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Textbook of Surgical Gastroenterology (2 Volumes)
PK Mishra
SECTION 1: GENERAL
CHAPTER 1:
Approach to a Patient of Digestive Disease
INTRODUCTION
HISTORY AND EXAMINATION
COMMON PITFALLS
WRITING A PRESCRIPTION
ANGRY AND VIOLENT PATIENTS
PROGNOSIS AND END STAGE CARE
GI SURGERY AS SUPER SPECIALTY
LIVER TRANSPLANT
FOLLOW-UP OF PATIENTS
RESEARCH
ETHICS
CHAPTER 2:
Gastrointestinal Imaging
INTRODUCTION
PLAIN RADIOGRAPHS
BARIUM STUDIES AND FLUOROSCOPY
ULTRASONOGRAPHY, CONTRAST-ENHANCED ULTRASOUND AND ULTRASOUND ELASTOGRAPHY
MULTIDETECTOR COMPUTED TOMOGRAPHY
MAGNETIC RESONANCE IMAGING
DIGITAL SUBTRACTION ANGIOGRAPHY
RADIONUCLIDE STUDIES
CONCLUSION
CHAPTER 3:
Infections and Antibiotics in Gastrointestinal Surgery
INTRODUCTION
COMMON INFECTIONS ENCOUNTERED IN GI SURGERY1,3,4
Wound and Tissue Infections
Density of Bacterial Contamination
Duration of the Operation
Host Susceptibility
Diagnosis of Wound Infections
Treatment of Wound Infections
Perioperative Antimicrobial Prophylaxis
Definition of Antimicrobial Prophylaxis
Guidelines for Antimicrobial Prophylaxis in Surgery
Pharmacological Considerations
Inoculum Effect
Postantibiotic Effect
Specific Recommendations for the Selection of Prophylactic Antimicrobials for Various Surgical Procedures (American Society of Health-System Pharmacists)
Biliary-Tract Surgery
Gastroduodenal Surgery
Colorectal Surgery
Appendectomy
Common Errors in Antibiotic Prophylaxis
Pulmonary Complications
Ventilator-Associated Pneumonia
Diagnosis of VAP
Bacteriological Diagnosis
Blood and Pleural Fluid Cultures
Etiological Agents
Treatment of VAP
Factors which Influence the Outcome of VAP
Prevention
Intra-abdominal Infections
Recommendations by the World Society of Emergency Surgery (WSES) for Management of Intra-Abdominal Infections (Table 1)
Community-acquired Extra-Biliary Intra-abdominal Infections (Table 2)
Biliary Intra-abdominal Infections
Antimicrobial Regimens Recommended by WSES for Hospital-Acquired IAIs (Table 3)
Prevalence and Antimicrobial Profile of Pathogens Isolated from Patients having Postoperative Infections in GI Surgery in Govind Ballabh Pant Institute of Post Graduate Medical Education and Research
Antibiotics Susceptibility (Tables 5 and 6)
Commonly used Antibiotics in Clinical Practice (Table 7)
CHAPTER 4:
Nuclear Medicine Imaging in Gastrointestinal Diseases
INTRODUCTION
99mTC-PERTECHNETATE MECKEL'S SCAN
GASTROINTESTINAL BLEEDING
99mTc-labeled Autologous Erythrocyte (RBC) Scintigraphy
99mTc-labeled Sulfur Colloid Scintigraphy
Other Techniques
GASTROESOPHAGEAL REFLUX SCINTIGRAPHY
ESOPHAGEAL TRANSIT SCINTIGRAPHY
GASTRIC EMPTYING
COLON TRANSIT
BILIARY ATRESIA VERSUS NEONATAL HEPATITIS
CHOLEDOCHAL CYST
BILIARY OBSTRUCTION AND CHOLECYSTITIS
BILIARY LEAK
SPLENIC SCINTIGRAPHY
PROTEIN-LOSING ENTEROPATHY
INFLAMMATORY BOWEL DISEASES
Evaluation with 99mTc-WBC
Evaluation with Fluorodeoxyglucose (FDG) PET/CT
FDG PET/CT IN GI MALIGNANCY
Colorectal Cancer
Minimally Invasive Radionuclide Interventional Therapies
Esophageal Cancer
Gastric Carcinomas
Gastrointestinal Stromal Tumors
Hepatocellular Carcinoma
Cholangiocarcinoma and Gallbladder Cancer
Pancreatic Cancer
Carcinoma of Unknown Primary
NEUROENDOCRINE TUMORS
Hyperinsulinism of Infancy
CHAPTER 5:
Radiation Therapy
BASIC ASPECTS OF RADIATION THERAPY
HISTORY
TYPES OF RADIOTHERAPY
COMBINATION OF RADIATION THERAPY WITH SURGERY
COMBINATION OF RADIATION THERAPY WITH CHEMOTHERAPY
MODES OF RADIOTHERAPY
1. Teletherapy
X-rays
Gamma Ray Units
Linear Accelerators (Fig. 2)
2. Brachytherapy
3. Internal Therapy
RADIOBIOLOGY
Radiation-induced Cell Kill
Time Frame of Reaction
Repair of Deoxyribonucleic Acid Damage
CELL SURVIVAL CURVE
CELL CYCLE EFFECT
Oxygen Effect
REPAIR OF RADIATION DAMAGE
RADIATION RESPONSE MODIFIERS
1. Radiosensitizers
2. Bioreductive Drug
3. Radioprotectors
RADIATION DOSE AND UNITS
FRACTIONATION
Therapeutic Ratio (Fig. 7)
Effect of Tumor Volume
Effect of Fractionation
Time Factor
DELINEATION OF TUMOR
CARE DURING RADIOTHERAPY
Late Effects
Secondary Neoplasm
CONCLUSION
FUTURE
CHAPTER 6:
Chemotherapy Principles and Techniques for GI Cancers
INTRODUCTION
Adjuvant Therapy
Neoadjuvant Therapy
Concurrent Chemoradiation
Palliative Therapy
DRUGS USED IN GI CANCERS
Chemotherapy Drugs: Largely in the Order of Alphabets
Capecitabine
Carboplatin
Cisplatin
Epirubicin
5-Fluorouracil
Gemcitabine
Irinotecan
Mitomycin-C
Oxaliplatin
Taxanes
Targeted Agents
COMMON PROTOCOLS USED IN GI CANCERS25
Anal Canal
Biliary Tract Cancers (for Unresectable Tumors)
Colon-Rectal
Adjuvant Therapy
Metastatic Disease
Gastric Cancer and Gastroesophageal
Neoadjuvant
Adjuvant
Esophagus
Chemotherapy Protocols
Pancreas
Adjuvant
Unresectable/Metastatic
FOLFIRINOX
CHAPTER 7:
Nutritional Support to Hospitalized Patients
BASIC CONCEPTS IN NUTRITION
Macronutrients
Carbohydrate
Dietary Fiber
Fat
Protein
Water
Micronutrients
Vitamins
Minerals
Balanced Diet
Recommended Dietary Allowance
NUTRITIONAL SUPPORT FOR PATIENT ADMITTED IN A HOSPITAL
Assessment of Nutritional Status
Body Weight
Height
Body Mass Index (BMI) of the Patient
Mid Upper Arm Circumference
Skin-fold Thickness
Clinical Nutritional Examination
Current Dietary Intake of the Nutrients
Laboratory Investigations
Functional Test
Calculation of the Energy Requirements
Calculation of TER (Method I)
Calculation of TER (Method II)
Type of Diets and Mode of their Administration
Oral Nutrition
Enteral Nutrition
Routes of Administration
Type of Diet: Same as for Nasogastric Route
Type of Diet: Same as for Nasogastric Route
Type of Diet: Same as for Nasogastric Route
Parenteral Nutrition
Routes of Administration
STATUS OF NUTRITION SUPPORT SERVICES IN INDIA
APPENDIX I: RECOMMENDED DIETARY ALLOWANCES FOR INDIANS
APPENDIX II: CLASSIFICATION OF PHYSICAL ACTIVITIES (NUTRITIVE VALUE OF INDIAN FOODS, 2007)
Sedentary Activities of PAL Value of 1.53
Moderate Activities of PAL Value of 1.8
Heavy Activities of PAL Value of 2.3
APPENDIX III: APPROXIMATE RANGE OF NUTRIENT CONTENTS OF VARIOUS FOOD GROUPS (ALL VALUES ARE PER 100 G OF EDIBLE PORTION)
DIETARY FIBER COMMON INDIAN FOODS (ALL VALUES ARE PER 100 G OF EDIBLE PORTION)
APPENDIX IV: COMMON INDIAN FOODS WITH HIGH CALORIE, LOW CALORIE, HIGH FAT (≥25 G/100 G OF EDIBLE PORTION) AND HIGH PROTEIN (ALL VALUES ARE PER 100 G OF EDIBLE PORTION)
APPENDIX V: SODIUM AND POTASSIUM CONTENT OF COMMON INDIAN FOODS (ALL VALUES ARE PER 100 G OF EDIBLE PORTION)
APPENDIX VI: GLYCEMIC INDEX OF COMMON INDIAN FOODS
APPENDIX VII: HOSPITAL DIET—FEW IMPORTANT ISSUES
ABBREVIATIONS
GLOSSARY OF DEFINITIONS
CHAPTER 8:
Statistics for Surgeons
NUMBERS, DATA, INFORMATION AND VARIABLES
TABULATION
AVERAGES
MEASURES OF DISPERSION
STANDARD ERROR AND CONFIDENCE INTERVAL
STATISTICAL TESTING OF HYPOTHESIS, NULL HYPOTHESIS, ALTERNATIVE HYPOTHESIS, TYPES OF ERRORS AND POWER OF A TEST
Types of Statistical Tests
COMPARISON OF MEAN BETWEEN TWO INDEPENDENT GROUPS
Assumptions for a Student's t Test
COMPARISON OF MEAN BETWEEN TWO DEPENDENT OR PAIRED GROUPS
Comparison of a Proportion in Two Independent Samples
Comparison of Two proportions from Independent Samples: Contingency Table Method
Calculation of Expected Frequency for the Cell (a)
STUDY DESIGNS
Cross-sectional Design
Prospective Study or Cohort Design
SAMPLE SIZE
Estimating the Sample Size for the Presence of a Condition or Prevalence of a Condition
Estimating the Sample Size for a Diagnostic Study
Estimating the Sample Size for Estimating the Mean of a Characteristic
Estimation of Sample Size for Studies Involving Testing of Hypothesis
Estimation of Sample Size for Testing Hypothesis Involving Two Paired Means
Estimation of Sample Size for Testing Hypothesis Involving Two Independent Means
Estimation of Sample Size for Testing Hypothesis Involving Two Independent Proportions
MEASURES OF ASSOCIATION
NUMBER NEEDED TO TREAT
UNIVARIATE AND MULTIVARIABLE ANALYSES
Multivariable Analysis
COMMON PITFALLS IN STATISTICAL CALCULATIONS AND INTERPRETATIONS
WRONG ANALYSIS TECHNIQUES
MISLEADING PRESENTATION OF DATA THROUGH DIAGRAMS AND FIGURES
STATISTICAL SIGNIFICANCE VERSUS CLINICAL OR PUBLIC HEALTH SIGNIFICANCE
DATA MANIPULATION/FUDGING
DATA DREDGING
CHAPTER 9:
Interventional Radiology of the Gastrointestinal Tract and Hepatobiliary System
INTRODUCTION
GENERAL INTERVENTIONS
Fine Needle Aspiration/Biopsy
Drainage of Abdominal Abscesses and Fluid Collections
Indications
Diagnostic
Therapeutic
Types of Drainage
Catheter Care
Catheter Removal
SPECIAL CONSIDERATIONS
Enteric Abscesses
Abscess-Fistula Complex
Subphrenic Abscess
Hepatic Abscess
Pancreatic Collections
Pancreatic Pseudocyst
Pancreatic Abscess
Pancreatic Necrosis
Retroperitoneal Abscess
Splenic Abscess
Transvaginal and Transrectal Access
ORGAN OR DISEASE SPECIFIC INTERVENTIONS
Vascular Diseases of Liver
Budd-Chiari Syndrome/Hepatic Venous Outflow Tract Obstruction
Acute Portal and Mesenteric Vein Thrombosis
Chronic Portal Vein Thrombosis
Complications of Chronic Liver Disease and Portal Hypertension
Transjugular Intrahepatic Portosystemic Shunt
Partial Splenic Artery Embolization
Balloon-occluded Retrograde Transvenous Obliteration (B-RTO)
Interventional Radiology in the Management of Hepatocellular Carcinoma
Image-guided Tumor Ablation
Chemical Ablation
Radiofrequency Ablation
Microwave Ablation
Laser Ablation
Cryoablation
New Nonchemical Nonthermal Ablation Techniques
Irrerversible Electroporation
Light Activated Drug Therapy
Transarterial Embolization Therapies
Transarterial Chemoembolization
Transarterial Radioembolization
RADIOLOGICAL INTERVENTIONS FOR POST-LIVER TRANSPLANT COMPLICATIONS
Vascular
Nonvascular
Biliary Interventions
Percutaneous Liver Biopsy
Drainage of Abdominal Collections
Percutaneous Biliary Interventions
Percutaneous Transhepatic Biliary Drainage
Biliary Stent Insertion
Biliary-enteric Anastomotic Strictures
Management of Hepaticolithiasis
Intraluminal Brachytherapy with PTBD
Percutaneous Cholecystostomy
Preoperative Portal Vein Embolization
Procedure
Postprocedural Management
Visceral Arterial Interventions
Visceral Artery Aneurysms
Results
Abdominal Trauma
Hepatic Injury
Procedure
Splenic Injury
Indications
Procedure
Percutaneous Vascular Gastrointestinal Tract Interventions
Acute Gastrointestinal Tract Bleeding
Upper Gastrointestinal Bleeding
Procedure
Lower Gastrointestinal Bleeding
Etiology
Results
Mesenteric Ischemia
Acute Mesenteric Ischemia
Chronic Mesenteric Ischemia
Percutaneous Nonvascular Interventions in Gastrointestinal Tract
Types of Tubes
Percutaneous Gastrostomy
Indications
Procedure
Percutaneous Gastrojejunostomy
Percutaneous Jejunostomy
Percutaneous Cecostomy
SECTION 2: ESOPHAGUS
CHAPTER 10:
Anatomy and Physiology of the Esophagus
ANATOMY
Arterial Supply
Venous Drainage
Lymphatic Drainage
Innervation
PHYSIOLOGY
Swallowing
CHAPTER 11:
Diagnostic Tests in Esophageal Diseases
INTRODUCTION
ENDOSCOPY
Basics
Image Enhancement Techniques
Indications
Dysphagia
Peptic Stricture
Radiation Injury
Eosinophilic Esophagitis
Extrinsic Compression
Malignant Strictures
Role of Endoscopy in Evaluation of Heartburn, Odynophagia, Chest Pain, Hiccups
ESOPHAGEAL CAUSES OF GI BLEED
ESOPHAGEAL MANOMETRY
Indications for Manometry
ESOPHAGEAL pH-METRY
Procedure
Indications of pH-Metry
IMPEDANCE pH MONITORING
ENDOSCOPIC ULTRASOUND FOR ESOPHAGEAL DISORDERS
CHAPTER 12:
Approach to a Patient with Dysphagia
INTRODUCTION
PHYSIOLOGY OF SWALLOWING
PATHOPHYSIOLOGY OF DYSPHAGIA
APPROACH TO A PATIENT WITH DYSPHAGIA (FLOW CHART 1)
History
Examination
Investigations
Endoscopy
Barium Swallow
Manometry
Further Evaluation
SPECIAL SITUATION: POSTOPERATIVE DYSPHAGIA
Post-reflux Surgery Dysphagia
Post-esophagectomy Dysphagia
Dysphagia after Achalasia Treatment
CHAPTER 13:
Gastroesophageal Reflux Disease
INTRODUCTION
PATHOPHYSIOLOGY
PATHOGENESIS
Pathogenesis of Columnar Lined Epithelium
Pathological Basis of Symptoms
CLINICAL FEATURES
DIAGNOSIS
Endoscopy
pHmetry
Manometry
Radiological Imaging
Nuclear Imaging
MEDICAL MANAGEMENT
Lifestyle Changes
Proton Pump Inhibitor Therapy
Other Drugs
Therapy of Barrett's Esophagus
SURGICAL MANAGEMENT
Indications for Surgery
Surgical Options
Nissen Fundoplication
Complete or Partial Fundoplication
Complications of Antireflux Surgery
Surgery of Hiatus Hernia
Prosthesis-based Antireflux Surgery
GERD and Bariatric Surgery
ENDOTHERAPY OF GERD
CONCLUSION
Acknowledgment
CHAPTER 14:
Motility Disorders of the Esophagus
INTRODUCTION
CLASSIFICATION OF MOTILITY DISORDERS: WHY?
