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Other longitudinal studies report good to excellent long-term results in 80% to 93% of surgically treated patients (Table 12 buy levitra super active cheap online causes juvenile erectile dysfunction. Barrett’s oesophagus: effect of antireflux surgery on symptom control and development of complications buy 20mg levitra super active mastercard erectile dysfunction scrotum pump. Conservative treatment versus antireflux surgery in Barrett’s oesoph- agus: long-term results of a prospective study. Long-term results of classic antireflux surgery in 152 patients with Barrett’s esophagus: clinical, radiologic endoscopic, manometric, and acid reflux test analysis before and late after operation. Swallowing Difficulty and Pain 221 Indications: Antireflux surgery should be considered in patients in whom intensive medical therapy has failed. Antireflux surgery also should be offered to patients whose symptoms recur immedi- ately after stopping medications and who require long-term daily medication. Many patients want to avoid the cost, inconvenience, and side effects of long-term medication and want to preserve their quality of life. However, patients with these complications usually have more severe disease, require more intensive medical therapy, and are referred for surgical evaluation. Ambulatory pH monitoring has been thought to provide the most objective way to select these patients for surgery, but an abnormal pH study does not correlate well with symptom relief following antireflux surgery. Preoperative Evaluation: The preoperative evaluation should both justify the need for surgery and direct the operative technique to opti- mize outcome. Equally important is its use in assessing esophageal body pressures and identifying individuals with impaired esophageal clearance who may not do as well with a 360-degree fundoplication. Advances in laparoscopic technology and technique allow the repro- duction of “open” procedures while eliminating the morbidity of an upper midline incision. Open antireflux operations remain indicated when the laparoscopic technique is not available or is contraindicated. Only a very experienced laparoscopic surgeon should attempt the minimally invasive approach in the presence of previous upper abdominal operation or prior antireflux surgery. In patients with normal esophageal body peristalsis, laparoscopic Nissen fundoplication (Fig. Thousands of laparoscopic Nissen fundoplication patients have been reported in the world litera- 222 J. The Toupet fundoplication may be best used in patients with impaired esophageal body peristalsis. Hiatal Hernias: Sliding and Paraesophageal Hernias Overview The majority of patients with hiatal hernia are asymptomatic, and the diagnosis often is made incidentally during investigation of other gas- trointestinal problems. It consists of a simple herniation of the gastroesophageal junction into the chest. This is the most common hiatal hernia and is frequently diagnosed in women and in the fifth and sixth decades of life. Swallowing Difficulty and Pain 223 hiatus while the gastric fundus herniates alongside the esophagus, through the hiatus, and into the chest. As in Case 3, paraesophageal hernias are found predomi- nantly in older individuals. Diagnosis When symptoms are present, sliding hernias have a different pre- sentation from paraesophageal hernias. Paraesophageal hernias tend to produce more dysphagia, chest pain, bloating, and respiratory prob- lems than do sliding hernias. Sutyak Treatment Because a hiatal hernia is a purely mechanical abnormality, nonop- erative treatment does not exist. In contrast, a significant number of patients with type I hiatal hernias are asymptomatic and remain so throughout the remainder of their life. Therefore, the presence of a sliding (type I) hiatal hernia alone does not mandate intervention. However, patients with a type I hernia and gastroesophageal reflux, chest pain, dysphagia, regurgitation, or other symptoms referable to their hernias should undergo symptom-specific workup and may be best treated with an operative repair. Occult gastrointestinal bleeding is a complication of hiatal hernia thought to result from the mechanical trauma of the stomach moving into and out of the chest, causing subtle erosions in the stomach that slowly bleed and lead to anemia. The operation can be performed through the chest or abdomen and via “open” or minimally invasive techniques. Routine addition of a fun- doplication to the repair of the other three types of hiatal hernia is con- troversial. Barrett’s Esophagus Overview Barrett’s esophagus is a condition in which the normal squamous epithelium of the esophagus is partially replaced by metaplastic columnar epithelium, placing patients at risk for developing adeno- carcinoma. Intestinal metaplasia (not gastric-type columnar changes) constitutes true Barrett’s esophagus, with a risk of progression to dys- plasia and adenocarcinoma. The estimated incidence of adenocarcinoma in patients with Barrett’s esophagus is 0. Only patients with specialized columnar epithelium are at an increased risk of developing Barrett’s adenocarcinoma. The presence of epithelial dysplasia, partic- ularly