Cetirizine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Meredith Minkler DrPH

• Professor Emerita

https://publichealth.berkeley.edu/people/meredith-minkler/

The frst group represents 2/3 of myxomas and corresponds to solid tumors treatment allergy to cats order genuine cetirizine line, sometimes polypoid allergy count houston order cetirizine from india, Besides allergy medicine no juice purchase 10 mg cetirizine fast delivery, it was found that some recurrent lesions may exhibit with unstriated and smooth surfaces related to a high superfcial more aggressive histology and signifcantly faster cell proliferation collagenation allergy symptoms due to weather purchase cetirizine without prescription. One particular characteristic, explained by the of benign myxomas, others think that these tumors correspond to secretory activity of these tumors, is the release of metalloproteinase undiagnosed malignant primary tumors [40-43]. Tese characteristics explain why Clinical presentations of cardiac myxomas are polymorphic and obstructive heart failure is usually associated with solid tumors while unspecifc. They depend for the most part on their base, shape, size and embolic events represent the most common clinical feature of fragile mobility. As a consequence, a wide spectrum of clinical manifestations papillary myxoma [26] (Figure 1). While The histology of cardiac myxoma resembles closely the in the series of Beghetti et al. It is characterized were diagnosed during a routine examination, others stated that by a myxoma stroma rich in elastin, collagen and proteoglycans in only 10% to 15% of myxomas are asymptomatic and constitute the which reside small fusiform or stellate cells with round or oval nuclei prerogative of small tumors [21]. Tese cells are sometimes the myxoma’s growth remains imprecise but it can be inferred from a multi-nucleated. Other cells can also be observed like of myxoma quiescent in patients ranging from 7 to 16 years! Roudaut lymphocytes, plasma cells, histiocytes and mast cells, which may all and Allal reported respectively 1 and 3 cases of lef atrial myxomas together contribute to systemic manifestations [27]. General signs General signs appear in approximately 90% of patients and may be the sole symptoms in 30% of cases [7,66]. Tese events refect an infammatory response as well as immune frst echocardiography without visible image [46-47]. The reported reaction against the tumor, or even immune response reaction to growth rate of lef atrial myxomas varies from 0 to 1. However, these parameters may undergo a change in cases of may have a positional character. Streptococcus is progressive or intermittent, ofen simulates a mitral or tricuspid the most frequently incriminated germ. More rarely, other bacterial stenosis and can cause dyspnea, malaise, or sudden death [50]. This or fungal agents were found (Enterococcus faecalis, Staphylococcus intra-cardiac obstruction is found in approximately 50% of cases, but lugdunensis, Gemella morbillorum, Porphyromonas asaccharolytica, may appear later in the disease evolution [24,51]. Mitral valve the chest radiograph can emphasize on cardiomegaly secondary to repair was performed with a satisfactory result (Figure 2). Embolic events Currently, echocardiography remains the key examination tool Embolic complications represent a serious complication of for the diagnosis of atrial myxoma. This phenomenon is related to the migration of the tumor determines the localization, shape, and size of the tumor and its or its fragmentation, or even the posting of thrombi and vegetations various connections with the adjacent cardiac structures (Figure 3 adherent to the tumor surface. Patients (30% to 45%) with lef atrial myxoma get complicated Trans-thoracic echocardiography is the most commonly used. While all organs may be afected, It typically provides all the information necessary prior to surgical nevertheless, the central nervous system remains the most afected resection, but transesophageal echocardiography has, to our (more than 50% of cases) [54-57]. It is particularly helpful to evaluate the posterior lef atrial wall, atrial It’s widely admitted to consider at high risk of embolism, patients septum, and right atrium, which ofen are not well displayed on trans presenting with some threatening echocardiographic images papillary thoracic examination, in order to potentially exclude the possibility of of large multi-lobed tumors, or intermittently prolapsing mass bi-atrial multiple tumors [71]. In two patients, the approach was the right parasternal mini thoracotomy and the subsequent 3 patients had direct-access partial sternotomy. Yu and colleagues reported the use of extensive thoracoscopic surgery in resecting cardiac myxomas in 12 cases with 10 in the lef atria and 2 in the right atria. Extensive thoracoscopic surgical resection of myxoma was successfully performed in all cases Figure 4: Echocardiographic views showing right atrial myxomas. It ensured a safe outcome and achieved complete Natural History & Surgery tumor resection [79]. This approach is widely accepted; deliver the promise of expediency, safety, minimal discomfort, less however, some authors think that emergency management appears postoperative pain, quick functional recuperation, excellent cosmetic to be less clearly indicated in some stable patients having tumors less healing, shortened hospital stays, and therefore cost savings. In such patients, the risk of embolism seems to be low and is not amplifed by a 2 days’ preoperative assessment. Tere is no real consensus on the modalities of surgical The latter will allow performing surgery under better conditions and, management of cardiac myxomas. In the study conducted by Jones obviously, with improved outcomes, particularly in elderly or high et al. It is therefore conclusive that the lef Surgery is usually performed through a median sternotomy atriotomy by itself is an approach that does not meet all these criteria. It is important to minimize cardiac The impossibility of an exploration of the four heart chambers can manipulation to prevent embolic complications. Furthermore, the be easily compensated by new methods of medical imaging and vent should be inserted afer aortic clamping in cases of lef atrial echocardiography. Figure 5: Operative view showing left atrial myxoma approached through Trans septal route. It brings several advantages: (1) defnition of tumor pedicle in all these cases using amiodarone [83,88,89]. Nevertheless, this