Primary versus Secondary
Achalasia versus Non-achalasia Disorders
DEFINITION OF VARIOUS ESOPHAGEAL MOTILITY DISORDERS
CLINICAL DIAGNOSIS
INVESTIGATIONS
Upper GI Endoscopy and Biopsy
Radiology Studies
Esophageal Physiology Studies
High-Resolution Manometry
Ambulatory pH Studies
MANAGEMENT OF ESOPHAGEAL MOTILITY DISORDERS
Achalasia
Surgical versus Nonsurgical Methods
Surgical Management of Achalasia Cardia
Pneumatic Dilatation
Botox Injection
POEM for Achalasia
NUTCRACKER ESOPHAGUS
DIFFUSE ESOPHAGEAL SPASM
HYPERTENSIVE ESOPHAGEAL SPHINCTER
EPIPHRENIC ESOPHAGEAL DIVERTICULUM
CONCLUSION
CHAPTER 15:
Esophageal Perforation: Diagnosis and Management
INTRODUCTION
EPIDEMIOLOGY
ETIOLOGY
PATHOPHYSIOLOGY
CLINICAL FEATURES
DIAGNOSIS AND WORK UP
IMAGING MODALITIES
MANAGEMENT
NONOPERATIVE TREATMENT
SURGICAL TREATMENT
Primary Repair
Drainage
Conservative Treatment
Esophageal Exclusion and Diversion
Esophagectomy
Functional Outcome of Esophageal Perforation
ENDOSCOPIC TREATMENT
Endoscopic Stent Therapy
Endoscopic Endoluminal Vacuum Therapy
Other Endoscopic Therapies
PREDICTIVE FACTORS AND PATIENT SELECTION FOR MANAGEMENT
SUMMARY
CHAPTER 16:
Corrosive Injury of Esophagus and Stomach
INTRODUCTION
EPIDEMIOLOGY
PATHOPHYSIOLOGY
CLINICAL FEATURES
INVESTIGATIONS
MANAGEMENT: ACUTE PHASE
Nonoperative Treatment
Surgical Management
MANAGEMENT: CHRONIC PHASE
Endoscopic Dilatation of Stricture
SURGICAL MANAGEMENT OF STRICTURE
Optimum Time for Reconstruction
ESOPHAGEAL RESECTION VERSUS ESOPHAGEAL BYPASS WITHOUT RESECTION
CHOICE OF ESOPHAGEAL REPLACEMENT
ROUTES FOR ESOPHAGEAL BYPASS
MANAGEMENT OF PHARYNGEAL STRICTURES
MANAGEMENT OF CORROSIVE GASTRIC STRICTURE
SIMULTANEOUS ESOPHAGEAL AND GASTRIC STRICTURES
LAPAROSCOPIC ESOPHAGEAL BYPASS
SOCIOECONOMIC IMPACT OF CORROSIVE INGESTION
CHAPTER 17:
Benign Tumors of the Esophagus
INTRODUCTION
EPIDEMIOLOGY
CLASSIFICATION
INTRAMURAL/EXTRAMUCOSAL TUMORS
Mesenchymal Tumors
Leiomyoma
Gastrointestinal Stromal Tumors
Schwannoma
Other Intramural/Extramucosal Tumors
Granular Cell Tumors
Hemangioma
Rhabdomyoma
Lipoma
INTRALUMINAL/MUCOSAL TUMORS
CHAPTER 18:
Carcinoma Esophagus
INTRODUCTION
EPIDEMIOLOGY AND RISK FACTORS
Esophageal Adenocarcinoma
Squamous Cell Carcinoma
CLINICAL PRESENTATION
STAGING
Summary of Stage Grouping
INVESTIGATIONS
Barium Esophagography
Endoscopy
Endoscopic Ultrasonography (EUS)
Computed Tomography (CT)
Positron Emission Tomography (PET)
Staging Laparoscopy
Bronchoscopy
MANAGEMENT
SURGERY
Types of Surgery
Extent of Lymphadenctomy
MULTIMODALITY THERAPY
Definitive Chemoradiotherapy (CRT)
Neoadjuvant Therapy
Neoadjuvant CRT
Neoadjuvant Chemotherapy
Perioperative Chemotherapy
PALLIATION OF ESOPHAGEAL CANCER
Esophageal Stenting
Surgery
External Beam Radiotherapy
Endoluminal Brachytherapy
Photodynamic Therapy
Laser Therapy
PROGNOSIS AND SURVIVAL
SUMMARY
CHAPTER 19:
Esophageal Cancer: Operative Strategies and Lymphadenectomy
SURGICAL TREATMENT OF ESOPHAGEAL CANCER
PATIENT SELECTION AND PREOPERATIVE PREPARATION
TECHNIQUES IN SURGICAL MANAGEMENT
Principles of Esophageal Resection
Types of Esophageal Resection
Operative Technique
Postoperative Care
ISSUES IN SURGICAL TREATMENT OF ESOPHAGEAL CANCER
Surgical Approach
Extent of Lymphadenectomy
Anastomotic Technique
Route of Reconstruction
Pyloric Drainage
SUMMARY
CHAPTER 20:
Multimodality Treatment in Carcinoma of the Esophagus
INTRODUCTION
SHOULD PATIENTS WITH RESECTABLE CANCER OF THE ESOPHAGUS BE OFFERED PREOPERATIVE OR POSTOPERATIVE THERAPY TOGETHER WITH SURGERY?
NEOADJUVANT CHEMORADIOTHERAPY FOLLOWED BY SURGERY: EVIDENCE BASE AND CRITIQUE
What are the Realistic Risks of NACRT in the Western Literature?
What Proportions of Patients Who Start a Course of NACRT Go on to Surgery?
What Proportion of Patients Achieved a Complete Resection, i.e. an R0 Resection Both in Longitudinal and Circumferential Resections Margins (CRMs)?
What Proportions of Operated Specimens had a Pathologically Complete Response?
Postoperative Morbidity?
Indian Experience
NEOADJUVANT CHEMOTHERAPY FOLLOWED BY SURGERY: EVIDENCE BASE AND CRITIQUE
Comparison of the Medical Research Council (UK) and the Radiation Therapy Oncology Group (USA) Trials
Indian Experience
THE CHOICE BETWEEN NEOADJUVANT CHEMOTHERAPY COMPARED WITH NEOADJUVANT CHEMORADIOTHERAPY, BOTH TO BE FOLLOWED BY SURGERY: EVIDENCE BASE AND CRITIQUE
Recommendations
POSTOPERATIVE THERAPY FOR NODE POSITIVE (N+), MICROSCOPIC (R1), OR GROSS RESIDUAL (R2) DISEASE
Indian Experience
COMBINED MODALITY TREATMENT IN THE NON-SURGICAL MANAGEMENT OF CANCER ESOPHAGUS
Indian Data
Recommendations
CHEMORADIOTHERAPY OR NACRT FOLLOWED BY SURGERY FOR OPERABLE PATIENTS?
Identifying Responders to NACRT Using FDG-PET
MANAGEMENT OF PATIENTS WITH NON-REGIONAL NODAL METASTASIS AJCC M1A OR OTHER SMALL VOLUME OLIGOMETASTASIS IN GOOD GENERAL CONDITION
PRIORITIZING MANAGEMENT OF PATIENTS WITH ADVANCED DISEASE, M1B IN POOR GENERAL CONDITION
CONCLUSION
CHAPTER 21:
Minimal Invasive Esophagectomy
INTRODUCTION
HISTORY
CLASSIFICATION OF MINIMAL INVASIVE ESOPHAGECTOMY
Anesthetic Considerations
Thoracic Epidural
SURGICAL TECHNIQUE
Thoracoscopic Esophageal Mobilization and Mediastinal Dissection in the Left Lateral Decubitus Position
Thoracoscopic Phase (As Described by Luketich et al.)11
Positioning and Port Placement
Thoracoscopic Phase in Prone Position
VISUALIZATION OF THE OPERATIVE FIELD DURING THORACOSOPY
TECHNICAL ADVANTAGES OF THE PRONE POSITION TECHNIQUE
BENEFITS AND LIMITATIONS OF PRONE ESOPHAGEAL SURGERY13
Potential Advantages
Potential Disadvantages
Minimally Invasive Esophagectomy in Semiprone Position
ROLE OF AZYGUS VEIN PRESERVATION
LAPAROSCOPIC PHASE (TECHNIQUE AS FOLLOWED AT SIDSS)
Position
Ivor Lewis Minimally Invasive Esophagectomy
Results
ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY
OUTCOME OF MINIMALLY INVASIVE ESOPHAGECTOMY
Learning Curve
SURGICAL OUTCOME
ONCOLOGICAL OUTCOME
QUALITY OF LIFE
AUTHOR'S EXPERIENCE
CHAPTER 22:
Esophageal Replacement Procedures
INTRODUCTION AND HISTORY
PLANNING OF ESOPHAGEAL REPLACEMENT
Indications of One Stage Operation
Contraindications for One Stage Operation
Timing of Second Stage Operation
SELECTION OF ESOPHAGEAL SUBSTITUTE
Contraindications for the Use of Stomach as Esophageal Substitute
Contraindications for the Use of Colon as Esophageal Substitute
Contraindications for the Use of Jejunum as Esophageal Substitute
Factors Affecting the Choice of Replacement Organ
ROUTES FOR ESPOPHAGEAL REPLACEMENTS
Posterior Mediastinal Route (Orthotopic)
Contraindications of this Route
Technique
Substernal/Retrosternal Space (Heterotopic)
Disadvantages
Technique
Subcutaneous Route/Antesternal (Heterotopic)
Drawbacks
Technique
STOMACH AS THE ESOPHAGEAL REPLACEMENT
Operative Technique
Complications after Gastric Pull-up
Postoperative Function of Gastric Conduit
COLON AS THE REPLACEMENT
Special Anatomic Considerations
Types of Colonic Conduits for Replacements
Operative Technique
Complications Related to Colonic Transpositions
Postoperative Function of the Transpositioned Colon
JEJUNAL GRAFTS
Pedicled Jejunal Grafts
Complications after Jejunal Interposition
Postoperative Function after Jejunal Interposition
Free Jejunal Grafts
Complications
Postoperative Function after Free Jejunal Grafts
ARTIFICIAL TUBES FOR ESOPHAGEAL REPLACEMENTS
Need of Artificial Esophagus
OUR EXPERIENCE
SECTION 3: STOMACH, DUODENUM, SMALL INTESTINE AND RETROPERITONEUM
CHAPTER 23:
Stomach and Duodenum
STOMACH
Gross Anatomy
Peritoneal Arrangement
Cardia
Fundus
Body
Pyloric Part
Lesser Curvature
Greater Curvature
Relations of the Stomach
Greater and Lesser Omentum
Lesser Omentum
Greater Omentum
BLOOD SUPPLY
Left Gastric Artery
Right Gastric Artery
Left Gastroepiploic Artery
Right Gastroepiploic Artery
Short Gastric Arteries
Arterial Circulation of the Gastric Wall
Veins of the Stomach (Fig. 4)
Left Gastric (Coronary) Vein
Right Gastric Vein
Right Gastroepiploic Vein
Short Gastric Veins
Left Gastroepiploic Vein
Lymphatic Drainage of the Stomach
NERVE SUPPLY
PHYSIOLOGY OF DUODENUM
Absorption
Calcium Absorption
Iron Absorption
Carbohydrate Absorption
Protein Absorption
Fat Absorption
Secretion
Motility
Mucosal Defense
CHAPTER 24:
Surgery for Peptic Ulcer Disease
INTRODUCTION
HISTORY AND EVOLUTION OF PEPTIC ULCER SURGERY
ELECTIVE SURGERY FOR PEPTIC ULCER DISEASE
Surgery for Intractable Duodenal Ulcer
Management of Difficult Duodenal Stump
Surgery for Intractable Gastric Ulcer
Gastric Ulcer: Benign or Malignant
EMERGENCY SURGERY FOR PEPTIC ULCER DISEASE
Perforation
Simple Perforated Duodenal Ulcer
Large Perforated Duodenal Ulcer
Laparoscopic or Open Repair
Role of Natural Orifice Transluminal Endoscopic Surgery
Perforated Gastric Ulcer
Bleeding
Surgery for Bleeding Duodenal Ulcer
Bleeding Gastric Ulcer
Gastric Outlet Obstruction
COMPLICATIONS FOLLOWING PEPTIC ULCER SURGERY
Postoperative Complications
Postgastrectomy Syndromes
Secondary to Gastric Resection
Secondary to Gastric Reconstruction
Secondary to Vagotomy
CHAPTER 25:
Carcinoma Stomach
EPIDEMIOLOGY
ETIOPATHOGENESIS
Helicobacter pylori
Dietary Factors
Hereditary and Genetic Factors
Other Risk Factors
CLINICAL FEATURES
CLASSIFICATION
STAGING
Extent of Node Metastasis
INVESTIGATIONS
MANAGEMENT
SURGERY
Endoscopic Mucosal Resection
Endoscopic Submucosal Dissection
GASTRECTOMY
SENTINEL LYMPH NODE BIOPSY
SYSTEMATIC LYMPH NODE DISSECTION
Metastatic Lymph Node Ratio
MARUYAMA INDEX (MI)
LAPAROSCOPIC GASTRECTOMY
ROBOTIC SURGERY
NEOADJUVANT TREATMENT
ADJUVANT THERAPY
PALLIATIVE THERAPY
TARGETED THERAPY
TREATMENT SUMMARY
SURVEILLANCE
CHAPTER 26:
Duodenal and Small Intestinal Tumors
INTRODUCTION
PATHOLOGY AND CLINICAL FEATURES
Benign Tumors
Duodenal Adenomas
Brunner's Gland Adenomas
Other Benign Tumors
Malignant Tumors
DIAGNOSIS AND TREATMENT
PROGNOSIS
INTRODUCTION
ADENOCARCINOMA
Clinical Presentation
Pathology and Risk Factors
Diagnosis
Treatment
Surgical Management
Treatment of Locally Advanced Disease
Treatment of Metastatic Disease
LYMPHOMA
CARCINOIDS
Classification
Clinical Features
Pathology
Treatment
Surgery
Medical Therapies
BENIGN TUMORS AND POLYPS
Small Bowel Polyposis
Classification
Presentation
Treatment and Prevention
CHAPTER 27:
Gastric Bezoar and Gastric Volvulus
INTRODUCTION
INCIDENCE
ETIOLOGY
TYPES
PRESENTATION
DIAGNOSIS
TREATMENT
Surgery
Endoscopic Therapy
Medical Therapy
PREVENTION
INTRODUCTION AND HISTORY
CLASSIFICATION
Anatomical Classification
Organoaxial Type
Mesenteroaxial Type
Combined Type
Etiological Classification
Type 1
Type 2
CLASSIFICATION ACCORDING TO ONSET
Acute Gastric Volvulus (Usually Organoaxial Type)
Chronic Gastric Volvulus (Usually Mesenteroaxial Type)
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
Biochemistry
Imaging
Endoscopy
MANAGEMENT
OPEN SURGICAL APPROACH
Preoperative Management
Surgical Approach
Endoscopic Reduction
Future Trends
Complications
Prognosis
CHAPTER 28:
Intestinal Obstruction
PATHOPHYSIOLOGY
Clinical Features
Investigation
Management
SPECIAL PROBLEMS AND THEIR MANAGEMENT
Obstructed Hernia
