close monitoring is needed as complications can include fistulas, vascular issues, or bowel obstructions.
Bile Duct Injury and Post Cholecystectomy Biliary StrictureArifuzzaman Shehab
Bile duct injuries are a devastating complication of gallbladder surgery that can have tremendous physical and mental effects on both surgeons and patients. Early recognition within 72 hours allows for minimal inflammation and the highest chance of successful repair. Diagnosis involves signs of abdominal pain and jaundice along with imaging and blood tests showing bile leakage and liver dysfunction. Management depends on the severity and location of the injury, ranging from endoscopic stenting to immediate surgical repair.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
1) Duodenal injuries are uncommon and difficult to diagnose and repair due to the duodenum's retroperitoneal location. The mortality rate for duodenal injuries is high.
2) Diagnosis of duodenal injuries requires a high index of suspicion as there is no single, fully accurate diagnostic test. CT scans, upper GI studies, and exploratory laparotomy can help diagnose duodenal injuries.
3) Treatment depends on the grade of the duodenal injury. Lower grade injuries may be treated with primary closure, tube duodenostomies, or jejunal patching. Higher grade injuries involving complete wall disruption may require duodenal resection or diversion procedures like duodenal divertic
The document discusses various surgical procedures for treating cancer of the rectum, including:
1. Abdomino-Perineal Resection (APR), the classic operation pioneered by Miles, which removes the rectum and anus through an abdominal and perineal approach.
2. Anterior Resection, which removes the rectum and part of the sigmoid colon and performs a colorectal or coloanal anastomosis.
3. Local excision techniques like Transanal Endoscopic Microsurgery (TEM) for early-stage or palliative cases.
4. Other procedures mentioned include Hartman's operation (resection with end colostomy), pelvic exenter
This document discusses bowel preparation prior to surgery to reduce risks. It describes two types of preparation: mechanical which involves diet changes and laxatives/enemas 1-4 days before surgery, or rapid preparation using whole gut irrigation via NG tube until clear fluids; and chemical which uses intestinal antiseptics like neomycin or metronidazole for 2 days or systemic antibiotics pre- and post-operatively like cephalosporins with metronidazole. The goal is to empty the large bowel and reduce bacterial flora to prevent anastomosis leakage and wound infection.
Esophagectomy : APPROACHES, CONTROVERSIES AND CURRENT EVIDENCEDr Amit Dangi
This document discusses esophagectomy, the surgical approaches for esophageal cancer resection. It covers the relevant anatomy, blood supply, lymph drainage, and histology of esophageal cancer. It then discusses pre-treatment evaluation including staging assessments and criteria for resection. The key surgical procedures for cervical, thoracic, and esophagogastric junction cancers are described including the transhiatal, Ivor-Lewis, and tri-incisional approaches. Post-operative outcomes from recent studies comparing these approaches are summarized.
Carcinoma of the stomach is usually suspected based on symptoms like abdominal pain or indigestion. Investigations include endoscopy with biopsy, which is the gold standard for diagnosis. Staging involves endoscopic ultrasound, CT, PET scans and laparoscopy. Treatment depends on the stage, and may involve surgery such as gastrectomy with lymph node dissection, adjuvant chemotherapy and/or radiotherapy. Prognosis depends on factors like stage, lymph node involvement and response to treatment, with 5-year survival rates ranging from 95% for early stage to near 0% for metastatic disease.
This document summarizes key information about duodenal injuries:
- The duodenum is 12 inches long and located retroperitoneally behind the liver and pancreas. It has four parts and is vulnerable to trauma due to its location and proximity to other abdominal organs.
- Duodenal injuries can be from penetrating or blunt trauma. Diagnosis involves imaging like CT scans and upper GI series. Management principles involve restoring intestinal continuity, decompressing the duodenum, providing drainage, and nutritional support.
- Treatment options depend on the severity of injury and include primary repair, diversion procedures like gastrojejunostomy, or pancreaticoduodenectomy for severe injuries involving other structures. Complications can include
Bile Duct Injury and Post Cholecystectomy Biliary StrictureArifuzzaman Shehab
Bile duct injuries are a devastating complication of gallbladder surgery that can have tremendous physical and mental effects on both surgeons and patients. Early recognition within 72 hours allows for minimal inflammation and the highest chance of successful repair. Diagnosis involves signs of abdominal pain and jaundice along with imaging and blood tests showing bile leakage and liver dysfunction. Management depends on the severity and location of the injury, ranging from endoscopic stenting to immediate surgical repair.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
1) Duodenal injuries are uncommon and difficult to diagnose and repair due to the duodenum's retroperitoneal location. The mortality rate for duodenal injuries is high.
2) Diagnosis of duodenal injuries requires a high index of suspicion as there is no single, fully accurate diagnostic test. CT scans, upper GI studies, and exploratory laparotomy can help diagnose duodenal injuries.
3) Treatment depends on the grade of the duodenal injury. Lower grade injuries may be treated with primary closure, tube duodenostomies, or jejunal patching. Higher grade injuries involving complete wall disruption may require duodenal resection or diversion procedures like duodenal divertic
The document discusses various surgical procedures for treating cancer of the rectum, including:
1. Abdomino-Perineal Resection (APR), the classic operation pioneered by Miles, which removes the rectum and anus through an abdominal and perineal approach.
2. Anterior Resection, which removes the rectum and part of the sigmoid colon and performs a colorectal or coloanal anastomosis.
3. Local excision techniques like Transanal Endoscopic Microsurgery (TEM) for early-stage or palliative cases.
4. Other procedures mentioned include Hartman's operation (resection with end colostomy), pelvic exenter
This document discusses bowel preparation prior to surgery to reduce risks. It describes two types of preparation: mechanical which involves diet changes and laxatives/enemas 1-4 days before surgery, or rapid preparation using whole gut irrigation via NG tube until clear fluids; and chemical which uses intestinal antiseptics like neomycin or metronidazole for 2 days or systemic antibiotics pre- and post-operatively like cephalosporins with metronidazole. The goal is to empty the large bowel and reduce bacterial flora to prevent anastomosis leakage and wound infection.
Esophagectomy : APPROACHES, CONTROVERSIES AND CURRENT EVIDENCEDr Amit Dangi
This document discusses esophagectomy, the surgical approaches for esophageal cancer resection. It covers the relevant anatomy, blood supply, lymph drainage, and histology of esophageal cancer. It then discusses pre-treatment evaluation including staging assessments and criteria for resection. The key surgical procedures for cervical, thoracic, and esophagogastric junction cancers are described including the transhiatal, Ivor-Lewis, and tri-incisional approaches. Post-operative outcomes from recent studies comparing these approaches are summarized.
Carcinoma of the stomach is usually suspected based on symptoms like abdominal pain or indigestion. Investigations include endoscopy with biopsy, which is the gold standard for diagnosis. Staging involves endoscopic ultrasound, CT, PET scans and laparoscopy. Treatment depends on the stage, and may involve surgery such as gastrectomy with lymph node dissection, adjuvant chemotherapy and/or radiotherapy. Prognosis depends on factors like stage, lymph node involvement and response to treatment, with 5-year survival rates ranging from 95% for early stage to near 0% for metastatic disease.