approach seems to be the initial resection (average of 4 years) [21]. Tere is also a report correlated to a lower risk of bleeding and rhythm disorders, as well as of a patient whose secondary lesion was diagnosed 20 years afer the postoperative conduction [85,86]. This complication is more frequent Another important problem in the surgical treatment of atrial in the familial types (12%–22%) versus the sporadic ones (1% 4%). According to McCarthy and colleagues [93], the The site of the attachment should be respected with a clear margin. Tereafer, all defects must be repaired by direct closure or by using The explanation of the intracardiac recurrence is related to the synthetic or pericardial patch. An inspection of the various cavities following features: (1) family predisposition, (2) unrecognized and an extensive washing with serum are highly recommended to multicentric origin of primary lesion, (3) incomplete resection remove any tumor fragments. Moreover, atrioventricular valves or intraoperative dissemination of tumor cells, and, (4) the de function should be controlled per-operatively with saline and novo proliferation of the pre-tumor or reserve cells present in the subsequently with transesophageal echocardiography. The role of incomplete resection still remains Right sided atrial myxomas are approached through right controversial since recurrent tumors ofen do not resurge at the same atriotomy. Consequently, it is necessary to perform superior and the inferior venae cavae have to be cannulated directly, annual echocardiography throughout a patient’s life, and particularly and, as much as possible, by using the right angled cannula to avoid in patients with multifocal, atypical, or familial myxomas. We already reported the case of a 57 year-old woman with a Conclusion large right atrial myxoma and severe lef ventricular dysfunction who underwent successful on-pump beating heart resection. The mass was Myxomas are the most frequent among cardiac tumors and completely removed afer a side-clamping of both the base as well as may present with a wide range of symptom spectrum. Early diagnosis is currently obtained by echocardiography Data from the literature show that myxoma’s surgery remains which represents the gold standard tool for diagnosis. Virtually all deaths are in patients with advanced Various surgical approaches are possible. Most centers usually disability or old age, the mode of death being generally related not prefer the biatrial and transseptal approaches. Surgery with to the atrial myxoma itself but to coexisting cardiac or degenerative complete excision of the tumor, results in excellent survival rate but disease [66]. The major postoperative complication remains the do not exclude the risk of reoperation. Cardiac myxoma: molecular markers, critical disease pathways, drug targets, and putative targeting miRs. World Health Organization tumours of the lung, pleura, thymus Curr Cancer Drug Targets. Brain metastasis of cardiac myxoma: case report and review of the Cardiothorac Surg. Clinical and molecular features of the Carney complex: diagnostic criteria and recommendations for patient 30. Recurrent cardiac myxoma: seeding of spotty skin pigmentation, myxomas, endocrine overactivity, and or multifocal disease? Vascular endothelial growth factor is an autocrine growth factor for 1975;89(1):4-17. Expression of vascular endothelial growth factor and angiogenesis in cardiac myxoma: a study of ffeen patients. Changing Management of Cardiac Myxoma Based on a Series of 40 Cases 1997;134(6):1107-14. The role of interleukin-6 in cases of [Spontaneous course of myxoma of the lef atrium].

The reversible reactions occurring at the electrodes upon charge/discharge can be then expressed in the following way: + − : + + ⇆ (2 allergy symptoms medicine purchase cetirizine on line. The separator typically consists either of a polymeric membrane (polyethylene allergy forecast lees summit mo generic cetirizine 10 mg online, polypropylene or their blend) or of non-woven fabric mat (polyolefin allergy treatment breastfeeding cetirizine 10mg generic, polyamide allergy symptoms dark circles under eyes buy discount cetirizine 5 mg line, etc. The properties, challenges and promising alternatives of the main battery components will be discussed in details in the following subchapters. The current used to cycle a battery is generally defined as the rate at which battery is charged/discharged with respect to its maximum (theoretical) capacity. For example, 1C rate means that the current will charge/discharge the battery in 1 hour. For a battery with a capacity of 100 Ah, this equals to a charge/discharge current of 100 A. Such important parameter as density of stored energy depends on the discharge current and can be acquired by measuring the time necessary for the complete battery discharge (or capacity): ∆ (,) = ∫ =, (2. The reversibility of the charge/discharge processes is measured by the coulombic efficiency, expressed in %, and calculated using the following formula: = × 100 (2. Hence, upon discharge the negative electrode acts as the anode (undergoing oxidation), whereas the positive electrode is the cathode (undergoing reduction). Upon charge the redox reaction is reversed, and so does the designation of the electrodes. Thus, it is more correct to denote the electrodes as negative and positive, which is independent of the operation mode. However, in this thesis for simplicity the galvanic cell mode (discharge) is used for the electrodes designation. Therefore, graphitic carbon is always denoted as the anode (or negative electrode), whereas lithium iron phosphate is designated as the cathode (or positive electrode). Peled [14] for the alkali metals, and later extended to carbon materials by Dahn et al. Finally, it should be flexible and elastic to accommodate the volume changes of the active material upon repeated charge/discharge cycles. Lithium metal anodes Lithium metal batteries have been intensively investigated since 1970s. Indeed, the use of lithium metal as anode offers several significant advantages, such as the lowest redox potential -1 (-3. Upon storage lithium spontaneously reacts with the atmospheric gases and a passivating surface film is formed. The main challenge with commercialization of Li metal batteries is related to the inhomogeneous metal plating upon cycling that leads to the formation of “dendrites” on the I n t r o d u c t i o n : L i t h i u m I o n B a t t e r i e s | 9 lithium anode