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• Professor
• Anesthesiology
• Mount Sinai Medical Center
• New York, New York

The energy balance equation may be stated as follows: Gross energy intake= energy excreted+energy expended+energy stored or Metabolizable energy=energy expended+energy stored 19 skin care regimen for 30s buy aldara. The energy cost of growth includes the energy used for synthesis of new tissues skin care 45 years old cheap aldara 5percent on line. Separate evaluations of energy expenditure requirement for fat and protein deposition in premature newborns estimate that 1 g of protein deposition requires 7 acne products purchase aldara 5percent free shipping. Strict carbohydrate requirements are diffcult to estimate because glucose acne before and after order online aldara, a preferred metabolic fuel for many organs (including the brain) skin care with peptides buy discount aldara 5percent, is synthesized endogenously from other compounds acne in hair best order aldara. Several methods have been used to assess carbohydrate requirements in neonates: n Breast milk intake of lactose (assuming breast milk provides optimal intakes of all nutrients) n Constant infusion of labeled glucose to determine the rates of glucose production and oxidation (as a refection of overall carbohydrate metabolism) n Altering the amount of the carbohydrate intake in the diet and determining its effect on energy metabolism and nitrogen retention 23. The rate of endogenous glucose production in neonates has been estimated to range from 4 to 6 mg/kg/min. The rates of endogenous glucose production should be regarded as only the minimal carbo hydrate requirement because of the methods and conditions in which these measurements were performed. These studies were done in neonates under basal or resting metabolic conditions and during fasting periods. In addition, these studies did not take into account the energy cost of physical activity, growth, and thermal effect of feeding. Excessive intake of carbohydrate in infant feedings may lead to delayed gastric emptying, emesis, diarrhea, and abdominal distention caused by excessive gas formation as colonic bacteria digest the extra carbohydrates. Early overfeeding may be an important factor in later childhood and adult obesity, though more recent work suggests that genetic factors may be as important. Why do infant formulas contain comparable amounts of lactose and glucose polymers These short chain fatty acids are absorbed in the colon, reducing energy losses in the stools and maintaining the nutrition and function of the colon. The amino acids that cannot be synthesized in the body are regarded as essential amino acids: n Leucine n Threonine n Phenylalanine n Isoleucine n Methionine n Tryptophan n Valine n Lysine n Histidine 28. Which of the amino acids are considered conditionally essential for the preterm infant Cysteine, tyrosine, and taurine are essential because of immaturity of the enzymes (decreased activity) involved in their synthesis. The ratio of whey to casein is about 90:10 at the beginning of lactation and rapidly decreases to 60:40 (or even 50:50) in mature milk. Whey protein, however, is less likely to precipitate and is emptied more rapidly from the stomach. What is the rate of protein loss in premature infants who receive only 10% dextrose and water in the immediate newborn period Even with good early protein administration, however, rates of intrauterine growth are virtually never achieved and some degree of extrauterine growth failure is the norm. How do protein requirements differ when protein is delivered parenterally versus enterally Protein requirements are higher parenterally because preterm infants retain only 50% of amino acids administered intravenously but 70% to 75% of formula or human milk protein. What is the ideal calorie-to-protein ratio to ensure complete assimilation of protein A small amount of fat is synthesized by the breast itself, with that percentage increasing in women receiving a low-fat, high-carbohydrate diet. Synthesis of fat from glucose requires about 25% of the glucose energy invested in synthesis. In comparison, synthesis of fat from fat requires only 1% to 4% of the energy invested. In addition, eicosapentaenoic and arachidonic acids are precursors for prostaglandins, leukotrienes, and other lipid mediators. What is the advantage of supplying calories as lipid rather than carbohydrate in infants with chronic lung disease What is the advantage of using a 20% lipid emulsion versus a 10% lipid emulsion in newborn infants Twenty-percent lipid emulsions are cleared from the circulation more rapidly than 10% emulsions. Ten-percent lipid emulsions contain proportionately more emulsifer (egg yolk phospholipid). The excess phospholipid forms bilayer vesicles that extract free cholesterol from peripheral cell mem branes to form lipoprotein X. What is the maximum acceptable triglyceride level in infants receiving lipid emulsions, and how often should they be checked Routine monitoring of serum triglycerides is necessary as they are being advanced. What are the metabolic advantages of using different regimens containing high carbohydrate (67%) and low fat (5%) or low carbohydrate (34%) and high fat (58%) Effect of energy source on changes in energy expenditure, respiratory quotient and nitrogen balance during total parenteral nutrition in children. In most infants hyperglycemia is a transient problem and resolves when the rate of glucose or lipid administration is reduced. Insulin infusions have been used for infants weighing less than 1000 g who develop hyperglycemia (serum glucose level in excess of 150 mg/dL) and glycosuria during the course of parenteral nutrition, providing low glucose infusion rates (<12 mg/kg/min). Interventions for prevention of neonatal hyperglycemia in very low birth weight infants. Interventions for treatment of neonatal hyperglycemia in very low birth weight infants. The clearance of intravenous fat emulsions in neonates is improved by all the following measures except for which of the following Exposure of lipid