This document summarizes key information about duodenal injuries:
- The duodenum is 12 inches long and located retroperitoneally behind the liver and pancreas. It has four parts and is vulnerable to trauma due to its location and proximity to other abdominal organs.
- Duodenal injuries can be from penetrating or blunt trauma. Diagnosis involves imaging like CT scans and upper GI series. Management principles involve restoring intestinal continuity, decompressing the duodenum, providing drainage, and nutritional support.
- Treatment options depend on the severity of injury and include primary repair, diversion procedures like gastrojejunostomy, or pancreaticoduodenectomy for severe injuries involving other structures. Complications can include
This document discusses carcinoma of the rectum. It begins by explaining the anatomy of the rectum and its blood supply, lymphatic drainage and innervation. It then discusses the epidemiology, risk factors, staging systems including Dukes and TNM classification. Signs and symptoms, diagnostic workup including endoscopic, radiological and biopsy evaluation are explained. Principles of surgical treatment including resection margins are outlined. The goal of surgery is eradication of the primary tumor along with adjacent mesorectal tissue.
Endoscopic management of walled of pancreatic necrosisVarun Gupta
This document discusses endoscopic management of necrotizing pancreatitis. It begins with an agenda that covers diagnosis and classification of pancreatic fluid collections, indications for intervention in necrotizing pancreatitis, endoscopic techniques for drainage and necrosectomy, risks of EUS-guided drainage, and a literature review. It then provides details on classifying and diagnosing acute pancreatitis, grading severity, classifying pancreatic fluid collections based on the revised Atlanta criteria, and indications for intervening in infected or symptomatic walled-off pancreatic necrosis. Finally, it outlines endoscopic methods for draining or debriding pancreatic necrosis including EUS-guided transmural drainage, the multiple gateway technique, risks and preparations.
This document provides an overview of rectal carcinoma. It discusses the epidemiology, risk factors, clinical presentation, investigations, staging, and treatment options. Rectal carcinoma is the third most common cause of cancer deaths in the USA, with over 150,000 new cases diagnosed annually. Treatment may involve local excision, low anterior resection, abdominoperineal resection, or multivisceral resection depending on the stage, size, and location of the tumor. Total mesorectal excision and adjuvant chemoradiation are important to reduce local recurrence rates.
This document discusses chronic pancreatitis, including its definition, causes, symptoms, diagnostic tests, and surgical treatment options. It notes that chronic pancreatitis is characterized by irreversible morphological changes and permanent loss of pancreatic function. The main indications for surgery are intractable pain and complications. Surgical options include drainage procedures like longitudinal pancreaticojejunostomy or cyst-enterostomies, as well as resections like Whipple procedure or distal pancreatectomy. The goals of surgery are pain relief, control of complications, and improved quality of life. While surgery provides sustained pain relief in over 85% of patients, outcomes may be complicated by associated issues like portal hypertension.
Gall bladder carcinoma seen in Indian popluation most common in women and presents at a very late stage .Survival is in months hence palliative treatment is being preferred .
Peritoneal carcinomatosis refers to the spread of cancer to the peritoneal cavity. It has traditionally had a poor prognosis with best supportive care or chemotherapy alone. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) or early postoperative intraperitoneal chemotherapy (EPIC) has emerged as a treatment approach that can provide long-term survival or cure in properly selected patients. Key factors in patient selection include ensuring no distant metastases, thorough staging to determine peritoneal cancer index and completeness of cytoreduction, and histology of primary tumor. The goal of CRS is to remove all visible tumor nodules followed by HIPEC or EPIC to treat any remaining microscopic
This document provides information about Pseudomyxoma Peritonei (PMP), including its historical background, epidemiology, pathology, clinical presentation, diagnosis, and treatment. It discusses the various theories about its origin and pathogenesis. Treatment involves aggressive cytoreductive surgery to remove all visible tumor deposits, followed by hyperthermic intraperitoneal chemotherapy (HIPEC) to treat any remaining microscopic disease. Combined modality treatment with complete cytoreduction and HIPEC can achieve long-term remission or cure. Recent studies show the importance of surgical experience, as morbidity and mortality decrease with increasing number of procedures performed.
Role and types of surgery in chronic pancreatitisShambhavi Sharma
This document discusses the role and types of surgery in chronic pancreatitis. It begins with an introduction and overview of chronic pancreatitis and its causes. It then discusses the various symptoms and complications that can arise. The document outlines the surgical and non-surgical management options, including drainage procedures like Puestow's procedure and resection procedures like pancreaticoduodenectomy. It provides details on the indications, advantages, and disadvantages of different surgical procedures. The key message is that surgery aims to relieve pain and complications while preserving pancreatic function as much as possible.
This document discusses esophageal motility disorders. It begins with the anatomy of the esophagus, including its three parts (cervical, thoracic, abdominal) and normal narrowings. It then covers the physiology of peristalsis and swallowing. The main types of esophageal motility disorders are described - achalasia (failure of LES to relax), spastic disorders like DES and nutcracker esophagus, and presbyoesophagus in elderly patients. Diagnostic tests like manometry and scintigraphy transit tests are also summarized.
The document summarizes key anatomical and clinical aspects of the rectum:
1. The rectum is 12-15 cm long, located in the pelvis behind the lower sacrum and coccyx. It has three sections with varying peritoneal coverage and blood supply.
2. Rectal cancer is the third most common cancer in the US. Risk factors include diet, family history, and conditions like ulcerative colitis. Symptoms often include changes in bowel habits or bleeding.
3. Treatment involves surgery like low anterior resection or abdominoperineal resection. Total mesorectal excision improves outcomes by completely removing the mesorectum and reducing local recurrence rates.
Anatomy of gastroesophagial junction with specail reference to hiatus hernia...Rana Singh
This document discusses the anatomy of the gastroesophageal junction, with a focus on hiatal hernia and the anatomical basis for therapeutic intervention. Key points include:
- The gastroesophageal junction is defined anatomically by the squamocolumnar junction, the transition from esophageal to gastric lining, and the junction of the esophageal and gastric musculature.
- Hiatal hernias are classified based on the location of the hernia, with type I being a sliding hernia and type II being a paraesophageal hernia where the gastric fundus herniates alongside a normal cardia.
- Indications for surgical repair of paraesophageal hernias include symptoms and the risk
Pancreatic injuries can occur from both penetrating and blunt trauma. Penetrating injuries include stab or gunshot wounds while blunt injuries are often caused by direct blows to the abdomen from car accidents. Symptoms include epigastric pain, flank bruising, and progressive pain due to leakage of pancreatic fluids. Diagnosis involves blood tests showing elevated amylase levels and imaging studies like CT scans or MRCP to identify duct disruption. Treatment depends on the severity and location of the injury but may include surgery, drainage, or observation. Complications can include pancreatic fistulas, pseudocysts, or endocrine/exocrine insufficiency. The case report describes a 29-year old male who presented with abdominal pain after a car
- Cholangiocarcinoma is a rare cancer that affects the bile ducts. It can originate in the intrahepatic, perihilar, or distal bile ducts.