high-grade dysplasia, is a risk factor for adenocarcinoma, and the progression of specialized columnar epithelium to dysplasia and invasive carcinoma is well documented. Swallowing Difficulty and Pain 225 Diagnosis Heartburn, regurgitation, and—with stricture formation—dysphagia are the most common symptoms. Heartburn is milder than in the absence of Barrett’s changes, presumably because the metaplastic epithelium is less sensitive than squamous epithelium. The diagnosis often is suggested by the esophagoscopic finding of a pink epithelium in the lower esophagus instead of the shiny gray-pink squamous mucosa, but every case should be verified by biopsy. Radiographic findings consist of hiatal hernia, stricture, ulcer, or a reticular pattern to the mucosa—changes of low sensitivity and specificity. Treatment Treatment goals for patients with Barrett’s esophagus are relief of symptoms and arrest of ongoing reflux-mediated epithelial damage. Patients with Barrett’s have more severe esophagitis and frequently require more intensive therapy for control of reflux. Regardless of medical versus surgical treatment, patients with Barrett’s esophagus require long-term endoscopic surveillance with biopsy of columnar segments for progressive metaplastic changes or progression to dys- plasia. Esophagectomy, if performed with a low operative mortality, is indicated in patients with a diagnosis of high-grade dysplasia. Several studies have compared medical and surgical therapy in patients with Barrett’s esophagus. Current evidence suggests that neither medical nor surgical therapy result in regression of Barrett’s epithelium. There is evidence suggest- ing that antireflux surgery may prevent progression of Barrett’s changes and protect against dysplasia and malignancy. These are very strong data in support of the favorable impact of operative therapy on the natural history of Barrett’s esophagus.

Complications of Parenteral Feeding: Tolerance to parenteral feedings should be evaluated throughout the course buy levitra super active 40 mg low price erectile dysfunction doctors boise idaho. In that acute parenteral nutrition is most common in patients who are critically ill discount levitra super active generic erectile dysfunction treatment ayurvedic, considera- tion always must be given to fluid status as well as glucose intolerance and electrolyte abnormalities. An acute shift toward anabolism may unmask preexisting body electrolyte deficiencies (see Monitoring Progress and Complications, below. Abnormalities of acid–base balance also occur more frequently in such patients, and alterations in electrolyte compo- sition (such as acetate salts) of solutions may be indicated. As always, patients with indwelling catheters must be monitored carefully for 58 S. An abrupt change in glucose tolerance may indicate infection related to the catheter or another source. Problems Related to Access These problems can be life-threatening and include misadventures related to placement of enteral or parenteral feeding portals. Acute pneumothorax, inadvertent arterial puncture, air embolism, and per- foration of the vena cava or heart can accompany attempts at central venous access. Insertion of catheters by experienced personnel serves to minimize these complications. More frequently, however, it is the initial misplacement of the catheter or latent events such as insertion-site infection or vessel thrombosis that provide troubling morbidities to patients. These complications are monitored by a rigorous adherence to sterility guidelines and protocols and by regular physical examination of the patient. A constant awareness of the potential for these events promotes early intervention and treatment. Problems related to placement of enteral feeding portals arise with similar, if not greater, frequency. Although it is increasingly popular to return to intragastric feeding, proper tube placement and function also must be assured. Problems of aspiration, especially in patients prone to reflux, may preclude this route of enteral nutrient provision. Under such circumstances, the placement of small-bore feeding catheters either transgastrically or transcutaneously requires experienced per- sonnel. As noted above, enteral feeding tubes may cause abdominal distention or symptoms that must be investigated. Careful, daily physical examination is an essential component of the monitoring regimen. Problems related to access portals as well as organ dys- function and fluid imbalance may be detected initially, or solely, on this basis. A determination of red blood cell indices may help to define iron deficiency (not routinely provided in intravenous nutrition). Eval- uation of basic bleeding parameters is undertaken to detect the pres- ence of vitamin K deficiency, which also may develop in parenterally fed patients. Trace mineral deficiencies may be a latent problem, especially in patients with preexisting malnutrition and prolonged inflammatory conditions. Attention should be given to patients with previous compromise of intestinal absorption. Problems of Excess Significant changes in overall clinical status as well as specific organs may provoke a state of excess provision. At least daily evalua- tion of glucose tolerance, by