emulsions to ambient or phototherapy lights increases the forma tion of triglyceride hydroperoxide radicals but does not enhance lipid clearance. Why do premature infants who receive prolonged courses of parenteral nutrition develop osteopenia resulting in pathologic bone fractures These measures allow for a greater, though still inadequate, intake of calcium and phosphorus. The administration of calciuric diuretics such as furosemide, the use of postnatal steroids, and the development of cholestatic liver disease further aggravate calcium homeostasis in these patients. Both of these trace elements are metabolized in the liver and primarily excreted in bile. Therefore the chronic administration of trace elements in patients with cholestasis may result in toxic states. Other organisms include Staphylococcus aureus, Escherichia coli, Pseudomonas species, Kleb siella species, and Candida albicans. It is evident that this complication is far more preventable than was once thought possible. Lactose is the major source of carbohydrate in human milk and in formulas for term infants. Lactose, however, remains important both in calcium absorption and as a prebiotic. Glycosidase enzymes involved in the digestion of glucose polymers are active in preterm infants. The lower fat absorption reported in preterm infants is attributed to their relative defciency of pancreatic lipase and bile salts. Because soy protein has low concentrations of methionine, this amino acid is added to all soy-based formulas. The success of feeding a preterm infant by nipple depends on the ability of the infant to coordinate sucking and swallowing, which develops at approximately 33 to 34 weeks of gestational age. Transpyloric feedings may result in fat malabsorption as a result of bypassing the lipolytic effect of gastric lipase. Why are early minimal enteral feedings recommended for preterm infants receiving parenteral nutrition Gastrointestinal hormones such as gastrin, enteroglucagon, and pancreatic polypeptide may have a trophic effect on the gut. Postnatal surges of these hormones occur in preterm infants receiving minimal enteral feedings. Minimal enteral feeding has also been reported to produce more mature small intestinal motor activity patterns in preterm infants. Thus early minimal enteral feedings given along with parenteral nutrition may improve subsequent enteral feeding tolerance and may shorten the time to achieve full enteral intake. The most recent Cochrane Review, however, suggests that the evidence for this effect is unclear, at best. What are the reported advantages of feeding human milk to preterm infants over the commercially available infant formulas In addition, the calcium and phosphorus content of human milk is insuffcient to fully support adequate skeletal mineralization. Supplementation of human milk with available human milk fortifers that provide protein, calcium, phosphorus, sodium, zinc, and up to 23 vitamins helps overcome these nutritional inadequacies. Newly designed preparations of pooled human breast milk (Prolacta) do contain adequate calories and minerals for growth. Initially, hormonal factors (prolactin and oxytocin) affect the synthesis and secretion of milk. The frequency of breastfeeding then becomes the most important factor affecting the continuation of adequate milk production. The term infant should receive between 8 and 12 feedings per day in the frst week and more than 5 daily thereafter. To minimize the volume of residual milk, mothers should alternate the breast they start with at the next feeding. When breastfeeding is frst initiated, mothers should switch the infant from one side to the other approximately every 5 to 10 minutes. Maternal diet and fuid intake rarely affect milk volume; however, in the setting of severe malnutrition there may be diminished milk production. There are no magic potions or medications that increase milk production, though increasing maternal fuid intake may be of modest help. The administration of metoclopramide will occasionally increase serum prolactin and increase milk production. Unfortunately, this medication has side effects, including sedation and extrapyramidal neurologic signs. Oxytocin will not increase milk production, but it may help milk ejection (once milk already has been synthesized). Herbal remedies have been advocated, but no data are available that determine their effcacy or associated risks. A small percentage of women (2% to 5%) have lactation insuffciency and cannot produce adequate quantities of milk. The risk-to-beneft ratio must be determined for particular populations outside the United States. Efforts are under way to determine the risk-to-beneft ratio and cost-to-beneft ratio for the use of antiretroviral therapy along with breastfeeding or the use of infant formula in high-risk populations. Only a few medications are incompatible with breastfeeding, although most medications do enter breast milk in low concentrations. She now calls with the concern that she has recently noticed a burning pain in her nipple during breastfeeding. You diagnose a fssure and advise her to use dry heat and a few drops of milk on her areola after breastfeeding. If thrush is evident, the baby should be treated with an oral medication and the mother with an antifungal. A mother calls you and explains that she is worried because her 4-day-old baby is not receiving enough breast milk. How do you assess whether a newborn is receiving suffcient amounts of breast milk during the frst week after birth Some practitioners use the fol lowing rough guide for urine and stool output in the frst week: minimum of one urine output in the frst 24 hours, two to three in the next 24 hours, about four to six on day 3, and six to eight on day 5; stools should be one per day on days 1 and 2, two per day on day 3, and four or more afterward, although this can vary substantially among infants. The baby should have established feeding activities, such as lip smacking and rooting. If a mother experiences leaking from one breast while the child is nursing at the other, her milk supply is usually quite adequate.

