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On the lateral plain film x-ray (part 1) buy generic finpecia 1 mg on-line hair loss cure4you, there are on this sagittal reformatted image buy finpecia 1mg with mastercard hair loss kid. Note that there is also a grade 1 findings—absence of visualization of the pars interarticularis— anterolisthesis (small black arrow) at L5–S1 buy genuine finpecia hair loss in men rings. A mild retrolisthesis is however the best way to evaluate the bony spine per se, with the of L4 on L5 is also present, and can be seen as well on the plain film. Retrolistheses are less often graded, relative to the degree of displacement, when compared to an anterolisthesis (in which the degree of dis- placement is always described), although a similar grading system can be used. On the sagittal T1-weighted scan a discontinuity 1 anterolisthesis (large white arrow) of L5 on S1, best seen on the (small black arrow) of the L5 pars is well seen, indicating spondy- midline sagittal image. Although there is fat (best seen on the T1-weighted scan) noted to involve L5 (small white arrow), the definition of spondyloly- both anterior and posterior to the L5 nerve in the L5–S1 foramen, sis. There is compromise of the L5–S1 neural foramen both due to the nerve (white arrow) is markedly compressed in the superoinfe- the anterolisthesis (slippage) and the disk bulge. Axial scans (not illustrated) in this instance are often terolisthesis is due to a bilateral lysis, the spinal canal dimensions misleading, showing fat anterior and posterior to the nerve, with the will be preserved, as in this case. The lack of spinal canal stenosis compression not evident due to the dimension in which it occurs. For one or two level involvement, a common procedure is an ante- rior diskectomy, with placement either of a bone graft or a disk replacement device, with an accompanying anterior plate and screw vertebral body fusion. In the case where a bone graft is placed, the desired end result is bony fusion at the level of surgery, often without evidence of either the original bone graft or the native disk on imaging. By limiting motion at the site of surgi- cal fusion, the patient is more predisposed to development of degenerative changes, and disk herniations, at the levels above and below the fusion, with attention thus manda- tory to these levels in scan review (Fig. A posterior cervical laminectomy is reserved for con- genital narrowing or extensive, multilevel, contiguous disease. Postoperatively, on T2-weighted scans, abnormal high signal intensity within the cord at the level of sur- gery can represent gliosis, which could have been present preoperatively, or represent a postoperative complication including, specifically, cord contusion. In the setting of a disk herniation with compression of the adjacent nerve, surgery may be undertaken to decom- press the affected nerve. In the lumbar spine, the spectrum of surgery extends from percutaneous diskectomy to lami- nectomy with diskectomy, with removal of as little bone Fig. Absence of the ligamentum flavum of a level will accentuate normal motion (in flexion and extension) unilaterally, at the level of interest, is an important key to at both the level above and below. This increases the incidence of disk herniation at these levels, together with degenerative disease. In the case presented, there is an anterior plate and screw fusion of a Orthopedic spine surgery for pain generally involves midcervical level. Anterior plate and screw fu- on sagittal and axial images at the level below, causing moderate sion of a single level is common, with placement either deformity (flattening) of the adjacent cord. In the past these were often dimension that can result in either an anterolisthesis or done with bone grafts only, although placement of ortho- a retrolisthesis. Multilevel posterior decompression (laminectomy) is Scar is often not masslike, but can appear as a mass performed much less frequently today, due to the poten- lesion and thus mimic a disk herniation on unenhanced tial for destabilization of the spine (Fig. C6–7 is not fused, with sclerotic, irregular end- plate margins and a slight retrolisthesis of C6 on C7. One often performed in the past, can result long-term in destabilization important caveat is that scar is commonly present circum- of the spine, specifically relative to vertebral body alignment. The ferential to a disk herniation, in cases both after surgery posterior elements in this patient are missing at four contiguous lev- els. Complications include canal compromise, with cord compres- and without surgery, and is visualized as a thin rim of en- sion, atrophy, and gliosis as illustrated. A