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When bacterial endocarditis is suspected purchase cheapest extra super cialis impotence young males, what are the skin lesions that should be searched for purchase extra super cialis 100 mg overnight delivery erectile dysfunction juicing, and how often are they seen? How should blood samples for culture be drawn if the clinician suspects bacterial endocarditis? Are bacteriostatic antibiotics effective in the treatment of bacterial endocarditis? In the patient with Staphylococcus aureus line-related bacteremia, how long should antibiotics be administered? Epidemiology Infective endocarditis remains a serious but relatively uncommon problem. The incidence varies from series to series, being estimated to be as high as 11 per 100,000 population, and as low as 0. The exact incidence is difficult to ascertain, because the definitions for endocarditis differ in many surveys. This means that a primary care physician will encounter only 1-2 cases over a working lifetime. Endocarditis is more common in men than in women, and the disease is increasingly becoming a disease of elderly individuals. In recent series, more than half of the patients with endocarditis were over the age of 50 years. With available rapid treatment for group A streptococcal infections, the incidence of rheumatic heart disease has declined, eliminating this important risk factor for endocarditis in the young. With life expectancy increasing worldwide, the percentage of elderly people will continue to rise, and the number of elderly patients with infective endocarditis can be expected to increase in the future. A rare disease; a primary care physician is likely to see just 1-2 cases in an entire career. This sterile lesion serves as an ideal site to trap bacteria as they pass through the bloodstream. Patients with congenital heart disease and rheumatic heart disease, those with an audible murmur associated with mitral valve prolapse, and elderly patients with calcific aortic stenosis are all at increased risk. The higher the pressure gradient in aortic stenosis, the greater the risk of developing endocarditis. Intravenous drug abusers are at high risk of developing endocarditis as a consequence of injecting bacterially contaminated solutions intravenously. Platelets and bacteria tend to accumulate in specific areas of the heart based on the Venturi effect. When a fluid or gas passes at high pressure through a narrow orifice, an area of low pressure is created directly downstream of the orifice. The Venturi effect is most easily appreciated by examining a rapidly flowing, rock-filled river. When the flow of water is confined to a narrower channel by large rocks, the velocity of water flow increases. As a consequence of the Venturi effect, twigs and other debris can be seen to accumulate on the downstream side of the obstructing rocks, in the area of lowest pressure. Similarly, vegetations form on the downstream or low-pressure side of a valvular lesion. In aortic stenosis, vegetations tend to form in the aortic coronary cusps on the downstream side of the obstructing lesion. In mitral regurgitation, vegetations are most commonly seen in the atrium, the low- pressure side of regurgitant flow. Upon attaching to the endocardium, pathogenic bacteria induce platelet aggregation, and the resulting dense plateletfibrin complex provides a protective environment. Phagocytes are incapable of entering this site, eliminating an important host defense. Colony 9 11 counts in vegetations usually reach 10 —10 bacteria per gram of tissue, and these bacteria within vegetations periodically lapse into a metabolically inactive, dormant phase. Venturi effect results in vegetation formation on the low-pressure side of high-flow valvular lesions. Disease of the mitral or aortic valve is most common; disease of tricuspid valve is rarer (usually seen in intravenous drug abusers). The frequency with which the four valves become infected reflects the likelihood of endocardial damage. Shear stress would be expected to be highest in the valves exposed to high pressure, and most cases of bacterial endocarditis involve the valves of the left side of the heart. The mitral and aortic valves are subjected to the highest pressures and are the most commonly infected. Right-sided endocarditis is uncommon (except in the case of intravenous drug abusers), and when right-sided disease does occur, it most commonly involves the tricuspid valve. The closed pulmonic valve is subject to the lowest pressure, and infection of this valve is rare. Patients with prosthetic valves must be particularly alert to the symptoms and signs of endocarditis, because the artificial material serves as an excellent site for bacterial adherence. Patients who have recovered from an episode of infective endocarditis are at increased risk of developing a second episode. Streptococci that express dextran on the cell wall surface adhere more tightly to dental enamel and to other inert surfaces. Streptococci that produce higher levels of dextran demonstrate an increased ability to cause dental caries and to cause bacterial endocarditis. Streptococcus viridans, named for their ability to cause green (“alpha”) hemolysis on blood agar plates, often have a high dextran content and are a leading cause of dental caries and bacterial endocarditis. This bacterium often enters the bloodstream via the gastrointestinal tract as a consequence of a colonic carcinoma. Whenever a mucosal surface heavily colonized with bacterial flora is traumatized, a small number of bacteria enter the bloodstream, where they are quickly cleared by the spleen and liver. Patients undergoing dental extraction or periodontal surgery are at particularly high risk, but gum chewing and tooth brushing can also lead to bacteremia. Oral irrigation devices such as the Waterpik should be avoided in patients with known valvular heart disease or prosthetic valves, because these devices precipitate bacteremia more frequently than simple tooth brushing. Other manipulations that can cause significant transient bacteremia include tonsillectomy, urethral dilatation, transurethral prostatic resection, and cystoscopy. Pulmonary and gastrointestinal procedures cause bacteremia in a low percentage of patients. In native valve endocarditis, in earlier series, Streptococcus species were the most common cause, representing more than half of all cases. However, Staphylococcus species are now the most common cause of native valve endocarditis followed by Streptococcal species. Staphy-lococcus aureus predominates, with coagulase-negative staphylococci playing a modest role.