Comparison of diets of diabetic and non diabetic elderly men in Finland skin care vitamins and minerals purchase aldara with mastercard, the Netherlands and Italy acne extractor tool buy cheap aldara. The postprandial effect of components of the Mediterranean diet on endothelial function acne neck buy aldara now. The metabolism of 7 acne 8th ave buy aldara 5percent without a prescription, 10 skin care 4 less order generic aldara online, 13 skin care anti aging purchase genuine aldara, 16, 19-docosapentaenoic acid to 4, 7, 10, 13, 16, 19-docosahexaenoic acid in rat liver is independent of a 4-desaturase. The relationships of abdominal obesity, hyperinsulinemia and saturated fat intake to serum lipid levels: the Normative Aging Study. Total and high density lipo protein cholesterol as risk factors for coronary heart disease in elderly men during 5 years of follow-up. The development of essential fatty acid deficiency in healthy men fed fat-free diets intravenously and orally. Metabolism of linolenic acid and docosahexaenoic acid in rat retinas and rod outer seg ments. Visual membranes: Specificity of fatty acid precursors for the electrical response to illumination. A prospective case-control study of lipoprotein(a) levels and apo(a) size and risk of coronary heart disease in Stanford Five-City Project participants. Effect of long chain polyunsaturated fatty acids in infant formula on problem solving at 10 months of age. Eicosapentaenoic acid ethyl ester as an antithrombotic agent: Comparison to an extract of fish oil. Effect of butter, mono and polyunsaturated fatty acid-enriched butter, trans fatty acid margarine, and zero trans fatty acid margarine on serum lipids and lipoproteins in healthy men. Effect of palm oil, marga rine, butter, and sunflower oil on the serum lipids and lipoproteins of normocholesterolemic middle-aged men. Effect of eicosapentaenoic and docosahexaenoic acid on natural killer cell activity in human peripheral blood lymphocytes. Encapsu lated fish oil enriched in tocopherol alters plasma phospholipid and mono nuclear cell fatty acid compositions but not mononuclear cell functions. Dietary docosahexaenoic acid enhances ferric nitrilotriacetate-induced oxidative damage in mice but not when additional alpha-tocopherol is supple mented. Plasma cholesterol-predictive equations demonstrate that stearic acid is neutral and monounsaturated fatty acids are hypocholesterolemic. Effect of glyburide and t3 fatty acid dietary supplements on glucose and lipid metabolism in patients with non-insulin-dependent diabetes mellitus. Effects of stearic acid and trans fatty acids versus linoleic acid on blood pressure in normotensive women and men. Effects of dietary fish oil on platelet function and plasma lipids in hyperlipoproteinemic and normal subjects. Number of days of food intake records required to estimate individual and group nutrient intakes with defined confidence. Independence of the effects of cholesterol and degree of saturation of the fat in the diet on serum cholesterol in man. Energy, nutrient intake and prostate cancer risk: A population based case-control study in Sweden. Influence of formula versus breast milk on cholesterol synthesis rates in four-month-old infants. Effect of egg yolk feeding on the concentration and composition of serum lipoproteins in man. Reproducibility of the variations between humans in the response of serum cholesterol to cessation of egg consumption. Comparison of the lipid composition of breast milk from mothers of term and preterm infants. Dependence of the effects of dietary cholesterol and experimental conditions on serum lipids in man. A proteolytic pathway that controls the cholesterol content of membranes, cells, and blood. Body fat distribution is a determinant of the high-density lipoprotein response to dietary fat and cholesterol in women. The interrelated effects of dietary choles terol and fat upon human serum lipid levels. Comparison of deuterium incorporation and mass isotopomer distribution analysis for measurement of human cholesterol biosynthesis. Role of liver in the maintenance of cho lesterol and low density lipoprotein homeostasis in different animal species, including humans. Effect of dietary cholesterol on plasma cholesterol concentration in subjects follow ing reduced fat, high fibre diet. Dietary choles terol and the origin of cholesterol in the brain of developing rats. The effect of partial hydrogenation of dietary fats, of the ratio of polyunsaturated to saturated fatty acids, and of dietary cholesterol upon plasma lipids in man. Relationship between dietary intake and coronary heart disease mortality: Lipid research clinics prevalence follow-up study. Rela tion of infant feeding to adult serum cholesterol concentration and death from ischaemic heart disease. Effects of dietary cholesterol and fat saturation on plasma lipoproteins in an ethnically diverse population of healthy young men. Franceschi S, Favero A, Decarli A, Negri E, La Vecchia C, Ferraroni M, Russo A, Salvini S, Amadori D, Conti E, Montella M, Giacosa A. A dose-response study of the effects of dietary cholesterol on fasting and postprandial lipid and lipo protein metabolism in healthy young men. Plasma and dietary cholesterol in infancy: Effects of early low or moderate dietary cholesterol intake on sub sequent response to increased dietary cholesterol. Cholesterol synthesis and accretion within various tissues of the fetal and neonatal rat. Identification of a receptor mediating absorption of dietary cholesterol in the intestine. Comparison of serum cholesterol in children fed high, moderate, or low cholesterol milk diets during neonatal period. Plasma lipid and lipoprotein responses to dietary fat and cholesterol: A meta-analysis. Triglycerides, fatty acids, sterols, mono and disaccharides and