broad irregular osteophyte hancement encompassing (“wrapping”) the nonenhancing (posteriorly) accentuates the compression in this instance. Following contrast injection, there is enhancement of prior to administration of intravenous contrast abnormal soft tissue, this tissue, consistent with postoperative scar. The right S1 nerve is masslike in appearance, is seen posterior to the L5–S1 disk space level, seen on the post-contrast axial image to be encompassed by scar, lying in a right paracentral position (white arrows). This could represent centrally within the abnormal soft tissue identified pre-contrast. A large soft disk material (due to the lack of contract enhancement), wrapped tissue mass is noted immediately posterior and inferior to the L3–4 by enhancing scar tissue, and with some dilated enhancing epidural disk space level. There has been prior surgery, reflected by the ab- venous plexus both cranial and caudal to the disk. Due to the inferior normal soft tissue posterior to the thecal sac at this level, and the extent of this disk material relative to the disk space it also likely extensive fat also posteriorly. On the T2-weighted scan the mass is represents a sequestered disk (free disk fragment). However the enhancement in the soft tissues posterior to the thecal sac at only on the post-contrast scan is the mass definitely identified as this level, reflecting postoperative scar. Scans should not be obtained (ankylosing spondylitis, reactive arthritis, enteropathic post-contrast in a delayed fashion because there can be spondylitis associated with inflammatory bowel diseases, diffusion with time of contrast into the disk itself from psoriatic arthritis, and undifferentiated spondyloarthropa- adjacent vascular tissue (such as scar). Contrast enhance- thies) and are all characterized by inflammation that fre- ment can also be seen in a nerve that is compressed, as quently progresses to bony ankylosis. Although strictly a brachial plexus avulsion injury is a pseudo- meningocele, most of the lesions that are seen on imaging in the spine are large on presentation and a complication of surgery. Surgery involving the occiput, perhaps due to the difficulty of surgery in this area, and that involving the lumbar region, perhaps due to how common such surgery is, lead to the majority of cases. It is a disease of the elderly, and is seen most anterior longitudinal ligament ossification (“flowing” calcification) is commonly in the thoracic spine. Myelopathy can occur due noted from T12 to L5 (satisfying the requirement of involvement of to associated ossification of the posterior longitudinal liga- four or more levels). Disk space height is generally preserved, other ment or vertebral complications (fracture or subluxation). Although there are some facet degenerative changes, these are much less prominent than the disease involving the ante- rior spine. In addition to the spine, the chest wall (including the sternum, sternoclavicular joints, and costosternal joints) is also often involved in inflammation and should be in- cluded in the imaging protocol. In ankylosing spondylitis, the sacroiliac joints are in- volved early in the disease course. Erosion of cortical mar- gins, typically first on the iliac side of the joint, is seen early in the disease process (Fig. Proliferative changes subsequently dominate, with subchondral sclerosis pro- gressing to ankylosis (fusion) of the joint (Fig. In the spine, inflammation occurs joint space is evident on the precontrast T1-weighted scan, together often at the junction of the annulus fibrosus and the ver- with subchondral sclerosis (with low signal intensity) and irregularity tebral body (the enthesis, which is the connective tissue involving the margins of the sacrum and iliac bones bordering the between the ligament and bone). On the fat suppressed post-contrast scan, enhance- become replaced by bone, syndesmophytes, which even- ment is seen both within bone bordering the joint space and within tually bridge the adjacent vertebral bodies (Fig. Syndesmophytes are slender, vertical ligamentous calcifi- cations that extend from the corner of one vertebral body fracture following minor trauma, which in the cervical to the next, and are the hallmark of ankylosing spondylitis spine can lead to quadriplegia. The articulation of the atlas theses and ankylosed facet joints are often seen together (C1) and the dens is most often involved. Characteristic im- with the appearance of a “bamboo spine,” featuring mul- aging findings include erosion of the dens by surrounding tilevel syndesmophytes in addition to relative “squaring” inflammatory pannus and involvement of the transverse of the vertebral bodies (Fig.