- Risk factors include primary sclerosing cholangitis, parasitic infections, hepatolithiasis, and viral infections like HCV and HBV.
- Diagnosis involves blood tests, imaging like MRI/MRCP and ERCP, and biopsy. Surgery is the main treatment for resectable tumors while chemotherapy may be given for unresectable cases. The prognosis is poor even after resection due to high recurrence rates.
1) Carcinoma of the rectum arises from the adenoma-carcinoma sequence and risk factors include red meat, alcohol, smoking, and inflammatory bowel disease.
2) Evaluation involves digital rectal exam, rigid proctoscopy, colonoscopy, CT, MRI, and lab tests to stage the tumor and check for metastases.
3) Treatment depends on tumor stage but commonly includes total mesorectal excision surgery with clear margins and may involve radiation or chemoradiation to downstage the tumor preoperatively.
This document discusses safe laparoscopic cholecystectomy and management of bile duct injuries. It begins with an overview of laparoscopic cholecystectomy and the increased risk of bile duct injury compared to open procedures. It then covers bile duct injury mechanisms, classifications, prevention techniques such as obtaining the critical view of safety, and management strategies whether the injury is recognized intraoperatively or postoperatively. The key messages are that obtaining the correct anatomical views and following established safety procedures can help prevent bile duct injuries, and injuries need to be promptly addressed either by repair or biliary reconstruction to reestablish bile flow.
Information about Low Anterior Resection by Dr Dhaval Mangukiya.
Details of GOAL of LAR, Margins, Reconstructions, Anal Anastomosis, End to Side Colorectal Anastomosis, Stapler Vs Hand Sewn, Intersphincteric Resection, Colonic J pouch Anastomosis etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Liver resection indications & methodsDr Harsh Shah
This document provides information on liver resection techniques and methods. It discusses the history and indications for liver resection, preoperative assessment including future liver remnant assessment, portal vein embolization to augment the liver volume, and surgical techniques for vascular control and parenchymal transection including the Pringle maneuver, water jet dissection, CUSA, and radiofrequency devices. The key steps in liver resection are preoperative planning, intraoperative assessment, inflow and outflow control, low central venous pressure, and parenchymal transection using various techniques and instruments.
Lt hemicolectomy - Surgical Approach, Complications.Vikas V
This is a detailed Presentation of the surgical procedure - Left Hemicolectomy. It deals with the Surgical anatomy, Indications, Surgical Steps, Complications of the Procedure
Gastric cancer is a major cause of cancer mortality worldwide. Risk factors include H. pylori infection, older age, smoking, and diets high in smoked/salted foods. Diagnosis involves endoscopy with biopsy. Staging uses TNM classification and evaluates tumor invasion depth, lymph node involvement, and distant metastasis. Treatment depends on stage but may include surgery, chemotherapy, and radiation. Prognosis is best for early stage cancers that can be completely surgically resected.
Endoscopic drainge of pancreatic absces inchildrenMEDHAT EL-SAYED
This case study describes the minimally invasive management of necrotizing pancreatitis in a 13-year-old pediatric patient. The patient presented with severe abdominal pain, respiratory distress, shock, and other symptoms. Imaging showed necrosis of the pancreatic body and tail with fluid collections. The patient was admitted to the ICU and received antibiotics, fluids, and other supportive care. An endoscopic transmural drainage was performed to drain the fluid collections. The patient's condition improved and follow-up imaging showed resolution of the fluid collections over time with endoscopic management. The case demonstrates the successful treatment of necrotizing pancreatitis in a pediatric patient with minimally invasive endoscopic drainage.
Strangulated inguinal hernias occur when herniated tissue becomes trapped within the hernia sac, cutting off blood flow. This can lead to tissue death. Symptoms include swelling, pain, and signs of bowel obstruction. Diagnosis is usually made through surgical exploration, which may involve bowel resection. While tension-free mesh repairs have been successfully used in strangulated hernias, non-mesh techniques are generally preferred due to the risk of mesh infection in contaminated fields. Proper surgical technique and mesh choice can help reduce infection risks for tension-free repairs in strangulated hernias.
This document discusses carcinoma of the rectum. It begins by explaining the anatomy of the rectum and its blood supply, lymphatic drainage and innervation. It then discusses the epidemiology, risk factors, staging systems including Dukes and TNM classification. Signs and symptoms, diagnostic workup including endoscopic, radiological and biopsy evaluation are explained. Principles of surgical treatment including resection margins are outlined. The goal of surgery is eradication of the primary tumor along with adjacent mesorectal tissue.
Endoscopic management of walled of pancreatic necrosisVarun Gupta
This document discusses endoscopic management of necrotizing pancreatitis. It begins with an agenda that covers diagnosis and classification of pancreatic fluid collections, indications for intervention in necrotizing pancreatitis, endoscopic techniques for drainage and necrosectomy, risks of EUS-guided drainage, and a literature review. It then provides details on classifying and diagnosing acute pancreatitis, grading severity, classifying pancreatic fluid collections based on the revised Atlanta criteria, and indications for intervening in infected or symptomatic walled-off pancreatic necrosis. Finally, it outlines endoscopic methods for draining or debriding pancreatic necrosis including EUS-guided transmural drainage, the multiple gateway technique, risks and preparations.
This document provides an overview of rectal carcinoma. It discusses the epidemiology, risk factors, clinical presentation, investigations, staging, and treatment options. Rectal carcinoma is the third most common cause of cancer deaths in the USA, with over 150,000 new cases diagnosed annually. Treatment may involve local excision, low anterior resection, abdominoperineal resection, or multivisceral resection depending on the stage, size, and location of the tumor. Total mesorectal excision and adjuvant chemoradiation are important to reduce local recurrence rates.
This document discusses chronic pancreatitis, including its definition, causes, symptoms, diagnostic tests, and surgical treatment options. It notes that chronic pancreatitis is characterized by irreversible morphological changes and permanent loss of pancreatic function. The main indications for surgery are intractable pain and complications. Surgical options include drainage procedures like longitudinal pancreaticojejunostomy or cyst-enterostomies, as well as resections like Whipple procedure or distal pancreatectomy. The goals of surgery are pain relief, control of complications, and improved quality of life. While surgery provides sustained pain relief in over 85% of patients, outcomes may be complicated by associated issues like portal hypertension.
Gall bladder carcinoma seen in Indian popluation most common in women and presents at a very late stage .Survival is in months hence palliative treatment is being preferred .