sugar alcohols in human milk and current types of infant formula milk. Fat composition of the infant diet does not influence subsequent serum lipid levels in man. Human milk total lipid and cholesterol are dependent on interval of sampling during 24 hours. Dietary fat and breast cancer in the National Health and Nutrition Examination Survey. Congruence of individual responsiveness to dietary cholesterol and to satu rated fat in humans. Effects of dietary cholesterol on cholesterol and bile acid homeostasis in patients with cholesterol gallstones. Intestinal cholesterol absorption efficiency in man is related to apoprotein E phenotype. Effect of dietary cholesterol in normolipidemic subjects is not modified by nature and amount of dietary fat. The influence of egg consumption on the serum cholesterol level in human sub jects. Duration of breast feed ing and arterial distensibility in early adult life: Population based study. A case-control study of diet and colorectal cancer in a multiethnic population in Hawaii (United States): Lipids and foods of animal origin. The long term effects of dietary cholesterol upon the plasma lipids, lipoproteins, cholesterol adsorption, and the sterol balance in man: the demonstration of feedback inhibition of cholesterol biosynthesis and increased bile acid excretion. Phytosterolaemia in a Norwegian family: Diagnosis and characterization of the first Scandinavian case. Alterations in human high-density lipoproteins, with or without increased plasma-cholesterol, induced by diets high in cholesterol. Long term steroid metabolism balance studies in subjects on cholesterol-free and cholesterol-rich diets: Comparison between normal and hypercholesterolemic individuals. The relationship of dietary fat and cholesterol to mortality in 10 years: the Hono lulu Heart Program. Dietary cholesterol and the plasma lipids and lipoproteins in the Tarahumara Indians: A people habituated to a low cholesterol diet after weaning. The absorp tion of cholesterol and the sterol balance in the Tarahumara Indians of Mexico fed cholesterol-free and high cholesterol diets. Cholesterol, phytosterols, and polyunsaturated/saturated fatty acid ratios during the first 12 months of lactation. Individual variation in the effects of dietary cholesterol on plasma lipoproteins and cellular choles terol homeostasis in man. Studies of low density lipoprotein receptor activity and 3-hydroxy-3-methylglutaryl coenzyme A reductase activity in blood mono nuclear cells. Lipoprotein cholesterol responses in healthy infants fed defined diets from ages 1 to 12 months: Comparison of diets predominant in oleic acid versus linoleic acid, with parallel observations in infants fed a human milk-based diet. Differences in cholesterol metabolism in juvenile baboons are programmed by breast-versus formula-feeding. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Changes in cholesterol synthesis and excretion when cholesterol intake is increased. Effect of dietary egg on variability of plasma cholesterol levels and lipoprotein cholesterol. Intake of fatty acids and risk of coronary heart disease in a cohort of Finnish men. Effects of dietary cholesterol on the regulation of total body cholesterol in man. Tissue storage and control of choles terol metabolism in man on high cholesterol diets. Infant feeding and adult glucose tolerance, lipid profile, blood pressure, and obesity. Control of serum cholesterol homeostasis by choles terol in the milk of the suckling rat. The role of orphan nuclear receptors in the regula tion of cholesterol homeostasis. Genetic factors influence the atherogenic response of lipoproteins to dietary fat and cholesterol in nonhuman primates. U-shape relationship between change in dietary cholesterol absorption and plasma lipoprotein responsiveness and evidence for extreme inter individual variation in dietary cholesterol absorption in humans. Dietary palmitic acid results in lower serum cholesterol than does a lauric-myristic acid combination in normolipemic humans. The effect of increased egg consump tion on plasma cholesteryl ester transfer activity in healthy subjects. Tzonou A, Kalandidi A, Trichopoulou A, Hsieh C-C, Toupadaki N, Willett W, Trichopoulos D. Dietary oxysterols are incorporated in plasma triglyceride-rich lipoproteins, increase their suscepti bility to oxidation and increase aortic cholesterol concentration of rabbits. Apolipoprotein A4-1/2 polymorphism and response of serum lipids to dietary cholesterol in humans. Dietary cholesterol from eggs increases the ratio of total cholesterol to high-density lipoprotein cholesterol in humans: A meta-analysis. Total and high density lipoprotein cholesterol as risk factors for coronary heart disease in elderly men during 5 years of follow-up. Egg yolk and serum-cholesterol levels: Impor tance of dietary cholesterol intake. Relation of meat, fat, and fiber intake to the risk of colon cancer in a prospective study among women. Effect of dietary cholesterol on cholesterol synthesis in breast-fed and formula-fed infants. Effect of egg choles terol and dietary fats on plasma lipids, lipoproteins, and apoproteins of normal women consuming natural diets. Correlates of over and under reporting of energy intake in healthy older men and women. Changes in catecholamine excretion after short-term tyrosine ingestion in normally fed human subjects. Effect of potassium-magnesium aspartate on the capacity for prolonged exercise in man. Elevation of urinary catecholamines and their metabolites following tyrosine administra tion in humans. In utero and dietary administration of monosodium L-glutamate to mice: Reproductive performance and development in a multigeneration study. Correlation between the plasma tryptophan to neutral amino acid ratio and protein intake in the self-selecting weanling rat.