surface, whose formation mechanism is shown in Figure 5. This phenomenon poses serious safety concerns as the uncontrolled growth of dendrites results in the separator penetration, leading to internal short circuits. The latter may induce local heating, thermal runways and finally, in the worst case scenario, battery fire and explosion [18, 19]. Additionally, the continuous renewal of the lithium surface results in a low coulombic efficiency, which limits the cycle life of the battery. Schematic diagrams of the dendrites formation and growth: a) and b) Li plating at the anode surface, c) and d) nucleation and growth of Li dendrites at the anode surface upon discharge (taken with permission from Ref. Finally, the substitution of the liquid organic electrolytes by solid polymer electrolytes was shown to effectively suppress but not completely prevent the dendrite growth on lithium metal, especially at higher current densities [30, 31]. Although solid polymer electrolytes are promising candidates for the commercialization of Li-metal batteries, they bring several issues, which will be further addressed in Section 2. Graphitic carbon anodes Carbon is a unique material, which is used for various applications: from jewelry to electronic gadgets and pencil leads. Since 20 years carbonaceous materials have been also employed as negative electrode in lithium-ion batteries. Carbonaceous materials have low redox potential vs lithium, high Li diffusivity and high electric conductivity. They also show moderate volume expansion upon lithium intercalation/deintercalation. Furthermore, their low cost and abundancy make them a state-of-the-art material, still unbeatable by other anode candidates (such as spinels, alloying or conversion materials) [32, 33]. Although graphitic carbon 10 | I n t r o d u c t i o n : L i t h i u m I o n B a t t e r i e s possesses relatively high gravimetric capacities, the volumetric capacity is not high enough -3 (~830 mAh cm) to satisfy the growing needs on the increased energy densities for the wider driving range of the electric vehicles. Additionally, the low intercalation rate capability limits the use of this material for high power applications [34]. In general, carbon materials can be categorized into graphitic and non-graphitic carbons, as displayed in Figure 6. Although in theory term “graphite” applies only to the material having a perfect stacking order of graphene planes, in practice any material comprised of aggregates of perfectly stacked crystallites with different orientations is also defined as graphite. Graphite lattice belongs to P63/mmc space group and comprises two types of characteristic surfaces: normal to (basal) and parallel to the c-axis planes (edge or prismatic). Non-graphitic (or disordered) carbons, in turns, also consist of hexagonal graphene layers, but without long-range crystallographic order, also defined as turbostratic disorder. Non-graphitic carbons can be further classified in graphitizing (“soft”) or non-graphitizing (“hard”) carbons. The soft carbons are mostly originating from the pyrolysis of liquid precursors. Hard carbons, produced mainly by pyrolysis of solid precursors (such as chars or glassy carbons), show no graphitic ordering even during high temperature treatment as the motion of the layers is hindered by strong cross-linking. I n t r o d u c t i o n : L i t h i u m I o n B a t t e r i e s | 11 Both soft and hard carbons generally offer higher capacities as compared to graphite. Soft carbons are typically pyrolyzed at lower temperature, which results in the high amount of hydrogen in the carbon layers. Lithium intercalation is believed to occur at the sites close to the hydrogen atoms. Upon lithiation the modifications of C-H bonds occur due to (H-C)-Li 2 3 bridging, resulting in carbon transformation from sp to sp hybridization [33, 36]. This leads to the large hysteresis and higher voltage required for lithium deintercalation [37], which lowers total (cell) voltage and reduces the volumetric capacity. Hard carbons are generally heat-treated at high temperatures (≥1000 °C); thus, the hydrogen content can be substantially decreased. On the contrary to soft carbons, hard carbons are believed to consist of two domains, including carbon layers and micropores. Both domains can accommodate lithium ions in accordance to the + model, known as the “house of cards” [38-40], resulting in high Li storage capability. However, hard carbons have low density, which negatively affects the volumetric energy density, and high surface area, leading to high irreversible lithium losses due to extended electrolyte decomposition. Therefore, in lithium-ion batteries hard carbons are rather employed as additives to increase the electronic conductivity of the electrode. Per contra, hard carbons have been widely employed as anode materials for sodium-ion batteries, in which the use of graphite is hindered due to the mismatch between the graphite interlayer spacing and the size of Na ions, and higher potential of Na (-2. As mentioned above, since 20 years natural or synthetic graphite has been the most commonly used anode material for Li-ion batteries. Lithium intercalates in between the graphene planes, resulting in the storage of up to 1 Li atom per 6 C atoms, corresponding to the theoretical -1 capacity of 372 mAh g. Intercalation is only possible along the edge (or prismatic) planes (Figure 7), whereas at the basal planes the ion transfer can occur only through the defects [43]. Therefore, the electrochemical performance of the graphite varies depending on the ratio between the edge-plane to basal-plane area [44]. As displayed in the schematic voltage profile in Figure 8, through the whole concentration range the coexistence of the two stages is observed, indicated by the voltage plateaus. In reality the transitions between the stages in the voltage profiles are very smooth due to only slight variation in LixC6 packing density. Moreover, the sloping of the plateaus is observed due to various overpotential occurring during the galvanostatic measurements. As the ionic radius of I n t r o d u c t i o n : L i t h i u m I o n B a t t e r i e s | 13 lithium ions is much smaller than that of the salt counter anion, lithium ions get solvated by the electrolyte solvent molecules, forming lithium solvation shells [48]. Due to the concentration gradient under the cathodic currents, solvated ions diffuse towards the graphite surface, where the formation of the passivation film is initiated.