Peritoneal carcinomatosis refers to the spread of cancer to the peritoneal cavity. It has traditionally had a poor prognosis with best supportive care or chemotherapy alone. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) or early postoperative intraperitoneal chemotherapy (EPIC) has emerged as a treatment approach that can provide long-term survival or cure in properly selected patients. Key factors in patient selection include ensuring no distant metastases, thorough staging to determine peritoneal cancer index and completeness of cytoreduction, and histology of primary tumor. The goal of CRS is to remove all visible tumor nodules followed by HIPEC or EPIC to treat any remaining microscopic
This document provides information about Pseudomyxoma Peritonei (PMP), including its historical background, epidemiology, pathology, clinical presentation, diagnosis, and treatment. It discusses the various theories about its origin and pathogenesis. Treatment involves aggressive cytoreductive surgery to remove all visible tumor deposits, followed by hyperthermic intraperitoneal chemotherapy (HIPEC) to treat any remaining microscopic disease. Combined modality treatment with complete cytoreduction and HIPEC can achieve long-term remission or cure. Recent studies show the importance of surgical experience, as morbidity and mortality decrease with increasing number of procedures performed.
Role and types of surgery in chronic pancreatitisShambhavi Sharma
This document discusses the role and types of surgery in chronic pancreatitis. It begins with an introduction and overview of chronic pancreatitis and its causes. It then discusses the various symptoms and complications that can arise. The document outlines the surgical and non-surgical management options, including drainage procedures like Puestow's procedure and resection procedures like pancreaticoduodenectomy. It provides details on the indications, advantages, and disadvantages of different surgical procedures. The key message is that surgery aims to relieve pain and complications while preserving pancreatic function as much as possible.
This document discusses esophageal motility disorders. It begins with the anatomy of the esophagus, including its three parts (cervical, thoracic, abdominal) and normal narrowings. It then covers the physiology of peristalsis and swallowing. The main types of esophageal motility disorders are described - achalasia (failure of LES to relax), spastic disorders like DES and nutcracker esophagus, and presbyoesophagus in elderly patients. Diagnostic tests like manometry and scintigraphy transit tests are also summarized.
The document summarizes key anatomical and clinical aspects of the rectum:
1. The rectum is 12-15 cm long, located in the pelvis behind the lower sacrum and coccyx. It has three sections with varying peritoneal coverage and blood supply.
2. Rectal cancer is the third most common cancer in the US. Risk factors include diet, family history, and conditions like ulcerative colitis. Symptoms often include changes in bowel habits or bleeding.
3. Treatment involves surgery like low anterior resection or abdominoperineal resection. Total mesorectal excision improves outcomes by completely removing the mesorectum and reducing local recurrence rates.
Anatomy of gastroesophagial junction with specail reference to hiatus hernia...Rana Singh
This document discusses the anatomy of the gastroesophageal junction, with a focus on hiatal hernia and the anatomical basis for therapeutic intervention. Key points include:
- The gastroesophageal junction is defined anatomically by the squamocolumnar junction, the transition from esophageal to gastric lining, and the junction of the esophageal and gastric musculature.
- Hiatal hernias are classified based on the location of the hernia, with type I being a sliding hernia and type II being a paraesophageal hernia where the gastric fundus herniates alongside a normal cardia.
- Indications for surgical repair of paraesophageal hernias include symptoms and the risk
Pancreatic injuries can occur from both penetrating and blunt trauma. Penetrating injuries include stab or gunshot wounds while blunt injuries are often caused by direct blows to the abdomen from car accidents. Symptoms include epigastric pain, flank bruising, and progressive pain due to leakage of pancreatic fluids. Diagnosis involves blood tests showing elevated amylase levels and imaging studies like CT scans or MRCP to identify duct disruption. Treatment depends on the severity and location of the injury but may include surgery, drainage, or observation. Complications can include pancreatic fistulas, pseudocysts, or endocrine/exocrine insufficiency. The case report describes a 29-year old male who presented with abdominal pain after a car
- Cholangiocarcinoma is a rare cancer that affects the bile ducts. It can originate in the intrahepatic, perihilar, or distal bile ducts.
- Risk factors include primary sclerosing cholangitis, parasitic infections, hepatolithiasis, and viral infections like HCV and HBV.
- Diagnosis involves blood tests, imaging like MRI/MRCP and ERCP, and biopsy. Surgery is the main treatment for resectable tumors while chemotherapy may be given for unresectable cases. The prognosis is poor even after resection due to high recurrence rates.
1) Carcinoma of the rectum arises from the adenoma-carcinoma sequence and risk factors include red meat, alcohol, smoking, and inflammatory bowel disease.
2) Evaluation involves digital rectal exam, rigid proctoscopy, colonoscopy, CT, MRI, and lab tests to stage the tumor and check for metastases.
3) Treatment depends on tumor stage but commonly includes total mesorectal excision surgery with clear margins and may involve radiation or chemoradiation to downstage the tumor preoperatively.
This document discusses safe laparoscopic cholecystectomy and management of bile duct injuries. It begins with an overview of laparoscopic cholecystectomy and the increased risk of bile duct injury compared to open procedures. It then covers bile duct injury mechanisms, classifications, prevention techniques such as obtaining the critical view of safety, and management strategies whether the injury is recognized intraoperatively or postoperatively. The key messages are that obtaining the correct anatomical views and following established safety procedures can help prevent bile duct injuries, and injuries need to be promptly addressed either by repair or biliary reconstruction to reestablish bile flow.
Information about Low Anterior Resection by Dr Dhaval Mangukiya.
Details of GOAL of LAR, Margins, Reconstructions, Anal Anastomosis, End to Side Colorectal Anastomosis, Stapler Vs Hand Sewn, Intersphincteric Resection, Colonic J pouch Anastomosis etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Liver resection indications & methodsDr Harsh Shah
This document provides information on liver resection techniques and methods. It discusses the history and indications for liver resection, preoperative assessment including future liver remnant assessment, portal vein embolization to augment the liver volume, and surgical techniques for vascular control and parenchymal transection including the Pringle maneuver, water jet dissection, CUSA, and radiofrequency devices. The key steps in liver resection are preoperative planning, intraoperative assessment, inflow and outflow control, low central venous pressure, and parenchymal transection using various techniques and instruments.
Lt hemicolectomy - Surgical Approach, Complications.Vikas V
This is a detailed Presentation of the surgical procedure - Left Hemicolectomy. It deals with the Surgical anatomy, Indications, Surgical Steps, Complications of the Procedure
Gastric cancer is a major cause of cancer mortality worldwide. Risk factors include H. pylori infection, older age, smoking, and diets high in smoked/salted foods. Diagnosis involves endoscopy with biopsy. Staging uses TNM classification and evaluates tumor invasion depth, lymph node involvement, and distant metastasis. Treatment depends on stage but may include surgery, chemotherapy, and radiation. Prognosis is best for early stage cancers that can be completely surgically resected.
Endoscopic drainge of pancreatic absces inchildrenMEDHAT EL-SAYED
This case study describes the minimally invasive management of necrotizing pancreatitis in a 13-year-old pediatric patient. The patient presented with severe abdominal pain, respiratory distress, shock, and other symptoms. Imaging showed necrosis of the pancreatic body and tail with fluid collections. The patient was admitted to the ICU and received antibiotics, fluids, and other supportive care. An endoscopic transmural drainage was performed to drain the fluid collections. The patient's condition improved and follow-up imaging showed resolution of the fluid collections over time with endoscopic management. The case demonstrates the successful treatment of necrotizing pancreatitis in a pediatric patient with minimally invasive endoscopic drainage.
