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Sinus biopsy order kamagra effervescent no prescription, specifically the nasal septum kamagra effervescent 100mg fast delivery, is less sensitive and has more false-negative results discount 100 mg kamagra effervescent otc. Churg- Strauss syndrome is now called eosinophilic granulomatosis with polyangiitis buy genuine kamagra effervescent on-line. All forms of vasculitis are characterized by fever, weight loss, and a generalized malaise. Diagnostic keys include a history of asthma, eosinophilia, or another atopic disease. Renal involvement is common and manifests as hypertension, renal insufficiency, and hemorrhage due to microaneurysms. The abdominal pain may mimic mesenteric ischemia, and the pain will occur with eating. Anemia and an elevated sedimentation rate are present but are too nonspecific to be useful. The most accurate diagnostic test is biopsy of an affected area, with sural nerve biopsy being particularly high yield especially if there are neurologic symptoms. Besides the renal disease, cryoglobulinemia is associated with joint pain, neuropathy, and purpuric skin lesions. For severe disease (renal failure, heavy proteinuria), pulse doses of steroids and plasmapheresis may help. Nephritic glomerular diseases The following disorders show a nephritic clinical presentation, but the disease process is limited to the glomerulus. If not caused by group A beta hemolytic streptococci (Streptococcus pyogenes), it may be caused by throat or skin infection with Streptococcus pyogenes (although rheumatic fever occurs only with the strains that cause pharyngitis). Renal biopsy is rarely needed, but if done would show epithelial “humps” on electron microscopy. Treatment is supportive (management of fluid overload and hypertension with diuretics). Glucocorticoids are sometimes used for unusual persistence of proteinuria or renal failure in adults. When there is lung involvement (65%), patients present with hemoptysis, cough, and/or shortness of breath. The single most accurate test is lung or kidney biopsy, which will show linear deposits on immunofluorescence. It has 2 possible presentations: Mild or gross hematuria appearing 1-2 days after a upper respiratory infection (most common on board exams); resolves spontaneously in 30% of patients. Treatment: Glucocorticoids with mycophenolate for severe proliferative disease (nephritic). Clinical Recall Which of the following is the most accurate diagnostic test for granulomatosis with polyangiitis? They are often accompanied by a cluster of metabolic abnormalities (termed the nephrotic syndrome). Proteinuria arises because the damaged glomerular basement membrane loses its negative charges; negatively charged albumin and key serum proteins then spill into the urine. Complications of the nephrotic syndrome include: Edema due to increased salt and water retention by the kidney, as well as low oncotic pressure in the serum. Hypercoagulable states or thrombophilia, due to the urinary loss of natural anticoagulant proteins such as antithrombin, protein C, and protein S. Iron, copper, and zinc deficiency may be present as a result of the urinary loss of their transport proteins such as transferrin and ceruloplasmin. The urinalysis will commonly only show 4+ protein, although some mild hematuria may be seen in several of the nephrotic glomerular diseases. Control of the underlying disease, usually with glucocorticoids in the primary disorders. Treatment: glucocorticoids (30-50% response) Minimal Change Disease The most common nephrotic disease in children (90- 95%); may account for 15% of adult disease. Light microscopy is normal and electron microscopy is needed to see fusion of foot processes. The disease is often treated in kids without biopsy, with biopsy reserved for non-responders. Now largely type 1, associated with chronic hepatitis C and B; with or without cryoglobulinemia and vasculitis. Secondary nephrotic diseases Diabetic