The pharyngotympanic (Eustachian) tube reaches downwards acne essential oils aldara 5percent low cost, the special senses 417 forwards and medially from the anterior part of the tympanic cavity to the lateral walls of the nasopharynx acne nodules buy aldara 5percent low price. The mucous membrane is thin in its bony part but the cartilaginous segment con tains numerous mucous glands and skin care summer cheap aldara 5percent with visa, near its pharyngeal ori ce acne wiki purchase aldara 5percent otc, a con siderable collection of lymphoid tissue termed the tubal tonsil acne killer purchase aldara american express. Conduction of sound through the middle ear is by way of the malleus skin care acne purchase generic aldara on-line, incus and stapes. The incus comprises a body, which articu lates with the malleus, and two processes, a short process attached to the posterior wall of the middle ear and a long process for articulation with the stapes. The shadow of the long process can often be seen through an auroscope running downwards behind the handle of the malleus. The disposition of the semicircular canals in three planes at right angles to each other renders this part of the labyrinth particularly well 418 the central nervous system Fig. The organ of Corti is adapted to record the sound vibrations transmitted by the stapes at the oval window. Posteriorly it is pierced by the optic nerve and anteriorly it is connected to the iris by the ciliary body. The neural coat the retina is formed by an outer pigmented and an inner nervous layer, and is interposed between the choroid and the hyaloid mem brane of the vitreous. Anteriorly, it presents an irregular edge, the ora serrata, while posteriorly the nerve bres on its surface collect to form the optic nerve. The central artery of the retina emerges from the disc and then divides into upper and lower branches; each of these in turn divides into a nasal and tem poral branch. The lens is biconvex and is placed between the vitreous and the aqueous humour, just behind the iris. From here it passes through the pupillary aperture into the special senses 421 Fig. The anterior part of the hyaloid mem brane is thickened, receives attachments from the ciliary processes and gives rise to the suspensory ligament of the lens. This ligament is attached to the capsule of the lens in front of its equator and serves to retain it in position. It is pierced by the vessels and nerves of the eye and by the tendons of the extra-ocular muscles. The eyelids and conjunctiva Of the two eyelids, the upper is the larger and more mobile, but apart from the presence of the levator palpebrae superioris in this lid, the structure of the eyelids is essentially the same. Each consists of the fol lowing layers, from without inwards: skin, loose connective tissue, bres of the orbicularis oculi muscle, the tarsal plates, of very dense brous tissue, tarsal glands and conjunctiva. The eyelashes arise along the mucocutaneous junction and immediately behind the lashes there are the openings of the tarsal (Meibomian) glands. The conjunctiva is the delicate mucous membrane lining the inner surface of the lids from which it is re ected over the anterior part of the sclera to the cornea. Over the lids it is thick and highly vascular, but over the sclera it is much thinner and over the cornea it is reduced to a single layer of epithelium. The line of re ection from the lid to the sclera is known as the conjunctival fornix; the superior fornix receives the openings of the lacrimal glands. Movements of the eyelids are brought about by the contraction of the orbicularis oculi and levator palpebrae superioris muscles. The main part of the gland is about the size and shape of an almond, but it is connected to a small terminal process which extends into the posterior part of the upper lid. The two canaliculi, superior and inferior, open into the lacrimal sac, which is situated in a small depression on the medial surface of the orbit. Broadly speaking, the cerebrospinal system is concerned with the responses of the body to the external environ ment. In contrast, the autonomic system is concerned with the control of the internal environment, exercised through the innervation of the non-skeletal muscle of the heart, blood vessels, bronchial tree, gut and the pupils and the secretomotor supply of many glands, including those of the alimentary tract and its outgrowths, the sweat glands, and, as a rather special example, the suprarenal medulla. The two systems should not be regarded as being independent of each other, for they are linked anatomically and functionally. In this respect they differ from the cerebrospinal efferent nerves, which pass without interruption to their terminations (Fig. The autonomic system is subdivided into the sympathetic and parasympathetic systems on anatomical, functional, and to a consid erable extent, pharmacological grounds. Anatomically, the sympathetic nervous system has its motor cell stations in the lateral grey column of the thoracic and upper two lumbar segments of the spinal cord. Functionally, the sympathetic system is concerned principally with stress reactions of the body. When this system is stimulated, the pupils dilate, peripheral blood vessels constrict, the force, rate and oxygen consumption of the heart increase, the bronchial tree dilates, visceral activity is diminished by inhibition of peristalsis and increase of sphincter tone, glycogenolysis takes