It is worth mentioning that parenchymal transection during segmental resection causes more bleeding than during conventional hepatectomy allergy fatigue purchase cetirizine 10 mg free shipping, since there is no previous control of the portal pedicles and the raw surface following sectioning is large allergy partners asheville cheap cetirizine online visa. There is an almost avascular plane zyto allergy testing cheap 5mg cetirizine with mastercard, with the exception of one artery directed upwards to the liver that has to be ligated allergy medicine on plane purchase cetirizine 10mg without prescription. Parenchymal division is shifted slightly to the left, thus preserving the middle hepatic vein. Note the location of the portal pedicle of segment V and the proximity of the tip of the right liver from the right area of resection. The latter is located higher in the parenchyma and should not be searched for at the hilus because of its depth. It is worth pointing out that there are no clear guiding landmarks for dividing between these two territories. Resection of smal hepatocellular carcinoma in cirrhosis 107 Segmentectomy V the limits of segment V are as follows: the main portal scissura on the left and the right portal scissura on the right, which is in the vicinity of the anterior tip of the right liver and the plane of the hilus posteriorly. After cholecystectomy, the main portal scissura is first opened up to the hilum, avoiding injury to the middle hepatic vein. Liver division is slightly displaced to the left in order to preserve the right hepatic vein. This manoeuvre facilitates the division of the posterior boundary of segment V, which has a transverse direction and is located at the level of the plane of the hilum. The main biliovascular pedicle of segment V is divided at the left superior corner of the resected specimen (Fig. After complete mobilization of the right liver, parenchymatous division is performed posteriorly and transversely at the level of the hilum without damaging the right hepatic Figure 5. The right portal scissura is opened on the right side of the right hepatic vein, which marks the anterior limit of the resection. Complete mobilization of the right liver up to the inferior vena cava and the distal portion of the right hepatic vein is paramount. The right portal scissura is then opened and divided in the direction of the inferior vena cava. Parenchymatous division is carried out, 1 cm to the right of the main portal scissura, taking care to ligate a large branch of the middle hepatic vein in the cranial portion of the liver division. The main pitfalls of this resection are injuries to the hepatic veins on the borders of the segment. Resection of smal hepatocellular carcinoma in cirrhosis 109 the portal pedicle is ligated intraparenchymally, taking care to avoid the accidental injury to the adjacent Figure 5. Removal of small tumours located in the left portion of the dorsal sector (segment I) is relatively easy to accomplish after liberation of segment I posteriorly from its connections to the vena cava, by sectioning the accessory veins and, anteriorly, by dividing the arterial and portal vein branches (Fig. However, similar to what has been suggested in a normal liver, 91, 92 procedures of isolated dorsal sectorectomy have been described also in cirrhosis. In the first, the liver is completely mobilized on both sides up to the insertion of the three main hepatic veins into the inferior vena cava by sectioning the right and left liver ligaments and dividing the accessory hepatic veins (Fig. The dorsal sector is freed from the inferior vena cava posteriorly and from the hilum anteriorly. The posterior branches of the portal vein directed to the dorsal sector are ligated and divided. Because of uncertainty as to the right border of the sector, Japanese authors have suggested injecting dye into the posterior portal branches. The resection starts from the Surgical management of hepatobiliary and pancreatic disorders 110 Figure 5. Note (A) the planes of dissection behind the portal vein and in front of the inferior vena cava and (B) the site of ligation of the accessory hepatic veins and posterior portal vein branches. In the second technique, dorsal sectorectomy can be performed by using a transhepatic approach, as described by Yamamoto et al. The liver is completely freed and transection is carried out along the main portal scissura, thus exposing the middle hepatic vein on most of its length. Two planes of transection are followed on each side of the vein: on the left, following the direction of Arantius’ sulcus, and on the right, behind the middle hepatic vein towards the right side of the inferior vena cava (Fig. Pulling the resected dorsal sector forwards through the main portal scissura, the resection is ended by division of the portal branches directed towards the dorsal sector. The volume of non-tumourous liver removed is conspicuous (about 30%) and, therefore, the risks of hepatic failure and worsening portal hypertension are high. Moreover, the raw cut surface is the largest of the different hepatic resections and, as a consequence, postoperative fluid collection is not uncommon. Falciform and coronary ligaments are divided up to the inferior vena cava, whose anterior surface is exposed in order to locate the confluence of the hepatic veins, particularly the middle one, into the vena cava. Note the planes of liver division to the left in the direction of Arantius’ sulcus (arrow) and to the right on the right side of the inferior vena cava (arrow), behind the middle hepatic vein. It is actually harmful, in most cases, to encircle the pedicle: it is easier and safer to ligate it intraparenchymally during transection. If, for any reason, the right hepatic vein is encountered, the plane of section should be shifted medially. In front of the inferior vena cava, the trunk of the middle hepatic vein is easily identified and ligated on a vascular clamp by a running suture. Perioperative treatment Antibiotics Although some authors argue for the use of antibiotic therapy in cirrhotic patients undergoing liver resection, we do not routinely use this approach. Septic complications seem to be no higher in our patients compared to other series. In patients in whom a prolonged total portal clamping is foreseen, a preoperative selective intestinal decontamination may be proposed to prevent bacterial translocation. Blood transfusion the risks entailed in allogeneic blood transfusion are manifest in cirrhotic patients undergoing liver resection, and include worsening of hepatic function, increase in postoperative complications and a higher recurrence rate. Therefore all attempts should be made to identify patients at risk of bleeding in order to minimize the risk of transfusion. As shown in a multivariate study, 77 patients undergoing extended resections or with abnormal coagulation should be specially considered