Strangulated inguinal hernias occur when herniated tissue becomes trapped within the hernia sac, cutting off blood flow. This can lead to tissue death. Symptoms include swelling, pain, and signs of bowel obstruction. Diagnosis is usually made through surgical exploration, which may involve bowel resection. While tension-free mesh repairs have been successfully used in strangulated hernias, non-mesh techniques are generally preferred due to the risk of mesh infection in contaminated fields. Proper surgical technique and mesh choice can help reduce infection risks for tension-free repairs in strangulated hernias.
A 45-year-old alcoholic man presented with an abdominal mass. A pseudocyst is a fluid-filled sac that can develop after pancreatitis as the pancreas digests itself. Pseudocysts are usually identified on imaging and distinguished from tumors using cyst fluid analysis. Large or long-lasting pseudocysts may require drainage through endoscopic or surgical procedures into the stomach or small intestine to prevent complications, with success rates over 85% depending on the approach.
ERCP is an endoscopic procedure that combines endoscopy and fluoroscopy to diagnose and treat issues in the duodenum, bile ducts, pancreatic duct, and gallbladder. During ERCP, an endoscope is inserted and a catheter is used to inject radiocontrast dye to identify any blockages. If needed, a wire can enlarge the opening to the bile duct to remove gallstones or perform other procedures like stent placement. Potential but rare complications include infection, pancreatitis, bleeding, and perforation of the GI tract. ERCP requires an experienced physician due to its risks.
This document provides an overview of pancreatic surgery and management of pancreatic conditions. It discusses the anatomy of the pancreas, classification and management of acute pancreatitis including necrotizing pancreatitis. It covers the indications, timing and approaches for intervention in infected pancreatic necrosis, including radiologic drainage, minimally invasive techniques like VARD and nephroscopic debridement, and open necrosectomy. It also summarizes the principles and techniques of surgical management of pancreatic cancer.
This document discusses the surgical management of hydatid cysts of the liver. It notes that surgery is the treatment of choice for uncomplicated cysts and aims to inactivate cyst contents, prevent spillage, eliminate cyst elements, and manage residual cavities. Surgical techniques discussed include excision, marsupialization, drainage, omentoplasty, and partial hepatectomy. Laparoscopic removal using specialized instruments is also described. Percutaneous aspiration, injection with scolicidal agents, and reaspiration (PAIR) is discussed as an alternative to surgery for selected cases.
This document discusses complications that can occur during and after laparoscopic cholecystectomy (gallbladder removal surgery). It first describes common complications of gallstones, both within and outside the gallbladder, such as pancreatitis, jaundice, and cholangitis. It then discusses benefits and steps of the laparoscopic procedure. Potential complications of laparoscopic cholecystectomy are outlined, including CO2 embolism, bile duct injury, bleeding, gallbladder perforation, and port site issues. Bile duct injuries are described in further detail using classification systems to characterize the extent of injury. Factors involved in bile duct injuries during the procedure are also mentioned.
This document provides guidance on treating a perforated ulcer or subphrenic abscess. It describes:
1) Preparing patients preoperatively by administering IV fluids/antibiotics and gastric suction.
2) Closing perforations by suturing the ulcer and reinforcing it with omentum, or sealing it if too indurated.
3) Draining subphrenic abscesses extraperitoneally by making incisions below the costal margin or through the 12th rib bed and inserting drains into the abscess cavity.
1. Surgery is the main treatment for rectal carcinoma, with total mesorectal excision being the standard surgical approach. The main surgeries are abdominoperineal resection for low tumors and anterior resection for mid and upper tumors.
2. Preoperative radiotherapy with or without chemotherapy can downstage the cancer and reduce local recurrence. Adjuvant chemotherapy improves survival for node-positive cancers.
3. Other treatments include transanal total mesorectal excision, palliative procedures like Hartmann's operation, and chemotherapy and immunotherapy for metastatic disease. Prognosis depends on stage and tumor characteristics, with 5-year survival rates ranging from 90% for stage I to 5% for stage IV
This document provides guidelines from the British Association of Urological Surgeons on suprapubic catheter placement and care. It discusses indications for suprapubic catheters including acute urinary retention and long-term bladder drainage needs. Risks like bowel injury are addressed, and techniques like ultrasound-guidance are recommended to mitigate these risks. Precatheter assessment, consent discussions, and various insertion methods are outlined. Complications, long-term care including catheter changes, and blockage management are also covered. The guidelines aim to standardize safe suprapubic catheter practice based on evidence and expert consensus.
This document discusses the management and complications of acute pancreatitis. For mild cases, the disease is usually self-limiting and resolves within a week with conservative treatment like analgesics and IV fluids. Severe cases require intensive care monitoring and aggressive rehydration. Systemic complications can affect various organ systems in the first week while local complications like pancreatic necrosis and pseudocysts usually develop after the first week. Infected necrosis has a high mortality rate and requires percutaneous or surgical drainage. Pseudocysts are managed with endoscopic or surgical drainage depending on their size and complications.
This document discusses the surgical management of genitourinary tuberculosis (GUTB). It outlines various surgical indications including obstructions, drainages, and reconstructive or ablative procedures. Specific techniques are described for managing infections, strictures, and reconstructing the ureters and bladder. Endoscopic and open surgical options are presented for addressing lesions in the kidneys, ureters and bladder. Reconstructive techniques including psoas hitch, Boari flap, and ileal ureteral substitution are summarized.
This document discusses the management of intestinal obstructions in small animals like dogs and cats. It covers general principles like fluid therapy, antibiotic prophylaxis, assessing intestinal viability, choices for suture materials and patterns for enteric closure. It also discusses various surgical techniques like enterotomy, enterectomy, intestinal resection and anastomosis. Various causes of obstruction are explained like intussusception, mesenteric volvulus, intestinal neoplasms and foreign bodies. Post-operative complications and other conditions causing obstruction are also outlined.
This document discusses the complications of acute pancreatitis, including local complications like acute pancreatic fluid collections and acute necrotic collections, as well as chronic complications like pancreatic pseudocysts. It provides details on the diagnosis, management, and treatment options for each complication, which include observation, percutaneous drainage, endoscopic drainage, and surgery. Endoscopic and percutaneous drainage are preferred over surgery when possible due to lower mortality and morbidity. Infected complications generally require invasive drainage to prevent further infection and impacts on patient outcomes.
This document discusses vesicovaginal fistula (VVF), including:
1. VVF is an abnormal opening between the bladder and vagina, causing continuous urinary incontinence.
2. VVF has various classifications based on location, size, and complexity.
3. Treatment involves conservative management or surgical repair, with the surgical approach depending on the fistula characteristics.
This document discusses vesicovaginal fistula (VVF), including its causes, classification, presentations, investigations, management options, surgical techniques, and outcomes. It provides details on:
- The classification of VVF based on location, size, complexity factors.
- Presentations include continuous urinary leakage, menouria, recurrent infections.
- Investigations include cystoscopy, imaging to evaluate fistula characteristics and rule out other injuries.