Obstruction Due to Adhesions or Bands
TUBERCULAR OBSTRUCTION
CROHN'S' STRICTURE
GALLSTONE ILEUS
COLONIC MALIGNANCY
DIVERTICULITIS
VOLVULUS
INTUSSUSCEPTION
POSTOPERATIVE ILEUS (POI)
CONCLUSION
CHAPTER 29:
Abdominal Tuberculosis
INTRODUCTION
ETIOPATHOGENESIS AND PATHOLOGY
CLINICAL FEATURES
INVESTIGATIONS
Microscopy and Culture
Ascitic Fluid Analysis
Endoscopy
Laparoscopy
Serological Tests
Amplification Methods
Intestinal Tuberculosis
Complications
Tubercular Peritonitis
Lymph Nodal Disease
Esophageal Tuberculosis
Gastroduodenal Tuberculosis
Anorectal Disease
Pancreatic Tuberculosis
Hepatobiliary Tuberculosis
Medical Management
SURGICAL TREATMENT
CHAPTER 30:
Gastrointestinal Lymphomas
INTRODUCTION
SYMPTOMS
STAGING
DIAGNOSIS
Gastric Lymphoma
Intestinal Lymphoma
TREATMENT
Gastric Lymphoma
Intestinal Lymphoma
PROGNOSIS
Subtypes of Lymphoma Arising in the Small Intestine
Diffuse Large B-cell Lymphoma
Mucosal-associated Lymphoid Tissue Lymphoma
Burkitt's Lymphoma
T-cell Lymphomas of the Small Intestine
SUMMARY
CHAPTER 31:
Visceral Artery Aneurysms
INTRODUCTION
EPIDEMIOLOGY
ETIOLOGY
DIAGNOSIS
TREATMENT
SPLENIC ARTERY ANEURYSM (SAA)
Splenic Artery Aneurysm and Pregnancy
Splenic Artery Aneurysm and Portal Hypertension
False Aneurysm
Pancreatitis and Pseudoaneurysm
Natural History and Clinical Symptoms
Rupture of Splenic Artery Aneurysm
Postoperative
Diagnosis
Management
Endovascular
Surgery
Emergency Indications
Elective
HEPATIC ARTERY ANEURYSM (HAA)
Clinical Presentation
Management
CELIAC ARTERY ANEURYSM
Management
SUPERIOR MESENTERIC ARTERY ANEURYSM (FIG. 8)
Management
GASTRODUODENAL ARTERY (GDA) ANEURYSM AND PANCREATICODUODENAL ARTERY (PDA) ANEURYSM
Others
CONCLUSION
CHAPTER 32:
Mesenteric Ischemia
INTRODUCTION
ANATOMIC CONSIDERATIONS
Arterial Supply
Venous Drainage
PHYSIOLOGY
Regulation of Mesenteric Blood Flow
Extrinsic Control
Intrinsic Regulation
ACUTE MESENTERIC ISCHEMIA
Etiopathogenesis
Acute Arterial Embolism
Mesenteric Artery Thrombosis
Nonocclusive Mesenteric Ischemia
Mesenteric Venous Thrombosis
Clinical Features
Symptoms
Signs
MANAGEMENT
Investigations
Laboratory Investigations
Radiological Investigations
TREATMENT
Medical
Volume Resuscitation
Choice of Vasopressors and Other Drugs
Intestinal Decompression
Antibiotics
Anticoagulation
Interventional (Nonsurgical)
Selective Vasodilator Infusion
Thrombolysis
Angioplasty
Other Interventions
Surgery
Operating Room Set-up and Requirements
Incision and Exposure
Revascularization
Resection
PROGNOSIS
CHAPTER 33:
Radiation Enteritis: Pathophysiology, Prevention and Management
INTRODUCTION
PATHOPHYSIOLOGY
CLINICAL MANIFESTATIONS
GRADING
Acute Enteritis
Chronic Enteritis
DIAGNOSIS AND MANAGEMENT
Conservative Management
Surgical Management
MEDICAL MANAGEMENT OF RADIATION ENTERITIS
Hyperbaric Oxygen Therapy
Role of Sulfasalazine
PREVENTION OF RADIATION-INDUCED INTESTINAL INJURY
Radiation Delivery Techniques
Patient Positioning Techniques
Defining Bowel Loops in Simulation and Image Segmentation
Preoperative Radiation Therapy
Role of Surgical Bowel Displacement before Radiation
PHARMACOLOGICAL PREVENTION OF RADIATION ENTERITIS
CONCLUSION
CHAPTER 34:
Gastrointestinal Stromal Tumor
INTRODUCTION AND HISTORICAL ASPECT
EPIDEMIOLOGY
FAMILIAL GASTROINTESTINAL STROMAL TUMOR SYNDROMES
ANATOMICAL LOCATION OF TUMOR
Esophagus
Stomach
Small Bowel
Colon and Rectum
PRESENTATION
Signs and Symptoms of Gastrointestinal Stromal Tumors
EVALUATION
IMAGING TESTS
BARIUM X-RAYS
COMPUTED TOMOGRAPHY (CT) SCAN
MAGNETIC RESONANCE IMAGING SCANS
POSITRON EMISSION TOMOGRAPHY (PET) SCAN
ENDOSCOPY
ENDOSCOPIC ULTRASOUND
BIOPSY AND IMMUNOHISTOCHEMISTRY
STAGING
AJCC TNM Staging System
T Categories for Gastrointestinal Stromal Tumor
N Categories for Gastrointestinal Stromal Tumor
M Categories for Gastrointestinal Stromal Tumor
Histological Grade
Stage Grouping
Gastric Gastrointestinal Stromal Tumor
Small Intestinal Gastrointestinal Stromal Tumor
PROGNOSTIC FACTORS
Grading of Gastrointestinal Stromal Tumors
Resectable versus Unresectable Tumors
Survival Rates for Gastrointestinal Stromal Tumors
TREATMENT OPTIONS AND ALGORITHM
Surgery for Gastrointestinal Stromal Tumors
TARGETED THERAPY FOR GASTROINTESTINAL STROMAL TUMOR
Resistance to Imatinib
Assessment of Response
Adjuvant Therapy
Preoperative Therapy
Palliative Therapy
Follow-up Care
CHAPTER 35:
Retroperitoneal Tumors
INTRODUCTION
ANATOMY OF RETROPERITONEAL SPACE
PATHOLOGY OF RETROPERITONEAL TUMORS
CLINICAL FEATURES OF RETROPERITONEAL TUMORS
INVESTIGATION OF A RETROPERITONEAL MASS
Imaging
Tumor Detection and Characterization
Tumor Staging
Imaging Follow Up
Biopsy
Tumor Markers
PROGNOSTIC FACTORS
TREATMENT
Surgery for Retroperitoneal Tumors
Radiation Therapy
Chemotherapy
Recurrent Disease
Local Recurrence
Metastatic Disease
Palliative Procedures
SUMMARY
SECTION 4: PANCREAS
CHAPTER 36:
Pancreas: Embryology, Anatomy and Physiology
INTRODUCTION
EMBRYOLOGY
DEVELOPMENTAL ANOMALIES
ANATOMY
PANCREATIC DUCTS
MAJOR PAPILLA
MINOR PAPILLA
SPHINCTER OF ODDI
ARTERIAL SUPPLY
VENOUS DRAINAGE
LYMPHATIC DRAINAGE
NERVE SUPPLY
PHYSIOLOGY
Exocrine Pancreas
Endocrine Pancreas
Intra-Islet Regulation
CHAPTER 37:
Acute Pancreatitis
INTRODUCTION
DEFINITION
MAGNITUDE
CLINICAL PRESENTATION
ETIOLOGY
Mechanism of Pancreatic Injury and Inflammation
Pathophysiological Perturbations in the Initiation and Progression of Acute Pancreatitis
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
Differential Diagnosis
Investigations
Imaging Investigations
Microbiological Investigations
CLINICAL COURSE AND COMPLICATIONS
Local Complications
Fluid Collections
Necrosis
Other Non-pancreatic Local Complications
Systemic Complications
Prediction of Severity of Acute Pancreatitis
Scoring Systems
Single Prognostic Markers
Imaging-based Assessment of Severity
Classification of the Severity of Acute Pancreatitis
Treatment
INITIAL STABILIZATION AND RESUSCITATION
Nutritional Support
Prevention and Treatment of Infection
Management of Organ Failure
MANAGEMENT OF FLUID COLLECTIONS AND NECROSIS
Pancreatic Necrosectomy
Management of Complications
PSEUDOCYST
Prognosis
Prevention of Recurrence
CHAPTER 38:
Surgery in Acute Pancreatitis
NATURAL HISTORY OF ACUTE PANCREATITIS
DIAGNOSIS OF INFECTED PANCREATIC NECROSIS
TIMING OF INTERVENTION
CURRENT MANAGEMENT GUIDELINES
ROLE OF PERCUTANEOUS CATHETER DRAINAGE IN PANCREATIC NECROSIS
INDICATIONS FOR SURGERY
MINIMALLY INVASIVE APPROACHES TO NECROSECTOMY (TABLE 1)
Laparoscopic Transperitoneal Necrosectomy
Minimally Invasive Retroperitoneal Necrosectomy
Open Necrosectomy
Closed Continuous Lavage
Planned Staged Relaparotomies with Repeated Lavage
Ventral Open Packing
Closed Packing
CONCLUSION
CHAPTER 39:
Pseudocyst and Other Complications of Pancreatitis
INTRODUCTION
DEFINITION AND NOMENCLATURE
CLINICAL FEATURES
DIAGNOSIS
ROLE OF OTHER IMAGING MODALITIES
TREATMENT
When to Intervene?
Whom to Intervene?
How to Intervene?
IMAGE-GUIDED PERCUTANEOUS APPROACHES
Transperitoneal Approach
Retroperitoneal Approach
ENDOSCOPIC TREATMENT TECHNIQUES
Hybrid Approaches
Pseudocyst
CLASSIFICATION
CLINICAL FEATURES
DIAGNOSIS
Laboratory Parameters
CECT Scan
MRI/MRCP
Endoscopic Ultrasound
MANAGEMENT
Expectant Treatment
Internal Drainage
Endoscopic Drainage
CONCLUSION
CHAPTER 40:
Medical Management of Chronic Pancreatitis
INTRODUCTION
EPIDEMIOLOGY
ETIOLOGICAL CLASSIFICATION OF CHRONIC PANCREATITIS
CLINICAL FEATURES
DIAGNOSIS
Tests of Function
Direct Hormonal Stimulation Test (With Secretin or Cholecystokinin)
Magnetic Resonance Cholangiopancreatography with Secretin Stimulation (sMRCP)
Fecal Elastase Levels
Fecal Chymotrypsin Activity
13C-Mixed Triglyceride Breath Test
Fecal Fat Estimation
Tests of Structure
Plain Abdominal Radiographs
Ultrasound
CT or MRI
Endoscopic Retrograde Cholangiopancreatography
Magnetic Resonance Cholangiopancreatography
Endoscopic Ultrasound
MEDICAL MANAGEMENT OF CHRONIC PANCREATITIS
Diet and Life-style Modifications
Abdominal Pain
Pancreatic Exocrine Insufficiency
Pancreatogenic Diabetes
OTHER COMPLICATONS OF CHRONIC PANCREATITIS
CHAPTER 41:
Surgery for Chronic Pancreatitis
INTRODUCTION
INDICATIONS FOR SURGERY
Rationale of Surgery in Chronic Pancreatitis
Timing of Surgery
Surgical Options
Preoperative Assessment
RESECTIONAL PROCEDURES
Pancreaticoduodenectomy
Distal Pancreatectomy
Distal Pancreatectomy (95%)
Total Pancreatectomy
Autologous Islet Transplantation
DRAINAGE PROCEDURES
HYBRID PROCEDURES
Frey Procedure
Duodenum Preserving Head Resection
Modifications of Hybrid Procedures
Comparison of Operative Procedures
Frey's versus Pancreaticoduodenectomy
Beger versus Pancreaticoduodenectomy
Frey versus Beger
Denervation Procedure
MANAGEMENT OF COMPLICATIONS OF CHRONIC PANCREATITIS
Biliary Obstruction
Duodenal Obstruction
Portal Hypertension
CONCLUSION
CHAPTER 42:
Pancreatic and Periampullary Cancer
INTRODUCTION
FACTORS IMPLICATED IN PATHOGENESIS
TNM Classification of Pancreatic Cancer
Signs and Symptoms of Pancreatic Cancer20,21
INVESTIGATIONS
Complementary Investigations
DIAGNOSIS OF IPMN/MCN
SURGICAL MANAGEMENT
Resectable Pancreatic Cancer
Head, Uncinate Process and Proximal Neck of Pancreas (Including Periampullary Cancer)
Distal Neck, Body and Tail of Pancreas
Resectable Locally Advanced Pancreatic Cancer
Borderline Resectable Tumors
Vascular Resections
PANCREATIC RESECTION IN METASTATIC DISEASE
LAPAROSCOPY AND ROBOTIC SURGERY FOR PANCREATIC AND PERIAMPULLARY CARCINOMA
SURGICAL MANAGEMENT GUIDELINES FOR INVASIVE AND NON-INVASIVE IPMN AND MCN
Recommendations from the International Consensus Guidelines 201215
FAST-TRACK PROTOCOLS/ENHANCED RECOVERY20
PALLIATIVE GASTROENTEROSTOMY AND/OR BILIODIGESTIVE BYPASS77
CHEMOTHERAPY AND CHEMORADIOTHERAPY FOR RESECTABLE PANCREATIC CANCER
Adjuvant Therapy
Neoadjuvant Therapy
Palliative Therapy
SUMMARY
CHAPTER 43:
Pancreatic Surgery
INTRODUCTION
MODIFICATIONS OF PANCREATICODUODENECTOMY
Artery First Dissection
Standard versus Pylorus Preserving (PPPD) versus Subtotal Stomach Preserving Pancreaticoduodenectomy (SSPPD)
Vascular Resection
Venous Resection
Arterial Resection
Multivisceral Resection
Role of Extended Lymphadenectomy
Ultraradical Surgery
Minimally Invasive Pancreaticoduodenectomy
RECONSTRUCTION OF GASTROINTESTINAL CONTINUITY
Pancreatic Reconstruction
Biliary Anastomosis
Duodenal Anastomosis
Role of Drains
Postoperative Management
Complications Related to Pancreaticoduodenectomy
PERIOPERATIVE MORBIDITY AND MORTALITY
T Stage96
Nodal Status
Margin Status
SPECIAL SITUATIONS
Aberrant Arteries
Uncinate Process Tumors
Pancreaticoduodenectomy in Non-pancreatic Neoplasm
Pancreaticoduodenectomy in Chronic Pancreatitis
Metastases to the Pancreas
TRANSDUODENAL EXCISION OF PAPILLA OF VATER
Technique
INTRODUCTION
DISTAL PANCREATECTOMY
STANDARD PROCEDURE: OPEN DISTAL PANCREATECTOMY WITH EN BLOC SPLENECTOMY
MODIFICATIONS OF DISTAL PANCREATECTOMY
Distal Pancreatectomy with Spleen Preservation
Radical en bloc Distal Pancreatectomy
Radical Antegrade Modular Pancreaticosplenectomy (RAMPS)/Multivisceral Resection