Behçet disease is a type of vasculitis associated with recurrent oral and geni- 5 generic finpecia 1mg with visa hair loss from lupus. There is some evidence that vitamin is another disease that afects the brainstem and resembles D defciency plays a role in this diference in prevalence 1 mg finpecia hair loss in men zara. B also reactive astrocytes and macrophages containing Injection site reactions buy generic finpecia 1 mg online hair loss women, fu-like symptoms, elevated myelin debris. Astrocytes become gemistocytes, which liver enzymes, and neutralizing antibodies can occur in are plump cells with abundant fbrillary processes. A Chronic plaques are characterized by astrocytic Dalfampridine (Ampyra) is the extended -release form of fbrillary gliosis and sharp margins on gross specimens. They contain remyelinating axons, which Fingolimod (Gilenya) is a sphingosine-1-phosphate have thin myelination. B pregnancy, but there is a higher risk in the postpartum Fingolimod has been associated with cardiac arrhyth- period. B Glatiramer acetate (Copaxone) is pregnancy category Natalizumab is an antibody to α4 integrin. It consists of a polymer that includes salt forms of feres with the interaction between the integrin very late four amino acids (l- glutamic acid, l- lysine, l- alanine, antigen-4 and vascular endothelial adhesion molecule-1. It is administered by injection, and It prevents entry of lymphocytes into the central nervous some patients have an immediate postinjection reaction. D Dalfampridine, fngolimod, interferon-beta, and natalizumab are pregnancy category C. A maximum cumulative dose of mitoxantrone for a patient’s lifetime has been determined. It potentially xantrone therapy because there can be delayed cardio- could reactivate tuberculosis. Natalizumab should not be combined Interferon-beta 1a (Avonex, Immunomodulation with immunosuppressants. A washout period is recom- Rebif); peginterferon- beta 1a mended before starting natalizumab if the patient has (Plegridy) been taking an immunosuppressant. Alemtuzumab (Lemtrada) Infusion Extensive perivascular cufng and necrosis indi- 4- Aminopyridine/ Dalfampridine Oral cates signifcant infammation, as might be seen in (Ampyra) encephalitis. Alemtuzumab carries a risk for autoimmune complica- Interferon-beta 1a (Avonex, Rebif); Injection tions such as immune thrombocytopenic purpura, auto- peginterferon-beta 1a (Plegridy) immune thyroiditis, and glomerular nephropathy. There is weak evidence that plasma exchange neuritis, acute myelitis, area postrema syndrome, acute can be used in patients if treatment with methylpred- brainstem syndrome, symptomatic narcolepsy or acute nisolone fails. A complete spinal cord syndrome and centrally located lesions also Aquaporin-4 is a water channel protein. B useful in diferentiating patients with acute complete Azathioprine is a purine analog. Children typically have more relapses than adults be involved in the mechanism of action of daclizumab. A myelin on multiple axons, so injury to a few oligoden- drocytes can produce a noticeable area of demyelination. An incomplete rim of enhancement is consistent with Schwann cells produce one internode of myelin and demyelination. This occurs imity to the internode of myelin, whereas the oligoden- in acute hemorrhagic leukoencephalitis. Pathology shows hemorrhagic demyelin- ating lesions with necrosis surrounding blood vessels. Central nervous system Peripheral nervous system There is axonal injury and prominent edema. It is defective in Pelizaeus- Marchiafava-Bignami disease is demyelination of the Merzbacher disease. Morvan syndrome is characterized by limbic encephali- Acetylcholine receptor antibodies may be measured in tis, neuromyotonia, hyperhidrosis, and polyneuropathy. This patient has epilepsia partialis continua due to These antibodies are involved in clustering acetylcho- Rasmussen encephalitis. Some with these antibodies tend to be young females and patients with Rasmussen encephalitis have antibodies to have less ocular involvement than most patients with the glutamate receptor. Natalizumab treatment for mul- multiple sclerosis: 2010 Revisions to the McDonald criteria. Ann tiple sclerosis: Updated recommendations for patient selection and Neurol 2011;69:292– 302. Evidence-based guide- ment of neuro-Behçet’s disease: International consensus recommen- line: Clinical evaluation and treatment of transverse myelitis. International Pediatric ment responsive to steroids—Review of an increasingly rec- Multiple Sclerosis Study Group criteria for pediatric multiple ognized entity within the spectrum of inflammatory central sclerosis and immune-mediated central nervous system demy- nervous system disorders. Clin Exper Immunol 2014;175: elinating disorders: Revisions to the 2007 defnitions. Evidence-based guideline report: The efcacy and safety of mitoxantrone (Novantrone) update: Plasmapheresis in neurologic disorders. Neurology 2010;74: T erapeutics and Technology Assessment Subcommittee of the 1463– 1470. Focal epileptiform discharges over the centrotemporal regions that increase during sleep. Seizures are preceded by nausea clonic from psychogenic nonepileptic seizures if measured and accompanied by headache and vomiting. The family reports charges with a photoconvulsive response that the patient’s father, paternal uncle, and paternal B. Generalized 3-Hz spike and wave discharges grandmother had similar events, but their seizures C. An 18-year-old female patient who is taking valproic from 6 months to 7 years of age. In one episode, department with increased seizures despite documented the seizure activity was primarily lef-sided; the other good serum levels of lamotrigine. Which of the following statements activity) for the past 30 minutes arrives in the emer- is false? Pregnancy is associated with a signifcantly increased risk nytoin, and the clonic activity stops. To reduce major congenital malformations, valproic acid and his eyes intermittently deviate to the lef. His seizures have not responded to levetiracetam or The mother says he pauses during activities, stares of, lacosamide. Referral to an epilepsy monitoring unit for an epilepsy sur- tion during the episodes. Treatment with oxcarbazepine, levetiracetam, and he once had an episode while blowing a pinwheel. Which of the following is not a common feature of sei- zures arising from the supplemental motor area? Which of the following medications is least likely to lower the seizure threshold? Which of the following anti-epileptic medications is tures is associated with mutations in which gene?