for other procedures, such as autologous blood predeposit, isovolemic haemodilution or intraoperative autotransfusion. To be effective, autologous blood transfusion requires painstaking organizational efforts prior to the patient’s hospitalization. While the procedure is mandatory in patients with benign tumours, its use in patients with malignant disease is debatable in view of the very high cost/benefit ratio. The best candidates for this procedure are those patients with Surgical management of hepatobiliary and pancreatic disorders 114 haemoglobin concentrations >13 g/dl. When haemoglobin is <11 g/dl, human recombinant erythropoietin and iron may also be effective in cirrhotic patients to accelerate erythrogenesis. Isovolemic haemodilution represents a very inexpensive and reliable method to substitute allogeneic transfusion in cirrhotic patients, 97 provided that contraindications such as major coagulation defects, cardiac disease or anaemia do not co-exist. Haemodilution is probably the best alternative method to allogeneic blood transfusion. The cell-saver for intraoperative blood recovery is practically unused in elective hepatic resection for malignant tumours because of its costs and the potential risk of tumoural cell dissemination, despite experimental evidence showing that this latter risk is absent. A policy of fluid and sodium restriction in cirrhotic patients is the best method for preventing ascites formation in the postoperative period. In the case of ascites formation, the intravenous administration of albumin or macromolecules associated with furosemide usually induces a diuresis and a reduction in intraperitoneal fluid accumulation. Paracentesis is mandatory in patients with massive ascites, in order to avoid prolonged leakage of fluid through the abdominal incision. Postoperative nutritional support is not a common practice after hepatectomy in our experience. Provided that a good selection of patients has been made preoperatively on the basis of residual hepatic function, the appearance of encephalopathy is nearly always exceptional. As a consequence, the use of special formulations, such as branched-chain amino acid enriched solution, does not lead to any clinical advantage over other standard formulations. An early resumption of oral intake in patients without complications is, in our current view, the best way to manage cirrhotic patients. When data from a number of series are collected, the mean 3 and 5-year survivals are 59. In a large series of 1000 patients treated by hepatectomy Resection of smal hepatocellular carcinoma in cirrhosis 115 Table 5.

Whereas of the morphology of the leaflets allergy list best purchase cetirizine, but must include ex Typ I is corrected by insertion of an annuloplasty-ring allergy testing gluten discount cetirizine online amex, amination of the whole mitral valve apparatus allergy symptoms numbness purchase cetirizine 10 mg without a prescription. For echocardiographic evaluation the standard the anterior leaflet has a small base and more triangu views according to the guidelines of the American so lar shape with a longer basal-to free edge-distance than ciety of echocardiography and the society of cardio the posterior leaflet allergy symptoms of dogs cetirizine 5mg sale, which has a broad base (2/3 of the vascular anesthesiologists (2) and additionally the circumference). The chordae tendineae, which prevent midesophageal 5 chamber view are used (Table 1). Remember that chords), the middle of the leaflets (secondary chords) the degree of mitral regurgitation depends on preload and to the base of the leaflets (tertiary chords). Chords and afterload and that both are influenced by general from the anterior papillary muscle insert from the an anesthesia, means that sometimes a volume and/or af terolateral commissure to the middle portion, whereas terload challenge (by vasopressors) is necessary to de chords from the posterior papillary muscle insert from termine the real degree of mitral regurgitation. Standard nomenclature is Important informations for the surgeon before that by Carpentier adopted by the Society of Cardio mitral repair vascular Anesthesiologists and the American Society of Echocardiography (2), where the segment close to 1. Underlying pathology : the anterolateral commissure is called P1, the middle Typ 1: diameter of the native mitral ring segment P2 and the segment close to the posteromedi localisation of a cleft al commissure P3. This constellation consists of a long posterior leaflet (> 1,9 cm) and a C-sept of < 2,5 cm (6), is there a ruptured chord or papillary muscle whereas C-sept is the closest distance between the ventricular septum and the coaptation point of both Lambert et al (5) found in 13 prospectively leaflets in systole. J Am Soc Echocardiogr 12: 884-898 – Detection of regional wall motion abnormalities in 3. J Tho promised flow in the circumflex artery due to suture rac Cardiovasc Surg 61: 1-13 necessary to fix the annuloplasty-ring is a rare but 4. Tavilla G, Pacini D (1998) Damage to the circumflex coronary ar tery during mitral valve repair with sliding leaflet technique. Ann In the hand of an experienced examiner it can give rel Thorac Surg 66 (6): 2091-3 evant information to the surgeon before and after mi 8. Speziale G, Fattouch K, Ruvolo G, Fiorenza G, Papalia U, Marino tral valve repair. B (1998) Myocardial infarction caused by compression of anom alous circumflex coronary artery after mitral valve replacement. Erb Universitätsklinik für Anästhesiologie und operative Intensivmedizin, Campus Charité Mitte, Berlin, Germany the aim of this summary is to review the intraopera lar junction and carries a fibrous nodule, the node of tive echocardiographic assessment of the aortic valve, Arantius, in the middle, at the central point of coapta its pathology and the results of aortic valve repair tech tion of all three cusps. Together with the wall of the si niques for the clinician with basic experience in nuses of Valsalva each semilunar leaflet forms a little echocardiography. Ejection is echocardiography is usually not feasible in the intraop also accompanied and supported by sequential expan erative setting. When ejection is completed and the ventricle relaxes at the beginning of diastole, blood starts flow Normal aortic valve anatomy and function ing backwards towards the left ventricular outflow tract, thereby filling the little sacks formed by the the aortic valve sits at the junction of the left ventric semilunar leaflets and pushing them towards the mid ular outflow tract and the ascending aorta and has the dle and against each other, thus closing the aortic valve task to connect (in systole) as well as separate (in di and preventing diastolic backflow. This fact is important in understanding aor tic valve function, pathology and surgical repair tech niques. The aortic root has a green onion shaped fig Echocardiographic assessment of