Modified Appleby's Procedure
Laparoscopic Distal Pancreatectomy
COMPLICATIONS OF DISTAL PANCREATECTOMY
Pancreatic Fistula
Endocrine and Exocrine Insufficiency
CENTRAL/MEDIAN PANCREATECTOMY OR REGIONAL PANCREATECTOMY
Procedure
TOTAL PANCREATECTOMY
ENUCLEATION
MIDDLE PRESERVING PANCREATECTOMY
CHAPTER 44:
Cystic Neoplasms of the Pancreas
INTRODUCTION
INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM
General Aspects
Classification by Macroscopic Type
Diagnosis
Histological Aspects
Characteristics of Each Macroscopic Type
MD-IPMN
BD-IPMN
Association of Pancreatic Ductal Adenocarcinoma with IPMN
Prognosis of IPMN
MUCINOUS CYSTIC NEOPLASM
Differentiation of IPMN and MCN
SEROUS CYSTIC NEOPLASM
SOLID-PSEUDOPAPILLARY TUMOR
DERMOID CYST
CHAPTER 45:
Neuroendocrine Tumors of the Pancreas
INTRODUCTION
EPIDEMIOLOGY
PATHOLOGY
STAGING
CLINICAL FEATURES
SPECIFIC pNETs
Investigations
Biochemical Tumor Markers
Immunohistochemical Markers
Imaging (Morphological)
Imaging (Functional)
Treatment
Surgical Management
Liver-Directed Therapy
Thermal Ablation
Transarterial Embolization (TAE) and Transarterial Chemoembolization (TACE)
Selective Internal Radiation Therapy (SIRT)
Hepatic Artery Infusion
Percutaneous Alcohol Injection (PAI)
Systemic Therapy
Somatostatin Analogs
Peptide Receptor Radionuclide Therapy
Systemic Chemotherapy
Targeted Therapy
CONCLUSION
CHAPTER 46:
Minimally Invasive Approach to Pancreatic Lesions
INTRODUCTION
HISTORY
TYPES OF RESECTION
Distal Pancreatectomy (Figs 1A to F)
Indications
Contraindications
Preoperative Preparation
Operative Technique
Results and Review of Literature
Parenchyma Preserving Pancreatectomy
Need for Parenchyma Preservation
Enucleation
Median Pancreatectomy (Figs 2A to E)
Indications
Contraindications
Our Operative Technique
Results and Review of Literature
Pancreaticoduodenectomy (Figs 3A to I)
Indications
Team Set-Up, Patient Positioning and Instrumentation
Operative Details
Phase 1: Resection
Phase 2: Reconstruction
Results and Review of Literature
CONCLUSION
CHAPTER 47:
Pancreaticoduodenal Injuries
INTRODUCTION
CLINICAL PRESENTATIONS
Emergency Setting: Unstable Patient
Lifesaving Laparotomy for Abdominal Trauma3
Exploration for Pancreatic or Duodenal Injury
Emergency Setting: Stable Patient
Mechanism of Injury
Clinical Examination
INVESTIGATIONS
GRADING OF INJURIES
DEFINITIVE TREATMENT
ISOLATED DUODENAL INJURIES
ISOLATED PANCREATIC INJURIES
COMBINED PANCREATICO-DUODENAL INJURY
Drainage
Octreotide
Outcome
Complications
AUTHOR'S VIEWS
SUMMARY
CHAPTER 48:
Pancreas and Islet Transplantation
INTRODUCTION
HISTORY
INDICATION OF PANCREAS TRANSPLANT
CADAVERIC PANCREAS TRANSPLANTATION
Selection of Cadaver Donor
Donor Surgery
Backbench Surgery
Recipient Evaluation
Diabetic Retinopathy
Gastroparesis
Coronary Artery Disease
Stroke
Peripheral Vascular Disease
Autonomic Neuropathy
Motor and Sensory Neuropathies
Mental or Emotional Illnesses
Recipient Surgery
COMPLICATIONS OF PANCREAS TRANSPLANT
Surgical Complications
Vascular Thrombosis
Leak
Pancreatitis
Bleeding
Lymphocoele
Immunological Complication
Acute Rejection
Chronic Rejection
Other Complications
Postoperative Management
Immunosuppression
Outcome of Pancreas Transplant
PANCREAS TRANSPLANTATION AND EFFECT ON SECONDARY COMPLICATIONS OF DIABETES
Nephropathy
Retinopathy
Neuropathy
Living Donor Pancreas Transplant
Donor Selection
Living Donor Surgery
Recipient Surgery
Results
SECTION 5: GALLBLADDER AND BILE DUCTS
CHAPTER 49:
Gallbladder and Bile Ducts: Anatomy and Physiology
INTRODUCTION
EMBRYOLOGY OF GALLBLADDER AND BILIARY SYSTEM
ANATOMY OF GALLBLADDER
Histology of Gallbladder
Mucous Membrane
Muscularis
Adventitia or Serosa
Cystic Duct
Extrahepatic Biliary Anatomy
Common Bile Duct
Pancreatobiliary Junction
Histology of Extrahepatic Biliary Ducts
Intrahepatic Ducts
Hilar Plate
Sphincter of Oddi
Sphincter of Oddi Physiology and Functional Issues
Vascular Anatomy
Venous Drainage
Calot's Triangle
Lymphatic Drainage of Gallbladder
ANOMALIES OF GALLBLADDER AND BILIARY APPARATUS
Anomalies of Hepatic Ducts
Cystic Duct Anomalies
Gallbladder Anomalies
Abnormal Formation
Abnormal Number
Abnormal Position of Gallbladder
Anomalies of Common Bile Duct
Vascular Anomalies
GALLBLADDER PHYSIOLOGY
Bile Formation
Bile Composition3
Bile Salt Secretion
Enterohepatic Circulation
Cholesterol Saturation
Bilirubin Metabolism
Bile Flow
GALLBLADDER FUNCTION
Absorption
Secretion
Motility
CHAPTER 50:
Imaging of Liver and Biliary Tract
INTRODUCTION
GALLBLADDER IMAGING
Congenital Pathology
Gallbladder Duplication
Inflammatory Lesions
Acute Cholecystitis
Chronic Cholecystitis
Gangrenous Cholecystitis
Gallbladder Perforation
Gallbladder Empyema
Emphysematous Cholecystitis
Xanthogranulomatous Cholecystitis
Acalculous Cholecystitis
Noninflammatory Lesions
Adenomyomatosis
Malignant Lesions
Gallbladder Carcinoma
BILIARY TRACT IMAGING
Congenital Bile Duct (Choledochal) Cysts
Stone Disease
Bile Leak
Inflammatory Disorders
Infectious Cholangitis
Recurrent Pyogenic Cholangitis
Primary Sclerosing Cholangitis
Bile Duct Tumors
Benign Bile Duct Adenoma
Precancerous Tumor
Biliary Intraepithelial Neoplasia
Intraductal Papillary Mucinous Neoplasm of Bile Duct (IPMN-B)
Malignant
Cholangiocarcinoma
HEPATIC IMAGING
Hepatic Trauma
Hepatic Infections
Pyogenic Abscess
Amebic Abscess
Hydatid Disease
Benign Hepatic Tumors
Hemangioma
Focal Nodular Hyperplasia
Hepatocellular Adenoma
Lipomatous Tumors
Infantile Hemangioendothelioma
Mesenchymal Hamartoma
Malignant Hepatic Tumors
Hepatocellular Carcinoma
Fibrolamellar Carcinoma
Hepatoblastoma
Epithelioid Hemangioendothelioma
Angiosarcoma
Metastases
CHAPTER 51:
Endoscopic Retrograde Cholangiopancreatography in Biliary and Pancreatic Diseases
BACKGROUND
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: ROLE IN DIAGNOSIS OF PANCREATICOBILIARY DISORDERS
INDICATIONS OF DIAGNOSTIC ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
PANCREATICOBILIARY STRICTURES
ENDOSCOPIC DIAGNOSIS OF BILIARY TRACT DISEASE: RECENT ADVANCES
Digital Image Analysis and Fluorescent in situ Hybridization
Cholangioscopy
Confocal Laser Endomicroscopy
THERAPEUTIC ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN PANCREATICOBILIARY DISORDERS
Indications of Therapeutic Endoscopic Retrograde Cholangiopancreatography in Biliary Disorders
Choledocholithiasis
Endoscopic Therapy in Difficult Common Bile Duct Stones
Acute Cholangitis
Bile Leaks
Endoscopic Retrograde Cholangiopancreatography in Benign Biliary Strictures
Chronic Pancreatitis-related Biliary Strictures
Primary Sclerosing Cholangitis
Autoimmune Cholangiopathy
Endoscopic Management of Malignant Biliary Obstruction
Novel Endoscopic Techniques for Palliation of Cholangiocarcinoma
Sphincter of Oddi Dysfunction
ENDOSCOPIC RETROGRADE PANCREATOGRAPHY (ERP) IN PANCREATIC DISORDERS
Indications of Endoscopic Retrograde Pancreatography
Endoscopic Retrograde Cholangiopancreatography in Acute Pancreatitis
Endoscopic Retrograde Cholangiopancreatography in Acute Gallstone Pancreatitis
Recurrent Acute Pancreatitis
Pancreas Divisum
Pancreatic Duct Leak
Endoscopic Retrograde Cholangiopancreatography in Chronic Pancreatitis
Role in Diagnosis
Endotherapy in Chronic Pancreatitis
Endoscopic Management of Pancreatic Ductal Strictures and Stones
Pseudocyst
SUMMARY
CHAPTER 52:
Gallstone Disease
INTRODUCTION
PATHOGENESIS OF GALLSTONES
Normal Bile
Black Pigment Stones
Brown Pigment Stones
Cholesterol Stones
CLINICAL PRESENTATIONS AND DECISION-MAKING IN GALLSTONE DISEASE
Asymptomatic Gallstones
Selective Cholecystectomy
Concomitant Cholecystectomy
Acute Cholecystitis
Criteria for Acute Cholecystitis
Severity Assessment Criteria for Acute Cholecystitis
Sensitivity and Specificity of Criteria Considered in TG13
Gangrenous Cholecystitis
Emphysematous Cholecystitis
Empyema Gallbladder
Chronic Cholecystitis
Xanthogranulomatous Cholecystitis (XGC)
Radiographic Features of Xanthogranulomatous Cholecystitis
Gallstones and Pancreatitis
Acute Pancreatitis
Chronic Pancreatitis
Gallstones and Gallbladder Cancer
Laparoscopic Cholecystectomy
Difficult Cholecystectomy: Factors Predicting Overall Operative Difficulty
Clinical Factors
Ultrasonographic Factors
Preoperative
Position
Access to Peritoneal Cavity
Laparoscopic Inspection
Decision-Making
Dissection and Clipping of Cystic Duct
Isolation of Cystic Artery and Clipping of Artery
Dissection of Gallbladder from Fossa
Removal of Gallbladder and Closure
Extraction of Gallbladder
Closure of Port Wounds
Common Ending for All Methods
Complications
On Table
Early
Late
CONCLUSION
CHAPTER 53:
Current Management of Common Bile Duct Stones
INTRODUCTION
HISTORY
INCIDENCE
CLINICAL PRESENTATION
DIAGNOSTIC INVESTIGATIONS
LABORATORY TESTS
IMAGING MODALITIES
Transabdominal Ultrasonography
Endoscopic Retrograde Cholangiopancreatography
Percutaneous Transhepatic Cholangiography
Endoscopic Ultrasound
Magnetic Resonance Cholangiopancreatography
Intraoperative Cholangiography
Intraductal Ultrasonography
MANAGEMENT OPTIONS
Open Common Bile Duct Exploration
Preoperative Endoscopic Retrograde Cholangiopancreatography
Intraoperative Endoscopic Retrograde Cholangiopancreatography
Postoperative Endoscopic Retrograde Cholangiopancreatography
Laparoscopic Common Bile Duct Exploration
Extracorporeal Shock Wave Lithotripsy
Dissolution Techniques
Percutaneous Extraction
ENDOSCOPIC VERSUS LAPAROSCOPIC REMOVAL
CURRENT SCENARIO
Stones Diagnosed Preoperatively
Stones Discovered Intraoperatively
Stones Discovered Postoperatively
LAPAROENDOSCOPIC SINGLE-SITE SURGERY
ROBOTIC
CONCLUSION
CHAPTER 54:
Cholangitis
DEFINITION
ETIOPATHOGENESIS OF CHOLANGITIS
DIAGNOSIS OF CHOLANGITIS
Diagnosis
Laboratory Values
Imaging
Ultrasonography
Computed Tomography
Magnetic Resonance Cholangiopancreatography
Endoscopic Retrograde Cholangiopancreatography
Endoscopic Ultrasound
Other Tests
Blood Culture
Bile Culture
TREATMENT
General Supportive Care
Antibiotics
Biliary Drainage
Endoscopic Biliary Drainage
Percutaneous Transhepatic Cholangiography
Surgery
CHAPTER 55:
Biliary Atresia
INTRODUCTION
EPIDEMIOLOGY
ANATOMICAL CLASSIFICATION OF BILIARY ATRESIA
ETIOLOGICAL CLASSIFICATION OF BILIARY ATRESIA
Embryonic/Congenital/Developmental Form
Patients with Syndromic Biliary Atresia
Cystic Biliary Atresia9,15
Acquired or Perinatal Form
CLINICAL FEATURES
DIAGNOSIS
Ultrasonography
Duodenal Intubation
Radioisotope Scan
Liver Biopsy
Other Tests
SCREENING FOR BILIARY ATRESIA
Surgery
PORTOENTEROSTOMY
COMPLICATIONS
Cholangitis
Intrahepatic Biliary Lakes
Portal Hypertension and Esophageal Varices
Ascites
Malignancy
ADJUVANT THERAPY FOR BILIARY ATRESIA
Antibiotics
Corticosteroids
Ursodeoxycholic Acid
Antiviral Drugs
LIVER TRANSPLANTATION
PROGNOSTIC FACTORS
Age at Kasai Portoenterostomy
Type of Biliary Atresia
Liver Histology and Biliary Remnant: Anatomical Effect
Postoperative Biochemical Results
Post-KPE Intrapulmonary AV Shunts
Manganese Toxicity
Centralization: Who Should Do the Kasai Portoenterostomy?