nephropathy is by far most common glomerular disease in developed countries. Following the appearance of microalbumin, the proteinuria worsens, eventually becomes nephrotic (>3. Over 5-10 years the patient progresses to dialysis-requirement or transplantation. Although a renal biopsy is the most accurate test for renal involvement in diabetes, it is not routinely performed unless there is the possibility of another disease causing the renal failure. Hypertensive nephrosclerosis is the progressive chronic kidney disease associated with long-standing, poorly controlled hypertension. The renal pathology is characterized by non-immune, non-inflammatory glomerular sclerosis. If the hypertension is untreated, proteinuria and renal insufficiency progress gradually (over decades) to dialysis requirement. Patients present with the combination of mild hematuria and proteinuria, along with ear (sensorineural hearing loss) and eye abnormalities. There is typically acute renal failure, mild hematuria, and low-grade proteinuria (non-nephrotic). Metabolic acidosis due to retained acids not filtered from the blood by the failing kidney. Hypocalcemia due to the loss of 1,25-dihydroxy vitamin D production and from hyperphosphatemia (inability of the kidney to excrete phosphate). High phosphate levels contribute to low calcium levels by precipitating out in tissues in combination with the calcium. Hyperphosphatemia is treated with phosphate binders, such as calcium carbonate or calcium acetate. Sevelamer and lanthanum are phosphate binders that do not contain aluminum or calcium. Cinacalcet is a substance which simulates the effect of calcium on the parathyroid; it will tell the parathyroid to shut off parathyroid hormone production, thus helping to decrease phosphate. Bone abnormalities occur because chronic hypocalcemia leads to secondary hyperparathyroidism, which removes calcium from the bones. Renal osteodystrophy is controlled with improving calcium and phosphorous levels and with cinacalcet. Parathyroidectomy may be needed for severe hyperparathyroidism that does not respond to medications. The anemia is treated with erythropoietin replacement, and iron replacement is often necessary when starting erythropoietin due to chronic losses from blood draws, dialysis, and malnutrition. A secondary cause in patients still making urine is nephrotic-syndrome associated loss of clotting factors in the urine. Pericarditis: caused by unknown uremic toxins; may or may not be an associated effusion. Vascular access infections (hemodialysis) and peritonitis (peritoneal dialysis) are common. The most common organism is Staphylococcus due to the frequent skin punctures required in dialysis. However, when conservative management fails, renal replacement therapy is required. Common medications include erythropoietin, 1,25 dihydroxyvitamin D, phosphate binders, multiple anti-hypertensives, and furosemide (if patient still makes urine). Taking so many medications is very difficult for patients who often lack energy or who are confused. Acute indications for dialysis are life-threatening abnormalities that require hospitalization: Pulmonary edema refractory to diuretics Hyperkalemia resistant to therapy Metabolic acidosis Pericarditis Altered mental state Chronic indications for dialysis (usually initiated from the outpatient setting) include: Severe neuropathy such as myoclonus, wrist/foot drop Persistent nausea and vomiting Weight loss/malnutrition Bleeding diathesis Severe itching Fatigue not correctable with anemia correction Overall, chronic hemodialysis is used in 85% of patients and peritoneal dialysis in 15%. The 5-year survival rate is by far superior with transplantation when compared with dialysis: Dialysis alone: 30–40% Diabetics on dialysis: 20% Live related donor: 72% at 5 years Cadaveric donor: 58% at 5 years The average wait to obtain a kidney for transplantation is 2–4 years and becoming longer because of an insufficient donor supply.