the aortic valve ure, where we discriminate between the aortic annulus, and aortic root the sinuses of Valsalva, the sino-tubular junction, and the ascending aorta. Anatom sample anatomical and functional information of the ic studies have shown that a sino-tubular diameter of aortic valve and the aortic root in the two-dimensional 85% of the annular diameter describes normal aortic (2D) mode. Three semilunar leaflets or cusps near field of the transducer, just separated from the oe form the aortic valve. The use of colour flow ented towards the ascending aorta, with the edges at Doppler in these views will contribute useful informa tached on either side to the aortic wall at the level of tion about the location of flow velocities, but it needs the sino-tubular junction, while the base is anchored in to be noted that the measured velocities will differ an U-shape fashion to the aortic annulus. The free edge markedly from the existing velocities due to the large has a length of 1. Erb Likewise, useful spectral Doppler information of the transgastric long axis view and the deep trans blood flow through the aortic valve cannot be acquired gastric view are the appropriate planes to interrogate in these planes. Normally, laminar flow is seen in sys the aortic valve using all Doppler modalities. Turbulent systolic due to the near parallel alignment of flow direction and flow and more than trivial diastolic flow are signs of ultrasound beam in these views, allowing for only valve pathology. Certainly the short axis view of the aortic valve normally 2D anatomical and functional information can also be shows three symmetrical leaflets, which are identified acquired in these views, but usually is inferior in qual as the noncoronary cusp oriented towards the interatri ity to the information obtained in the midoesophageal al septum, the left coronary cusp oriented towards the views due to a larger distance between valve and ultra left atrium and the right coronary cusp oriented to sound probe and much more tissue interposition. The anatomy and motion of Normal flow across the aortic valve is only de the leaflets is easily assessed in this view. Using colour flow Doppler, the sig the closure lines between the three cusps form a sym nal colour is usually blue, but single aliasing into red metrical star displaying three arms at 120-degree an is in the normal range, depending on the achievable gles. In systole, the rims of the leaflets form a triangu Nyquist limit of the equipment and the angle of inter lar to circular symmetrical opening, the area of which rogation. Turbulent systolic flow is always suspicious can easily be measured by planimetry. Changes from for valve stenosis or marked deformation of the open this symmetrical appearance and motion are indica ing geometry. The form, size and direction of the jet tions for structural and functional abnormalities, give valuable information about the underlying pathol whether congenital or acquired, and should be precise ogy. The most frequent congenital abnormali ways raise suspicion for pathology leading to valve in ty is the bicuspid valve, where only two usually asym competence, as only in 5% of all normal aortic valves metric leaflets are present, the larger of which often minimal, trivial aortic insufficiency can be detected, displays a raphe as indication of a fusion of two initial most often originating centrally and always limited to ly developing cusps into one. Asymmetry of the valve a very narrow jet with minimal penetration into the left and abnormal motion can also be the result of commis ventricular outflow tract. The use of spectral Doppler interrogation of veloc the long axis view shows the aortic valve and the ities across the aortic valve has a higher timely resolu ascending aorta as well as their relationship and inter tion and allows measurements of velocities throughout dependence. This information can be used for the cusps are visible in the imaging plane at any one time, calculation of systolic gradients across the aortic valve with the more distant, on the lower part of the monitor using the simplified Bernoulli equation or the calcula screen appearing leaflet always being the right coro tion of systolic valve orifice using the continuity equa nary cusp, while the upper, closer to the transducer lo tion, thereby enabling the quantification of aortic cated cusp is either the left or non coronary cusp. Intraoperative echocardiography for aortic valve repair surgery 21 Aortic valve pathology suitable for surgical repair comes have not been satisfactory in severe valvular stenosis. Today, these techniques are sometimes used Independent of the underlying pathology, the two ba to address additional moderate stenosis in the presence sic resulting aortic valve dysfunctions are aortic steno of other leading pathologies of the aortic valve. Regarding surgical interventions, aortic stenosis can be only rarely taken care of by aortic valve repair. For Aortic valve repair procedures for aortic genuine aortic valve stenosis, repair procedures are regurgitation caused by type 1 pathology usually restricted to mild or moderate stenosis due to commissural adhesions, mild calcifications, and ob For type 1a pathology, reconstruction focuses on structions of the valve opening by non-destructing tu restoration of the function of the sino-tubular ridge mours or thrombosis. Other reasons are membranous with or without replacement of the ascending aorta as obstructions at the level of the aortic valve. Recent literature de sino-tubular junction to its physiological diameter in fined three types of pathologies in a functional classi relation to the annular and sinus dimensions. They all include replacement of the dilated nuses of Valsalva ascending aorta by a tube graft including the resection 1c: annular dilatation of the sinuses, re-suspension of commissural pillars in 1d: leaflet defect (perforation) to the tube graft and reinsertion of the coronary arter Type 2: cusp prolapse ies. Type 3: restricted cusp motion Leaflet defects (type 1d) can be repaired using patch repairs or pericardial cusp extensions. Type 1 pathologies are found to be most likely ad dressable with surgical, valve-sparing and valve-con serving repair procedures, type 2 pathologies are much Aortic valve repair procedures for aortic more difficult to repair, while there are very few indi regurgitation caused by type 2 and type 3 pathology cations for surgical repair procedures in type 3 pathologies. Shortening of the leaflets and resuspension of the pil lars have been described as repair procedures where si nus of Valsalva aneurysms lead to excess tissue caus Aortic valve repair procedures ing loss of effective coaptation due to prolapse of the leaflet edge. Other methods to deal with cusp prolapse As it will be beyond the scope of this short review to include triangular resection, commissural plication cover the wide field of