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By: Y. Falk, MD
Professor, Wayne State University School of Medicine
Moreover gastritis diet of worms buy gasex on line, during their entrainment protocol gastritis symptoms foods avoid buy discount gasex line, 15 beats of pacing were used before assessing the return cycle gastritis joint pain order line gasex. As discussed in Chapter 11 and demonstrated in Figures 11-173 and 11-174, the response to “entrainment” may yield misleading information with respect to the excitable gap. If the n + 1th stimulus falls on the relative refractory period of the nth stimulus, prolongation of return cycle or termination will be observed. Obviously, in this situation, prolongation of the orthodromic activation time would be a result of a combination of impingement of successive extrastimuli on the refractory period of the prior resetting stimulus and a primary effect on conduction velocity. This prolonged conduction time, in fact, may be unrelated to a primary effect of the drug on conduction velocity within the tachycardia circuit but may simply represent impingement of the n + 1th and subsequent extrastimuli on the refractory period of the preceding reset circuit. Unfortunately, as mentioned in prior paragraphs, this cannot be done completely in most tachycardias. The ability to demonstrate a flat curve with resetting and “decremental” conduction during entrainment suggests that these methods are measuring different properties. Studies comparing the two methods are required to assess the relative merits of each. Slowing of conduction may be due to the influence of a drug on “active membrane” properties (i. Studies by Saltman200 suggest that following infarction, significant nonuniform anisotropy must exist because the areas of block and slow conduction do not relate to fiber orientation. We have demonstrated that the effect of procainamide on infarcted tissue with nonuniform anisotropic characteristics (i. Experimental studies using multisite mapping will hopefully resolve these issues in the next decade. On the other hand, Spinelli and Hoffman have shown drug-induced block in their reentrant model of atrial flutter around a fixed obstacle without a change in wavelength and without eliminating the excitable gap. Several possibilities exist including (a) selected depression of conduction or cellular uncoupling in the narrow isthmus such that propagation through it is not possible; (b) prolongation of refractoriness in the isthmus causing block of the impulse; (c) creating an increase in the wavelength of the cardiac impulse so that it cannot fit within the circuit;208 209, (d) slow conduction around the arc of block slowing the proximal part of the refractory-determined arc of block to recover excitability, resulting in earlier entrance of the impulse into the isthmus at a time when it is refractory; or (e) slow conduction of the impulse allowing further saltatory slow conduction in the region of “pseudoblock” leading to narrowing of the isthmus such that it becomes inexcitable by the electrotonic influence of the arc of “pseudoblock”. Nonetheless, we have demonstrated that procainamide can produce conduction delay and/or block in areas of fractionated electrograms at a time when propagation through normal tissue is only slightly altered (Figs. If conduction through the isthmus was saltatory and associated with such electrograms, procainamide might be able to terminate the arrhythmia. Procainamide may not be expected to work in the first case but theoretically could work in the latter instance. A change in the effective refractory period in the right ventricle and changes at abnormal sites in the left ventricular electrogram rarely exceed 40 msec. In such tachycardias, the excitable gap usually significantly exceeds such a change in refractoriness. The excitable gaps in such tachycardias are typically in the range of 50 to 100 msec in the control state. The excitable gap is even less likely to be “closed” by the prolongation of refractoriness by procainamide since the drug slows conduction, which tends to increase the excitable gap. Clinical data suggest that tachycardias with short cycle lengths are more responsive to antiarrhythmic therapy. Although the model of the cardiac wavelength, which incorporates both refractoriness and conduction velocity, may be useful in assessing the effects of drugs in tachycardias with short cycle lengths and no excitable gap (i. Furthermore, the study by Spinelli and Hoffman207 demonstrated termination of tachycardia without any effect on the wavelength of that tissue. While I believe that wavelength is an important determinant of the initiation of reentry, it does not seem to be applicable to mechanism of drug termination in anatomically or anisotropically determined reentrant models. In my opinion, the latter two potential mechanisms may be applicable, that is, slow conduction allowing proximal parts P. A shift in the arc of block has been observed in nonsustained tachycardias199 200, altering the pathway length, and Lesh et al. Block I believe primarily occurs at or near the proximal entrance to the isthmus, by whatever mechanism. As for the mechanism of prevention of initiation of arrhythmia, this may be totally different from the mechanism of termination of the arrhythmia. For example, the wavelength of the stimulated impulse may be a critical determinant of the ability to initiate an arrhythmia. However, I do not think this is predictable since drugs that prolong refractoriness may make it easier or more difficult to initiate the arrhythmia by either facilitating the development of block or extending the refractory period beyond the wavelength of the stimulated impulse.