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Preinduction Period of these should be in a large central vein cheap finpecia 1 mg with mastercard hair loss vitamins that work, usually an internal or external jugular or subclavian vein generic 1 mg finpecia visa hair loss cure for man. Premedication Central venous cannulations may be accomplished The prospect of heart surgery is frightening discount finpecia 1 mg overnight delivery hair loss in men zip up hoodies, and while the patient is awake but sedated or afer induc- relatively “heavy” oral or intramuscular premedica- tion of anesthesia. Studies show no beneft from tion was ofen given in the past, particularly when placing either central venous or pulmonary arterial patients had coronary artery disease with good lef catheters in awake (versus anesthetized) patients ventricular function (see Chapter 21). Multilumen central venous Benzodiazepine sedative-hypnotics (diazepam, catheters and multilumen pulmonary artery cathe- 5–10 mg orally), alone or in combination with an ter introducer sheaths allow for multiple drug infu- opioid (morphine, 5–10 mg intramuscularly or sions with simultaneous measurement of vascular hydromorphone, 1–2 mg intramuscularly), were pressures. Longer acting premedicant for drug infusions and nothing else; drug and fuid agents (eg, lorazepam) are avoided by most practi- boluses should be administered through another tioners to permit “fast tracking” of patients through site. The best practitioners of cardiac anesthesia formu- Blood should be immediately available for 5 late a simple anesthetic plan that includes adequate transfusion if the patient has already had a preparations for contingencies. Many patients are midline sternotomy (a “redo”); in these cases, the critically ill, and there is little time intraoperatively right ventricle or coronary grafs may be adherent to to have an assistant search for drugs and equipment. Arterial Blood Pressure Venous Access In addition to all basic monitoring, arterial cannula- Cardiac surgery is sometimes associated with large tion is always performed either prior to or immedi- and rapid blood loss, and with the need for multiple ately afer induction of anesthesia, as the induction drug infusions. Ideally, two large-bore (16-gauge or period represents a time when major hemodynamic larger) intravenous catheters should be placed. Catheters placed through the other sites, side of a previous brachial artery cutdown should be particularly on the lef side, are more likely to kink avoided, because its use is associated with a greater following sternal retraction (above) and are not incidence of arterial thrombosis and wave distor- nearly as likely to pass into the superior vena cava tion. Obviously, if a radial artery will be harvested as those placed through the right internal jugular for a coronary bypass conduit, it cannot be used as vein. Infation of the balloon under manual or automatic blood pressure cuf should also these conditions can rupture a pulmonary artery be placed on the opposite side for comparison with causing lethal hemorrhage. Central venous pressure is not terribly useful for diagnosis of hypovolemia but has been customarily D. Urinary Output monitored in nearly all patients undergoing cardiac Once the patient is anesthetized, an indwelling uri- surgery. The decision about whether to use a pulmo- nary catheter is placed to monitor the hourly output. The sudden nearly universal in adult cardiovascular practice, is appearance of reddish urine may indicate excessive controversial. Temperature tricular flling pressures can be measured with a lef Multiple temperature monitors are usually placed atrial pressure line inserted by the surgeon during once the patient is anesthetized. In general, pulmonary artery catheter- esophageal, and pulmonary artery (blood) tempera- 6 ization has been most ofen used in patients tures are ofen simultaneously monitored. Because with compromised ventricular function (ejection of the heterogeneity of readings during cooling and fraction <40–50%) or pulmonary hypertension and rewarming, bladder and rectal readings are gener- in those undergoing complicated procedures. The ally taken to represent an average body temperature, most useful data are pulmonary artery pressures, the whereas esophageal represents core temperature. Specialized cathe- estimate of blood temperature, which should be the ters provide extra infusion ports, continuous mea- same as core temperature in the absence of active surements of mixed venous oxygen saturation and cooling or warming. Nasopharyngeal and tympanic cardiac output, and the capability for right ventricu- probes may most closely approximate brain tem- lar or atrioventricular sequential pacing. Blood gases, hematocrit, ber dimensions, valvular anatomy, and the presence serum potassium, ionized