blood or urine sampling, is indicated in all patients. An abrupt increase in glucose levels in an otherwise stable patient must suggest infection until proven otherwise. Glucose excess also may precipitate or aggravate pulmonary prob- lems in some patients. If the rate of endogenous glucose oxidation is exceeded, carbon dioxide retention may result in respiratory distress or weaning problems in ventilated patients. Other evidence of nutrient excess occurs during conditions of evolv- ing organ dysfunction. A reduction in volume and nitrogen load as well as evaluation of electrolyte tolerance may be indicated. Under such circumstances, a reduction in nitrogen load or alteration in amino acid formulation may be indicated. Some patients may require liquid diets as a transition to solid food, but this does not necessitate an interruption of the tapering schedule. In patients who have been receiving supplemental insulin, peripheral low-dose dex- trose infusions minimize the chances of hypoglycemia. This decision requires input from several sources, including family and home healthcare agencies as well as social work and nursing professionals. Nutrition Support in the Surgery Patient 61 juncture, particularly if the patient does not steadily recover from her injuries. A prospective, randomized trial of total parenteral nutrition after major pancreatic resection for malignancy. Enteral nutrition during multimodality therapy in upper gastrointestinal cancer patients. Perioperative nutritional support in patients undergoing hepatectomy for hepatocellular carcinoma. A prospective, randomized trial of early enteral feeding after resection of upper gastrointestinal malignancy. Immediate postoperative enteral feeding results in impared respiratory mechanics and decreased mobility. To understand the normal electrolyte composition of body fluids and how they are modified by injury and surgical disease. To recognize the clinical manifestation of common electrolyte abnormalities and methods for their correction. Case 2 A 40-year-old woman presents with a 1 week history of persistent upper abdominal pain in association with nausea and vomiting. Physical examination is unrevealing except for loss of skin turgor and reduced breath sounds over the right chest. Case 3 A 58-year-old woman presents with a 1-week history of confusion, lethargy, and persistent nausea. Introduction An understanding of changes in fluid, electrolyte, and acid–base con- cepts is fundamental to the care of surgical patients. These changes can range from mild, readily correctable deviations to life-threatening abnormalities that demand immediate attention. This chapter outlines some of the physiologic mechanisms that initiate such imbalances and methods to systematically evaluate the diverse clinical and biochemi- cal data that lead to decisions regarding therapy. The information and data presented below are intended for application in adult patients, although the principles espoused also are germane to pediatric patients. Basic Concepts The Stress Response The normal physiologic response to injury or operation produces a neuroendocrine response that preserves cellular function and pro- motes maintenance of circulating volume. This is readily demon- strable in terms of retention of water and sodium and the excretion of potassium.

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Generally generic 20 mg levitra super active with mastercard erectile dysfunction diabetes permanent, your participation in coaching would first come as a suggestion from the therapist working with your loved one order levitra super active 40mg with visa erectile dysfunction commercial. In either case, you only want to serve as a coach if your partner clearly expresses an interest in and a desire for your assistance. In fact, the effort could easily harm your relationship if you push your help too hard. Chapter 18: When a Family Member or Friend Suffers from Anxiety 273 Not everyone is cut out to be a coach. Perhaps you can help your loved one in other ways, such as by taking on a few extra household tasks or simply by being an interested, supportive bystander. Assuming you choose to accept the position, coaching requires you to take the following actions to be the best coach you can be: ✓ Define your role: Come to a clear understanding of how much and what type of input your loved one and her therapist want. Ask whether they want you to simply observe the exposure activities or actively encourage carrying out the tasks involved with exposure. For example, ask whether you should stand next to your partner, hold a hand, or stand a few feet away during expo- sure tasks. That doesn’t mean you don’t care; in fact, you may simply care too much to be a good coach. You may help the one you care about develop a few details of the plan, but don’t take on the full responsibility for designing an exposure hierarchy. People who have problems with anxiety frequently feel insecure and ask for excessive help and reassurance. If changes need to be made, consult with your loved one or have her discuss it with her therapist. People work hard for praise and become immobilized and defensive in response to criticism. Avoid saying anything like, “You