Subsequently gastritis diet quality gasex 100 caps, the general principles apply: pan out the video camera gastritis diet gasex 100caps on line, irri- gate and clean the area around the bleeding gastritis diet buy cheap gasex line, and then do selective hemostasis by using either clips or electrocautery. The author therefore recommends the use of clips rather than monopolar electrocautery on the lesser curvature itself. Alternatively, a highly selective vagotomy can be performed using harmonic scissors (Fig. Harmonic scissors are welding tools that enable one to perform the operation safely in less than 2 h, minimizing lateral injury to the stomach or to the nerves of Latarjet. Lesser Curvature Seromyotomy and Posterior Truncal Vagotomy This is a technique that has been popularized in open surgery by T. Taylor and was performed by the author as the frst published laparoscopic vagotomy technique. It com- bines a posterior truncal vagotomy, as described earlier, with an anterior lesser curvature seromyotomy. The anterior lesser curvature seromyotomy starts at the posterior aspect of the angle of His, proceeds parallel 10–15 mm from the lesser curvature, and ends approximately 6 cm from the pylorus at the frst branch of the crow’s foot. Both aspects of the stomach are grasped and the dissection is started by creating a small groove between the graspers, using an electrical hook. The combination of traction by the graspers and the electrocautery leads to exposure of the submucosal layer, which can be recognized by its blue color. If one stays at the submucosal layer, the risk of opening the mucosa is absolutely minimal. Starting at the angle of His, the seromyotomy goes down to include the last branch of the crow’s foot. It is recommended that two or three large vessels running on the ante- rior aspect of the stomach are divided before one starts the seromyotomy, as initially advocated by Taylor in open surgery (Fig. When the seromyotomy is complete, a continuous suture is placed in an overlap fashion to bring the two edges of the stomach on each other. This will prevent nerve regeneration and blood oozing, and therefore postoperative adhesions (Fig. Surg Laparosc Endosc 6(2):147–149 Further Anvari M, Allen C, Borm A (1995) Laparoscopic Nissen fundoplication is a satisfactory Reading alternative to long-term omeprazole therapy. Surg Endosc 10(12):1171–1175 Awad W, Csendes A, Braghetto I et al (1997) Laparoscopic highly selective vagotomy: technical considerations and preliminary results in 119 patients with duodenal ulcer or gastroesophageal refux disease. Formation for the development of laparoscopic sur- gery for gastroesophageal refux. Am J Surg 169(6):622–626 Croce E, Azzola M, Golia M et al (1994) Laparoscopic posterior truncal vagotomy and anterior proximal gastric vagotomy. Endosc Surg Allied Technol 2(2):113–116 Csendes A (2007) Prosthetic hiatal closure during laparoscopic Nissen fundoplication. Am J Surg 172(1):9–12 Dor J, Humbert P, Dor V et al (1962) L’interêt de la technique de Nissen modifée dans la prevention du refux après cardiomyotomie extramuqueuse de Heller. Mem Acad Chir 88:877–884 Dubois F (1994) Vagotomies—laparoscopic or thoracoscopic approach. Arch Surg 143(5):482–487 Geagea T (1991) Laparoscopic Nissen fundoplication: preliminary report on the cases. Br J Surg 83(4):547–550 Hallerback B, Glise H, Johansson B, Radmark T (1994) Laparoscopic Rosetti fundoplica- tion. Surg Endosc 9(10):1146 Heloury Y, Plattner V, Mirallie E, Gerard P, Lejus C (1996) Laparoscopic Nissen fundopli- cation with simultaneous percutaneous endoscopic gastrostomy in children. Br J Surg 81(2):161–163 Katkhouda N, Steichen F, Ravitch M, Welter R, Mouiel J (1989) Integrated anastomotic resection in esogastric surgery. Lyon Chir 85:190–191 Selected Further Reading 99 Katkhouda N, Khalil M, Grant S, Manhas S, Velmahos G, Umbach T, Kaiser A (2002) Andre Toupet: surgeon technician par excellence. Gut 38(4):487–491 Mouiel J, Katkhouda N, Gugenheim J, Fabian P, Crafa F, Iovine L (1992) Endolaparoscopic Vagotomy. Ann Surg 248(6):1081–1091 Nissen R (1956) Eine Einfache operation zur beeinfussung der Refuxesophagitis. Ann Thorac Surg 61(4):1062–1065 Ozmen V, Musleumanoglu M, Igci A, Bugra D (1995) Laparoscopic treatment of duodenal ulcer by bilateral truncal vagotomy and endoscopic balloon dilatation.