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Treatment of these cases is palliative X-ray therapy with or without chemotherapy order genuine kamagra effervescent online. Most authorities feel that X-ray therapy or radiotherapy does not work appre­ ciably in adenocarcinoma of kidney and its metastasis buy kamagra effervescent in india, so its effectivity either pre- or post-operatively have been disagreed by majority of the urosurgeons cheap 100mg kamagra effervescent free shipping. But in this group as operation is almost impossible cheap kamagra effervescent 100 mg visa, this is the only form of treatment available. The treatment of this group is radical nephrectomy with excision of the solitary metastasis, be it lobectomy or pneumonectomy for lung metastasis or amputation for a bone metastasis. In these cases partial nephrectomy should be considered with removal of adjacent perirenal fat and regional lymph nodes. After opening the abdomen the surgeon should carefully assess the resectability of the tumour. Once it is determined that the tumour is resectable, the tumour is not further handled and the surgeon puts all attention to the renal pedicle. Before manipulating the kidney it is advisable to deal with the renal pedicle to prevent further blood borne metastasis due to handling of the tumour. The inferior vena cava should be palpated carefully to detect any tumour thrombus within it. Al the time of dissecting the renal vein, if tumour thrombus is detected it should be opened and the tumour thrombus is removed. Now the renal artery is ligated and divided and the ureter is ligated and divided as low as possible. The perinephric fat and fascia are gradually separated from the surrounding tissues from outside inwards. While the dissection is proceeding inward, all the regional lymph nodes are included within the kidney mass. Ultimately the tumour with the whole kidney, perirenal fat and regional lymph nodes are removed. Many urosurgeons now recommend transcatheter renal arterial embolisation 1 to 7 days before nephrectomy which facilitates operation. By this technique tumour cell dissemination during the operation is also prevented to certain extent. This technique should also be considered in case of life threatening gross haematuria. A course of post-operative radiotherapy may be applied but its effectivity has been seriously questioned. In one series 5-year survival in the postoperative radiotherapy group was even lower with a high complication rate due to the radiotherapy, which was mainly gastrointestinal and in some cases fatal. The single drug vinblastine has been used and showed an overall response rate of about 24%. Attempts to improve the response rate by combining cytotoxic agents have not been very successful. However vinblastine + bleomycin + high dose of methotrexate have produced a response rate of 30%. Tamoxifen at a low dose appears to be virtually inactive, but if given at high dose — 800 mg/day it has shown some response. Combination of hormones with chemotherapy does not seem to have anything to add to the response rate. The duration of remission to interferon-alpha varies from patient to patient, however median durations have been reported as from 5 to 16 months, which do not defer with interferon-beta or gamma. Unlike chemotherapy, where response occurs within weeks or even days, the time taken to respond to interferon varies widely from 3 to 11 months. The overall response rate by continuous infusion or bolus intravenous injection is about 29%. This is an immunotherapy, which has also been used by taking tumour-infiltrating lymphocytes at operation or by using peripheral blood lymphocytes stimulated by means other than interleukin-2. A number of groups have also attempted to combine interferon-alpha with interleukin-2 given either subcutaneously. The cumulative data suggests that 28% of patients respond to this combination with 8% complete remission rate. In conclusion it may be said that metastatic renal cell carcinoma is an incurable condition, but 10% to 20% of patients remain alive for 2 to 4 years. Radical nephrectomy is the treatment of choice for primary lesions and there is no evidence that postoperative radiotherapy improves survival. Nephrectomy may be indicated in patients with metastatic disease, but only for specific reasons— usually for local palliation. The place of interleukin-2 remains controversial and cumulative data do not suggest an improvement in response rate over interferon-alpha. Wilms first gave a comprehensive description ofthe tumour in 1899 but suggested that the tumour arises embryologically from undifferentiated cells in the Wolffian ridge. It occurs in all parts of the world and is unaffected by race, climate or environment. As mentioned earlier the maximum incidence occurs in the first 4 years with a pick incidence at the age of 3 years. The association of nephroblastoma with congenital abnormalities and its familial occurrence imply that there may be genetic factors which play in the development of this tumour. The majority present as a single expanding tumour surrounded by a pseudocapsule of connective tissue. Sometimes the tumour may appear juxtarenal but it is usually attached to the kidney with a small pedicle. Occasionally the tumour may be multiple separated nodules spread throughout the renal parenchyma. Rapid increase in size is the rule, but the renal pelvis is not invaded until later in the disease, a fact which may account for the absence of haematuria. On section, the tumour is fleshy with a lobular appearance separated by fibrous septa. But it looks comparatively uniform in contrast to the variegated appearance of renal cell carcinoma. But the tissue is heterogeneous with usually myxomatous areas with haemorrhagic and cystic areas. The epithelial elements often form abortive or embryonic glomerulo- tubular structures and are surrounded by interstitial tissues. As the tumour consists of mixture of two types of cells, it is often called ‘adenomyosarcoma’. The tumour gradually invades the kidney and later on the neighbouring organs such as the liver, spleen, colon, adrenal glands, diaphragm and posterior abdominal muscles. Renal capsule however remains intact for a long time, so that invasion of the neighbouring structures are comparatively late. Though regional lymph nodes are frequently enlarged at operation, these glands on section usually show simple hyperplasia without evidence of secondary tumour. Though blood spread to the lungs is the commonest site; this spread may occur to the vertebrae, liver and to the opposite kidney. It denotes that the tumour has burst into renal pelvis and indicates bad prognosis. In fact majority of patients with Wilms’ tumour who complain of haematuria die within 1 year. No excretion of the dye may sometimes occur due to renal vein thrombosis caused by the tumour, but this is more due to polycystic kidney or giant hydronephrosis. Excretory urography also yields essential information about the opposite kidney e. Bone scan may reveal bony metastasis, similarly hepatic scan may show tumour deposits in the liver. No child should be rushed to the operation theatre without proper clinical evaluation. Blood should be cross-matched lo cover any loss during surgery or to cover preoperative anaemia. On opening the peritoneum, the liver and para-aortic lymph nodes are examined for evidence of metastasis.