place in the liver, the supra drenal medulla is stimulated to secrete, and there is cutaneous sweat ing and pilo-erection. The sympathetic pelvic nerves inhibit bladder contraction and are motor to the internal vesical sphincter. The parasympathetic system tends to be antagonistic to the sym pathetic system (Table 6). This differ ence can be explained, at least in part, by differences in anatomical peripheral connections of the two systems, as will be shown below. In addition, some organs receive their autonomic innervation from one system only; for example, the suprarenal medulla and the cutaneous arterio les receive only sympathetic bres, whereas neurogenic gastric secre tion is entirely under parasympathetic control via the vagus nerve. Pharmacologically, the sympathetic postganglionic terminals release adrenaline and noradrenaline, with the single exception of the terminals to the sweat glands which, in common with all the parasympathetic postganglionic terminations, release acetylcholine. The bres from the viscera ascend in the autonomic plexuses; those from the body wall are conveyed in the peripheral spinal nerves. The afferent course from any structure is therefore along the same pathway as the efferent autonomic bres which supply the part. Normally, we are unaware of the affer ent impulses from the viscera unless they become suf ciently great to exceed the pain threshold when they are perceived as visceral pain. From each of these segments small medullated axons emerge into the corresponding anterior primary ramus and pass via a white ramus communicans into the sympathetic trunk. The sympathetic trunk the sympathetic trunk on each side is a ganglionated nerve chain which extends from the base of the skull to the coccyx in close rela tionship to the vertebral column, maintaining a distance of about 1 inch (2. Commencing in| the superior cervical ganglion beneath the skull base, the chain descends closely behind the posterior wall of the carotid sheath, enters the thorax anterior to the neck of the rst rib, descends over the heads of the upper ribs and then on the sides of the bodies of the last 428 the central nervous system three or four thoracic vertebrae. The sympathetic trunks end below by meeting each other at the ganglion impar on the anterior face of the coccyx. The details of the cervical, thoracic and lumbar portions of the trunk are given on pages 331, 50 and 166 respectively. Only the ganglia of T1 to L2 receive white rami directly; the higher and lower ganglia must receive their preganglionic supply from medullated nerves which travel through their corresponding ganglia without relay and which then ascend or descend in the sympathetic chain. Somatic distribution Each spinal nerve receives one or more grey rami from a sympathetic ganglion which distributes postganglionic non-medullated sympa the autonomic nervous system 429 Fig. These may (A) relay in their corresponding ganglion and pass to their corresponding spinal nerve for distribution, (B) ascend or descend in the sympathetic chain and relay in higher or lower ganglia, or (C) pass without synapse to a peripheral ganglion for relay. These bres are vasoconstrictor to the skin arterioles, sudomotor to sweat glands and pilomotor to the cutaneous hairs. Visceral distribution Postganglionic bres to the head and neck and to the thoracic viscera arise from the ganglion cells of the sympathetic chain. The suprarenal medulla has a unique nerve supply comprising a rich plexus of preganglionic bres which pass without relay from the coeliac ganglion to the gland. The parasympathetic system As already stated, this system has a cranial and a sacral component. Postgan glionic bres therefore have only a short and direct course to their the autonomic nervous system 431 Fig. These ganglia also transmit (without synapse and therefore without functional connection) sympathetic and sensory bres which have similar peripheral distribution. These ganglia are the ciliary (see page 396), pterygopalatine (see page 400), submandibular (see page 401) and otic (see page 401). It is respon sible for all the functions of the parasympathetic cranial out ow enu merated above, apart from the innervation of the eye and the secretomotor supply to the salivary and lacrimal glands. The sacral out ow the anterior primary rami of S2, 3 and occasionally 4 give off nerve bres termed the pelvic splanchnic nerves or nervi erigentes, which join the sympathetic pelvic plexus for distribution to the pelvic organs. Sacral afferents are conveyed in the pelvic splanchnic nerves and are responsible for visceral pain experi enced in the bladder, prostate, rectum and uterus. The reference of pain from these structures to the sacral area, buttocks and posterior aspect of the thighs is explained by the similar segmental supply of the sacral dermatomes. Note that although afferent bres are conveyed in both sympa thetic and parasympathetic nerves, they are completely independent of the autonomic system. They do not relay in the autonomic ganglia the autonomic nervous system 433 and have their cell stations, just like somatic sensory bres, in the dorsal ganglia of the spinal and cranial nerves. Wepfer, actually of Surgery in Dublin and an early pioneer of discovered these glands! Married another famous and his brother, William, founded the Mayo neurologist, Joseph Dejerine. He jugular vein during lumbar puncture produces had served as a surgical dresser to Joseph Lister.