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Many obstetricians currently use transvaginal ultra- However generic extra super cialis 100 mg mastercard erectile dysfunction doctor in columbus ohio, the cervix may have its structural integrity sound measurement of cervical length to assess risk of compromised without necessarily being rendered any preterm birth and target intervention by cervical cer- shorter and would nevertheless still benefit from cer- clage in women where there is uncertainty about the clage order 100 mg extra super cialis mastercard experimental erectile dysfunction drugs. If ultrasound‐indicated cervical cer- inflammation within the vagina and cervix, in which case clage is to be used, the appropriate threshold has not yet cerclage might be detrimental. It is possible that some of been universally agreed, although a length below 25 mm the dramatic differences in the effectiveness of interven- is a commonly used cut‐off. The presence of visible fetal tions that are seen in different clinical trials may arise membranes at the time of cervical cerclage is a strong from enrolment of women whose underlying aetiology of prognostic indicator for the risk of preterm delivery. An individual patient data meta‐analysis of four large At present, no prophylactic therapy has been demon- studies of targeted cervical cerclage in women with a strated to be unequivocally beneficial in preventing the short cervix taken from a general obstetric population onset of preterm labour in a high‐risk population. Previously, non‐steroidal anti‐inflamma- therefore generally been concluded that cervical cerclage tory drugs and oral beta‐sympathomimetics have been is of no benefit in a woman with a short cervix but no used. The results of omized trial of cervical cerclage, published in 1993, was this meta‐analysis also stands in stark contrast to a much to assess whether cervical cerclage in women deemed to smaller earlier study which showed a marked benefit of be at increased risk of cervical incompetence prolongs cervical cerclage undertaken by a single senior skilled pregnancy and thereby improves fetal and neonatal out- obstetrician. However, women were randomized only if their of the technical performance of the operation that will obstetrician was uncertain whether to recommend cer- affect the outcome. Therefore cervical cerclage was compared onstrate benefit of cervical cerclage in a large general with a policy of withholding the operation unless it was population of women with short cervix is partly due to considered to be clearly indicated. In this study, the larg- the short cervical length cut‐off, late gestational age at est ever conducted of this question, the overall preterm screening, variable skill and experience of the operators delivery rate was 28% and there were fewer deliveries and technique of the procedure. This case that a population of women at risk of preterm birth difference was reported to be reflected in deliveries char- with a short cervix at the end of the second trimester of acterized by features of cervical incompetence: painless pregnancy represents a mixture of women with genuine cervical dilatation and pre‐labour rupture of the mem- mechanical cervical problems, who would probably ben- branes. The use of cervical cerclage was associated with efit from cervical cerclage, and women whose cervix is a doubling of the risk of puerperal pyrexia. Preterm Labour 399 Whilst the current evidence is that cervical cerclage is the end of the pregnancy. Similarly, leaving large amounts not beneficial in women whose only risk of preterm birth of Mersilene tape in the vagina after cerclage to facilitate is a short cervix in the late second trimester, there is good removal probably increases the risk of adverse outcome. A meta‐analysis of easier, whilst the stitch itself is in an anatomical location four randomized controlled trials of cervical length‐ unexposed to the vaginal microbiota. This group is now often managed in a similar women with multiple pregnancy and a short cervix but way, with a cut‐off cervical length of 25 mm being used to no other risk factors for preterm birth. Although there are no rand- the aetiological differences in the risk of preterm birth omized controlled trials in this group of patients, current between singleton and multiple pregnancy. There are no observational data suggest that this policy reduces their large studies of the role of cerclage in women with twins risk of preterm birth to that of the background popula- who have a past history of second‐trimester pregnancy tion. However, it would be illogical 16 weeks can be used as a screen to discharge women in to deny a woman who had previously benefited from this cohort from further surveillance. Cervical cerclage technique Various different techniques have been described for Emergency ‘rescue’ cerclage cervical cerclage. The operation was originally popular- Rescue cervical cerclage may