should be able to do this,” or, “You aren’t working hard enough. But you must always remember that determining how the plan plays itself out isn’t up to you. Here are a few additional tips: • Before asking your loved one to carry out a step, see whether she wants you to model the task first. In other words, describe the scene in detail and have your loved one imagine it first. Don’t carry it out in real life until your partner feels more comfortable with the imagery. You can consult Chapter 8 for details about using your imagination through exposure as well. You can also give some honest praise for success; just be sure not to sound patron- izing or condescending. Looking at a coach in action Coaching someone you care about can seem overwhelming. The follow- ing example about Doug and Rosie helps you see how one couple worked through a mild case of anxiety with the help of a good game plan. In all that time, they’ve never gone to a movie together because Rosie wrestles with a mild case of ago- raphobia. Although she’s able to go most places and do what she needs Chapter 18: When a Family Member or Friend Suffers from Anxiety 275 to in life, she dreads going anywhere that makes her feel trapped, espe- cially movie theaters. She fantasizes that she’ll need to get out, but she won’t find her way to an exit because of the crowd and the darkness. She imagines that she would trip over people, fall on her face, and desper- ately crawl through the darkened theater. Doug realizes that Rosie makes one excuse after another to avoid going to movies, even though she enjoys watching them on television. Gently, he asks Rosie, “Some things make me a little anxious — heavy traffic or big crowds — what makes you anxious? Several days later, Doug sees a copy of Overcoming Anxiety For Dummies in a bookstore and buys it with Rosie in mind. Doug and Rosie have a productive discussion about her concerns and decide to face them. First, together they devise a staircase of fear, which breaks down the feared situation into small steps. Attending a movie alone and sitting in the middle (95) Attending a movie alone and sitting in the back row by the door (92) Going to the movies with Doug and having him sit in a row behind me (88) Going to the movies with Doug and sitting in the middle (75) Going to the movies and sitting with Doug in the last row by the door (71) Imagining going to the movie and getting stuck in a crowd (70) Going into the theater lobby for a while (69) Buying a ticket by myself (68) Walking up to the ticket window and asking for times of shows (65) Figure 18-1: Walking by the theater while imagining buying a ticket (60) Rosie’s staircase Driving past the theater (48) of fear. Imagining going to the movie (28) 276 Part V: Helping Others with Anxiety Doug plays a role in most of Rosie’s tasks. He reads the script out loud to Rosie while she closes her eyes and tries to picture the experiences. She rates her level of anxiety, and during the first few steps, he stays with her until her anxiety goes down. Not only does he accompany her to the movies, but he also celebrates her successes and encourages her when she starts to falter. It takes attending a number of movies with Doug before she agrees to the final tasks of going by herself. In fact, they begin enjoying their nights at the movies and find that they both love talking about their experiences afterwards over coffee and dessert. Although Rosie balks at going to the theater by herself, her comfort level has increased over the last few months. Rosie and Doug drive to the theater together on her last two items, but he chooses a movie playing on a different screen. Rosie’s fear of the movies had not yet reached the level of severely interfer- ing with her life. Had Rosie not dealt with her fear in this early stage, it would likely have spread from fear of movies to fear of other crowded places. Most people with fears, obsessions, or compulsions need to develop a plan with the help of a therapist. However, the example of Rosie and Doug can serve as an illustration of how a simple plan can be carried out without a therapist. Teaming Up against Anxiety One way you can help your partner overcome anxiety is to collaborate on ways to decrease stress in both your lives. With a little ingenuity, you can explore a variety of solutions that are likely to feel good to you even if you per- sonally don’t suffer from anxiety at all. For example: ✓ Take a stress management class at a local center for adult continuing education. Many of the ideas make life more fun and interesting in addition to reducing stress. It’s a great way to reduce stress, but even if you don’t have much stress, strolling under the sky together is a wonderful time to talk and is great for your health. Chapter 18: When a Family Member or Friend Suffers from Anxiety 277 ✓ Take a yoga, Pilates, or tai chi class together. Again, even if you don’t have anxiety, these classes are terrific for balance, muscle strength, flex- ibility, and overall health. You may choose to attend a church, a synagogue, or a mosque, or scope out a less traditional method of com- muning with a higher power, such as immersing yourselves in nature.

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