The liver should be fully mobilized to allow adequate examination of the tumour and non-involved liver acne zapping machine buy aldara 5percent with amex. It is usual to sling the portal triad structures individually and the inferior vena cava above and below the liver skin care jakarta timur aldara 5percent fast delivery. In addition acne remedies cheap aldara master card, one must decide whether to divide the right suprarenal vein or not and this will depend on the position of the tumour in relation to the inferior vena cava acne 2015 heels buy aldara toronto. Blood vessel and biliary involvement Although much information will have been gained by preoperative radiology skin care 15 days before marriage 5percent aldara with visa, careful dissection to examine the hepatic artery and portal vein in cholangiocarcinoma or the inferior vena cava in metastatic disease or hepatoma is sensible skin care laser clinic buy aldara 5percent otc. This can normally be done without taking any irreversible steps, although we have found that final decisions about the degree of vessel invasion will need to be made once the liver has been removed. In addition, involvement of the biliary tree by metastatic tumours can necessitate a cholangiocarcinoma style approach, with resection of the biliary tree to the segmental level in order to gain a margin of surgical clearance. Conduits Major blood vessel involvement should not prevent successful surgical resection as there are many strategies for vessel repair and conduit formation. Often an adequate repair can be created by a simple suture technique or end-to-end anastomosis. We have found that a satisfactory angioplasty/venoplasty patch can be created using vein remnants from the excised portion of the liver. Alternatively, the saphenous vein can be used to replace the hepatic artery, or opened out sections can be sutured together to create a wider vessel to repair the portal vein or inferior vena cava. The internal jugular vein, internal iliac vein or common iliac vein can be used to replace a section of portal vein without long-term detriment as collateral channels should open up. If a wide area of inferior vena cava must be excised then it is our preference to use a prosthetic graft. Some experience with vascular conduits made from vessels retrieved along with donor organs has also been reported but there is a theoretical risk of allograft rejection and stricture formation. It has been our practice to use a jejunal Roux loop for biliary diversion to reduce the chance of ischaemic stricture formation following biliary reanastomosis. In addition, in most cases it is necessary to ligate and divide the right suprarenal vein in order to gain adequate clearance of the tumour. The portal vein and hepatic artery should be mobilized so that they can be clamped individually, maximizing lengths for subsequent reanastomosis. The portal limb of the bypass is inserted and secured with a snugger technique, and once portal and systemic veno-venous bypass has been established the patient should remain stable for several hours. In our own practice, the median bench time for ex-vivo resection for tumour is 2 hours and the longest has been 4 hours, although the total ischaemic time was a little over 5 hours up to reperfusion. Bench resection and reconstruction Hepatic parenchymal fracture techniques or ultrasonic dissection may be used without the fear of blood loss, but great care must be taken to ligate or clip all visible vessels or ducts to avoid significant haemorrhage at reperfusion (Fig. It is our practice to use a tissue sealant such as fibrin glue at the end of dissection. Hepatic reimplantation and reperfusion the reimplantation technique is identical to that used in orthoptic liver transplantation. Once haemostasis has been achieved, the bypass can be stopped and a further period aimed at control of haemorrhage follows. A direct hepatic artery to hepatic artery anastomosis will usually be possible, although a saphenous vein conduit may be needed, and if so this is most easily anastomosed first to the liver end on the bench. Other authors have used a duct-to-duct anastomosis but reported a high incidence of biliary stricturing. Postoperative care the postoperative care of the ex-vivo liver resection patient should be similar to any major liver resection or liver transplant candidate. Nursing care should be initially on a high dependency ward or intensive care unit. Short stays can be anticipated in cases where there has been significant preresection hypertrophy because of the size of the tumour, as in this case where the major tumour was 17 cm diameter and the resected specimen weighed in excess of 2 kg. It is our practice to use intravenous antibiotics for the first 5 days whilst assessments for liver failure are being made. Gastric acid secretion suppression with a proton pump inhibitor or H2 antagonist is sensible as there is often an associated acute portal hypertension which may be additive to postoperative stress ulceration. A Ex-vivo resection for liver tumors 81 daily requirement for fresh frozen plasma and 20% human albumin solution (200 ml/day) can be calculated from the blood results. Our group uses N-acetyl cysteine by intravenous infusion for major hepatic resection cases as we have found it to be useful in our fulminant hepatic failure programme. In addition, there is usually a requirement for potassium, magnesium and phosphate supplementation intravenously following very radical resection. The use of a small arteriovenous fistula, as described above, may obviate the need for long-term anticoagulation. However, if the warfarin is not causing any significant problems then it will provide an extra safeguard against thrombosis so it is likely that the majority of our patients will continue on this drug in the long term. In our experience, if a thrombosis occurs more than 7 days postoperatively after major liver resection it can be managed conservatively. Anticoagulation with intravenous heparin and then by warfarin for 3 months should allow portal vein recanalization or arterial collateral formation. Dopexamine appears to increase splanchnic blood flow 27 and we have used this with both portal vein and hepatic artery thrombosis. This is at variance with experience in liver transplantation where regrafting is almost always required if early arterial thrombosis occurs. Unfortunately, in addition, significant stenosis can occur in any of the vascular anastomoses. Radiological intervention can solve most problems by balloon angioplasty or the use of endovascular stents. Biliary strictures There is a theoretical risk of biliary or biliaryenteric stricture formation. We have not experienced any difficulty in this regard and this may be because of our preference to hepaticojejunostomy. Intrahepatic strictures as a result of preservation injury or arterial thrombosis are much more difficult to deal with and some consideration would have to be given to liver transplantation in order to correct this. We have used liver transplantation in one patient following a failed biliary reconstruction after the development of severe Surgical management of hepatobiliary and pancreatic disorders 82 intrahepatic stricturing as a result of a right hepatectomy for colorectal metastases 18 months previously: at 5 years he is tumour free. Long-term follow-up Long-term follow-up after