be performed when a woman ized in the 1950s by Shirodkar as a transvaginal purses- is admitted with silent cervical dilatation and bulging of tring suture placed following bladder mobilization and the membranes into the vagina but without the onset of posterior dissection to allow insertion at the level of the uterine contractions. In the 1960s the simpler McDonald proce- sent with slight vaginal bleeding, a watery vaginal dis- dure of a transvaginal pursestring suture without bladder charge, or vague pelvic or vaginal pain. Some exponents of the literature, mostly composed of case reports and small case McDonald procedure deliberately place the suture mid- series, suggests that rescue cerclage may delay delivery by way along the cervix to reduce the risk of bladder injury a further 5–7 weeks on average compared with expectant and to facilitate removal. It is now clear that the success management/bed rest alone, associated with a twofold of cervical cerclage depends on placing the suture as reduction in the risk of delivery before 34 weeks. In my experience this there are concerns that emergency or rescue cerclage will require dissection of the bladder off the cervix in might convert a second‐trimester pregnancy loss into an more than 50% of cases. Whether antibiotics Mersilene, when used for cervical cerclage and in other are beneficial in such cases has not been established. Some operators who use Mersilene tape completely the central role for prostaglandins and inflammatory bury the suture. Oligohydramnios occurs in Progesterone is probably the most widely used interven- up to 30% of fetuses exposed to indometacin. Currently, is dose dependent and may occur with both short‐term two different progestin preparations are in common use. Discontinuation of therapy the synthetic 17α‐hydroxyprogesterone caproate, which usually results in a rapid return of normal fetal urine out- is chemically similar to testosterone and is not a natural put and resolution of the oligohydramnios. There is a relationship dence suggests that 17α‐hydroxyprogesterone caproate between dose and duration of therapy and gestational is not effective in the group of women whose risk of pre- age. Ductal constriction is seen less commonly below term birth is predicted by a short cervix, nor is it effec- 32 weeks and rarely below 28 weeks. Long‐term indo- tive in women at risk of preterm birth because of multiple metacin therapy, particularly after 32 weeks, is therefore pregnancy. Concentrations of progesterone in shown that administration of indometacin is associated the circulation during normal pregnancy are substan- with a rapid reduction in hourly fetal urine production tially above the Kd for the progesterone receptor. As dis- but that oligohydramnios may develop more slowly and cussed, unlike in other species, in the human progesterone become significant at between 15 and 28 days. The inducible and catalyses the synthesis of prostaglandins at relative binding affinity of 17α‐hydroxyprogesterone the sites of inflammation. In addition, seen in fetuses exposed to indometacin and there have 17α‐hydroxyprogesterone caproate is given as a weekly been isolated case reports of fatal fetal renal failure. The reasons for this are unclear but vention of preterm birth is natural progesterone admin- probably represent an effect on anti‐inflammatory as istered as a vaginal pessary. Unlike 17α‐hydroxyprogesterone caproate, natu- may act to increase the volume and quality of cervical ral progesterone has not been associated with any harm mucus, hence improving physical and biochemical barri- to either mother or fetus. One widely excepted hypoth- Both an individual patient data meta‐analysis of five esis is that progesterone may act as an anti‐inflammatory. This included women ● Vaginally administered progesterone does not reduce at risk of preterm birth for a variety of reasons and was the risk of preterm birth in women at risk because of powered to include three primary outcomes: preterm their past history who have a normal cervical length. It birth, a composite of neonatal death or severe morbidity, may reduce the risk in women with a short cervix in or childhood neurodevelopment. It seems likely that the mechanism tional ages at which the outcome would usually be good. A pool of amniotic childhood morbidity at 7 years, and in particular no dif- fluid greater than 2 cm is associated with a low incidence ferences in cerebral palsy rates between babies whose of pulmonary hypoplasia. In cases where the vaginal This may be based on history, identification of a pool of microbiota is largely Lactobacillus dominated, erythro- liquor in the vagina and of oligohydramnios on ultra- mycin may lead to the elimination of potentially protec- sound. Nitrazine amnionitis and funisitis and is therefore a risk factor for (pH) testing does not appear to be useful in diagnosis of later neurodevelopmental problems. In any woman labour should be induced