- Surgical repair techniques for different fistula types including vaginal, abdominal, laparoscopic approaches, with the goal of wide mobilization and layered closure without tension.
- Factors affecting outcomes include adequate drainage, prevention of infections, and
The document discusses surgical pathology of the pancreas, including:
1. Acute and chronic pancreatitis, their etiology, pathophysiology, diagnosis, and treatment.
2. Malignant pancreatic tumors, tumors of the ampulla of Vater, and endocrine pancreatic tumors.
3. Classification and treatment of penetrating and blunt pancreatic injuries, including complications.
4. Pathology, definitions, and histologic features of acute pancreatitis.
Similar to Complications of acute panctratitis (20)
This document provides an overview of basic principles of liver resection, including:
- A brief history of liver resection and techniques like hepatic inflow occlusion.
- Concepts of liver regeneration, surgical anatomy, and terminology as described by Couinaud.
- Surgical techniques for liver transection including finger fracture, water jet, CUSA, Ligasure, and vascular staplers.
- Methods of vascular control during resection like Pringle maneuver, liver hanging maneuver, and total hepatic vascular exclusion.
- Postoperative management considerations like fluid/electrolyte balance, nutrition, pain control, and monitoring for liver failure.
This document discusses fluid management in acute pancreatitis. It begins by introducing acute pancreatitis and noting its potential severity. It then discusses the pancreatic microcirculation and how microcirculatory derangement occurs in acute pancreatitis, leading to edema, ischemia and necrosis. Several theories for these microcirculatory disturbances are presented. The rationale for fluid resuscitation to correct third spacing of fluid and increase tissue perfusion is explained. Guidelines are provided on which patients require fluid resuscitation and choices of fluid, including benefits of colloids over crystalloids and vice versa. Parameters for volume and rate of fluid resuscitation are outlined as well as goals for resuscitation monitoring.
Biliary atresia is a progressive disease affecting the bile ducts in infants. It is the most common cause of liver transplantation in children. The Kasai procedure involves removing the damaged bile ducts and connecting the liver to the intestine to restore bile flow, but only half of patients achieve long-term native liver survival. Even after a successful Kasai procedure, patients remain at risk of complications like cholangitis, portal hypertension, and hepatopulmonary syndrome that may eventually require liver transplantation.
The Whipple procedure, also known as pancreaticoduodenectomy, involves removal of the pancreatic head, duodenum, gallbladder and bile duct. It is one of the most complex surgical procedures performed and is used to treat various conditions of the pancreas and surrounding organs. The key steps of the procedure include mobilization of the pancreas and attached organs, resection of these structures, and reconstruction by anastomosing the pancreas and bile duct to the small intestine. Post-operative management focuses on pain control, early feeding and mobilization using evidence-based protocols to optimize recovery.
The document discusses neuroendocrine tumors of the pancreas (PNETs). It provides information on:
1) PNETs are rare tumors that originate from neuroendocrine cells in the pancreas. They can be functional, secreting hormones like insulin, or non-functional.
2) Functional PNETs include insulinomas, gastrinomas, VIPomas, and glucagonomas. They are generally detected earlier due to hormone secretion symptoms.
3) Treatment involves surgical resection if possible. For advanced disease, options include chemotherapy, targeted drug therapy, and controlling hormone symptoms medically.
This document defines hemobilia and provides information on its history, causes, clinical presentation, diagnosis, prevention, and management. Hemobilia refers to bleeding into the biliary tract from abnormal connections between blood vessels and bile ducts. It can result from traumatic or iatrogenic injuries, gallstones, tumors, or vascular abnormalities. Clinical features include gastrointestinal bleeding, abdominal pain, and jaundice. Angiography and endoscopy are important diagnostic tools. Treatment depends on the bleeding source but may involve endoscopic methods, transarterial embolization, covered stents, or surgery. The goal is to achieve hemostasis while maintaining bile flow.
This document summarizes chronic pancreatitis, including its definition, pathogenesis, clinical manifestations, diagnosis, and treatment options. It provides details on the histopathological changes in chronic pancreatitis, including fibrosis, reduced acinar cells and islets of Langerhans, duct dilation, and pancreatic stones. Medical management focuses on pain control and enzyme supplementation, while surgical options are considered for complications or intractable pain, and include pancreaticoduodenectomy, duodenum-preserving pancreatic head resection, and decompressive procedures.
This document discusses bile duct injuries during cholecystectomy. It covers the anatomy and development of the biliary system, risk factors and mechanisms for bile duct injury, classification systems for injuries, clinical presentation, investigation, and management approaches. For injuries recognized during the initial operation, immediate open conversion and repair is recommended. For those found later, radiological imaging can evaluate and percutaneous drainage or stenting may help prior to definitive repair. The goal of surgical repair is to maintain ductal length and avoid bile leakage.
1. Cystic neoplasms of the pancreas include serous cystic neoplasms (SCNs), mucinous cystic neoplasms (MCNs), and intraductal papillary mucinous neoplasms (IPMNs), which represent approximately 90% of cases.
2. SCNs have little malignant potential and surgery is only recommended for symptomatic cases or diagnostic uncertainty. MCNs and IPMNs have higher malignant potential related to size and presence of mural nodules.
3. Differentiating between SCNs, MCNs and IPMNs requires imaging like MRI/CT along with cyst fluid analysis and pathology given differences in histology, genetic factors and malignant
This document provides an outline and overview of gallbladder carcinoma. It discusses the epidemiology, risk factors, presentation, workup, treatment and follow up of gallbladder cancer. Key points include: gallbladder cancer is the most common biliary tract malignancy and 20th most common cancer worldwide. The highest incidence is found in Chilean and Indian women. Risk factors include gallstones, salmonella infection, obesity and genetic predisposition. Presentation is often asymptomatic but can include jaundice, weight loss and palpable mass. Workup involves imaging like ultrasound, CT and MRI to determine extent of disease. Surgical resection along with lymph node dissection is the main treatment but prognosis remains poor with 5-year survival of only
The document discusses sphincter of Oddi dysfunction (SOD), a benign obstruction of the pancreaticobiliary junction. SOD most often affects middle-aged women and can develop after cholecystectomy. It has two types - SO dyskinesia is a primary motor abnormality, while SO stenosis is a structural alteration from inflammation. Clinical presentation involves postprandial abdominal pain. Diagnosis involves provocative tests, imaging, and sphincter manometry. Treatment progresses from medical management with nitrates/calcium channel blockers, to endoscopic sphincterotomy which is the standard therapy, and sometimes surgery.
This document discusses patient safety and medical errors. It notes that around 1 in 10 hospitalized patients experience harm from medical errors, with at least 50% being preventable. Common causes of errors include inadequate assessment, communication issues, training deficiencies, and environmental factors like understaffing. The document advocates for strategies like checklists, reporting systems, and process redesign to promote patient safety and minimize harm from errors. It also discusses the psychological impact on healthcare workers who make errors and the importance of a supportive learning environment.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
3. A pancreatic pseudocyst is defined as a fluid
collection within or adjacent to the pancreas that
becomes completely encapsulated with a mature,
nonepithelialized, fibrous, inflammatory wall.