OVERALL SURVIVAL
FUTURE CONSIDERATIONS
CHAPTER 56:
Choledochal Cysts
INTRODUCTION
DEMOGRAPHICS
CLINICAL FEATURES
CLASSIFICATION
Caroli Disease and Caroli Syndrome
PATHOPHYSIOLOGY
COMPLICATIONS
Cystolithiasis
Pancreatitis
Pseudopancreatitis19
Chronic Pancreatitis
Cholangitis and Intrahepatic Abscesses
Cirrhosis
Cyst Perforation
Malignancy
DIFFERENTIAL DIAGNOSIS
IMAGING
HISTOPATHOLOGY
FORME FRUSTE
SURGICAL MANAGEMENT
TECHNIQUE
LILLY TECHNIQUE
BILIARY RECONSTRUCTION (HEPATICOJEJUNOSTOMY VS HEPATICODUODENOSTOMY)
Type I Cysts
Type II Cysts
Type III Choledochal Cysts
Type IV Cysts
Type V Cysts
LAPAROSCOPIC CHOLEDOCHAL CYST EXCISION
BILIARY CIRRHOSIS AND PORTAL HYPERTENSION
FOLLOW-UP
CHAPTER 57:
Bile Duct Injury, Biliary Fistula and Benign Biliary Stricture
INTRODUCTION
POST-CHOLECYSTECTOMY BILE DUCT INJURY
Mechanism of Injury
Factors Predisposing to Bile Duct Injury
Prevention of the Injury
Classification
Clinical Presentation
Bilioma
External Biliary Fistula
Bile Duct Ligation/Clipping (Figs 5A and B)
Early versus Delayed Presentation
Differentiation of Biliary Injury from Enteric Injury
Evaluation
Cholangiography
IOC (Fig. 7)
ERCP (Fig. 8)
MRCP (Figs 9A to D)
PTC (Fig. 10)
Tubogram and Fistulogram (Fig. 11)
Scintigraphy
Management
Management of Bilioma
Management of EBF
Fistula Closure
Definitive Management
Endoscopic Treatment
Percutaneous Transhepatic Biliary Catheterization
Surgical Treatment
Timing of Repair
Early versus Delayed Repair
Operative Management of Injuries Which are Recognized Immediately (Figs 12A and B)
Role of Laparoscopy
Vasculobiliary Injuries (Fig. 13)
Sectoral Duct Injuries (Figs 14A and B)
INTRODUCTION
EXTERNAL BILIARY FISTULA
Causes of External Biliary Fistula
Post-cholecystetomy EBF
Traumatic
Post-gastrectomy
Following Common Bile Duct Exploration
Following Biliary Enteric Anastomosis
Following Liver Resection
Spontaneous External Fistulization
After Interventions
INTERNAL BILIARY FISTULA
Biliobiliary Fistula
Biliary Enteric Fistula
intravascular Fistulization
Hemobilia
Bilhemia
Intrathoracic Fistulization
INTRODUCTION
CLASSIFICATION OF BENIGN BILIARY STRICTURES
Iatrogenic
Traumatic
Ischemic
Inflammatory
Infectious
Post-cholecystectomy Benign Biliary Stricture
PRESENTATION
Differentiation between Benign and Malignant Strictures
Sequelae of Biliary Stricture
INVESTIGATIONS
MANAGEMENT
Operative Management
Operative Procedure
Results of Surgical Repair
Factors Deciding Successful Repair
Liver Transplantation
Nonoperative Management
Benign Biliary Stricture Due to Other Causes
Secondary to Peptic Ulcer Disease
Secondary to Chronic Pancreatitis
Endoscopic Management
Surgical Management
Bilioenteric Bypass
CHAPTER 58:
Primary Sclerosing Cholangitis
INTRODUCTION
EPIDEMIOLOGY
CURRENT PATHOGENETIC CONCEPTS IN PRIMARY SCLEROSING CHOLANGITIS
MANIFESTATIONS
Clinical Features
Natural History
Autoantibodies in Primary Sclerosing Cholangitis
Radiology
Classic Primary Sclerosing Cholangitis
Small Duct Primary Sclerosing Cholangitis
Liver Biopsy
CAUSES OF SECONDARY SCLEROSING CHOLANGITIS
COMPLICATIONS OF SECONDARY SCLEROSING CHOLANGITIS
MALIGNANCIES IN PRIMARY SCLEROSING CHOLANGITIS
PROGNOSIS
Calculated Patient Survival35
MANAGEMENT
Ursodeoxycholic Acid
High-dose UDCA
UDCA Plus Therapies
ENDOSCOPIC THERAPY
LIVER TRANSPLANTATION
CHAPTER 59:
Recurrent Pyogenic Cholangitis
INTRODUCTION
PATHOGENESIS
PATHOLOGY
CLINICAL PRESENTATION
INVESTIGATIONS
MANAGEMENT
Management of Acute Episode
Definitive Management
Role of Minimally Access Approach
Role of Surgery
Outcome of Different Modalities of Treatments
CHAPTER 60:
Gallbladder Polyps
INTRODUCTION
RISK FACTORS FOR GALLBLADDER POLYPS
PATHOLOGICAL TYPES
MORPHOLOGY
PRESENTING FEATURES
DIAGNOSIS
Ultrasonography
Transabdominal Ultrasonography
Harmonic and Contrast Ultrasonography
Endoscopic Ultrasonography
Computed Tomography
Magnetic Resonance Imaging
Positron Emission Tomography
PREDICTORS OF MALIGNANCY
MANAGEMENT OF GALLBLADDER POLYP
SURVEILLANCE OF GALLBLADDER POLYPS
CHAPTER 61:
Carcinoma Gallbladder
INTRODUCTION
EPIDEMIOLOGY
ETIOLOGY
GENETICS IN GALLBLADDER CANCER
RELEVANT ANATOMY OF GALLBLADDER
PATHOLOGY
CLINICAL FEATURES
Investigation
CT Scan
MRI and MRCP
PET
Endoscopic Ultrasound
Tumor Markers
Staging
Modified Nevin Classification
Tumor
Node
Metastasis
Clinical Staging
SURGICAL MANAGEMENT
PREOPERATIVE PREPARATION
INCIDENTAL GALLBLADDER CANCER
Primary Gallbladder Cancer
Role of Staging Laparoscopy in Primary GBC
Extent of Lymphadenectomy
Extent of Hepatic Resection
Management of Locally Advanced Tumors
Role of Hepatopancreatoduodenectomy
Role of Vascular Resection in Locally Advanced GBC
GALLBLADDER CANCER WITH JAUNDICE
ROLE OF CHEMOTHERAPY AND RADIOTHERAPY IN GALLBLADDER CANCER
Palliative Therapy
Adjuvant Therapy
Neoadjuvant Treatment
Palliative Therapy for Gallbladder Cancer
Coeliac Plexus Block for Pain
CHAPTER 62:
Cholangiocarcinoma
INTRODUCTION
LOCATION
ETIOLOGY
PATHOLOGY
HILAR CHOLANGIOCARCINOMA
Clinical Presentation
Differential Diagnosis
Carcinoma Gallbladder
Mirizzi Syndrome
Choledocholithiasis
Other Benign Focal Strictures (Malignant Masquerade)
Diagnosis
Imaging
Endoscopic Approaches
Preoperative Evaluation
Assessment of Resectability
Preoperative Biliary Drainage
Vascular Involvement and Resectability
Portal Venous Anatomy
Preoperative Staging
Bismuth-Corlette System
TNM Classification for Extrahepatic Bile Duct Tumors
MSKCC Classification
Classification by International Cholangiocarcinoma Group (DeOliviera's Classification)
Surgical Treatment
Objectives
Types of Operations
Liver Resection Alone
Liver Resection with Vascular Resection and Reconstruction
Hepatopancreatoduodenectomy
Adjuvant Therapy
Palliation
DISTAL CHOLANGIOCARCINOMA
Clinical Presentation
History
Examination
Investigations
Treatment
Palliation: Endoprosthesis versus Surgical Bypass
INTRAHEPATIC CHOLANGIOCARCINOMA (PERIPHERAL CHOLANGIOCARCINOMA)
Clinical Presentation
Evaluation
Treatment
SECTION 6: LIVER
CHAPTER 63:
Surgical Anatomy of the Liver
INTRODUCTION
EMBRYOLOGY
ARCHITECTURE OF THE LIVER
Classic Lobule
Portal Lobule
Liver Acinus
Perisinusoidal Space of Disse
SURGICAL ANATOMY
Anatomical Lobes of the Liver
HEPATIC VASCULATURE
Portal Vein
Hepatic Artery
Hepatic Vein
Intrahepatic Bile Duct
Lymphatics
PHYSIOLOGICAL CONSIDERATIONS
Bilirubin Metabolism
CHAPTER 64:
Liver Function Tests
INTRODUCTION
TESTS DEPICTING HEPATOCYTE INJURY
Aminotransferases
Peak of Aminotransferase Elevation
Pattern of Aminotransferase Elevation
ALT Elevation in Preoperative Setting
Elevated Aminotransferases Detected in the Postoperative Period
TESTS INDICATING CHOLESTASIS
Alkaline Phosphatase13
Gamma-glutamyl Transpeptidase
TESTS DEPICTING LIVER SYNTHETIC CAPACITY
Albumin
Prothrombin Time and International Normalized Ratio
TESTS ASSESSING METABOLIC CAPACITY OF THE LIVER
Bilirubin
Dye Tests
Indocyanine Green Test
MEGX Test
Breath Tests to Assess Hepatic Functions
CONCLUSION
CHAPTER 65:
Approach to a Patient with Jaundice
INTRODUCTION
PATHOPHYSIOLOGY OF OBSTRUCTIVE JAUNDICE
APPROACH TO A PATIENT WITH JAUNDICE
CLINICAL FEATURES
Clinical Pearls from the History and Presentation
INVESTIGATIONS (FLOW CHART 1)
Laboratory Investigations
Imaging
CHAPTER 66:
Liver Abscess
INTRODUCTION
PYOGENIC LIVER ABSCESS
Etiology and Pathogenesis
Clinical Presentation
Diagnosis
Microbiology
Treatment
Surgical Drainage
Summary
AMEBIC LIVER ABSCESS (ALA)
Etiology and Pathogenesis
Clinical Features
Laboratory Findings
Imaging
Treatment
Complications
Outcome
CHAPTER 67:
Hydatid Disease of Liver
INTRODUCTION
EPIDEMIOLOGY
Life Cycle of Echinococcus granulosus (Fig. 1)
HYDATID CYST STRUCTURE (FIG. 2)
NATURAL HISTORY AND CLINICAL FEATURES
COMPLICATIONS OF HYDATID CYST OF THE LIVER
INVESTIGATIONS
SEROLOGY AND IMMUNOLOGICAL TESTS
IMAGING TECHNIQUES
Plain Radiographs
Ultrasonography
Computed Tomographic Scan (Figs 7 to 10)
Magnetic Resonance Imaging (MRI) Scan
Endoscopic Retrograde Cholangiopancreatography
Direct Cholangiography
TREATMENT
Surgery
Indications
Contraindications
Incision and Protection
Conservative Technique
Controlled Evacuation of Cyst (Figs 14A and B)
Radical Surgical Procedures
Laparoscopic Management of Hydatid Cysts28–30
Complications of Surgery
Percutaneous Treatment of Hydatid Cyst (Figs 20A to F)
Chemotherapy for Hydatid Disease of Liver
Indications
Contraindications
Side Effects
Dosing Schedules WHO Recommendation
Watchful Waiting
Treatment of Hydatid Cysts Rupture into the Biliary Tracts
Identification of Communication
Treatment of Cystobiliary Communication (Figs 22 and 23)
HYDATID AT OTHER SITES
Hydatid Cyst of Lung (Figs 25A to C)
Epidemiology and Mode of Spread
Clinical Presentation
Diagnosis
Treatment
Hydatid Cyst of Spleen (Fig. 26)
Epidemiology and Mode of Spread
Clinical Features
Diagnosis
Treatment
Hydatid Cyst of Pancreas (Figs 27 and 28)
Epidemiology and Mode of Spread
Clinical Features
Diagnosis
Treatment
CHAPTER 68:
Imaging and Intervention in Hemobilia
INTRODUCTION
ETIOLOGY (TABLE 1)
PRESENTATION
MECHANISM7,8
DIAGNOSIS (FIGS 1 TO 3)
Endoscopy
Ultrasonography
Computed Tomography
Angiography
TREATMENT
Role of Interventional Radiology
Role of Surgery
Biliary Tract Management
CHAPTER 69:
Hepatic Trauma
INTRODUCTION
MECHANISM OF INJURY
CLINICAL PRESENTATION AND DIAGNOSIS
NONOPERATIVE MANAGEMENT
NON-OPERATIVE MANAGEMENT OF PENETRATING LIVER TRAUMA
OPERATIVE MANAGEMENT
SUMMARY
CHAPTER 70:
Approach to Space-occupying Lesion of Liver
INTRODUCTION
HISTORY AND PHYSICAL EXAMINATION
LABORATORY TESTS
IMAGING TECHNIQUES
Ultrasound
Computed Tomography
Magnetic Resonance Imaging
Suspicious Features of Malignancy on CT or MRI
Other Imaging
IMAGE-GUIDED BIOPSY
DIAGNOSTIC APPROACH
INCIDENTAL LIVER SOL
SUGGESTED ALGORITHM FOR EVALUATION OF LIVER SOL
ACKNOWLEDGMENTS
CHAPTER 71:
Benign Liver Tumors
INTRODUCTION
HEMANGIOMA
FOCAL NODULAR HYPERPLASIA
HEPATIC ADENOMA
RARE LESIONS
SUMMARY OF MANAGEMENT
CHAPTER 72:
Malignant Neoplasms of Liver
HEPATOCELLULAR CARCINOMA
Risk Factors
Prevention of Hepatocellular Carcinoma
Clinical Features
Diagnosis
Staging
Treatment
Salvage Transplants
Nonsurgical Modes
INTRAHEPATIC CHOLANGIOCARCINOMA
Risk Factors
Pathology
Clinical Features and Diagnosis
Radiological Evaluation
Treatment
OTHER RARE PRIMARY MALIGNANT TUMORS OF LIVER
CHAPTER 73:
Liver Metastases
INTRODUCTION
DIAGNOSIS
Radiology
Role of CEA
Biopsy
SURGERY
Margins
Hilar Lymph Nodes
Increasing Resectability
Neoadjuvant Chemotherapy
Portal Vein Embolization/Ligation24,25
Staged Hepatectomy26,27 (Figs 3A and B)
Portal Vein Ligation with in-situ Split28,29
Ex-vivo Resections30
Liver Transplantation31,32
SYSTEMIC CHEMOTHERAPY
ABLATIVE THERAPY41
SYNCHRONOUS LESIONS42,43
FOLLOW-UP AFTER LIVER RESECTION1,39
INTRODUCTION44–47
Staging
Surgery44–47
Intra-arterial Therapies and Peptide Receptor Radionuclide Therapy44–47
External Radiotherapy44
Other Medical Therapies44–46
PERSONAL EXPERIENCE
CHAPTER 74:
Perioperative Management in Patients with Biliary Tract and Liver Disease
INTRODUCTION
GENERAL ASSESSMENT AND PREOPERATIVE PREPARATION
NUTRITIONAL STATUS AND INTERVENTION
COAGULOPATHY
BILIARY OBSTRUCTION AND ROLE OF PREOPERATIVE BILIARY DRAINAGE
Preoperative Biliary Drainage in Patients Undergoing Pancreatoduodenectomy
Preoperative Biliary Drainage in Patients Undergoing Hepatic Resection
HEPATIC FUNCTIONAL RESERVE AND PORTAL VEIN EMBOLIZATION
RENAL FUNCTION STATUS
INTRAOPERATIVE MANAGEMENT
Anesthesia Considerations
Operative Considerations
Postoperative Considerations
CHAPTER 75:
Liver Resection
INTRODUCTION AND HISTORY
INDICATIONS FOR LIVER RESECTION
SURGICAL ANATOMY AND NOMENCLATURE