if increasing gestational age at delivery by increasing the there is good evidence of infection, although making a latency period is not necessarily associated with improve- diagnosis of chorioamnionitis may be challenging (dis- ments in neonatal and childhood outcomes. Antibiotics of any type, given pro- babies than expected born to the women in the expect- phylactically, do not reduce the incidence of perinatal ant management group developed neonatal sepsis, the death or neonatal encephalopathy and do not affect trial was underpowered for this outcome; however, a the rates of maternal sepsis or maternal death. These subsequent meta‐analysis of eight trials confirmed all Preterm Labour 403 these findings. Chorioamnionitis should therefore be Mothers in the expectant management group were more strongly suspected if there is clinical evidence (tender- likely to have evidence of sepsis at the time of delivery, ness, pyrexia, maternal and/or fetal tachycardia), if there but less likely to require caesarean section. Positive cultures for potential to digital assessment since it appears to be associated pathogens do not correlate well with the risk, or devel- with little risk of the introduction of infection.

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Bonnar J purchase extra super cialis online pills impotence 24, Flynn A order extra super cialis 100mg on line erectile dysfunction with diabetes type 1, Freundl G, Kirkman Sottong U, Natural family planning with R, Royston R, Snowden R, Personal hor- and without barrier method use in the mone monitoring for contraception, fertile phase: efficacy in relation to sexual Br J Fam Plann 24:128, 1999. Trussell J, Contraceptive efficacy of the term study, Adv Contracept 13: personal hormone monitoring system 179, 1997. Arévalo M, Jennings V, Nikula M, Sinai the ovulation method of natural family I, Efficacy of the new TwoDay method of planning. Characteristics of the men- family planning, Fertil Steril 82: strual cycle and of the fertile phase, Fertil 885, 2004. Kost K, Singh S, Vaughan B, Trussell preterm delivery of natural family plan- J, Bankole A, Estimates of contraceptive ning users, Adv Contracept 13:215, 1997. Boue J, Boue A, Lazar P, Retrospective of insemination and length of the fol- and prospective epidemiological studies licular phase in planned and unplanned of 1500 karyotyped spontaneous human pregnancies during use of natural family abortions, Teratology 12:11, 1975. Urbanization, education, and modernization all contributed to a decline in breastfeeding, which, fortunately, has been somewhat reversed. The tradition of wet nursing (the practice of breastfeeding by someone other than the mother) was popular from the days of the ancient Greeks to the time of medieval Europe. The domestication of cattle dates back thousands of years, but the use of animal milk for infant feeding is recent. But it was not until the 1930s that the preparation of infant “formu- las” moved from the home kitchen to commercial production and promo- tion. Breast milk substitutes were initially developed to meet specifc needs (allergies and intolerance with cow’s milk), but eventually came to be viewed as a means to free women from the responsibility of breastfeeding. By the 1950s, the prevalence of breastfeeding on discharge from the hospital fell to 30%, and the downward trend reached its nadir (22%) in 1972. By the 1940s, the mortality diference between early and late weaned infants was recognized to be due to conditions of hygiene and general care. In the developed parts of the world, where infants receive good health super- vision, the mortality diference is no longer a signifcant problem. However, 327 A Clinical Guide for Contraception in the developing world, excess mortality due to early weaning continues to be high. The revival of breastfeeding can be attributed to the growth of knowl- edge regarding the health of infants. Breastfeeding has a child-spacing efect, which is very important in the developing world as a means of limiting family size and providing good nutrition for infants. Human milk prevents infections and illnesses in infants, both by the transmission of immunoglobulins and by modifying the bacte- rial fora of the infant’s gastrointestinal tract. Beginning in the 1960s, breastfeeding became more popular in the United States, Sweden, Canada, and the United Kingdom. But this upward trend in the United States peaked in 1982 (at 61% for initiation and 40% for 3 or more months). But the good news is that since the 1980s, there has been a steady and consistent increase in breastfeeding. Breast Physiology The basic component of the breast lobule is the hollow alveolus or milk gland lined by a single layer of milk-secreting epithelial cells, derived from an ingrowth of epidermis into the underlying mesenchyme at 10 to 12 weeks of gestation. Also surrounding the milk gland is a rich capillary the Postpartum Period, Breastfeeding, and