Its formation requires at least 4 weeks by definition.
typically homogeneous with minimal or no necrosis
present and without a significant solid component on
CECT imaging .
Pancreatic Pseudocyst
4. Computed tomography scan showing a large horseshoe-
shaped pancreatic pseudocyst (PP) after acute gallstone
pancreatitis.
5. Common- abdominal pain and early satiety
Less frequent- jaundice, intestinal obstruction, intracystic
hemorrhage , peritonitis and pseudocyst rupture.
Imaging -Contrast-enhanced CT imaging is highly sensitive
(closeto 100%) for the presence of pancreatic cystic lesions
but does not reliably exclude the possibility of a cystic
neoplasm. The presence of nonenhancing internal dependent
debris on T2-weighted magnetic resonance imaging (MRI)
sequences was a highly specific finding for pseudocysts in a
recent review of pancreatic cystic lesions
new or worsening abdominal, flank, or back pain, intolerance
of oral intake and weight loss, mechanical obstruction
(gastric, duodenal, or biliary), evidence of infection (gas in a
non-intervened-on lesion), or concerns for PD leakage
(fistula) should prompt concerns for symptomatic pseudocyst
development
CM of Pseudocysts
7. Nealon classification of
pancreatic ductal disruption and
pseudocyst formation.
Type I is a normal main pancreatic
duct.
Type II is a pancreatic duct
stricture.
Type III is pancreatic duct
occlusion (disconnected
pancreatic duct syndrome).
Type IV depicts chronic
pancreatitis with dilatation of
pancreatic duct
Classification
8. Likelihood of resolution :pseudocyst with diameter
less than 5 cm .
Nealon Classification was significant predictor of
spontaneous resolution .
Type I pseudocyst mostly resolution was seen
Type II, III, IV were typically symptomatic and require
intervention
Non- Operative Management
9. Cystogastrostomy: This technique involves a
longitudinal gastrotomy at the level of the anterior
wall of the stomach, typically in the body. The
pseudocyst is entered by incision (or excisional
biopsy) of the posterior stomach wall at least 3 cm
long and the pseudocyst contents are suctioned out.
a cystogastrostomy anastomosis is fashioned with a
running, locking, absorbable 2-0 or 3-0 suture such as
polydioxanone (PDS). The anterior gastrotomy is then
closed with sutures or a surgical stapler.
Treatment :
Surgical Options for internal drainage
Basic Principle : the wall of the pseudocyst must be mature
and thick enough to hold suture for anastomosis
11. Performed in a Roux-en-Y configuration
and it is anastomosed to the pseudocyst
through the window in the right or left
side of the transverse mesocolon.
The proximal jejunum is divided about
30 cm from the ligament of Treitz and
jejunojejunostomy is made creating a
Roux limb apprx 40 to 60 cm long. A
two-layered anastomosis is done using
silk for the outer layer and continuous
absorbable suture for the inner layer.
Closure of the mesenteric defect is
routine.
Cystojejenostomy
12. Done when the pseudocyst is located in the
pancreatic head and immediately abutting the
duodenal wall. A longitudinal duodenotomy should
be used to expose the medial wall of the duodenum.
Injury to the gastroduodenal artery , CBD, main
pancreatic duct should be avoided
Complication like anastomotic dehiscence and
abscess formation . So it is rarely performed .
Cystoduodenostomy
13. EUS-guided approach has a higher technical success rate and
safety profile than CTD and is the preferred method in
nonbulging pseudocysts, portal hypertension, or coagulopathy.
The major complications associated with endoscopic pseudocyst
drainage—infection, bleeding, stent migration/ obstruction,
perforation.
EUS Guided Drainage transmural
drainage
14. Endoscopic transpapillary drainage is effective for
pseudocyst & that communicate with the pancreatic
duct.
Pancreatic duct sphincterotomy should be performed
regardless of whether there is successful pseudocyst
drainage.
Endoscopic guided
Transpapillary Drainage
16. In the emergency pseudocyst rupture , external
drainage may temporary solution.
If the pseudocyst wall is unexpectedly too thin and
immature for anatomosis , external drainage can be
performed.
Also if internal drainage is anatomically unachievable
due to adhesions, then external drainage is a
reasonable bailout option.
External Drainage
18. APFCs are predominantly fluid-filled
collections that occur subsequent to an
episode of acute interstitial pancreatitis
with no radiologic evidence of
parenchymal or peripancreatic necrosis.
are identified radiographically as
“puddles” in the vicinity of the pancreas
vast majority, approximated to be 85% to
90%, undergo spontaneous, self-
resolution within 7 to 10 days
Acute Pancreatic Fluid
Collection(APFC)
19. In the initial 2-week time period, Acute Necrotic Collections
(ANC)s are typically sterile and should be treated with
aggressive medical management.
Surgical débridement of ANCs in the early stages should be
avoided unless infection is confirmed
If the patient develops recurrent systemic symptoms, such as
fever, new or worsening abdominal pain, rising leukocytosis,
an infected ANC should be suspected. In these cases,
antibiotics with adequate pancreatic penetration should be
initiated in an attempt to allow time for the transition from
ANC to WON defined by the development of a mature, well-
defined wall
Acute Pancreatic Necrosis
20. a mature, encapsulated collection of pancreatic and/ or
peripancreatic necrosis that has developed a well defined
inflammatory wall.” WON typically develops as an evolution of an
ANC 4 weeks after an episode of severe acute necrotizing
pancreatitis.
If sterile, treatment is conservative
If infected, drainage and culture of the collection, antibiotics and
invasive therapy are warranted
Standard of therapy for WON has been a multimodality “step up
approach,” consisting of percutaneous catheter drainage followed
by surgical necrosectomy
Int Association of Pancreatology and the American Pancreatic
Association evidence-based guidelines endorse percutaneous
catheter or endoscopic transmural drainage as the first step in the
treatment, followed by either endoscopic or minimally invasive
surgical necrosectomy
Walled-off
necrosis (WON)
21. For patients with an organized WON located within close
proximity (~1 cm) to the gastric or duodenal wall
The technique involves initial guidewire access to the
necroma either via direct puncture (in the case of a luminal
bulge) or through the use of endoscopic ultrasound (EUS)-
guided needle puncture and subsequent wire guided access.
Once access is secured, the tract is dilated using a graduated
dilating catheter, needle knife sphincterotome, or
cystotome, and subsequent dilation to 15 to 20 mm is
performed using a balloon dilator to allow passage of an
upper endoscope into the necroma. Débridement is then
performed using a combination of endoscopic accessories.
Preservation of the tract is achieved by the placement of
stents into the cavity across the gastric or duodenal wall.
ENDOSCOPIC NECROSECTOMY
23. Patients with infected pancreatic necrosis were
randomized to either open necrosectomy or a step-up
approach based on endoscopic or percutaneous
drainage as the initial intervention, with progression to
retroperitoneal debridement with lavage if no
improvement was observed.