This pseudorectocele has its posterior vaginal wall exposed because of the lack of inferior support; this may be corrected by surgical reconstruction of the perineum gastritis diet gastritis treatment cheap 100caps gasex with visa. Congenital absence allows for deepening of the cul-de-sac and weakening of the rectovaginal septum gastritis diet 900 buy online gasex, leading to the development of a high rectocele and enterocele [10 gastritis zittern cheap gasex 100 caps otc,12]. Clinical Presentation The symptoms associated with a rectocele are summarized in Table 84. A common complaint is constipation, which can occur in 20%–58% of patients with rectoceles [16]. Patients may also complain of incomplete rectal emptying, a sense of rectal pressure, or a vaginal bulge. Vaginal digitation/splinting or perineal support is sometimes necessary to facilitate defecation [5,17–19]. It is also important to note that many women with rectoceles do not have to splint with defecation, and women without rectoceles may require splinting [4]. Constipation and straining may worsen the symptoms and lead to left lower quadrant abdominal pain if impaction occurs. The patient may be in the dorsal lithotomy position (for the gynecologist) or in the left lateral decubitus position (for the colorectal surgeon). The use of the split blade of a Sims or Graves speculum will support the apex and the anterior compartment and can aid in visualization. An exam should also be performed with the patient standing, as a vaginal exam in this position may identify a more prominent rectocele and rectovaginal examination will reveal small bowel herniating into this space when an enterocele is present. Of women with rectoceles, up to 80% are asymptomatic and can only be diagnosed on physical examination [9,20]. This nomenclature has replaced the respective terms cystocele, enterocele, and rectocele as it is often uncertain which specific structures are contributing to prolapse at each segment. Prolapse is measured in centimeters relative to the hymenal ring in relation to the six defined points. Points proximal to the hymen are denoted as negative and points distal as positive. Point Ba corresponds to a point 3 cm proximal to the hymen in the midline of the posterior segment. In the presence of complete vaginal eversion, the maximum value equals the value of C. Richardson described site-specific defects in the rectovaginal septum that occur in various locations including the superior, inferior, right, left, and midline areas [6]. One study has suggested that locating defects during clinical evaluation of the posterior vaginal wall is often inaccurate when compared to surgical assessment at the time of defect-specific repair [18]. However, the use of imaging 1286 studies does become useful when combined with other ancillary data, especially history and symptomatology for the following patients: (1) symptomatology and physical findings do not correlate, (2) the pelvic anatomy is unusual or altered due to previous pelvic surgery or a congenital defect, and (3) the patient is unable to exert maximal straining during pelvic examination. Imaging results should not be used alone to make treatment decisions as studies have noted that radiographic findings of posterior compartment defects do not necessarily correlate with patient symptomatology [23,24]. Currently, universally accepted radiologic criteria for defining pelvic organ prolapse are lacking [25]. In order to identify a rectocele on imaging, a measurement is made from a reference line to a predefined point. Dynamic Proctography or Defecography The use of contrast media in pelvic fluoroscopy allows the various prolapsed organs to be opacified and seen in real time providing a two-dimensional view of rectal emptying. Traditionally, it has mainly been used in the study of anorectal dysfunction as evacuation proctography, which is also known as defecography. The addition of a cystogram (dynamic cystoproctography) to this modality allows further information to be gained during the assessment especially when the possibility of an enterocele or sigmoidocele exists [28]. The equipment required includes a thick barium paste, a radiolucent toilet, and video equipment. Images are taken at rest, during straining effort, and during and after evacuation. A rectocele is seen radiographically as an anterior rectal bulge that is usually measured as the distance from the anterior border of the anal canal to the maximal point of the bulge of the anterior rectum into the posterior vagina wall. The cutoff value has not been universally agreed, but some authors consider a depth of >3 cm to be abnormal (many asymptomatic women will be found to have a small rectocele 2 cm or less in depth) [11,29]. Identification of posterior anatomic defects on defecography does not always indicate the need for evaluation.