Contraception network. The lumen of the alveolus connects to a collecting intralobular duct by means of a thin nonmuscular duct. Contractile muscle cells line the intralobular ducts that eventually reach the exterior via 15 to 20 collecting ducts in a radial arrangement, corresponding to the 15 to 20 distinct mam- mary lobules in the breast, each of which contains many alveoli. Growth of this milk-producing system is dependent on numerous hor- monal factors that occur in two sequences, frst at puberty and then in pregnancy. In most girls, the frst response to the increasing levels of estrogen is an increase in size and pigmentation of the areola and the formation of a mass of breast tissue just underneath the areola. The primary efect of estrogen in subprimate mammals is to stimulate growth of the ductal por- tion of the gland system. Full diferentiation of the gland requires insulin, cortisol, thyroxine, prolactin, and growth hormone. Nevertheless, experimental evidence in mice indicates that progesterone is the key hormone required for mammary growth and diferentiation; estro- gen is necessary because the synthesis of progesterone receptors requires the critical presence of estrogen. Dur- ing the normal menstrual cycle, estrogen receptors in mammary gland epi- thelium decrease in number during the luteal phase, whereas progesterone receptors remain at a high level throughout the cycle. However, important studies indicate that with increas- ing duration of exposure, progesterone imposes a limitation on breast cell proliferation. A Clinical Guide for Contraception Final diferentiation of the alveolar epithelial cell into a mature milk cell is accomplished by the gestational increase in estrogen and progesterone, combined with the presence of prolactin, but only afer prior exposure to cortisol and insulin. Tus, the endocrinologically intact individual in whom estrogen, progesterone, thyroxine, cortisol, insulin, prolactin, and growth hormone are available can have appropriate breast growth and function. During the frst trimester of pregnancy, growth and proliferation are maximal, changing to diferentiation and secretory activity as pregnancy progresses. As the years go by, the breasts contain progressively more fat, but afer menopause, this process accelerates so that soon into the postmenopausal years, the breast glandular tissue is mostly replaced by fat. Lactation During pregnancy, prolactin levels rise from the normal level of 10 to 25 ng/mL to high concentrations, beginning about 8 weeks and reaching a peak of 200 to 400 ng/mL at term. Although prolactin stimulates signifcant breast growth and is available for lactation, only colostrum (composed of desquamated epithelial cells and transudate) is produced during gestation. Full lactation is inhibited by progesterone, which interferes with prolactin action at the alveolar cell pro- lactin receptor level. Both estrogen and progesterone are necessary for the expression of the lactogenic receptor, but progesterone antagonizes the posi- tive action of prolactin on its own receptor while progesterone and pharma- cologic amounts of androgens reduce prolactin binding. With- out prolactin, synthesis of the primary protein, casein, will not occur, and the Postpartum Period, Breastfeeding, and Contraception true milk secretion will be impossible. The hormonal trigger for initiation of milk production within the alveolar cell and its secretion into the lumen of the gland is the rapid disappearance of estrogen and progesterone from the circulation afer delivery. The clearance of prolactin is much slower, requiring 7 days to reach nonpregnant levels in a nonbreastfeeding woman. Tese discordant hormonal events result in removal of the estrogen and pro- gesterone inhibition of prolactin action on the breast. Breast engorgement and milk secretion begin 3 to 4 days postpartum when steroids have been sufciently cleared. Maintenance of steroidal inhibition or rapid reduction of prolactin secretion (with a dopamine agonist) is efective in preventing postpartum milk synthesis and secretion. In the frst postpartum week, prolactin levels in breastfeeding women decline approximately 50% (to about 100 ng/mL). Until 2 to 3 months postpartum, basal levels are approximately 40 to 50 ng/mL, and there are large (about 10- to 20-fold) increases afer suckling. Troughout breastfeeding, baseline prolactin levels remain elevated, and suckling pro- duces a 2-fold increase that is essential for continuing milk production. The optimal quantity and the quality of milk are dependent upon the availability of thyroid, insulin, and the insulin-like growth factors, corti- sol, and the dietary intake of nutrients and fuids. Secretion of calcium into the milk of lactating women approximately doubles the daily loss of calcium. It is possible that recovery is impaired in women with inadequate calcium intake; total calcium intake during lactation should be at least 1,500 mg per day.