calcium, and glucose of intracardiac air. Surgical Field monly used for monitoring during cardiac surgery One of the most important actions in intraopera- are the four-chamber view (Figure 22–3) and the tive monitoring is inspection of the surgical feld. Tree- Once the sternum is opened, lung expansion can be dimensional echocardiography ofers great promise observed through the pleura. When the pericardium for better visualization of complex anatomic fea- is opened, the heart (primarily the right ventricle) is tures, particularly of cardiac valves. The following visible; thus cardiac rhythm, volume, and contractil- represent the most important applications of intra- ity can ofen be judged visually. Assessment of valvular function—Valvular mor- to changes in hemodynamics and rhythm. A:The relationship between the angle The probe is also rotated clockwise or counterclockwise of the ultrasound beam and image orientation relative to to optimize viewing of the various structures. Colors are usually regurgitation, and can detect vegetations from endo- adjusted so that fow toward the probe is red and fow carditis. Pulse-wave Doppler demonstrates backward flow (regurgitant jet) across the recording of mitral valve inflow showing two phases, E mitral valve during systole (mitral regurgitation) (B ). The commissural view (at about 60°) is par- valve must be measured looking up from the deep ticularly helpful because it cuts across many scallops transgastric view (Figure 22–7). The mitral valve is examined from the function can be assessed by global systolic function, mid-esophageal position, looking at the mitral valve estimated by means of ejection fraction (ofen cal- apparatus with and without color in the 0° through culated using Simpson’s method of disks) and lef 150° views (Figure 22–9). Between 110° and 130°, the left ventricular outflow, aortic valve, and ascending aorta are clearly visualized (B). Regional wall motion abnormalities can be classifed into three categories based on severity (Figure 22–10): hypokinesis (reduced wall motion), akinesis (no wall motion), and dyskinesis (paradoxical wall motion). The location of a regional wall motion abnormal- ity can indicate which coronary artery is experienc- ing reduced fow. The posterior leaflet has corresponding to the opposing corresponding areas of three scallops, P , P1 2, and P3. Upper-, mid-, and lower-esophageal 1 2 1 views are valuable in diagnosing aortic disease pro- 2 cesses such as dissection, aneurysm, and atheroma 5 7 3 4 4 (Figure 22–13). The extent of dissections in the 3 ascending and descending aorta can be accurately 7 7 defned; however, airway structures prevent com- 7 plete visualization of the aortic arch. Examination for residual air—Air is introduced 2 into the cardiac chambers during all “open” heart 2 procedures, such as valve surgery. Residual amounts of air ofen remain in the lef ventricular apex even 3 3 afer the best deairing maneuvers. Green, right coronary artery; blue, left anterior and right ventricles in three views: the short-axis view descending artery; pink, left circumflex artery. Other cen- be visualized in the upper mid-esophagus at 110–130° with anteflexion at the aortic valve level (see Figures 22–2B ters use a single intrathecal morphine injection to and 22–6B). The principles are from primarily volatile inhalation anesthesia to discussed in Chapter 21. Indeed, studies have failed to show difer- short-acting agents and combinations of intra- ences in long-term outcome with various anesthetic venous and volatile agents have become most techniques. Severely compromised patients should be This technique was originally developed to circum- given anesthetic agents in incremental, small doses. Blood duces prolonged postoperative respiratory depres- pressure and heart rate are continuously evaluated sion (12–24 h), is associated with an unacceptably following unconsciousness, insertion of an oral air- high incidence of patient awareness (recall) during way, urinary catheterization, and tracheal intuba- surgery, and ofen fails to control the hypertensive tion. A sudden increase in heart rate or blood response to stimulation in many patients with pre- pressure may indicate light anesthesia and the need served lef ventricular function. Other undesirable for more anesthetic prior to the next challenge, efects include skeletal muscle rigidity during induc- whereas a decrease or no change suggests that the tion and prolonged postoperative ileus. Muscle simultaneous administration of benzodiazepines relaxant is given afer consciousness is lost. Patients anesthetized erally call for administration of a vasopressor (see with sufentanil (and other shorter acting agents) below). Patients was a major impetus for development of anesthe- will usually respond to fuid boluses or a vasocon- sia techniques with short-acting agents.