CURRENT CONCEPTS OF LIVER REGENERATION
PREOPERATIVE EVALUATION
Clinical Examination
Laboratory Investigations
Assessment of Preoperative Functional Status of the Liver
Assessment of Patient-related Factors
Radiological Imaging
Computerized Tomography
Ultrasonography
MRI and MRCP
PET Scans
Liver Volumetry
Portal Vein Embolization Prior to Major Hepatic Resections
PREOPERATIVE PREPARATION
TECHNIQUES OF LIVER TRANSECTION
Low Central Venous Pressure
Delineation of the Proper Transection Plane
Methods of Liver Transection
Finger Fracture or Clamp Crushing
Water Jet Transection
Ultrasonic Dissection
Harmonic Scalpel
Ligasure
Tissue Link Dissecting Sealer
Radiofrequency-Assisted Liver Transection
Use of Vascular Staplers in Liver Transection
TECHNIQUES OF VASCULAR CONTROL
Ligation of Inflow and Outflow Vessels for Hemihepatectomies
Liver Hanging Maneuver (LHM)
Methods of Temporary Vascular Control
Total Inflow Occlusion: The Pringle's Maneuver (PM)
Hepatic Tolerance and Preconditioning
Hemihepatic Vascular Occlusion (HHVO)
Selective Occlusion of Segmental Sectoral Portal Branches
Total Hepatic Vascular Exclusion
In Situ Hypothermic Liver Perfusion with Total Hepatic Vascular Exclusion
BASIC OPERATIVE STEPS
EXTENDED HEPATIC RESECTIONS
Right Trisectionectomy
Left Trisectionectomy
Mesohepatectomy
Transverse Hepatectomy
SEGMENT-ORIENTED RESECTIONS OF THE LIVER
Resections of Segments V and VIII
Resection of Segments VI and VII
Left Lateral Sectionectomy (Segments II and III)
Left Medial Sectionectomy (Segment IV Resection)
Caudate Lobe (Segment I) Resection
Resections for Live-related Liver Transplantation (LRLT)
Postoperative Management
Fluid and Electrolyte Management
Nutrition
Glycemic Control
Coagulopathy
Pain Management
Postoperative Infection
Thromboprophylaxis
Portal Hypertension
Liver Failure
Operative Mortality
NEW DEVELOPMENTS
Laparoscopic Liver Resections
Indications
Laparoscopic Major Hepatectomy
Intraoperative and Postoperative Benefits of Laparoscopic Liver Resection
Safety of Laparoscopic Liver Resections
Robotic Liver Resections
Advantages of Robotic Surgery
Results of Robotic Liver Resections
CHAPTER 76:
Non-Cirrhotic Portal Hypertension
INTRODUCTION
ETIOLOGY
Infection
Congenital Defects
Hypercoagulable States
PATHOPHYSIOLOGY
Clinical Presentation
Bleeding
Portal hypertensive Gastropathy (PHG) or Portal Hypertensive Colopathy (PHC)
Splenomegaly
Ascites
Growth Retardation
Portal Biliopathy
INVESTIGATIONS
Radiology
Abdominal Ultrasound with Doppler
Computed Tomography Portography (Fig. 4)
Magnetic Resonance Cholangiopancreatography
Hemodynamic Studies
Liver Biopsy
Immune Function
Management
Primary Prophylaxis of Variceal Bleeding
Acute Bleeding
Prevention of Rebleeding
Surgery
Portosystemic Shunts
Results of Shunt Surgery
Mesenterico-Left Portal Vein Bypass (Rex Shunt)
Esophagogastric Devascularization
Comparison of Results of Endotherapy with Surgery
Portal Biliopathy
INTRODUCTION
DEFINITION
EPIDEMIOLOGY
ETIOPATHOGENESIS
PATHOLOGY
Ultrastructure
HEMODYNAMICS
NATURAL HISTORY
CLINICAL FEATURES
LABORATORY FEATURES
Hematology
Viral Serology
Liver Function Tests
IMAGING
ENDOSCOPY
DIFFERENTIAL DIAGNOSIS
Child's A Cirrhosis
EHPVO
Tropical Splenomegaly Syndrome
Idiopathic Portal Hypertension
MANAGEMENT
Primary Prophylaxis
Acute Variceal Bleeding
Prevention of Rebleeding
LIMITATIONS OF AVAILABLE DATA
SUMMARY
ACKNOWLEDGEMENTS
CHAPTER 77:
Budd-Chiari and Other Vascular Diseases of Liver
INTRODUCTION
ETIOLOGY
Myeloproliferative Disorders
Infections of the Liver
Benign Liver Lesions
Malignancies
Other Hypercoagulable States
Vasculitis
Obstructing Membranous Webs
Oral Contraceptives and Pregnancy
Miscellaneous and Idiopathic
Physiological Changes Due to Budd-Chiari Syndrome
EPIDEMIOLOGY
Classification Based on Clinical Presentation
Acute Disease
Subacute and Chronic Disease
CLINICAL FEATURES
Radiological Evaluation
Ultrasound Abdomen with Doppler
Contrast-enhanced Computerized Tomography
Magnetic Resonance Imaging
Venography
Arteriography
Liver Biopsy
TREATMENT
Medical Therapy
Symptom Relief
Anticoagulation
Thrombolytic Therapy
Role of Interventional Radiology
Angioplasty
TIPSS and Direct Intrahepatic Portosystemic Shunt in Budd-Chiari Syndrome
Pre-TIPSS Evaluation
COMPLICATIONS
PRINCIPLES OF OPERATIONS FOR BUDD-CHIARI SYNDROME
OPERATIVE APPROACHES
SHUNT OPERATIONS
PERIOPERATIVE MANAGEMENT AND FOLLOW-UP
LIVER TRANSPLANTATION
SUMMARY BASED ON AASLD GUIDELINES FOR TREATMENT OF BUDD-CHIARI SYNDROME4
CHAPTER 78:
Cirrhosis and its Complications
INTRODUCTION
ETIOLOGY OF CIRRHOSIS
PATHOPHYSIOLOGY OF CIRRHOSIS
NATURAL HISTORY OF CIRRHOSIS
ASSESSMENT OF FIBROSIS-CIRRHOSIS
REGRESSION OF CIRRHOSIS
PORTAL HYPERTENSION
COLLATERAL SYSTEM IN PORTAL HYPERTENSION (TABLE 6)
COMPLICATIONS OF PORTAL HYPERTENSION
Ascites
Refractory Ascites
SPONTAENOUS BACTERIAL PERITONITIS
DIFFICULT TO TREAT SPONTANEOUS BACTERIAL PERITONITIS
HEPATIC HYDROTHORAX AND SPONTANEOUS BACTERIAL PLEURITIS (EMPYEMA)
REFRACTORY HYDROTHORAX
VARICEAL DISEASE (FIG. 6)
Esophageal Varices
Primary Prophylaxis: Prevention of Varices and First Variceal Bleed
Management of Acute Varcieal Bleed (Figs 8A and B)
Gastric Varices
Ectopic Varices (Fig. 11)
HEPATOPULMONARY SYNDROME
PORTOPULMONARY HYPERTENSION
HEPATORENAL SYNDROME
HEPATIC ENCEPHALOPATHY
PORTAL HYPERTENSIVE GASTROPATHY
GASTRIC ANTRAL VASCULAR ECTASIA (FIGS 15A TO D)
CIRRHOTIC CARDIOMYOPATHY
CHAPTER 79:
Artificial Liver Support in Liver Failure
INTRODUCTION
NON-CELL BASED EXTRACORPOREAL LIVER SUPPORT SYSTEM
Peritoneal Dialysis
Hemodialysis
Hemofiltration
Continuous Renal Replacement Therapy (CRRT)
Charcoal Hemoperfusion
Plasma Exchange
Single Pass Albumin Dialysis
Molecular Adsorbent and Recirculation System
Prometheus (FPSA–Fractional Plasma Separation and Adsorption)
Indications of Extracorporeal Liver Support
Therapeutic Effects of Extracorporeal Therapy
Effect on Toxin Removal
Effect on Hepatic Encephalopathy and Survival
Effect on Systemic Hemodynamics
Effect on Hepatic Encephalopathy, Renal Dysfunction and Survival
Safety of Currently Available Nonbiological Liver Support Systems
Other Indications
CELL-BASED THERAPIES
Extracorporeal or ex vivo Therapies
Bioartificial Liver
Cell-based in vivo Therapy
Adult and Fetal Liver Stem Cells
Bone Marrow-derived Hepatocyte-like Cells
Human Annex Stem Cells
Embryonic Stem Cells
Hepatocyte-like Cells from IPSCs
Xenotransplantation
Auxiliary Liver Transplantation
CHAPTER 80:
Surgery in Acute and Chronic Liver Disease
INTRODUCTION
APPROACH
ACUTE AND CHRONIC HEPATITIS
CLINICAL EVALUATION
APPROACH TO A PATIENT WITH TRANSAMINITIS
Acute Viral Hepatitis and Acute Liver Failure
Persistent Transaminitis and Chronic Hepatitis
Chronic Liver Disease
Scores for Assessing the Risk
Risk in Relevance to Child Status
MELD Score in Predicting the Risk
Other Factors Influencing Outcome of Surgery
Other Methods to Assess Risk
TYPE OF SURGERY
MANAGEMENT
RECOMMENDATIONS
SECTION 7: SPLEEN
CHAPTER 81:
Anatomy and Physiology of Spleen
INTRODUCTION
EMBRYOLOGY
EMBRYOLOGICAL ANOMALY
ANATOMY
Splenic Circulation
TOPOGRAPHY AND RELATIONS
VASCULAR ANATOMY OF SPLEEN
Arterial Supply
Venous Drainage
FUNCTIONS OF THE SPLEEN
Mechanical Filtration
Immunological Function
Hypersplenism and Splenomegaly
LATE MORBIDITY AFTER SPLENECTOMY
Overwhelming Postsplenectomy Infection
Immunization
Antibiotic Prophylaxis
Postsplenectomy Thrombocytosis
CHAPTER 82:
Splenic Trauma
INTRODUCTION
SPLENIC ANATOMY AND PHYSIOLOGY, RELEVANT TO TRAUMA
MECHANISM OF TRAUMA TO SPLEEN
EVALUATION OF A PATIENT WITH SUSPECTED SPLENIC TRAUMA
History and Clinical Examination
Diagnostic Work-Up
FAST
CT Scan
GRADING OF SPLENIC INJURY (AAST SPLEEN INJURY SCALE 1994 REVISION)
THE APPROACH TO MANAGEMENT
Hemodynamically Unstable Patients
Hemodynamically Stable Patients
Nonoperative Management
Follow-Up Care of Cases Managed by NOM
ASPLENIA AND IMMUNOCOMPETENCE
ALGORITHMIC APPROACH TO MANAGEMENT OF SPLENIC TRAUMA
CHAPTER 83:
Splenic Cysts, Tumors and Abscess
SPLENIC CYSTS
Primary (True) Cysts
Parasitic Cysts
Non-parasitic Cysts
Secondary Cyst or Pseudocyst
SPLENIC TUMORS
SPLENIC ABSCESS
CHAPTER 84:
Non-Traumatic Splenectomy
INTRODUCTION
COMMON INDICATIONS
ANATOMY AND PHYSIOLOGY OF SPLEEN
ACCESORY SPLEEN
PREOPERATIVE EVALUATION
Imaging
Splenic Artery Embolization
PREOPERATIVE PREPARATION
TECHNIQUE
Patient Preparation
Open Splenectomy
Laparoscopic Splenectomy
Multiport Laparoscopic Splenectomy
Hand-assisted Laparoscopic Splenectomy
Robotic Technology
Single Port Access Splenectomy
Limitation of Laparoscopic Splenectomy
Postsplenectomy
Partial Splenectomy
COMPLICATIONS
SECTION 8: COLON, RECTUM AND ANAL CANAL
CHAPTER 85:
History and Examination in Colorectal Disease
BLEEDING PER ANUS
LUMP ABDOMEN
PERIANAL PAIN
CHANGE IN BOWEL HABITS
DIARRHEA
MUCUS DISCHARGE
PROLAPSE
INCONTINENCE
ABDOMINAL DISTENSION
EXAMINATION
CHAPTER 86:
Imaging in Colorectal Disease
INTRODUCTION
SPECIFIC DISEASES OF LARGE BOWEL AND THEIR LOGICAL IMAGING FOR SURGICAL DECISION MAKING
Colorectal Malignancies
Imaging in Colorectal Bleeding (Lower Gastrointestinal Bleeding)28,29
Inflammatory Bowel Disease
Appendicitis, Epiploic Appendagitis and Diverticulitis40–44
CHAPTER 87:
Anal Fistula
INTRODUCTION
ETIOPATHOGENESIS
SURGICAL ANATOMY
CLASSIFICATION
CLINICAL PRESENTATION
CLINICAL ASSESSMENT
INVESTIGATIONS
IMAGING
Fistulography
Anal Endosonography
Magnetic Resonance Imaging
Computed Tomography
ANAL MANOMETRY
SIGMOIDOSCOPY AND COLONOSCOPY
MICROBIOLOGICAL INVESTIGATIONS
BIOPSY
MANAGEMENT
Fistulotomy/Fistulectomy
Triple Procedure
Partial Fistulectomy/Fistulotomy
Drainage of the Abscess
Seton Placement
Anocutaneous Advancement Flap
Mucosal Advancement Flap
OTHER NEWER TECHNIQUES
Fibrin Glue
Collagen Plug
LIFT (Ligation of Intersphincteric Fistula Tract)
VAAFT (Video-Assisted Anal Fistula Treatment)
PALLIATION FOR REFRACTORY FISTULA
CHAPTER 88:
Rectal Prolapse
INTRODUCTION
History
Pathopysiology
Sliding Hernia Theory
Intussusception Theory
Epidemiology
Clinical Evaluation
History
Examination
Evaluation
Management
Non-operative Treatment
Surgical Treatment
Perineal Approaches
Thiersch Operation (Anal Encirclement) (Fig. 5)
Mucosal Plication and Linear Cauterization
Delorme's Procedure (Figs 6A to D)
Perineal Proctosigmoidectomy
STARR Procedure
Abdominal Approaches
Suture Rectopexy
Posterior Rectopexy Using Prosthetics (Fig. 7)
Anterior Rectopexy
Resection
Resection and Rectopexy
Laparoscopy
Robotic Surgery for Rectal Prolapse
SUMMARY
CHAPTER 89:
Rectovaginal Fistula
INTRODUCTION
ETIOPATHOGENESIS
Obstetric Cause
Inflammatory Bowel Disease
Infection
Postoperative Complications
Malignancy
Other Causes
PRESENTATION
EXAMINATION
EVALUATION
CLASSIFICATION
TREATMENT
Conservative Treatment
SURGICAL OPTIONS FOR RECTOVAGINAL FISTULA
Timing of Surgery
LOCAL REPAIR
Fistulotomy
Conversion to Complete Perineal Laceration (Perineoproctotomy) with Layer Closure
Transperineal Repair with Layered Closure
Sliding Flap Advancement
Transvaginal Techniques of Local Repair
ADVANCEMENT SLEEVE FLAP
TRANSABDOMINAL REPAIR
Radiation-induced Rectovaginal Fistulas
Coloanal Sleeve Anastomosis
Onlay Patch Anastomosis
Role of Fecal Diversion
TISSUE INTERPOSITION PROCEDURES
MISCELLANEOUS
Fibrin Glue
Collagen Fistula Plug with Button
Bioprosthetics
Rectovaginal Fistula in Crohn's Disease
RECURRENT RECTOVAGINAL FISTULA
CHAPTER 90:
Rectourethral Fistula
INTRODUCTION
ETIOLOGY
Congenital
Iatrogenic
Traumatic
CROHN'S DISEASE
PRESENTATION
DIAGNOSIS
MANAGEMENT
PERINEAL APPROACH
POSTERIOR-SAGITTAL APPROACH (FIGS 3A TO D)
TRANS-SPHINCTERIC APPROACH
TRANSANAL APPROACH