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Laboratory values such as basic metabolic panel and complete blood count are routinely obtained in patients presenting to the emergency department purchase extra super cialis 100mg line causes of erectile dysfunction young males. Patients usually require multiple returns to the operating room to evaluate the wound and to ensure all involved tissue is excised purchase extra super cialis with mastercard impotence depression. Iodine, Dakin solution, as well as other chemicals can be added to the early wet to dry dressings to help decrease the bacterial load in the wound. Since the bacteria commonly found in this disease are gram-positive cocci, rods or anaerobes, broad-spectrum antibiotic coverage should be started initially. Other studies recommend use of meropenem plus clindamycin or ciprofloxacin, or clindamycin and metronidazole combination for broad-spectrum coverage. Clindamycin is also used frequently because it has been shown to decrease the release of Clostridium α-toxin as well as the Streptococcal M protein [9,13,20]. It is not a widely accepted option for treatment and requires more research to evaluate its efficacy [9,21]. Some retrospective studies have shown an additional benefit in patients treated primarily with surgical debridement and antibiotics. At the current time, there is no randomized prospective trial evaluating the benefit of hyperbaric oxygen in these patients. Lancerotto L, Tocco I, Salmaso R, et al: Necrotizing fasciitis: classification, diagnosis, and management. Khamnuan P, Chongruksut W, Jearwattanakanok K, et al: Necrotizing fasciitis: risk factors of mortality. Majeski J, Majeski E: Necrotizing fasciitis: improved survival with early recognition by tissue biopsy and aggressive surgical treatment. However, high-risk, noncardiac populations, including those who are at high risk due to the presence of cancer, are a subgroup that requires special consideration. As morbidity and mortality after major oncologic surgery for cancer can be substantial, herein we focus on the complications specific to these operations, which can have significant implications on perioperative management and outcomes. While survival remains dismal with little improvement in recent decades, surgical resection currently offers the best option for long-term survival and cure. The type of resection is largely dependent upon tumor characteristics such as size, location, and vascular involvement. Total pancreatectomy for neoplastic purposes may be considered for selected cases, particularly in the setting of main duct intraductal papillary mucinous neoplasm. Early ambulation, pulmonary secretion clearance, and pain control (particularly with epidural analgesia) are paramount during the early postoperative period. Attention should be paid to clinical signs of perioperative complications that warrant additional workup and management. Patients are at risk of postoperative diabetes and thromboembolic events and, therefore, generally receive close glucose monitoring and insulin supplementation and venous thromboembolism prevention. Feeding jejunostomies and parenteral nutrition are generally unnecessary unless a complication that would result in nutritional deficiency warrants their use. Additional complications include, but are not limited to, wound infections, need for reoperation, other anastomotic leakage (biliary, gastric, or duodenal), cholangitis, pancreatitis, and complications of other organ systems reported with other operations (including deep venous thrombosis, pulmonary embolus, cardiopulmonary complications, cerebral complications including stroke, and urinary tract infection). Numerous reports have been published exploring the incidence of this complications as well as means by which to prevent and treat this issue. As the patients are clinically well with without signs of infection, these do not result in changes in management. Grade B fistulas are characterized by patients who are generally well, but may have a change in management: alteration in diet (i. A postoperative collection, which preferably is drained via a percutaneous or endoscopic approach, may be identified on imaging and addressed. When collections are present, drains (whether placed surgically or postoperatively via a percutaneous approach) allow for control of contamination. Reoperation is uncommon, but should be considered in the setting of an unstable patient or in one who fails conservative management. It is generally accepted that careful handling