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If a significant number of air leaks from the gastrotomies in 195 patients undergoing esophageal resec- lung are noted discount kamagra effervescent 100mg with mastercard, pass a second chest catheter anterior to the tion using circular stapling instruments buy generic kamagra effervescent. Tie the pericostal sutures tion for failure of the stapled gastrotomy closure to heal and the final diaphragm sutures and close the muscles in two properly is the use of a 3 purchase kamagra effervescent in united states online. Stapling technic for esophagogastrostomy after esophago- diaphragm is continuous with the endoabdominal fascia purchase kamagra effervescent with visa, and gastric resection. Use Esophagogastrectomy for carcinoma of the esophagus and cardia: a comparison of findings and results after standard resection in three staples or a subcuticular suture to close the skin (Fig. Recurrence after neoadjuvant chemoradiation and surgery for esophageal cancer: does the pattern of recurrence differ for patients with complete response and those with See Chap. Chassin† Indications Undetected pneumothorax Ischemia or trauma to tip of gastric tube in the neck inducing Carcinoma of the esophagus necrosis and sepsis Barrett’s esophagus with severe dysplasia Anastomotic leak Esophageal stricture Inadvertent laceration of right gastroepiploic artery Achalasia Perforation Operative Strategy Preoperative Preparation Although a large portion of this operation is accomplished by blunt dissection, there are five areas where dissection See Chap. A small linear laceration of the Prepare a single-lumen endotracheal tube, not cut short. However, if a patch of the membranous trachea is avulsed while dissecting an esophageal cancer that has invaded the trachea, adequate repair may be impossible. In the Pitfalls and Danger Points absence of a malignancy in the area of the trachea, dissec- tion of the esophagus away from the trachea should not be Excessive bleeding difficult if carried out in a gentle manner. While dissecting the omen- Injury to spleen tum away from the gastroepiploic artery, continually keep Hypotension during mediastinal dissection due to compres- in mind that this vessel constitutes the major blood supply sion of the heart to the tip of the gastric tube to be constructed. In many Trauma to thoracic duct, chylothorax areas this vessel is covered by omental fat so its exact Traction injury or laceration of the recurrent laryngeal nerve location is not obvious to the naked eye. Consequently, Bowel herniation through a too large diaphragmatic hiatus when dividing the omentum, leave a few centimeters of omentum attached to the artery, as inadvertent division of this vessel makes the stomach useless as an esophageal substitute. Be aware that the gastroepiploic artery does Department of Surgery , not continue to the tip of the gastric tube. Chassin sary trauma to this area can threaten this precarious anas- Abdomen tomosis. Consequently, be aware throughout the operation that this tissue must be protected from rough handling. Make a midline incision from the xyphoid to a point a few Even inserting a suture between the gastric tip and the centimeters distal to the umbilicus, and enter the abdomi- prevertebral fascia in the neck has been reported to have nal cavity. Check the stomach carefully to ascertain that it caused focal necrosis of the stomach and a gastric fistula is indeed suitable for the development of a gastric tube that with vertebral osteomyelitis. Liberate the left lobe of the liver by incising the place the suture too deeply, and do not tie a tight knot. Aside from hoarseness, dam- sions that involve the capsule of the spleen, so the short gas- age to the left recurrent laryngeal nerve during the cervi- tric and left gastroepiploic vessels are easily identified. Insert cal dissection can also result in swallowing difficulty and the Weinberg blade of the Thompson retractor underneath the aspiration. Use the assistant’s index finger rather than a sternum and retract the liver in a cephalad direction, exposing rigid instrument to retract the trachea and the thyroid the esophageal hiatus. Encircle the esophagus results in massive hemorrhage that in most cases requires with the index finger and then with a 2 cm wide Penrose drain. Apply caudad traction operative staging and careful dissection at the point where to the esophagus via the