ANTERIOR TRANSANORECTAL APPROACH
COMBINED ABDOMINOPERINEAL APPROACH
ENDOSCOPIC APPROACH
MISCELLANEOUS METHODS
Fibrin Glue
Perineal Pedicled Dartos Flap
Outcome Following Repair of RUF
CHAPTER 91:
Fecal Incontinence
INTRODUCTION
PATHOPHYSIOLOGY
CLASSIFICATION/SCORING
EVALUATION
History and Physical Examination
Endoscopy
Endoanal Ultrasound
Magnetic Resonance Imaging
Defecography
Anorectal Manometry
Pudendal Nerve Terminal Motor Latency
MANAGEMENT
Nonoperative
Biofeedback
Sacral Nerve Stimulation
OPERATIVE PROCEDURES
Sphincteroplasty
Graciloplasty
Artificial Bowel Sphincter
Bulking Agents
Radiofrequency
Fecal Diversion
INDIAN EXPERIENCE
CONCLUSION
CHAPTER 92:
Ulcerative Colitis
INTRODUCTION
EPIDEMIOLOGY
PATHOGENESIS OF INFLAMMATORY BOWEL DISEASE
Genetic Factors
Microbial Flora
CLINICAL MANIFESTATIONS
EXTRAINTESTINAL MANIFESTATIONS OF ULCERATIVE COLITIS
DIAGNOSTIC CRITERIA
EVALUATION OF PATIENTS WITH ULCERATIVE COLITIS
INVESTIGATIONS FOR THE DIAGNOSIS AND EXTENT OF THE DISEASE
Endoscopic Examination
Imaging Studies
PATHOLOGY
Assessment of the Activity of the Disease
Assessment for the Extent of the Disease
DIFFERENTIAL DIAGNOSIS
NATURAL HISTORY
MANAGEMENT
Drugs Used in Inflammatory Bowel Disease
5-Aminosalicylates (5-ASA)
Corticosteroids
Immunosuppressants: Azathioprine and 6-mercaptopurine
Cyclosporine
Biological Agents
Probiotics in Ulcerative Colitis
Management of Ulcerative Colitis
Induction of Remission
Maintenance of Remission
Colonic Cancer in Ulcerative Colitis
Surgery for Ulcerative Colitis
Fertility and Pregnancy in Ulcerative Colitis
BREASTFEEDING
NUTRITION IN INFLAMMATORY BOWEL DISEASE
CHAPTER 93:
Surgery for Ulcerative Colitis
INTRODUCTION
INDICATIONS FOR SURGERY
SURGICAL OPTIONS
EMERGENCY SURGERY FOR ULCERATIVE COLITIS
Indications for Emergency Surgery
Acute Fulminant Colitis
Toxic Megacolon
Colonic Perforation
Colonic Hemorrhage
Preoperative Preparation for Emergency Surgery
Subtotal Colectomy with End Ileostomy
Key Points
Laparoscopic Subtotal Colectomy
Postoperative Care and Complications
Follow-up
ELECTIVE SURGERY FOR ULCERATIVE COLITIS
Indications for Elective Surgery
Intractable Disease
Presence of Dysplasia or Malignancy
Long-standing Disease
Severe Extraintestinal Manifestations
Special Considerations for Surgery
Inflammatory Bowel Disease Multidisciplinary Team
Surgical Options in the Elective Setting
PREOPERATIVE ASSESSMENT AND PREPARATION
Operating Room Adjuncts
Choice of Operation
Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis
Abdominal Colectomy
Complete Rectal Mobilization and Proctectomy (With or Without Mucosectomy)
Mucosectomy versus No Mucosectomy
Technique of Mucosectomy
Creation of a Pouch
Ileal Reservoir (Pouch) to Anal Anastomosis (IPAA)
Use of a Covering Ileostomy
Laparoscopic Restorative Proctocolectomy
POSTOPERATIVE MANAGEMENT AND COMPLICATIONS
Follow-up and Ileostomy Closure
Proctocolectomy with End Ileostomy
Stoma Counseling and Life with a Stoma
CONCLUSION
CHAPTER 94:
Crohn's Disease
INTRODUCTION
DIAGNOSIS OF CROHN'S DISEASE
Clinical Features
Laboratory Investigations
Endoscopy
Histology
Radiologic Procedures
Barium Studies
Cross-sectional Imaging
Differentiation of Crohn's Disease from Intestinal Tuberculosis
Clinical Features
Extraintestinal Manifestations
Site of Involvement
Endoscopy
Pathology
Serological Tests
Tuberculin Skin Test
Quantiferon Tuberculosis Gold Test
Radiology
Role of Immunological Markers
CONCLUSION
GOALS OF MANAGEMENT
ASSESSMENT OF DISEASE ACTIVITY
WORKING DEFINITION FOR THE PRACTICING PHYSICIAN
PHENOTYPIC CLASSIFICATION OF CROHN'S DISEASE
MANAGEMENT
Symptom Assessment
General Considerations
Mild-to-Moderate Crohn's Disease
Moderate-to-Severe Crohn's Disease
Fulminant Disease
Top-down Therapy (Fig. 6)
Management of Fistulizing Crohn's Disease
Maintenance Therapy in Crohn's Disease
Maintenance with Immunomodulators (Purine Analogs and MTX)
Maintenance with Biologics
Infliximab and Tuberculosis
Role of Surgery
Indications of Surgery (Fig. 8)
Surgical Procedures
Emergency or Urgent Procedures
Elective Procedures
Postoperative Recurrence
Algorithm for Management of Crohn's Disease (Fig. 9)
CHAPTER 95:
Surgery for Crohn's Disease
INTRODUCTION
PRINCIPLES OF SURGERY IN CROHN'S DISEASE
Extent of Resection
Mode of Anastomosis
Measurement of Bowel Length
Assessment of Strictures
ILEOCECAL DISEASE
FISTULATING DISEASE (FIGS 3A AND B)
BYPASS OPERATIONS
COLONIC CROHN'S DISEASE
Indications for Surgery
Preoperative Preparation
Site Specific Operations
Gastroduodenal Crohn's Disease
Small Bowel Crohn's Disease (Figs 1A and B)
Fistulating Disease (Figs 3A and B)
Intra-abdominal Abscesses
ILEOCOLIC DISEASE
COLONIC CROHN'S DISEASE
HEMORRHAGE
PERIANAL DISEASE
LAPAROSCOPIC SURGERY
CMC EXPERIENCE
CHAPTER 96:
Colonic Polyps and Polyposis Syndromes
INTRODUCTION
NONNEOPLASTIC POLYPS
Hyperplastic Polyps
Serrated Polyps
Mucosal Polyps
Juvenile Polyps (Retention Polyps)
Peutz-Jeghers Polyps
Inflammatory Polyps
NEOPLASTIC POLYPS
Adenoma Variants
Flat Adenomas
Serrated Adenomas
Aberrant Crypts
Pathogenesis
Epidemiology
Risk Factors
Genetics
Dietary and Lifestyle Risk Factors
Conditions Associated with Adenomatous Polyps
Clinical Features
Investigations
Fecal Occult Blood Testing (FOBT)
Fecal Immunochemical Testing (FIT)
Sigmoidoscopy
Barium Enema
Colonoscopy
Computed Tomography Colonography
Altered Human DNA in Stool
Natural History
Treatment
MANAGEMENT OF THE MALIGNANT POLYP
Polyp Recurrence
Colorectal Cancer Incidence and the Effect of Polypectomy
Surveillance Colonoscopy
COLONIC POLYPOSIS SYNDROMES
Familial Adenomatous Polyposis
Clinical Features
Treatment
Medical Treatment
Screening
Hamartomatous Polyposis Syndromes
Noninherited Polyposis Syndromes
Cronkhite-Canada Syndrome
Hyperplastic Polyposis Syndrome (HPS)
Lymphomatous Polyposis
Hereditary Nonpolyposis Colon Cancer (HNPCC)
CHAPTER 97:
Colorectal Cancer: An Overview
INTRODUCTION
EPIDEMIOLOGY
ETIOLOGY
Genetic Mutations
Family History of Colon Cancer
Inflammatory Bowel Disease
Modifiable Risk Factors
GENETICS OF COLORECTAL CANCER
Proto-oncogenes
Tumor Suppressor Genes
Mismatch Repair Genes (MMR)
CLINICAL FEATURES OF COLON CANCER
CLINICAL FEATURES OF RECTAL CARCINOMA
DIAGNOSIS OF COLONIC CANCER
Treatment Strategy of Colonic Carcinoma
Diagnosis and Management of Rectal Cancers
Neoadjuvant Treatment
Surgical Lay Out Including Neoadjuvant Treatment for Stagewise Disease
Need for Proximal Diversion (Either Ileostomy or Transverse Colostomy)
Reconstruction after Sphincter Saving Resection
SUMMARY
CHAPTER 98:
Colectomy for Colon Cancer
INTRODUCTION
PREOPERATIVE PREPARATION
Assessment of Preoperative Nutritional Status
Preoperative Chest X-rays
Preoperative Tattooing of the Polyps
Marking of Stoma and its Consent
Deep Venous Thrombosis Prophylaxis
Preoperative Bowel Preparation
Antibiotics
Relevant Anatomy
PRINCIPLES OF SURGERY
Position of Patient
Incision
Anesthesia
STEPS OF OPERATION
Right Hemicolectomy
Extended Right Hemicolectomy
Transverse Colectomy
Extended Left Hemicolectomy
Left Hemicolectomy
Total Colectomy
Minimally Invasive Colectomy
Single Incision Laparoscopic Surgery (SILS) Colectomy
POSTOPERATIVE CARE AND COMPLICATIONS
CHAPTER 99:
Surgery for Carcinoma Rectum
SURGICAL PERSPECTIVE
HISTORICAL NOTES
TREATMENT OF RECTAL CANCER
Surgical Approaches
General Guidelines for Surgery based on TNM Staging (Fig. 1)
Local Excision
Indications
Trans-sphincteric
Transcoccygeal Excision
Transanal Excision
Transanal Enodoscopic Microsurgery
TAMIS
Fulguration
Radical Surgeries for Locally Advanced Rectal Cancers
Concept of Total Mesorectal Resection
Basic Steps of Transanal Endoscopic Microsurgery
TME Plus
Pelvic Autonomic Nervous System
Sphincter Preserving Resections
Basic Concepts
Anterior Resection for Upper Rectal Cancer
Low Anterior Resection (LAR) for Mid- and Low-Rectal Cancer
Colorectal Reconstruction
Side-to-End Anastomosis
Protective Diversion
Ultra Low Anterior Resection
Intersphincteric Proctectomy with Colonic Pouch to Anal Anastomosis
Surgical Steps
Resection Margins
Distal Margin
Radial Margins
Hartmann's Procedure
Abdominoperineal Resection (APR)
Technique of Abdominal Dissection
Technique of Perineal Dissection
Posterior Dissection
Lateral Dissection
Anterior Dissection
Closure of the Pelvic Floor and Biological Spacers
Extralevator APR
Pelvic Exenteration
Complications
Complications of APR
Complications of Anterior Resection
CHAPTER 100:
Recurrent Rectal Cancer and Pelvic Exenteration
INTRODUCTION
FACTORS RELATED TO INCREASED INCIDENCE OF LOCAL RECURRENCES
CLASSIFICATION/STAGING
PRESENTATION
MANAGEMENT
CONTRAINDICATIONS
SURGICAL TREATMENT
Total Pelvic Exenteration
Modified Pelvic Exenteration11,12
Composite Pelvic Exenteration
GENERAL PRINCIPLES OF PELVIC EXENTERATION
RECONSTRUCTION PHASE
Urinary Diversion
Filling of Pelvic Dead Space
Vaginal Reconstruction
COMPLICATIONS
PERINEAL SMALL BOWEL FISTULA (PSF)
SURVIVAL
CONCLUSION
OUR EXPERIENCE
CHAPTER 101:
Minimally Invasive Colorectal Cancer Surgery
LAPAROSCOPIC SURGERY
HAND-ASSISTED LAPAROSCOPIC COLORECTAL SURGERY (HALC)
SINGLE INCISION LAPAROSCOPIC SURGERY
ROBOTIC SURGERY
NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES)
CHAPTER 102:
Chemotherapy for Colorectal Cancer
WHY COLORECTAL CANCER IN INDIA OCCURS A DECADE EARLIER THAN THE WESTERN POPULATION?
CLINICAL BIOMARKERS FOR COLORECTAL CANCER
Novel Biomarker for Colorectal Cancer
Adjuvant Treatment of Colorectal Cancer13–17
Which Agents Should Not be Used in the Adjuvant Therapy?
TREATMENT FOR METASTATIC CRC (mCRC)
IMPROVEMENT IN SURVIVAL AFTER COLORECTAL LIVER METASTASIS (CLM) RESECTION
NEW DRUGS APPROVED IN 2012 FOR COLORECTAL CANCER22–23
CHAPTER 103:
Radiotherapy for Colorectal and Anal Carcinoma
HISTORY OF RADIATION THERAPY IN COLORECTAL CARCINOMA
RADIOTHERAPY FOR RECTAL CARCINOMA
Adjuvant Postoperative Radiotherapy
Postoperative Chemoradiotherapy
NEOADJUVANT CHEMOTHERAPY/RADIOTHERAPY
Neoadjuvant Radiotherapy
Neoadjuvant Radiotherapy versus Neoadjuvant Chemoradiotherapy
Chemoradiotherapy Regimens
Neoadjvuant Chemoradiation versus Adjuvant Chemoradiation
Advantages of Neoadjuvant Chemoradiation
Disadvantage of Neoadjuvant Chemoradiation
Recommended Radiation Treatment
Conventional Technique
Short-course Radiotherapy: High-dose per Fraction RT (25 Gy in Five Fractions)
Contact X-ray Treatment
Re-irradiation in Carcinoma Rectum
Palliative Treatment of Rectal Cancer
Radiotherapy in Metastatic Colorectal Carcinomas
RADIOTHERAPY IN COLON CARCINOMA
CHEMORADIOTHERAPY IN CARCINOMA ANAL CANAL
RADIATION THERAPY
Dose and Fractionation
Management of Lymph Nodes
Treatment of Residual or Recurrent Anal Carcinomas
Perianal Carcinomas
CONCLUSION
SECTION 9: LIVER TRANSPLANTATION
CHAPTER 104:
History of Liver Transplantation
CHAPTER 105:
Liver Transplantation in India
BACKGROUND
THINKING ABOUT IT
FIRST STEPS
CATCHING FIRE
INNOVATIONS
CONTROVERSIES
FUTURE
CHAPTER 106:
Indications and Contraindications for Liver Transplantation
INTRODUCTION
SCORING SYSTEMS AND TIMING OF REFERRAL
Exceptions to the Model for End-stage Liver Disease Scoring System
Patient Selection and Allocation Policies in the United Kingdom
Selection Criteria for Adult Elective Transplantation
Selection Criteria for Pediatric Elective Transplantation
Selection Criteria for Adult Super-urgent Transplantation
Selection Criteria for Pediatric Super-urgent Transplantation
Hepatocellular Carcinoma
INDICATIONS FOR LIVER TRANSPLANTATION
CONTRAINDICATIONS
DELISTING CRITERIA
LIVING DONOR LIVER TRANSPLANT
CONCLUSION
CHAPTER 107:
Organ Preservation in Liver Transplant
INTRODUCTION
WHY ORGAN PRESERVATION?