of the pancreas and preservation of the blood supply are critical to minimize morbidity. Multiple studies, including a recent multicenter randomized controlled trial, have failed to demonstrate that there are differences in the rate of fistula, irrespective of whether a pancreaticojejunostomy or pancreaticogastrostomy is performed [16–19]. Variations in reconstruction, with “binding” techniques, “invagination” techniques, and duct obliteration have been met with different levels of success [20–24] To date, a single method of pancreatic reconstruction has not been accepted as superior to others. In a single-institution, prospective, randomized trial, intraoperative drain placement was associated with no overall increase in complications, but placement was associated with a significantly greater incidence of intraabdominal abscesses/collections [26]. The authors evaluated their more recent experience and again demonstrated that operatively placed drains were associated with a longer hospital stay, increased morbidity (including fistula rates), and increased readmission rates [27]. A multicenter, prospective randomized trial recently demonstrated that subjects who did not have routine intraoperative drainage had a higher incidence of gastroparesis, intraabdominal fluid collection and abscess, severe diarrhea, need for additional drainage, and prolonged length of stay [28]. However, if embolization fails or the patient remains unstable, exploration and control of hemorrhage is warranted. It is critically important to have a high level of suspicion for this complication: if recognized and treated expeditiously, mortality is up to 15%. The pathologic mechanisms are poorly understood, though it has been proposed that duodenal resection, remnant duodenal length, disrupted innervation (i. However, multiple trials have failed to demonstrate a difference in this complication based on the preservation or resection of the pylorus [31–33]. Endocrine and Exocrine Pancreatic Insufficiency the incidence of postpancreatectomy endocrine and exocrine insufficiency has been most commonly reported among studies focusing on the chronic pancreatitis population. Postoperative exocrine insufficiency may be detected by continued postoperative weight loss or steatorrhea, and may be treated with enzyme supplementation. Due to substantial morbidity and mortality of esophagectomy as well as the large number of patients with advanced disease in whom surgery in unlikely to be curative, there has been an increasing interest in nonsurgical options, including endomucosal resection, endoscopic ablation with techniques such as photodynamic therapy, and definitive chemoradiotherapy [45]. However, esophagectomy currently remains the best option for long-term survival and cure in early stage disease and to achieve local control (e. Common operative approaches include the Ivor Lewis esophagectomy, McKeown esophagectomy, Sweet procedure (left-sided thoracotomy), left thoracoabdominal approach, and the transhiatal esophagectomy. A number of factors determine the operative approach, including tumor location and stage, extent of lymphadenectomy, conduit options (e. There is ongoing debate about a number of issues, including the role of minimally invasive surgery, the extent of lymphadenectomy, and the location of the anastomosis (cervical versus thoracic). Chest physiotherapy, optimization of pain control (for instance with epidural analgesia), early ambulation incentive spirometry, careful fluid management, and early extubation, when possible, are paramount to try to minimize perioperative morbidity. Chest tubes and nasogastric decompression to prevent dilation are commonly employed, the latter to reduce distension which can lead to regurgitation and aspiration. The role of feeding jejunostomy or nasoduodenal tube placement for perioperative enteral feeding is variable among surgeons. Some advocate placement to allow for nutritional optimization, particularly if inadequate or delayed diet advancement is anticipated. While some surgeons will proceed with diet advancement based on the patient’s clinical picture, a swallow study with Gastrografin contrast is the gold standard for diagnosis of complications, such as esophageal leak, and may be pursued prior to diet advancement. Esophageal Anastomotic Leak Series from large volume centers have reported leak rates of approximately 10% [46–49], though an incidence of greater than 30% has been reported for low volume centers [50].

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