Penrose drain and free up the lower the azygos vein crosses the esophagus. If the tumor can be reached by digital palpation, ascertain that it is not fixed to the aorta or vertebral column. If it is fixed, transhiatal esophagectomy Documentation Basics without thoracotomy is contraindicated. If not, expose the gastric cardia and then carefully divide and ligate each of the Coding for esophageal procedures is complex. In clamps leaving 3–5 cm of omentum attached to the right gas- general, it is important to document: troepiploic arcade to avoid injury to the gastroepiploic artery. Elevate the greater curvature of the stomach in a cephalad direction and identify the origin of the left gastric artery. Cover the abdominal incision with sterile and insert bilateral intravenous catheters and one intra- towels and start the neck operation. If a central venous pressure or a Swan- Cervical Dissection Ganz catheter is to be used, insert it into the right internal jugular vein, as the left side of the neck is preserved for the Expose and mobilize the cervical esophagus as described in esophagogastric anastomosis. Encircle the esophagus with a Penrose drain and gist use a standard endotracheal tube of standard length that apply cephalad traction. If the membranous trachea is inad- aspect of the fingers facing the esophagus to dissect the vertently lacerated, the anesthesiologist can then advance the esophagus away gently from the overlying trachea and the tip of the endotracheal tube into the left main bronchus. With this dissection, the index the balloon is inflated, this maneuver enables the anesthesi- finger can reach down almost to the carina of the trachea. Attach a self-retaining Thompson, Omni, or similar retractor to the operating table Wear a headlamp for this phase of the operation. Enlarge 16 Transhiatal Esophagectomy 165 the hiatal opening by incising the diaphragm with electro- cautery in an anterior direction through the middle of the central tendon, dividing and ligating the transverse phrenic vein during this step. If necessary, insert a flat malleable retractor behind the heart and elevate gently. Determine that they are flexible and mobile and that there are no points of tumor invasion that would make resection without thoracotomy inadvisable. Before embarking on further dissection, pass a 28F Argyle Saratoga suction catheter into the neck incision and then down into the lower mediastinum to facilitate evacuation of blood from the surgical field. Despite the limited exposure allowed by the transhiatal approach, the transhiatal esophagectomy is neither a blind nor a crude operation. Dissection of the esophagus from the diaphragm to the arch of the aorta is performed under direct vision. Exposure can be enhanced by inserting long, narrow retractors along the lateral aspects of the hiatal aperture. Many of the vascular attachments to the esophagus can be divided and occluded by hemostatic clips or ligatures. When dissecting the esophagus in the mediastinum, make no spe- cial effort to excise any pleura or lymph nodes. The strategy of the operation is to separate the surrounding anatomy from the esophageal tube as efficiently as possible. When dissect- ing the esophagus along its posterior surface, keep the hand flat against the vertebral column. After the esophagus has been removed from the mediastinum, and before the stomach is brought into the chest, examine the pleura visually and by palpation. If a tear has occurred, insert an appropriate chest tube to prevent a postoperative tension pneumothorax. After the lower esophagus has been mobilized, insert a small sponge on a long sponge holder (“sponge on a stick”) along the prevertebral fascia in the neck behind the esopha- gus while the other hand is placed behind the esophagus in the mediastinum (Fig. When the sponge-stick meets the hand, the posterior dissection of the esophagus has been completed. With the assistant exerting traction in a caudal direction on the Penrose trachea – left main stem bronchus. After this has been drain encircling the esophagogastric junction, place the accomplished, there remain lateral attachments to be dis- hand, palm down, on the anterior surface of the esophagus rupted before the esophagus is freed. Again retract the upper and with finger dissection free the esophagus from overlying esophagus in a cephalad direction and separate the esopha- pericardium and carina. With the other hand, insert one