History
Components of Organ Preservation
Hypothermia
Preservative Solutions
Main Preservative Solutions (Table 1)
Methods of Use
CHAPTER 108:
Anesthetic Management in Liver Transplantation
INTRODUCTION
Preanesthetic Evaluation
Risk Stratification
Modifications in Child–Turcotte–Pugh Score
Model for End-stage Liver Disease Score
Pediatric End-stage Liver Disease Score
ACUTE LIVER FAILURE
Preoperative Preparation
Induction and Intubation
Vascular Access
Venous
Arterial
Intraoperative Monitoring
Intraoperative Coagulation
Phases of Transplantation
Dissection Phase
Anhepatic Phase
Reperfusion Phase
Intraoperative Issues
Blood Conservation Strategies
Postoperative Care
CHAPTER 109:
Immunology of Liver Transplantation
INTRODUCTION
TYPES OF GRAFTS
IMMUNE SYSTEM
Transplantation Antigens
Human Major Histocompatibility Complex
Immunological Basis of Allograft Rejection
Hyperacute Rejection
Acute Rejection
Chronic Rejection
Clinical Human Leukocyte Antigen Testing
Immunosuppressive Drugs
Corticosteroids
Immunophilin Binding Agents
Cyclosporine
Tacrolimus
Antimetabolites
Azathioprine
Mycophenolate Mofetil
Mammalian Target of Rapamycin (mTOR) Inhibitors
Biologic Agents
Depleting Antibodies
Muromonab or OKT3
Alemtuzumab
Nondepleting Antibodies
Costimulation Blockade
Drug Interactions of Immunosuppressive Drugs
Phases of Immunosuppression
Immunologic Basis of Tolerance
Central Tolerance
Clonal Deletion
Clonal Anergy
Receptor Editing
Peripheral Tolerance
Immune Deviation
Suppression
Immune Privilege
Coreceptor Modulation
Role of Dendritic Cells and Regulatory T-cells in Tolerance
Induction of Tolerance
Tolerogenic Immunosuppression
CONCLUSION
CHAPTER 110:
Pediatric Liver Transplant
INTRODUCTION
Biliary Atresia
Progressive Familial Intrahepatic Cholestasis
Biliary Hypoplasia (Alagille's syndrome)
Fulminant Hepatic Failure
Neonatal Hemochromatosis
Hemophagocytic Lymphohistiocytosis
Hepatoblastoma
Hereditary Tyrosinemia
Maple Syrup Urine Disease
Urea Cycle Disorders
Organic Acidemias
Glycogen Storage Disorder
CONTRAINDICATIONS
PERIOPERATIVE CHALLENGES
Preoperative Issues
Cardiac Assessment
Intraoperative Issues
Specific Complications
Post-transplant Lymphoproliferative Disease
Tolerance
Immunosuppression
CHAPTER 111:
Liver Transplantation in Acute Liver Failure
INTRODUCTION
DEFINITION
INCIDENCE
ETIOLOGY
PRINCIPLES OF MANAGEMENT IN ACUTE LIVER FAILURE
PROGNOSTICATION OF PATIENTS FOR LIVER TRANSPLANTATION
Factors Affecting Prognosis
Etiology
Clinical and Laboratory Criteria
Multiorgan Failure
Hepatic Encaphalopathy
Infection
Psychological Issues
Prognostic Models
King's College Criteria
Clichy Criteria
Acute Physiology and Chronic Health Evaluation II
Model for End-stage Liver Disease Score
Other Prognostic Models
WHO WOULD BENEFIT FROM LIVER TRANSPLANTATION?
SURGICAL OPTIONS
Deceased Donor Liver Transplant
Living Donor Liver Transplant
Auxillary Liver Transplant
ABO Incompatible Transplant
OUTCOME
QUALITY OF LIFE
FUTURE PERSPECTIVES
CHAPTER 112:
Deceased Donor Liver Transplantation
INTRODUCTION
HISTORY
DONOR IN DECEASED DONOR LIVER TRANSPLANTATION
DONOR MAINTENANCE
Hormonal Support
DECEASED DONOR ORGAN RETRIEVAL
Assessment of the Liver
Steps of Retrieval
DONATION AFTER CARDIAC DEATH
Back Table Preparation of the Liver Graft
RECIPIENT SURGERY
Preparation and Anesthesia
Recipient Hepatectomy
CLASSIC TECHNIQUE
PIGGYBACK TECHNIQUE
IMPLANTATION OF THE LIVER
Cava Anastomosis
Classic Technique
Piggyback Technique
Portal Vein Anastomosis
Reperfusion Phase
SPECIAL SITUATIONS
Portal Vein Thrombosis
Split Liver Transplantation
Ex situ Technique
In situ Split Technique
Full-left Full-right Split
Pediatric Liver Transplantation
Auxiliary Partial Orthotopic Liver Transplantation
CHAPTER 113:
Living Related Liver Transplantation
BACKGROUND
HISTORY
Donor Selection
ABO Incompatible Donation
Radiological Investigations
Plain Computed Tomography Abdomen
Computed Tomography Liver Angiogram
Liver Volumetry
Operation: Donor Right Hepatectomy
Middle Hepatic Vein: Right Hepatic Artery Clamp
Complications
Ethical Dilemmas
CONCLUSION
RECIPIENT SURGERY
TECHNIQUE
Preoperative Preparation
Incision (Figs 20 to 24)
Assessment
Left Lobe Mobilization
Right Lobe Mobilization
Right Adrenal Gland Separation
Inferior Vena Cava Clearance
Phrenic Veins
Suprahepatic Cava
Portal Dissection
Division of Porta
Explantation
Anhepatic Phase
Benching
Dealing with Portal Vein Thrombosis
Implantation
Hepatic Artery Anastomosis
Biliary Reconstruction
Drain Placement
Closure
CHAPTER 114:
Complications in Living Donor Liver Transplantation
INTRODUCTION
VASCULAR COMPLICATIONS
Hepatic Artery Thrombosis
Clinical Presentation and Diagnosis
Treatment
Our Protocol for Managing Hepatic Artery Thrombosis
Portal Vein Thrombosis
Clinical Presentation and Management
Our Protocol for Managing Portal Vein Thrombosis
Hepatic Venous Outflow Obstruction
BILIARY COMPLICATIONS
Bile Leak
Clinical Presentation and Management
Bile Duct Strictures
Clinical Presentation and Management
Our Protocol for Managing Biliary Complications
Bile Leak and Management
Biliary Stricture and Management
PRIMARY NONFUNCTION OF GRAFT
SMALL-FOR-SIZE SYNDROME
ALLOGRAFT REJECTION
Acute Cellular Rejection
Our Protocol for Managing Acute Cellular Rejection
Chronic Rejection
RENAL DYSFUNCTION
INFECTION
Early Infections (<1 Month)
Intermediate Infections (1–6 Months)
Our Protocol for Cytomegalovirus
Late Infections (>6 Months)
IMMUNOSUPPRESSIVE DRUG TOXICITY
LONG-TERM COMPLICATIONS
Metabolic Syndrome
Bone Diseases
Renal Dysfunction
Neuropsychiatric Complications
Recurrent Diseases
Our Experience with Living Donor Liver Transplantation for Hepatocellular Carcinoma
SUMMARY
SECTION 10: MISCELLANEOUS
CHAPTER 115:
Variceal Upper Gastrointestinal Bleeding
INTRODUCTION
DEFINITION
EPIDEMIOLOGY
ETIOLOGY
PORTAL CIRCULATION ANATOMY
PATHOPHYSIOLOGY
HEMODYNAMICS IN PORTAL HYPERTENSION
CLINICAL FEATURES
Measurement of Portal Pressure
Hepatic Vein Pressure Gradient
METHODS TO DETECT VARICES
Defining the Varices Based on Endoscopic Findings
Ultrasonography
COMPUTED TOMOGRAPHY
Magnetic Resonance Imaging
Endoscopic Ultrasonography
MANAGEMENT OF VARICES
Preprimary Prophylaxis
Management of Non-bleeding Varices (Primary Prophylaxis)
Management of Bleeding Varices
Resuscitation
Management of Bleed
Management of Treatment Failure
Pharmacologic Agents
Endoscopic Therapy
Balloon Tamponade
Transjugular Intrahepatic Portosystemic Shunt
Secondary Prophylaxis
PROPHYLACTIC THERAPY IN PATIENTS WITH PORTAL HYPERTENSION
ROLE OF SURGERY
Nonselective Shunts
Selective Shunts
Distal Splenorenal Shunt
Inokuchi Shunt
Partial Shunts
Nonshunt Operations
Sugiura Procedure
Hassab Procedure
Management of Variceal Bleed in Non-cirrhotic Portal Hypertension
CHAPTER 116:
Management of Nonvariceal Hemorrhage
INTRODUCTION
ETIOLOGY
Peptic Ulcer Disease
Stress Gastritis
Mallory–Weiss Tears
Dieulafoy's Lesion
Aortoenteric Fistula
Approach to the Patient
Resuscitation
Localization of Bleeding
Role of Esophagogastroduodenoscopy in Uppergastrointestinal Bleeding
Disease-specific Management
Recurrent Bleeding Following Endoscopy
Acknowledgment
CHAPTER 117:
Approach to the Management of Lower Gastrointestinal Hemorrhage
INTRODUCTION
EPIDEMIOLOGY
Etiology
DIAGNOSIS
Presentation
Clinical Evaluation
APPROACH TO MANAGEMENT
Clinical Assessment, Resuscitation, and Indications for Blood Transfusion
Etiopathology
Localization of Bleeding Site
Colonoscopy
Nuclear Scintigraphy
Computed Tomographic Scanning
Intervention to Stem the Bleeding
Emergency Angiography
Provocative Mesenteric Angiography
Surgical Options and Outcome
Emergency Surgery
Surgical Options
“Blind” Right Hemicolectomy
Outcome
OBSCURE GASTROINTESTINAL BLEED
Definition
Etiology
Evaluation of Obscure Gastrointestinal Bleeding
Capsule Endoscopy
Double-balloon Endoscopy
Intraoperative Enteroscopy
SUMMARY
CHAPTER 118:
Bariatric and Metabolic Surgery
INTRODUCTION
Modalities of Weight Management
Indications for Bariatric Surgery
Contraindication for Bariatric Surgery
Bariatric Surgery
Rarely Performed Procedures
Intestinal Bypass
Vertical Gastroplasty
Commonly Performed Procedure
Restrictive
Mechanism of Action
Indications
Contraindications
Advantages
Disadvantages/Complications (Table 5)
Outcomes
Adjustable Gastric Band
Mixed Malabsorbative and Restrictive Procedures
Roux-en-Y Gastric Bypass
Mechanism of Action
Indications
Contraindications for Gastric Bypass
Perioperative Complications
Expected Outcomes
Biliopancreatic Bypass with Duodenal Switch
Outcomes
Revision Surgery
Indications
Workup
Revision Surgery Algorithms (Flow charts 1 to 3)
CHAPTER 119:
Robotics in Gastrointestinal Surgery
INTRODUCTION
DA VINCI SURGICAL SYSTEM AND ITS COMPONENTS
DOCKING AND OPERATING ROOM SETUP
ADVANTAGES OF ROBOTIC SURGERY OVER CONVENTIONAL LAPAROSCOPIC SURGERY
CURRENT APPLICATION OF ROBOTIC SURGICAL SYSTEM IN GASTROINTESTINAL SURGERY
Esophagus
Stomach
INDICATIONS FOR ROBOTIC GASTRECTOMY
BARIATRIC SURGERY
Colon and Rectum
PANCREATIC SURGERY
ROBOTIC GALLBLADDER SURGERY
ROBOTIC LIVER SURGERY
ROBOTIC BILIARY-ENTERIC RECONSTRUCTION
CONCLUSION
CHAPTER 120:
Tumor Markers in Gastrointestinal Malignancy
INTRODUCTION
Tumor Markers in Specific Gastrointestinal Malignancies
Colorectal Cancer
Pancreatic Cancer
Hepatocellular Carcinoma
Other Commonly Used Markers in Hepatocellular Carcinoma
Neuroendocrine Tumors (Table 2)
General Markers
Specific Markers
Carcinoma Gallbladder
Cholangiocarcinoma
Carcinoma Esophagus
Carcinoma Stomach
CHAPTER 121:
Chylous Ascites
INTRODUCTION
HISTORY
ANATOMY AND PHYSIOLOGY OF LYMPH
PATHOPHYSIOLOGY
ETIOLOGY
Traumatic
Atraumatic
CLINICAL FEATURES
COMPLICATIONS OF CHYLOUS ASCITIS
MANAGEMENT
Diagnosis
Laboratory Findings
IMAGING
TREATMENT
Medical
Diet Therapy
Drugs
Abdominal Paracentesis
Tranjugular Intrahepatic Portosystemic Shunt
Peritoneovenous Shunting
Angiography
Surgical (Figs 4A and B)
PROGNOSIS
CHAPTER 122:
Acute Postoperative Pain and its Management in Major Abdominal Surgeries
INTRODUCTION
EFFECTS OF POSTOPERATIVE PAIN
Acute Effects
Chronic Effects
PRE-EMPTIVE ANALGESIA
MULTIMODAL PERIOPERATIVE PAIN MANAGEMENT
METHODS TO TREAT ACUTE POSTOPERATIVE PAIN
Regional Analgesic Techniques
Single-Dose Neuraxial Opioid
Intermittent Bolus Administration
Continuous Epidural Analgesia
ANALGESIC DRUGS
Local Anesthetics
Opioids
Local Anesthetic-Opioid Combination
Adjuvant Drugs
Dosing of Neuraxial Opioids2 (Table 1)
LOCATION OF CATHETER INSERTION
RECOMMENDED LOCATION OF CATHETER INSERTION FOR VARIOUS ABDOMINAL SURGICAL PROCEDURES2 (TABLE 2)
SIDE EFFECTS OF NEURAXIAL ANALGESIC DRUGS
PATIENT-CONTROLLED EPIDURAL ANALGESIA
Benefits of Epidural Analgesia
Gastrointestinal
Pulmonary
Cardiac
Risks of Epidural Analgesia
SYSTEMIC ANALGESICS (TABLE 4)
PATIENT-CONTROLLED ANALGESIA (TABLE 5)
LOCAL INFILTRATION
NEUROLYTIC NERVE BLOCKS
Celiac Plexus Block
SUPERIOR HYPOGASTRIC PLEXUS BLOCK
IONTOPHORESIS
RELATIONSHIP BETWEEN ACUTE PAIN AND CHRONIC PAIN
SUMMARY
CHAPTER 123:
Telemedicine: Principles and the Future
WHY TELEMEDICINE NOW?
WHAT YOU NEED TO START
WHAT YOU CAN DO
NEW TRENDS AND THE FUTURE
ACKNOWLEDGMENTS
CHAPTER 124:
Surgery for Portal Hypertension
INTRODUCTION
HEMODYNAMICS WITH RESPECT TO SURGERY
PORTOSYSTEMIC SHUNTS
INDICATIONS FOR SHUNT SURGERY
PREOPERATIVE EVALUATION
OUTCOME OF SHUNT SURGERY IN PATIENTS WITH CIRRHOSIS
Role in Primary Prophylaxis
Surgery for Acute Variceal Bleeding
Role in Secondary Prophylaxis
OUTCOME OF SHUNT SURGERY IN PATIENTS WITH NONCIRRHOTIC PORTAL HYPERTENSION
TECHNIQUE OF PROXIMAL LIENORENAL SHUNT
COMPLICATIONS OF SHUNT SURGERY (PROXIMAL LIENORENAL SHUNT)
MESENTERICOPORTAL (REX) SHUNT
DEVASCULARIZATION AND OTHER NONSHUNT PROCEDURES
DEVASCULARIZATION PROCEDURES
INDICATIONS FOR DEVASCULARIZATION PROCEDURES
COMPLICATIONS
TECHNIQUE OF SPLENECTOMY AND DEVASCULARIZATION (MODIFIED HASSAB)
SUMMARY
CHAPTER 125:
Ethics in Surgery
INTRODUCTION
DISTINCTION BETWEEN ETHICS AND LAW
INDIAN SCENARIO
WHY SHOULD SURGICAL ETHICS BE ADDRESSED SEPARATELY?
INFORMED CONSENT IN THE CONTEXT OF SURGERY
INNOVATIVE SURGERY
END OF LIFE AND WITHDRAWAL OF CARE
ORGAN TRANSPLANTATION AND LIVER TRANSPLANTATION
CLINICAL TRIALS
RELATIONSHIP WITH PHARMACEUTICAL AND EQUIPMENT INDUSTRY
SURGICAL WORKSHOPS
APPENDIX:
Appendix
GENERAL
BILIARY SYSTEM
LIVER
PANCREAS
ESOPHAGUS AND STOMACH
COLON
INDEX
TOC
Index
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