In patients with infected necrotizing pancreatitis,
endoscopic necrosectomy reduced the inflammatory
response, had a lower rate of complications, and
prevented new-onset multiple organ failure.
The PANTER (PAncreatitis, Necrosectomy
versus sTEp up appRoach) trial from Dutch
Pancreatitis Group
26. Open Necrosectomy With Open Packing: sepsis control being
achieved by leaving the abdomen open following
debridement, packing the cavity as a laparostomy.
Open Necrosectomy With Closed Packing: Primary closure of the
abdomen is the intention over gauze-stuffed Penrose drains,
with the intention to fill the cavity and provide some
compression.
Open Necrosectomy With Continuous Closed Postoperative
Lavage:
Programmed Open Necrosectomy: conservative debridement,
with the intention of performing repeat procedures every 48
hours until debridement is no longer required.
Open surgical necrosectomy
27. DPDS is a condition in which there is complete disruption of
the main pancreatic duct, resulting in a normal upstream
pancreatic gland having no communication with the
gastrointestinal tract. Traditional management approach
has been surgical intervention with either distal
pancreatectomy or drainage procedures.
Endoscopic approach: use of permanent indwelling
transmural stents. This allows for creation and maintenance
of a fistulous tract for pancreatic secretions to drain into the
gastrointestinal lumen.
DISCONNECTED PANCREATIC DUCT
SYNDROME(DPDS)
28.
29. External Fistula : Failure of percutaneous drain
placement. Sepsis, electrolyte disturbances, and skin
excoriation are common in high output fistulas.
Internal Fistula : can occur after pancreatitis due to a
local peripancreatic necrotizing inflammatory process . It
may develop de novo or as a complication following
manipulation by necrosectomy or close drain. Most
commonly, these fistulas occur between the pancreas
and the splenic flexure or transverse colon.
PANCREATIC FISTULAS
30. Treatment : Percutaneous drainage of the associated
fluid collection. Diet restriction , octreotide and
parenteral nutrition are often required to decrease
fistula output. Early intervention shows faster time to
closure of fistula and less complication.
Distal pancreatectomy is reserved for fistulas of the
tail. Fistulas originating from the head, neck, or body
are usually treated by Roux-en-Y pancreatico-
jejunostomy
Pancreatic Fistulas
31. Recommended for recalcitrant non healing external
fistulas
Fistula Tract-jejunostomy
32. Splenic Vein thrombosis: can cause gastric or
esophageal varices. If bleeding occurs splenectomy is
reccomended. Splenic artery embolization is also
another option for unfit patients .
Pseudoaneurysm and hemorrhage: less frequent and
late presentation. Rx : Angiographic embolization.
Obstruction: paralytic ileus due to compression from
pseudocyst. After decompression ileus is resolved.
Extrapancreatic Complication
Homogenous means uniform compostion throughout
CECT is highly sensitive
Nealon catogories by the appearance of main pancreatic duct and presence or absence of pseudocyst- duct communication
Principle : which is typically 6 weeks after the appearance of pseudocyst
Fig. 1. Techniques of transpapillary drainage of the pancreatic pseudocyst (A) ERCP demonstrating pancreatic pseudocyst with catheter in pseudocyst. B to pancreatic pseudocyst with pancreatic duct balloon dilatation, (C) pancreatic stent in place.
Teclmlques of transmural drainage of pancreatic pseudocyst
(B) endoscopic view of bulging pseudocyst in stomach, (C) initial use of cautery to enter into the pseudDCyst. (D) further cautery
using circumferential cautery ring of cystotome, (E) guide wire placed through cyst gastrostomy (F) balloon dilatation of cyst gastrostomy using wire-guided technique, (G) guttie view of pseudocyst stents entering into the pseudocyst
Algorithm for elective management of pancreatic pseudocysts
These collections often do not require any therapeutic intervention as they are generally sterile, lack a well-defined, mature wall, and self-resolve after a few weeks. However, if they become infected or symptomatic, therapy may need to be considered. Ct shows fluid collection
With this transition, the WON can undergo minimally invasive débridement with reduced risk of complications.
If left untreated, IPN has a mortality rate that approaches 100%.
The “step up” protocol for IPN involves antibiotics, percutaneous drainage (PCD), and surgical intervention instituted sequentially based on response. PCD is indicated if the patient fails to respond to antibiotics alone. Surgery is indicated if the patient fails to improve despite adequate PCD.
A variety of stenting options are available, including two or more pigtail stents, biliary or esophageal fully covered self-expanding metal stents (FCSEMS) and as of 2013, a FCSEMS with double-walled flanges, known as the lumen apposing metal stent (LAMS),
Placement of a lumen-apposing metal stent (LAMS) to provide access to the necroma.
Necrotic tissue visualized through an endoscopically dilated LAMS.
The 20 hospitals of the Dutch Acute Pancreatitis Study Group are currently enrolling patients in a randomised trial to compare
A, Percutaneous necrosectomy: percutaneous flank drain. B, Percutaneous necrosectomy: drain tract balloon dilation. C, Percutaneous
necrosectomy: nephroscope and sheath. D, Percutaneous necrosectomy: necrosis on grasper. E, Percutaneous necrosectomy: lavage drain
A subcostal incision of 5 cm is placed in the left flank at the midaxillary line, close to the exit point of the percutaneous drain. Using the in situ percutaneous drain as a guide, the retroperitoneal collection is entered. The cavity is cleared of purulent material using a standard suction device. Visible necrosis is carefully removed with the use of long grasping forceps, and deeper access is facilitated using a 0-degree laparoscope; further debridement is performed with laparoscopic forceps under videoscopic assistance
Open packing techniques have been reported to have higher incidences of fistulae, bleeding, and incisional hernias, as well as a slightly higher mortality rate
Postoperative continuous lavage is instituted at 1 to 10 L per day and continued until the effluent is clear and the patient shows improvement in clinical and laboratory parameters
Pancreatic secretions from this disconnected portion of the gland continue to be produced, resulting in persistent and/or recurring pancreatic collections, pancreatic fistulas and recurrent acute pancreatitis.
high output fistulas (more than 200 ml per day).
These patients can often be treated non-operatively with a combination of catheter removal and ocreotide, sometimes supplemented with endoscopic transpapillary stenting. reducing gastrointestinal secretions and inhibiting gastrointestinal motility
Roux-en-Y pancreatic fistula tract–jejunostomy for disconnected pancreatic duct syndrome. (A) Dissection of a pancreatic
fistula associated with an external pancreatic drainage catheter left through the root of the transverse mesocolon at the time of the initial
pancreatic necrosectomy. (B) Opening of a fistula tract and the placement of stay suture. (C) Construction of a Roux-en-Y pancreatic
fistula tract–jejunostomy. (D) Completed anastomosis between the fistula tract and the jejunum
Pancreatitis can often result in splenic vein thrombosis, due to the location of the splenic vein immediately posterior to the pancreas, which is susceptible to peripancreatic fibrosis.
direct erosion by a pseudocyst or necrotic collection into a major vessel such as the portal vein or splenic artery.