or gus from these attachments until the upper 8 cm of thoracic two fingers, volar surface down, over the anterior face of the esophagus is freed circumferentially. Now insert the hand esophagus in the neck while cephalad traction is being into the hiatus and slide upward along the anterior esophagus applied to the Penrose drain encircling the cervical esophagus. Trap the esophagus against the ver- attachments between the esophagus and the membranous tebral column between the index and middle fingers. Chassin esophagogastric junction and note where the second or third branch down of the left gastric artery enters the lesser curvature. At this point, apply the linear cutting stapler and aim it in a cephalad direction toward the cardia. Sequentially reapply and fire the stapler until the lesser curvature has been amputated, leaving about 6–8 cm width of cardia intact at the gastric tip (Fig. Deliver 7–8 cm of thoracic esophagus into the neck and transect the esophagus with a linear cutting surgical stapler. This maneuver provides a few centimeters of extra esopha- gus, allowing the option of selecting the best length when the anastomosis is performed. This drain with its two identifying hemostats is later used to draw the stomach up through the posterior mediastinum into the neck. If a laceration is encountered, insert a 32F chest tube into the chest cavity on the side of the laceration, in the midaxillary line.

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In a few instances the lesion is even missed during appendicectomy and is only detected on histopathological report ofthe appendicectomy specimen generic kamagra effervescent 100 mg online. Care must be taken to avoid rupture of mucous-filled appendix buy kamagra effervescent 100mg low price, as there is a chance of pseudomyxoma peritonei to develop safe kamagra effervescent 100mg. It is believed to be the result of failure of migration of neuroblasts into the gut from vagal nerve trunks cheap 100 mg kamagra effervescent with visa. Aganglionosis may result if there is cessation of migration of neuroblasts, which migrate from the primitive node along the alimentary track distal- wise. The internal anal sphincter is aganglionic in every case of Hirschsprung’s disease. This aganglionosis extends proximaliy to variable distance according to the failure of descent of the neuroblasts. Approximately 80% of cases involve the rectosigmoid junction and 15% have aganglionic segment extending as far proximaliy as the hepatic flexure. The former condition is called ‘short segment aganglionosis’ and the latter condition is called ‘long segment aganglionosis’. There are some cases where aganglionosis occurs in skip areas, these are known as ‘segmental aganglionosis’. There is absence of peristalsis in the aganglionic segments thus producing adynamic intestinal obstruction. Lack of peristalsis in the aganglionic segment and failure of relaxation of the internal anal sphincter produce varying degrees of intestinal obstruction found in this disease. There is a visible transition zone, usually 1 to 5 cm in length between the dilated bowel which contains ganglionic cells on the proximal side and normal sized aganglionic segment of bowel on the distal side. The pelvic mesocolon is elongated and thickened and its blood vessels are large and prominent. As in majority of cases the aganglionic segment stops proximaliy at sigmoid colon, the grossly dilated portion mostly involves the upper sigmoid colon and lower descending colon. The symptoms appear within 3 days of birth and the presenting features are as follows : (i) Constipation. If the little finger is introduced into the rectum meconium is passed in inadequate amount and toothpaste like. In some babies the symptoms may suggest mildgastroenteritis or a feeding problem associated with mild constipation. As the condition becomes more chronic the baby fails to gain weight, becomes hypoproteinaemic and suffers from intermittent episodes of severe constipation and diarrhoea. Eventually enterocolitis may develop, a lethal complication of Hirschsprung’s disease. The clinical picture includes fever, vomiting, watery or bloody diarrhoea, septic shock and finally death. Enterocolitis develops due to invasion of bacteria from the dilated colon through erosion and ulceration in the mucosa into the wall of the colon. Rectal examination — reveals that the rectum is empty and the anus is free from any