Ofen buy finpecia 1mg mastercard hair loss zurich, one lung is Bronchiectasis lavaged finpecia 1mg online hair loss in men 50s hairstyles, allowing the patient to recover for a few days Obstructive Chronic obstructive pulmonary disease before the other lung is lavaged; the “sicker” lung is α -antitrypsin deficiency 1 therefore lavaged frst discount finpecia 1 mg hair loss treatment uae. Increasingly, both lungs are Pulmonary lymphangiomatosis lavaged during the same procedure, creating unique Restrictive challenges to ensure adequate oxygenation during Idiopathic pulmonary fibrosis Primary pulmonary hypertension lavage of the second lung. Cor pulmonale does not necessarily require with ketamine, etomidate, an opioid, or a combina- combined heart–lung transplantation because right tion of these agents is employed, avoiding precipi- ventricular function may recover when pulmonary tous drops in blood pressure. Hypoxemia and hypercar- normal lef ventricular function and be free of coro- bia must be avoided to prevent further increases nary artery disease, as well as other serious health in pulmonary artery pressure. Intra- ically performed in patients with cystic fbrosis, bul- operative difculties in ventilation are not uncom- lous emphysema, or vascular diseases. Hypercarbia and aci- dosis may lead to pulmonary vasoconstriction and Efective coordination between the organ-retrieval acute right heart failure, and hemodynamic support team and the transplant team minimizes graf isch- with inotropes may be required for these patients. Single-Lung Transplantation Administration of a clear antacid, an H2 blocker, or Single-lung transplantation is often attempted metoclopramide should be considered. The procedure is performed very sensitive to sedatives, so premedication is usu- through a posterior thoracotomy. Immunosuppressants based on the patient’s response to collapsing the and antibiotics are also administered afer induction lung to be replaced and clamping its pulmonary and prior to surgical incision. Persistent arterial hypoxemia (Spo < 88%) 2 or a sudden increase in pulmonary artery pres- 2. Prostaglandin E1, mil- rinone, nitroglycerin, and dobutamine may be Monitoring utilized to reduce pulmonary hypertension and Strict asepsis should be observed for invasive moni- prevent right ventricular failure. After the recipient lung accomplished only afer induction of anesthesia is removed, the pulmonary artery, left atrial cuff because patients may not be able to lie fat while (with the pulmonary veins), and bronchus of the awake. Flexible bronchos- risk of paradoxical embolism because of high right copy is used to examine the bronchial suture line atrial pressures. Deteriorating lung function may result from rejection or reperfu- A “clamshell” transverse sternotomy can be used for sion injury. Other Posttransplantation Management postoperative surgical complications include dam- Afer anastomosis of the donor organ or organs, ven- age to the phrenic, vagus, and lef recurrent laryn- tilation to both lungs is resumed. Esophageal Surgery Methylprednisolone and mannitol are usually administered prior to the release of vascular clamps. Pulmonary vasodilators, inhaled nitric tumors, gastroesophageal refux, and motility disor- oxide, and inotropes (above) may be necessary. Surgical procedures include simple Transesophageal echocardiography is helpful in dif- endoscopy, esophageal dilatation, cervical esoph- ferentiating right and lef ventricular dysfunction, as agomyotomy, open or thoracoscopic distal esoph- well as in evaluating blood fow in the pulmonary agomyotomy, insertion or removal of esophageal vessels, particularly afer transplantation. Squamous cell carcino- Transplantation disrupts the neural innerva- mas account for the majority of esophageal tumors; tion, lymphatic drainage, and bronchial circulation adenocarcinomas are less common, whereas benign of the transplanted lung. Most tumors occur unafected, but the cough refex is abolished below in the distal esophagus. Hypoxic pulmonary vasoconstriction is generally poor, surgical therapy ofers the only remains normal. Afer esophageal resection, the extravascular lung water and predisposes the trans- stomach is pulled up into the thorax, or the esopha- planted lung to pulmonary edema. Intraoperative gus is functionally replaced with part of the colon fuid replacement must therefore be kept to a mini- (interposition). Loss of the bronchial circulation predisposes