aortic valve repair procedures and synthetic or pericardial reinforcements. For detailed infor methods of pericardial cusp extension or leaflet re mation and illustration, the reader is referred to the placement [14]. Intraoperative echocardiographic evaluation and Aortic valve repair procedures for stenosis support of decision making Aortic commissurotomy, aortic valvulotomy and de A thorough examination as described above, using all calcification have been early described as techniques obtainable imaging planes and imaging modalities is in aortic valve stenosis [9,10], but in general, the out required intraoperatively before, during and after the 22 J. All available infor ly a problem and can be detected echocardiographical mation should be gathered at any time. If the na ways be based on a most thorough anatomical descrip tive aorta is closed around the tube prosthesis, the tion of the nature, extent and location of the pathology forming haematoma can lead to compression of the based on a high quality 2D examination combined graft causing significant gradients, which needs to be with Doppler data and respective calculations using detected. This section will focus on specific informa coronary arteries needs to be documented and quanti tion and measurements the surgeon might depend on fied, as obstruction, torsion and also dissection can im related to the individual pathology and intended surgi pair coronary flow significantly. Aortic dissection, most like evaluated before and after the repair and compared to ly starting from the distal graft anastomosis extending each other. Problems / challenge: After the repair, the aortic Aortic valve repair procedures for stenosis valve is expected to be patent, with no or only minimal regurgitation detectable. Torsion or size mismatch of the extent and location of commissural fusion and cal the prosthesis leads to valvular regurgitation. Pressure gradients should routinely be obtained, but Aortic valve repair procedures for aortic are difficult to compare before and after reconstruc regurgitation caused by type 2 and type 3 pathology tion, as marked differences in contractility, volume status and vascular resistance as well as haematocrit In these repairs, evaluation of the regurgitant orifice before and after cardiopulmonary bypass will influ location and geometry as well as the extension and ence these measurements. Special focus needs to be on three-dimensional orientation of the regurgitant jet is the exclusion respective detection and grading of the main task. This should always be combined with valvular insufficiency or shunt flow into surrounding measurements of the length of the coaptation zone be structures, most often the right cardiac cavities or the tween the cusps and its position in regard to the annu pericardium.

The surgeon should be completely comfortable with the relevant anatomy and the common variations allergy shots bruising order generic cetirizine online, as well as the standard techniques of hepatic resection allergy and asthma care 5 mg cetirizine otc. Complete resection of the caudate lobe of the liver: technique and results [review] allergy symptoms upon waking order 10 mg cetirizine fast delivery. One hundred consecutive hepatic resections: blood loss allergy shots for dust mites purchase generic cetirizine canada, transfusion, and operative technique. Surgery 1992; 111:699–702 Surgical management of hepatobiliary and pancreatic disorders 64 16. Hepatic segmentectomy with caudate lobe resection for bile duct carcinoma of the hepatic hilus. Resection of the caudate lobe of the liver for primary and recurrent hepatocellular carcinomas [see comments]. Bilan d’une experience de la chirurgie d’exerese hepatique pour cancer par la technique d’hepatectomie reglee par voie transparenchymateuse: a propos de 941 hepatectomies. Hilar cholangiocarcinoma: patterns of spread, the importance of hepatic resection for curative operation, and a presurgical clinical staging system. Resectional surgery of hilar cholangiocarcinoma: a multivariate analysis of prognostic factors. J Clin Oncol 1997; 15:947–54 4 Ex-vivo resection for liver tumours J Peter A Lodge Introduction these days it seems that virtually no liver tumour should be considered to be unresectable, even though the majority of patients continue to present at a late stage in their disease. Many experts have challenged the old dogma relating to hepatic resection and candidates with multiple and bilobar hepatic tumours as well as patients with limited extrahepatic tumour infiltration are now considered for resection. In addition, patients with metastases from tumours other than colorectal cancer are also regularly undergoing liver resection. Improvements in anaesthesia have been integral to the success of hepatic surgery, primarily through the use of low central venous pressure techniques for liver resection. This is despite the fact that 85% of our current resection practice is hemihepatectomy or more and the majority is trisectionectomy (extended hepatectomy) and bilateral resection work. In the majority of hepatobiliary centres, Pringle’s manoeuvre and total vascular isolation (hepatic vascular exclusion) are used routinely, 1 – 16 and this short-term warm ischaemia is reported to be well tolerated. However, it has been our preference in recent years to avoid ischaemia whenever possible as we had noticed an increased postoperative morbidity and longer hospital stay in those patients in whom vascular isolation techniques had been used for prolonged periods. In our experience, the use of hepatic ischaemia techniques and blood transfusion is more often necessary for the more complex resections. Recent internal audit of the first 22 left hepatic trisegmentectomies carried out by this author has shown that 11 required Pringle’s manoeuvre and five needed a period of total vascular isolation. Eleven of the 22 patients required blood transfusion, although the median requirement was only 1. This may partly be explained by a high proportion of cholangiocarcinoma cases (32%) in this series as resection of these tumours is associated with a greater degree of operative difficulty. In this group of 22 patients, six of the seven patients with major postoperative morbidity had required either Pringle’s manoeuvre or total vascular isolation, confirming our previous observation. It is also true to say that increasing experience helps to reduce the use of Ex-vivo resection for liver tumors 67 ischaemia and blood transfusion, and there has been little morbidity in a further 15 left trisectionectomies carried out recently by this author. Although orthoptic liver transplantation and cluster resection are the most radical forms of tumour clearance, results for otherwise unresectable tumours have been uniformly disappointing. Tumours account for only 3% of our liver transplant programme in terms of primary indication. However, transplantation remains