pathology. This examination will demonstrate dilated colon followed by narrow aganglionic segment. The diagnosis becomes difficult if the child has a very short segment involved or if the entire colon is aganglionic. In infants the proximal non-affected colon may not become very much dilated, but in these cases the retention of barium after 24 hours is quite diagnostic. It is always essential that both anteroposterior and lateral views should be taken as narrow short segments may be overlapped by dilated proximal colon in one of the views. An attempt should be made to take full thickness wall for biopsy, as superficial biopsy cannot confirm presence or absence of ganglion cells in the intramural plexus. The upper limit of resection must include the transitional zone and a little of the healthy dilated colon above it. The lower limit should be so designed as to preserve the anal canal with its sphincters. If the infant has enterocolitis and is septic, he must be treated quickly and aggressively to control the sepsis, dehydration and hypoproteinaemia. While the sepsis is being treated by vigorous antibiotics, decompression should be done by nasogastric suction and dilatation of the anal sphincter. Rectal tube may be inserted through the anus and wash-outs can be made in the distal colon, but adequate care is required as it may perforate the bowel. But only in case of patients above 2 years of age with slight dilatation of the colon and in moderately fair health, one may go for one stage operation, i. Two types of colostomy can be performed — (i) right transverse colostomy and (ii) loop colostomy placed just above the transition zone. If one wants to protect the anastomosis right transverse colostomy is better, but it requires a third operation, i. In case of the loop colostomy above the transition zone, at the time of second operation i. Right transverse colostomy is better than the left transverse colostomy as more bowel can be used if a greater segment is to be resected. Definitive operation is postponed till the child becomes at least 1 year of age and of normal weight. The rectum, the contracted aganglionic part and the commencement of the normal dilated portion are freed from their attachments as far down as towards the anal canal. One may go for frozen section biopsy to know that he is above the transition zone. The colon is transected through the normal dilated portion well above the transitional zone. The mobilised aganglionic segment with purse-string suture is now everted through the anus. The anterior half of the junction of the inverted rectum with the anal canal is incised transversely and through this the proximal colon is pulled through. The anastomosis of the normal to the remaining rectum must not be higher than twice the width of the internal sphincter. It also includes resection of a portion of internal sphincter and thereby overcomes the tightness. The anus is widely stretched and a transverse incision is made in the posterior wall just above the sphincter. Through this opening the colon lying behind the rectum is brought down to the anal opening. The colon is then fixed to the rectum by a few catgut stitches to make a colorectal anastomosis. A special crushing clamp is introduced to include the posterior wall of the rectum and anterior wall of the colon between its blades. Ganglionic normal colon is indicated as dotted (Dots represent ganglia) and striped wall. The faecal content from the colon comes into the colorectal junction so that the rectal sensation remains intact so is its reflex defaecation. In this operation it preserves rectal sensation yet avoids the blind rectal loop because the sphincter is not damaged, many patients have recurrence of their symptoms and require repeated dilatations or sphincterotomies. The rectum is fully mobilised as mentioned above and transected just above the level of the pelvic floor which should be normal. This normal colon is now joined to the top of the anal canal with stapling technique. A sleeve technique can also be applied following mucosectomy of the rectum and upper anal canal. Chagas’ disease is caused by infection with Trypanosoma cruzi, en­ demic in south and central America. There are certain conditions which may give rise to mechanical obstruction in the rectum and anal canal. These are lymphogranuloma venereum, endometriosis, radiation proctitis and anorectal injury.

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