Gastroesophageal refux is treated surgi- to ischemic breakdown of the bronchial suture line. A Patients are extubated afer surgery as soon as variety of antirefux operations may be performed is feasible. A thoracic epidural catheter may be (Nissen, Belsey, Hill, or Collis–Nissen) via tho- employed for postoperative analgesia when coagu- racic or abdominal approaches, ofen laparoscopi- lation studies are normal. Tey all involve wrapping part of the stomach may be complicated by acute rejection, infections, around the esophagus. The former usually fuid warmers, and a forced-air body warmer are occurs as an isolated fnding, whereas the latter is advisable. During the trans hiatal approach to esoph- part of a generalized collagen–vascular disorder. Moreover, as ated with a variety of neurogenic or myogenic dis- the esophagus is freed up blindly from the poste- orders and ofen results in a Zenker’s diverticulum. Regardless of the procedure, a common anes- 9 Colonic interposition involves forming a pedi- thetic concern in patients with esophageal cle graf of the colon and passing it through the pos- disease is the risk of pulmonary aspiration. Tis terior mediastinum up to the neck to take the place may result from obstruction, altered motility, or of the esophagus. In fact, most patients maintenance of an adequate blood pressure, cardiac typically complain of dysphagia, heartburn, regurgi- output, and hemoglobin concentration is necessary tation, coughing, and/or wheezing when lying fat. Graf ischemia may be her- Dyspnea on exertion may also be prominent when alded by a progressive metabolic acidosis. Postoperative ventilation will ofen be used in Patients with malignancies may present with ane- patients undergoing esophagectomy, because so mia and weight loss. Esophageal cancer patients many of them will have coexisting cardiac and pul- usually have a history of cigarette smoking and monary disease. Postoperative surgical complica- alcohol consumption, so patients should be evalu- tions include damage to the phrenic, vagus, and lef ated for coexisting chronic obstructive pulmonary recurrent laryngeal nerves. In patients with refux, consideration should Mediastinal Adenopathy be given to administering metoclopramide, an A 9-year-old boy with mediastinal lymphade- H2-receptor blocker, or a proton-pump inhibitor nopathy seen on a chest radiograph presents for preoperatively. A double-lumen tube is used for procedures involving thoracoscopy or tho- What is the most important preoperative racotomy. Tese pro- Asymptomatic compression is also common cedures ofen involve considerable blood loss. The and may be evident only as tracheal deviation on former requires an upper abdominal incision and a physical or radiographic examinations. Therefore, biopsy of a peripheral node (usu- importance of the obstruction (above). Although establishing Does the absence of any preoperative dyspnea a diagnosis is of prime importance, the presence make severe intraoperative respiratory of significant airway compromise or the superior compromise less likely? Severe airway obstruction can occur fol- ment with corticosteroids prior to tissue diagnosis lowing induction of anesthesia in these patients at surgery (cancer is the most common cause); pre- even in the absence of any preoperative symp- operative radiation therapy or chemotherapy may toms. The point of obstruction is typi- way compromise and other manifestations of the cally distal to the tip of the tracheal tube. Lymphomas are most How does the presence of airway obstruction commonly responsible, but primary pulmonary and the superior vena cava syndrome influence or mediastinal neoplasms can also produce the management of general anesthesia? Premedication: Only an anticholinergic should associated with severe airway obstruction and car- be given. The patient should be transported to diovascular collapse on induction of general anes- the operating room in a semiupright position thesia. Direct mechanical compression, as well as an arterial line is helpful, but it should be placed mucosal edema, severely compromise airflow in after induction in young patients. Most patients favor an upright pos- large-bore intravenous catheter should be ture, as recumbency worsens the airway obstruc- placed in a lower extremity, as venous drainage tion. Airway management: Difficulties with ventila- body, direct mechanical compression of the heart, tion and intubation should be anticipated.