a valuable option for patients with tumours as secondary indications: principally small hepatomas within cirrhosis. Our centre has been investigating cluster resection and multivisceral grafting as an alternative for extensive tumours and the neuroendocrine group lends itself neatly to this concept. These are most often tumours of midgut origin with foregut metastases and adequate lymphadenectomy involves both the coeliac and superior mesenteric arterial distributions, and if purely foregut (pancreatic tail) then a lesser cluster resection can also be appropriate. These concepts will be discussed at the end of this chapter as they are helpful in defining the place of ex-vivo liver resection in the spectrum of hepatic surgical techniques. In addition there are many lessons to be learnt from the practice of liver transplantation, not least anaesthesia and the role of veno-venous bypass. The short-term survival of untreated patients with both primary and secondary liver tumours, the unpredictability of chemotherapy response on an individual patient basis and the disappointing results of transplantation for cancer provide adequate impetus for attempts to extend the boundaries of liver resection as far as possible. Hilar involvement can be adequately dealt with by short periods of vascular isolation and warm ischaemia and this can often be done without caval or hepatic vein isolation. This fraction is expected to increase as more advanced cases are being considered and it accounts for 6% of cases during the past 12 months in our centre. Ex-vivo resection 18 – 20 offers a potential lifeline for this group of patients and this technique deserves discussion, although it accounts for less than 2% of this author’s total hepatic resection experience. The processes of patient selection and operative assessment of operability by more conventional yet advanced techniques have meant that we have found ex-vivo resection to be necessary in only five of 28 cases (21%) considered during the past 7 years. Before considering a surgical procedure of this scale it is essential to be as sure as possible that the patient is fit enough to withstand the operation. It is important to take a detailed history of previous cardiovascular disease, including myocardial infarction, angina pectoris and hypertension. Clearly, a history of smoking or peripheral vascular disease should raise the clinical suspicion of coronary artery disease. Respiratory diseases, particularly emphysema and chronic bronchitis, are quite prevalent in the Surgical management of hepatobiliary and pancreatic disorders 68 elderly population and clinical examination with chest radiology can be helpful. Patient selection Cardiorespiratory assessment Resting and exercise electrocardiography are the standard cardiological objective assessment tests in our centre. Failure to achieve an adequate heart rate for true stress testing can be a problem in the elderly population, most often due to osteoarthritis of the hips and knees. In this situation a great deal of useful information can be gained from echocardiography, with measurement of end diastolic and systolic volumes to calculate left ventricular ejection fraction, or by radioisotope assessment with dobutamine stress. This procedure is carried out in 10% of major liver surgery candidates in our experience, ruling out surgery in 3% but providing reassuring information in the rest. Only five patients in our experience have been suitable for preoperative coronary artery angioplasty, stenting or bypass grafting prior to liver surgery, but these are clearly potential treatment options to consider. Routine lung function tests including vital capacity and forced expiratory volume form part of our standard assessment as well as chest radiology. In cases where severe pulmonary hypertension is suspected a pulmonary artery wedge pressure line is placed at the commencement of anaesthesia before definitely deciding to proceed with the resection. If there is a very high index of suspicion then we prefer to check the pulmonary artery pressures as a day case procedure in advance of the planned surgical date so that the patient can be advised more accurately about operative risk. Hepatic reserve Preoperative blood tests necessary before proceeding to major resection include full blood count, urea and electrolytes, liver function tests, clotting screen and tumour marker studies. Prothrombin time, bilirubin and albumin give a fairly accurate indication of global hepatic function, but in some cases a liver biopsy of the residual tumour-free liver will also be necessary if there is a doubt about hepatic reserve, in particular in hepatoma. This is particularly important in the group of patients with a previous history of excess alcohol consumption or if there is serological evidence of hepatitis B or C. It is also useful when dealing with cholangiocarcinoma, as there may be underlying sclerosing cholangitis. Some consideration needs to be given to the number of viable tumour-free hepatic segments that will be reimplanted, but this should not usually be less than two, unless there is considerable hypertrophy of the tumour-free liver (Fig. It is inevitable that a degree of temporary hepatic failure will be induced in some patients undergoing very major resection. If the tumour-free segments are affected by biliary obstruction, it is our current practice to attempt biliary decompression by endoscopic or percutaneous techniques a few days in advance of surgery as this may speed up the postoperative recovery. Surgical management of hepatobiliary and pancreatic disorders 70 Tumour type It is reasonable to consider any malignant tumour of the liver, primary or secondary, for ex-vivo liver resection if there is an acceptable chance of clearance of all the disease. It is not our routine to biopsy the tumour unless there is a serious doubt about the diagnosis after radiological assessment. A biopsy can be useful if a benign tumour is suspected, for example hepatic adenoma occurring as a result of a glycogen storage disease, as liver transplantation may be more appropriate in that case. Small metastases or hepatomas not detected by other methods will rule out some candidates and variations in hepatic arterial anatomy can be helpful in some cases, particularly in cholangiocarcinoma. Venography to examine the inferior vena cava and hepatic veins is occasionally useful if all three major hepatic veins are involved with tumour as an adequate inferior or middle right hepatic vein (Fig. An isotope bone scan may be useful in hepatoma, cholangiocarcinoma and some metastatic tumours, and we have recently found it to be of use in colorectal metastatic disease. This is at variance with our usual practice for patients with hepatic metastases from colorectal cancer and may reflect the late stage of presentation of the ex-vivo candidates.

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