ex-vivo liver resection for tumour should be designed to examine the patients primarily for tumour recurrence, but also for complications related to the extensive hepatic resection and vascular replacement. Doppler ultrasound should usually be diagnostic, with rapid recourse to arteriography and venography when necessary for consideration of endovascular correction. A rise in alkaline phosphatase or bilirubin may indicate an ischaemic biliary stricture or recurrent disease causing biliary obstruction. Long-term results There are very few series of ex-vivo liver resection in the world literature. Disease recurrence is inevitable for some of the surviving patients as the tumours have been so extensive at the time of presentation. Our experience does suggest, however, that a significant period of good quality palliation can be achieved by these elaborate techniques. In addition, as these techniques become more common place, the risk should reduce. This is exemplified by our most recent case where there was no requirement for blood transfusion and the patient was fit enough for discharge from hospital by day 6 despite being 75 years of age. At the time of writing this patient is alive with asymptomatic recurrent disease at 33 months from surgery. In five cases, ex-vivo resection was necessary and two of these patients died within 30 days from multiorgan failure. This high mortality rate is comparable to that in other series and reflects the gravity of the surgery combined with the late stage of disease in these patients. Our longest surviving ex-vivo Ex-vivo resection for liver tumors 83 patient is alive at 33 months. A second patient lived for 30 months, and although the resection had been carried out for colorectal metastases, she died from complications relating to the development of a renal cell carcinoma. These data lend support to arguments for the use of adjuvant therapies despite the potential risk of systemic sepsis associated with the use of prosthetic graft material, and again relate to the late stage at presentation. Prospects for transplantation There is much experience in transplantation for hepatoma. There is no doubt that it is a suitable therapy for patients with small hepatomas in cirrhotic livers, where the cirrhosis is the primary indication for the transplant. Unfortunately, however, where the hepatoma is the primary indication for liver transplantation because of the enormity of the lesion, the results of transplantation have been almost universally poor. This is probably related to the necessary immunosuppression used following organ transplantation, and the development of more specific immunosuppressive agents may enable transplantation to be used in the future for these tumours. Our group has been investigating the use of cluster resection and multivisceral grafting 34 as an alternative for neuroendocrine tumours. These are most often tumours of midgut origin with foregut metastases and adequate lymphadenectomy involves both the coeliac and superior mesenteric arterial distributions, so surgery involves excision of all organs supplied by these arteries: stomach, duodenum, liver, pancreas, spleen, jejunum, ileum and large bowel as far as the descending/sigmoid colon. This approach provides superb access to the para-aortic lymph nodes for adequate lymphadenectomy. This is followed by implantation of a multiorgan block of liver, pancreas, duodenum, jejunum and ileum. We have used a Roux loop (created from the transplanted jejunum) to the oesophagus, as gastric stasis can be a problem for several weeks following stomach transplantation. An ileostomy is used to provide access for regular endoscopic biopsies for careful monitoring for rejection and cytomegalovirus infection during the first few months, but it is our practice to reverse this at about 6 months if graft function is stable. We have found that the donor innominate artery forms an ideal conduit for anastomosis of the donor coeliac and superior mesenteric arteries to the recipient aorta. Our early results with neuroendocrine disease are more encouraging than with other tumours, but long-term analysis is necessary. This may be related to the more extensive resection or, more probably, to the tumour type. The immunosuppressed and non-immunosuppressed control groups showed no significant differences from normal. An alternative growth factor may be active in the resection group both before and after resectional surgery. Our results supported the hypothesis that rapid tumour recurrence following liver transplantation is the result of the necessary immunosuppression. The development of more specific immunosuppressive agents may enable transplantation to be used in the future for more hepatic tumours, but for the moment the role of transplantation remains very limited. Summary Techniques for hepatic resection continue to advance and the involvement of liver transplant teams has aided the development of new types of resection and anaesthetic techniques. Short-term warm hepatic ischaemia is practised widely but there is often a necessity to hurry during this demanding surgery as prolonged warm ischaemia can result in irreversible liver failure. Transplant experience, particularly relating to cut-down and split liver techniques, has demonstrated that bench dissection and reimplantation after long periods of cold ischaemia can be successful in the majority of cases. Summary panel 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. Major improvements in hepatic surgery have occurred during the past few years and improvements in anaesthesia have been integral to this success. Portal triad clamping or hepatic vascular exclusion for major liver resection: a controlled study. Intermittent vascular exclusion of the liver (without vena cava clamping) during major hepatectomy. Partial hepatic resection under intermittent hepatic inflow occlusion in patients with chronic liver disease. Mortality, endotoxaemia and cytokine expression after intermittent and continuous hepatic ischaemia. Normothermic complete hepatic vascular exclusion for extensive resection of the liver. Liver ischemia for hepatic resection: where is the Surgical management of hepatobiliary and pancreatic disorders 86 limit Resection of benign hepatic lesions with selective use of total vascular isolation. Effects and limitations of prolonged intermittent ischaemia for hepatic resection of the cirrhotic liver. Total vascular exclusion for hepatic resection in cirrhotic patients: application of venovenous bypass. In situ and ex situ in vivo procedure for complex major liver resections requiring prolonged hepatic vascular exclusion in normal and diseased livers. Reconstruction of the hepatic vein to the prosthetic inferior vena cava in right extended hemihepatectomy with ex situ procedure. Four new hepatectomy procedures for resection of the right hepatic vein and preservation of the inferior right hepatic vein. Extended left hepatic trisegmentectomy with resection of main right hepatic vein and preservation of middle and inferior right hepatic veins. In situ and surface liver cooling with prolonged inflow occlusion during hepatectomy in patients with chronic liver disease. Experience of orthoptic liver transplantation and hepatic resection for hepatocellular carcinoma of less than 8 cm in patients with cirrhosis.

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